A hands-on resident umbilical cord blood educational curriculum compared to online education of post-residency obstetricians: comparison of the volume of collected cord blood units.

BACKGROUND: Umbilical cord blood unit (CBU) volume is a predictor of its later clinical utility. Many studies suggest the need to increase the volume of CBU collected, but most obstetrical providers receive no formal collection training. STUDY DESIGN AND METHODS: We designed and implemented an educational curriculum for obstetrics residents aimed at improving collection methods and increasing CBU volumes (CBUV). Residents were required to attend grand rounds and interactive didactic sessions on CBU collection followed by work with a simulated collection kit and then performed training collections under observation by a trained collector. Residents completed a self-assessment after each collection and received immediate personal feedback. Outside providers (non-UAMS physicians) received written instructional materials with the collection kits and had access to online training materials. They received feedback regarding their collection via standard mail. CBU donated to Cord Blood Bank of Arkansas for public use from 2014-2016 were analyzed. CBUV from residents were compared to those from outside providers. RESULTS: After adjusting for maternal age and race, infant gender, gestational age, and birth weight, the least-squared mean CBUV was 92.1 mL for UAMS collections and 65.5 mL for outside provider collections. The improved CBUV of UAMS providers is statistically significant (p < 0.0001). CONCLUSION: Our educational intervention was successful, and we believe that it can be replicated in other obstetrical residency programs. Cord blood collection education involving hands-on training with a model and immediate feedback improves CBUV, decreases kit waste, increases likelihood of CBU storage, and, therefore, inventory for transplantation.

Childhood Respiratory Morbidity after Late Preterm and Early Term Delivery: a Study of Medicaid Patients in South Carolina.

BACKGROUND: There is a growing body of research documenting an increased risk of neonatal morbidity for late preterm infants (LPI, 34(0/7) weeks to 36(6/7) weeks) and early term infants (ETI, 37(0/7) weeks to 38(6/7) weeks) compared with term infants (TI, 39(0/7) to 41(6/7) ); however, there has been little research on outcomes beyond the first year of life. In this study, we examined respiratory outcomes of LPI and ETI in early childhood. METHODS: South Carolina Medicaid claims data for maternal delivery and infant birth hospitalisations were linked to vital records data for the years 2000 through 2003. Medicaid claims for all infants were then followed until their fifth birthday or until a break in their eligibility. Infants born between 34(0/7) and 41(6/7) weeks were eligible. Infants with congenital anomaly, birthweight below 500 g or above 6000 g, and multiple births were excluded. We fit Cox proportional hazard models from which adjusted hazard ratio (HR) and 95% confidence interval (CI) were derived. RESULTS: A total of 3476 LPI, 12 398 ETI, and 25 975 term infants were included. Both LPI and ETI were associated with an increased risk for asthma (LPI: HR 1.24, 95% CI 1.10, 1.40; ETI: HR 1.12, 95% CI 1.06, 1.19), and bronchitis (LPI: HR 1.15, 95% CI 1.00, 1.34; ETI: HR 1.13, 95% CI 1.05, 1.2) at 3 to 5 years of age. CONCLUSIONS: Late preterm infants and early term infants are at increased risk for asthma and bronchitis.

A phase I dose-escalation clinical trial of a peptide-based human papillomavirus therapeutic vaccine with Candida skin test reagent as a novel vaccine adjuvant for treating women with biopsy-proven cervical intraepithelial neoplasia 2/3.

PURPOSE: Non-surgical treatments for cervical intraepithelial neoplasia 2/3 (CIN2/3) are needed as surgical treatments have been shown to double preterm delivery rate. The goal of this study was to demonstrate safety of a human papillomavirus (HPV) therapeutic vaccine called PepCan, which consists of four current good-manufacturing production-grade peptides covering the HPV type 16 E6 protein and Candida skin test reagent as a novel adjuvant. PATIENTS AND METHODS: The study was a single-arm, single-institution, dose-escalation phase I clinical trial, and the patients (n = 24) were women with biopsy-proven CIN2/3. Four injections were administered intradermally every 3 weeks in limbs. Loop electrical excision procedure (LEEP) was performed 12 weeks after the last injection for treatment and histological analysis. Six subjects each were enrolled (50, 100, 250, and 500 µg per peptide). RESULTS: The most common adverse events (AEs) were injection site reactions, and none of the patients experienced dose-limiting toxicities. The best histological response was seen at the 50 µg dose level with a regression rate of 83% (n = 6), and the overall rate was 52% (n = 23). Vaccine-induced immune responses to E6 were detected in 65% of recipients (significantly in 43%). Systemic T-helper type 1 (Th1) cells were significantly increased after four vaccinations (P = 0.02). CONCLUSION: This study demonstrated that PepCan is safe. A significantly increased systemic level of Th1 cells suggests that Candida, which induces interleukin-12 (IL-12) in vitro, may have a Th1 promoting effect. A phase II clinical trial to assess the full effect of this vaccine is warranted.

