A preliminary evaluation of trust and shared decision making among intensive care patients' family members.

PURPOSE: The purpose of this study was to preliminarily evaluate ICU family members' trust and shared decision making using modified versions of the Wake Forest Trust Survey and the Shared Decision Making-9 Survey. METHODS: Using a descriptive approach, the perceptions of family members of ICU patients (n=69) of trust and shared decision making were measured using the Wake Forest Trust Survey and the 9-item Shared Decision Making (SDM-9) Questionnaire. Both surveys were modified slightly to apply to family members of ICU patients and to include perceptions of nurses as well as physicians. RESULTS: Overall, family members reported high levels of trust and inclusion in decision making. Family members who lived with the patient had higher levels of trust than those who did not. Family members who reported strong agreement among other family about treatment decisions had higher levels of trust and higher SDM-9 scores than those who reported less family agreement. CONCLUSION: The modified surveys may be useful in evaluating family members' trust and shared decision making in ICU settings. Future studies should include development of a comprehensive patient-centered care framework that focuses on its central goal of maintaining provider-patient/family partnerships as an avenue toward effective shared decision making.

Discordant circulating fetal DNA and subsequent cytogenetics reveal false negative, placental mosaic, and fetal mosaic cfDNA genotypes.

BACKGROUND: The American College of Obstetrics and Gynecology (ACOG) and Maternal Fetal Medicine (MFM) Societies recommended that abnormal cfDNA fetal results should be confirmed by amniocentesis and karyotyping. Our results demonstrate that normal cfDNA results inconsistent with high-resolution abnormal ultrasounds should be confirmed by karyotyping following a substantial frequency of incorrect cfDNA results. METHODS: Historical review of our ~4,000 signed prenatal karyotypes found ~24% of reported abnormalities would not have been detected by cfDNA. Akron Children's Hospital Cytogenetics Laboratory has completed 28 abnormal cfDNA cases among the 112 amniocenteses karyotyped. RESULTS: Following abnormal cfDNA results our karyotypes confirmed only 60% of the cfDNA results were consistent. Our cases found a normal cfDNA test result followed by a 20 weeks anatomical ultrasound detected a false negative trisomy 18 cfDNA result. One cfDNA result that reported trisomy 21 in the fetus was confirmed by karyotyping which also added an originally undetected balanced reciprocal translocation. Another reported karyotyped case followed by a repeated microarray of pure fetal DNA, together revealed one phenotypically normal newborn with a complex mosaic karyotype substantially decreasing the newborn's eventual reproductive fitness. This second case establishes the importance of karyotyping the placenta and cord or peripheral blood when inconsistent or mosaic results are identified following an abnormal cfDNA result with a normal newborn phenotype without a prenatal karyotype. CONCLUSIONS: These Maternal Fetal Medicine referrals demonstrate that positive NIPT results identify an increased abnormal karyotypic frequency as well as a substantial proportion of discordant fetal results. Our results found: (1) a normal NIPT test result followed by a 20 week anatomical ultrasound detected a false negative trisomy 18 NIPT result, (2) a substantial proportion of abnormal NIPT tests identify chromosomal mosaicism that may or may not be confined to the placenta, (3) follow up karyotyping should be completed on the newborn placenta and peripheral blood when the amniocyte karyotype does not confirm the NIPT reported abnormality in order to identify ongoing risk of developing mosaic symptoms, and (4) karyotyping all high risk fetuses tested by amniocentesis defines the 24% of chromosome abnormalities not currently screened by NIPT.

Neonatal morbidity by week of gestational age for twins compared to singletons: a population-based cohort study.

OBJECTIVE: Quantify neonatal morbidity by week of gestation for twins compared with singletons. STUDY DESIGN: We performed a population-based retrospective cohort study of all Ohio births from 2006 to 2007. Composite neonatal morbidity consisting of Apgar score < 7 at 5 minutes, assisted ventilation > 6 hours, neonatal transport, or seizures was compared between singletons and twins from 34 to 41 weeks. RESULTS: Neonatal morbidity was the lowest in twins delivered at 37 completed weeks and 2 weeks later for singletons at 39 weeks. Twin morbidity rapidly increased after 37 weeks and reached 15.8% at 41 weeks versus the singleton morbidity rate of 3.4% at 41 weeks. Twins delivered at 39 weeks and beyond were more than twice as likely to incur neonatal morbidity compared with singletons. CONCLUSION: The lowest rate of neonatal morbidity occurs at 37 weeks for twins versus 39 weeks for singleton births. The increased risk after 37 weeks for twins accelerates at a faster rate compared with that for singletons born past 39 weeks.

