Ten reasons to be nice to the program director.

Residency application season is a wonderful and increasingly challenging time for Program Directors. One Program Director describes some of the factors that have come to complicate the assessment of applicants to OBGYN residency and asks for your understanding and appreciation.

Treatment of early cervical pregnancy with cerclage, carboprost, curettage, and balloon tamponade.

BACKGROUND: Cervical pregnancy, an uncommon variety of ectopic gestation is associated with high morbidity and adverse consequences for future fertility. Currently there are no specific recommendations for the best treatment of this entity. CASE: A 35-year-old nullipara presented with 8 weeks of amenorrhea and painless brown discharge. The patient was diagnosed with cervical pregnancy with embryonic cardiac activity. A conservative surgical treatment under general anesthesia involved intracervical infiltration of carboprost, cerclage, suction curettage of cervix, and Foley balloon tamponade was performed. The Foley was removed on day 2 and the cerclage on day 7. CONCLUSION: Early cervical pregnancy was treated with combined cervical cerclage, intracervical infiltration of carboprost, curettage, and balloon tamponade. Severe hemorrhage during suction curettage and the adverse effects and complications of systemic methotrexate treatment were avoided.

Transabdominal cerclage after comprehensive evaluation of women with previous unsuccessful transvaginal cerclage.

OBJECTIVE: The purpose of this study was to assess the outcome after transabdominal-cerclage placement during pregnancy in women with previous unsuccessful transvaginal cerclage. STUDY DESIGN: We conducted a retrospective case series that described pregnancy outcome in women who were treated with transabdominal cerclage between 1994 and 2006. RESULTS: Seventy-five women with negative evaluation for recurrent pregnancy loss and > or = 1 previous unsuccessful transvaginal cerclage procedures were treated with transabdominal cerclage. The median gestational age at the time of cerclage placement was 13 weeks, and the median gestational age at delivery was 36 weeks. Seventy-two women delivered after 24 weeks of gestation, and 3 women delivered < or = 24 weeks of gestation. The fetal-salvage after transabdominal cerclage was 96%. CONCLUSION: Our findings suggest that, in women with a history of > or = 1 failed transvaginal cerclage, transabdominal cerclage is an effective procedure.

Patient satisfaction with the laborist model of care in a large urban hospital.

BACKGROUND: The obstetric practice environment is evolving to include more laborists staffing obstetric units, with the hope of improving quality of care and provider satisfaction, yet there are scant data on the impact of a laborist care model on patient satisfaction or delivery outcomes. We sought to assess patient satisfaction after implementation of the laborist model of obstetric care in a large urban teaching hospital. METHODS: Postpartum patients were asked to complete an anonymous survey assessing their satisfaction with care, particularly with regard to the laborist model. Survey questions included rating the overall experience of labor and delivery. All responses were based on a five-point Likert scale. Press-Ganey results were compared from before and after initiation of the model. Descriptive statistics were used to analyze the results. RESULTS: Post-laborist implementation obstetric and delivery experience surveys were collected from 4166 patients, representing a 54% response rate. Ninety percent of patients reported that they were highly satisfied with the overall experience in the labor and delivery unit. A subgroup was asked to rate their experience with the practitioner for their current delivery. Of the 687 respondents, 75% answered excellent, 18% answered good/very good, and 3.4% answered neutral. Eighty-five percent of this subgroup stated that they were informed during prenatal care that they may be delivered by someone other than the practitioner or group that they saw during the pregnancy. Thirty-seven percent (n = 1553) of the total respondents reported that they had had a previous delivery at this institution, 97% (n = 1506) of whom stated "yes" to having their next delivery at this institution. Press-Ganey results were similarly favorable in both time periods (91.3 [n = 811] versus 93.4 [n = 747], P = 0.08). CONCLUSION: Patient satisfaction does not appear to be adversely affected by initiation of the laborist model. Additional research is needed to understand further the implications of this model for provider satisfaction, and maternal and neonatal outcomes.

Diet-controlled gestational diabetes mellitus does not influence the success rates for vaginal birth after cesarean delivery.

