Methods of Glycemic Control and Neonatal Outcomes after Antenatal Corticosteroid Administration among Women with Pregestational Diabetes.

OBJECTIVE: The objective of this study was to evaluate the association between the method of maternal glycemic control after antenatal corticosteroid, administration and maternal hyperglycemia and neonatal morbidity among women with diabetes. STUDY DESIGN: This was a retrospective cohort study of women with pregestational diabetes who received antenatal corticosteroids and delivered in <34 weeks. The primary maternal outcome was adequate glycemic control, defined as <50% of glucose values above goal (fasting <100 mg/dL, 2-hour postprandial <120 mg/dL, or <115 mg/dL on insulin infusion). The primary neonatal outcome was composite morbidity (continuous positive airway pressure, mechanical ventilation, intraventricular hemorrhage, or death). Demographic characteristics and outcomes were compared by the method of glycemic control and neonatal morbidity using chi-square test, Fisher's exact test, Mann-Whitney U-test, and Student's t-test, as appropriate. RESULTS: Of 52 eligible women, only 1 (1.9%) had adequate maternal glycemic control. There was no significant association between the method of glycemic control and maternal hyperglycemia or neonatal morbidity. There was no association between maternal glucose and neonatal morbidity; however, neonates with composite morbidity were more likely to be born to women who received less insulin. CONCLUSION: Maternal glycemic control among women with diabetes was poor after the antenatal corticosteroid administration, regardless of glycemic control method. Neither the method of maternal glycemic control nor the degree of control was associated with neonatal morbidity.

Estimating Gestational Age from Ultrasound: External Validation of the NICHD Formula with Comparison to the Hadlock Regression.

OBJECTIVE: To externally validate the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) formula developed from the National Fetal Growth Studies-Singletons and compare with 1984 Hadlock regression in a general obstetrical population. STUDY DESIGN: Cross-sectional study of nonanomalous singletons with a crown-rump length (CRL) and ≥1 additional ultrasound (US) with complete fetal biometrics. CRL established the referent estimated due date to calculate the error at every examination from both formulas. Error was the difference between the CRL-derived gestational age (GA) and each method's predicted GA. Comparisons were also made in three GA intervals: 1 (140/7-206/7), 2 (210/7-286/7), and 3 (≥290/7). Odds ratios evaluated the likelihood of errors outside the prespecified (±) day ranges. Repeated measures analysis of variance and generalized estimating equations controlled multiple US in the same patient. RESULTS: A total of 6,043 patients produced 16,904 USs for evaluation. The NICHD formula yielded significantly smaller mean errors in all GA ranges compared with the Hadlock formula (p < 0.01). In interval 3, the NICHD formula had significantly lower odds of discerning examinations outside the prespecified error range (odds ratio: 1.27). CONCLUSION: The NICHD formula is a valid estimate of estimating GA in a general obstetrical population and was superior to the Hadlock formula, most notably in the third trimester.

Adverse Outcomes with Maternal Blood Pressure Less than 140/90 in Pregnancy Complicated by Hypertension.

OBJECTIVE: We assessed the risk of small for gestational age and other outcomes in pregnancies complicated by chronic hypertension with blood pressure <140/90 mm Hg. STUDY DESIGN: Retrospective cohort of singletons with hypertension at a single institution from 2000 to 2014. Mean systolic blood pressure and mean diastolic blood pressure were analyzed as continuous and dichotomous variables (<120/80 and 120-139/80-89 mm Hg). The primary outcome was small for gestational age. Secondary outcomes included birth weight, preeclampsia, preterm birth <35 weeks, and a composite of adverse neonatal outcomes. RESULTS: Small for gestational age was not increased with a mean systolic blood pressure <120 mm Hg compared with a mean systolic blood pressure 120 to 129 mm Hg (adjusted odds ratio [AOR] 1.6; 95% confidence interval [CI] 0.92-2.79). Mean diastolic blood pressure <80 mm Hg was associated with a decrease in the risk preeclampsia (AOR 0.57; 95% CI 0.35-0.94), preterm birth <35 weeks (AOR 0.35; 95% CI 0.20-0.62), and the composite neonatal outcome (AOR 0.42; 95% CI 0.22-0.81). CONCLUSION: Mean systolic blood pressure <120 mm Hg and mean diastolic blood pressure <80 mm Hg were not associated with increased risk of small for gestational age when compared with higher, normal mean systolic and diastolic blood pressures.

Incidence and Risk Factors for Postpartum Severe Hypertension in Women with Underlying Chronic Hypertension.

