A collection of standards, guidelines, tools and articles for the OB interested in learning more about intiatives organziations are taking to reduce maternal mortality. 

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A collection of standards, guidelines, tools and articles for the OB interested in learning more about initiatives organizations are taking to reduce maternal mortality.

Maternal Mortality Resources - Initiatives

"  target="_blank">In 2018, maternal mortality is a major topic of discussion in obstetrical, public health and political circles. 

has dedicated a great deal of editorial space this year to articles and commentary on causes and consequences of these deaths. There clearly are many issues to explore about death of US mothers during pregnancy and the puerperium, including who is dying and why, and what can be done about it. 

Disparities in care received by certain patients and populations have been the focus of strong pushes for solutions from multiple sources. With health disparities, the focus typically is on race/ethnicity and socioeconomic factors as they relate to access to and quality of care. But an often forgotten disparity is geographic location. Earlier this year, an article in 

discussed the challenges of improving rural health care,

addressed general aspects of care, especially for rural hospitals and the current reimbursement system. 

The American College of Obstetricians and Gynecologists (ACOG) describes rural America as representing 75% of the national landmass and being home to 22.8% of US women aged 18 and older, with substantial variance in ethnic and racial composition.

ACOG Committee Opinion #586 outlines health disparities for rural women. Significantly, it notes that data describing both health and outcomes for these patients are limited overall, although risks related to level of rurality are evident. Clearly the challenges for a state such as Pennsylvania (reported to have the third largest rural population in the United States) will be different than those for states such as Montana or Alaska, which have smaller absolute numbers of rural residents spread over a much larger geographic area. But some statistics stand out. 

Overall, rural women are less likely to receive any preventative health care and screenings. Fewer than half of rural women live within a 30-minute drive to a hospital with perinatal services, and over 10% have a drive of 100 miles or more. Some states, such as Wyoming, have no tertiary care centers for pregnant women at all.

And because overall health outcomes generally are worse in rural communities due to increased incidences of obesity, cancer, cardiovascular disease, opioid use, and violent deaths, it would seem reasonable to assume that these outcomes would be echoed in the maternal death rates seen in rural communities.

Nationally, rural health care availability is under attack with closure of hospitals and lack of medical personnel in communities, as described by Dr. Lockwood in this month’s 

. ACOG reports that in 2010, 49% of the nation’s counties lacked an obstetrician-gynecologist, leaving over 10 million women-or 8% of those in our country-without that service. The challenge is even greater when one looks at hospital-based obstetrical services (or lack of) and birth outcomes in rural communities.

Clearly, the impact of closing a maternity ward in a rural hospital where the next nearest obstetrical unit is 100 miles away would be very different than in an urban community with another center of care less than 10 miles away. 

It is possible that pregnancy-associated deaths, rather than pregnancy-related deaths, may provide a unique window into the socioeconomic and cultural challenges faced by rural communities. Teasing out the possible differences, however, is not possible with our current system of state-collected data. State and national statistics, therefore, are inevitably dominated by the cause of maternal deaths in population centers simply due to sample size. To begin to address this problem, policy makers need to look at aggregate rural-based data to see if the causes of mortality and morbidity there are similar to those in urban settings and determine if interventions for urban patients can be applied to those in rural settings. 

For example, maternal deaths from motor vehicle accidents may be more common in remote rural settings due to the long distances at high speeds that rural women travel on a regular basis to obtain care. In that setting, seat belt education may be more important than it would be in a metropolitan area. Postpartum hemorrhage (PPH) deaths may be more preventable if tranexamic acid and cryoprecipitate were available as well as six to eight units of total blood products in the hospital blood bank, together with streamlined procedures for obtaining those products in emergency situations. Or interventions in a rural setting may focus on early recognition of risk of PPH or active blood loss, basic stabilization techniques and prompt transport rather than a detailed mass transfusion protocol. 

In addressing any health care disparity, accurate data are critical to identifying specific problems and tailoring interventions to address actual issues rather than issues “perceived” by “outsiders.” Because the absolute numbers of maternal deaths are small in rural states given their overall lower populations and birth rates, it is impossible for a single state to have numbers sufficient to accurately interpret data without aggregation of five or more years of information. With current published state reports, it is also impossible to aggregate data across states because they use different definitions and presentations for their aggregate state data. Until recently, that has stood in the way of accurate data collection and management across the nation.   

Working toward solutions: ACOG maternal mortality task force

In 2017, to help address these challenges and better identify sources of health care disparities in rural settings, ACOG District VIII launched a Maternal Mortality Task Force. District VIII is uniquely situated to collect data on rural maternity care and deaths. District VIII is made up of 12 states as well as Guam, American Samoa, Alberta, British Columbia, and Central America. Those states alone make up over 50% of the land mass of the United States but only about 15% of the US population resides in those areas. Much of the population in the 12 states is concentrated in one or two urban settings (e.g., Alaska with Anchorage and Juno). Using data standards developed by the Centers for Disease Control (CDC) and the Association of Maternal and Child Health Programs (AMCHP) and employed by the national Maternal Mortality Review Information Application (or MMRIA) database, it is possible to capture information about the distance from the woman’s home to where she delivered as well as the level of maternity care available where the delivery occurred. The data collected also include details of a patient’s circumstances, building an extensive narrative that covers all aspects of her experience of pregnancy and then presenting those facts in standardized format for examination and analysis.  

The ACOG District VIII Task Force hopes to be able to aggregate the data over the 12 states using the structure of the MMRIA database. Without specifying state or county, data will be combined across the region, using references of distance from hospitals and levels of care as the standard. That, in turn, will produce samples sizes large enough to allow examination of rural vs urban causes of death on an annual or biannual basis. This larger data pool would also allow for quicker identification of unique evolving issues (Hantavirus, suicides or motor vehicle accidents) and evaluation of intervention strategies. Because the 12 states have some of the largest populations of indigenous people, a detailed data collection of this type may also be of great assistance in documenting data for increased maternal morbidity and mortality associated with this particular group and guiding interventions. 

To accomplish this ambitious goal, the sections in District VIII are working with their respective departments of health to enact legislation as needed to support MMRCs and to encourage and empower individual departments of health to provide their data through MMRIA to the CDC. As more states enter data into the CDC database, the task force will look at the reports, identify issues to address, identify already established interventions a state may have that can be exported to other states in the region and continue to educate our district providers as to steps they can take to decrease our unacceptable national maternal mortality statistics and disparities. 

Iglehart JK.  The Challenging Quest to Improve Rural Health Care – Health Policy report. N Engl J Med. 2018;378:473-479.

Murphy KM, Hughes LS, Conway P. A path to sustain rural hospitals. JAMA. 2018;319(12):1193-1194.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 586:  Health disparities in rural women.  2014 Feb;(2 Pt 1):384-388.

Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S.  Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the US. JAMA. 2018;319(12):1239-1247.

Shah NT. Eroding access and quality of childbirth care in rural US counties. JAMA. 2018;319(12):1203-1204.

Wetzel LM. Maternal mortality statistics; data collection methods improving but still a challenge. Contemp OB/GYN. 2018:63(1):24-27.

Women who give birth in rural areas face unique challenges because of geography but state-based data collection hampers efforts to understand and address the factors that place them at particular risk for morbidity and mortality.

Maternal death  in rural America

A national poll suggests that most adults with children favor some type of state support for pregnant teens. But how strongly someone feels about that and whether the help comes with caveats may be influenced by the person’s gender.

 are from the C.S. Mott Children’s Hospital National Poll on Children’s Health. It was commissioned by the University of Michigan institution and conducted by GfK Custom Research, LLC.

For the research, a randomly selected, stratified group of 2,005 parents aged 18 and older were polled. The sample was from GfK’s web-enabled KnowledgePanel, which closely resembles the US population, and was weighted to reflect Census Bureau population figures. Administered in November 2017, the survey had a completion rate of 60% with a margin of error of ±2% to 4%.

Many of the poll respondents placed caveats on a pregnant teen’s receipt of state support. Requirements endorsed included attending prenatal visits (90%), taking parenting classes (85%), undergoing drug testing (85%), and finishing high school (78%). Seventy percent of adults felt that all four of those requirements should be met in order for a teen to receive the support.

When asked about the state providing medical care, 60% of adults said it should definitely be offered to pregnant teens and 69% said it should be offered to their babies. Women were more likely than men to believe the state should provide medical care, formula and baby supplies for pregnant teens. The authors of the survey report said that “this may reflect women’s empathy with their situation, or their recognition that in many cases, it is the teen mother – not the father – who pays the financial, emotional and social cost of having a baby.”

Regarding putting caveats around state support for pregnant teens, the researchers cautioned that “the consequence for non-compliance may have a negative impact on the health of the pregnant teen or her baby.” They urged a “thoughtful approach to implementing requirements.” 
 

Teen pregnancy, depression and the Internet

Transgender teens: What about fertility preservation?

How do young women feel about IUD insertion?

How should states support pregnant teens?

Internet addiction often is linked with depression but a new study suggests that there is a way to use the technology to help encourage teens with postpartum depression to get treatment. The 

Supported by funding from the National Institute of Nursing Researcher, the study was led by a researcher from the University of Louisville. The aim was to determine whether an Internet-based depression intervention was effective in spurring adolescent mothers to get treatment for their depression.

The participants were a small group (n = 151) of adolescent mothers from Kentucky and data on their experiences were compared with outcomes in a control group (n =138). All the women (97.1%) had given birth in the last year (average < 4 months prior) and were living with the infant. Eighty-nine percent were African American and 51.7% had less than a high school education; mean age was 18.2 years.

The intervention included vignettes, questions and answers, and resources.  The video vignettes were of other adolescent mothers describing their experience with depression and how they successfully sought depression treatment. They were also shown a list of 10 questions commonly asked about postpartum depression and mental health treatment, including information about medication, counseling, and the range of feelings that teens may experience postpartum. Resources described were county and national resources for pregnant and parenting adolescent mothers including referrals for counseling services and suicide and child abuse prevention hotlines.

Before, immediately after, and two weeks after being exposed to the Internet intervention, the teens answered questions related to the theory of planned behavior (TPB) variables and depression treatment. (TPB predicts an individual’s intention to engage in a behavior at a specific time and place.) For the control group, data were collected in community organizations or home visits; those in the intervention group used a computer of their choice.

The authors found that those in the intervention group more often intended to seek treatment (

 = 0.003) and actually receive treatment (P = 0.009) over time when compared with the control group. The intervention independently increased positive attitudes about treatment (

 = 0.018), beliefs of perceived control (

 = 2.05, P = 0.021), intention to seek treatment (

 < 0.001), and actually receiving treatment (

 < 0.001). Being depressed (OR = 2.15, 95% CI 1.15-4.04, 

 = 0.005) and being exposed to the intervention (OR = 1.65, 95% CI 1.06-2.32, 

 = 0.012) increased the odds of seeking treatment. (Incidence of depression was 12.3% in the intervention group and 13.0% in the control group.) Unadjusted, a majority of those who intended to seek treatment (n = 26, 17.1%) actually did report receiving treatment (n = 22, 84.6%), which is strongly correlated (

Limitations of the study included use of self-report measures and unavailability of medical records to confirm participants’ reports of use of mental health services. Because the majority of the adolescent mothers found the Internet intervention acceptable, the authors said similar tools should be considered to promote the health of teens and their infants.

Internet addiction often is linked with depression but a new study suggests that there is a way to use the technology to help encourage teens with postpartum depression to get treatment.

Pediatric Academic Society (PAS) 2018 Meeting

 suggests that when it comes to decision-making about hormone therapy (HT), transgender teens and their parents may have different views about preserving biologic fertility.

Included in the study, by researchers from Children’s Hospital of Philadelphia, were 66 youth and 52 parents who obtained medical care at a pediatric hospital-based clinic for transgender/
gender non-conforming (T/GNC) between January 2017 and December 2017. Youth participants were mean age 16 and a majority (63%) of the participants were assigned female sex at birth. The mean age of the parents was 48. Both youth and parents completed an electronic 36-item survey with questions about their knowledge of fertility preservation (FP), desire to have biologic children, and other factors that might affect desire to pursue FP.

Only 20% of youth and 11.5% of parents found it important to have biologic offspring. For the youths, the importance of having biologic children was associated with perceiving it as something that was important to their parents (OR = 6.07; 9% CI, 1.28 - 28.7). Only 4.5% of youth agreed that they would be willing to delay HT; the importance of having biologic children was the most important predictor for these youth (OR = 6.76; 95% CI, 1.28 – 28.7).

For parents, the most important predictor for delaying HT was lack of information about whether that treatment definitely prevents biologic fertility (OR = 24.57, 95% CI, 3.9 – 154.15). A significant majority of youth (70%) agreed that discomfort with a part of the body that they didn’t identify with was a factor that influenced their decision to undergo FP.

The findings show that fertility is not a major factor in decision-making about HT for the majority of T/NGC youth and their parents. The researchers believe, however, that their data underscore a need for more research on the impact FP has on biologic fertility so that parents and T/NGC youth can make more informed decisions when considering HT. 

Research presented during the Pediatric Academic Society (PAS) 2018 Meeting suggests that when it comes to decision-making about hormone therapy (HT), transgender teens and their parents may have different views about preserving biologic fertility.

Intrauterine devices (IUDs) are a highly effective form of long-acting reversible contraception and recommended by the American College of Obstetricians and Gynecologists but insertion can be associated with discomfort. In a new 

, researchers from Pennsylvania sought to quantify the impact of the procedure on IUD satisfaction in younger women.

