Abnormal fetal heart rate patterns caused by pathophysiologic processes other than fetal acidemia

Fetal acidemia is a common final pathway to fetal death, and in many cases, to fetal central nervous system injury. However, certain fetal pathophysiological processes are associated with significant category II or category III fetal heart rate changes before the development of or in the absence of fetal acidemia. The most frequent of these processes include fetal infection and/or inflammation, anemia, fetal congenital heart disease, and fetal central nervous system injury. In the presence of significant category II or category III fetal heart rate patterns, clinicians should consider the possibility of the aforementioned fetal processes depending on the clinical circumstances. The common characteristic of these pathophysiological processes is that their associated fetal heart rate patterns are linked to increased adverse neonatal outcomes despite the absence of acidemia at birth. Therefore, in these cases, the fetal heart rate patterns may provide more insight about the fetal condition and pathophysiology than the acid-base status at birth. In addition, as successful timing of intrapartum interventions on the basis of evolution of fetal heart rate patterns aims to prevent fetal acidemia, it may not be logical to continue to use the fetal acid-base status at birth as the gold standard outcome to determine the predictive ability of category II or III fetal heart rate patterns. A more reasonable approach may be to use the umbilical cord blood acid-base status at birth as the gold standard for determining the appropriateness of the timing of our interventions.

Perinatal Health Outcomes Across Rural and Nonrural Counties Within a Single Health System Catchment

Background

Perinatal health outcomes are influenced by a variety of socioeconomic, behavioral, and economic factors that reduce access to health services. Despite these observations, rural communities continue to face barriers, including a lack of resources and the fragmentation of health services.

Objective

To evaluate patterns in health outcomes, health behaviors, socioeconomic vulnerability, and sociodemographic characteristics across rural and nonrural counties within a single health system catchment area.

Methods

Socioeconomic vulnerability metrics, health care access as determined by licensed provider metrics, and behavioral data were obtained from FlHealthCHARTS.gov and the County Health Rankings. County-level birth and health data were obtained from the Florida Department of Health. The University of Florida Health Perinatal Catchment Area (UFHPCA) was defined as all Florida counties where ≥5% of all infants were delivered at Shands Hospital between June 2011 and April 2017.

Results

The UFHPCA included 3 nonrural and 10 rural counties that represented more than 64,000 deliveries. Nearly 1 in 3 infants resided in a rural county, and 7 out of 13 counties did not have a licensed obstetrician gynecologist. Maternal smoking rates (range 6.8%-24.8%) were above the statewide rate (6.2%). Except for Alachua County, breastfeeding initiation rates (range 54.9%-81.4%) and access to household computing devices (range 72.8%-86.4%) were below the statewide rate (82.9% and 87.9%, respectively). Finally, we found that childhood poverty rates (range 16.3%-36.9%) were above the statewide rate (18.5%). Furthermore, risk ratios suggested negative health outcomes for residents of counties within the UFHPCA for each measure, except for infant mortality and maternal deaths, which lacked sample sizes to adequately test.

Conclusions

The health burden of the UFHPCA is characterized by rural counties with increased maternal death, neonatal death, and preterm birth, as well as adverse health behaviors that included increased smoking during pregnancy and lower levels of breastfeeding relative to nonrural counties. Understanding perinatal health outcomes across a single health system has potential to not only estimate community needs but also facilitate planning of health care initiatives and interventions in rural and low-resource communities.

Safety of deep brain stimulation in pregnancy: A comprehensive review

Introduction

Deep brain stimulation (DBS) is increasingly used to treat the symptoms of various neurologic and psychiatric conditions. People can undergo the procedure during reproductive years but the safety of DBS in pregnancy remains relatively unknown given the paucity of published cases. We thus conducted a review of the literature to determine the state of current knowledge about DBS in pregnancy and to determine how eligibility criteria are approached in clinical trials with respect to pregnancy and the potential for pregnancy.

Methods

A literature review was conducted in EMBASE to identify articles involving DBS and pregnancy. Two reviewers independently analyzed the articles to confirm inclusion. Data extracted for analysis included conditions treated, complications at all stages of pregnancy, neonatal/pediatric outcomes, and DBS target. A second search was then conducted using www.clinicaltrials.gov. The same two reviewers then assessed whether each trial excluded pregnant individuals, lactating individuals, or persons of childbearing age planning to conceive. Also assessed was whether contraception had to be deemed adequate prior to enrollment.

Results

The literature search returned 681 articles. Following independent analysis and agreement of two reviewers, 8 pregnancy related DBS articles were included for analysis. These articles described 27 subjects, 29 pregnancies (2 with subsequent pregnancies), and 31 infants (2 twin pregnancies). There was 1 preterm birth at 35 weeks, and 3 patients who experienced discomfort from the DBS battery (i.e., impulse generator) placement site. All 27 patients had a DBS device implanted before they became pregnant, which remained in use throughout their pregnancy. There was exclusion of pregnant individuals from 68% of 135 interventional trials involving DBS. Approximately 44% of these trials excluded persons of childbearing age not on “adequate contraception” or wishing to conceive in the coming years. Finally, 22% excluded breastfeeding persons.

Conclusion

The data from 29 pregnancies receiving DBS treatment during pregnancy was not associated with unexpected pregnancy or post-partum complication patterns. Many clinical trials have excluded pregnant individuals. Documentation of outcomes in larger numbers of pregnancies will help clarify the safety profile and will help guide study designs that will safely include pregnant patients.

Outcomes of pregnancies at high-risk for placenta accreta spectrum following negative diagnostic imaging

OBJECTIVES

To assess the pretest and negative post-test probability for placenta accreta spectrum (PAS) in a group of patients with high-risk clinical factors.

METHODS

We included patients with suspected and/or confirmed PAS at our institution over 8 years. Sonography performed by maternal-fetal medicine specialists, and selected patients underwent MRI. Imaging was considered positive if either sonography or MRI suggested PAS. Histopathology was the gold standard for diagnosis of PAS. We assessed the pretest and negative imaging-test probability, and resources required.

RESULTS

We identified 82 high-risk patients with the following: (1) a history of ≥1 cesarean section and/or intrauterine gynecologic procedure and placenta previa in the index pregnancy; (2) a history of >3 cesarean deliveries and/or gynecologic procedures regardless of placental location; (3) prior PAS disorder, or retained placenta requiring manual extraction and/or curettage, complicated by postpartum hemorrhage; and (4) suspected cesarean section scar pregnancy. Histopathology confirmed PAS in 52 patients, with pretest probability of 63%. Imaging correctly identified 44/50 cases with PAS, and excluded this condition in 24/30 cases. Thus, the positive and negative post-test probability for PAS following negative imaging was 88 and 20%, respectively. Of the six patients with false-negative imaging, all had either surgical complications or required care beyond that for routine cesarean section.

