OB 101: Pregnancy Overview

1. OB 101: Pregnancy Overview Thao Thieu, MD OBGYN Mary OConnell RN Shelly Sepulveda RN

2. Objectives • Review Trimesters of Pregnancy • Review Phases of Labor • Review Pregnancy-Related Complications and Treatments • Review Coding Guidelines for OB • Review OB Query Opportunities • Review Case Studies

3. Disclosures • No financial disclosures

4. Due Date • EDC aka EDD aka Due Date • LMP + 280 days • Assumes 28 day cycle • Naegele’s rule • LMP – 3 months + 1 week • Gestational Age • First two weeks are prior to conception • 40 weeks

5. Gestational Age • Length of pregnancy 40 weeks • Three trimesters • 0 to 13 6/7 weeks • 14 to 27 6/7 weeks • 28 to 40 weeks • 24 0/7 weeks – viability • 37 0/7 weeks – term • Early term 37 0/7 to 38 6/7 weeks • Full term 39 0/7 to 40 6/7 weeks • Late term 41 weeks to 41 6/7 weeks

6. Gestational Age • > 40 weeks – post dates • > 42 weeks – post term

7. Labor • Contractions leading to cervical change • Preterm labor < 37 weeks • Tufts tocolysis < 34 weeks • Induction of labor • Prior to spontaneous labor • Cervical ripening, mechanical dilators, oxytocin, amniotomy • Augmentation of labor • Enhancement of contractions w amniotomy, oxytocin

8. Labor • First stage • Onset of labor to full dilation • Latent phase – onset of labor to active phase • Gradual change in the cervical dilation • Friedman curve, 1955 • Longer with induction of labor • Active phase – greatest rate of cervical change ~ 5-6 cm dilation • Dilating 1-2 cm/hr

9. Labor • Protracted First stage • Women ≥ 6 cm • Dilating < 1-2 cm/hr • Arrested labor • No cervical change for ≥ 4 hrs despite adequate contractions (> 200 MVU) • No cervical change for ≥ 6 hrs with inadequate contractions

10. Labor • Second stage – full dilation to delivery of fetus/newborn • Nullipara • Median time 1.1 hr • Allow 3 hrs of pushing • Multipara • Median time 0.4 hr • Allow 2 hrs of pushing • Epidural adds ~ 0.7 hr

11. Labor • Third stage – delivery of fetus/newborn to delivery of placenta • Up to 30 minutes

12. Labor • Shoulder Dystocia • OB emergency • 0.2-3% of vaginal deliveries • Can lead to birth injury • Cesarean delivery (C/S) does not prevent all injuries • Operative Vaginal Delivery • Forceps • Vacuum

13. Postpartum Hemorrhage • 10-15% of deliveries • EBL ≥ 500 mL VB, ≥ 1000 mL C/S • 10% drop in Hct • Bleeding requiring transfusion • Causes • Atony, retained placenta, laceration, uterine rupture, uterine inversion, abnormal placentation, coagulopathy

14. Diabetes • Gestational Diabetes • 3-5% of pregnancies • Risk of fetal macrosomia, C/S, birth injury • Screening 1 or 2 hour test • Confirmatory 3 hr test • Pregestational Diabetes • 1-2% of pregnancies • Risk of fetal congenital abnormalities, SAB, IUGR, etc. • Risk of preeclampsia

15. Hypertension • Chronic Hypertension • 140/90 • Identified before 20 weeks gestation • Associated w growth restriction, superimposed preeclampsia, placental abruption, IUFD • Gestational Hypertension • Identified after 20 weeks gestation • No lab abnormalities, no proteinuria

16. Preeclampsia • 6-8% of all pregnancies • Hypertension + proteinuria • >/= 140/90 • >/= 300 mg 24 hr urine collection • Severe Features • Symptoms of CNS, liver, renal dysfunction • Any BP >/= 160/110 • Pulmonary edema • Eclampsia • IUGR • HELLP syndrome

17. Preeclampsia • HELLP • Hemolysis, Elevated Liver enzymes, Low Platelets • Chronic hypertension with superimposed preeclampsia • Lab abnormalities, uncontrollable BP

18. Anemia • Increased intravascular volume leads to dilutional anemia, usually in 3rd trimester • Iron Deficiency • Check ferritin level • Common in patients s/p bariatric surgery, vegetarian/vegan diet • PICA • Acute Blood Loss • PPH

19. Placenta Previa • 5% complicated by placenta accreta • Placenta abnormally attaches to uterine wall • Placenta increta • Placenta percreta

20. Antepartum Hemorrhage • Bleeding after 24 weeks gestation and before labor • 4-5% of pregnancies • Placenta previa (0.5% of pregnancies) • Implantation of placenta over the cervix • Diagnosed by US • Complete, partial, marginal, low-lying • Not every previa bleeds • Painless bleeding

21. Antepartum Hemorrhage • Placental Abruption • Premature separation of the placenta from the uterine wall • 0.8% of pregnancies • Revealed vs. concealed • Often with abdominal tenderness, contractions • Only 2% of abruptions can be visualized on US • Risk of preterm delivery, IUGR, IUFD

