The Association of Maternal Satisfaction with Childbirth by Length of Second Stage

OBJECTIVE

 The aim of this study was to quantify patient satisfaction by hour of second stage of labor and subsequent delivery mode.

STUDY DESIGN

 Pilot cross-sectional study of nulliparous women delivered at George Washington University Hospital between April 2018 and March 2019. Patients completed three survey questionnaires in the immediate postpartum period: Patient Perception Score (PPS), Consumer Satisfaction Questionnaire (CSQ), and Six Simple Questions (SSQ). Length of second stage was divided into 2 groups (≤3 hours and >3 hours). Data on maternal characteristics, maternal outcomes, and neonatal outcomes were collected in REDCap and statistical analysis was performed using SAS version 9.4.

RESULTS

 Survey response rate was 100% (n = 100). Seventy-one patients had a normal second stage and 29 patients had a prolonged second stage. Prolonged second stage was significantly associated with a lower proportion of NSVD (65.5 vs. 90.1%; p <0.01) and a higher proportion of epidural (82.8 vs. 60.6%; p = 0.03) in comparison to a normal second stage. Length of second stage had a statistically significant negative correlation with overall PPS scores (ρ =  - 0.25, p ≤0.01). Length of second stage was not correlated with the SSQ (ρ = 0.05, p = 0.25) or CSQ (ρ =  - 0.18, p = 0.11) surveys. CSQ scores were statistically significantly lower in women who underwent second stage cesarean delivery.

CONCLUSION

 Maternal satisfaction with childbirth and health care experience was high regardless of length of second stage. Only the PSS survey showed that shorter length of second stage was correlated with higher satisfaction. Cesarean delivery in the second stage was significantly associated with decreased maternal satisfaction. Future studies with larger cohorts are needed to confirm our findings.

KEY POINTS

· There is limited data on maternal satisfaction with childbirth.. · Mode of delivery may affect maternal satisfaction.. · Shared decision-making about delivery mode and timing is crucial..

Interactions Between Endocannabinoid and Endogenous Opioid Systems Prospectively Influence Postoperative Opioid Use in Pregnant Patients Undergoing Cesarean Delivery

Both endocannabinoid (EC) and endogenous opioid systems are involved in nociceptive processing and may work together synergistically based on preclinical models. This study evaluated the interactive effects of preoperative beta-endorphin concentrations (a key analgesic endogenous opioid) in cerebrospinal fluid (CSF) and ECs (CSF and plasma 2-arachidonoylglycerol [2-AG] and plasma anandamide [AEA]) on postoperative opioid use and pain intensity in a prospective cohort of n = 112 pregnant patients undergoing scheduled cesarean delivery. Maternal blood and CSF samples were collected preoperatively for beta-endorphin and EC assays. Patients completed measures of outpatient opioid use (number of tablets used and days of use) and average pain intensity at 2 weeks postoperatively. Results of general linear model analyses controlling for maternal age, BMI at time of delivery, and race revealed significant multiplicative interactions between EC and beta-endorphin concentrations on number of opioid tablets used (based on pill count), days of opioid use, and total milligram morphine equivalents used in the 2 week follow-up period. Elevated preoperative plasma and CSF 2-AG predicted reduced outpatient opioid analgesic use particularly for patients low in CSF beta-endorphin. Similar analyses for pain intensity at 2-week follow-up indicated a significant interaction (p<.02) characterized by higher preoperative beta-endorphin concentrations being associated with lower subsequent pain only for individuals with low preoperative plasma AEA concentrations. Further exploration of interactions between EC and endogenous opioid inhibitory systems as they influence responses to opioid analgesics in other clinical pain populations may help guide development of precision pain management approaches. PERSPECTIVE: In the postoperative setting of patients undergoing cesarean delivery, elevated endocannabinoids were linked to reduced outpatient opioid analgesic use in individuals who had low endogenous opioid concentrations in cerebrospinal fluid. Further exploration of interactions between these two inhibitory systems as they impact on responses to pain management interventions appears warranted.

Prescription Opioid Exposure During Pregnancy and Risk of Spontaneous Preterm Delivery

Importance

Opioid exposure during pregnancy has been associated with preterm birth, but prior studies have not differentiated between spontaneous and indicated preterm birth or fully investigated these associations as functions of opioid dose.

Objective

To determine whether prescription opioid use during pregnancy is associated with spontaneous preterm birth and whether the association is dose-dependent.

Design, Setting, and Participants

This case-control study examined a retrospective cohort of pregnant patients enrolled in Tennessee Medicaid. Enrollment files were linked to health care encounters, hospital discharge information, birth certificate data, and prescription fills. Eligible participants were pregnant people ages 15 to 44 years without opioid use disorder who experienced birth of a single fetus at 24 weeks gestation or greater between 2007 and 2019 with linked birth certificate data. Cases of spontaneous preterm birth were matched with up to 10 controls based on pregnancy start date, race, ethnicity, age at delivery within 2 years, and history of prior preterm birth. Cases and matched controls were continuously enrolled in TennCare for at least 90 days prior to the index date (case delivery date).

Exposure

Total opioid MME filled during the 60 days prior to the index date.

Main Outcomes and Measures

The primary outcome was spontaneous preterm birth determined by a validated algorithm using birth certificate data. Conditional logistic regression was used to estimate the association between spontaneous preterm birth and total opioid morphine milligram equivalents (MME) dispensed, adjusting for parity, prepregnancy body mass index, education level, tobacco use, hepatitis infections, and pain indications.

