Correlation of fetal heart rate dynamics to inflammatory markers and brain-derived neurotrophic factor during pregnancy.

OBJECTIVES: This study aims to show the relation between biomarkers in maternal and cord-blood samples and fetal heart rate variability (fHRV) metrics through a non-invasive fetal magnetocardiography (fMCG) technique. METHODS: Twenty-three women were enrolled for collection of maternal serum and fMCG tracings immediately prior to their scheduled cesarean delivery. The umbilical cord blood was collected for measurement of biomarker levels. The fMCG metrics were then correlated to the biomarker levels from the maternal serum and cord blood. RESULTS: Brain-derived neurotrophic factor (BDNF) had a moderate correlation with fetal parasympathetic activity (0.416) and fetal sympathovagal ratios (-0.309; -0.356). Interleukin (IL)-6 also had moderate-sized correlations but with an inverse relationship as compared to BDNF. These correlations were primarily in cord-blood samples and not in the maternal blood. CONCLUSIONS: In this small sample-sized exploratory study, we observed a moderate correlation between fHRV and cord-blood BDNF and IL-6 immediately preceding scheduled cesarean delivery at term. These findings need to be validated in a larger population.

Assessing uterine electrophysiology prior to elective term induction of labor.

Objective: The purpose of this study was to determine if uterine electrophysiological signals gathered from 151 non-invasive biomagnetic sensors spread over the abdomen were associated with successful induction of labor (IOL). Study design: Uterine magnetomyogram (MMG) signals were collected using the SARA (SQUID Array for Reproductive Assessment) device from 33 subjects between 37 and 42 weeks gestational age. The signals were post-processed, uterine contractile related MMG bursts were detected, and parameters in the time and frequency domain were extracted. The modified Bishop score calculated at admission was used to determine the method of IOL. Wilcoxon's rank-sum test was used to compare IOL successes and failures for differences in gestational age (GA), parity, modified Bishop's score, maximum oxytocin, and electrophysiological parameters extracted from MMG. Results: The average parity was three times (3x) higher (1.53 versus 0.50; p = 0.039), and the average modified Bishop score was 2x higher (3.32 versus 1.63; p = 0.032) amongst IOL successes than failures, while the average GA and maximum oxytocin showed a small difference. For the MMG parameters, successful IOLs had, on average, 3.5x greater mean power during bursts (0.246 versus 0.070; p = 0.034) and approximately 1.2x greater mean number of bursts (2.05 versus 1.68; p = 0.036) compared to the failed IOLs, but non-significant differences were observed in mean peak frequency, mean burst duration, and mean duration between bursts. Conclusion: The study showed that inductions of labor that took less than 24 h to deliver have a higher mean power in the baseline electrophysiological activity of the uterus when recorded prior to planned induction. The results are indicative that baseline electrophysiological activity measured prior to induction is associated with successful induction.

Alternate Birth Strategies.

Community birth is defined as birth that occurs outside the hospital setting. Birthing in a birth center can be safe for certain patient populations. Home birth can also be safe in well-selected patient with a well-established transfer infrastructure should an emergency occur. Unfortunately, many areas of the United States and the world do not have this infrastructure, limiting access to safe community birth. Immersion during labor has been associated with decreased need for epidural and pain medication. Delivery should not occur in water due to concerns for infection and cord avulsion. Umbilical cord non-severance (also called lotus birth) and placentophagy should be counseled against due to well-documented risks without clear benefit. Birth plans and options should be regularly discussed during pregnancy visits.

Increasing Access: Telehealth and Rural Obstetric Care.

Parturients in rural areas face many barriers in access to care, including distance to maternity care sites and lack of maternity providers. Expanding telehealth modalities is recommended to help expand access to care. Although there is increasing evidence in support of telehealth in rural America, the success of telehealth lies in infrastructure (broadband network availability), regional support, and funding.

The effect of maternal pregestational diabetes on fetal autonomic nervous system.

Heart rate variability assessment of neonates of pregestational diabetic mothers have shown alterations in the autonomic nervous system (ANS). The objective was to study the effect of maternal pregestational diabetes on ANS at the fetal stage by combining cardiac and movement parameters using a non-invasive fetal magnetocardiography (fMCG) technique. This is an observational study with 40 participants where fetuses from a group of 9 Type 1, 19 Type 2 diabetic, and 12 non-diabetic pregnant women were included. Time and frequency domain fetal heart rate variability (fHRV) and coupling of movement and heart rate acceleration parameters related to fetal ANS were analyzed. Group differences were investigated using analysis of covariance to adjust for gestational age (GA). When compared to non-diabetics, the Type 1 diabetics had a 65% increase in average ratio of very low-frequency (VLF) to low-frequency (LF) bands and 63% average decrease in coupling index after adjusting for GA. Comparing Type 2 diabetics to non-diabetics, there was an average decrease in the VLF (50%) and LF bands (63%). Diabetics with poor glycemic control had a higher average VLF/LF (49%) than diabetics with good glycemic control. No significant changes at p < 0.05 were observed in high-frequency (HF) frequency domain parameters or their ratios, or in the time domain. Fetuses of pregestational diabetic mothers exhibited some differences in fHRV frequency domain and heart rate-movement coupling when compared to non-diabetics but the effect of fHRV related to fetal ANS and sympathovagal balance were not as conclusive as observed in the neonates of pregestational diabetic mothers.

