Racial Disparities in Prenatal Care Utilization and Infant Small for Gestational Age Among Active Duty US Military Women.

OBJECTIVES: To examine racial disparities in prenatal care (PNC) utilization and infant small for gestational age (SGA) among active duty US military women, a population with equal access to health care and known socioeconomic status. METHODS: Department of Defense Birth and Infant Health Research program data identified active duty women with singleton live births from January 2003 through August 2015. Administrative claims data were used to define PNC utilization and infant SGA, and log-binomial regression models estimated associations with race/ethnicity. To examine whether associations between maternal race/ethnicity and infant SGA were subject to effect measure modification, respective analyses were stratified by demographic and health characteristics. RESULTS: Overall, 12.2% of non-Hispanic White women initiated PNC after the first trimester, compared with 14.8% of American Indian/Alaska Native, 15.1% of Asian/Pacific Islander, 14.2% of non-Hispanic Black, and 13.0% of Hispanic women. Infant SGA prevalence was 2.4% and 1.6% among non-Hispanic Black and White women, respectively (aRR 1.52, 95% CI 1.40-1.64). This disparity persisted across stratified analyses, particularly among non-Hispanic Black versus White women with a preeclampsia or hypertension diagnosis in pregnancy (RR 1.96, 95% CI 1.67-2.29) and those aged 35 + years at infant birth (RR 2.04, 95% CI 1.56-2.67). CONCLUSIONS FOR PRACTICE: In multiple assessments of PNC utilization and infant SGA, non-Hispanic Black military women had consistently worse outcomes than their non-Hispanic White counterparts. This suggests that equal access to health care does not eliminate racial disparities in outcomes or utilization; additional research is needed to elucidate the underlying etiology of these disparities.

Validation of a scoring system to identify women with near-miss maternal morbidity.

OBJECTIVE: To validate a five-factor scoring system that identifies parturients who experience near-miss morbidity. STUDY DESIGN AND SETTING: This study was conducted in an urban, tertiary care hospital over a 2-year period. A narrative case summary was prepared for women with high potential for significant obstetric morbidity. The summary was then reviewed by three physicians, and the extent of morbidity was assigned based on subjective assessment. The same cases were then scored using the proposed five-factor scoring system previously described by Geller et al. Test characteristics of the scoring system were assessed. RESULTS: Eight hundred fifteen cases with a high potential for significant morbidity were identified. Subjective review and the scoring system classified 4.5% and 4.2% as near-miss morbidity, respectively, with the scoring system having a corresponding sensitivity of 81.1% (95% confidence interval 64.8 to 92.0%) and a specificity of 99.5% (95% confidence interval 98.7 to 99.9%). CONCLUSION: The scoring system produced similar results to those obtained at its initial development and demonstrated acceptable sensitivity and specificity for identifying near-miss morbidity.

Improving patient understanding of preeclampsia: a randomized controlled trial.

OBJECTIVE: We developed a standardized educational tool to inform women about preeclampsia. The objective of this study was to assess whether exposure to this tool led to superior understanding of the syndrome. STUDY DESIGN: This was a randomized controlled trial in which 120 women were assigned to (1) a newly developed preeclampsia educational tool, (2) a standard pamphlet addressing preeclampsia that had been created by the American College of Obstetricians and Gynecologists, or (3) no additional information. Preeclampsia knowledge was assessed with the use of a previously validated questionnaire. RESULTS: There were no demographic differences among the groups. Patients who received the tool scored significantly better on the preeclampsia questionnaire than those who received the American College of Obstetricians and Gynecologists pamphlet or no additional information (71%, 63%, 49%, respectively; P < .05). This improved understanding was evident equally among women with and without adequate health literacy (interaction: P > .05). CONCLUSION: Patients who were exposed to a graphics-based educational tool demonstrated superior preeclampsia-related knowledge, compared with those patients who were exposed to standard materials or no education.

The (After)life of a Trial: Biocommunicability of an At-Risk Pregnancy.

The publication of A Randomized Trial of Induction Versus Expectant Management (ARRIVE), conducted in the United States in 2018, heralded a paradigm shift within the obstetrical management of term pregnancy among people who have not previously given birth. ARRIVE finds its home among other canonical - and controversial - randomized controlled trials (RCTs) within obstetrics. We argue that RCTs have their own (after)life, both creating new subjects for biomedical intervention and recalibrating who reproductive health practitioners consider to be at risk of adverse health outcomes. These data have important consequences for medical social scientific engagement with RCTs to further interrogate the questions of risk and intervention within reproductive health.

Cultivating the ideal obstetrical patient: How physicians-in-training describe pain associated with childbirth.