CONCLUSIONS

Although diagnostic imaging is sensitive, the negative posttest probability remains high in women with high pretest probability for PAS. Therefore, women at high risk for PAS should be managed in experienced centers by a multidisciplinary team even if imaging is negative.

Timing intrapartum management based on the evolution and duration of fetal heart rate patterns

One of the most important challenges in obstetrics is to determine the appropriate time to deliver the fetus without exposing the mother to unnecessary operative interventions. The use of continuous cardiotocography (cCTG) during labor has resulted in dramatic reductions in intrapartum fetal deaths, but fetal central nervous system (CNS) injury and cerebral palsy (CP) rates have remain relatively unchanged as related to the use of cCTG . In our view, this is due to continuing inability to recognize progressive fetal deterioration and intervene promptly prior to the development of fetal CNS injury. Although the 2008 NICHD workshop proposed a 3-tier classification system, most fetuses born with severe (pathologic) acidemia (cord artery pH < 7.00), as well as those who eventually develop CP, will never reach the stage of NICHD Category III fetal heart rate (FHR) pattern. In the present "Clinical Opinion," we promote a concept derived from observations, that the evolution of the FHR changes of the deteriorating fetus can be visually defined by three color "zones" that are clinically recognizable and, therefore, are actionable. In addition, we will review information regarding how long the fetus may be able to tolerate an abnormal FHR pattern before it suffers an adverse perinatal outcome, an area of investigation that has been rarely addressed before. Based on the available evidence, Category III FHR patterns should not be used as screening criteria because of low sensitivity for either fetal CNS injury (45%) or severe (pathologic) fetal acidemia (36-44%). In addition, the duration of the Category III pattern required for the development of severe fetal acidemia is extremely short to allow for a timely preventative operative intervention. On the contrary, the use of our proposed "red" zone, which includes the most advanced stages in the progressive deterioration of Category II patterns and Category III, will identify the overwhelming majority of fetuses who develop severe (pathologic) acidemia (96%) and/or CNS injury during labor (100%); moreover, the detection of fetal jeopardy by the use of the "red" zone occurs much earlier, as compared to using Category III, thus allowing reasonable amount of time for a timely obstetrical intervention. Further research is needed to determine the false positive rate and positive predictive value for a pre-determined period of time in the red zone.

COVID-19: changing the care process for women's health-the patient's perspective

OBJECTIVE

Assess women's perceptions of the impact of COVID-19 on their health care and well-being, access to and satisfaction with medical care due to the changes in delivery of care triggered by the pandemic.

METHODS

An online survey of women having health care appointments in the outpatient facilities across all divisions of a Department of Obstetrics and Gynecology at a tertiary care referral center in North Central Florida. Patients had outpatient appointments that were scheduled, canceled or rescheduled, in person or by telemedicine, between 11 March 2020 and 11 May 2020, a time during which a COVID-19 stay-at-home order was enacted across our state. A total of 6,697 visits were planned. Patients with multiple visits were unified, leaving 6,044 unique patients to whom the survey was emailed between 20 July 2020 and 31 July 2020. The survey was closed on 21 August 2020. Analyses were focused on simple descriptive statistics to assess frequency of responses. Analyses of variance and chi-square analyses were conducted to compare outcomes when all cells were ≥ 10, based on sub-specialty and insurance status; otherwise, frequencies were examined for the entire sample only. Missing data were excluded listwise.

RESULTS

A total of 6044 patients were contacted. Completed surveys numbered 1,083 yielding a response rate of 17.9%. The most common sub-specialty visit was gynecology (56.7%) followed by obstetrics (31.5%,), pelvic floor disorders (4.8%), gynecological oncology (2.9%,), and reproductive endocrinology (0.5%). A substantial percentage of women had visits canceled (19.2%), rescheduled (32.8%) or changed (42.1%) to telemedicine. In our patient population, 32.6% were worried about visiting the clinic and 48.1% were worried about visiting the hospital. COVID-19 triggered changes were perceived to have a negative impact by 26.1% of respondents. Refusal of future telemedicine visits was by 17.2%, however, 75.2% would prefer to use both in-person and telemedicine visits.

CONCLUSION

During the initial COVID-19 surge with lockdown, the majority of survey respondents were following public health precautions. However, there were significant concerns amongst women related to obstetric and gynecologic medical appointments scheduled during that period. During pandemics, natural disasters and similar extreme circumstances, digital communication and telemedicine have the potential to play a critical role in providing reassurance and care. Nevertheless, given the concerns expressed by survey respondents, communication and messaging tools are needed to increase comfort and ensure equity with the rapidly changing methods of care delivery.

Patient compliance and satisfaction using web-based glucose monitoring for the management of pregnant women with pregestational diabetes

BACKGROUND

Optimal glycemic control is vital in decreasing the risk of congenital birth defects and perinatal complications in women with diabetes. Although frequent blood glucose (BG) monitoring is essential during pregnancy, studies have highlighted poor compliance and falsification of glucose readings. We designed this study to assess whether a web-based glucose monitor improves compliance, glycemic control, and patient satisfaction.

METHODS

This was a prospective study of 30 women with pre-gestational diabetes. After 4 weeks of using paper logs, patients were given a web-based glucose monitor. The primary outcome of interest was the average number of BG readings prior to and during web-based implementation. Secondary outcomes included glycemic control and patient satisfaction as determined by a pre- and post-study survey.

RESULTS

The number of BG readings after 2 months using the web-based meter was similar to baseline. Hemoglobin A1c (HbA1c) significantly improved and there was a trend toward improved overall glycemic values. Survey results demonstrated satisfaction with the new system, although 20% of patients felt uncomfortable with glucose values being available to providers in real time.

CONCLUSIONS

Compliance with BG monitoring was similar when comparing a web-based system with written logs. Since other studies have highlighted that some glucose data from written logs are falsified, actual compliance using the web-based monitor may be improved. This study demonstrates potential patient concerns using a web-based system. Further studies should explore patient reactions to providers having real-time access to online glycemic data given our survey results.

Educational Attainment of Grandmothers and Preterm Birth in Grandchildren

BACKGROUND

Maternal education has been shown repeatedly to be inversely associated with preterm birth. Both preterm birth and educational level of families are correlated across generations, but it is not clear if educational level of grandparents affects the risk of preterm delivery of their grandchildren, and, if so, if the association with grandmother's education is independent of mother's education.

METHODS

We used New Jersey birth certificates to create a transgenerational dataset to examine the effect of grandmother's education on risk of PTB in White, Black and Hispanic grandchildren. We matched birth certificates of girls born in 1979-1983 to mothers listed on NJ birth certificates for the years 1999-2011. Thus, grandmothers were the women delivering in 1979-1983, and mothers were those born to the grandmothers who in turn delivered grandchildren in 1999-2011. We performed descriptive tabulations and multivariate logistic regression to develop risk estimates.

