Challenges in the Contemporary Management of Syphilis among Pregnant Women in New Orleans, LA.

Objective: The aim of this retrospective review is to evaluate trends in the management of maternal and congenital syphilis (CS) in a tertiary care center in New Orleans, LA. Study Design: All cases of maternal and neonatal syphilis over a five year period at Touro Infirmary, New Orleans, LA, were identified using ICD-9/10 codes. Charts were reviewed for demographic and obstetrical variables, stage of syphilis at diagnosis, lab values, and treatment regimen. Newborn treatment and other outcomes were recorded. Results: During the study period 106 infected mother-baby pairs were identified. Of these, 73 charts are available for review. 41% (n = 30) of women received inadequate therapy according to their stage of disease. 9% of newborns (n = 6) were found to be symptomatic for CS; however, only 83.3% of these were admitted to the neonatal intensive care unit. Only 20% (n = 6) of infants were adequately treated with an extended penicillin regimen if the mother was not adequately treated. Furthermore, only 63.0% of newborns had a nontreponemal titer performed. Conclusion: With rising rates of CS, strict adherence to the 2015 CDC guidelines for treatment of syphilis must be maintained.

Acute feTal behavioral Response to prenatal Yoga: a single, blinded, randomized controlled trial (TRY yoga).

BACKGROUND: In 2012, yoga was practiced by 20 million Americans, of whom 82% were women. A recent literature review on prenatal yoga noted a reduction in some pregnancy complications (ie, preterm birth, lumbar pain, and growth restriction) in those who practiced yoga; to date, there is no evidence on fetal response after yoga. OBJECTIVES: We aimed to characterize the acute changes in maternal and fetal response to prenatal yoga exercises using common standardized tests to assess the well-being of the maternal-fetal unit. STUDY DESIGN: We conducted a single, blinded, randomized controlled trial. Uncomplicated pregnancies between 28 0/7 and 36 6/7 weeks with a nonanomalous singleton fetus of women who did not smoke, use narcotics, or have prior experience with yoga were included. A computer-generated simple randomization sequence with a 1:1 allocation ratio was used to randomize participants into the yoga or control group. Women in the yoga group participated in a 1-time, 1 hour yoga class with a certified instructor who taught a predetermined yoga sequence. In the control group, each participant attended a 1-time, 1 hour PowerPoint presentation by an obstetrician on American Congress of Obstetricians and Gynecologists recommendations for exercise, nutrition, and obesity in pregnancy. All participants underwent pre- and postintervention testing, which consisted of umbilical and uterine artery Doppler ultrasound, nonstress testing, a biophysical profile, maternal blood pressure, and maternal heart rate. A board-certified maternal-fetal medicine specialist, at a different tertiary center, interpreted all nonstress tests and biophysical profile data and was blinded to group assignment and pre- or postintervention testing. The primary outcome was a change in umbilical artery Doppler systolic to diastolic ratio. Sample size calculations indicated 19 women per group would be sufficient to detect this difference in Doppler indices (alpha, 0.05; power, 80%). Data were analyzed using a repeated-measures analysis of variance, a χ(2), and a Fisher exact test. A value of P < .05 was considered significant. RESULTS: Of the 52 women randomized, 46 (88%) completed the study. There was no clinically significant change in umbilical artery systolic to diastolic ratio (P = .34), pulsatility index (P = .53), or resistance index (P = .66) between the 2 groups before and after the intervention. Fetal and maternal heart rate, maternal blood pressure, and uterine artery Dopplers remained unchanged over time. When umbilical artery indices were individually compared with gestational age references, there was no difference between those who improved or worsened between the groups. CONCLUSION: There was no significant change in fetal blood flow acutely after performing yoga for the first time in pregnancy. Yoga can be recommended for low-risk women to begin during pregnancy.

Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: a comparison.