We explore the work labor pain does in cultivating obstetrics and gynecology (OB/GYN) resident physicians' conceptualization of the "ideal" obstetrical patient - replete with moral, pharmacological, classed, and racialized dimensions. Our data is derived from a single-site, qualitative study conducted at an urban academic OB/GYN residency program in the midwestern U.S. between 2018 and 2019. 36 residents, 9 from each post-graduate year, were randomly selected to complete a semi-structured interview on their perceptions of patient pain surrounding OB/GYN procedures. Grounded theory analysis of the OB/GYN residents' interviews revealed the idealized obstetrical patient is quiet and easily controlled. Residents praised women whom they believed were suppressing their labor pain, a racialized and classed concept that furthers misconceptions about the "obstetric hardiness" of Black women and the hypersensitivity of wealthy White women. Participants' conceptions of "bad" patients included those with less cultural health capital due to low health literacy and socioeconomic status, which impeded the patients' ability to participate in shared decision-making. Despite acknowledging the importance of patient autonomy regarding pain control during labor, the interviewed residents positioned themselves as the ultimate authority. Their subjective assessment of patients' pain inherently invoked their personal biases, such as conflating low socioeconomic status and race. Some participants posited an inverse relationship between hardship and pain, while others questioned whether those with low health literacy exaggerate their pain due to fear of the clinical encounter or to secure medical attention. Both framings have concerning implications for inadequate pain control and the unintentional perpetuation of obstetric violence and obstetric racism within the profession.

Improving pregnancy drug warnings to promote patient comprehension.

OBJECTIVE: We sought to evaluate the effectiveness of a pharmaceutical labeling strategy intended to improve comprehension of a teratogen warning. STUDY DESIGN: This is a secondary analysis that evaluated women of childbearing age who were assigned prescription containers with the current teratogen warning, a label with simplified text, or a label with simplified text and icons. The association between label type and understanding of label instructions was assessed. RESULTS: A total of 132 women were interviewed. Comprehension of the icon label (94%) was higher than for the standard and enhanced text-only labels (76% and 79%), respectively (P < .05). Adjustment for age, race/ethnicity, education, literacy, and number of current medications revealed that the label with the enhanced text and icon yielded superior comprehension (risk ratio vs standard, 1.26; 95% confidence interval, 1.04-1.53; risk ratio vs enhanced, 1.22; 95% confidence interval, 1.02-1.46). CONCLUSION: In our study, a teratogen warning label that had easy-to-read messages with icons significantly improved comprehension.

Implementation of a text-based postpartum blood pressure monitoring program at 3 different academic sites.

BACKGROUND: Up to 30% of patients with hypertensive disorders of pregnancy continue to have elevated blood pressures after delivery, often necessitating medication titration or hospital evaluation in the weeks following hospital discharge. A previous randomized controlled trial demonstrated that remote blood pressure monitoring programs led to an increase in the number of blood pressure measurements obtained and increased compliance with clinical guidelines regarding the monitoring of patients for persistent or worsening postpartum hypertension. OBJECTIVE: The aims of this study were to measure the program participant response rates during the first 10 days after hospital discharge, to assess the replicability and scalability of the program, and to evaluate patient satisfaction at 3 distinct sites. STUDY DESIGN: We conducted a prospective observational cohort study across 3 US academic medical centers during which postpartum participants with hypertensive disorders of pregnancy were enrolled in a previously validated, remote, text message-based blood pressure monitoring program known as Heart Safe Motherhood. English-speaking patients with access to a text message-enabled cell phone and with a diagnosis of hypertensive disorders of pregnancy were candidates for enrollment in the study. Each study site planned to enroll approximately 66 participants in this pilot implementation phase. All the enrolled participants received a validated blood pressure cuff, education on proper use of the device, and were sent text messages as a reminder to check their blood pressures twice daily for 10 days after discharge. They were asked to reply via text message with their blood pressure readings. All blood pressure readings were reviewed via a web-based platform by a physician. Physicians communicated with patients whose blood pressure levels exceeded 160 mm Hg systolic or 100 mm Hg diastolic to determine the next management steps. Enrollees were texted a survey at the end of the 10 days and the responses were recorded. The proportion of eligible parturients who were enrolled, the number of measured blood pressure values, and the postprogram survey results were measured. We assessed the number of patients who reported elevated blood pressures, required antihypertensive medication, and were readmitted for blood pressure control during the program duration. RESULTS: A total of 199 participants were enrolled in the program: 66 at site A, 67 at site B, and 66 at site C. In the 10 days after hospital discharge, 192 (97%) participants submitted at least 1 blood pressure measurement via text message. More enrolled patients submitted a blood pressure measurement on postpartum days 7 to 10 (171, 86%) than on days 1 to 4 (134, 67%). A total of 126 (63%) participants submitted blood pressures during both time frames. Elevated blood pressures were recorded for 70 (35%) participants, 32 (16%) of whom were started on oral antihypertensives after discussing their blood pressure measurements with an on-call provider. A total of 10 participants (5%) required hypertension-related readmission after delivery. The end-of-program survey was completed by 98 (49%) of the participants. Of those who completed the survey, 93% agreed that the program helped them to monitor their blood pressure (89% at site A; 88% at site B, and 100% at site C), and 93% would recommend it to friends or family members (94% at site A, 96% at site, and 88% at site C). CONCLUSION: Postpartum participants are willing and capable of using the Heart Safe Motherhood program for remote blood pressure monitoring and reported high satisfaction with the program across multiple sites. Our study demonstrated that this remote blood pressure monitoring program can be implemented successfully and demonstrated replicable efficacy at diverse sites.