RESULTS

Overall, maternal education was associated inversely with PTB in each of the demographic groups. There was a substantial inter-generational increase in education between grandmothers and mothers in each group, which was most striking in Hispanics After adjusting for maternal age and education, grandmother's education continued to be associated with preterm birth of her grandchildren.

CONCLUSIONS

Grandmother's education was an additional, independent predictor of PTB in her grandchildren. This result supports the idea that mother's childhood and preconception socioeconomic environment, including the educational level of her childhood household affect her reproductive health.

Coronavirus disease 2019 pandemic: staged management of surgical services for gynecology and obstetrics

The coronavirus disease 2019 pandemic warrants an unprecedented global healthcare response requiring maintenance of existing hospital-based services while simultaneously preparing for high-acuity care for infected and sick individuals. Hospitals must protect patients and the diverse healthcare workforce by conserving personal protective equipment and redeployment of facility resources. While each hospital or health system must evaluate their own capabilities and surge capacity, we present principles of management of surgical services during a health emergency and provide specific guidance to help with decision making. We review the limited evidence from past hospital and community responses to various health emergencies and focus on systematic methods for adjusting surgical services to create capacity, addressing the specific risks of coronavirus disease 2019. Successful strategies for tiered reduction of surgical cases involve multidisciplinary engagement of the entire healthcare system and use of a structured risk-assessment categorization scheme that can be applied across the institution. Our institution developed and operationalized this approach over 3 working days, indicating that immediate implementation is feasible in response to an unforeseen healthcare emergency.

Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know

Coronavirus disease 2019 is an emerging disease with a rapid increase in cases and deaths since its first identification in Wuhan, China, in December 2019. Limited data are available about coronavirus disease 2019 during pregnancy; however, information on illnesses associated with other highly pathogenic coronaviruses (ie, severe acute respiratory syndrome and the Middle East respiratory syndrome) might provide insights into coronavirus disease 2019's effects during pregnancy. Coronaviruses cause illness ranging in severity from the common cold to severe respiratory illness and death. Currently the primary epidemiologic risk factors for coronavirus disease 2019 include travel from mainland China (especially Hubei Province) or close contact with infected individuals within 14 days of symptom onset. Data suggest an incubation period of ∼5 days (range, 2-14 days). Average age of hospitalized patients has been 49-56 years, with a third to half with an underlying illness. Children have been rarely reported. Men were more frequent among hospitalized cases (54-73%). Frequent manifestations include fever, cough, myalgia, headache, and diarrhea. Abnormal testing includes abnormalities on chest radiographic imaging, lymphopenia, leukopenia, and thrombocytopenia. Initial reports suggest that acute respiratory distress syndrome develops in 17-29% of hospitalized patients. Overall case fatality rate appears to be ∼1%; however, early data may overestimate this rate. In 2 reports describing 18 pregnancies with coronavirus disease 2019, all were infected in the third trimester, and clinical findings were similar to those in nonpregnant adults. Fetal distress and preterm delivery were seen in some cases. All but 2 pregnancies were cesarean deliveries and no evidence of in utero transmission was seen. Data on severe acute respiratory syndrome and Middle East respiratory syndrome in pregnancy are sparse. For severe acute respiratory syndrome, the largest series of 12 pregnancies had a case-fatality rate of 25%. Complications included acute respiratory distress syndrome in 4, disseminated intravascular coagulopathy in 3, renal failure in 3, secondary bacterial pneumonia in 2, and sepsis in 2 patients. Mechanical ventilation was 3 times more likely among pregnant compared with nonpregnant women. Among 7 first-trimester infections, 4 ended in spontaneous abortion. Four of 5 women with severe acute respiratory syndrome after 24 weeks' gestation delivered preterm. For Middle East respiratory syndrome, there were 13 case reports in pregnant women, of which 2 were asymptomatic, identified as part of a contact investigation; 3 patients (23%) died. Two pregnancies ended in fetal demise and 2 were born preterm. No evidence of in utero transmission was seen in severe acute respiratory syndrome or Middle East respiratory syndrome. Currently no coronavirus-specific treatments have been approved by the US Food and Drug Administration. Because coronavirus disease 2019 might increase the risk for pregnancy complications, management should optimally be in a health care facility with close maternal and fetal monitoring. Principles of management of coronavirus disease 2019 in pregnancy include early isolation, aggressive infection control procedures, oxygen therapy, avoidance of fluid overload, consideration of empiric antibiotics (secondary to bacterial infection risk), laboratory testing for the virus and coinfection, fetal and uterine contraction monitoring, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, and a team-based approach with multispecialty consultations. Information on coronavirus disease 2019 is increasing rapidly. Clinicians should continue to follow the Centers for Disease Control and Prevention website to stay up to date with the latest information (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy

BACKGROUND

Prior studies have reported an increased risk for preterm delivery following a term cesarean delivery. However, these studies did not adjust for high-risk conditions related to the first cesarean delivery and are known to recur.

OBJECTIVE

The objective of the study was to determine whether there is an association between term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated preterm delivery.

STUDY DESIGN

This was a retrospective cohort study of women with the first 2 consecutive singleton deliveries (2007-2014) identified through a linked pregnancy database at a single institution. Women with a first pregnancy that resulted in cesarean delivery at term were compared with women whose first pregnancy resulted in a vaginal delivery at term. Exclusion criteria were known to recur medical or obstetrical complications during the first pregnancy. A propensity score analysis was performed by matching women who underwent a cesarean delivery with those who underwent a vaginal delivery in the first pregnancy. The association between cesarean delivery in the first pregnancy and preterm delivery in the second pregnancy in this matched set was examined using conditional logistic regression. The primary outcome was overall preterm delivery <37 weeks in the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous vs indicated), late preterm delivery (34-36 6/7 weeks), early preterm delivery (<34 weeks), and small-for-gestational-age birth.

RESULTS

Of a total of 6456 linked pregnancies, 2284 deliveries were matched; 1142 were preceded by cesarean delivery and 1142 were preceded by vaginal delivery. The main indications for cesarean delivery in the first pregnancy were dystocia in 703 (61.5%), nonreassuring fetal status in 222 (19.4%), breech presentation in 100 (8.8%), and other in 84 (7.4%). The mean (SD) gestational ages at delivery for the second pregnancy was 38.8 (1.8) and 38.9 (1.7) weeks, respectively, for prior cesarean delivery and vaginal delivery. The risks of preterm delivery in the second pregnancy among women with a previous cesarean and vaginal delivery were 6.0% and 5.2%, respectively (adjusted odds ratio, 1.46, 95% confidence interval, [CI] 0.77-2.76). In an analysis stratified by the type of preterm delivery in the second pregnancy, no associations were seen between cesarean delivery in the first pregnancy and spontaneous preterm delivery (4.6% vs 3.9%; adjusted odds ratio, 1.40, 95% confidence interval, 0.59-3.32) or indicated preterm delivery (1.6% vs 1.4%; adjusted odds ratio, 1.21, 95% confidence interval, 0.60-2.46). Similarly, no significant differences were found in late preterm delivery (4.6% vs 4.1%; adjusted odds ratio, 1.13, 95% confidence interval, 0.55-2.29), early preterm delivery (1.6% vs 1.2%; adjusted odds ratio, 1.25, 95% confidence interval, 0.59-2.67), or neonates with birthweight less than the fifth percentile for gestational age (3.6% vs 2.2%; adjusted odds ratio, 1.26, 95% confidence interval, 0.52-3.06).