OBJECTIVE: To compare the obstetric recommendations in American Congress of Obstetricians and Gynecologists (ACOG) practice bulletins (PB) with similar topics in UpToDate (UTD). STUDY DESIGN: We accessed all obstetric PB and cross-searched UTD (May 1999-May 2013). We analyzed only the PB which had corresponding UTD chapter with graded recommendations (level A-C). To assess comparability of recommendations for each obstetric topic, two maternal-fetal medicine (MFM) subspecialists categorized the statement as similar, dissimilar, or incomparable. Simple and weighted kappa statistics were calculated to assess agreement between the two raters. RESULTS: We identified 46 ACOG obstetric PB and 86 UTD chapters. There were 50% fewer recommendations in UTD than in PB (181 vs. 365). The recommendations being categorized as level A, B, or C was significantly different (p < 0.001) for the two guidelines. While the overall concordance rate between the two MFM subspecialists was 83% regarding the recommendations for the same topic as similar, dissimilar, or incomparable, the agreement was moderate (kappa, 0.56; 95% confidence intervals, 0.48-0.65). CONCLUSION: Though obstetricians have two sources for graded recommendations, incongruity among them may be a source of consternation. Congruent recommendations from ACOG and UTD could enhance compliance and potentially optimize outcomes.

Neonatal brachial plexus palsy with vaginal birth after cesarean delivery: a case-control study.

OBJECTIVE: The objective was to determine the rate of neonatal brachial plexus palsy (NBPP) among women with vaginal birth after cesarean delivery (VBAC) and to compare the peripartum characteristics with control subjects. STUDY DESIGN: The Maternal-Fetal Medicine Unit cesarean registry data were used to identify nonanomalous singleton pregnancies with VBAC and NBPP at gestational age of ≥37 weeks (term) and 4 control subjects (matched for gestational age and diabetes mellitus status but without brachial injury). Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. RESULTS: Among 11,313 VBACs at term, there were 23 women with NBPP (rate of 2.0/1000 women). Newborn infants with NBPP, compared with control infants, were significantly more likely to weigh ≥4000 g (48% vs 10%, respectively; OR, 8.45; 95% CI, 2.58-28.44) and to require admission to the neonatal intensive care unit (30% vs 13%; OR, 12.98; 95% CI, 2.61-72.18). CONCLUSION: Women who desire VBAC should be informed about the low rate of NBPP and, if eligible, encouraged to have a trial of labor after cesarean delivery.

Severe small size for gestational age and cognitive function: catch-up phenomenon possible.

OBJECTIVE: We sought to compare cognitive functioning in children born with birthweight <3% vs ≥3% for gestational age (GA) between 9 months and kindergarten. STUDY DESIGN: Nonanomalous singletons from the Early Childhood Longitudinal Study-Birth Cohort were included. Associations between weight for GA and cognitive functioning were examined using a series of confounder-adjusted general linear models. RESULTS: Of 3633 cohorts, 585 (16%) were <3% for GA. At 9 months, cognitive performance of newborns <3% was about 12 percentile points lower than their normal counterparts (P < .001). By 2 years, however, no significant cognitive differences between these groups were observed (P = .668). Academic performance at preschool age (around 3.5 years) was not different for reading (P = .245) or math (P = .880), nor different at kindergarten age. CONCLUSION: Newborns <3% for GA exhibit catch-up cognitive functioning by 2 years, with relatively no decrements in academic functioning observed by kindergarten.

Vaginal birth after cesarean delivery: comparison of ACOG practice bulletin with other national guidelines.

Evidence-based guidelines regarding vaginal birth after cesarean from 3 countries (United States, Canada, and United Kingdom) were reviewed. The similarities in the 3 national guidelines (trial of labor after 1 previous cesarean, informed consent, delivery facility and available resources, epidural analgesia, continuous fetal monitoring, and induction and augmentation of labor) are understandable. Differences in recommendations (uterine rupture risk, success rate, intrauterine pressure catheter, and mechanical cervical ripening) are not explained. The likelihood of recommendations being categorized as level A differed: United States, 27% (3/11); Canada, 32% (6/19); and United Kingdom, 0% (0/17). Only 6 publications were cited by all 3 guidelines.

