Successful management of maternal anti-PP1Pk alloimmunization in pregnancy with therapeutic plasma exchange and intravenous immunoglobulin.

Anti-PP1PK alloimmunization is rare given ubiquitous P1PK expression. Prevention of recurrent miscarriages and hemolytic disease of the fetus and newborn (HDFN) in pregnant individuals with anti-PP1PK antibodies has relied upon individual reports. Here, we demonstrate the successful management of maternal anti-PP1PK alloimmunization in a 23-year-old, G2P0010, with therapeutic plasma exchange (TPE), intravenous immunoglobulin (IVIG), and monitoring of anti-PP1Pk titers. Twice-weekly TPE (1.5 plasma volume [PV], 5% albumin replacement) with weekly titers and IVIG (1 g/kg) was initiated at 9 weeks of gestation (WG). The threshold titer was ≥16. Weekly middle cerebral artery-peak systolic velocities (MCA-PSV) for fetal anemia monitoring was initiated at 16 WG. PVs were adjusted throughout pregnancy based on treatment schedule, titers, and available albumin. Antigen-negative, ABO-compatible RBCs were obtained through the rare donor program and directed donation. An autologous blood autotransfusion system was reserved for delivery. Titers decreased from 128 to 8 by 10 WG. MCA-PSV remained stable. At 24 WG, TPE decreased to once weekly. After titers increased to 32, twice-weekly TPE resumed at 27 WG. Induction of labor was scheduled at 38 WG. Vaginal delivery of a 2950 g neonate (APGAR score: 9, 9) occurred without complication (Cord blood: 1+ IgG DAT; Anti-PP1Pk eluted). Newborn hemoglobin and bilirubin were unremarkable. Discharge occurred postpartum day 2. Anti-PP1Pk alloimmunization is rare but associated with recurrent miscarriages and HDFN. With multidisciplinary care, a successful pregnancy is possible with IVIG and TPE adjusted to PV and titers. We also propose a patient registry and comprehensive management plan.

A Framework for Diversifying Obstetrics and Gynecology Training Programs.

There is an urgent need to diversify the physician workforce in obstetrics and gynecology to serve a diverse patient population and mitigate disparities in care. There is a paucity of data on how to improve recruitment of individuals from underrepresented minoritized groups to the field of obstetrics and gynecology. This article outlines important steps for sharing the department's commitment to diversity, equity, and inclusion; addresses ways to attract a diverse applicant pool; and reviews the importance of and need to perform a holistic review of applicants. This commentary also shares some approaches to support faculty and trainees that may lead to sustained increases in diversity. Using this framework, the authors successfully increased the diversity of their obstetrics and gynecology residency program.

Linguistic Analysis of Letters of Recommendation for Vascular Surgery and Obstetrics and Gynecology Applicants Detects Differences in Attributable Strengths Based on Gender.

OBJECTIVE: We asked whether letters of recommendation (LOR) written for applicants to vascular surgery (VS), a field where men have traditionally predominated, differentially highlight attributes based on applicant gender. For comparison, LOR for applicants to Obstetrics and Gynecology (Ob/Gyn), a surgical field where women are highly represented were evaluated. DESIGN: We performed a cross-sectional review of LORs for students applying to VS or Ob/Gyn at our institution from 2017 to2018. Blinded to the gender of both the applicant and the letter author, investigators assessed word count per letter and used published rubrics to quantify how many words in the following categories: communal ("friendly"), able ("competent"), standout ("exceptional"), and grindstone ("hardworking"). Frequencies were reported as a function of specialty and gender. SETTING: The study was performed at the University of Pittsburgh Medical Center and included letters written for applicants only to the stated residency programs at University of Pittsburgh Medical Center. PARTICIPANTS: LOR written for self-identified women and men applying to both residencies from US-based allopathic medical schools were de-identified and evaluated by blinded reviewers. RESULTS: One hundred and ninety-eight letters were reviewed for vascular surgery applicants. Two hundred letters were randomly selected from applications to Ob/Gyn as a comparison. Fifty-four vascular (27.8% women) and 63 Ob/Gyn (77.8% women) applicants were reviewed (p < 0.001 for gender). Licensing exam scores were higher for women than men applying to Ob/Gyn. Honor status was similar across fields and gender. Letters were shorter for VS applicants (p = 0.04). Gender-specific words (i.e., "lady" or "gentleman") were used more in VS letters (0.24 ± 0.50 vs 0.14 ± 0.42, p = 0.048). Ability words were more common (4.7 ± 2.6 vs 3.8 ± 2.1, p = 0.028) and grindstone adjectives were less common (3.4 ± 2.3 vs 4.5 ± 3.1, p = 0.024) in letters written for women compared to men VS applicants. Twenty-nine letters written for students applying to VS had honors status. While none written for women mentioned this achievement, 43% of those written for men did (p < 0.05). Letters for women applicants to Ob/Gyn contained more standout adjectives than those written for men (2.12 ± 2.2 vs 1.39 ± 1.25, p = 0.021). CONCLUSIONS: Reference letters for both specialties highlighted attributes differently depending on the gender of the applicant. Although this likely represents an unconscious process, care should be taken to limit potential biases in LOR which are "gatekeepers" to access and advancement.