CONCLUSION

After robust adjustment for confounders through a propensity score analysis related to the indication for the first cesarean delivery at term, cesarean delivery is not associated with an increase in preterm delivery, spontaneous or indicated, in the subsequent pregnancy.

Length of the second stage of labor and preterm delivery risk in the subsequent pregnancy

BACKGROUND

Cervical injury is regarded as an important risk factor for preterm delivery. A prolonged second stage of labor may increase the risk of cervical injury that, in turn, may be associated with increased risk of spontaneous preterm delivery in the subsequent pregnancy.

OBJECTIVE

We sought to evaluate whether the duration of the second stage of labor in a term primiparous singleton delivery is associated with an increased risk of singleton spontaneous preterm delivery (<37 weeks) in the second pregnancy.

STUDY DESIGN

We carried out a retrospective cohort analysis of women with 2 consecutive pregnancies: a first term (≥37 weeks) delivery and second birth. Data were derived from a single institution's prospectively collected obstetrical database from January 2005 through January 2015. Duration of the second stage of labor was examined as a continuous variable, modeled based on nonparametric restricted cubic regression spline with 4 degrees of freedom. Second-stage duration was also examined as short (<30 minutes), normal (30-179 minutes), and prolonged, defined as ≥180 minutes. The association between the duration of the second stage of labor in the first term pregnancy and the risk for spontaneous preterm delivery in the second pregnancy was evaluated before and after adjusting for potential confounders based on the Cox proportional hazards regression model. Associations were expressed based on the adjusted hazard ratio and 95% confidence interval.

RESULTS

In all, 6715 women met inclusion criteria. The hazard of spontaneous preterm delivery in the second pregnancy trended higher with both shorter and longer second-stage labors. The length of the second stage of labor in the first term delivery was categorized as short (<30 minutes) in 1749 (26.0%), normal (30-179 minutes) in 4551 (67.8%), and prolonged (≥180 minutes), in 415 (6.2%) women. Of these 6715 women with a first term delivery, 4.2% (n = 279) delivered spontaneously preterm in the second pregnancy. The risks of spontaneous preterm delivery among women with prolonged (≥180 minutes) second stage of labor and normal labor duration (30-179 minutes) were 5.4% (n = 22) and 3.5% (n = 158), respectively (adjusted hazard ratio, 1.81; 95% confidence interval, 1.15-2.84). This increased risk for prolonged second stage of labor was primarily seen among women who underwent a cesarean (hazard ratio, 3.38; 95% confidence interval, 1.09-10.49), but was imprecise among women who delivered vaginally (hazard ratio, 1.52; 95% confidence interval, 0.62-3.74). The risk of spontaneous preterm delivery among women with short second stage of labor (<30 minutes) in their first term pregnancy was 5.8% (n = 99; hazard ratio, 1.28; 95% confidence interval, 0.99-1.67).

CONCLUSION

The risk of spontaneous preterm delivery in the second pregnancy was increased in women with a prolonged (≥180 minutes) second stage in the first term pregnancy. This risk was even greater among women who were delivered by cesarean in the first pregnancy.

Impact of Race Versus Education and Race Versus Income on Patients' Motivation to Participate in Clinical Trials

Our study investigates whether levels of motivation and barriers to participation in clinical trials vary with patients' education and income. A self-administered survey asked outpatients to rank potential influential factors on a "0" to "4" significance scale for their motivation to participate in clinical trials. Principal component analysis (PCA), analysis of variance (ANOVA), Kruskal-Wallis, and Mann-Whitney U tests analyzed the impact of race, education, and income on their motivation to participate. Analysis included 1841 surveys; most respondents had a high school education or some college, and listed annual income < $30,000. There was a significant interaction between race and income on our motivation scale 1 scores (p = .0261). Compared with their counterparts, subjects with less education/lower income ranked monetary compensation (p = .0420 and p < .0001, respectively) as a higher motivator. Minorities and patients with less education and lower income appear to be more influenced by their desire to please the doctor, the race and sex of the doctor, and the language spoken by the doctor being the same as theirs. For all races, education appeared to have a direct relationship with motivation to participate, except for African-Americans, whose motivation appeared to decline with more education. Income appeared to have an inverse relationship with motivation to participate for all races.

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties

Introduction

This study investigated factors that influence emergency medicine (EM) patients’ decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties.

Methods

A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants’ responses.

Results

A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient’s gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285–2.389}], ID [OR:3.281, 95% CI{2.293–4.695}], and OB/GYN [OR:2.408, 95% CI{1.741–3.330}]). EM’s rankings of “how well the research was explained” and whether “the knowledge learned would benefit others” as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated “risk of unknown side effects” as their strongest barrier. Regardless of the patients’ race, “time commitment” was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218–2.136}], ID [OR:1.340, 95% CI{1.006–1.784}], or OB/GYN [OR:1.901, 95% CI{1.431–2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked “having all material provided in my own language” as the most helpful resource.

Conclusion

There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient’s own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials.

Racial Differences Among Factors Associated with Participation in Clinical Research Trials

OBJECTIVE

To identify whether racial differences exist among various factors associated with patients' decision to participate in clinical research trials.

METHODS

A self-administered, IRB-approved survey was utilized with inclusion criteria requiring subjects to be 18 years of age or older, having active patient status and ability to complete the survey without assistance. Subjects were asked to rate potential influential motivators, barriers, and facilitators on a "no influence" (0) to "most influence" (4) scale for participation in research that tests a new drug or device. Kruskal-Wallis testing was used to identify factors significantly associated with race.

RESULTS

Analysis included 1643 surveys: 949 (57.8 %) Caucasian; 217 (13.2 %) African-American; 317 (19.3 %) Hispanic; 62 (3.8 %) Multiracial; and 98 (6.0 %) "Other" minorities. Statistically significant differences (p ≤ .02) by race were found for five out of ten motivating factors. "How well the research study is explained to me" had the highest mean value for all races except other minorities, for whom "Knowledge learned from my participation will benefit someone in the future" scored highest. "Risk of unknown side-effects" was the greatest barrier for all races.