Intrapartum fetal surveillance: review of three national guidelines.

Evidence-based guidelines regarding intrapartum fetal surveillance from three countries (United States, Canada, and Australia/New Zealand) were reviewed. The similarities in the three national guidelines (purported etiology, management of periodic changes, and intermittent auscultation for low-risk women) are understandable. Differences in recommendations (role of fetal admission test, amnioinfusion for variable decelerations, scalp pH, umbilical arterial acid-base status, and education in interpretation of fetal heart tracing) are not explained. The likelihood of recommendations being categorized as level A differed for the countries: United States, 41% (7/17); Canada, 18% (3/17); and Australia and New Zealand, 17% (2/12). Only one publication was cited by all three guidelines. To avoid confusion and possibly enhance their quality, national guidelines should acknowledge the presence of others on the same topic, and if there are differences then provide explanations for dissimilarities.

Oligohydramnios, small for gestational age and pregnancy outcomes: an analysis using precise measures.

BACKGROUND/AIM: Marginal or decreased amniotic fluid volume by ultrasound estimate and fetal growth restriction have been shown to be significantly associated with perinatal mortality. The association of fetal growth restriction and precisely measured amniotic fluid volume is unknown. The purpose of this study was to determine if adverse pregnancy outcomes are more likely in pregnancies complicated by small-for-gestational-age (SGA) neonates and dye-determined oligohydramnios. METHODS: Admissions to neonatal intensive care unit (NICU) and other pregnancy outcomes were analyzed in parturients with known amniotic fluid volume, calculated by the dye-dilution technique. The pregnancy outcomes of those with oligohydramnios and SGA were compared with pregnancies complicated by just one of these two conditions and pregnancies with normal fluid and birth weight. RESULTS: Of 202 patients, oligohydramnios was present in 26% (53), SGA in 15% (30) and both conditions in (5%) (11). Logistic regression, controlling for gestational age, demonstrated that the combination of oligohydramnios and SGA, compared to normal growth and fluid strongly predicted NICU admission (OR 11.1; 95% CI 2.1-59.2) but not other complications. (OR 4.8; 95% CI 0.3-62.9). CONCLUSIONS: SGA with oligohydramnios significantly increases the likelihood of a NICU admission, but not other morbidity.

Maintenance tocolytics for preterm symptomatic placenta previa: a review.

The purpose of the review article is to determine if prolonged (≥48 hour) tocolytics with symptomatic preterm placenta previa improves perinatal outcome. OVID MEDLINE and Cochrane Databases were searched from January 1950 to January 2009. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. We identified two retrospective studies ( N = 217) and one randomized clinical trial (RCT; N = 60), and they were analyzed separately. Results of the RCT indicated that pregnancy is prolonged for more than 7 days with continued tocolytics (OR 3.10, 95% CI 1.38 to 6.96) but combined results of two retrospective studies did not confirm the prolongation (OR 1.19, 95% CI 0.63 to 2.28). The RCT was inadequately compliant with Consolidated Standards of Reporting Trials statement. While awaiting an appropriately designed RCT to determine the duration of tocolytics with placenta previa and preterm labor, it should be limited to 48 hours.

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

BACKGROUND: Retained sponges (gossypiboma) following vaginal delivery are an uncommon occurrence. Although significant morbidity from such an event is unlikely, there are many reported adverse effects, including symptoms of malodorous discharge, loss of confidence in providers and the medical system, and legal claims. OBJECTIVE: To report a protocol intended to reduce the occurrence of retained sponges following vaginal delivery. METHODS: After identification of limitations with existing delivery room protocols, we developed a sponge count protocol to reduce occurrence of retained vaginal sponges. We report our experience at Naval Medical Center Portsmouth, a large tertiary care military treatment facility with our efforts to implement a sponge count protocol to reduce retained sponges following vaginal delivery. CONCLUSIONS: With appropriate pre-implementation training, protocols which incorporate post-delivery vaginal sweep and sponge counts are well accepted by the health care team and can be incorporated into the delivery room routine.

