Using Middle Cerebral Artery Doppler Ultrasound to Predict Clinical Chorioamnionitis After Preterm Prelabor Rupture of Membranes.

BACKGROUND: In neonates, blood flow to the brain as measured by peak systolic velocity (PSV) in the middle cerebral artery (MCA) is altered in pregnancies affected by chorioamnionitis. OBJECTIVE: We aim to determine whether PSV and other measures of flow in the MCA in the fetus are altered prior to the development of clinical chorioamnionitis following preterm prelabor rupture of membranes (PPROM). METHODS:  This was a prospective observational study. Fifty patients from one institution were recruited after being diagnosed with PPROM between 23 weeks zero days and 33 weeks six days gestation. We performed measurements of the PSV in the fetal MCA on a weekly basis following PPROM and used the value taken closest to the time of delivery for our statistical analysis. The primary outcome assessed was clinical chorioamnionitis, and the exposure of interest was MCA PSV. Additional independent variables of interest were other Doppler measures of the MCA. Secondary outcomes included histological chorioamnionitis and other measures of neonatal health, including sepsis, days in the neonatal intensive care unit (NICU), and death. RESULTS: Of the 50 patients recruited to our study, eight (16%) developed clinical chorioamnionitis, similar to previously reported values in the general population. The PSV in the MCA was not significantly associated with the development of clinical chorioamnionitis. However, an elevated MCA pulsatility index (PI), a measure of resistance to flow, was associated with a higher probability of developing clinical chorioamnionitis. CONCLUSION:  There does not appear to be a difference in the PSV of the MCA of fetuses in pregnancies following PPROM with impending chorioamnionitis. However, elevated PI in the MCA could be a marker of impending chorioamnionitis in PPROM. Larger studies are needed to confirm these findings.

Stage 1 Hypertension in Nulliparous Pregnant Patients and Risk of Unplanned Cesarean Delivery.

OBJECTIVE: The aim of the study is to determine whether stage 1 hypertension is a risk factor for cesarean at ≥390/7 weeks. STUDY DESIGN: This is a retrospective cohort study of nulliparas delivering at ≥390/7weeks. Exposure was defined as stage 1 hypertension and compared with normotension. The primary outcome was unplanned cesarean. Statistical analysis was performed using SPSS 27. RESULTS: Two hundred and fifty patients had stage 1 hypertension and 250 had normotension. Thirty-eight percent of the patients with stage 1 hypertension required cesarean as did 22% of controls (risk ratio [RR]=1.55, 95% confidence interval [CI]: 1.23-1.96, p <0.001). This remained significant after controlling for confounders in a logistic regression (odds ratio [OR]=1.61, 95% confidence interval [CI]: 1.02-2.55, p <0.040). Upon secondary analysis, these results were statistically significant for gestational age ≥395/7 weeks (adjusted odds ratio [AOR]=1.89, 95% CI: 1.05-3.39, p=0.033) but not from 390/7 to 394/7weeks (AOR=0.68, 95% CI: 0.31-1.50, p=0.34). CONCLUSION: In nulliparas, stage 1 hypertension is an independent risk factor for unplanned cesarean. KEY POINTS: · Stage 1 hypertension correlates with more cesareans.. · Unplanned cesarean for nonreassuring fetal status correlates with impaired placental function.. · Stages 1 and 2 hypertension carry similar risks..

Use of gestation adjusted projection method for predicting fetal head circumference.

OBJECTIVES: The aim of this study is to determine if the gestation adjusted projection (GAP) method applied to a fetal head circumference (FHC) measured on ultrasound between 32 and 36 weeks and 6 days gestation can predict birth head circumference, specifically ≥ 35 cm, which is a known risk factor for Cesarean. METHODS: This is a retrospective chart review of 60 pregnancies from January to December 2019. Eligible patients delivered a singleton term neonate and received two ultrasounds, one at 32-36 weeks and 6 days gestation (period 1) and a second within 7 days of a term birth (period 2). Fetal head circumference was predicted two ways, by applying (1) the GAP method to the period 1 ultrasound and (2) by direct measurement with a period 2 ultrasound. These estimates were compared to the birth head circumference (HCBIRTH) by measures of error and with paired t-tests. McNemar's test compared the ability to predict head circumference (HC) ≥ 35 cm. RESULTS: None of the measures of error were significantly different between the GAP and the period 2 ultrasound, including the ability to predict HC ≥ 35 cm. In patients who delivered at ≥ 39 weeks, the period 2 ultrasound performed poorly while the GAP's performance remained good. CONCLUSION: The GAP method applied to an early third trimester ultrasound predicts HCBIRTH with accuracy similar to an ultrasound performed seven days from delivery and may be superior for deliveries ≥ 39 weeks. The ability to predict HCBIRTH could improve clinical management of affected pregnancies.