Modulation of lipopolysaccharide-induced chorioamnionitis by Ureaplasma parvum in sheep.

OBJECTIVE: Ureaplasma colonization in the setting of polymicrobial flora is common in women with chorioamnionitis, and is a risk factor for preterm delivery and neonatal morbidity. We hypothesized that Ureaplasma colonization of amniotic fluid would modulate chorioamnionitis induced by Escherichia coli lipopolysaccharide (LPS). STUDY DESIGN: Sheep received intraamniotic (IA) injections of media (control) or live Ureaplasma either 7 or 70 days before delivery. Another group received IA LPS 2 days before delivery. To test for interactions, U parvum-exposed animals were challenged with IA LPS, and delivered 2 days later. All animals were delivered preterm at 125 ± 1 day of gestation. RESULTS: Both IA Ureaplasma and LPS induced leukocyte infiltration of chorioamnion. LPS greatly increased the expression of proinflammatory cytokines and myeloperoxidase in leukocytes, while Ureaplasma alone caused modest responses. Interestingly, 7-day but not 70-day Ureaplasma exposure significantly down-regulated LPS-induced proinflammatory cytokines and myeloperoxidase expression in the chorioamnion. CONCLUSION: Acute (7-day) U parvum exposure can suppress LPS-induced chorioamnionitis.

Influence of adolescence and obesity on the rate of stillbirth.

BACKGROUND: We hypothesise that the rate of stillbirth is increased in mothers younger than 18 years of age compared to adult mothers, and that obesity further increases the risk of stillbirth in this population. METHODS: We conducted a population-based cohort study comparing rates of stillbirth between adolescent, defined as young women under the age of 18 and adult women. We then compared the rate of stillbirth in normal weight vs. obese adolescents. These effects were stratified according to gestational age. Log-binomial regression models were used to estimate the effect of adolescence and obesity on stillbirth risk while adjusting for important confounders. Risk ratios (RR) with 95% confidence intervals [CI]were calculated. RESULTS: We reviewed data from 650 760 births in Missouri between 1998 and 2005. Stillbirth rates were 6.7 and 4.1 per 1000 in adolescents and adult women, respectively (RR 1.2, 95% CI 1.03-1.5). A higher proportion of stillbirths occurred prior to 28 weeks in adolescents vs. adults (53% vs. 37% respectively, P = 0.002). The risk of stillbirth in obese adolescents was further increased over normal weight adolescents (adjusted RR [aRR] 1.7, 95% CI 1.02-2.9). CONCLUSION: Adolescent pregnancies, particularly obese adolescents, are at an increased risk of stillbirth.

Fetal cervical teratoma: What is the role of fetal MRI in predicting pulmonary hypoplasia?

OBJECTIVE: To determine whether total fetal lung volumes estimated by MRI could predict lethal pulmonary hypoplasia in a cohort of fetuses with cervical teratomas. METHODS: We performed a retrospective cohort study of fetal cervical teratomas from January 1, 2005, through April 1, 2012. The primary outcome was the ability of total lung volumes measured by MRI to predict neonatal mortality specifically due to pulmonary hypoplasia. Measured lung volumes were compared to previously reported normal values. The percent of observed-to-expected lung volume and the percent predicted lung volume were calculated. The positive and negative predictive values were calculated for each variable. RESULTS: Fetal MRI-derived total lung volumes 1 standard deviation below the median for gestational age had a positive predictive value of 100% in predicting lethal pulmonary hypoplasia. Conversely, total lung volumes above this level were uniformly associated with pulmonary survival (100% negative predictive value). Additionally, percent predicted lung volume ≤75.7 and observed-to-expected lung volume ≤68.3 were associated with lethal pulmonary hypoplasia. CONCLUSION: In this small cohort, MRI-estimated lung volumes were helpful in predicting the presence of pulmonary hypoplasia complicating fetal cervical teratoma.

The effect of maternal obesity on the rate of failed induction of labor.

