Medical education for obstetricians and gynecologists should incorporate environmental health.

Obstetricians-gynecologists can protect the reproductive health of women, men, and their offspring from environmental hazards through preconception and prenatal counseling and encouraging patients to take actions to reduce environmental exposures. Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, education on environmental health in medical education is limited. The Mid-Atlantic Center for Children's Health and the Environment and the Department of Obstetrics and Gynecology of George Washington University convened a meeting to begin integration of environmental health topics into medical education for obstetricians-gynecologists. Several avenues were identified to incorporate environmental health topics into medical education including continuing education requirements, inclusion of environmental health questions on board certification examinations and the creation of a curriculum on environmental health specific to obstetrics-gynecology.

Gestational angiogenic biomarker patterns in high risk preeclampsia groups.

OBJECTIVE: Several conditions are associated with increased preeclampsia (PE) risk. Whether altered maternal angiogenic factor levels contribute to risk in these conditions is unknown. Our objective was to compare angiogenic biomarker patterns in high-risk pregnancies and low-risk controls. STUDY DESIGN: We conducted a planned secondary analysis of a 2-center observational study of angiogenic biomarkers in high-risk women. A total of 156 pregnant women with a PE risk factor and 59 low-risk controls were studied. Serial maternal serum samples were collected during 3 gestational windows: 23-27 weeks, 28-31 weeks, and 32-35 weeks. Soluble fms-like tyrosine kinase 1 (sFlt1), soluble endoglin (sEng), and placental growth factor (PlGF) were measured by enzyme-linked immunosorbent assay. Geometric mean angiogenic biomarker levels and angiogenic ratio (sFlt1 + sEng):PlGF were compared with low-risk controls for each risk group, at each gestational window. RESULTS: Gestational biomarker patterns differed in PE risk groups as compared with low-risk controls. Women with multiple gestations had markedly higher sFlt1 and sEng at all gestational windows. Women with prior PE had higher sFlt1 and angiogenic ratio, and lower PlGF, from 28 weeks onward. Women with chronic hypertension had significantly higher angiogenic ratio for all 3 gestational windows, but differences disappeared when women with PE were excluded. Obese and nulliparous women had significantly lower PlGF, but no differences in the angiogenic ratio. CONCLUSION: High-risk groups have altered angiogenic biomarker patterns compared with controls, suggesting that altered production or metabolism of these factors may contribute to PE risk, particularly in women with multiple gestations and prior PE.

Outcomes of women age 40 or more undergoing repeat cesarean or trial of labor after cesarean.

AIM: Despite the increasing trend in delayed childbirth and the known associated complications in advancing maternal age, limited information exists regarding outcomes in very advanced maternal age by delivery type. This study aims to evaluate maternal and neonatal outcomes in women age 40 or more undergoing cesarean delivery or trial of labor after cesarean delivery. MATERIALS AND METHODS: We performed a secondary analysis of the Cesarean Section Registry Maternal-Fetal Medicine Units (MFMU) Network data, which was a prospective study of women undergoing repeat cesarean delivery or trial of labor after cesarean delivery from 1 January 1999 to 31 December 2002. Women age 40 years or more at the time of delivery were compared to the control group of women less than 40 years of age. RESULTS: There were 67,389 cases identified that met inclusion criteria. 2,436 (3.6%) were age ≥40 years old, and 65,403 (97.05%) were <40 at delivery. The >40 group had a higher rate of PRBC transfusion (aRR 1.75; 95% CI 1.20-2.56), maternal ICU admission (aRR 2.02; 1.41-2.89), bowel injury (aRR 3.65; 1.43-9.31), placenta accreta (aRR 1.92; 1.09-3.38) and classical uterine incision (aRR 1.59; 1.43-9.31) compared to the control group. Maternal death rates were similar in both groups (p = .30). CONCLUSION: Women aged 40 or more undergoing repeat cesarean delivery or trial of labor after cesarean delivery are more likely to have maternal complications including intraoperative transfusion, maternal ICU admission, abnormal placentation and surgical complications in comparison to women under age 40.