Quick Sequential Organ Failure Assessment: Modifications for Identifying Maternal Morbidity and Mortality in Obstetrical Patients.

OBJECTIVE: Screening tools, including the Systemic Inflammatory Response Syndrome (SIRS) criteria and Sequential Organ Failure Assessment (SOFA) criteria, have not been validated in the pregnant population. We aimed to determine if pregnancy-specific modifications to the quick SOFA (qSOFA) can improve prediction of severe maternal morbidity in pregnant women with serious infections. STUDY DESIGN: We performed a retrospective cohort study of pregnant patients with severe infections admitted to a single institution from January 1, 2011, through December 31, 2017. The primary outcome was severe maternal morbidity, defined as a composite of adverse maternal outcomes: intensive care unit (ICU) admission for >48 hours, need for invasive monitoring (central line or arterial line), intubation, pharmacologic hemodynamic support (intravenous vasopressors or inotropes), and/or maternal death. A logistic regression was then applied and the resulting predictors were analyzed individually and in combination with receiver operating characteristic (ROC) curves to modify qSOFA for pregnancy, that is, qSOFA-P. RESULTS: Analysis of 104 pregnant patients with severe infections found that the standard qSOFA did not accurately predict severe maternal morbidity (ROC area under the curve [AUC] = 0.54, p = 0.49, sensitivity = 0.38, and specificity = 0.70). Pregnancy-specific modifications or "qSOFA-P" (respiratory rate [RR] ≥ 35 breaths/minute and systolic blood pressure [SBP] ≤ 85 mm Hg) significantly improved prediction of severe maternal morbidity (AUC = 0.77, p < 0.001, sensitivity = 0.79, and specificity = 0.74). CONCLUSION: The standard qSOFA is a poor screening tool in the prediction of severe maternal morbidity in pregnant patients with infections. A pregnancy-specific screening system, qSOFA-P, improved prediction of severe maternal morbidity in pregnant women with severe infections. Further prospective and large multicenter studies are needed to validate this scoring system in pregnant women. KEY POINTS: · Validated scoring systems for evaluating pregnant patients with sepsis are needed.. · Modifications to existing systems may improve the evaluation of pregnant patients with sepsis.. · The qSOFA-P (RR ≥ 35 breaths/minute and SBP ≤ 85 mm Hg) includes modifications to qSOFA, and improves the detection of patients who would develop severe maternal morbidity...

Risk factors for needing postpartum antihypertensive medications with hypertensive disorders: Timing of diagnosis, presence of proteinuria, and severity of disease.

OBJECTIVES: Evaluate the association between the need for post-partum antihypertensive medications in patients with hypertensive disorders of pregnancy (HDP) and the following: timing of disease onset (antepartum vs. intrapartum), presence of proteinuria, and severity of disease. STUDY DESIGN: This was a retrospective cohort study. We reviewed the charts of 204 patients diagnosed with HDP: 106 were diagnosed antepartum and 98 diagnosed intrapartum. Patients withchronichypertensionwereexcluded. MAIN OUTCOME MEASURES: The need for outpatient antihypertensive medications at time of hospital discharge was the primary outcome. We performed logistic regression of covariates and a stratified analysis for each specific HDP (gestational hypertension (GHTN), preeclampsia and preeclampsia with severe features). RESULTS: While the diagnosis of HDP in the antepartum period was a statistically significant risk factor for needing postpartum anti-hypertensive medications at discharge in bivariate analysis RR 2.07 (1.27-3.37), p = 0.001, it did not remain significant after correction for the covariates RR 1.41 (0.45-4.49), P = 0.55. However, the presence of proteinuria was an independent risk factor after logistic regression. Compared to GHTN, there was a significant difference in the need for postpartum anti-hypertensive medications in patients with preeclampsia OR 10.70 (1.54-74.42), p = 0.017 and in preeclampsia with severe features OR 112.14 (20.05-627.22), p < 0.001. CONCLUSION: Timing of onset of HDP (antepartum vs. intrapartum) was not an independent risk factor for needing antihypertensive medications postpartum. However, proteinuria and the presence of severe features were. Patients with proteinuria and those with severe disease may warrant closer surveillance in the post-partum period than those without proteinuria.