OBJECTIVE: The purpose of this study was to quantify the relationship between class of obesity and rate of failed induction of labor. STUDY DESIGN: Using the Ohio Department of Health's birth certificate database from January 1, 2006, through December 31, 2007, we performed a population-based cohort study that compared failed induction of labor rates between obese and normal-weight women. RESULTS: The rate of induction is associated with increasing body mass index from 28% in normal-weight women to 34% in class III obese women (body mass index, ≥40 kg/m2). Induction failure rates are also associated with increasing obesity class from 13% in normal-weight women to 29% in class III obese women. Women with class III obesity without a previous vaginal delivery and a macrosomic fetus had the highest rate of failed induction at 80%. CONCLUSION: Obesity is associated with an increased risk of failed labor induction that appears to be related directly to increasing class of obesity.

The influence of hospital type on induction of labor and mode of delivery.

OBJECTIVE: The purpose of this study was to compare labor induction and cesarean delivery rates at term in community vs university hospitals. STUDY DESIGN: A population-based retrospective cohort study of births was performed. Primary outcomes were term gestation at <39 weeks, labor induction, and cesarean delivery. After we adjusted for comorbidities, malpresentation, and previous cesarean delivery, logistic regression assessed the association between hospital type and primary outcomes. RESULTS: Births occur less often in week 37 (n = 24390 [11%] vs 4006 [13%]; adjusted odds ratio [OR], 0.9; 95% confidence interval [CI], 0.8-0.9) and are similar in week 38 in community vs university hospitals. Inductions occur more commonly in community vs university settings at 37 weeks (n = 6440 [27%] vs 757 [19%]; adjusted OR, 1.7; 95% CI, 1.5-1.8) and at 38 weeks (n = 16586 [31%] vs 1530 [21%]; adjusted OR, 1.8; 95% CI, 1.7-1.9). Cesarean rates are no different between hospital types. CONCLUSION: Induction is 70-80% more likely at community vs university hospitals before the optimal gestational age of ≥ 39 weeks, but cesarean delivery rates do not differ at term.

The rates of abnormal glucose challenge tests and gestational diabetes in women receiving 17α-hydroxyprogesterone caproate.

We compared the rates of abnormal 1-hour glucose challenge tests (GCT) and gestational diabetes (GDM) between women receiving 17α-hydroxyprogesterone caproate (17-P) and women who did not receive 17-P to determine if the effect varies based on the number of doses received or in a group of high-risk obese women. We performed a secondary analysis of a prospective cohort study where women with a history of a previous preterm delivery in the antecedent pregnancy followed at a high-risk clinic were offered 17-P. GCT was performed after the initiation of 17-P, and doses given prior to testing were recorded. Rates of abnormal GCT and GDM were compared between those receiving 17-P ( N = 67) and controls ( N = 140). Mean glucose values (112.4 versus 111.3, P = 0.8), rate of abnormal GCT (23.9% versus 20%, adjusted odds ratio 1.45, 95% confidence interval 0.7 to 3.0), and rate of GDM (6% versus 8.6%, adjusted odds ratio 1.21, 95% confidence interval 0.3 to 4.5) were similar between groups. In this prospective study, 17-P administration to women at risk of recurrent preterm delivery did not significantly affect glucose tolerance.

Modulation of lipopolysaccharide-induced chorioamnionitis in fetal sheep by maternal betamethasone.

OBJECTIVE: We tested the hypothesis that the order of exposure to maternal betamethasone and intra-amniotic (IA) lipopolysaccharide (LPS) will differentially modulate inflammation in the chorioamnion. STUDY DESIGN: Time-mated Merino ewes with singleton fetuses received saline alone, IA LPS alone, maternal betamethasone before LPS, or betamethasone after LPS. We assessed inflammatory markers in the chorioamnion and the amniotic fluid. RESULTS: Inflammatory cell infiltration, expression of myeloperoxidase, serum amyloid A3 (acute phase reactant) in the chorioamnion, and levels of interleukin (IL)-8 in the amniotic fluid increased 7 days after LPS exposure. Betamethasone prior to LPS decreased infiltration of the inflammatory cells, CD3+ T cells, and decreased the levels of IL-1ß and IL-8 in the amniotic fluid. CONCLUSIONS: Betamethasone 7 days prior to LPS exposure suppressed LPS-induced inflammation. The markers of inflammation largely had returned to the baseline 14 days after LPS exposure.