Patients in the study, which was published in 

, were aged 14 to 22. The results reflect data from three family planning clinics in Philadelphia. 

For the multi-site, single-blind, sham-controlled randomized trial, the researchers sought women who had a levonorgestrel 13.5-mg IUD inserted between March 2015 and July 2016 at the clinics. Eligible participants were aged 14 to 22, nulliparous, not pregnant and English-speaking. Participants were randomly assigned through computer-generated allocation to block sizes of four to a 1% lidocaine paracervical or sham block. The patients were blinded about which treatment they received. To measure satisfaction, participants were asked to respond to three items: overall satisfaction with the procedure, if they would recommend the IUD to a friend, and whether the associated discomfort with the IUD was worth it. Pain at IUD insertion was recorded using a 100-mm visual analog scale.

The study enrolled 95 women and 93 (97.9%) were included in the analysis. Of the participants, 45 (47.4%) were white and 34 (36.0%) were black. Sixty-four (67.4%) were privately insured and 75 (79%) had used contraception previously. 

The majority (73 [76.8%]) reported high satisfaction with the procedure, 67 (67.4%) would recommend the device to a friend, and 79 (83.2%) perceived the IUD to be worth the discomfort. The median pain score reported immediately after insertion was 63.5 (IQR = ±53) though the lidocaine paracervical block group reported lower scores (less pain) compared to the sham block group (30.0±52 vs. 71.5±23.5, P<0.001). Higher pain scores were negatively correlated with the odds of recommending the device to a friend and perceiving the IUD as being worth the discomfort. However, there was no significant difference in likelihood of recommending IUD insertion to a friend between the lidocaine block group and the sham block group (91.5% vs 85.4%, 

 High overall satisfaction with the device had higher odds among young adults compared to adolescents (OR = 0.07, 95% CI, 0.008-0.68); those who had a gynecologic exam compared to those who had never had one (OR = 0.26, 95% CI, 0.07-0.99). Satisfaction scores were also inversely linked to pain scores and decreased as pain scores increased (OR = 0.96, 95% CI, 0.94-0.99). There were no differences between the lidocaine block group and the sham block group in terms of satisfaction (91.5% vs 91.7%, 

While the study results show that most young women are satisfied with IUD insertion, the inverse relationship between that sentiment and young age, the authors said, suggests that delaying IUD insertion until patients are older may be beneficial.

Intrauterine devices (IUDs) are a highly effective form of long-acting reversible contraception but insertion can be associated with discomfort. In a new study, researchers from Pennsylvania sought to quantify the impact of the procedure on IUD satisfaction in younger women.

Ventriculomegaly, or dilation of the fetal cerebral ventricles, is a relatively common ï¬nding on prenatal ultrasound. This summary of SMFM Consult Series #45 reviews key points for diagnosis, evaluation, and management of mild fetal ventriculomegaly.

Fetal cerebral ventriculomegaly is defined as an atrial diameter  ≥ 10 mm on prenatal ultrasound. Ventriculomegaly is typically categorized in one of two ways: mild (10–15 mm) or severe (> 15 mm); or as mild (10–12 mm), moderate (13–15 mm), or severe (> 15 mm). Because the chance of an adverse outcome and potential for other abnormalities are higher when the ventricles measure 13–15 mm vs 10–12 mm, the latter classification method should be used for the purposes of patient counseling. The incidence of mild to moderate fetal ventriculomegaly is approximately 1%. 

Q| What are the causes of ventriculomegaly?

The differential diagnosis of ventriculomegaly is extensive and includes a normal variant as well as disorders associated with severe impairment. A thorough evaluation is critical to make the correct diagnosis and to provide an accurate prognosis.

Fetuses with a ventricular atrial diameter of 10–12 mm are found to have a normal postnatal evaluation in > 90% of cases. The chance that mild ventriculomegaly represents a normal variant decreases with increasing degrees of dilation. Mild ventriculomegaly is likely to represent a normal variant if no other structural abnormalities are noted and if aneuploidy screening or diagnostic genetic testing results are normal. Because it is not possible to determine with certainty that mild ventriculomegaly is truly isolated during pregnancy, normal variation is a diagnosis of exclusion that cannot be made with certainty until after birth.

Structural abnormalities that can lead to dilation or enlargement of the lateral ventricles include agenesis of the corpus callosum, Dandy-Walker malformation, neural tube defects, cortical defects, and migrational abnormalities or heterotopia. Some structural central nervous system (CNS) anomalies, such as holoprosencephaly, hydranencephaly, porencephaly, or schizencephaly, and cystic lesions, such as arachnoid cysts, result in abnormal fluid collections in the fetal brain that may be misdiagnosed as ventriculomegaly, although these anomalies do not truly represent dilation of the ventricular system. In rare cases, a tumor or choroid plexus papilloma may result in overproduction of cerebrospinal fluid with resultant ventriculomegaly. Large isolated choroid plexus cysts may transiently dilate the fetal cerebral ventricles.

The most common cause of severe ventriculomegaly is aqueductal stenosis, which results from narrowing of the cerebral aqueduct of Sylvius located between the third and fourth ventricle, leading to progressive dilatation of the lateral and third ventricles. Aqueductal stenosis can be genetic or can result from fibrosis secondary to fetal infection (e.g., cytomegalovirus [CMV], toxoplasmosis, or Zika virus) or bleeding (e.g., intraventricular hemorrhage). A mass or congenital tumor can also lead to compression of the aqueduct with resultant ventriculomegaly. In many cases, the cause of aqueductal stenosis is unknown.

Approximately 5% of cases of mild to moderate ventriculomegaly are reported to result from congenital fetal infections, including cytomegalovirus (CMV), toxoplasmosis, and Zika virus. Many cases of ventriculomegaly associated with congenital infection demonstrate other sonographic features, including fetal growth restriction; periventricular, hepatic, and other intra-abdominal calcifications; echogenic fetal bowel; hepatosplenomegaly; ascites; meconium peritonitis; polyhydramnios, and microcephaly. However, these features may not be evident until later in gestation, and not all infected fetuses will have other sonographic signs.

Approximately 5% of fetuses with apparently isolated mild to moderate ventriculomegaly have an abnormal karyotype, most commonly trisomy 21. Another 10% to 15% have abnormal findings on chromosomal microarray. Although hydrocephalus is a component of several congenital syndromes, there are relatively few genetic causes of isolated ventriculomegaly or hydrocephalus. Syndromes typically associated with more severe ventriculomegaly as well as additional abnormalities that may be identified sonographically or by fetal magnetic resonance imaging (MRI) include Walker-Warburg, Bardet-Biedl, Meckel, Joubert, and hydrolethalus syndromes. 