Results

A total of 25 391 cases (median [IQR] age, 23 [20-28] years; 127 Asian [0.5%], 9820 Black [38.7%], 664 Hispanic [2.6%]; 14 748 non-Hispanic White [58.1%]) with spontaneous preterm birth were identified and matched with 225 696 controls (median [IQR] age, 23 [20-27] years; 229 Asian [0.1%], 89 819 Black [39.8%], 3590 Hispanic [1.6%]; 132 002 non-Hispanic White [58.5%]) (251 087 patients total), with 18 702 patients (7.4%) filling an opioid prescription in the 60 days prior to the index date. Each doubling of nonzero opioid MME was associated with a 4% increase in the odds of spontaneous preterm birth compared with no opioid exposure (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08).

Conclusions and Relevance

In this case-control study, a positive association was found between total prescription opioid dose dispensed and the odds of spontaneous preterm birth. These findings support guidance to minimize opioid exposure during pregnancy and prescribe the lowest dose necessary.

Imaging and outcomes of fetal adrenal hemorrhage: A systematic review

OBJECTIVE

To describe prenatal and postnatal imaging findings of fetal adrenal hemorrhage (FAH) and its associated perinatal outcomes, including frequency of postnatal surgical intervention.

METHOD

A systematic literature review of seven electronic databases was conducted from inception until January 2022, with 2008 articles identified reporting prenatally identified fetal adrenal masses. Studies with confirmed FAH diagnosis were included. Quality and risk assessment were evaluated.

RESULTS

Thirty-five studies, including 102 FAH cases, were analyzed. FAH was commonly described as cystic (28/90, 31%), anechoic (25/90, 28%), or mixed echogenic (14/90, 16%) on ultrasound. Outcome data were available for 65 cases (64%) of FAH: 9% (6/65) resolved prenatally, 35% (23/65) resolved postnatally, 34% (22/65) regressed in size after birth, and 22% (14/65) persisted postnatally. Overall, 25% (16/65) of cases underwent postnatal surgical intervention. Neuroblastoma was suspected in all 16 surgical cases. Only one case (1/16, 6%) confirmed a cystic hematoma with microscopic islets of neuroblastoma in situ on pathology.

CONCLUSION

Prenatal diagnosis of FAH is challenging due to the significant heterogeneity of ultrasound findings. Final pathology did not support the need for surgical intervention. Persistent postnatal FAH warrants shared decision making for further management based on the clinical presentation.

Long-Term Effectiveness of a Nonsurgical BPH Treatment System in Prostate Radiation Patients with Medication-Refractory Lower Urinary Tract Symptoms

PURPOSE/OBJECTIVE(S)

To evaluate the long-term outcomes and toxicity of a nonsurgical prostatic urethral lift system in patients with prior prostate cancer radiation therapy (RT).

MATERIALS/METHODS

From 2018 to 2020, nineteen patients with a history of prior prostate RT underwent a nonsurgical prostatic urethral lift (PUL) procedure for lower urinary track symptoms (LUTS) refractory to alpha blocker medications. Prostate cancer RT was completed a median of 17.8 months (IQR 13.4-27.4) prior to PUL procedure. All patients were assessed with IPSS/quality of life (QOL) scores and urinary post void residual (PVR) ultrasound before and after PUL. Patients were also assessed for ability to discontinue alpha blockade medications for their LUTS and any post PUL toxicity based on CTCAE v5.0 criteria.

RESULTS

All patients underwent successful placement of the PUL implants. Median pre-PUL IPSS score was 20 (IOR 17.5-22.5) and the median prostate volume was 41cc (IQR 33-49). Median follow up was 22 months (IQR 5-30). The average improvement in IPSS score was 8.5 points (IRQ 5.5-11) at 3 months and 7.5 points (IQR 6-10) at last follow-up. Two patients (10%) initially had improvement in IPSS score at 3 months with subsequent significant increase in IPSS (>5 points) at last follow-up. Overall, there was minimal change in reported QOL scores (median 0, IQR 0-1.75). The average reduction in PVR was 90cc. The percentage of patients able to discontinue alpha blockade at last follow-up was 68%. There was no grade 3 or higher GU toxicity in either group.

CONCLUSION

Use of a nonsurgical prostatic urethral lift system in patients with prior prostate RT refractory to alpha blocker medications results in significant long-term improvement of LUTS after radiation therapy for the majority of patients with minimal toxicity.

Initial Clinical Outcomes of a Phase II Trial of Focal Salvage LDR Brachytherapy for Local Recurrence of Prostate Cancer after External Beam Radiation Therapy

PURPOSE/OBJECTIVE(S)

To evaluate the clinical outcomes of focal salvage low dose rate brachytherapy (FSB) for biopsy proven local recurrence of prostate cancer after definitive external beam radiation therapy (EBRT).

MATERIALS/METHODS

Patients with a Phoenix definition PSA recurrence (nadir + 2.0ng/dL) after definitive EBRT for localized prostate cancer and a negative metastatic work up were enrolled in a Phase II clinical trial. Patients first underwent MR-guided transperineal mapping biopsy of the prostate using a template grid. Patients with a pathologically confirmed recurrence underwent FSB using iodine-125 seeds to a prescription dose of 145 Gy. The brachytherapy planning target volume (PTV) was defined by the positions of the pathologically negative core biopsies adjacent to the positive core biopsies as recorded on the template grid during the biopsy procedure. An intraoperative treatment plan was then developed to cover the PTV with the 145 Gy isodose line. Follow up included assessment of genitourinary (GU) and gastrointestinal (GI) toxicities using Common Terminology Criteria for Adverse Events version 4.03 (CTCAEv4.03), patient reported outcomes using the International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index-26 (EPIC-26) forms, and serial PSA blood draws.

