Poster Session III
org
Demographics and patient characteristics
LHR: Lung to head ratio
545 Is communication improved with the implementation of
an obstetrical version of the world health organization (WHO)
safe surgery checklist?
Shravya Govindappagari1, Amanda Guardado1, Dena Goffman1,
Jeffrey Bernstein2, Colleen Lee1, Sara Schonfeld1, Robert Angert3,
Andrea Mcgowan1, Peter Bernstein1
1
Albert Einstein College of Medicine/Montefiore Medical Center, OBGYN,
Bronx, NY, 2Albert Einstein College of Medicine/Montefiore Medical Center,
Anesthesia, Bronx, NY, 3Albert Einstein College of Medicine/Montefiore
Medical Center.., Pediatrics, Bronx, NY
OBJECTIVE: Communication failures are consistently seen as a root
cause of preventable adverse outcomes in obstetrics. We assessed
whether use of an Obstetric Safe Surgery Checklist for cesarean
deliveries (CD), based on the WHO Safe Surgery Checklist, can
improve communication, reduce team member confusion about
urgency of the case and decrease documentation discrepancies
among nursing, obstetric, anesthesia, and pediatric staff.
STUDY DESIGN: Retrospective review of 600 CDs on our 2 labor and
delivery suites before and after the introduction of 2 consecutive
versions of our obstetric safe surgery checklist (200 cases in each
cohort) was undertaken. The first version was released in 2010 and
after modifications based on initial findings our current version was
released in 2014. 100 consecutive CDs were identified from each of
the three time periods at each hospital, and charts for those patients
and their newborns were abstracted. Notes by Obstetricians, Nurses,
S272 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2015
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Anesthesiologists, and Pediatricians were reviewed and indications
for CD were compared. Chi square analyses were performed.
RESULTS: Complete agreement among the 4 specialties in the docu-
mented indication for CD prior to introduction of our initial safe
surgery checklist was noted in 59% (n¼118) of cases. After initial
checklist introduction, agreement decreased to 43% (n¼86) (p ¼
0.002). We then modified our checklist to include indication for CD
and level of urgency and changed our policy to include pediatric staff
participation in the timeout. Agreement in a subsequent chart review
increased to 80% (n¼160), significantly better than in our initial
analysis (p < 0.001) and our interim review (p < 0.001). Results are
shown in the table. The greatest improvement in agreement was
observed between obstetricians and pediatricians.
CONCLUSION: Implementation of a safe surgery checklist can have
unanticipated consequences. Ongoing review allows for modifica-
tions to promote quality communication and safer medical care.
Agreement between providers comparing baseline
to after implementation of a revised checklist
546 No evidence of superior cardiac displacement in
pregnancy: implications for cardio-pulmonary resuscitation
technique
Signy Holmes1, Iain Kirkpatrick2, Carolyn Zelop3, Davinder Jassal4
1
University of Manitoba, Winnipeg, MB, Canada, 2St. Boniface General
Hospital, Radiology, Winnipeg, MB, Canada, 3The Valley Hospital, MFM,
Ridgewood, NJ, 4St. Boniface General Hospital, Cardiology/Internal
Medicine, Winnipeg, MB, Canada
OBJECTIVE: Cardio-pulmonary resuscitation guidelines during preg-
nancy recommend placing the hands 2-3 cm higher on the sternum
than in non-pregnant individuals. This recommendation is based on
the presumption that the heart is displaced superiorly by the dia-
phragm during the third trimester. Whether there is true cardiac
displacement due to the expanding uterus in pregnancy remains to
be proven. We sought to determine if there is vertical displacement
of the heart during pregnancy using cardiac magnetic resonance
imaging (CMR).
STUDY DESIGN: A total of 34 healthy female volunteers aged 18 to
35 years were prospectively enrolled between 2010-2012 at a single
tertiary care site. All participants were evaluated using CMR in half
left lateral decubitus position during the third trimester of pregnancy
and again at a minimum of 3 months post-partum (surrogate for the
non-pregnant state). Superior displacement of the heart was deter-
mined by measuring the distance between the easily reproducible
landmarks of the inferior aspect of the clavicular heads and the
coronary sinus at baseline and during the third trimester off of a
transverse ECG-gated dark blood single-shot fast spine echo
sequence (db-HASTE). See figure I.
RESULTS: The study population included 34 females (mean age 29 
3 years, BMI of 24  4 kg/m2). The mean gestational age at third
trimester imaging was 237  16 days (34 weeks  16 days) and
mean number of days for postpartum imaging (baseline) was 107 
25 days (16 weeks  25 days). There was no statistical difference
between the cardiac position at baseline (10.1  1.2 cm) and during
the third trimester (10.3  1.1 cm) (p ¼ 0.22).
CONCLUSION: Contrary to popular assumption, there is no significant
vertical cardiac displacement in the third trimester of pregnancy
relative to the non-pregnant state. Accordingly, there is no need
to alter hand placement for chest compressions during CPR in
pregnancy.
ajog.org Poster Session III