Physical examination-indicated cerclage in twin pregnancy: a randomized controlled trial.

BACKGROUND: Women with twin pregnancies and a dilated cervix in the second trimester are at increased risk of pregnancy loss and early preterm birth; there is currently no proven therapy to prevent preterm birth in this group of women. OBJECTIVE: This study aimed to determine whether physical examination-indicated cerclage reduces the incidence of preterm birth in women with a diagnosis of twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation. STUDY DESIGN: Multicenter, parallel group, open-label, randomized controlled trial of women with twin pregnancies and asymptomatic cervical dilation of 1 to 5 cm between 16 weeks 0/7 days of gestation and 23 weeks 6/7 days of gestation were enrolled from July 2015 to July 2019 in 8 centers. Eligible women were randomized in a 1:1 ratio into either cerclage or no cerclage groups. We excluded women with monochorionic-monoamniotic twin pregnancy, selective fetal growth restriction, twin-twin transfusion syndrome, major fetal malformation, known genetic anomaly, placenta previa, signs of labor, or clinical chorioamnionitis. The primary outcome was the incidence of preterm birth at <34 weeks of gestation. Secondary outcomes were preterm births at <32, <28, and <24 weeks of gestation, interval from diagnosis to delivery, and perinatal mortality. Data were analyzed by intention-to-treat methods. RESULTS: After an interim analysis was performed, the Data and Safety Monitoring Board recommended stopping the trial because of a significant decrease in perinatal mortality in the cerclage group. We randomized 34 women, with 4 women being excluded because of expired informed consent. A total of 17 women were randomized to physical examination-indicated cerclage and 13 women to no cerclage. Whereas 4 women randomized to cerclage did not receive the surgical procedure, no women in the no cerclage group received cerclage. Maternal demographics were not significantly different. All women in the cerclage group also received indomethacin and antibiotics. When comparing the cerclage group vs the no cerclage group, the incidence of preterm birth was significantly decreased as follows: preterm birth at <34 weeks of gestation, 12 of 17 women (70%) vs 13 of 13 women (100%) (risk ratio, 0.71; 95% confidence interval, 0.52-0.96); preterm birth at <32 weeks of gestation, 11 of 17 women (64.7%) vs 13 of 13 women (100%) (risk ratio, 0.65; 95% confidence interval, 0.46-0.92); preterm birth at <28 weeks of gestation, 7 of 17 women (41%) vs 11 of 13 women (84%) (risk ratio, 0.49; 95% confidence interval, 0.26-0.89); and preterm birth at <24 weeks of gestation, 5 of 17 women (30%) vs 11 of 13 women (84%) (risk ratio, 0.35; 95% confidence interval, 0.16-0.75). The mean gestational age at delivery was 29.05±1.7 vs 22.5±3.9 weeks (P<.01), respectively; the mean interval from diagnosis of cervical dilation to delivery was 8.3±5.8 vs 2.9±3.0 weeks (P=.02), respectively. Perinatal mortality was also significantly reduced in the cerclage group compared with the no cerclage group as follows: 6 of 34 women (17.6%) vs 20 of 26 women (77%) (risk ratio, 0.22; 95% confidence interval, 0.1-0.5), respectively. CONCLUSION: In women with twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation, a combination of physical examination-indicated cerclage, indomethacin, and antibiotics significantly decreased preterm birth at all evaluated gestational ages. Most importantly, cerclage in this population was associated with a 50% decrease in early preterm birth at <28 weeks of gestation and with a 78% decrease in perinatal mortality.

Relationship Between Maternal Serum Bile Acid Levels and Fetal Cardiac Troponin-I Levels in Asymptomatic Pregnant Patients at Term: A Cross-sectional Observational Study.