RESULTS

Ten patients underwent FSB. The median prior EBRT dose was 7805 cGy (interquartile range IQR 7560-7920) and the median time from completion of EBRT to FSB was 81 months (IQR 68-134). The median PSA prior to FSB was 3.2 ng/dL (IQR 2.3 - 4.5). The median follow up after FSB was 32 months (IQR 18-57). Eight patients were free of Phoenix definition PSA failure at last follow up. Of the two patients who experienced a PSA failure, one developed distant metastases 5 months after FSB and the other a biopsy proven seminal vesicle recurrence 3 years after FSB. The median change in post FSB IPSS score compared to the pre-FSB IPSS score was an increase of 1.5 (IQR -1.5 to 8) at 3 month follow up and an increase of 3.5 (IQR 0.5 to 5.5) at last follow up (≥1 year). The median change in post FSB EPIC-26 urinary domain score compared to the pre-FSB score was -1 (IQR -26 to +14.5) at 3 month follow up and +2 (IQR -12.5 to +14.5) at last follow up (≥1 year). The median change in post FSB EPIC-26 bowel domain score compared to the pre-FSB score was -2 (IQR -9.5 to 0.0) at 3 month follow up and 0 (IQR -6.0 to +3.0) at last follow up (≥1 year). No patients experienced post FSB Grade 3 or higher GU or GI toxicities.

CONCLUSION

High dose FSB for a local recurrence of prostate cancer after EBRT can be delivered with good biochemical control and a favorable toxicity profile. Further clinical trial enrollment and longer follow up will be needed to better assess long term outcomes.

Prospective evaluation of cerebrospinal fluid levels of β-Endorphin as a predictor of opioid use after scheduled cesarean delivery

Background

Prior laboratory work indicates that lower endogenous opioid function is associated with greater analgesic and subjective responses to opioid analgesics. We evaluated whether lower preoperative cerebrospinal uid (CSF) levels of the analgesic endogenous opioid β-Endorphin (BE) were associated with increased opioid use after cesarean delivery (CD).

Methods

We enrolled 136 pregnant women without opioid use or chronic pain who were undergoing CD under regional anesthesia. Preoperatively, participants completed validated pain measures and biospecimens were collected to assess BE levels in plasma and CSF. Postoperatively, pain measures at 48 hours and 2 weeks postpartum were assessed. We evaluated the association between CSF BE levels and total opioid use (in morphine milligram equivalents; MMEs) using linear regression controlling for confounding factors (primary analysis). In secondary analyses, we examined: 1) associations between plasma BE levels and total opioid use, and 2) associations between CSF and plasma BE levels and secondary outcomes (inpatient versus outpatient opioid use, pain intensity).

Results

Participants completed surveys with 100% response rate. The majority were non-Hispanic white (65%), college educated (58%), had private insurance (71%), and had a prior cesarean delivery (69%). Psychiatric diagnoses (depression or anxiety) were common, both currently (22%) and in the past (26%).The median total opioid use across the inpatient and 2-week postpartum follow-up period was 89.1 milligram morphine equivalents (IQR 25-138). Preoperative cerebrospinal uid β-Endorphin levels were not associated with total opioid use (beta = -0.05, SE 0.45, p = 0.64). Similar findings were noted for plasma β-Endorphin levels. cerebrospinal uid β-Endorphin levels were only weakly correlated with plasma β-Endorphin levels (r = 0.30, p < .01). Preoperative cerebrospinal uid and plasma β-Endorphin levels were both positively associated with postpartum pain measures (cerebrospinal uid: at 48 hours, beta = 0.19, SE 0.16, p < 0.05; Plasma: at 48-hours, beta = 0.02, SE 0.03, p = 0.02, and at 2-weeks, beta = 0.27, SE 0.03, p < 0.01).

Conclusions

Lower preoperative cerebrospinal uid levels of β-Endorphin are not associated with increased opioid analgesic use after scheduled cesarean delivery. It is possible that unassessed variability in baseline opioid receptor sensitivity may have confounded ability to test associations between β-Endorphin levels and opioid use outcomes.

Maternal Opioid Use Disorder and the Risk of Postneonatal Infant Mortality

Importance

The risk of serious long-term outcomes for infants born to individuals with opioid use disorder (OUD) is not fully characterized, nor is it well understood whether risks are modified by infant diagnosis of neonatal opioid withdrawal syndrome (NOWS).

Objective

To characterize the risk of postneonatal infant mortality among infants with a NOWS diagnosis or born to individuals with OUD.

Design, Setting, and Participants

The study team conducted a retrospective cohort study of 390 075 infants born from 2007 through 2018 to mothers who were enrolled in Tennessee Medicaid from 183 days prior to delivery through 28 days post partum (baseline). Maternal and infant baseline characteristics were measured using administrative claims and birth certificates, and infants were followed up from day 29 post partum through day 365 or death. Deaths were identified using linked death certificates through 2019. These data were analyzed from February 10, 2022, through March 3, 2023.