Genetic thrombophilias and intrauterine growth restriction: a meta-analysis.

OBJECTIVE: To estimate the relationship between inherited thrombophilias and intrauterine growth restriction (IUGR) using meta-analytic techniques. METHODS: A literature review identified case-control and cohort studies evaluating the relationship between IUGR and the following thrombophilias: homozygous or heterozygous factor V Leiden or prothrombin (PT) G20210A mutations and homozygous methylenetetrahydrofolate reductase (MTHFR) C677T mutation. Using mixed effects and random-effects models, the association between thrombophilias and IUGR was explored. Publication bias was assessed with funnel plots and corrected for with Duval and Tweedie's trim-and-fill method. RESULTS: The following number of related studies were found: studies evaluating relationships between factor V Leiden mutation and IUGR, 12 case-control and four cohort; between PT mutation and IUGR, 11 case-control and 0 cohort; and between MTHFR C677T homozygosity and IUGR, 10 case-control and two cohort. The overall summary odds ratio (OR) for the association between factor V Leiden and IUGR was significant (OR 1.23, 95% confidence interval [CI] 1.04-1.44); however, this was mainly driven by the positive association seen in the case-control studies (OR 1.91, 95% CI 1.17-3.12). The association between PT and IUGR was only explored in case-control studies yielding a summary OR that was not significant (OR 1.52, 95% CI 0.98-2.35). The overall summary OR for the association between MTHFR and IUGR was not significant (OR 1.01, 95% CI 0.88-1.17), but was significant for the case-control studies alone (OR 1.35, 95% CI 1.04-1.75). For both factor V Leiden and MTHFR mutations, a funnel-plot analysis of the case-control studies suggests publication bias. When the trim-and fill-method was used to correct for the publication bias, these summary estimates were no longer significant. CONCLUSION: The association between inherited thrombophilias and IUGR can only be discerned in case-control studies and seems to be largely because of publication bias. LEVEL OF EVIDENCE: III.

Cervical biopsy and excision procedure specimens lack sufficient predictive value for lymph-vascular space invasion seen at hysterectomy for cervical cancer.

OBJECTIVE: The purpose of this study was to determine whether lymph-vascular space invasion (LVSI) that is discovered in cervical biopsy and excision specimens is associated with LVSI in the hysterectomy specimen of patients with cervical cancer. STUDY DESIGN: A retrospective pathologic review to determine the presence of LVSI in cervical biopsy specimens, cold-knife cone biopsy (CKC biopsy), and loop electrical excision procedure (LEEP) specimens that contained cervical cancer was performed if subsequent hysterectomy results were available for review. Data were analyzed with chi-square analysis testing. RESULTS: One hundred six patients were identified. The negative predictive value of the biopsy is lower at 0.45 than either the CKC biopsy (0.83) or LEEP (0.57); however, the positive predictive value (0.83) is higher than either CKC biopsy (0.50) or LEEP (0.75). LVSI, when present in cervical biopsy (odds ratio, 4.13; 95% CI, 0.414-98.446), CKC biopsy (odds ratio, 4.8; 95% CI, 0.542-46.280), and LEEP (odds ratio, 4.0; 95% CI, 0.439-43.793) specimens, is associated with a statistically insignificant increased risk of LVSI in the hysterectomy specimen. CONCLUSION: Cervical biopsy and excision specimens lack sufficient negative predictive value for the detection of LVSI in the hysterectomy specimen.

Uterine torsion and subsequent rupture in a gravid bicornuate uterus associated with an elevated alpha-fetoprotein.