CONCLUSION

Racial differences exist not only between Caucasians and Minorities for the factors associated with their clinical trial participation, but also among different minority races themselves. To promote diversity in research, recruitment strategies for each individual race should be customized based on what matters to the target population.

The natural history of an umbilical cord hemangioma

Umbilical cord hemangiomas are rare, and the natural history is poorly understood. We present a case where the clinical course was complicated by distal umbilical cord edema, episodes of proximal obstruction of umbilical artery blood flow, transient fetal pleural and pericardial effusions, and position-dependent abnormal fetal heart rate monitoring with periods of sustained fetal tachycardia. Delivery was performed for fetal growth restriction with abnormal fetal surveillance. This case highlights possible mechanisms for fetal decompensation as well as the importance of a multifaceted approach to the management of an umbilical cord mass using multiple tools for fetal assessment. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:455-458, 2016.

Effectiveness and short-term safety of modified sodium hyaluronic acid-carboxymethylcellulose at cesarean delivery: a randomized trial

BACKGROUND

The rising cesarean birth rate has drawn attention to risks associated with repeat cesarean birth. Prevention of adhesions with adhesion barriers has been promoted as a way to decrease operative difficulty. However, robust data demonstrating effectiveness of such interventions are lacking.

OBJECTIVE

We report data from a multicenter trial designed to evaluate the short-term safety and effectiveness of a modified sodium hyaluronic acid (HA)-carboxymethylcellulose (CMC) absorbable adhesion barrier for reduction of adhesions following cesarean delivery.

STUDY DESIGN

Patients who underwent primary or repeat cesarean delivery were included in this multicenter, single-blinded (patient), randomized controlled trial. Patients were randomized into either HA-CMC (N = 380) or no treatment (N = 373). No other modifications to their treatment were part of the protocol. Short-term safety data were collected following randomization. The location and density of adhesions (primary outcome) were assessed at their subsequent delivery using a validated tool, which can also be used to derive an adhesion score that ranges from 0-12.

RESULTS

No differences in baseline characteristics, postoperative course, or incidence of complications between the groups following randomization were noted. Eighty patients from the HA-CMC group and 92 controls returned for subsequent deliveries. Adhesions in any location were reported in 75.6% of the HA-CMC group and 75.9% of the controls (P = .99). There was no significant difference in the median adhesion score; 2 (range 0-10) for the HA-CMC group vs 2 (range 0-8) for the control group (P = .65). One third of the HA-CMC patients met the definition for severe adhesions (adhesion score >4) compared to 15.5% in the control group (P = .052). There were no significant differences in the time from incision to delivery (P = .56). Uterine dehiscence in the next pregnancy was reported in 2 patients in HA-CMC group vs 1 in the control group (P = .60).

CONCLUSION

Although we did not identify any short-term safety concerns, HA-CMC adhesion barrier applied at cesarean delivery did not reduce adhesion formation at the subsequent cesarean delivery.

Using ultrasound in the clinical management of placental implantation abnormalities

Placental implantation abnormalities, including placenta previa, placenta accreta, vasa previa, and velamentous cord insertion, can have catastrophic consequences for both mother and fetus, especially as pregnancy progresses to term. In these situations, current recommendations for management usually call for an indicated preterm delivery even in asymptomatic patients. However, the recommended gestational age(s) for delivery in asymptomatic patients are empirically determined without consideration of the recent literature regarding the usefulness of specific ultrasound findings to help individualize management. The purpose of this article is to propose literature-supported guidelines to the current opinion-based management of asymptomatic patients with placental implantation abnormalities based on relevant and specific ultrasound findings such as cervical length, distance between the internal cervical os and placenta, and placental edge thickness.

A multi-center randomized trial of two different intravenous fluids during labor

OBJECTIVE

To determine if the intrapartum use of a 5% glucose-containing intravenous solution decreases the chance of a cesarean delivery for women presenting in active labor.

METHODS

This was a multi-center, prospective, single (patient) blind, randomized study design implemented at four obstetric residency programs in Pennsylvania. Singleton, term, consenting women presenting in active spontaneous labor with a cervical dilation of <6 cm were randomized to lactated Ringer's with or without 5% glucose (LR versus D5LR) as their maintenance intravenous fluid. The primary outcome was the cesarean birth rate. Secondary outcomes included labor characteristics, as well as maternal or neonatal complications.

RESULTS

There were 309 women analyzed. Demographic variables and admitting cervical dilation were similar among study groups. There was no significant difference in the cesarean delivery rate for the D5LR group (23/153 or 15.0%) versus the LR arm (18/156 or 11.5%), [RR (95% CI) of 1.32 (0.75, 2.35), p = 0.34]. There were no differences in augmentation rates or intrapartum complications.

CONCLUSIONS

The use of intravenous fluid containing 5% dextrose does not lower the chance of cesarean delivery for women admitted in active labor.

Characteristics of participants in peripartum interventional research

OBJECTIVE

To identify characteristics of pregnant women potentially influencing the decision to participate in peripartum interventional research.

METHODS

Women screened as eligible to participate in two prospective interventional trials conducted in the labor and delivery unit at a single center were included. Characteristics of eligible women were compared based on their decision whether to participate or not. The best predictors of research participation were identified using multivariable logistic regression analyses.

RESULTS

Of the 605 subjects who screened as eligible to participate, 363 (60%) agreed to participate and 242 (40%) declined. Women using a private obstetric provider or who had prior obstetrical complications were less likely to participate [aOR 0.6 (95% CI: 0.4-0.8)] and [aOR 0.6 (95% CI: 0.4-0.9)], respectively. A history of a mental health condition and a higher body mass index (BMI) were marginally more likely to participate [aOR 1.5 (95% CI: 1.0-2.3)] and [aOR 1.03 (95% CI: 1.0-1.1)], respectively. Overall logistic regression model R(2) was 0.23.

CONCLUSIONS

There are differences between eligible subjects who decide to participate or not participate in prospective peripartum interventional research. There is a need to better understand non-participation in order to improve recruitment of representative populations that allow more generalizable research results.

Universal versus risk factor-targeted early inpatient postpartum depression screening

OBJECTIVE

To assess differences in two different approaches to early inpatient Edinburgh Postnatal Depression Scale (EPDS) screening (targeted risk factor screening versus universal screening).

METHODS

Retrospective study of two cohorts delivering from January 2010 to June 2010. Cohort 1 included 5-weeks of consecutive deliveries. Risk factors for a positive EPDS screen were determined by multivariable logistic regression. Cohort 2 included all delivering women in the subsequent 5 months who had the most common risk factor (history of mental illness) for postpartum depression identified from Cohort 1.