OBJECTIVE: To determine risk factors and time to diagnosis of postpartum severe hypertension (PHTN) in women with chronic hypertension (CHTN). STUDY DESIGN: Retrospective cohort of singleton pregnancies with CHTN at a tertiary care center. The primary outcome was PHTN, defined as hypertension ≥160/ ≥ 110 mm Hg during an emergency room (ER) or outpatient visit, or hospitalization within 8 weeks postpartum. Multivariable logistic regression was used to assess independent risk factors for PHTN. RESULTS: Two-hundred thirty-five women had CHTN: 30 (12.8%) were diagnosed with PHTN, and 17 (7.2%) were hospitalized or seen in the ER for PHTN. Women with PHTN had more severe superimposed pre-eclampsia (p < 0.05), higher average systolic blood pressures at discharge (141 vs. 135 mm Hg, p = 0.04), and required antihypertensives after delivery (p < 0.01). The number of antihypertensive medications (adjusted odds ratio [aOR] 1.78, 95% confidence interval [CI], 1.25-2.55) and a systolic blood pressure >135 mm Hg (aOR 4.55, 95% CI, 1.64-12.61) at discharge remained independently associated with PHTN. Median time to diagnosis of PHTN was 10 days (interquartile range [IQR] 6-32 days); time to diagnosis among women requiring readmission or ER evaluation was 8 days (IQR 5-11 days). CONCLUSION: PHTN occurred in 13% of women with CHTN, and was associated with blood pressure level and number of medications at discharge.

Validation of the SunTech Medical Advantage Model 2 Series Automated Blood Pressure Module in Pregnancy.

OBJECTIVE: We sought to validate the SunTech Medical Advantage Model 2 Series with firmware LX 3.40.8 algorithm noninvasive blood pressure module in a pregnant population, including those with preeclampsia. STUDY DESIGN: Validation study of an oscillometric noninvasive blood pressure module using the ANSI/AAMI ISO 81060-2:2013 standard guidelines. Pregnant women were enrolled into three subgroups: normotensive, hypertensive without proteinuria, and preeclampsia (hypertensive with random protein-to-creatinine ratio ≥ 0.3 or a 24-hour urine protein > 300 mg). Two trained research nurses, blinded to each other's measurements, used a mercury sphygmomanometer to validate the module by following the protocol set forth in the ANSI/AAMI ISO 81060-2:2013 standard guidelines. RESULTS: A total of 45 patients, 15 in each subgroup, were included. The mean systolic and diastolic differences with standard deviations between the module and the mean observers' measurements for all participants were -2.3 ± 7.3 and 0.2 ± 6.5 mm Hg, respectively. The systolic and diastolic standard deviations of the mean of the individual patient's paired module and observers' measurements were 6.27 and 5.98 mm Hg, respectively. The test device, relative to a mercury sphygmomanometer, underestimated the systolic blood pressure in patients with preeclampsia by at least 10 mm Hg in 24% (11/45) of paired measurements. CONCLUSION: The SunTech Medical Advantage Model 2 Series with firmware LX 3.40.8 algorithm noninvasive blood pressure module is validated in pregnancy, including patients with preeclampsia; however, it may underestimate systolic blood pressure measurements in patients with preeclampsia.

Estimating Gestational Age With Sonography: Regression-Derived Formula Versus the Fetal Biometric Average.

OBJECTIVES: To compare the accuracy of a new regression-derived formula developed from the National Fetal Growth Studies data to the common alternative method that uses the average of the gestational ages (GAs) calculated for each fetal biometric measurement (biparietal diameter, head circumference, abdominal circumference, and femur length). METHODS: This retrospective cross-sectional study identified nonanomalous singleton pregnancies that had a crown-rump length plus at least 1 additional sonographic examination with complete fetal biometric measurements. With the use of the crown-rump length to establish the referent estimated date of delivery, each method's (National Institute of Child Health and Human Development regression versus Hadlock average [Radiology 1984; 152:497-501]), error at every examination was computed. Error, defined as the difference between the crown-rump length-derived GA and each method's predicted GA (weeks), was compared in 3 GA intervals: 1 (14 weeks-20 weeks 6 days), 2 (21 weeks-28 weeks 6 days), and 3 (≥29 weeks). In addition, the proportion of each method's examinations that had errors outside prespecified (±) day ranges was computed by using odds ratios. RESULTS: A total of 16,904 sonograms were identified. The overall and prespecified GA range subset mean errors were significantly smaller for the regression compared to the average (P < .01), and the regression had significantly lower odds of observing examinations outside the specified range of error in GA intervals 2 (odds ratio, 1.15; 95% confidence interval, 1.01-1.31) and 3 (odds ratio, 1.24; 95% confidence interval, 1.17-1.32) than the average method. CONCLUSIONS: In a contemporary unselected population of women dated by a crown-rump length-derived GA, the National Institute of Child Health and Human Development regression formula produced fewer estimates outside a prespecified margin of error than the commonly used Hadlock average; the differences were most pronounced for GA estimates at 29 weeks and later.

Peripartum thromboprophylaxis before and after implementation of a uniform heparin protocol.