NEXT: How should a fetus with mild or moderate ventriculomegaly be evaluated?

Q| How should a fetus with mild or moderate ventriculomegaly be evaluated?

When mild or moderate ventriculomegaly is detected, further evaluation is indicated. Such evaluation is focused on determining whether additional structural (CNS and non-CNS) anomalies, genetic abnormalities, or congenital infection are present.

Incidence of additional CNS and non-CNS sonographic abnormalities identified in fetuses with mild or moderate ventriculomegaly ranges from 10% to 76% but appears to be < 50% in most studies. When ventriculomegaly is identified, a detailed ultrasound should be performed by a practitioner experienced in diagnosis of fetal anomalies. Careful attention should be given to intracranial anatomy including the lateral, third, and fourth ventricles; corpus callosum; thalami; germinal matrix region; cerebellum; and the cerebellar vermis. The fetal heart should be carefully examined, and fetal biometry should be assessed for evidence of growth restriction. Finally, a thorough inspection should be performed for signs of fetal infection, including intracranial or extracranial calcifications, hepatosplenomegaly, ascites, and fetal growth restriction.

Diagnostic testing (amniocentesis) with chromosomal microarray should be offered when ventriculomegaly is detected. Cell-free DNA screening can be considered for women who decline diagnostic testing after counseling about the limitations of this approach. Women with prior normal screening test results, including cell-free DNA, should still be offered diagnostic testing due to the higher diagnostic yield.

The woman’s history should be reviewed for symptoms suggestive of CMV infection, and exposure to potential sources of toxoplasmosis (e.g., outdoor cats, gardening, consumption of undercooked meat) and Zika virus should be assessed. A detailed travel history should be included in the evaluation. For women with a history of travel to any Zika-endemic area, testing according to the Centers for Disease Control and Prevention guidelines is recommended. Testing for CMV and toxoplasmosis is recommended when ventriculomegaly is detected, regardless of known exposure or symptoms. Testing can include maternal serology or polymerase chain reaction (PCR) on amniotic fluid. For women who decline amniocentesis, serum testing for CMV includes IgG and IgM, as does screening for toxoplasmosis

Fetal MRI can be useful in evaluation of ventriculomegaly because this modality can identify significant abnormalities not easily detected by ultrasound, such as cortical malformations and migrational abnormalities. The most common abnormality detected on MRI but missed on fetal ultrasound is agenesis of the corpus collosum. MRI may also be of benefit in assessing the extent of destructive injury in fetuses with known infection, hemorrhage, or ischemia, and when other sonographically evident CNS malformations, such as agenesis of the corpus callosum or Dandy-Walker malformation, are present.

MRI is most useful at > 22–24 weeks’ gestation, as milestones of CNS development become more evident with advancing gestation. The added value of MRI depends in part on the degree of ventricular dilation, as well as on the quality of the original ultrasound and whether a detailed neurosonography examination was performed by a provider with specific expertise. MRI can be considered in cases of mild or moderate fetal ventriculomegaly when this modality and expert radiologic interpretation are available. It is likely to be of less value if the patient has had a detailed ultrasound exam performed by an individual with specific experience and expertise in sonographic imaging of the fetal brain.

Q| What is the appropriate antenatal management of a pregnancy after mild to moderate ventriculomegaly is detected? 

Follow-up ultrasound after initial detection of fetal ventriculomegaly is helpful to assess progression, stability, or resolution. The optimal timing and frequency of follow-up ultrasound examinations in the setting of mild to moderate ventriculomegaly is dependent on the initial gestational age at diagnosis as well as other clinical factors.

Women should receive counseling from a health care provider with specific expertise in prenatal diagnosis and prognosis of fetal ventriculomegaly. They should be informed that the prognosis varies widely based on the exact findings of the complete prenatal and postnatal evaluation. If ventriculomegaly is progressive, consultation with a pediatric neurosurgeon may be useful, as some neonates may require postnatal surgical intervention, such as ventriculoperitoneal shunting. Overall, the likelihood of mild to moderate ventriculomegaly requiring surgical intervention after birth is low.

Antepartum fetal testing is not likely to be beneficial in the setting of mild to moderate ventriculomegaly, as this abnormality is not typically associated with placental insufficiency, unless other abnormalities such as fetal growth restriction or amniotic fluid abnormalities are present.

Q| What is the optimal timing and mode of delivery for fetuses with ventriculomegaly?  

There is no evidence that preterm or cesarean delivery improves maternal or neonatal outcomes in the setting of mild to moderate ventriculomegaly. Timing and mode of delivery should therefore be based on standard obstetric indications. Given the potential for mild to moderate ventriculomegaly to be associated with long-term adverse neurodevelopmental outcomes, the primary pediatrician should be made aware of this prenatal finding.

Q| What is the prognosis for infants with mild ventriculomegaly? 

The prognosis for infants with mild to moderate ventriculomegaly is widely variable and depends on presence or absence of structural or genetic abnormalities, fetal infection, and severity of ventricular dilation. After a complete evaluation, if the ventriculomegaly is mild and isolated, the outcome is most commonly normal. With isolated moderate ventriculomegaly of 13–15 mm, after a complete evaluation, the outcome is likely to be favorable, but there is an increased risk of neurodevelopmental disabilities. In the setting of mild to moderate ventriculomegaly with associated abnormalities, the prognosis primarily depends on the specific abnormality rather than the degree of ventricular dilation.

Progression is also a factor in outcomes. In cases in which ventriculomegaly progresses, the rate of adverse outcomes is reported to be as high as 44%, while outcomes are normal in > 90% of cases in which ventriculomegaly improves. In most cases, risk of recurrence of isolated ventriculomegaly in future pregnancies is low. In cases with an underlying cause, such as a chromosomal or genetic condition, risk of recurrence will depend on the specific diagnosis. 

Ventriculomegaly, or dilation of the fetal cerebral ventricles, is a relatively common ﬁnding on prenatal ultrasound. This summary of SMFM Consult Series #45 reviews key points for diagnosis, evaluation, and management of mild fetal ventriculomegaly.

Seven recommendations for mild fetal ventriculomegaly

In October 2007, the patient presented to a women’s health center, at which time an intrauterine device (IUD) was placed. In July 2009, the patient returned, requesting that the IUD be removed. On exam, the IUD thread was not seen and, as such, the removal could not be accomplished. Later that month, transvaginal ultrasonography (TVUS) showed that the device was in the uterine cavity, but part of the device appeared to have penetrated the myometrium posteriorly.  

The plaintiff presented to Defendant Hospital emergency department (ED) in August 2009, with complaints of abdominal pain with foul-smelling discharge, vaginal spotting, and fever for three days. TVUS was performed and the IUD was again noted to have the distal end within the posterior myometrium. The IUD had not changed position since the patient’s prior TVUS in July. She was discharged from the ED with one dose of azithromycin and acetaminophen/oxycodone and was scheduled for an appointment at the women’s health center the next morning.