Exposure

Infant exposures included birth to an individual with OUD or postnatal diagnosis of NOWS. The study team defined a pregnant individual's OUD status (maternal OUD) as having OUD diagnosis or a maintenance medication prescription fill during baseline; this study defined NOWS as having NOWS diagnosis up to day 28. Groups were categorized by exposures as maternal OUD with NOWS (OUD positive/NOWS positive), maternal OUD without NOWS (OUD positive/NOWS negative), no documented maternal OUD with NOWS (OUD negative/NOWS positive), and no documented maternal OUD or NOWS (OUD negative/NOWS negative, unexposed).

Main Outcome and Measures

The outcome was postneonatal infant death, confirmed by death certificates. Cox proportional hazards models were used, adjusting for baseline maternal and infant characteristics, to estimate adjusted hazard ratios (aHRs) and 95% CIs for the association between maternal OUD or NOWS diagnosis with postneonatal death.

Results

Pregnant individuals in the cohort had a mean (SD) age of 24.5 (5.2) years; 51% of infants were male. The study team observed 1317 postneonatal infant deaths and incidence rates of 3.47 (OUD negative/NOWS negative, 375 718), 8.41 (OUD positive/NOWS positive, 4922); 8.95 (OUD positive/NOWS negative, 7196), and 9.25 (OUD negative/NOWS positive, 2239) per 1000 person-years. After adjustment, the risk of postneonatal death was elevated for all groups, relative to the unexposed: OUD positive/NOWS positive (aHR, 1.54; 95% CI, 1.07-2.21), OUD positive/NOWS negative (aHR, 1.62; 95% CI, 1.21-2.17), and OUD negative/NOWS positive (aHR, 1.64; 95% CI, 1.02-2.65).

Conclusions and Relevance

Infants born to individuals with OUD or with a NOWS diagnosis had an increased risk of postneonatal infant mortality. Future work is necessary to create and evaluate supportive interventions for individuals with OUD during and after pregnancy to reduce adverse outcomes.

Social Vulnerability and Initiation of Pharmacotherapy for Gestational Diabetes Mellitus in a Medicaid Population

OBJECTIVE

Our study examines the association between social vulnerability index (SVI) and pharmacotherapy initiation for gestational diabetes mellitus (GDM).

METHODS

We studied a retrospective cohort of pregnant patients with GDM, enrolled in Tennessee Medicaid, who gave birth between 2007 and 2019. Enrollment files were linked to birth and death certificates, state hospitalization registries, and pharmacy claims. SVI, measured at the community level and determined by residential census tract, ranged from 0 to 100 (low to high vulnerability). Multivariable logistic regression assessed the association between SVI and the odds of initiating the most common pharmacotherapies for GDM-insulin, glyburide, or metformin-and adjusted for relevant covariates. SVI was modeled with restricted cubic splines to account for nonlinear associations, using the median Tennessee SVI as a reference. Secondary analysis assessed associations with the SVI subthemes.

RESULTS

Among 33,291 patients with GDM, 21.7% (7,209) initiated pharmacotherapy during pregnancy. Patients from areas with higher SVI were more likely to be non-Hispanic Black with higher body mass index, whereas those with lower SVI were more likely to be nulliparous. Multivariable modeling demonstrated a complex nonlinear association between SVI and GDM pharmacotherapy initiation, relative to the reference. Higher SVI was associated with elevated odds of GDM pharmacotherapy initiation (e.g., odds ratio 1.11 [95% confidence interval 1.02-1.22] for SVI 80) and low to medium SVI had variable nonsignificant associations with GDM pharmacotherapy initiation, relative to the reference (lower odds of initiation for values 25-50, higher odds of initiation for values < 25). Secondary analysis demonstrated a nonlinear association between subtheme 3 and the odds of GDM pharmacotherapy initiation.

CONCLUSION

Social vulnerability is associated with initiation of pharmacotherapy for GDM, highlighting the possible role of social determinants of health in achieving glycemic control.

A Novel Simulation Model for Resident Education in Mechanical Cervical Ripening

INTRODUCTION

This study aims to evaluate resident satisfaction with a novel simulation model for learning transcervical balloon catheter placement for mechanical cervical ripening.

STUDY DESIGN

A descriptive pretest and post-test survey study of Obstetrics and Gynecology (OBGYN) residents was conducted at a single academic medical center using a low-cost model.

RESULTS

Of 28 residents, 14 (50%) were recruited. 100% of participants completed the pretest and post-test survey. Residents agreed that both learning and achieving correct placement of a transcervical balloon catheter are difficult. Pretest and post-test comparisons were statistically different with respect to comfort (2.8 ± 1.5 vs. 4.0 ± 1.0, p = 0.03) and ease of learning (3.1 ± 0.8 vs. 4.1 ± 0.6, p ≤ 0.001).

DISCUSSION

We present a novel simulation model that can be used by OBGYN residents in training for learning transcervical balloon catheter placement for mechanical cervical ripening.

KEY POINTS

· There is no current validated model for teaching placement of mechanical cervical ripening.. · This study outlines a novel and simple simulation model.. · This model is easily made, accessible, and of a low cost design..

Statins in Pregnancy: Can We Justify Early Treatment of Reproductive Aged Women?

PURPOSE OF REVIEW

Statins are the pillar of secondary prevention in reducing cardiovascular disease in high-risk adults. However, statin discontinuation is the standard recommendation in pregnant and lactating patients. This review evaluates whether we can justify the early treatment of reproductive aged women with statin therapy.