Social Contributors to Glycemic Control in Gestational Diabetes Mellitus.

OBJECTIVE: To evaluate the association of social factors with glycemic control in women with gestational diabetes mellitus (GDM). METHODS: A survey instrument assessing social support, access to healthy food, cooking and meal preparation, chaotic lifestyle, employer support, and physical and emotional responses to food was developed and administered to women with GDM at maternal-fetal medicine office visits. Validated scales were used to measure social support and life chaos (defined as organization, instability, and the ability to plan and prepare for the future). Glycemic control and pregnancy outcome were ascertained by chart review. Multivariable logistic regression was used to quantify the association of these factors with the primary outcome of satisfactory glycemic control, defined as greater than 70% of blood sugars within goal. RESULTS: We approached 145 women, of whom 111 agreed to participate (76.5%). Seventy-seven percent of patients (86/111) achieved satisfactory glycemic control. Chaotic lifestyle (Confusion, Hubbub and Order Scale score 12.5±2.9 for those with good control, 16.3±3.9 for poor control; odds ratio [OR] 0.71, 95% confidence interval [CI] 0.59-0.85) and receipt of food stamps (11/86 [12.9%] for good control and 10/25 [40%] for poor control; OR 0.22, 95% CI 0.08-0.62) were associated with decreased likelihood of achieving glycemic control. Being married (67/86 [77.9%] for good control and 12/25 [48.0%] for poor control; OR 3.82, 95% CI 1.49-9.74) and regular exercise (49/86 [57.0%] for good control and 5/25 [20.0%] for poor control; OR 5.03, 95% CI 1.72-14.72) increased the likelihood of achieving glycemic control. Transportation time to food stores, home cooking, and social support were not associated with glycemic control or pregnancy outcomes. CONCLUSION: Social factors are associated with glycemic control in GDM and may be modifiable to improve glucose control.

Training obstetrics and gynecology residents to be effective communicators in the era of the 80-hour workweek: a pilot study.

BACKGROUND: To ensure optimal patient care, physicians must establish effective patient-physician relationships and thoughtfully incorporate their patients' perspectives into their counseling. Historically, these skills are acquired with increasing clinical experience. However, given increasing work-hour restrictions, OB/GYN residents have fewer opportunities to develop these skills. Therefore, the objective of this study was to determine if an interactive learning method is an effective tool by which to teach OB/GYN residents how to communicate with complicated patients. METHODS: An experiential simulation model was developed to teach OB/GYN residents effective communication skills for dealing with patients experiencing a pregnancy-related complication. A simulated patient interaction was designed for first-year residents. Specific scenarios were constructed based on challenging clinical scenarios identified by second-year residents. Non-judgmental communication, culture competency awareness and reflective listening were key skills that were taught as part of the clinical scenarios. Both acceptability and utility of the exercise with the first-years was assessed by a follow-up survey. RESULTS: Seven first-year residents participated in the education session consisting of four physician-patient interactions with specific learning objectives for each. These first-year residents all indicated that they would employ the skills practiced during the intervention into their future practice of medicine, and that their comfort level in caring for complex obstetric patients had increased. Moreover, all first-year residents endorsed that this educational strategy was potentially applicable to other aspects of their training. CONCLUSIONS: Simulated patient exercises can be utilized in multiple arenas to teach OB/GYN residents communication skills, while simultaneously addressing their clinical knowledge deficits. Early implementation of such a curriculum in an OB/GYN residency will lay the foundation for the development of empathetic and culturally competent physicians.

Expectant management of preeclampsia superimposed on chronic hypertension.