Tracking the changes in synchrony of the electrophysiological activity as the uterus approaches labor using magnetomyographic technique.

The objective of the study was to perform serial magnetomyographic examinations in order to detect changes in synchrony characteristics of myometrial electrophysiological activity as women approach labor. Of the total of 56 patients recruited, the results of 149 examinations from 29 patients were included in the analysis. The global synchrony across each sensor spread over the abdomen was computed and quantified as synchronization index. The mean and the median value of the global synchrony were computed and correlated with time to active labor from the last recording. Overall, synchrony increased as the patient approached active labor (P = .035). Furthermore, mean synchronization index increased twice as fast in the nonnulliparous group compared to the nulliparous group (P = .039). The changes in synchrony of uterine electrophysiological activity near term could aid in prediction of labor.

Differences in the sleep states of IUGR and low-risk fetuses: An MCG study.

BACKGROUND: Intrauterine growth restriction (IUGR) is a fetal condition characterized by growth-rate reduction. Afflicted fetuses tend to display abnormalities in heart rate. OBJECTIVE: To study the differences in the heart-rate variability of low-risk fetuses and IUGR fetuses during different behavioral states. METHODS: A total of 40 fetal magnetocardiograms were analyzed from 20 low-risk and 20 IUGR fetuses recorded using a 151-sensor SQUID-array system. The maternal cardiac signals were attenuated using signal-space projection. Fetal R waves were identified using an adaptive Hilbert transform approach and fetal heart rate was calculated. In each three-minute window, the heart rate was classified into patterns reflective of quiet sleep (pattern A) and active sleep (pattern B) using the criteria of Nijhuis. Two adjacent 3-min windows exhibiting the same pattern were selected for analysis from every dataset. Heart-rate variability in that 6-min window was characterized using three measures, standard deviation of normal to normal (SDNN), root mean square of successive differences (RMSSD) and phase plane area (PPA). RESULTS: All three measures tended to be lower in the IUGR group compared to the low-risk group. However, when the measures were analyzed in patterns, only PPA showed significant difference between the risk groups in pattern A, whereas both PPA and SDNN showed highly significant risk-group differences in pattern B. RMSSD did not show any significant risk-group difference. CONCLUSION: The result signifies that the heart-rate variability of IUGR fetuses is different from that of low-risk fetuses, and only PPA was able to capture the HRV differences in both quiet and active states. The difference between these two groups of fetuses shows that the fetal-activity states are potential confounders when characterizing heart-rate variability.

Risk factors for a prolonged third stage of labor and postpartum hemorrhage.

OBJECTIVES: To determine the effect of a third stage of labor ≥15 minutes on bleeding after delivery and other risk factors for a postpartum hemorrhage (PPH). METHODS: This was a case-control study of women undergoing vaginal delivery with placental delivery ≥15 minutes matched by gestational age to the next delivery with placental delivery <15 minutes. Multiple risk factors were evaluated for association with delayed placenta and with PPH. RESULTS: There were 226 pregnancies ≥15 minutes (cases) versus 226 whose placental time was <15 minutes (controls). The best-fit model identified placental delivery ≥15 minutes, history of retained placenta, nulliparity, and increased length of first stage of labor as significant factors for PPH. CONCLUSIONS: The best risk model for PPH includes placental delivery ≥15 minutes, history of retained placenta, nulliparity, and longer first stage of labor.

Evolving trends in maternal fetal medicine referrals in a rural state using telemedicine.

OBJECTIVE: To determine maternal fetal medicine (MFM) referral trends in a Medicaid population over time. STUDY DESIGN: Sixteen clinical guidelines and 23 clinical conditions were identified where co-management/consultation with MFM specialist is recommended. Linked Medicaid claims and birth certificate data for 2001-2006 were used to identify pregnancies with these conditions and whether they received co-management/consultation from a MFM specialist. RESULTS: Between 2001 and 2006, there were 108,703 pregnancies with delivery of 110,890 neonates. Forty-five percent had one or more of the conditions identified for co-management/consultation. Overall pregnancies receiving MFM contact remained unchanged at 22.2% in 2001 and 22.1% in 2006. However, face to face contacts decreased from 14.6% (2001) to 8.7% (2006) while telemedicine consults increased from 7.6% (2001) to 13.3% (2006). Health departments were most likely and family practitioners least likely to refer to MFM (p<0.001). Pregnancy complications leading to MFM referrals include cardiac complications, renal disease, systemic disorders, PPROM, suspected fetal abnormalities, and cervical insufficiency. CONCLUSION: Referral of high-risk pregnancies to MFMs varies with the level of expertise at the primary prenatal site. Increased contact between MFMs and local providers increased MFM referrals.

