The timing of initiation of pharmacotherapy for women with gestational diabetes mellitus.

BACKGROUND: The decision to initiate pharmacotherapy is integral in the care for pregnant women with gestational diabetes mellitus (GDM). We sought to compare pregnancy outcomes between two threshold percentages of elevated glucose values prior to initiation of pharmacotherapy for GDM. We hypothesized that a lower threshold at pharmacotherapy initiation will be associated with lower rates of adverse perinatal outcomes. METHODS: This was a retrospective cohort study of women with GDM delivering in a single tertiary care center. Pregnancy outcomes were compared using bivariable and multivariable analyses between women who started pharmacotherapy (insulin or oral hypoglycemic agent) after a failed trial of dietary modifications at two different ranges of elevated capillary blood glucose (CBG) values: Group 1 when 20-39% CBG values were above goal; Group 2 when ≥40% CBG values were above goal. The primary outcome was a composite GDM-associated neonatal adverse outcome that included: macrosomia, large for gestational age (LGA), shoulder dystocia, hypoglycemia, hyperbilirubinemia requiring phototherapy, respiratory distress syndrome, stillbirth, and neonatal demise. Secondary outcomes included cesarean delivery, preterm birth (< 37 weeks), neonatal intensive care unit (NICU) admission, and small for gestational age (SGA). RESULTS: A total of 417 women were included in the study. In univariable analysis, the composite neonatal outcome was statistically significantly higher in Group 2 compared to Group 1 (47.9% vs. 31.4%, p = 0.001). In addition, rates of preterm birth (15.7% vs 7.4%, p = 0.011), NICU admission (11.7% vs 4.0%, p = 0.006), and LGA (21.2% vs 9.1% p = 0.001) were higher in Group 2. In contrast, higher rates of SGA were noted in Group 1 (8.0% vs. 2.9%, p = 0.019). There was no difference in cesarean section rates. These findings persisted in multivariable analysis after adjusting for confounding factors (composite neonatal outcome aOR = 0.50, 95%CI [0.31-0.78]). CONCLUSIONS: Initiation of pharmacotherapy for GDM when 20-39% of CBG values are above goal, compared to ≥40%, was associated with decreased rates of adverse neonatal outcomes attributable to GDM. This was accompanied by higher rates of SGA among women receiving pharmacotherapy at the lower threshold. Additional studies are required to identify the optimal threshold of abnormal CBG values to initiate pharmacotherapy for GDM.

Thinking Twice about the Cervical Mass: A Case Report of Primary Vaginal Leiomyosarcoma and Review of the Literature.

Primary vaginal leiomyosarcoma (LMS) is an unusual cause of aggressive gynecologic cancer which requires prompt surgical treatment for favorable outcomes. Definitive diagnosis and treatment render unique challenges to clinicians based on vague presentation and limited evidence for management. Here, we describe a case of vaginal LMS in a middle-aged woman with a history of cervical dysplasia found to have a proximal vaginal mass after presenting with vaginal discharge and cramping pain. The patient was diagnosed on pathologic surgical specimen and subsequently underwent definitive surgical treatment. She remains with no evidence of disease 20 months later. In our report, we emphasize the nuances of surgical management including localized source control in those desiring future fertility. Ultimately, we make recommendations for surgical treatment and surveillance based on the available published literature.

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care.

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Antenatal maternal hypoglycemia in women with gestational diabetes mellitus and neonatal outcomes.

OBJECTIVE: To examine the prevalence of antenatal maternal hypoglycemia after initiation of pharmacotherapy for gestational diabetes mellitus (GDMA2) and its association with pregnancy outcomes. STUDY DESIGN: Retrospective cohort of GDMA2 women receiving either insulin or oral hypoglycemic agents. Composite neonatal outcome included macrosomia, jaundice, respiratory distress syndrome, large for gestational age, shoulder dystocia, birth trauma, 5-minute Apgar < 7, and neonatal hypoglycemia, and was compared between women with and without hypoglycemia using bivariate and multivariate analyses. RESULTS: Of 489 women included in the study, 95 (19.4%) had at least one episode of hypoglycemia, most often in the setting of glyburide. Newborns exposed to maternal hypoglycemia had higher rates of the composite neonatal outcome (54.7% vs. 38.3%, p = 0.004). After controlling for confounding factors, maternal hypoglycemia remained independently associated with the composite neonatal outcome (aOR = 1.69, 95% CI 1.04-2.72). CONCLUSION: Maternal hypoglycemia in GDMA2 was associated with higher rates of adverse neonatal outcomes.

Disseminated Histoplasmosis: An Unusual Cause of Bowel Obstruction.