Association of birth weight with polymorphisms in the IGF2, H19, and IGF2R genes.

There is a substantial genetic component for birth weight variation. We tested 18 single nucleotide polymorphisms (SNPs) in the IGF2, H19, and IGF2R genes for associations with birth weight variation in 342 mother-newborn pairs (birth weight 2.1-4.7 kg at term) and 527 parent-newborn trios (birth weight 2.1-5.1 kg) across three localities. SNPs in the IGF2R (rs8191754; maternal genotype), IGF2 (rs3741205; newborn genotype), and 5' region of the H19 (rs2067051, rs2251375, and rs4929984) genes were associated with birth weight. Detailed analyses to distinguish direct maternal, direct newborn, and parent of origin effects for the most strongly associated H19 SNP (rs4929984) determined that the association of maternal genotype with newborn birth weight was due to parent of origin effects not direct maternal effects. That SNP is located near the CTCF binding sites that influence expression of the maternally imprinted IGF2 and paternally imprinted H19 locus, and there are statistically significant and independent opposite effects of the same rs4929984 allele, depending on the parent from which it was inherited.

Abnormal 1 hour glucose challenge test followed by a normal 3 hour glucose tolerance test: does it identify adverse pregnancy outcome?

OBJECTIVE: To determine if pregnancies with an abnormal glucose challenge test (GCT) but a normal (GTT) are at increased risk for fetal macrosomia or an adverse pregnancy outcome. STUDY DESIGN: This prospective observational study matched women with an abnormal glucose challenge test and a normal GTT with the next patient with a normal GCT. RESULTS: Over 12 months, 107 women with abnormal GCT were matched with 107 women with normal GCT. Women with an abnormal GCT were older (27.3 vs. 24.7, p = 0.001) and less likely to be African-American (OR = 2.2, 95% CI 1.06-4.49) but no more likely to have an adverse pregnancy outcome. ROC curves could not differentiate between macrosomic vs non-macrosomic newborns using GCT values. CONCLUSION: Women with an abnormal GCT but a normal GTT are more likely to be older, less likely to be African-American, but no more likely to have an adverse pregnancy outcome or a macrosomic fetus.

Does hypoglycemia following a glucose challenge test identify a high risk pregnancy?

OBJECTIVE: An association between maternal hypoglycemia during pregnancy with fetal growth restriction and overall perinatal mortality has been reported. In a retrospective pilot study we found that hypoglycemia was linked with a greater number of special care/neonatal intensive care unit admissions and approached significance in the number of women who developed preeclampsia. That study was limited by its retrospective design, a narrow patient population and the inability to perform multivariate analysis because of the limitations in the data points collected. This study was undertaken to compare the perinatal outcome in pregnancies with hypoglycemia following a glucose challenge test (GCT) to pregnancies with a normal GCT. METHODS: Obstetric patients (not pre-gestational diabetics or gestational diabetes before 24 weeks were eligible. Women with a 1 hour glucose < or = 88 mg/dL (4.8 m/mol) following a 50-gram oral GCT were matched with the next patient with a 1 hour glucose of 89-139 mg/dL. Pregnancy outcomes were evaluated. RESULTS: Over 22 months, 436 hypoglycemic patients and 434 normal subjects were identified. Hypoglycemia was increased in women < 25 (p = 0.003) and with pre-existing medical conditions (p < 0.001). Hypoglycemia was decreased if pre-pregnancy BMI > or = 30 (p = 0.008).Preeclampsia/eclampsia was more common in hypoglycemic women. (OR = 3.13, 95% CI 1.51 - 6.51, p = 0.002) but not other intrapartum and perinatal outcomes. CONCLUSION: Hypoglycemic patients are younger, have reduced pre-pregnancy weight, lower BMIs, and are more likely to develop preeclampsia than normoglycemic women.