Objective The objective of our study was to determine if a correlation exists between maternal total bile acid levels, degree of maternal pruritus, and fetal cardiac troponin-I levels in asymptomatic patients without a diagnosis of intrahepatic cholestasis of pregnancy. Study design In this cross-sectional observational study, patients were enrolled at the time of the scheduled term cesarean section. Maternal blood was drawn for fasting total bile acid levels and cord blood was collected for fetal cardiac troponin-I levels. Pruritus during pregnancy was quantified by the patient on a visual analog scale (VAS). Correlation coefficients between these variables were calculated. Results There was not a positive correlation between any of the primary variables studied (pruritis, total bile acid, cardiac troponin I). Pearson's R between total bile acid and cardiac troponin I was -0.058 (weak correlation in the opposite direction), and between total bile acid and pruritus severity, it was 0.031. Conclusion In patients without intrahepatic cholestasis of pregnancy, higher levels of maternal total bile acids did not correlate with increased cardiac troponin-I (fetal cardiomyocyte damage) or increased pruritus. This supports the current theory that the adverse outcomes associated with intrahepatic cholestasis of pregnancy require a threshold value of total bile acids, one high enough to cause clinically significant maternal pruritis.

Predicting periviable birthweight and survival: bedside ultrasound versus anatomy scan gestational adjusted age projection.

OBJECTIVE: Two methods of birthweight (BW) prediction in the periviable period: bedside ultrasound proximate to delivery versus gestation-adjusted-projection (GAP) method was compared. METHODS: Periviable births were identified over a 6-year period. The GAP method was applied to the estimated fetal weight (EFW) from anatomy scans and the gestational age at delivery to predict BW, designated EFWGAP. EFW from the bedside ultrasound (EFWUS), and the EFWGAP were compared to actual BW to calculate absolute values of error in BW estimates. Neonatal survival estimates were made utilizing a National Institute of Child Health and Human Development calculator. RESULTS: EFWUS was more accurate than EFWGAP in predicting BW as the mean absolute value of error with bedside ultrasound ǀEFWUS-BWǀ was significantly lower than mean absolute value of error with GAP method ǀEFWGAP-BWǀ, 75.32 ± 74.64 g versus 125.68 ± 130.62 g, p = 0.01. Predicted neonatal survival based on EBWUS was closer to reference than predicted survival based on EBWGAP 9.66% ± 9.43% versus 7.76% ± 7.78% p = 0.26. CONCLUSIONS: EFWUS is more accurate than EFWGAP for predicting BW in this period. However, the GAP technique could have utility in survival predictions when timely performance of ultrasound is not feasible.

Chorionic Villus Sampling, Early Amniocentesis, and Termination of Pregnancy Without Diagnostic Testing: Comparison of Fetal Risk Following Positive Non-invasive Prenatal Testing.

BACKGROUND: With the increased accuracy of non-invasive prenatal testing (NIPT) based on cell-free DNA (cfDNA) techniques, the likelihood of false-positive screening results has been reduced for high-risk populations. Following a positive screening test, a diagnostic procedure to confirm the result is strongly recommended, although some patients have terminated pregnancies because of a positive NIPT alone. Chorionic villus sampling (CVS), the diagnostic procedure of choice in the first trimester, is not available in all locations. Amniocentesis before 15 weeks, referred to as early amniocentesis (EA), is associated with a 1% rate of talipes and an increased rate of early pregnancy loss compared with CVS. Our objective was to compare the level of risk for euploid pregnancies following a positive NIPT based on the invasive procedure chosen. METHOD: Using data from a 2003 meta-analysis, we estimated the rates of adverse pregnancy outcome in euploid pregnancies based on the positive predictive value (PPV) of NIPT and the invasive procedure used-that is, CVS, EA, or termination of pregnancy (TOP). RESULTS: Following NIPT, we found that the rate of adverse fetal outcomes in euploid pregnancies was lower for CVS than for EA at all PPV levels. As the PPV of NIPT increased, the difference in risk between EA and CVS decreased. The risk to euploid pregnancies of TOP was excessive at all PPVs. CONCLUSION: CVS is the recommended diagnostic test in the first trimester because it is safer than EA for the fetus. However, EA is better than no testing when early TOP is planned. Patients should be strongly counselled against TOP without confirmatory testing.

Effect of taurocholic acid on fetoplacental arterial pressures in a dual perfusion placental cotyledon model: a novel approach to intrahepatic cholestasis of pregnancy.