Uterine torsion is a rare obstetric complication with a non-specific presentation. We describe a patient with a bicornuate uterus and a pregnancy complicated by a markedly elevated second-trimester maternal serum alpha-fetoprotein (MSAFP), intermittent pelvic pain and fetal growth restriction. At 24 weeks gestational age, she presented to labour and delivery with an acute abdomen. A subsequent exploratory laparotomy revealed torsion and rupture of her right uterine horn. Uterine torsion can be difficult to diagnose because it is not associated with specific symptoms or characteristic imaging findings. In patients with a bicornuate uterus who present with abdominal pain, an elevated mid-trimester MSAFP may be a harbinger of placental ischaemia as a result of uterine torsion.

Gynecologic malignancies in women aged less than 25 years.

OBJECTIVE: To describe the epidemiologic characteristics of gynecologic malignancies in patients 25 years of age or younger. METHODS: The Automated Central Tumor Registry (ACTUR), the cancer registry for the Department of Defense, was used to identify children, adolescents, and young adults diagnosed with gynecologic malignancies. Specifically, primary ovarian, uterine, cervical, vaginal, and vulvar malignancies diagnosed between 1990 and 2002 were included in the analysis. Data from the Department of Defense tumor registry were then compared with results obtained from the national Surveillance, Epidemiology, and End Report (SEER) program database. RESULTS: Two hundred fifty-one cases were identified in the Department of Defense tumor registry. The most common primary site was ovary, with 116 cases (46%), followed by cervix, with 108 cases (43%). The most common histological types were germ cell (35%) for ovary, squamous cell (52%) for cervix, choriocarcinoma (18%) for uterus, and squamous cell (30%) for vulva/vagina. The 21- to 25-year-old age group had the greatest number of cases for the entire cohort (23%). Most patients had only local disease at time of diagnosis, and the 5-year survival percentage was 86% (95% confidence interval 80-91) for all patients with ovarian and cervical carcinoma. Data from the SEER program demonstrated a similar distribution and incidence pattern. CONCLUSION: The ovary and cervix are the most common primary sites of gynecologic malignancies in patients 25 years of age or younger. Health maintenance programs for patients in this age group should continue to include pelvic exams and Pap test screening.

Readability, content, and quality of online patient education materials on preeclampsia.

OBJECTIVE: The objective of this study was to evaluate the readability, content, and quality of patient education materials addressing preeclampsia. METHODS: Websites of U.S. obstetrics and gynecology residency programs were searched for patient education materials. Readability, content, and quality were assessed. A one-sample t-test was used to evaluate mean readability level compared with the recommended 6th grade reading level. RESULTS: Mean readability levels were higher using all indices (p < 0.001). Content was variable with good website understandability, but poor actionability. CONCLUSIONS: The mean readability was above the recommended 6th grade reading level. The content, readability, and actionability of preeclampsia patient education materials should be improved.

Ex utero intrapartum treatment of fetal micrognathia.

BACKGROUND: Ex utero intrapartum treatment (EXIT) procedures have emerged as a viable option for potentially life-saving procedures in fetuses with predicted airway compromise at birth. The ability to maintain maternal-fetal uteroplacental perfusion allows for prolonged procedures in a stable fetal hemodynamic environment thereby avoiding neonatal hypoxemia or sequelae of an emergent tracheostomy. CASE: A 26-year-old female presents with a 20-week ultrasound and subsequent magnetic resonance imaging demonstrating severe fetal micrognathia (jaw index below the 5th percentile), glossoptosis, polyhydramnios, absence of a gastric bubble, and suspected microtia concerning for Treacher Collins syndrome. An EXIT procedure was completed with successful intrapartum endotracheal intubation with a flexible fiber-optic bronchoscope through a laryngeal mask airway. CONCLUSION: This case represents the first EXIT procedure completed at Naval Medical Center San Diego. Although this case is unique, the clinical skills and coordination of care required to perform this procedure are exemplified in our daily practice of stabilizing, transporting, and definitively treating our wounded warriors. The ability to work in coordination across multiple armed services to provide the EXIT procedure to our military families, for potentially life-saving procedures, is a true testament to the current state of Military Medicine.

Ondansetron compared with doxylamine and pyridoxine for treatment of nausea in pregnancy: a randomized controlled trial.