Hepatic epithelial hemangioendothelioma in pregnancy.

BACKGROUND: Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm that affects various tissues including liver, lung, gastrointestinal tract, head and neck, bone, heart and the central nervous system. CASE REPORT: A case of EHE is presented with lung and liver involvement during pregnancy. The patient had an uncomplicated antenatal course and delivery. Because of her asymptomatic presentation and the lack of safe and effective treatment during pregnancy, the decision was made to continue expectant management during her pregnancy. To our knowledge, this is the only published case report on this tumor with lung and liver involvement during pregnancy. CONCLUSION: Expectant management of hepatic EHE is possible during pregnancy and can result in good maternal and fetal outcomes.

A randomized clinical trial comparing vaginal misoprostol versus cervical Foley plus oral misoprostol for cervical ripening and labor induction.

We compared labor induced by vaginal misoprostol versus a supracervical Foley catheter and oral misoprostol. Singleton pregnancies at > or = 24 weeks' gestation were randomized to either an initial 25-microg dose of intravaginal misoprostol, followed by 50-microg intravaginal doses at 3- to 6-hour intervals, or a supracervical Foley balloon and 100 microg of oral misoprostol at 4- to 6-hour intervals. Primary outcome was time from induction to delivery. One hundred twenty-six women were randomized to vaginal misoprostol alone (group I) and 106 women to Foley and oral misoprostol (group II). The groups were similar in age, weight, gestational age, parity, indication for induction of labor, and oxytocin use. Cesarean delivery rates at 37% and cesarean indications were similar ( P = 0.25). The time from induction to delivery in group II (12.9 hours) was significantly shorter than that in group I (17.8 hours, P < 0.001). Uterine tachysystole occurred less often in the vaginal misoprostol group (21% versus 39%, P = 0.015). Compared with vaginal misoprostol, delivery within 24 hours was significantly more likely with a Foley balloon and oral misoprostol. The use of terbutaline and peripartum outcomes were similar in the two groups.

Ampicillin resistance and outcome differences in acute antepartum pyelonephritis.

OBJECTIVE: To measure the incidence of ampicillin-resistant uropathogens in acute antepartum pyelonephritis and to determine if patients with resistant organisms had different clinical outcomes. STUDY DESIGN: This was a secondary analysis of a prospective cohort study of pregnant women admitted with pyelonephritis, diagnosed by standard clinical and laboratory criteria. All patients received ampicillin and gentamicin. RESULTS: We identified 440 cases of acute pyelonephritis. Seventy-two percent (316 cases) had urine cultures with identification of organism and antibiotic sensitivities. Fifty-one percent of uropathogens were ampicillin resistant. The patients with ampicillin-resistant organisms were more likely to be older and multiparous. There were no significant differences in hospital course (length of stay, days of antibiotics, ECU admission, or readmission). Patients with ampicillin-resistant organisms did not have higher complication rates (anemia, renal dysfunction, respiratory insufficiency, or preterm birth). CONCLUSION: A majority of uropathogens were ampicillin resistant, but no differences in outcomes were observed in these patients.

Valacyclovir prophylaxis to prevent recurrent herpes at delivery: a randomized clinical trial.