RESULTS

For Cohort 1 of universal screening (N = 322), 11 (3.4%) had positive screens with seven (63.6%) having a history of any mental illness yielding the number needed to screen to identify one EPDS positive mother of 29. For Cohort 2 (N = 215), there were 33 (15.3%) positive screens and the number needed to have a positive screen was 6. Without a history of mental illness, predictive models for a positive screen were poor with the number needed to screen of 80.

CONCLUSIONS

Early EPDS screening targeted for those with a history of mental illness is an efficient way to identify postpartum women with active mental health problems, but may miss up to 36.4% of potential screen positive women.

The use of a comparability scoring system in reporting observational studies

The traditional statistical analyses with adjustment for confounders in observational studies assume that there is perfect similarity in the already-provided medical management between the comparison groups. However, variations in medical management frequently exist because of differences in circumstances of health care. We propose that to minimize the selection bias of observational studies, the degree of similarity or dissimilarity of the comparison groups regarding the circumstances of health care should be considered. Circumstances of health care include the geographic setting, health care setting, type of health care providers, and likelihood in having confounding introduced by differences in the medical management between comparison groups. We propose a comparability scoring system of circumstances of care and provide examples of the application of this system, using recent literature to assess comparability among study groups. In our examples, the presupposed statistical associations disappeared once the analyses accounted for the differences in circumstances of care. Authors of submitted manuscripts using an observational study design may consider incorporating our scoring system or an equivalent in their methods and in reporting of the results. The comparability score should be factored during statistical analysis so that the appropriate analysis can correct for differences in circumstances of care. The use of a comparability scoring system can provide important insights for reviewers and readers that will improve the interpretation of this type of research study.

Sonographic findings in acute uterine inversion

We present a case of acute uterine inversion in the third stage of labor in which critical management decisions were facilitated by ultrasound imaging in the operating room. Identification of the ovary and adnexa pulled into the indentation of the inversion allowed the successful diagnosis and guidance for uterine replacement.

Oxytocin discontinuation during active labor in women who undergo labor induction

OBJECTIVE

The purpose of this study was to determine whether there is an increase in the cesarean delivery rate in women who undergo induction when oxytocin is discontinued in the active phase of labor.

STUDY DESIGN

We conducted a prospective randomized controlled trial of women who underwent induction of labor at term; they were assigned randomly to either routine oxytocin use (routine) or oxytocin discontinuation (DC) once in active labor. Analysis was by intention to treat.

RESULTS

Two hundred fifty-two patients were eligible for study analysis: 127 patients were assigned randomly to the routine group and 125 patients were assigned randomly to the DC group. Cesarean delivery rate was similar between the groups (routine, 25.2% [n = 32] vs the DC group, 19.2% [n = 24]; P = .25). There was a higher chorioamnionitis rate and slightly longer active phase in those women who were assigned to the DC group. In adjusted analysis, the rate of chorioamnionitis was not different by randomization group but was explained by the duration of membrane rupture and intrauterine pressure catheter placement.

CONCLUSION

Discontinuation of oxytocin in active labor after labor induction does not increase the cesarean delivery rate significantly.

Comparison of 12-hour urine protein and protein:creatinine ratio with 24-hour urine protein for the diagnosis of preeclampsia

OBJECTIVE

The purpose of this study was to evaluate the performance of the 12-hour urine protein >165 mg and protein:creatinine ratio >0.15 for the prediction of 24-hour urine protein of ≥300 mg in patients with suspected preeclampsia.

STUDY DESIGN

We performed a prospective observational study of 90 women who had been admitted with suspected preeclampsia. Protein:creatinine ratio and 12- and 24-hour urine specimens were collected for each patient. Test characteristics for the identification of 24-hour urine protein ≥300 mg were calculated.

RESULTS

A 12-hour urine protein >165 mg and protein:creatinine ratio of >0.15 correlated significantly with 24-hour urine protein ≥300 mg (r = 0.99; P < .001; and r = 0.54; P < .001, respectively). A 12-hour urine protein >165 mg performed better than protein:creatinine ratio as a predictor of a 24-hour urine protein ≥300 mg (sensitivity, 96% and 89%; specificity, 100% and 49%; positive predictive value, 100% and 32%; negative predictive value, 98% and 91%, respectively).

CONCLUSION

The high correlation of a 12-hour urine protein >165 mg with a 24-hour urine protein ≥300 mg (with the benefit of a shorter evaluation time) and the high negative predictive value of protein:creatinine ratio suggest that the use of both these tests have a role in the evaluation and treatment of women with suspected preeclampsia.

Risk of Infant Mortality Among Twins in Relation to Placental Abruption: Contributions of Preterm Birth and Restricted Fetal Growth

While preterm birth and restricted fetal growth are strongly associated with infant mortality, the extent to which these associations are modified by placental abruption remains unknown. A retrospective cohort study was carried out to examine the risk of infant mortality among twins in relation to abruption, and explore the independent contributions of preterm birth and restricted fetal growth to these associations. The study was restricted to women who had delivered twins at 22 weeks' gestation or more and fetuses weighing 500 grams or more in the United States (1989–2000). Risks of preterm birth (less than 37 weeks' gestation), fetal growth restriction and infant mortality, in relation to placental abruption, were evaluated. All analyses were adjusted for potential sociodemographic confounding factors. The association between restricted twin fetal growth and abruption was the strongest among the most severely growth-restricted babies (i.e., less than 1 centile), with the strength of association diminishing with increasing birthweight centiles. The risk of preterm birth among pregnancies with and without abruption were 80.1% and 51.9%, respectively (relative risk [RR] 1.5, 95% confidence interval [CI] 1.4–1.6). The risk of small-for-gestational-age (SGA; birthweight of less than the 10th centile for gestational age) among abruption and nonabruption births was 11.7% and 9.2%, respectively (RR 1.3, 95% CI 1.2–1.4). Compared with twins of the appropriate growth delivered at term, the relative risks for infant mortality in the presence of abruption were 9.9 (95% CI 5.4–18.2) for term-SGA, 25.0 (95% CI 22.3–28.1) for preterm-non-SGA, and 36.2 (95% CI 28.4–46.1) for preterm-SGA births. The association between infant mortality and abruption among twins appears largely mediated through preterm birth, and to a lesser extent, through SGA. The association between fetal growth and abruption is strongest among the severely growth-restricted babies, suggesting that the origins of placental abruption may develop in early pregnancy.

Ischemic placental disease: maternal versus fetal clinical presentations by gestational age

OBJECTIVE

Preeclampsia, small for gestational age (SGA), and abruption are considered ischemic placental diseases (IPD), and are major contributors to both maternal and fetal morbidity and mortality. Although the placenta is considered a fetal organ, these conditions can present clinically with either maternal or fetal manifestations, but their relationship to preterm births is largely unexplored.