Figure I. Relative position of the heart was determined by

measuring the distance between (A) the inferior aspect of the
clavicular heads (long arrows) and (B) the coronary sinus (short Figure 1: Ratio of center nucleated fiber to the total number of
arrow) fibers calculated in the Tibialis Anterior muscle (TA) at 1 and 2
weeks time point.
547 Amniotic fluid stem cells accelerate muscle
regeneration
Silvia Zia1, Ester Sara Di Filippo2, Mattia Quattrocelli1,
Liesbeth Lewi1, Nikhil Sindhwani1, Maurilio Sampaolesi1,
Jan Deprest1, Jaan Toelen1
1
KU Leuven, Department of Development and Regeneration, Leuven,
Belgium, 2University “G. d’Annunzio”, Interuniversity Institute of Myology,
Chieti, Italy
OBJECTIVE: Structural birth defects in muscles (such as diaphrag-
matic defects in congenital diaphragmatic hernia) can be repaired by
the use of synthetic and biological patches, with or without the
addition of (stem) cells. Amniotic fluid stem cells (AFSc) are a
heterogeneous subpopulation of stem cells. Herein we investigate the
expression of pericyte markers, progenitors of the skeletal muscle,
their in vitro myogenic potential using a well-established cardiotoxin
(CTX) induced muscle injury rodent model.
STUDY DESIGN: 16 monoclonal cell lines derived from amniotic fluid
were characterized for Alkaline Phosphatase Activity (ALP) and for
the canonical pericyte markers NG2, PDGFRa, PDGFRb and a-
SMA. 2 cell lines were subsequently differentiated in a muscle lineage
with specific myogenic differentiation medium for 7 days in hypoxic
conditions (5% O2). In addition, AFSc were co-cultured with a
murine skeletal muscle cell line C2C12 for 7 days. To test the in vivo Figure 2: In vitro co-culture of murine skeletal muscle cell line
potential, 500,000 AFSc were injected into the muscle of the right C2C12 with GFP-AFSc (i, ii) and LAcZ-AFSC (iii, iv).
tibialis anterior (TA) muscle in 12 Black 6 mice 48 hours after local
CTX injection. Sham group consisted of 12 animals with injection of 548 Systemic lupus erythematosus: outcomes in women
CTX in the right TA and PBS infusion. The left leg of each animal treated with and without hydroxychloroquine
was used as internal control. Muscle biopsies were processed for Sima Baalbaki1, Akila Subramaniam1, Jeff Szychowski1,
laminin expression at 1 and 2 weeks after injection. The ratio of Ying Tang1, Luisa Wetta1
center nucleated fiber to the total number of fibers was calculated to 1
University of Alabama at Birmingham, Center for Women’s Reproductive
detect muscle regeneration. Health, Department of Obstetrics and Gynecology, Birmingham, AL
RESULTS: 5 of 16 monoclonal cell lines were highly positive for ALP OBJECTIVE: Women with systemic lupus erythematosus (SLE) have
and pericyte markers. AFSc with high expression profiles were increased risks of adverse pregnancy outcomes. Hydroxychloroquine
cultured with differentiated medium (Fig1), and were able to form (HQ) is used to treat SLE, but its efficacy in pregnancy is not well-
myotubes and to integrate when co-cultured with C2C12 cells described. We sought to compare maternal and neonatal outcomes
(Fig2). CTX injured muscles recovered faster after injection of AFSc in pregnant women with SLE treated with or without HQ.
with a reduction in the number of center nucleated fibers compared STUDY DESIGN: We conducted a retrospective cohort study of women
to the controls at 2 weeks. with SLE and singleton gestations delivered at our institution (2006-
CONCLUSION: This suggests that AFSc share some characteristic with 13). Women treated with HQ during pregnancy were compared with
pericyte cells. They have some myogenic potential in vitro and can women who did not receive HQ. Key outcomes included maternal
induce morphological regeneration in injured muscle in vivo. morbidities (hypertensive disorders (HD), intrauterine growth re-
striction (IUGR), preterm delivery (PTD), disease-related hospital-
izations, venous thromboembolism (VTE), and death) and a
composite of neonatal morbidity. Outcomes were compared using
Chi-square, Fisher’s exact, rank-sum, and Student t-tests - with odds
of adverse outcomes modeled with logistic regression.
RESULTS: 77 women with SLE were included for analysis: 47 (61%)
treated with HQ and 30 (39%) without. Women on HQ were
younger, more often nulliparous, and more frequently concomitantly
treated with oral corticosteroid therapy (83% vs. 40%, p < 0.01).
There were no differences in BMI, rates of chronic hypertension or
diabetes between groups. The groups had similar baseline creatinine,

Supplement to JANUARY 2015 American Journal of Obstetrics & Gynecology S273