The Case for Capping Residency Interviews.

OBJECTIVE: To determine 2020 residency cycle application practices and to model potential consequences in the 2021 cycle if (1) applicants scheduled an uncapped number of interviews; (2) applicants were capped to schedule 12 interviews; (3) residency programs kept their number of interview offers unchanged; and (4) programs increased their interview offers by 20%. DESIGN AND SETTING: The authors sent an anonymous survey to all obstetrics and gynecology applicants registered through the Electronic Residency Application Service in February 2020 asking respondents to share demographics and number of interview offers received and completed. Based on prior estimates that 12 interviews are needed to match in obstetrics and gynecology, respondents were divided into Group 12+ (those receiving ≥12 interview offers) and Group <12 (those receiving <12 offers). Model assumptions were (1) applicants can complete all interviews they are offered because they are virtual; (2) interview offers that applicants in Group 12+ decline are subsequently offered to applicants in Group <12; (3) the proportions of interviews offered to Group 12+ and Group <12 will remain the same if programs chose to increase their total number of interview spots. PARTICIPANTS: Among 2508 applicants, 750 (30%) provided the number of interview offers received and completed: 417 (56%) in Group 12+ and 333 (44%) in Group <12. RESULTS: In models where applicants are uncapped in the number of interviews, Group <12 applicants receive <1 interview offer, even if programs increase the number of interviews offered and performed. If applicants are capped at 12 interviews, Group <12 applicants will receive 9 interview offers on average and will reach 12 if programs increase the number of interviews offered by 20%. CONCLUSIONS: This work highlights how current inefficiencies may lead to negative consequences with virtual interviews. Interview caps and preference signaling systems need to be urgently considered.

Performance of a proteomic preterm delivery predictor in a large independent prospective cohort.

BACKGROUND: Preterm birth remains a common and devastating complication of pregnancy. There remains a need for effective and accurate screening methods for preterm birth. Using a proteomic approach, we previously discovered and validated (Proteomic Assessment of Preterm Risk study, NCT01371019) a preterm birth predictor comprising a ratio of insulin-like growth factor-binding protein 4 to sex hormone-binding globulin. OBJECTIVE: To determine the performance of the ratio of insulin-like growth factor-binding protein 4 to sex hormone-binding globulin to predict both spontaneous and medically indicated very preterm births, in an independent cohort distinct from the one in which it was developed. STUDY DESIGN: This was a prospective observational study (Multicenter Assessment of a Spontaneous Preterm Birth Risk Predictor, NCT02787213) at 18 sites in the United States. Women had blood drawn at 170/7 to 216/7 weeks' gestation. For confirmation, we planned to analyze a randomly selected subgroup of women having blood drawn between 191/7 and 206/7 weeks' gestation, with the results of the remaining study participants blinded for future validation studies. Serum from participants was analyzed by mass spectrometry. Neonatal morbidity and mortality were analyzed using a composite score by a method from the PREGNANT trial (NCT00615550, Hassan et al). Scores of 0-3 reflect increasing numbers of morbidities or length of neonatal intensive care unit stay, and 4 represents perinatal mortality. RESULTS: A total of 5011 women were enrolled, with 847 included in this planned substudy analysis. There were 9 preterm birth cases at <320/7 weeks' gestation and 838 noncases at ≥320/7 weeks' gestation; 21 of 847 infants had neonatal composite morbidity and mortality index scores of ≥3, and 4 of 21 had a score of 4. The ratio of insulin-like growth factor-binding protein 4 to sex hormone-binding globulin ratio was substantially higher in both preterm births at <320/7 weeks' gestation and there were more severe neonatal outcomes. The ratio of insulin-like growth factor-binding protein 4 to sex hormone-binding globulin ratio was significantly predictive of birth at <320/7 weeks' gestation (area under the receiver operating characteristic curve, 0.71; 95% confidence interval, 0.55-0.87; P=.016). Stratification by body mass index, optimized in the previous validation study (22

Fetal epignathus: the case of an early EXIT (ex utero intrapartum treatment).

BACKGROUND: Fetal epignathus, a teratoma arising from the oropharynx that may be lethal, can be diagnosed prenatally. CASE: A 29-year-old woman, gravida 1, was evaluated for an elevated alpha-fetoprotein level. Imaging evaluation revealed a fetal epignathus without intracranial extension. Preterm labor necessitated delivery at 27 5/7 weeks of gestation with ex utero intrapartum treatment (EXIT) procedure using a classical incision. The neonate's small size and short umbilical cord required complete exteriorization to secure the airway. Pathology revealed an immature teratoma. CONCLUSION: Prenatal diagnosis of fetal epignathus is imperative so that all options can be discussed. An EXIT procedure may be necessary for airway management at birth. If preterm delivery is necessary, choice of uterine incision and fetal size are important factors to consider for a successful outcome.

Herpes simplex and HIV infections and preterm PROM.

Maternal human immunodeficiency virus (HIV) and genital herpes simplex virus (HSV) infection in pregnancy have potential for vertical transmission that may result in death or morbidity. The risk increases with preterm delivery and prolonged ruptured membranes. When managing preterm premature rupture of membranes, the risk of transmission must be weighed against the risk of prematurity. Before 32 to 34 weeks, expectant management is preferred for patients with well controlled HIV or recurrent active genital HSV infection. For patients with advanced HIV disease or primary genital HSV infection, the risk of vertical transmission is higher and many clinical factors need to be considered.

Expectant management of preterm premature rupture of membranes complicated by active recurrent genital herpes.

OBJECTIVE: The study objective was to examine the neonatal outcome in pregnancies with early preterm premature rupture of the membranes (PPROM) who were managed expectantly despite the development of recurrent active genital herpes. STUDY DESIGN: Pregnancies complicated by PPROM at < or =14;31 weeks' gestation that developed an active recurrent genital herpes lesion were collected. The latency time from herpes lesion development to delivery and the neonatal outcome were analyzed. A control group of patients with PPROM at < or =14;31 weeks' gestation with no herpes infection was also obtained. RESULTS: A total of 29 patients were identified during the study period. The mean gestational age at herpes lesion development after PPROM was 28.7 weeks (range 24.6-31.0 weeks). The mean latency period from herpes development to delivery was 13.2 days (range 1-35 days). No cases of neonatal herpes developed in the delivered newborn infants and all neonatal cultures were negative (0 of 29 cases, 95% CI 0%-10.4%). Twelve newborn infants (41%) had major morbidity caused by prematurity and 3 of these (10.3%) died. There were no differences seen between the study cases and the control group. In the study, 15 of the 29 pregnancies were delivered beyond 30 weeks' gestation. If delivery had occurred on the day the herpes lesion developed, only 5 pregnancies would have been delivered beyond 30 weeks' gestation. CONCLUSION: On the basis of the 95% CI of these data, the maximum risk for development of a neonatal herpes infection in the face of PPROM and active recurrent genital herpes was 10.4%. This was equal to the mortality rate and was 75% lower than the major morbidity rate caused by prematurity. If delivery had occurred on the day the herpes lesions developed, on average, the neonates would have been nearly 2 weeks more premature, thereby potentially increasing the morbidity and mortality related to prematurity. These data concur with the American College of Obstetricians and Gynecologists consensus and expert opinion and would suggest that expectant management of PPROM at