METHODS

We designed a population-based study to assess the origins of IPD. IPD was classified as maternal (preeclampsia only), fetal (SGA only), or both (abruption only, preeclampsia with either SGA or abruption, or all 3). The study was based on 90,500 women that delivered singleton live births at 22-44 weeks gestation.

RESULTS

Among 77,275 term births with IPD, 23.2% presented as maternal disease only, 68.9% as fetal disease, and 7.9% as both. In contrast, among 12,906 preterm births with IPD, the proportions were roughly equal (maternal 32.9%, fetal 36.5%, and both 30.6%). Among spontaneous preterm births with IPD, a greater proportion had a fetal presentation (43.0%), whereas among indicated preterm births with IPD, a greater proportion (43.4%) had both maternal and fetal presentations.

CONCLUSIONS

IPD at preterm gestations is more likely to involve both the mother and fetus than at term. The differing clinical presentations by gestational age suggest different pathways between term and preterm births. This may reflect heterogeneous processes for IPD at early vs. late gestations, regardless of the effects of differing gestational age thresholds for interventions.

Pesticide concentrations in maternal and umbilical cord sera and their relation to birth outcomes in a population of pregnant women and newborns in New Jersey

We evaluated in utero exposures to pesticides by measuring maternal and cord serum biomarkers in a New Jersey cohort of pregnant women and the birth outcomes of their neonates. The study was based on 150 women that underwent an elective cesarean delivery at term in a hospital in central New Jersey. We evaluated the following pesticide compounds in both maternal and umbilical cord sera: chlorpyrifos, diazinon, carbofuran, chlorothalonil, dacthal, metolachlor, trifluralin and diethyl-m-toluamide (DEET). Of these compounds, chlorpyrifos, carbofuran, chlorothalonil, trifluralin, metolachlor and DEET were the pesticides most frequently detected in the serum samples. We found high (> or =75th percentile) metolachlor concentrations in cord blood that were related to birth weight (3605 g in upper quartile vs 3399 g; p=0.05). We also observed an increase in abdominal circumference with increasing cord dichloran concentrations (p=0.031). These observations suggest that in utero exposures to certain pesticides may alter birth outcomes.

Can sulfasalazine prevent infection-mediated pre-term birth in a murine model?

PROBLEM

Sulfasalazine (SASP) blocks activation of nuclear factor-kappa B (NF-kappaB) in gestational tissues in vitro- one of the earliest signals in the inflammatory response. We hypothesized that the administration of SASP would reduce the rate of infection-mediated pre-term birth in a murine model.

METHOD

of study CD-1 mice (n = 40) were assigned on gestational day (gd) 14.5 to 1 of 3 treatments: (1) Sham infection and vehicle; (2) 10(4) CFU Escherichia coli and vehicle; or (3) 10(4) CFU E. coli and SASP (150 mg/Kg daily). Mice were observed twice daily and deliveries prior to gd 18.5 were considered pre-term.

RESULTS

Significantly more mice delivered prior to gd 18.5 when infected with 10(4) CFU E. coli than sham-infected mice (P < 0.001) and this effect was significantly reduced in mice also treated with SASP (P = 0.002). SASP also tended to increase litter size (P = 0.060) and significantly increased weight of pups born to dams with intrauterine infections (P = 0.001).

CONCLUSION

SASP reduced rates of pre-term delivery and improved pregnancy outcomes for mice infected with 10(4) CFU E. coli. This suggests that SASP has the potential to play a role in strategies to prevent pre-term birth in women.

Perinatal exposure to perchlorate. thiocyanate, and nitrate in New Jersey mothers and newborns

Perchlorate is a commonly occurring environmental toxicant that may be transported across the placental barrier by the sodium-iodide symporter (NIS), possibly resulting in both increased perchlorate exposure and decreased iodide uptake by the fetus. Therefore, we measured levels of three physiologically relevant NIS-inhibitors (perchlorate, nitrate, and thiocyanate) and iodide in maternal and fetal fluids collected during cesarean-section surgeries on 150 U.S. women. Geometric means of perchlorate, thiocyanate, and nitrate levels in maternal urine (2.90, 947, and 47900 microg/L, respectively) were similar to previously published results, while urinary iodide levels (1420 microg/L) were significantly higher (p < 0.0001), likely because of prevalent prenatal vitamin use in the study population (74%). Thiocyanate levels were higher in the maternal serum, cord serum, and amniotic fluid of smokers compared to women with environmental tobacco smoke exposure and nonsmokers (p-values of 0.0006, 0.0011, and 0.0026, respectively). Perchlorate was detected in most samples: urine (100%), maternal serum (94%), cord serum (67%), and amniotic fluid (97%). Maternal urinary perchlorate levels were positively correlated with perchlorate levels in amniotic fluid (r = 0.57), indicating that maternal urine perchlorate is an effective biomarker of fetal perchlorate exposure. Maternal serum perchlorate was generally higher than cord serum perchlorate (median ratio 2.4:1 for paired samples), and maternal urine perchlorate was always higher than fetal amniotic fluid perchlorate levels (mean ratio 22:1); conversely, iodide levels were typically higher in fetal fluids compared to maternal fluids. We found no evidence of either disproportionate perchlorate accumulation or lack of iodide in the fetal compartment. In this panel of healthy infants, we found no association between cord blood levels of these anions and newborn weight length, and head circumference.

Does progesterone inhibit bacteria-stimulated interleukin-8 production by lower genital tract epithelial cells?

OBJECTIVE

Progesterone (P(4)) has been clinically shown to prevent the recurrence of preterm birth. The mechanism(s) of action is unclear, but may involve modulation of the immunologic inflammatory response of the lower genital tract. We evaluated the effects of P(4) on interleukin-8 (IL-8) production by vaginal and cervical epithelial cells stimulated with bacterial species that are commonly associated with preterm birth.

METHODS

Vaginal and endocervical epithelial cells were incubated with up to 10,000 ng/mL P(4) overnight and stimulated with heat-killed Escherichia coli, Gardnerella vaginalis, or Ureaplasma urealyticum. Concentrations of IL-8 in conditioned medium were quantified by ELISA and viability of the cell cultures was measured by the reduction of a tetrazolium salt.

RESULTS

E. coli, G. vaginalis and U. urealyticum-stimulated IL-8 production for both cell lines. P(4) inhibited basal and bacteria-stimulated IL-8 production for vaginal epithelial cells but enhanced IL-8 production by endocervical cells. P(4) reduced the number of viable cells for both cell lines.

CONCLUSIONS

P(4) inhibits IL-8 production by vaginal epithelial cells stimulated with pathogens associated with preterm birth, possibly by reducing the number of viable cells or by inhibiting their proliferation. Although P(4) also reduces proliferation of endocervical cells it also increases their production of IL-8.