ABO phenotype and other risk factors associated with chorioamnionitis.

OBJECTIVE: To examine risk factors associated with chorioamnionitis. STUDY DESIGN: We conducted a retrospective cohort study using data on women who delivered prematurely (< 37 weeks of gestation) over a 12-year period. Eleven potential risk factors were identified. Subjects were stratified according to their blood type into 2 groups: group 1, subjects with anti-B antibodies (blood types A and O), and group 2, subjects without anti-B antibodies (blood types B and AB). Univariate, bivariate, and logistic regression analyses were done to examine risk factors for chorioamnionitis while controlling for confounders. RESULTS: The study included 2879 subjects, 96 of whom (3.3%) were diagnosed with chorioamnionitis. Chorioamnionitis increased significantly with alcohol use (adjusted odds ratio [AOR] = 4.7), prolonged rupture of membranes (ROM) (AOR = 4.16), anemia (AOR = 2.17), and group 1 status (AOR = 1.88). Advanced maternal age was protective of chorioamnionitis (AOR = 0.96). CONCLUSION: Alcohol consumption during pregnancy, prolonged ROM, anemia, and blood types A and O are associated with increased risk for chorioamnionitis; advanced maternal age, with decreased risk. Further studies are needed to determine the efficacy of early prenatal care in the control of anemia and to examine its affect on the incidence of chorioamnionitis.

Use of a doula for labor coaching in a patient with indolent systemic mastocytosis in pregnancy.

BACKGROUND: Few cases of pregnancy in women with systemic mastocytosis have been reported. The effects of this disease on pregnancy have not been well documented, nor have the benefits of doula services for labor been reported for mastocytosis. CASE: A 35-year-old woman with indolent systemic mastocytosis sought preconception counseling regarding the effects of her disease on pregnancy and the effects of drugs and anesthesia on her disease. She then had an uncomplicated pregnancy and delivery, with multidisciplinary coordination and assistance by doulas to reduce the need for medication in labor. CONCLUSION: Mastocytosis patients can achieve normal pregnancy outcomes. Predelivery planning can help prepare staff and patients for complications. Doulas can assist with labor preparation and delivery using nonmedical approaches to relief of pain and anxiety.

Arrhythmogenic right ventricular dysplasia in pregnancy: a case report.

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by progressive fibrous or fibrofatty tissue replacement of the right ventricular myocardium. Interspersed adipocytes and fibrous tissue may provide foci for arrhythmias. The clinical spectrum of ARVD may include asymptomatic premature ventricular complexes to ventricular tachycardia and sudden death. There is currently little information about ARVD in pregnancy. CASE: A 29-year-old primigravida, diagnosed with ARVD 1 year prior to pregnancy, underwent a full-term, uncomplicated pregnancy and delivery while maintained on acebutolol and an implanted cardioverter defibrillator. Her infant was born without an apparent cardiac anomaly or heart rate abnormality. CONCLUSION: Successful management of pregnancy complicated by ARVD can be accomplished with an implanted cardioverter defibrillator and an antiarrhythmic agent. Such patients should be managed with close monitoring during pregnancy for signs and symptoms of arrhythmia and preventive obstetric care appropriate to their clinical profile to optimize normal deliveries.

Pregnancy in a woman with a continent appendicovesicostomy: a case report.

BACKGROUND: Few cases of pregnancy following the Mitrofanoff procedure (continent appendicovesicostomy) have been reported, but in those cases there was an increased rate of cesarean delivery with no long-term consequences to renal function or to the urinary diversion. CASE: A 15-year-old primagravida with a prior nephrectomy for a dysplastic kidney and prior continent appendicovesicostomy for urinary retention due to spina bifida occulta and neurogenic bladder had a pregnancy complicated by preterm premature rupture of membranes, preterm labor, breech presentation and cesarean delivery with the assistance of a urologist. The patient had a minimal decline in renal function, and she and the infant did well. CONCLUSION: Cesarean delivery should be reserved for obstetric indications. Surgical assistance by a urologist at the time of cesarean delivery may be helpful.