OBJECTIVE: Women with chronic hypertension (CHTN) are at an increased risk for pregnancy complications including preeclampsia. The objective of this study was to review pregnancy outcomes for women with expectant management of preeclampsia superimposed on CHTN prior to 37 weeks'. METHODS: We reviewed the inpatient charts of all women admitted to Magee-Womens Hospital (1995-2005) with the diagnosis of both CHTN and preeclampsia prior to term. RESULTS: Sixty-eight women diagnosed with both CHTN and preeclampsia prior to 37 weeks' were identified. Of these, 42 women were expectantly managed; one subject was excluded from analysis for pregestational diabetes. For the remaining 41 women, the median gestational age at diagnosis was 31.6 weeks (range 23.6-36.4). The mean time from diagnosis to delivery was 9.7 days (range 2-34 days). Adverse perinatal outcomes included one case of HELLP syndrome, two cases of placental abruptions, three cases of pulmonary edema, and five postpartum hemorrhages. There were no fetal/neonatal or maternal deaths. Average NICU stay was 17.9 days. CONCLUSIONS: Expectant management of preterm superimposed preeclampsia among women with CHTN is a reasonable management strategy, but associated with some maternal morbidity. Prospective studies are needed to definitively quantify the risks and benefits of this approach.

Correlation of catheterized and clean catch urine protein/creatinine ratios in preeclampsia evaluation.

OBJECTIVE: To examine whether clean catch urine specimens correlate with catheterized specimens for determination of protein/creatinine ratios in pregnant women being evaluated for preeclampsia. METHODS: Sixty pregnant women who were at least at 20 weeks of gestation were enrolled. Patients with ruptured membranes, vaginal bleeding, or urinary tract infections were excluded. Midstream clean catch urine specimens were collected. Catheterized specimens were then collected and used for clinical management. The specimens were analyzed for protein, creatinine, urinalysis, and culture. Based on sample size calculations, 60 participants were needed to detect a correlation of 0.90 with 80% power and alpha=0.05. RESULTS: Mean gestational age at enrollment was 35.9 weeks (range 23.1-41.7 weeks). Median (range) clean catch and catheterized protein/creatinine ratios were 0.204 (0.089-3.465) and 0.181 (0.067-3.335), respectively, with a correlation coefficient of 0.897 (P<.001). When results were categorized by degree of proteinuria using a cutoff of 0.3, sensitivity and specificity of the clean catch protein/creatinine ratios were 95.2% and 97.4%. When using a more conservative cutoff of 0.19, sensitivity and specificity of the clean catch protein/creatinine ratios were 96.4% and 75.0%. CONCLUSION: Clean catch and catheterized urine specimens correlate well in women with suspected preeclampsia. Routine catheterization of pregnant women is not necessary in the evaluation of preeclampsia.

Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal delivery.

OBJECTIVE: To examine whether episiotomy at first vaginal delivery increases the risk of spontaneous obstetric laceration in the subsequent delivery. METHODS: A review was conducted of women with consecutive vaginal deliveries at Magee-Womens Hospital between 1995 and 2005, using the Magee Obstetrical Maternal and Infant database. The primary exposure of interest was episiotomy at first vaginal delivery. Multivariable polytomous logistic regression modeling of potential risk factors was used to estimate odds ratios (ORs) for obstetric laceration in the second vaginal delivery. RESULTS: A total of 6,052 patients were included, of whom 47.8% had episiotomy at first delivery. Spontaneous second-degree lacerations at the time of second delivery occurred in 51.3% of women with history of episiotomy at first delivery compared with 26.7% without history of episiotomy (P<.001). Severe lacerations (third or fourth degree) occurred in 4.8% of women with history of episiotomy at first delivery compared with 1.7% without history of episiotomy (P<.001). Prior episiotomy remained a significant risk factor for second-degree (OR 4.47, 95% confidence interval 3.78-5.30) and severe obstetric lacerations (OR 5.25, 95% confidence interval 2.96-9.32) in the second vaginal delivery after controlling for confounders. Based on these findings, for every four episiotomies not performed one second-degree laceration would be prevented. To prevent one severe laceration, performing 32 fewer episiotomies is required. CONCLUSION: Episiotomy at first vaginal delivery increases the risk of spontaneous obstetric laceration in the subsequent delivery. This finding should encourage obstetric providers to further restrict the use of episiotomy. LEVEL OF EVIDENCE: II.