The plaintiff presented to the women’s health center as scheduled and was seen by co-defendant, Dr. A. An IUD removal was scheduled for the following day.  

On August 10, 2009, the patient returned to Defendant Hospital. Per the operative report, two attempts were made to remove the IUD with forceps and an IUD hook, but they were unsuccessful. Subsequently, a hysteroscope was introduced into the uterine cavity and normal saline was used to inflate it. The IUD strings were identified, and the device was removed. Of note, there was a 900-mL normal saline deficit noted at the end of the procedure and the operative report specifically indicates “

suspicion for perforation given the deficit.

Postoperatively, positive abdominal distention was noted, the abdomen was non-tender, and there was no vaginal bleeding. After transfer, the patient’s abdomen was still distended, semi-firm, and there was some vaginal bleeding. At 6 PM, the plaintiff’s hematocrit was 36.5 and her hemoglobin was 12.5. At 6:36 PM the woman was resting in bed and denied pain, shortness of breath, nausea or vomiting. Her abdomen was soft, non-tender, and there were positive bowel sounds. Dr. B noted that the plan was to discharge the patient home on ibuprofen and ciprofloxacin. At 7 PM, there was no vaginal bleeding, the plaintiff had not voided, her pain was 2/10, her oxygen was discontinued, and she was out of bed to a wheelchair. At 7:45 PM, she was discharged with instructions for activity as tolerated. Dr. B instructed the plaintiff to return to the hospital if she experienced fever, chills, abdominal pain, or weakness. An appointment was scheduled for later in August.  

The following day the plaintiff returned to Defendant Hospital with complaints of diffuse abdominal pain, tenderness, decreased bowel sounds, and guarding. On admission, her hemoglobin was 10, hematocrit was 29.9, platelets were 200, and white blood cell count was 11.2. An abdominal computed tomography (CT) scan was performed and the findings were compatible with intraperitoneal rupture of the uterus with free air and a hemoperitoneum seen. Following the CT, the plaintiff was seen by Dr. A at which time there was a discussion about the CT findings and the options of conservative management versus surgical intervention. Dr. A noted that she would proceed with a diagnostic laparoscopy and possible laparotomy. The risks of surgery were discussed.   

Intraoperatively, a clot in the uterine fundus was removed, and a defect, approximately 2 - 3 cm in the uterine fundus and right side of the uterus, was identified. It was then decided to perform a laparotomy. The uterus was exteriorized and repaired. A 5- x 3-cm right ovarian cyst was also identified, and a cystectomy was done without any complications. The next day Dr. A discussed with the patient that the perforation likely happened at the time her IUD was removed, the procedure extended it, and the area clotted, providing a tamponade. There was also a discussion of postponing pregnancy at least one year and then only delivering via cesarean.  

That evening, the patient complained of dizziness and difficulty passing gas, her abdomen was distended, and there was a tympanic note on percussion. The following morning, August 13, the patient’s abdomen was noted to be distended, tympanic, had mild bowel sounds, and there was no pain on pressure and neither guarding nor rebound. One unit of packed red blood cells was administered for symptomatic anemia. The next day  a repeat abdominal/pelvic CT was performed which evidenced repair of the uterus, an ileus, and residual hemoperitoneum. There were no signs of perforation. By the morning of August 15, the plaintiff was noted to be feeling and looking much better, and her abdomen was much less distended, soft, and non-tender, with positive bowel sounds.  

The patient remained at Defendant Hospital three more days. Discharge instructions included a follow-up appointment with Dr. A on September 1, but the plaintiff never returned.

In November 2009, the plaintiff presented to Hospital B’s ED. She complained of vaginal bleeding for the past three weeks and chronic pelvic pain since her Defendant Hospital admission in August. Pelvic ultrasound and TVUS showed that her endometrial cavity was distended with blood and/or exudate. She was diagnosed with pelvic pain and discharged the same day. Short-term follow-up of six weeks was recommended to assess for resolution. 

Three days later, the plaintiff returned to the ED at Hospital B with complaints of lower abdominal/pelvic pain since the previous night with vaginal spotting that started that day. According to the records, she had presented to the gynecology clinic earlier that day; they were unable to remove the blood from the uterus, so she was referred to the ED. 

Four days later, a consent form was signed for a cervical dilation, possible uterine suction/curettage, possible laparoscopy, and possible laparotomy. Risks of the procedure were discussed. Dr. C performed a dilatation and curettage for hematometra (collection of blood in the uterus). The pathology report noted small fragments of superficial endometrium with progesterone effect, stromal breakdown and reactive changes mixed with blood clots. The patient was discharged later that day with prescriptions for ibuprofen for pain and methergine for the bleeding.  

The plaintiff presented on December 15 to the Hospital B gynecology clinic for a follow-up appointment with a complaint of mild uterine/suprapubic tenderness. Oral contraceptives were prescribed for her complaints of vaginal bleeding. 

On January 5, 2010, a pelvic ultrasound showed that the distended endometrial cavity, which was seen on the November ultrasound, had resolved. On January 11 the plaintiff complained of vaginal bleeding for the past six months. Her examination was consistent with pelvic inflammatory disease (PID). Antibiotics for 14 days were prescribed. By January 19, she felt better but still complained of abdominal pain. She was informed that a hysterectomy would be the last alternative for management of her pain.

Ten days later, the plaintiff presented to the ED on referral from the gynecology clinic with complaints of abdominal pain 7/10 and vaginal bleeding. She described intermittent heavy vaginal bleeding and severe abdominal pain since the IUD removal in August 2009. She was admitted for pelvic inflammatory disease (PID) and IV antibiotics were started. She was given acetaminophen/oxycodone for the pain. She expressed a desire for a hysterectomy, but the physicians recommended conservative treatment with antibiotics.

On February 2, the plaintiff plateaued on the antibiotics. She signed a consent form for a diagnostic laparoscopy, diagnostic hysteroscopy, possible lysis of adhesions, possible lysis of synechiae and other indicated surgical procedures. Risks of the procedures were explained. 

The following day, laparoscopy revealed bowel and omental adhesions to the anterior mid-abdomen between the umbilicus and the pelvis. There were also adhesions of the bowel and omentum to the left lateral abdominal wall. The uterus was noted to be within normal limits with mild filmy adhesions to the adnexa. During enterolysis in the area of the left lateral abdominal wall, an incision was made into the peritoneum secondary to dense adhesions of peritoneum to the bowel. During the enterolysis, brisk bleeding was noted, suspected to be from the left epigastric artery. Due to poor visualization the decision was made to convert the procedure to an exploratory laparotomy. The plaintiff was discharged on February 6. 