RECENT FINDINGS

Statins have several potential benefits including its antioxidant, anti-inflammatory, and anti-thrombogenic properties that may prevent the worsening of atherosclerosis in high-risk women. Nevertheless, most studies on statins and teratogenicity have a limited sample size and the effects of long-term statin use on fetal and neonatal health remain unknown. Not all statins may be safe and pravastatin's cholesterol-lowering properties may be too limited to provide much maternal benefit in pregnancy. While emerging evidence supports the use of pravastatin in pregnancy, we need to better assess the risk of early cardiovascular disease and acute progression of atherosclerosis before and during pregnancy to better understand the risks and benefits of statin use.

Discovery and fine mapping of Rph28: a new gene conferring resistance to Puccinia hordei from wild barley

A new gene Rph28 conferring resistance to barley leaf rust was discovered and fine-mapped on chromosome 5H from wild barley. Leaf rust is a highly destructive disease of barley caused by the fungal pathogen Puccinia hordei. Genetic resistance is considered to be the most effective, economical and eco-friendly approach to minimize losses caused by this disease. A study was undertaken to characterize and fine map a seedling resistance gene identified in a Hordeum vulgare ssp. spontaneum-derived barley line, HEB-04-101, that is broadly effective against a diverse set of Australian P. hordei pathotypes. Genetic analysis of an F₃ population derived from a cross between HEB-04-101 and the H. vulgare cultivar Flagship (seedling susceptible) confirmed the presence of a single dominant gene for resistance in HEB-04-101. Selective genotyping was performed on representative plants from non-segregating homozygous resistant and homozygous susceptible F₃ families using the targeted genotyping-by-sequencing (tGBS) assay. Putatively linked SNP markers with complete fixation were identified on the long arm of chromosome 5H spanning a physical interval between 622 and 669 Mb based on the 2017 Morex barley reference genome assembly. Several CAPS (cleaved amplified polymorphic sequences) markers were designed from the pseudomolecule sequence of the Morex assembly (v1.0 and v2.0), and 16 polymorphic markers were able to delineate the RphHEB locus to a 0.05 cM genetic interval spanning 98.6 kb. Based on its effectiveness and wild origin, RphHEB is distinct from all other designated Rph genes located on chromosome 5H and therefore the new locus symbol Rph28 is recommended for RphHEB in accordance with the rules and cataloguing system of barley gene nomenclature.

Recycling waste plastics in roads: A life-cycle assessment study using primary data

The present study investigates - from an environmental perspective - the processes that lead to the conversion of waste plastics into recycled plastic pellets to be used either as an additive (wet method) or as a replacement of natural aggregate (dry method) in the production of asphalt mixes. Data from recycling facilities in Victoria, Australia, were collected and used as the basis for a comparative life cycle assessment (LCA) study. Analyses were conducted by considering several replacement ratios of virgin material by its recycled counterpart in the so-called wet and dry method. A case study considering the production of recycled-plastic asphalt to be applied in the construction of a typical surface layer of a road in Victoria was evaluated. In general, the results show that recycling plastics as a polymer for bitumen modification and as a synthetic aggregate replacement in asphalt mixes has the potential to be environmentally advantageous compared to their virgin counterpart (i.e. virgin polymers and natural quarry aggregates).

Risks associated with cesarean delivery during prolonged second stage of labor

BACKGROUND

Data regarding maternal and fetal morbidities are limited to surgical morbidity per each additional hour in the second stage of labor.

OBJECTIVE

This study aimed to quantify perinatal morbidities associated with cesarean delivery by duration of the second stage of labor.

STUDY DESIGN

Our work is a retrospective cohort study of cesarean deliveries during the second stage of labor using the Consortium on Safe Labor database. All term, singleton pregnancies in cephalic presentation were included. Women with stillbirth or contraindications to vaginal delivery were excluded. Groups were divided by duration of the second stage of labor: ≤3 hours, 3-4 hours, 4-5 hours, 5-6 hours, and >6 hours. The primary outcome was a composite of maternal morbidities. The secondary outcomes were a composite of neonatal morbidities and individual maternal and neonatal morbidities. Baseline demographic and clinical characteristics were compared among groups. Univariate and multivariate analyses were performed.

RESULTS

We included 6273 women in total. In addition, 3652 women (58.2%) went through the second stage for ≤3 hours, 854 (13.6%) for 3 to 4 hours, 618 (9.9%) for 4 to 5 hours, 397 (6.3%) for 5 to 6 hours, and 752 (12.0%) for >6 hours. Neither the maternal nor neonatal morbidity composite outcomes were statistically different among the groups. Extended maternal length of stay (>5 days), increased birthweight, and lower rates of general anesthesia were associated with an increased duration of the second stage of labor. Chorioamnionitis, wound complications, postpartum hemorrhage, and thrombosis did not increase over time.

CONCLUSION

Women should be counseled regarding the duration of the second stage of labor, which should include a discussion of the risks associated with a cesarean delivery with a prolonged second stage of labor. However, these risks may not be as high as anticipated.

Extending the window for thrombolysis for treatment of acute ischaemic stroke during pregnancy: a review

Historically, safety of intravenous recombinant tissue plasminogen activator (IV rt-PA) for the treatment of acute ischaemic stroke (AIS) is limited to use within 4.5 hours from symptom onset. Recent studies suggest the treatment window may be extended when patients have salvageable brain tissue on advanced neuroimaging. This paper describes a novel use of IV rt-PA for treatment of AIS in a pregnant patient within an extended-time window (>4.5 hours, and <9 hours) based on advanced neuroimaging with a favourable outcome. TWEETABLE ABSTRACT: Novel use of IV rt-PA for treatment of AIS in pregnancy within an extended-time window based on advanced imaging with a favourable outcome.