Changes in sweet taste across pregnancy in mild gestational diabetes mellitus: relationship to endocrine factors

Gestational diabetes mellitus (GDM) is glucose intolerance diagnosed during pregnancy. Previous work suggested that women with GDM showed exaggerated preferences for sweet taste, but data were limited to a single time point during pregnancy. This study longitudinally assessed sweet taste changes across pregnancy in women who developed GDM (n = 15) as compared with women with normal glucose tolerance (NGT; n = 93) and nonpregnant controls (n = 19). A second objective was to relate sweet taste changes in GDM to fasting leptin and insulin profiles. Following an overnight fast, subjects evaluated strawberry-flavored milks varying in sucrose and fat content, as well as glucose solutions. Evaluations were made at 3 time points during pregnancy and during early postpartum. At 34-38 weeks gestation, women with GDM gave higher liking ratings to moderately sweetened (5% and 10% sucrose) strawberry milks than women with NGT. These differences were not related to alterations in the perception of the samples. At 24-28 weeks gestation, and in women with GDM only, fasting insulin was correlated with liking of the glucose solutions (R(2) = 0.63, P = 0.004) and fasting leptin was correlated with sweetness liking of the 10% sucrose milk (R(2) = 0.42, P = 0.017). These data suggest that women with GDM exhibit higher liking ratings for a sweet fat milk drink late in pregnancy. Also, higher hedonic ratings for sweet taste in GDM may be related to elevated leptin and insulin concentrations at midpregnancy. GDM may increase the desire for sweet taste that could influence dietary management of this disease.

Maternal anterior sacral meningocele in pregnancy

Anterior sacral meningocele is a rare condition resulting from herniation of the meninges through a sacral defect. Women with this condition may undergo inappropriate surgery because the correct diagnosis is missed, resulting in serious complications. In labor, the cyst may rupture, with consequent meningitis and high maternal mortality. We report the case of a 31 year-old pregnant woman with an anterior sacral meningocele. We describe the role of magnetic resonance imaging in the evaluation and management planning in this condition. She was delivered by cesarean section at 34 weeks without complications. Accurate diagnosis and delivery by cesarean prior to labor are important in assuring good outcomes in women with anterior sacral meningoceles.

Neonatal hypoglycemia in term, nondiabetic pregnancies

OBJECTIVE

To define the incidence of hypoglycemia and identify risk factors in neonates from term, singleton, nondiabetic pregnancies.

STUDY DESIGN

We conducted a matched case-control study of term, singleton infants weighing more than 2500 g in nondiabetic pregnancies. Cases with hypoglycemia (glucose < 50 mg/dL) were identified by International Classification of Diseases, ninth revision, codes. Two controls per case were matched on race, maternal age, and birthweight. Conditional logistic regression analyses were performed.

RESULTS

There were 116 cases and 232 controls studied. The incidence density of neonatal hypoglycemia was 24.7 per 1000 infant-days at risk. Hypoglycemia was less commonly associated with later gestational age (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.53-0.85 per week of gestation). Maternal fever during labor was more common with hypoglycemia (OR, 4.08; 95% CI, 1.39-11.79). Public insurance was more than twice as common with hypoglycemia compared with those privately insured (OR, 2.31; 95% CI, 1.17-4.58).

CONCLUSION

Neonatal hypoglycemia was associated with earlier gestational age, intrapartum fever, and public insurance.

Gestational diabetes in the United States: temporal trends 1989 through 2004

OBJECTIVE

The objective of the study was to characterize trends in gestational diabetes (GDM) by maternal age, race, and geographic region in the United States.

STUDY DESIGN

The National Hospital Discharge Survey, comprised of births in the United States between 1989 and 2004 (weighted n = 58,922,266), was used to examine trends in GDM, based on an International Classification of Diseases, Ninth Revision, Clinical Modification code of 648.8. We examined temporal trends by comparing GDM rates in the earliest (1989-1990) vs most recent (2003-2004) biennial periods. Relative risks, quantifying racial disparity (black vs white) in GDM, were derived through logistic regression models after adjusting for confounders. These analyses were further stratified by maternal age and geographic region.

RESULTS

Prevalence rates of GDM increased from 1.9% in 1989-1990 to 4.2% in 2003-2004, a relative increase of 122% (95% confidence interval [CI] 120%, 124%). Among whites, GDM increased from 2.2% in 1989-1990 to 4.2% in 2003-2004 (relative increase of 94% [95% CI 91%, 96%]), and this was largely driven by an increase in the 25-34 year age group. In contrast, the largest relative increase in GDM (260% [95% CI 243%, 279%]) among blacks between 1989-1990 (0.6%) and 2003-2004 (2.1%) occurred to women aged younger than 25 years. The black-white disparity in GDM rates widened markedly among women aged younger than 35 years in the 1997-2004 periods. The largest relative increases were seen in the West (182% [95% CI 177%, 187%]) followed by the South and Northeast. The observed increase in GDM rates in the Northeast, Midwest, and South regions most likely is due to increase in GDM prevalence rates among blacks.

CONCLUSION

This study shows that the prevalence rate of GDM in the United States has increased dramatically between 1989 and 2004. The temporal increase and the widening black-white disparity in the rate of GDM deserves further investigation.

Acute and chronic respiratory diseases in pregnancy: associations with spontaneous premature rupture of membranes

OBJECTIVE

To examine whether acute and chronic respiratory diseases are associated with an increased risk of spontaneous premature rupture of the membranes (PROM).

METHODS

We used the 1993-2004 National Hospital Discharge Survey data of singleton deliveries in the USA (N = 41 250 539). The International Classification of Diseases Ninth Revision was utilized to identify acute (acute upper respiratory diseases, viral/bacterial pneumonia, and acute bronchitis/bronchiolitis) and chronic (chronic bronchitis and asthma) respiratory conditions and spontaneous PROM. All analyses were adjusted for potential confounders.

RESULTS

The incidence of PROM was 5%, and rates of acute and chronic respiratory conditions were 2.1 and 9.5 per 1000 pregnancies, respectively. Chronic bronchitis was associated with a reduced risk of PROM (RR 0.39, 95% CI 0.31, 0.48). Asthma was significantly associated with PROM at preterm (RR 1.15, 95% CI 1.14, 1.17) and term (RR 1.27, 95% CI 1.23, 1.30). Stratification by race showed that acute upper respiratory disease was associated with preterm PROM in whites (RR 1.90, 95% CI 1.71, 2.11) and blacks (RR 6.76, 95% CI 5.67, 8.07). Viral/bacterial pneumonia was associated with preterm PROM in blacks and term PROM in both races. Asthma was associated with term PROM in blacks but not whites.

CONCLUSIONS

Acute respiratory diseases and asthma during pregnancy are associated with spontaneous PROM, with substantially stronger association among blacks than whites. We speculate that timely diagnosis and treatment, coupled with closely mentoring of pregnant women may help reduce the rate of PROM and associated complications.