Rapid growth of a fetal sacrococcygeal teratoma in an HIV-infected woman: a case report.

BACKGROUND: Sacrococcygeal teratoma, the most common congenital neoplasm of the newborn, associated with fetal hydrops and high morbidity and mortality related to the secondary effects of the tumor mass, is of unknown etiology. Prompt diagnosis and early treatment have proven to be effective. CASE: A 24-year-old woman, gravida 3, para 2, at 385/7 weeks' gestation, with a pregnancy complicated by HIV diagnosed during pregnancy, seizure disorder and tobacco use, presented with premature rupture of membranes. Ultrasound examination at 17 weeks' gestation showed normal fetal anatomy. Cesarean delivery was complicated by difficulty delivering a live infant with a large sacral mass. Successful surgical excision of a 650-g mass and stabilization of the infant occurred in the neonatal period. CONCLUSION: This is the first case report to describe a rapidly growing sacrococcygeal teratoma in a neonate from a pregnancy complicated by HIV. Ultrasound in the first and second trimesters identified no fetal abnormalities of the spine. Further research concerning sacrococcygeal teratoma and HIV in pregnancy is necessary for prompt and early diagnosis and treatment of antepartum and peripartum complications.

Implementation and evaluation of a genetics curriculum to improve obstetrician-gynecologist residents' knowledge and skills in genetic diagnosis and counseling.

OBJECTIVE: This study was undertaken to develop, implement, and evaluate a genetics curriculum for obstetrician-gynecologist residents. STUDY DESIGN: We prospectively evaluated the effect of a genetics curriculum on obstetrician-gynecologist residents' knowledge and skills. Residents completed a needs assessment and pretest. Educational intervention included 2 3-hour didactic sessions with 1 hour of lecture followed by case discussion and 1 3-hour session of experiential learning using standardized patients who evaluated residents' knowledge and skills in taking family history, drawing genetic pedigrees, and counseling patients. Posttest scores were compared with pretest scores. RESULTS: Needs assessment was completed by all 40 obstetrics and gynecology residents and identified limited and variable genetics education in medical school. Twenty-eight of 40 residents attended the entire educational intervention and completed the pretest and posttest, and 25 of 28 showed improved test scores. Residents stated that they were more confident in their ability to take a family history, record a 3-generation pedigree, and counsel patients about genetic conditions after completion of the genetics curriculum. CONCLUSION: This multifaceted genetics curriculum improved residents' knowledge of genetics as well as their confidence in applying genetic concepts as assessed by the pretest and posttest and by their comments in the debrief session.

Erythropoietin use in a pregnant Jehovah's witness with anemia and beta-thalassemia: a case report.

BACKGROUND: Anemia in pregnancy is seen often because of iron deficiency and the "physiologic dilution" that occurs in the third trimester. Other causes include genetic conditions, such as sickle cell anemia and thalassemias. In cases not responding to iron therapy, patients occasionally require a blood transfusion to restore adequate circulating red blood cell mass. In patients belonging to the Jehovah's Witness sect, transfusion of blood products is not allowed, and treatment of anemia in pregnancy may require use of erythropoietin. CASE: A 26-year-old, African American woman belonging to the Jehovah's Witness sect presented with anemia associated with beta-thalassemia. Iron therapy and prenatal vitamins did not correct the anemia, and the patient became symptomatic, with fatigue and shortness of breath when walking. Therapy with synthetic erythropoietin corrected the anemia, and the patient had an otherwise-uncomplicated pregnancy and delivery. CONCLUSION: Synthetic erythropoietin has been used successfully in patients with renal failure and anemia. In pregnancy associated with renal failure and anemia, synthetic erythropoietin has been shown to be safe except for rare cases of hypertension. We treated anemia caused by beta-thalassemia in pregnancy with synthetic erythropoietin to avoid a transfusion in a Jehovah's Witness.