Fetal adrenal gland size and the ability to predict spontaneous term labor

OBJECTIVE

The objective of this study was to evaluate whether ultrasound measured fetal adrenal gland size can be a predictor of spontaneous term labor.

STUDY DESIGN

This study was a diagnostic test accuracy study using a prospective cohort design evaluating the ability of 2-dimensional ultrasound measurement of fetal adrenal gland total length, total width, fetal zone length and fetal zone width in women in the third trimester to predict the primary outcome of spontaneous term labor. Secondary outcomes were vaginal delivery, length of labor, and maternal and neonatal morbidities.

RESULTS

Of 43 patients recruited, 3 were excluded. 11 (25.6%) presented in spontaneous labor and 29 (67.4%) underwent induction of labor. Patient demographics were similar for all included except for admission cervical exam and oxytocin use. A receiver operative curve was created to assess test predictability. Weighted width of fetal adrenal gland was the best predictor of spontaneous labor amongst variables measured with an area under the curve of 0.674, p = 0.93. w/W ≥ 0.41 had a sensitivity of 91.0%, specificity of 44.8%, positive predictive value of 38.5% and a negative predictive value of 92.3%. Maternal and neonatal morbidities were not different between the spontaneous labor group and the induction of labor group.

CONCLUSION

Ultrasound measured fetal w/W was moderately predictive of spontaneous labor.

Pushing the bounds of second stage in term nulliparas with a predictive model

BACKGROUND

Management of the second stage of labor continues to be a clinical challenge with unclear indications for abandoning attempts at spontaneous vaginal delivery. The conflict between diminishing chances of spontaneous vaginal delivery and increasing maternal and neonatal morbidity is difficult to quantify, leading to significant variation in management between providers, and variation in rates of operative vaginal delivery and cesarean birth.

OBJECTIVE

The objective of the study was to develop an hourly prediction model for spontaneous vaginal delivery during the second stage of labor in nulliparous women with epidural anesthesia.

STUDY DESIGN

This was a secondary analysis of the Consortium for Safe Labor database. The Consortium for Safe Labor collected data from 228,652 patients at 19 hospitals in the United State from 2002 through 2008. Primary outcome was delivery type per hour of second stage: spontaneous vaginal delivery vs operative delivery (operative vaginal and cesarean delivery). Inclusion criteria were term nulliparas with singleton gestations, vertex presentation, and attainment of 10 cm cervical dilation with epidural anesthesia. Exclusion criteria were intrauterine fetal demise, planned cesarean delivery, and major congenital anomalies. An optimal decision tree was used to create a prediction model. A test set was withheld from the data set to perform validation. A risk calculator tool was developed for prediction of spontaneous vaginal birth as well as adverse perinatal outcomes per hour. Adverse maternal outcomes were a composite of postpartum hemorrhage, transfusion, endometritis and third-/fourth-degree laceration. Adverse neonatal outcomes were a composite of neonatal intensive care unit admission, hypoxic ischemic encephalopathy, respiratory distress, seizures, apnea, asphyxia, and shoulder dystocia.

RESULTS

The study population included 228,438 deliveries; 26,796 patients met inclusion and exclusion criteria. After removing cases with incomplete data, the study population consisted of 22,299 women, of which 16,593 women had a spontaneous vaginal delivery (74.4%). The number of deliveries at a given hospital per year, fetal position, cervical dilation on admission, chorioamnionitis, augmentation of labor, maternal age, and length of second stage were associated with the odds of spontaneous vaginal delivery. Using the predictors identified, a risk predictor calculator was created, taking into consideration the length of time in the second stage. A receiver-operator characteristic curve was developed to assess the calculator; area under the curve was 0.73. This calculator is available at https://www.pushprescriber.com/.

CONCLUSION

Spontaneous vaginal delivery for women with term, cephalic, singleton gestations with epidural anesthesia was associated with several variables. This calculator tool helps facilitate provider decision making and patient counseling about the value of continuing the second stage of labor based on changing rates of success and risks of maternal and neonatal morbidity with time.

Amalgam Strength Resistance to Various Contaminants

Purpose:

The purpose of this study was to quantify the relative strength tolerance of 1-day and 30-day amalgam following saturation contamination with water, saliva, blood, and handpiece lubricant oil during condensation.

Methods and Materials:

Valiant PhD XT amalgam was tested with 300 shear-strength (N=15) and 120 compressive-strength (N=6) specimens, divided into 1-day and 30-day groups, each with control, water, saliva, blood, and lubricant oil contamination samples. Shear specimens were condensed in 4 × 4-mm anchor wells inundated with contaminant fluids before adding a ring mold with 3.5-mm-diameter central hole adapted immediately to the top for continued condensation under contaminant-submerged conditions. Compressive specimen samples were condensed while completely inundated by each contaminant using the American Dental Association Specification No. 1 amalgam mold apparatus. All specimens were tested with the Instron E3000 and E10000 at 0.5 mm/min, with data statistically evaluated using the Kruskal-Wallis procedure with IBM SPSS v25 and Wilcoxon signed ranks test.

Results:

Shear test values (mean±SD) following intracapsular and extracapsular contamination after 30 days under 100% humidity at 37°C were as follows: control, 30.97±5.41 MPa; water, 30.63 ±4.41 MPa; saliva, 27.54 ±4.56 MPa; blood, 24.92 ±3.48 MPa; lubricant oil, 26.06 ±4.06 MPa. Compressive strengths (±SD) of similarly contaminated samples were as follows: control, 447.7 ±76.3 MPa; water, 343.6 ±70.1 MPa; saliva, 307.7 ±24.0 MPa; blood, 281.6 ±35.2 MPa; lubricant oil, 227.8 ±16.9 MPa.