INTRODUCTION: Although histoplasmosis is an extremely rare cause of bowel obstruction, this case describes disseminated gastrointestinal histoplasmosis as it progresses from acute colitis to subacute recurrent bowel obstructions. CASE PRESENTATION: A White man in his early 80s with history of multiple myeloma presented to the emergency department with lightheadedness and diarrhea. Following a diagnostic journey for unspecified colitis, urine antigen testing and endoscopic biopsies led to the diagnosis. During the initial 12 weeks of antifungal treatment, the disease process transitioned from an acute inflammatory syndrome into a recurrent bowel obstruction. DISCUSSION/CONCLUSIONS: Only one other case of histoplasmosis causing recurrent bowel obstruction has been reported; however, that patient succumbed to the disease without surgical intervention. No clear guidelines exist of how to manage bowel obstructions from rare infectious sources, such as histoplasmosis, but close surveillance, multidisciplinary care, and an understanding of gastrointestinal pathology can guide clinicians when encountering atypical etiologies of bowel obstruction.

Provider-based initiation and management of pharmacologic therapy for gestational diabetes mellitus.

OBJECTIVE: After failure of diet and exercise prescribed for gestational diabetes mellitus (GDM), pharmacotherapy initiation is recommended. The objective of this study was to examine the association between provider type and timing of pharmacotherapy initiation. METHODS: This was a retrospective cohort study of women with a singleton pregnancy and diagnosis of A2GDM (GDM requiring pharmacotherapy) delivering in a tertiary care center between 2009 and 2019. Variables including maternal demographics, GDM characteristics, and provider type (general obstetrician/gynecologists (OBGYN), maternal-fetal medicine (MFM), or endocrinology) were assessed. The percent of abnormal glucose values at pharmacotherapy initiation was compared among provider types via univariable and multivariable analyses. RESULTS: A total of 428 women were included in the analysis. Eighteen percent were managed by MFM, 54% by general OBGYN, and 28% by endocrinology. Insulin was prescribed in 45.8% of women. In univariable analysis, the percent of abnormal glucose values was higher in women managed by MFMs, compared with general OBGYN and endocrinology (58.0%±25.1, 50.0%±23.1, and 50.3%±26.8, respectively, p = .041). Women started on insulin as first-line pharmacotherapy were more likely to be managed by endocrinology (p < .001). After adjusting for confounding variables, provider type was not significantly associated with percent of abnormal glucose values at pharmacotherapy initiation, but endocrinology was more likely to initiate insulin (aOR = 9.33, 95% CI 4.27-20.39). CONCLUSIONS: Provider type was not associated with percent of elevated glucose values at the time of pharmacotherapy initiation for A2GDM, but it was associated with insulin usage as first-line pharmacotherapy.

Impact Evaluation of Patient-Centered, Community-Engaged Health Modules for Homeless Pregnant Women.

PURPOSE: Pregnant women who experience homelessness are at a greater risk for poor birth outcomes than the general population. This pilot study describes results of a service-learning program informed by previously identified unmet perinatal health needs. In this patient-centered service-learning program, medical students partnered with homeless women currently residing in a shelter in Milwaukee, Wisconsin. METHODS: Medical students in the Health Advocacy in Pregnancy and Infancy (HAPI) project at the Medical College of Wisconsin developed and taught 6 service-learning modules to shelter residents: healthy cooking, mental health, perinatal nutrition, infant care/safety, breastfeeding, and contraception. Implemented between 2018 and 2021, modules were hosted in person and via electronic videoconferences. We gathered qualitative data on participants' perceived impact of the modules and used grounded theory analysis to examine written comments and verbal feedback. RESULTS: A total of 141 participants attended 42 learning sessions. Participants included pregnant and postpartum mothers and women interested in learning about pregnancy-related health. Qualitative analysis revealed 3 universal themes regarding the impact of the sessions on participants: "Knowledge," "Intention to Change," and "Empowerment." CONCLUSIONS: Our community-engaged health education partnership program between homeless pregnant women and medical students focused on perinatal health. This well-received, effective strategy cultivated new knowledge, empowering participants to not only change their own behaviors, but to teach and support others. This study demonstrates the ability of using community-based teaching sessions to enhance participants' understanding of pregnancy and postpartum health and empower others to implement changes.

Cesarean delivery rates by hospital type among nulliparous and multiparous patients.