OBJECTIVE: We sought to determine whether women with diet-controlled gestational diabetes mellitus who attempt vaginal birth after cesarean delivery are at increased risk of failure, when compared with their non-diabetic counterparts. STUDY DESIGN: We identified 13,396 women who attempted vaginal birth after cesarean delivery among 25,079 pregnant women with a previous cesarean delivery who were delivered between 1995 and 1999 at 16 community and university hospitals. Analysis was limited to 9437 women without diabetes mellitus and 423 women with diet-controlled diabetes mellitus who attempted vaginal birth after cesarean delivery with a singleton gestation and 1 previous low-flap cesarean delivery. Data that were collected by trained abstractors, included demographics, medical history, and both pregnancy and neonatal outcomes. Multivariable logistic regression analysis was performed to determine an adjusted odds ratio for vaginal birth after cesarean delivery success among women with diet-controlled gestational diabetes compared with women with no diabetes mellitus. We controlled for birth weight, maternal age, race, tobacco, chronic hypertension, hospital settings, labor management, and obstetric history. RESULTS: Forty-nine percent of the women with gestational diabetes mellitus and 67% of the women with no diabetes mellitus attempted vaginal birth after cesarean delivery. The success rate for attempted vaginal birth after cesarean delivery among gestational diabetic women was 70%, compared with 74% for non-diabetic women. We found that gestational diabetes mellitus is not an independent risk factor for vaginal birth after cesarean delivery failure. The relative risk for vaginal birth after cesarean delivery success in women with gestational diabetes mellitus compared with women without gestational diabetes mellitus was 0.94 (95% CI, 0.87-1.00). After an adjustment was made for confounding, the odds ratio for success with gestational diabetes mellitus was 0.87 (95% CI, 0.68-1.10). CONCLUSION: Women with diet-controlled gestational diabetes mellitus who were carrying singleton fetuses who had no more than 1 previous low flap cesarean delivery should be counseled that their disease does not decrease their chances for a successful vaginal birth after cesarean delivery. Among diet-controlled diabetic women, the overall success rate for vaginal birth after cesarean delivery remains acceptable, and attempted vaginal birth after cesarean delivery should not be discouraged solely on the basis of gestational diabetes mellitus.

The effects of the time interval from antenatal corticosteroid exposure to delivery on neonatal outcome of very low birth weight infants.

OBJECTIVE: The purpose of this study was to determine whether the interval between antenatal steroid exposure and delivery influences neonatal outcome in very low birth weight infants. STUDY DESIGN: A retrospective review was performed of all live-born singleton infants who weighed between 500 and 1500 g and who were exposed to a partial course (1 dose) or a complete course (2 12-mg doses of betamethasone given 24 hours apart) of antenatal corticosteroids. Infants were divided into 4 groups, depending on the interval between the first dose of antenatal corticosteroids and delivery (<24 hours, between 24 and 48 hours, between 48 hours and 7 days, and >7 days). Logistic regression was used to control for differences between the 4 groups. RESULTS: Three hundred twenty-five singleton deliveries were reviewed. Gestational age at delivery and birth weight were similar for all 4 groups. The babies in the last group were treated with antenatal corticosteroids at a slightly earlier gestational age. There was no statistical difference between the groups with respect to respiratory distress syndrome treated with surfactant, intraventricular hemorrhage, necrotizing enterocolitis, and deaths. CONCLUSION: In infants who weighed 500 to 1500 g, the time interval between exposure to antenatal corticosteroids and delivery does not appear to affect neonatal outcome. Further studies should evaluate the effects of antenatal corticosteroids and the effects of the interval from exposure to delivery in very low birth weight infants.

Mild pyelectasis: evaluating the relationship between gestational age and renal pelvic anterior-posterior diameter.

OBJECTIVE: To determine the relationship between gestational age and renal pelvic anterior-posterior diameter and the feasibility of developing gestational age-specific thresholds for the diagnosis of mild pyelectasis. METHODS: Cross-sectional study of 420 singleton fetuses between 16 and 39 weeks' gestation. The mean renal AP diameter as a function of gestational age was determined using fractional polynomial regression models and centile plots were generated. Assessment of goodness of fit for each regression model was performed. RESULTS: There was a positive correlation between gestational age and renal pelvic AP diameter (Pearson's Correlation Coefficient 0.65). Using the derived mean and standard deviations of renal AP diameter, gestational-age specific 95% reference levels were generated. The sensitivity, specificity, positive, and negative predictive values of using the gestational age-specific cutoffs for predicting persistent postnatal renal anomaly were 80%; 99%; 29%; and 99% respectively. CONCLUSION: There is a positive correlation between gestational age and renal pelvic AP diameters. Reliable gestational age-specific renal AP thresholds for diagnosis of pyelectasis are provided.