Conclusions:

Saliva, blood, and handpiece oil diminish compressive strength significantly, but water shows no statistically significant effect (p&gt;0.05). Amalgam 30-day shear strength is significantly altered by contamination with water, blood, or handpiece lubricant oil (p&lt;0.05). Remaining amalgam strength after extensive contamination may still be clinically functional relative to a previous ADA recommendation and when compared with resin-based direct restorative materials.

Genetic abnormalities seen on CVS in early pregnancy failure

Objective: To determine the frequency and distribution of chromosome abnormalities in women with early pregnancy failure (EPF) detected by cytogenetic testing on chorionic villus sampling.Method: Retrospective observational cohort study of chromosomal analysis from transvaginal chorionic villus sampling (CVS) or reflex products of conception (POC) karyotype. CVS was offered as a training tool for Maternal Fetal Medicine fellows prior to manual vacuum aspiration for EPF 9-week gestation. POC were analyzed for cytogenetics if no results were obtained on CVS.Results: One hundred thirty samples were collected from December 2011 to April 2015. 33 (27.3%) cases had a normal karyotype and 88 (73.0%) cases had an abnormal karyotype. The most common group of abnormalities were trisomy, (n = 50, 41.3%), triploidy/tetraploidy, (n = 17, 14.0%), monosomy (n = 15, 12.4%), and structural rearrangements (n = 6, 5.0%). Nine (6.9%) samples were maternal decidua only. Abnormal karyotype in EPF was significantly increased in women by age group (p < .01) but not in women with a history of prior miscarriage (p = .5).Conclusion: Our cohort had a high detection rate of aneuploidy. The most common chromosomal abnormalities in EPF were: trisomy, followed by triploidy/tetraploidy, monosomy, and structural rearrangements. Maternal age had the strongest correlation with EPF associated with aneuploidy.

Endogenous attention improves perception in amblyopic macaques

Amblyopia, a developmental disorder of vision, affects many aspects of spatial vision as well as motion perception and some cognitive skills. Current models of amblyopic vision based on known neurophysiological deficiencies have yet to provide an understanding of the wide range of amblyopic perceptual losses. Visual spatial attention is known to enhance performance in a variety of detection and discrimination tasks in visually typical humans and nonhuman primates. We investigated whether and how voluntary spatial attention affected psychophysical performance in amblyopic macaques. Full-contrast response functions for motion direction discrimination were measured for each eye of six monkeys: five amblyopic and one control. We assessed whether the effect of a valid spatial cue on performance corresponded to a change in contrast gain, a leftward shift of the function, or response gain, an upward scaling of the function. Our results showed that macaque amblyopes benefit from a valid spatial cue. Performance with amblyopic eyes viewing showed enhancement of both contrast and response gain whereas fellow and control eyes' performance showed only contrast gain. Reaction time analysis showed no speed accuracy trade-off in any case. The valid spatial cue improved contrast sensitivity for the amblyopic eye, effectively eliminating the amblyopic contrast sensitivity deficit. These results suggest that engaging endogenous spatial attention may confer substantial benefit to amblyopic vision.

From Brain Disease to Brain Health: Primary Prevention of Alzheimer's Disease and Related Disorders in a Health System Using an Electronic Medical Record-Based Approach

BACKGROUND

Alzheimer's disease and aging brain disorders are progressive, often fatal neurodegenerative diseases. Successful aging, modern lifestyles and behaviors have combined to result in an expected epidemic. Risks for these diseases include genetic, medical, and lifestyle factors; over 20 modifiable risks have been reported.

OBJECTIVES

We aim to primarily prevent Alzheimer's disease and related disorders through electronic medical record (EMR)-based screening, risk assessments, interventions, and surveillance.

DESIGN

We identified modifiable risks; developed human, systems and infrastructural resources; developed interventions; and targeted at-risk groups for the intervention.

SETTING

A Community Based Health System.

PARTICIPANTS

In year one (June 2015 to May 2016), 133 at-risk patients received brain health services with the goal of delaying or preventing Alzheimer's disease and related disorders.

MEASUREMENTS

We created mechanisms to identify patients at high risk of neurodegenerative disease; EMR-based structured clinical documentation support tools to evaluate risk factors and history; evidence-based interventions to modify risk; and the capacity for annual surveillance, pragmatic trials, and practice-based and genomic research using the EMR.

RESULTS

This paper describes our Center for Brain Health, our EMR tools, and our first year of healthy but at-risk patients.

CONCLUSION

We are translating research into primary prevention of Alzheimer's disease and related disorders in our health system and aim to shift the paradigm in Neurology from brain disease to brain health.

Prehypertension in Early Pregnancy: What is the Significance?