In April, the plaintiff presented to the ED with lower abdominal pain/cramping. She stated that the pain was similar to the pain she experienced in January but stronger. Despite her complaint of vaginal bleeding since March 25, she stated that the bleeding had now resolved. A CT scan of the abdomen and pelvis showed a small hiatal hernia; a tiny right hepatic dome hypodensity that most likely represented a cyst; and an up to 1.9-cm left ovarian cystic structure that most likely represented a physiologic cyst. The diagnosis was abdominal pain possibly related to recurrence of adhesions. The woman was discharged later that day. 

On April 28, the plaintiff returned to the ED for complaints of vaginal bleeding for one day. She indicated that her last menstrual period (LMP) was on April 5, 2010. She was discharged with a diagnosis of vaginal bleeding. 

Later that year, on December 14, the plaintiff complained of vaginal bleeding since December 3 and pelvic pain. Extended-cycle levonorgestrel and ethinyl estradiol tablets had been prescribed for chronic pelvic pain, but she had stopped taking the medication in November. The assessment was possible PID and chronic pelvic pain with no specific etiology of findings except for adhesions. Ceftriaxone and azithromycin were given. An extensive risk, alternative and benefit conversation was had with the plaintiff regarding a hysterectomy. She was to obtain a second opinion. 

One week later, the woman complained of chronic pelvic pain and the physician noted that the “patient strangely desires [a] hysterectomy.” She was advised against a hysterectomy. She was treated for PID, but it was noted that PID was unlikely the cause of the chronic pain. 

On January 4, 2011, the plaintiff still complained of pain and stated that the bleeding improved. She was admitted for IV antibiotics and again said she desired a hysterectomy. Pelvic ultrasound noted a right adnexal cystic lesion. The woman underwent a laparoscopic hysterectomy, left salpingectomy, and lysis of adhesions on January 10, 2011.

In July 2011, the plaintiff presented to the ER with complaints of right-sided abdominal pain with nausea and dysuria. The pain was 8/10 and morphine was given. She later reported abdominal pain in the right lower quadrant for the past three days, on and off, which became constant the night before. A CT scan of the abdomen and pelvis showed a 4.7-cm right ovarian cystic structure. Pelvic ultrasound showed a 4.1-cm hemorrhagic right ovarian cyst with a small amount of associated hemoperitoneum. The patient was discharged home with pain medication.

The plaintiff alleged a failure to recognize the evidence of uterine perforation at the conclusion of the August 2009 procedure; that Dr. A failed to perform an ultrasound at the conclusion of the August 2009 procedure after the 900-mL fluid deficit was noted; that Dr. A discharged the plaintiff on August 10, 2009, without repairing the uterus; that Dr. A failed to timely repair the plaintiff’s uterus; that there was a failure to timely prescribe/administer antibiotics; a failure to timely perform surgery when the plaintiff was found to have a hemoperitoneum and blood in the abdomen; and that the failure to timely repair the plaintiff’s uterus resulted in the plaintiff having to undergo several surgeries including a hysterectomy. In particular, plaintiff asserted that her multiple surgeries, perforation, and hematoma/bleeds resulted in massive adhesion formation, which contributed to her chronic, unrelenting abdominal pain and discomfort.

The expert on behalf of the hospital felt that the attempt to remove the IUD in office was correct, however, when the attempt was unsuccessful, surgical removal was appropriate. She felt that the perforation was timely suspected/recognized due to the noted fluid deficit. Post-IUD removal, the defendants properly monitored vital signs for indication of a bleed and given that the plaintiff was clinically stable, it was appropriate for her to be discharged with instructions to return to the hospital if she experienced any pain or bleeding. Further, the expert felt that the plaintiff had a non-bleeding perforation that became symptomatic after she was discharged. There was no link, directly or indirectly, between surgical removal of the IUD and the plaintiff’s hysterectomy. In fact, plaintiff did not need a hysterectomy but insisted on one and the diagnosis of adenomyosis on pathology following the hysterectomy and, in retrospect, was the likely cause of the plaintiff’s chronic pelvic pain, heavy bleeding, and formation of adhesions. 

Plaintiff’s counsel argued that Dr. A discharged the plaintiff despite a suspicion of a perforation and that the discharge resulted in the plaintiff developing adhesions, which were the source of her continuing abdominal pain. Dr. A acknowledged that she suspected a perforation post-IUD removal, however, the monitoring post-procedure assured Dr. A that plaintiff was stable and could be discharged. The doctor also acknowledged that blood in the peritoneum could be an irritant and could result in formation of adhesions. Dr. A maintained that it was appropriate to monitor post-IUD removal even in light of a suspected perforation, given that the plaintiff was stable at discharge. In addition, the co-defendant reported that the patient had a number of conditions and procedures unrelated to the IUD removal that could have caused her adhesions. 

Plaintiff’s expert testified on direct examination that Dr. A departed from accepted standards of care by discharging with a suspected perforation without further investigating the status of the perforation. The expert explained that the hysteroscope used for the IUD removal could have been reinserted and then used to repair the perforation. Had Dr. A taken those steps, per plaintiff’s expert, the plaintiff would not have suffered a continuous bleed resulting in a hemoperitoneum and formation of peritoneal adhesions. On cross, he was confronted with prior testimony from a case where he was a defendant and had suspected a uterine perforation and did not use a hysteroscope to investigate or repair a patient’s uterus. The doctor also acknowledged that prior abdominal surgery, a cesarean with a vertical scar, PID, 

, and adenomyosis could all cause adhesions and that this plaintiff had all of those conditions. He acknowledged that one cannot distinguish between which adhesions cause pain and which will not.  

The patient essentially testified that since her IUD removal, she had and continued to have abdominal pain. On cross, she acknowledged that over the past six to seven years despite presenting to Hospital B numerous additional times, she never complained of abdominal pain, did not seek treatment for her abdominal pain, did not request medication for her abdominal pain, and never saw a gastroenterologist or surgeon about her abdominal pain. 

Plaintiff’s counsel asked that the jury return an award of $2.6 million for past pain and suffering and $1.8 million for future pain and suffering. After two days of deliberations, the jury returned a unanimous verdict on behalf of the defendants. 

Complications following IUD removal were the focus of this lawsuit.

Was this uterine perforation properly managed?

Telehealth is a modern-day solution to health problems both old and new. Though it presents benefits to a variety of patients, rural patients likely experience the richest benefits. As Health Resources & Services Administration (HRSA) notes, it can sometimes be difficult to determine whether an area is urban or rural.

In fact, the term “rural” is not even defined by the Census Bureau-it is considered to encompass “all population, housing, and territory not included within an urban area.” Essentially, according to this definition, whatever is not urban is considered rural. There are two types of urban areas identified by the Census Bureau: 1) Urbanized Areas (UAs) of 50,000 or more people and 2) Urban Clusters (UCs) of at least 2,500 and less than 50,000 people.