BACKGROUND: Cesarean delivery rates continue to remain high despite recent attempts to decrease these rates. Prior data suggest that there is great variation in cesarean rates by hospital. OBJECTIVE: The intent of this study is to examine the association of several hospital characteristics and cesarean delivery rates in California. METHODS: We performed a retrospective study of singleton, non-anomalous, term (37-42 week) deliveries in California. We excluded hospitals with <50 deliveries per year and missing hospital information. We separated hospitals by volume based on previously published categories: low-volume (<1200 deliveries/year), medium-volume (1200-2399 deliveries/year), and medium-high-volume (2400-3599 deliveries/year, and high-volume (3600 deliveries/year). We also evaluated rural versus urban and non-teaching versus teaching hospitals. We examined overall cesarean rates as well as stratified by parity and with and without prior cesarean. We analyzed data with chi-square tests and multivariable logistic regression models. RESULTS: In a total of 2,545,464 pregnancies, 772,539 (30.35%) resulted in cesarean deliveries. After controlling for race/ethnicity, age, body mass index, education, and insurance, rates of cesarean delivery were higher in low-volume hospitals (aOR: 1.07; 95% CI: 1.0-1.08) and lower in medium-high-volume hospitals (aOR: 0.97; 95% CI: 0.96-0.98) as compared to high-volume hospitals. Rural hospitals had higher rates of cesarean delivery (aOR: 1.08; 95% CI: 1.06-1.10) as compared to urban hospitals while non-teaching hospitals had higher odds of cesarean deliveries (aOR: 1.27; 95% CI: 1.25-1.28) as compared with teaching hospitals. Among nulliparous patients, medium- and medium-high-volume hospitals had lower rates of cesarean deliveries (aOR: 0.95; 95% CI: 0.93-0.96; aOR: 0.93; 95% CI: 0.91-0.94) as compared to high-volume hospitals, while non-teaching hospitals had higher rates of cesarean deliveries than teaching hospitals (aOR: 1.11; 95% CI: 1.10-1.13). Multiparous patients without prior cesarean had higher rates of cesarean delivery at low-volume hospitals and lower rates of cesarean delivery at medium-high-volumes (aOR: 1.07; 95% CI: 1.05-1.10; aOR: 0.96; 95% CI: 0.94-0.098) as compared to high-volume hospitals. Additionally, multiparous patients without prior cesarean had higher rates of cesarean delivery at non-teaching hospitals than teaching hospitals (aOR: 1.16; 95% CI: 1.13-1.19). Multiparous patients with prior cesarean had high rates of cesarean delivery at all volume hospitals with the highest odds at low-volume hospitals (aOR: 1.81; 95% CI: 1.74, 1.89) as well as at rural and non-teaching hospitals. CONCLUSION: Cesarean delivery rates were higher at low and high-volume hospitals for nulliparous and multiparous patients without prior cesarean, but increased with decreasing hospital volume for multiparous patients with prior cesarean. Additionally, cesarean delivery was more likely at rural and non-teaching hospitals. Our results suggest that further investigation is necessary to determine the structural and mechanistic causes of the differences in practice by hospital type in order to identify targets for approaches in reducing cesarean deliveries.

Expectant Management of a Twin Pregnancy with Complete Hydatidiform Mole and Coexistent Normal Fetus.

Twin pregnancies complicated by complete hydatidiform mole coexisting with a viable fetus are rare and may result in significant complications. We describe the expectant management and our surgical approach in a 27-year-old Rh-negative woman presenting with recurrent episodes of vaginal bleeding and a twin pregnancy consisting of a molar pregnancy coexisting with a normal fetus. Inpatient management was undertaken with close maternal and fetal monitoring until cesarean delivery of a healthy female infant and histopathologically confirmed complete hydatidiform molar pregnancy (karyotype 46XX) at 34 weeks with no evidence of malignancy.

EB 2017 Article: Interpretation of the lactulose:mannitol test in rural Malawian children at risk for perturbations in intestinal permeability.

The dual sugar absorption test, specifically the lactulose:mannitol test, is used to assess gut health. Lactulose absorption is said to represent gut damage and mannitol absorption is used as a measure of normal small bowel function and serves as normalizing factor for lactulose. A underappreciated limitation of this common understanding of the lactulose:mannitol test is that mannitol is not absorbed to any substantial extent by a transcellular process. Additionally, this interpretation of lactulose:mannitol is not consistent with current understanding of paracellular pathways, where three pathway types exist: pore, leak, and unrestricted. Pore and leak pathways are regulated biological constructions of the small bowel barrier, and unrestricted pathways represent micropathological damage. We analyzed 2334 lactulose:mannitol measurements rigorously collected from 622 young rural Malawian children at high risk for poor gut health in light of the pathway model. An alternative method of normalizing for gut length utilizing autopsy data is described. In our population, absorbed lactulose and mannitol are strongly correlated, r = 0.68 P <0.0001, suggesting lactulose and mannitol are traversing the gut barrier via the same pathways. Considering measurements where pore pathways predominate, mannitol flux is about 14 times that of lactulose. As more leak pathways are present, this differential flux mannitol:lactulose falls to 8:1 and when increased numbers of unrestricted pathways are present, the differential flux of mannitol:lactulose is 6:1. There was no substantial correlation between the lactulose:mannitol and linear growth. Given that mannitol will always pass through a given pathway at a rate at least equal to that of lactulose, and lactulose absorption is a composite measure of flux through both physiologic and pathologic pathways, we question the utility of the lactulose:mannitol test. We suggest using lactulose alone is as informative as lactulose:mannitol in a sugar absorption testing in subclinical gut inflammation. Impact statement Our work integrates the standard interpretation of the lactulose:mannitol test (L:M), with mechanistic insight of intestinal permeability. There are three paracellular pathways in the gut epithelium; pore, leak, and unrestricted. Using thousands of L:M measurements from rural Malawian children at risk for increased intestinal permeability, we predict the differential flux of L and M through the pathways. Our findings challenge the traditional notions that little L is absorbed through a normal epithelial barrier and that M is a normalizing factor for L. Our observations are consistent with pore pathways allowing only M to pass. And that substantial amounts of L and M pass through leak pathways which are normal, regulated, cell-junctional adaptations. So M is a composite measure of all pathways, and L is not a measure solely of pathologic gut damage. Using L alone as a probe will yield more information about gut health than L:M.