Objective Hypertensive disorders play a significant role in maternal morbidity and mortality. There is limited data on prehypertension (pre-HTN) during the first half of pregnancy. We sought to examine the risk of adverse pregnancy outcomes in patients with prehypertension in early pregnancy (<20 weeks' gestational age). Study Design A retrospective cohort study of 377 patients between 2013 and 2014. Patients were divided based on the highest blood pressure in early pregnancy, as defined per the JNC-7 criteria. There were 261 control patients (69.2%), 95 (25.2%) pre-HTN patients, and 21 (5.6%) chronic hypertension (CHTN) patients. The groups were compared using X², Fisher's Exact, Student t-test, and Mann-Whitney U test with p < 0.05 used as significance. Results Patients with pre-HTN delivered earlier (38.8 ± 1.9 weeks vs 39.3 ± 1.7 weeks), had more pregnancy related hypertension (odds ratio [OR], 4.62; confidence interval [CI], 2.30-9.25; p < 0.01) and composite maternal adverse outcomes (OR, 2. 10; 95% CI, 1.30-3.41; p < 0.01), NICU admission (OR, 2.21; 95% CI, 1.14-4.26; p = 0.02), neonatal sepsis (OR, 6.12; 95% CI, 2.23-16.82; p < 0.01), and composite neonatal adverse outcomes (OR, 2.05; 95% CI, 1.20-3.49; p < 0.01). Conclusion Although women with pre-HTN are currently classified as normal in obstetrics, they are more similar to women with CHTN. Pre-HTN in the first half of pregnancy increases the likelihood of adverse outcomes.

Theoretical prediction of long-range ferromagnetism in transition-metal atom-doped d0 dichalcogenide single layers SnS2 and ZrS2

We have systematically investigated the effects of transition-metal (TM) atom (Sc-Zn) doping in 2D d⁰ materials SnS₂ and ZrS₂via the density functional theory method. Our results demonstrate that the conductivity and magnetism of SnS₂ and ZrS₂ can be engineered to spin-polarize half-metal/metal with appropriate TM dopants. For both materials, nontrivial magnetic interactions can be induced by V/Cr/Mn/Fe/Co doping. Specifically, the various behaviors of the magnetic exchanges in TM-doped SnS₂ and ZrS₂ are due to the competition between the super-exchange, the double exchange, and the p-d exchange interactions, which are dependent on the dopants' chemistry and spatial positions. Thus, our results give potential guidance for future experiments to create functionalized d⁰ nano-electronic devices.

Uterocervical angle: a novel ultrasound screening tool to predict spontaneous preterm birth

BACKGROUND

Mechanical alteration of the cervical angle has been proposed to reduce spontaneous preterm birth. Performance of the uterocervical angle as measured by ultrasound for predicting spontaneous preterm birth is poorly understood.

OBJECTIVE

We sought to determine whether a novel ultrasonographic marker, uterocervical angle, correlates with risk of spontaneous preterm birth in a general population.

STUDY DESIGN

We conducted a retrospective cohort study from May 2014 through May 2015 of singleton gestations between 16 0/7-23 6/7 weeks undergoing transvaginal ultrasound for cervical length screening. Images were remeasured for uterocervical angle between the lower uterine segment and the cervical canal. Primary outcome was prediction of spontaneous preterm birth <34 weeks and <37 weeks by uterocervical angle and secondary outcome evaluated cervical length and spontaneous preterm birth.

RESULTS

A total of 972 women were studied. The rate of spontaneous preterm birth in this cohort was 9.6% for delivery <37 weeks and 4.5% for <34 weeks. Uterocervical angle of ≥95 degrees was significantly associated with spontaneous preterm birth <37 weeks with sensitivity of 80% (P < .001; confidence interval, 0.70-0.81; negative predictive value, 95%). Uterocervical angle of ≥105 degrees predicted spontaneous preterm birth <34 weeks with sensitivity of 81% (P < .001; confidence interval, 0.72-0.86; negative predictive value, 99%). Cervical length ≤25 mm significantly predicted spontaneous preterm birth <37 weeks (P < .001; sensitivity, 62%; negative predictive value, 95%) and <34 weeks (P < .001; sensitivity, 63%; negative predictive value, 97%). Regression analysis revealed a significant association of maternal age, nulliparity, race, and obesity at conception with spontaneous preterm birth and uterocervical angle. There was no correlation identified between history of dilation and curettage, abnormal Pap smear results, excisional cervical procedures, smoking, or obesity at delivery on spontaneous preterm birth and uterocervical angle.

CONCLUSION

A wide uterocervical angle ≥95 and ≥105 degrees detected during the second trimester was associated with an increased risk for spontaneous preterm birth <37 and <34 weeks, respectively. Uterocervical angle performed better than cervical length in this cohort. Our data indicate that uterocervical angle is a useful, novel transvaginal ultrasonographic marker that may be used as a screening tool for spontaneous preterm birth.

Engineering the electronic and magnetic properties of d(0) 2D dichalcogenide materials through vacancy doping and lattice strains

We have systematically investigated the effects of different vacancy defects in 2D d(0) materials SnS2 and ZrS2 using first principles calculations. The theoretical results show that the single cation vacancy and the vacancy complex like V-SnS6 can induce large magnetic moments (3-4 μB) in these single layer materials. Other defects, such as V-SnS3, V-S, V-ZrS3 and V-ZrS6, can result in n-type conductivity. In addition, the ab initio studies also reveal that the magnetic and conductive properties from the cation vacancy and the defect complex V-SnS6 can be modified using the compressive/tensile strain of the in-plane lattices. Specifically, the V-Zr doped ZrS2 monolayer can be tuned from a ferromagnetic semiconductor to a metallic/half-metallic material with decreasing/increasing magnetic moments depending on the external compressive/tensile strains. On the other hand, the semiconducting and magnetic properties of V-Sn doped SnS2 is preserved under different lattice compression and tension. For the defect complex like V-SnS6, only the lattice compression can tune the magnetic moments in SnS2. As a result, by manipulating the fabrication parameters, the magnetic and conductive properties of SnS2 and ZrS2 can be tuned without the need for chemical doping.