Generally, rural areas are characterized by low population and lack of access to critical resources such as medical care.

Rural individuals face many health disparities compared to urban individuals. Poverty and poor access to healthcare contribute greatly to these disparities. Overall, rural communities are in poorer health than others.

According to the Centers for Disease Control and Prevention, rural Americans are at higher risk of death from five leading causes: heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.

In addition, rural areas have higher rates of preterm births and infant mortality. 

Telehealth has helped combat these rural disparities through the following four modalities:

Live video, which uses audiovisual telecommunications technology; 

Store-and-forward, which involves transmission of health information such as x-rays and other images through a secure electronic communications system to a healthcare provider; 

Remote patient monitoring, which involves electronic transmission of health data from a patient in one location to a provider in another location; and 

Mobile health (mHealth), which includes healthcare and education supported by mobile devices such as tablets and cell phones. 

Although there are some barriers to successfully implementing telehealth, it is generally regarded as a convenient and cost-effective way to provide subspecialty healthcare that is not available locally. This is true in obstetrics and gynecology. In obstetrics, telehealth can be used for both low-risk and high-risk pregnancies, and in gynecology, it is used for both routine and specialty examinations.

Healthcare in America is becoming too expensive for companies, individuals, and taxpayers. Technology offers the potential to offer increased access to care at a better value. In utilizing telehealth, the overall healthcare system benefits from lower costs, less travel, improved health outcomes, and reduced emergency room utilization.

Although there are numerous benefits to telehealth, there are also many things to consider when beginning or expanding a telehealth program or clinic, including for obstetrics and/or gynecology (see box below).

Although the definition varies, low-risk pregnancies are generally defined as those that can be expected to proceed without major complications. Low-risk pregnant women can benefit from telehealth through routine, at-home appointments with their prenatal providers. Traditionally, even low-risk pregnant patients are seen for numerous in-person obstetrical visits to monitor progress. However, some clinics are offering integrated models of care for these women to save in-person appointments for situations that truly warrant this type of visit, such as for fetal anatomy ultrasounds. Women participating in these virtual visits are given supplies to use at home and are educated regarding how to use the supplies. A typical virtual visit includes the pregnant woman utilizing home monitoring supplies to track measures such as fetal heart rate, maternal blood pressure, and fundal height.

Pregnancy outcomes have proven to be similar between women who have traditional prenatal care and women who have telemedicine prenatal visits.

In addition, these virtual visits are associated with time savings and lower visit-related costs for patients,

something that is a benefit especially to rural patients who must otherwise often travel long distances for obstetrical appointments.

A pregnant patient at high risk will have current or prior conditions-such as high blood pressure, venous thromboembolism, psychiatric disorder, substance abuse, or family history of a genetic disorder-that may threaten the health or life of the mother or infant.

Telehealth has helped bring forth improved outcomes for high-risk obstetrics, offering a cost-effective solution to treating patients who are either difficult to transport or have inaccessibility to reliable transportation, a barrier many rural patients face. Within the telemedicine model, rural practitioners will oversee care for high-risk obstetrical patients while receiving direction from a specialist via telemedicine consultation. High-risk prenatal visits take place through videoconferencing between the rural practitioner, the patient, and the specialist, with the specialist at the hub (distant) site and the patient and rural practitioner at the spoke (originating) site. Specialists are able to view ultrasounds and other examinations through the available technology, often in real-time. Home monitoring is also possible for certain high-risk conditions, helping to reduce potentially dangerous travel, identify issues before they threaten the health of the pregnancy, and reduce hospital admissions, when appropriate. 

Maternal-fetal medicine (MFM) specialists are crucial to monitoring high-risk pregnancies, as they pursue additional years of training specifically for high-risk pregnancy after completion of their obstetrics-gynecology residency; however, these specialists are often in short supply, especially in rural areas.

The Medical University of South Carolina (MUSC) Center for Telehealth, a “National Telehealth Center of Excellence,” operates the MUSC Health Maternal Fetal Telemedicine program at six locations throughout South Carolina to address a shortage of MFM providers and high rates of pregnancy conditions such as diabetes and hypertension within many areas of the state.

As of 2010, over one-third of the state resided in a rural community and thus had a higher likelihood of restricted access to specialty care.

According to MUSC, “the Maternal Fetal Telemedicine program enables a partnership between MUSC Health’s Maternal Fetal specialists and local providers to co-manage the care and screening of patients with high risk pregnancies and support all the necessary steps to achieve the best possible outcome.” The program has been credited with helping to reduce premature birth rates and both neonatal and maternal mortality rates.

As many as 50 to 60 MFM telemedicine consultations are performed by MUSC every week, and the program is on call 24/7.

MUSC additionally uses telemedicine to treat pregnant women addicted to opioids,

The University of Arkansas for Medical Sciences (UAMS) also offers a high-risk obstetrical telemedicine program-the Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS)-to help combat rural health disparities. Arkansas is a largely rural state with vast medically underserved areas. It has few MFM specialists practicing outside of UAMS, which is located in one of the few urban areas of the state. Utilizing one of the largest telehealth networks in the nation, ANGELS extends the expertise of Arkansas’ few board-certified MFM specialists into the hands of Arkansas’ community providers and patients through telemedicine. This allows UAMS providers to plan interventions through a system of co-management with rural providers. ANGELS is supported by a 24/7 nurse-staffed call center that provides triage to patients and facilitates maternal transport to ensure high-risk patients deliver at neonatal intensive care unit-equipped hospitals. The program has been credited with cost savings, reduced infant mortality, and reduced maternal complications. In 2005, the Agency for Healthcare Research and Quality selected ANGELS as one of five Medicaid programs in the United States to serve as models of how to develop patient care and outreach programs. Other organizations use the ANGELS model by working with insurers (like Medicaid and other payors) to develop telemedicine interventions that bring specialty care to those that need it most but have the poorest access. For the UAMS high-risk obstetrical telemedicine program, management of a telemedicine patient consult reflects best practices for patient care (see Table 1 on next page). 

Patients may benefit from telehealth visits for follow ups to in-person well-woman exams. These virtual visits allow ob/gyns to discuss lab results and needed patient lifestyle changes. In addition, family planning and preconception care can be delivered via telehealth for the patient’s convenience.

Colposcopy is a specialty exam that is offered through some telemedicine programs to patients who need further testing after an abnormal pap smear. On average, rural areas have fewer practitioners who specialize in colposcopy than urban areas, and fewer ob/gyns in general, so these telehealth services especially benefit rural residents. Diagnostic outcomes were similar for tele-colposcopy when compared with in-person exams.

While telehealth has proven to be an effective method of increasing access to specialty care, there are myriad legal and regulatory issues complicating its expansion. These are issues that affect every clinical application of telemedicine, including obstetrics and gynecology.