Autosomal dominant polycystic kidney disease in pregnancy complicated by twin gestation and severe preeclampsia: a case report.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD), an autosomal dominant genetic disorder with a reported prevalence of 1 in 1,000, may be associated with hypertensive disease in pregnancy. The evaluation of a pregnant woman with an adult-onset genetic disorder is complex and involves counseling about inheritance, prenatal diagnosis and management of the current pregnancy. CASE: A 33-year-old woman presented for obstetric care with a history of hypertension and ADPKD for 6 years. The patient had secondary infertility, which was treated by in vitro fertilization. The case was complicated by twin gestation and superimposed severe preeclampsia, leading to preterm cesarean delivery at 26 weeks' estimated gestational age. CONCLUSION: Because of the heritable nature of ADPKD and the long-term risk of end-stage renal disease requiring dialysis and/or renal transplantation, the evaluation and counseling of women with ADPKD who are pregnant or considering pregnancy should include a discussion of the modes of inheritance, natural history, available prenatal diagnostic options, and pregnancy risks and management options. Specific counseling issues in this case include the genetic concepts of variable expression and penetrance and the medical management of chronic hypertension and preeclampsia.

Angiogenic biomarkers for prediction of early preeclampsia onset in high-risk women.

OBJECTIVE: Chronic hypertension, pregestational diabetes mellitus, history of prior preeclampsia and obese nulliparity are maternal conditions associated with increased preeclampsia risk. Whether altered maternal angiogenic factor levels allow for prediction of pending disease is unclear. Our objective was to evaluate angiogenic factors for early preeclampsia prediction in high-risk women. METHODS: Serial serum specimens were collected from 157 women at high preeclampsia risk and 50 low-risk controls between 23 and 36 weeks gestation in 3 windows (23-27.6, 28-31.6, and 32-35.6 weeks) in a two-center observational cohort. Soluble fms-like tyrosine kinase-1 (sFlt1), placental growth factor (PlGF) and soluble endoglin (sEng) were measured by ELISA. RESULTS: Multivariate parsimonious logistic regression analyses using backward elimination for prediction of early-preeclampsia (diagnosed < 34 weeks) found the best-fitting model included the predictors (1) sFlt1 measured in the second window (28-31.6 weeks) with AUC 0.85, sensitivity 67% and specificity 96% and (2) sFlt1 measured in the first window (23-27.6 weeks) and sEng change between first and second window with AUC 0.91, sensitivity 86% and specificity 96%. CONCLUSIONS: Two-stage sampling screening protocol utilizing sFlt1 and sEng is promising for prediction of preeclampsia diagnosed before 34 weeks. Larger studies are needed to confirm these findings.

Maternal asthma, race and low birth weight deliveries.

BACKGROUND: Asthma during pregnancy may compromise the well-being of the fetus and potentially impact an infant's birth weight via different mechanisms. AIMS: 1) To assess the influence of asthma during pregnancy on the incidence of LBW outcomes in white non-Hispanic (WNH) and black non-Hispanic (BNH) women. 2) To identify other risk factors that affect low birth weight (LBW) (birth weight<2500g) outcomes among asthmatic women. DESIGN/SUBJECTS: We conducted a retrospective analysis of compiled perinatal data on 17,073 patients including 9348 WNH and 7725 BNH women delivering at the George Washington University Hospital between 1990 and 2003. Univariate and logistic regression analyses were used to examine associations. RESULTS: A total of 423 (2.5%) women had an asthma diagnosis, with a higher incidence in BNH women when compared to WNH women (3.4% vs. 1.7%, P<0.001). In the WNH population, asthmatic women had higher incidences of gravidity, thyroid disease, and illicit drug use, whereas in the BNH population, asthmatic women had higher incidences of increased body mass index (BMI), and use of alcohol, tobacco and illicit drugs. After controlling for confounders in multiple logistic regression analyses, there was an association between asthma and LBW outcomes in BNH women (OR: 1.7, CI: 1.1-2.6, p=0.01), but not in WNH women (OR=0.99, CI=0.5-2.2, p=0.97). CONCLUSIONS: Asthma during pregnancy is a risk factor for LBW outcomes in BNH but not WNH women. The increased alcohol and illicit drug use in BNH women with asthma is an unexpected finding that deserves further study.