OBJECTIVE: To measure the efficacy of valacyclovir suppression in late pregnancy to reduce the incidence of recurrent genital herpes in labor and subsequent cesarean delivery. METHODS: A total of 350 pregnant women with a history of genital herpes were assigned randomly to oral valacyclovir 500 mg twice a day or an identical placebo from 36 weeks of gestation until delivery. In labor, vulvovaginal herpes simplex virus (HSV) culture and polymerase chain reaction (PCR) specimens were collected. Vaginal delivery was permitted if no clinical recurrence or prodromal symptoms were present. Neonatal HSV cultures and laboratory tests were obtained, and infants were followed up for 1 month after delivery. Data were analyzed using chi2 and Student t tests. RESULTS: One hundred seventy women treated with valacyclovir and 168 women treated with placebo were evaluated. Eighty-two percent of the women had recurrent genital herpes; 12% had first episode, nonprimary genital herpes; and 6% had first episode, primary genital herpes. At delivery, 28 women (8%) had recurrent genital herpes requiring cesarean delivery: 4% in the valacyclovir group and 13% in the placebo group (P = .009). Herpes simplex virus was detected by culture in 2% of the valacyclovir group and 9% [corrected] of the placebo group (P =.02). No infants were diagnosed with neonatal HSV, and there were no significant differences in neonatal complications. There were no significant differences in maternal or obstetric complications in either group. CONCLUSION: Valacyclovir suppression after 36 weeks of gestation significantly reduces HSV shedding and recurrent genital herpes requiring cesarean delivery. LEVEL OF EVIDENCE: I.

Acute pyelonephritis in pregnancy.

OBJECTIVE: To examine the incidence of pyelonephritis and the incidence of risk factors, microbial pathogens, and obstetric complications in women with acute antepartum pyelonephritis. METHODS: For 2 years, information on pregnant women with acute pyelonephritis was collected in a longitudinal study. All women were admitted to the hospital and treated with intravenous antimicrobial agents. We compared the pregnancy outcomes of these women with those of the general obstetric population received at our hospital during the same time period. RESULTS: Four hundred forty cases of acute antepartum pyelonephritis were identified during the study period (incidence 1.4%). Although there were no significant differences in ethnicity, pyelonephritis was associated with nulliparity (44% versus 37%, P = .003) and young age (P = .003). Thirteen percent of the women had a known risk factor for pyelonephritis. Acute pyelonephritis occurred more often in the second trimester (53%), and the predominant uropathogens were Escherichia coli (70%) and gram-positive organisms, including group B beta Streptococcus (10%). Complications included anemia (23%), septicemia (17%), transient renal dysfunction (2%), and pulmonary insufficiency (7%). CONCLUSION: The incidence of pyelonephritis has remained low in the era of routine prenatal screening for asymptomatic bacteriuria. First-trimester pyelonephritis accounts for over 1 in 5 antepartum cases. Gram-positive uropathogens are found more commonly as pregnancy progresses. Maternal complications continue, but poor obstetrical outcomes are rare.

Earthquakes and building design: a primer for the laboratory animal professional.

Earthquakes can occur in most regions of the United States, so it might be necessary to reinforce vulnerable animal facilities to better protect research animals during these unpredictable events. A risk analysis should include an evaluation of the seismic hazard risk at the proposed building site balanced against the estimated consequences of losses. Risk analysis can help in better justifying and recommending to building owners the costs of incorporating additional seismic reinforcements. The planning team needs to specify the level of post-earthquake building function that is desired in the facility, and then design the facility to it.

Treatment of syphilis in pregnancy and prevention of congenital syphilis.

Studies about the management of syphilis during pregnancy were reviewed. They lacked uniformity in diagnostic criteria and study design. Currently recommended doses of benzathine penicillin G are effective in preventing congenital syphilis in most settings, although studies are needed regarding increased dosing regimens. Azithromycin and ceftriaxone offer potential alternatives for penicillin-allergic women, but insufficient data on efficacy limit their use in pregnancy. Ultrasonography provides a noninvasive means to examine pregnant women for signs of fetal syphilis, and abnormal findings indicate a risk for obstetric complications and fetal treatment failure. Ultrasonography should precede antepartum treatment during the latter half of pregnancy to gauge severity of fetal infection. However, optimal management of the affected fetus has not been established; collaborative management with a specialist is recommended. Antepartum screening remains a critical component of congenital syphilis prevention, even in the era of syphilis elimination.