	Licensing and credentialing are essential in healthcare but present an especially difficult problem for telehealth providers. Overall, licensing is state-specific for all telemedicine healthcare providers. Moreover, telehealth providers must follow the credentialing rules of the patient’s location. These issues act as barriers to practicing telehealth across state lines. However, hospitals can agree to credential and privilege by proxy for telemedicine services, which allows “the hospital receiving services to accept the distant site (where the telehealth provider is located) hospital’s credentialing and privileging decisions.”

This would be done in a streamlined and simplified process in comparison to traditional credentialing and licensure, making it easier for providers to offer services across state lines.


	Before choosing a malpractice insurer, telemedicine providers should request proof in writing that the malpractice insurance policies cover telemedicine malpractice and that the coverage extends to other states in which the providers are practicing. Telemedicine providers also should check with malpractice insurers to see if there are limitations to telehealth services under the policy. Essentially, providers of telehealth must have total clarification from their insurance company concerning the nuances of telehealth to avoid complications.


	Reimbursement and billing, too, pose a problem for many telehealth providers. In some states, such as Arkansas, telemedicine parity allows for many of these services to be reimbursed on the same basis as in-person services.

But parity is not available in every state. Even if telemedicine parity laws are active within a state, telemedicine care can be complicated by reimbursement requirements that state rules such as the patient-physician relationship must first be established in person with a face-to-face visit before telemedicine treatment can begin.

There are some restrictions to payment for services through telemedicine, as well: for example, Arkansas Medicaid will reimburse for up to two live video healthcare visits per patient yearly.

There are also often limitations to services that can be provided through telemedicine, such as prescribing controlled substances. It is therefore important to be aware of state-specific telemedicine laws, especially as they change over time.

Despite telehealth’s barriers, it is an effective healthcare solution for many patients, especially those who are rural. Telehealth programs offer a cost-effective and convenient means to address for women’s obstetrical and gynecological health concerns, leading to improvements such as greater access to care and improved clinical outcomes such as reduced infant and maternal morbidity and mortality. By using best practices and applying lessons learned from telemedicine programs such as those at MUSC and UAMS, other medical institutions can implement successful obstetrical and gynecological telemedicine programs throughout the nation and world. 

The author reports no potential conflicts of interest with regard to this article.

Health Resources & Services Administration

Rural Health. Centers for Disease Control and Prevention. https://www.cdc.gov/ruralhealth/about.html. Published August 2, 2017. Accessed June 19, 2018.

CDC Newsroom. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html. Accessed June 19, 2018.

What is Telehealth? http://www.cchpca.org/what-is-telehealth. Accessed June 19, 2018.

Tobah YSB, Leblanc A, Branda M, Inselman J, Gostout B, Famuyide A. OB Nest-A Novel Approach to Prenatal Care [21]. 

. 2016;127. doi:10.1097/01.aog.0000483637.05137.18.

Morrison J, Bergauer NK, Jacques D, Coleman SK, Stanziano GJ. Telemedicine: cost-effective management of high-risk pregnancy. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/11761593. Published November 2001. Accessed June 19, 2018.

Etherington IJ. Telecolposcopy - a feasibility study in primary care. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/12217121. Published 2002. Accessed June 19, 2018.

Telemedicine for OB/GYN. Chiron Health. https://chironhealth.com/telemedicine/providers/obstetrics-and-gynecology/. Published 2017. Accessed June 19, 2018.

Vo A, Brooks GB, Farr R, Raimer B. Benefits of Telemedicine in Remote Communities & Use of Mobile and Wireless Platforms in Healthcare.

UAMS Center for Distance Health. Arkansas eLink: Starting Your Telemedicine Clinic.

Mooij MJMD, Hodny RL, Oneil DA, et al. OB Nest: Reimagining Low-Risk Prenatal Care. 

Barbour KD, Nelson R, Esplin MS, Varner M, Clark EAS. A randomized trial of prenatal care using telemedicine for low-risk pregnancies: patient-related cost and time savings. January 2017. Supplement to January 2017

High-Risk Pregnancy. Eunice Kennedy Shriver National Institute of Child Health and Human Development. https://www.nichd.nih.gov/health/topics/high-risk. Published 2017. Accessed June 19, 2018.

Fugate E. Decreasing Preterm Birth Rates | Telehealth. MUSC Health. http://www.muschealth.org/pn/2013/yir-2013/telehealth/preterm-birth-rates/index.html. Published March 20, 2015. Accessed June 19, 2018.

Thomas T. Maternal Fetal Medicine. MUSC Health. http://www.muschealth.org/telehealth/services/community-based/mfm/index.html. Published September 25, 2017. Accessed June 19, 2018.

South Carolina Urban and Rural Population (1790-2010). South Carolina Statistical Abstract: Population. http://abstract.sc.gov/chapter14/pop30.html. Accessed June 19, 2018.

Gainer C. Postpartum Mood Disorders Program: MUSC Health Women’s Care. MUSC Health. http://www.muschealth.org/womens/pregnancy/postpartum-mood-disorders/index.html. Published May 7, 2018. Accessed June 19, 2018.

UAMS Center for Distance Health. ANGELS Program Telemedicine Clinic Policy T-14. June 2016.

Center for Connected Health Policy. Credentialing and Privileging.

Arkansas. Search. http://www.cchpca.org/jurisdiction/arkansas?field_area_of_law_tid[] =101&field_law_type_tid=All&field_status_tid=104. Accessed July 13, 2018.

Arkansas Loosens Telemedicine Restrictions. Center for Telehealth and eHealth Law RSS. http://ctel.org/2016/09/arkansas-loosens-telemedicine-restrictions/. Accessed July 13, 2018.

These are the eight steps for successfully launching virtual visits in low- and high-risk obstetrics and gynecology.

Telehealth: A new frontier in ob/gyn

Often overlooked in the debate over health care reform are the growing disparities in health outcomes among America’s rural population. Overall mortality and age-adjusted annual death rates from heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke are all higher in rural compared with urban settings.

  Americans who live in rural counties are more likely to be obese, older, poorer, and addicted to opioids than their urban counterparts. However, reduced access to high-quality medical care is also a major contributor to adverse health outcomes in rural populations. At the heart of reduced rural access is a shortage in providers and hospitals. Rising health care fixed costs and declining reimbursement are exacerbating the problem. Indeed, it has been estimated that 673 of 2,161 rural hospitals (31.1%) may close over the next 5 years.

Childbirth is the most common reason for hospitalization in the United States and 28 million women of reproductive age live in rural counties giving birth to 500,000 infants each year.

More than half of rural counties in the United States have no hospital obstetrical services, many remaining services are closing at a frightening pace, and maternal and perinatal mortality and/or morbidity are rising as a consequence.

Vol. 64 No.08