Amniotic fluid volume in normal pregnancy: comparison of two different normative datasets.

AIM: The aim of the present study was to compare the two normative datasets of amniotic fluid volume (AFV). MATERIAL AND METHODS: The similarity of the two datasets to classify AFV as oligohydramnios, normal, and polyhydramnios based on fixed cut-offs, stratified by gestational ages (<24 weeks, 24-33(6/7), 34-36(6/7) , and >37 weeks, and to identify oligohydramnios/small for gestational age (SGA) and polyhydramnios/large for gestational age (LGA) was evaluated. RESULTS: Of the 209 pregnancies assessed, the AFV was 94 ≤ 500 mL, 101 between 501 and 1999 mL, and 14 ≥ 2000 mL. The datasets were in agreement classifying the AFV as oligohydramnios, normal, and polyhydramnios in 76% of the pregnancies. Brace classified more overall patients with oligohydramnios (19%) versus Magann (3%) (P < 0.001). In term pregnancies (>37 weeks), Brace was more likely to classify pregnancies with oligohydramnios (15%) than Magann (3%) (P = 0.004). The likelihood ratio (LR) to detect oligohydramnios/SGA was greater with Magann (LR 12.9) versus Brace (LR 2.75). CONCLUSION: The two datasets classify AFV differently in 24% of cases. Brace's dataset is more likely to categorize patients as having oligohydramnios and Magann's dataset is a more useful test for oligohydramnios/SGA identification.

The use of telemedicine in obstetrics: a review of the literature.

UNLABELLED: Telemedicine has been advertised for increasing efficiency, extending the scope of obstetric practice, improving pregnancy outcomes, and reducing costs in the healthcare system. The extent of telemedicine use in obstetrics was identified with a literature search. A total of 268 articles were identified of which 60 are the basis for this review. Telemedicine has been used to read ultrasounds, interpret nonstress tests, counsel patients, manage diabetes, manage postpartum depression, and support parents and children postpartum from remote sites. Reductions in time lost from work, transportation costs, more efficiency for the health care providers, and reducing medical costs all have been suggested as benefits of telemedicine. Despite the information published about telemedicine in obstetrics, this technology has not been shown to have adverse effects in obstetrics but neither has it demonstrated unequivocal benefits. Properly structured and powered investigations will be needed to determine the role of telemedicine in the future. TARGET AUDIENCE: Obstetricians & Gynecologists. LEARNING OBJECTIVES: After completing this CME activity, physicians should be better able to diagnose and treat diabetes using telemedicine techniques; assess the current scope of research in telemedicine in obstetrics; implement clinical telemedicine consultations based on the interaction and the needs of the participants; and the opportunities for further research in telemedicine in obstetrics.

Air travel and pregnancy outcomes: a review of pregnancy regulations and outcomes for passengers, flight attendants, and aviators.

To review flight regulations and gestational complications associated with air travel in pregnant passengers, flight attendants, and aviators. A literature search was undertaken on the relationship of air travel and spontaneous pregnancy losses, intrauterine fetal demise (IUFD), birth weight<10th percentile, preterm delivery, and neonatal intensive care unit admissions. The literature search identified 128 abstracts, of which 9 evaluated air travel and pregnancy outcomes. The risk of a pregnancy loss (spontaneous abortion or IUFD) was greater in flight attendants than controls (odds ratio [OR]: 1.62, 95% confidence interval [CI]: 1.29, 2.04). The risk of preterm birth<37 weeks was greater in passengers than controls (OR: 1.44, 95% CI: 1.07, 1.93). However, the risk of preeclampsia (OR: 0.86, 95% CI: 0.58, 1.27), neonatal intensive care unit admissions (OR: 1.19, 95% CI: 0.78, 1.82), or birth weight<10th percentile (OR: 1.25, 95% CI: 0.62, 2.48) was not increased. Flight attendants did not have an increased risk of preterm birth compared to controls (OR: 1.37, 95% CI: 0.85, 2.22) or delivering infants with birth weight<10th percentile (OR: 1.57, 95% CI: 0.68, 3.74). The risks of spontaneous abortions and other adverse pregnancy outcomes have been poorly studied in a limited number of investigations. An analysis of the available information suggests a greater risk of spontaneous abortions or IUFD in flight attendants, and a greater risk of preterm birth<37 weeks in air passengers. However, the literature on which these findings are based is generally not of high methodologic quality.