OBJECTIVE: To determine if continuous infusion of taurocholic acid into the fetoplacental and intervillous circulation of a placental cotyledon affects the fetal arterial pressure response after injection of the thromboxane mimetic U44619. Taurine conjugated bile acid is one bile acid putatively mediating intrahepatic cholestasis of pregnancy (ICP). STUDY DESIGN: We selected 5 placentas from normal, unlabored patients. Two cotyledons from each placenta were isolated and dually perfused. Taurocholic acid was continuously infused into the fetoplacental and intervillous circulation of the test cotyledon. After 30 minutes U44619 was injected into both the test and control cotyledon vascular circuits. Pressure excursions were measured and compared to baseline pressures using a paired Student's t test. RESULTS: There was significant attenuation of the pressure excursion in the cotyledons perfused with taurocholic acid as compared to controls after injection of U44619. The difference from baseline in the taurocholic cotyledon compared with controls was 44.2 mmHg vs. 71.8 mmHg (p = 0.009). CONCLUSION: The perfusion of taurocholic acid attenuated the pressure response to thromboxane mimetic U44619 in the fetoplacental arterial circulation of a placental cotyledon as compared to control. This finding in our ex-vivo model may represent changes that occur in the placental vasculature with intrahepatic cholestasis of pregnancy. These placentas may have dysregulated vascular tone, which could contribute to the adverse fetal effects observed in ICP.

Complications from Roux-en-Y gastric bypass mistaken for medical complications in gravid patients.

BACKGROUND: The increased frequency of bariatric surgery has resulted in a growing number of intrapartum surgical emergencies including internal hernia, bowel obstruction, and gastric rupture. CASE: We describe the cases of three gravid women with history of laparoscopic Roux-en-Y gastric bypass surgery who experienced significant complications during subsequent pregnancy. Two patients became hemodynamically unstable and required emergent laparotomy. In both cases, fetal outcomes were poor but the patients ultimately recovered after prolonged hospital courses. In the third patient, early recognition allowed for a minimally invasive surgical correction. CONCLUSION: After bariatric surgery, patients who become pregnant are at risk for serious postoperative complications. Because symptoms can be subtle, a high index of suspicion and early intervention by a multidisciplinary team is necessary to prevent catastrophic outcomes.

Adverse pregnancy outcomes in hypertensive patients: predictive value of protein concentration versus total protein.

OBJECTIVES: To compare the predictive value of protein concentration in a twenty-four hour urine collection to the conventional total protein in a twenty-four hour urine collection for adverse pregnancy outcomes in hypertensive patients. STUDY DESIGN: Retrospective cohort study. Hypertensive patients ≥20 weeks estimated gestational age (EGA) who completed twenty-four hour urine protein collections were identified; antepartum and delivery data were examined. For study patients who met criteria for adverse pregnancy outcome, multi-variable analysis was performed and summary receiver operating characteristic (ROC) curves were generated for each model (total protein compared to protein concentration). The models were compared by analyzing the area under the curve (AUC). RESULTS: A total of 150 patients were analyzed. Mean gestational age at delivery was 36.7 weeks. Analysis of the ROC curves showed no significant difference between the models (AUCs of 0.668 versus 0.656, p = 0.715). Optimal thresholds were 299.2 mg for total protein and 0.1 mg/ml for protein concentration. CONCLUSION: A protein concentration of 0.1 mg/ml on a twenty-four hour urine collection appears equivalent to the traditional 300 mg total protein. If confirmed by prospective studies, this finding would be clinically important in cases where collections fall short of the 300 mg threshold but exceed the 0.1 mg/ml concentration.

The use of middle cerebral artery Doppler ultrasonography to guide delivery of a viable pregnancy complicated by metastatic gestational chroriocarinoma.

Background: Choriocarcinoma is a rare, aggressive subtype of gestational trophoblastic neoplasia. The diagnosis of metastatic choriocarcinoma in the setting of a viable intrauterine pregnancy is exceedingly rare and often associated with feto-maternal hemorrhage. Case: An otherwise healthy Gravida 1 Para 0 at 34 weeks gestational age presented with metastatic choriocarcinoma and a viable fetus. Measured Doppler peak systolic velocity of the middle cerebral artery was used to detect fetal anemia, thus optimising the timing of delivery. Conclusion: This is the first case report to our knowledge using Doppler ultrasonography to detect fetal anemia in an effort to guide delivery in a case of choriocarcinoma diagnosed during pregnancy. If choriocarcinoma is diagnosed during pregnancy, middle cerebral artery Doppler ultrasonography may serve as a critical tool to help detect anemia, allowing pregnancy prolongation to promote fetal maturity while screening for the development of feto-maternal hemorrhage.