22. Abnormal Placentation • Vasa Previa • Umbilical vessels covering cervix • Bleeding is fetal

23. Perineal Lacerations • First degree laceration • Vaginal epithelium, skin and subcutaneous tissue, minimal repair • Second degree laceration • Fascia and muscle of perineal body • Third degree laceration • External anal sphincter involvement • 3a means < 50% of the EAS is torn • 3b means > 50% of the EAS is torn • 3c means both EAS and internal anal sphincter are torn • Fourth degree laceration • Extends to rectal mucosa

24. Obesity • Obesity – BMI ≥30 kg/m2 • Obesity class I – BMI 30 to 34.9 kg/m2 • Obesity class II – BMI 35 to 39.9 kg/m2 • Obesity class III – BMI ≥40 kg/m2 (also referred to as severe, extreme, or massive obesity)

25. Obesity Pregnancy Complications • Miscarriage • Diabetes • Hypertension • Preterm birth • Multifetal pregnancy • Difficulties with anesthesia • Complications related to fetal macrosomia • VTE, infection, depression • Fetal congenital anomalies

26. Thyroid Disease • Overt hypothyroidism 0.6% of pregnancies • Elevated TSH, reduced free T4 • Risk of preeclampsia, placetal abruption, preterm delivery, IUGR, PPH, C/S, neuropsychological and cognitive impairment in child • Subclinical 2-2.5% of pregnancies • Elevated TSH, normal free T4 • Hyperthyroidism • 0.05-0.2% of pregnancies

27. Other Complications • Multifetal pregnancy • Preterm labor • Cervical insufficiency • Premature rupture of membranes • Intrahepatic cholestasis of pregnancy • Maternal cardiovascular disease • Thromboembolic disease • Disorders of fetal growth • Fetal congenital anomalies • Fetal hydrops

28. Thank You

29. Pedi/OB CDI Team Mary OConnell RN, MM, CCDS Shelly Sepulveda, MSN, MBA

30. Intro to OB Coding • Pregnancy, Childbirth and Puerperium (post-partum) codes and guidelines found in Chapter 15 • Chapter 15 codes have sequencing priority over codes from other chapters • Principal Diagnosis should be an “O” code when pregnancy impacts inpatient stay • Chapter 15 codes are only used in Moms charts, not the newborn record

31. Pregnancy as Incidental Finding • If a patient is admitted for a condition not directly related to the pregnancy, the medical record must clearly state. • Per Coding Clinic, “It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy. Unless the provider documents that the pregnancy is incidental to the encounter, the chapter 15 code is assigned for the condition occurring during pregnancy”.

32. Antepartum and Delivery Admission OB Coding Tips • Coding Summary should include: • Obstetric Admission Diagnosis (O Code) • Specify any condition that may complicate or impact pregnancy/delivery • Gestational Age • Chronic illnesses • Added character for trimester • 1st Trimester- less than 14 weeks 0 days • 2nd Trimester- 14 weeks 0 days to less than 28 weeks 0 days • 28 weeks 0 days until delivery • Additional code to indicate outcome of delivery

33. Postpartum Admission Coding Rules • Per Chapter 15 Guidelines • The postpartum period begins immediately after delivery and continues for six weeks following delivery • A postpartum complication is any complication occurring within the six week period • Chapter 15 codes may also be used to describe pregnancy-related complications after the peripartum or postpartum period if the provider documents that a condition is pregnancy related

34. CDI Query Opportunities • Medical • HTN (Chronic vs Gestastional) • Preeclampsia/ HELLP • Magnesium sulfate given to prevent seizures • Persistent oliguria treated with a carefully monitored fluid challenge • Cerebral or visual symptoms/ Severe Headache • Obesity • Clarification of Chronic Illness

35. CDI Query Opportunities • Labor/ Surgical • Prolonged Phase of Labor • Degree of Perineal Tear • Use of Forceps • Acute Blood Loss Anemia • Postpartum Hemorrhage

36. Case Study #1 • 30 yo G2P2 s/p elective low transverse caesarean section c/b extensive adhesiolysis. Methergine x1 administered. Per progress note, “preop HCT 31.4, EBL 1000, f/u AM CBC”. Post op H/H 22.1/7.1, HR 119-136. If possible, please specify diagnosis associated with above clinical picture. • Postpartum Hemorrhage • Acute Blood Loss Anemia • Acute Blood Loss Anemia secondary to PPH • Other (please specify) • Unable to clinically determine

37. Case Study #1 • Documentation updated with ABLA 2/2 Postpartum Hemorrhage • APR DRG 540.1  APR DRG 540.3 • RW 0.7371  1.3172 • GMLOS 2.6 days  4.47 days • Financial Impact $7,511  $14,669

38. Case Study #2 • 29 yo G2P0 admitted at 38w1d for induction of labor. Per nursing, BMI 37.9. Please clarify condition evaluated, treated or monitored in association with BMI. • Obesity • Overweight • Other (please specify) • Clinical insignificant

39. Case Study #2 • Documentation updated with “Obesity class II, BMI 37”. • APR DRG 560.2  APR DRG 560.3 • RW 0.6141  0.9122 • GMLOS 2.0 days  4.0 days • Financial Impact $9,592  $14,249

40. TMC CDI Common Queries in OB

41. TMC OB Physician Query and Response Rate

42. TMC OB Query Financial Impact

43. TMI OB CDI Impact on Case Mix Index