AIM: The objective of this study was to assess the utilization of postpartum thromboprophylaxis with heparin in patients according to the Royal College of Obstetrics and Gynaecology Green-Top guidelines after change from an opt-in to an opt-out policy for health care providers ordering heparin thromboprophylaxis after cesarean delivery. STUDY DESIGN: The present study is a retrospective review of 500 consecutive births at one academic institution before and after implementation of a uniform thromboprophylaxis policy with heparin for all cesarean deliveries. An "opt-out" policy for ordering physicians was implemented by automatically defaulting to order heparin in the electronic order set used after cesarean delivery. RESULTS: Cesarean delivery rates were similar during both time periods. Heparin thromboprophylaxis was indicated in 99.6% of the cesarean delivery population before implementation and 94.5% after implementation. Prior to implementation only 5.7% received thromboprophylaxis compared to 96.1% after implementation, P<0.0001. CONCLUSION: An opt-out heparin thromboprophylaxis policy improves compliance with thromboprophylaxis guidelines compared to an opt-in policy. Institutions should consider opt-out heparin thromboprophylaxis policies after cesarean deliveries to improve compliance with recommendations.

Mindfulness-based psychoeducation for parents of children with attention-deficit/hyperactivity disorder: an applied clinical project.

TOPIC: Attention-deficit/hyperactivity disorder (ADHD) affects more than 5 million American children; the likelihood of their parents experiencing stress is high, which may lead to negative outcomes. Mindful parenting is a parent training modality that teaches compassion, listening, and creative engagement with one's child, and has been shown to be effective in decreasing levels of parental stress. PURPOSE: An 8-week evidence-based applied clinical project (N = 7) was designed to answer the question: In parents of children with the diagnosis of ADHD, or exhibiting ADHD traits, what is the effect of providing mindful parenting psychoeducation in addition to standard of care treatment on levels of parental stress post intervention? SOURCES USED: An exhaustive literature search was performed using the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, Psyc-INFO, and PubMed. CONCLUSIONS: Outcomes were measured using the Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF). Scores on the Total Stress scale decreased significantly after 8 weeks (p = .018); a significant decrease also occurred across two of the three PSI-4-SF subscales (Parental Distress and Parent-Child Dysfunctional Interaction). Recommendations for practice change, suggestions for future clinical inquiry, and project limitations are discussed.

The performance of human mesenchymal stem cells encapsulated in cell-degradable polymer-peptide hydrogels.

Thiol-ene photopolymerization offers a unique platform for the formation of peptide-functionalized poly(ethylene glycol) hydrogels and the encapsulation, culture and differentiation of cells. Specifically, this photoinitiated polymerization scheme occurs at neutral pH and can be controlled both spatially and temporally. Here, we have encapsulated human mesenchymal stem cells (hMSCs) in matrix metalloproteinase (MMP) degradable and cell-adhesive hydrogels using thiol-ene photopolymerization. We find that hMSCs survive equally well in this system, regardless of MMP-degradability. When hMSCs are encapsulated in these cell-degradable hydrogels, they survive and are able to proliferate. In classic hMSC differentiation medias, hMSCs locally remodel their microenvironment and take on characteristic morphologies; hMSCs cultured in growth or osteogenic differentiation media are less round, as measured by elliptical form factor, and are smaller than hMSCs cultured in chondrogenic or adipogenic differentiation media. In addition, hMSCs encapsulated in completely cell-degradable hydrogels and cultured in osteogenic, chondrogenic, or adipogenic differentiation media generally express increased levels of specific differentiation markers as compared to cells in hydrogels that are not cell-degradable. These studies demonstrate the ability to culture and differentiate hMSCs in MMP-degradable hydrogels polymerized via a thiol-ene reaction scheme and that increased cell-mediated hydrogel degradability facilitates directed differentiation of hMSCs.

Identification of a novel pool of extracellular pro-myostatin in skeletal muscle.

Myostatin, a transforming growth factor-beta superfamily ligand, negatively regulates skeletal muscle growth. Generation of the mature signaling peptide requires cleavage of pro-myostatin by a proprotein convertase, which is thought to occur constitutively in the Golgi apparatus. In serum, mature myostatin is found in an inactive, non-covalent complex with its prodomain. We find that in skeletal muscle, unlike serum, myostatin is present extracellularly as uncleaved pro-myostatin. In cultured cells, co-expression of pro-myostatin and latent transforming growth factor-beta-binding protein-3 (LTBP-3) sequesters pro-myostatin in the extracellular matrix, and secreted pro-myostatin can be cleaved extracellularly by the proprotein convertase furin. Co-expression of LTBP-3 with myostatin reduces phosphorylation of Smad2, and ectopic expression of LTBP-3 in mature mouse skeletal muscle increases fiber area, consistent with reduction of myostatin activity. We propose that extracellular pro-myostatin constitutes the major pool of latent myostatin in muscle. Post-secretion activation of this pool by furin family proprotein convertases may therefore represent a major control point for activation of myostatin in skeletal muscle.