Interaction between maternal obesity and Bishop score in predicting successful induction of labor in term, nulliparous patients.

OBJECTIVE: Determine the Bishop score most predictive of induction of labor (IOL) success for different maternal weight groups. STUDY DESIGN: Retrospective cohort study. Prospectively collected database utilized to determine the optimum Bishop score within each prepregnancy body mass index (BMI) category of term, nulliparous patients undergoing IOL. RESULTS: For the total group (n = 696), Bishop score ≥ 5 was most predictive of success (75% versus 56%, p < 0.0001). Within each BMI category, Bishop score ≥ 5 remained most predictive: normal weight (79% versus 64%, p < 0.01); overweight (72% versus 58%, p = 0.03); and obese (73% versus 45%, p < 0.0001). Overall, nonobese patients had more success than obese patients (70% versus 59%, p < 0.01). The nonobese group had more success than the obese group when the Bishop score was < 3 (57% versus 39%, p < 0.05) but not when it was ≥ 3 (72% versus 65%, p = 0.1). Also, there was a higher fraction of patients with Bishop score < 3 in the obese group compared with the nonobese group (25% versus 14%, p < 0.001). CONCLUSION: The optimum Bishop score for predicting successful IOL in nulliparous patients was 5 regardless of BMI class. The higher IOL failure rate observed in obese women was associated with lower starting Bishop scores and was compounded by higher failure rates in obese women with Bishop scores < 3.

Reports to the Navy's Family Advocacy Program: impact of removal of mandatory reporting for domestic violence.

The impact of mandatory reporting laws on domestic violence reports is unclear. In 2006, the Department of Defense removed its requirement for mandatory reporting of domestic violence against adults. Our objective was to determine if there was a change in the incidence of domestic violence reports to the Navy's Family Advocacy Program after the shift from mandatory reporting to a policy allowing restricted reporting. Reports of domestic violence to the Navy Central Registry between fiscal year (FY) 2000 and 2010 were studied. Frequencies and rates of domestic violence reports, type of abuse, and victim and offender gender were studied. Over the past 11 years, the total number of unrestricted domestic violence reports to the Navy Central Registry has decreased by just over a third. In addition, the number of substantiated reports has decreased by approximately 50%. Since the collection of data on restricted reports in 2008, the aggregated reporting rate of substantiated reports is significantly smaller, 0.87% for FYs 2008 to 2010 compared to 1.34% for FYs 2000 to 2005, p < 0.01. Domestic violence reports to the Navy Central Registry have declined over the past 11 years, even with the removal of the requirement for mandatory reporting of domestic violence.

Return to military weight standards after pregnancy in active duty working women: comparison of marine corps vs. navy.

OBJECTIVE: To compare the likelihood of being within weight standards before and after pregnancy between United States Marine Corps (USMC) and Navy (USN) active duty women (ADW). METHODS: ADW with singleton gestations who delivered at a USMC base were followed for 6 months to determine likelihood of returning to military weight standards. Odds ratio (OR), adjusted odds ratio (AOR) and 95% confidence intervals were calculated; p < 0.05 was considered significant. RESULTS: Similar proportions of USN and USMC ADW were within body weight standards one year prior to pregnancy (79%, 97%) and at first prenatal visit (69%, 96%), respectively. However, USMC ADW were significantly more likely to be within body weight standards at 3 months (AOR 4.30,1.28-14.43) and 6 months after delivery (AOR 9.94, 1.53-64.52) than USN ADW. Weight gained during pregnancy did not differ significantly for the two groups (40.4 lbs vs 44.2 lbs, p = 0.163). The likelihood of spontaneous vaginal delivery was significantly higher (OR 2.52, 1.20-5.27) and the mean birth weight was significantly lower (p = 0.0036) among USMC ADW as compared to USN ADW. CONCLUSIONS: Being within weight standards differs significantly for USMC and USN ADW after pregnancy.