OBJECTIVE: To evaluate whether ondansetron or the combination of doxylamine and pyridoxine was superior for the treatment of nausea and vomiting of pregnancy. METHODS: This was a double-blind, randomized, controlled trial in which women with nausea and vomiting of pregnancy were assigned to 4 mg of ondansetron plus a placebo tablet or 25 mg pyridoxine plus 12.5 mg of doxylamine for 5 days. The primary outcome was an improvement in nausea as reported on a 100-mm visual analog scale (VAS). Secondary outcomes were a reduction in vomiting on the VAS and the proportion of patients reporting sedation or constipation while using either study regimen. RESULTS: Thirty-six women (18 in each group) were randomized to either ondansetron or pyridoxine and doxylamine, of whom 13 (72%) and 17 (94%) completed follow-up, respectively. There were no differences among the groups with regard to demographic characteristics or baseline nausea. Patients randomized to ondansetron were more likely to have an improvement in their baseline nausea as compared with those using pyridoxine and doxylamine over the course of 5 days of treatment (median VAS score decreased 51 mm [interquartile range 37-64] compared with 20 mm [8-51]; P=.019). Furthermore, women using ondansetron reported less vomiting (median VAS decreased 41 [interquartile range 17-57] compared with 17 [-4 to 38]; P=.049). There was no significant difference between the groups regarding sedation or constipation. CONCLUSION: Our investigation showed ondansetron to be superior to the combination of pyridoxine and doxylamine in the treatment of nausea and emesis in pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01668069. LEVEL OF EVIDENCE: : I.

Barriers to influenza vaccination among pregnant women.

OBJECTIVE: Despite pregnant women's increased morbidity and mortality from influenza, vaccination rates remain low. This study intended to evaluate barriers to pregnant women's uptake of influenza vaccine. STUDY DESIGN: A survey was designed that assessed participant demographics, knowledge, beliefs, attitudes, and general experiences with seasonal and 2009 novel H1N1 influenza. Associations between patient characteristics and vaccine uptake were then assessed. RESULTS: 88 women completed the survey. Women who correctly answered >75% of knowledge questions regarding influenza were significantly more likely to accept the influenza vaccine (seasonal: p=0.04, H1N1: p<0.01). Conversely, patients who declined the vaccine were more likely to hold false beliefs, such as perceiving that the vaccine was not protective (seasonal: p<0.01, H1N1: p<.01) and that they were not at risk for influenza (seasonal: p< 0.01). CONCLUSION: The reasons for influenza vaccine declination in pregnant patients include lower levels of knowledge and unfavorable attitudes regarding the safety and efficacy of the vaccine, and suggest the importance of education as a tool to improve vaccination uptake.

Postpartum herpes simplex virus endometritis and disseminated infection in both mother and neonate.

BACKGROUND: Herpes simplex virus (HSV) is an unusual cause of postpartum endometritis. We describe a rare case of primary disseminated maternal HSV in the postpartum period associated with endometritis. CASE: A previously healthy patient developed fundal tenderness and postpartum fevers after an uncomplicated vaginal delivery. Despite traditional broad-spectrum antimicrobial therapy, she had persistent fevers and systemic symptoms. Concurrently, her neonate developed fevers and a nonvesicular rash, with viral cultures ultimately returning positive for HSV. The patient developed active pharyngeal and genital herpetic lesions and was diagnosed with HSV endometritis and disseminated HSV. Symptoms and fevers in both the mother and neonate responded to antiviral therapy. CONCLUSION: Herpes simplex virus endometritis should be included in the differential diagnosis for postpartum fevers and fundal tenderness that are unresponsive to broad-spectrum antimicrobial treatment.

Factors associated with patient understanding of preeclampsia.

OBJECTIVE: To explore the extent to which pregnant women understand the symptoms and potential complications related to preeclampsia and to determine the factors that are associated with better understanding. METHODS: This was a cross-sectional study in which 112 pregnant patients were interviewed to determine their preeclampsia knowledge. Knowledge was evaluated using a 25-item survey addressing the symptoms, consequences, and proper patient actions associated with preeclampsia. Patients were also asked in an open-ended question to define preeclampsia; all responses were rated by three obstetricians. Information about demographics, medical and obstetrical history, and health literacy was also obtained. Health literacy was assessed using the short Test of Functional Health Literacy in Adults (S-TOFHLA). RESULTS: Patients correctly answered only 43% of the 25 questions assessing preeclampsia knowledge. Moreover, only 14% of the patients were able to provide a definition that correctly reflected the syndrome. Factors associated with a greater proportion of correct answers on the questionnaire were higher literacy, multiparity, history of preeclampsia, and receipt of information about preeclampsia from a clinician or another information source (e.g., the Internet, television, a book, or a friend). CONCLUSIONS: Pregnant patients have a generally poor understanding of preeclampsia, although improved understanding is associated with having received information about the disease. Further investigation will be needed to determine how best to educate patients and whether this education can also decrease adverse outcomes associated with this syndrome.