Nausea, vomiting, and heartburn in pregnancy: a prospective look at risk, treatment, and outcome.

OBJECTIVE: To examine risk factors, treatment, and outcomes for nausea/vomiting (N/V) and heartburn during pregnancy. METHODS: We included 2731 women from a prospective cohort study of gallbladder disease in pregnancy. Subjects completed questionnaires at enrollment, early third trimester, and 4-6 weeks postpartum. We used logistic regression to examine independent predictors of upper gastrointestinal symptoms. RESULTS: Ninety-five percent of pregnant women experienced either heartburn and/or N/V. Independent predictors for heartburn included prepregnancy heartburn (OR 5.28, 95% CI 3.78-7.37), multigravidity, prepregnancy body mass index, and pregnancy weight gain. Independent predictors for N/V included prepregnancy N/V (OR 2.25, 95% CI 1.52-3.31), other digestive problems prepregnancy, younger age, single gestation, and carrying a female fetus. 11% of women with N/V and 47% of women with heartburn used pharmacologic therapy. Infants born to women with heartburn had significantly higher birth weights (p = 0.03), but gestational age at delivery was not significantly different. N/V was not associated with birth weight or gestational age at delivery. 19.7% of women with heartburn during pregnancy reported postpartum heartburn. CONCLUSIONS: Heartburn and N/V are common pregnancy symptoms, particularly among women with a history of such symptoms. Neither condition appears to adversely affect the outcome of pregnancy. Pregnancy-related heartburn predisposes to early postpartum heartburn.

Persistent pulmonary hypertension of the newborn is associated with mode of delivery and not with maternal use of selective serotonin reuptake inhibitors.

We sought to determine if maternal use of selective serotonin reuptake inhibitors (SSRIs) in the second half of pregnancy is associated with persistent pulmonary hypertension of the newborn (PPHN). We performed a case-controlled study (1:6 ratio) of infants delivered at Madigan Army Medical Center with primary PPHN from 2003 through 2009. Study and control patients were compared for the following clinical factors: SSRI use after 20 weeks gestation, mode of delivery, maternal disease, body mass index, tobacco use, fetal gender, maternal age, and parity. We identified 20 cases of primary PPHN out of 11,923 births for an incidence of 0.17%. Mode of delivery was the only factor we found to be associated with PPHN. Specifically, cesarean delivery (CD) prior to the onset of labor increased the risk for PPHN: odds ratio (OR) = 4.9, confidence interval (CI) 1.7 to 14.0. Importantly, use of SSRIs in the second half of pregnancy was identified in 5% of the controls but none of the cases (OR = 0, CI 0 to 3). PPHN is associated with CD prior to the onset of labor but not with SSRI use in the second half of pregnancy. Previous studies linking PPHN to SSRI use relied on after-the-fact patient interviews and incomplete records. Additional studies are needed to verify these results.

Intramuscular 17α-hydroxyprogesterone caproate administration attenuates immunoresponsiveness of maternal peripheral blood mononuclear cells.

OBJECTIVE: 17α-hydroxyprogesterone caproate (17P) may decrease risk of prematurity by suppressing maternal immunity. We hypothesized that in vivo 17P treatment attenuates immunoresponsiveness of peripheral blood mononuclear cells (PBMCs). STUDY DESIGN: Study subjects were gravidas receiving weekly prophylactic intramuscular 17P injections. Peripheral blood samples were obtained at 21-27 weeks' gestation. Gestational age-matched, drug-naïve gravidas served as controls. To simulate infection, isolated PBMCs were stimulated with lipoteichoic acid (LTA) or lipopolysaccharide (LPS). Extracellular interleukin-6 (IL-6) concentrations were quantified by an enzyme-linked immunosorbent assay. RESULTS: Unstimulated IL-6 levels were comparable in PBMCs derived from drug-naïve and 17P-treated subjects. LPS and LTA induced a dose-dependent elevation of IL-6 in control PBMCs. In patients who received exogenous 17P, LPS, and LTA stimulated induction of IL-6 was significantly decreased compared with controls (P = .005 and P = .02). CONCLUSION: In vivo 17P attenuated immunoreactivity of PBMCs in our in vitro model of Gram-positive and Gram-negative bacterial infection.