Window to the Womb: Amniotic Fluid and Postnatal Outcomes.

Amniotic fluid volumes are tightly regulated, and amniotic fluid derangement can indicate maternal complications or fetal abnormalities. Ultrasound estimate of amniotic fluid provides a tool to evaluate the maternal-fetal-placental interface in real-time. Oligohydramnios and polyhydramnios are associated with adverse maternal and neonatal outcomes. Oligohydramnios is associated with adverse maternal and neonatal outcomes including cesarean delivery, operative vaginal delivery, induction of labor, postpartum hemorrhage, small for gestational age neonate, intrauterine demise, neonatal death, NICU admission, and APGAR less than 7 at. 5 minutes of life Polyhydramnios is associated with adverse outcomes including cesarean delivery, induction of labor, placental abruption, shoulder dystocia, cord prolapse, postpartum hemorrhage, intrauterine fetal demise, NICU admission, neonatal death, APGAR less than 7 at 5 minutes of life, large for gestational age neonate, and respiratory distress syndrome. Therefore, Amniotic fluid should be evaluated when maternal or fetal well-being is in question.

Are the Diagnosis and Treatment of Acute Cystitis in the Premenopausal, Pregnant, and Postmenopausal Women the Same? A Review of the Literature.

Importance: Acute cystitis is a common condition diagnosed in women. The diagnosis and treatment of this condition change throughout a woman's life. Understanding the differences in diagnosis and treatment in premenopausal, pregnant, and postmenopausal woman increases the likelihood of treatment success and decreases risk of complications from untreated or suboptimally treated infections. Objective: The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of acute cystitis and the similarities and differences of these aspects of the condition in the premenopausal, pregnant, and postmenopausal woman. Evidence Acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with the years 1990 to 2020 searched. Results: There were 393 articles identified, with 103 being the basis of review. Multiple risk factors for acute cystitis have been identified and are largely consistent throughout a woman's lifetime with few exceptions. The diagnoses by group with common diagnostic tools, such as urinalysis, vary in specificity and sensitivity between these groups. Management also varies between groups, with pregnancy having specific limitations related to drug safety in regard to possible fetal effects posed by certain medications commonly used to treat acute cystitis. Conclusions: Acute cystitis not only varies in presentation throughout a woman's lifespan, but also in appropriate diagnosis and treatment. Treatment of acute cystitis does have some commonalities between the groups; however, there are contraindications unique to each group. These differences are paramount to not only ensuring appropriate treatment but also treatment success. Relevance: Acute cystitis is a common condition with different diagnostic and management recommendations throughout a woman's lifespan.

Peripartum Hypertensive Crisis Simulation and Education Initiative among Rural Emergency Departments.

OBJECTIVE: To determine whether the introduction of hypertensive bundles through simulation and education would result in the timely assessment and treatment of a simulated patient in a peripartum hypertensive crisis. METHODS: This prospective observational pilot study evaluates the use of simulation and education on hypertension bundled care for peripartum patients in eight rural hospitals. Unannounced simulation exercises were conducted at each hospital. Emergency department staff response was assessed with a checklist. Primary outcomes included time to first antihypertensive medication administered, time to registered nurse assessment, and time to physician assessment. After the initial simulation, nurse educators conducted an in-person didactic on the management of peripartum hypertensive crisis, providing each hospital with materials for local bundle initiation and implementation for hypertensive emergency. The nurse educators conducted the same simulation at the individual sites 3 to 4 months later. Time of intervention improvement pre- and posteducation training scores were analyzed for each of these using a paired t test followed by a Wilcoxon signed-rank test. The average time of intervention improvement among delivering hospitals versus nondelivering hospitals was compared. RESULTS: Eight training simulation and training sessions were conducted at four delivering and four nondelivering hospitals. Seventy-three healthcare workers attended training. The average time decreased from pre- to postsimulation at all of the hospitals (this was not statistically significant, however). The average reduction in time for first nurse assessment was 1.25 ± 10.05 minutes (P = 0.99). The average reduction in time to physician assessment was 4.88 ± 14.74 minutes (P = 0.45). The average reduction of time to administration of first hypertensive medication was 12.0 ± 25.79 minutes (P = 0.15). The average times for nurse or physician assessment and time to first hypertension medication administration were similar between delivering and nondelivering hospitals. CONCLUSIONS: Our study demonstrates a trend toward improved treatment of a peripartum hypertensive emergency through bundled care and simulation. The training reduced the time to first medication given and improved the selection process for the preferred hypertensive medication. The time from nurse care to physician assessment also was reduced. Education in bundled peripartum hypertension care may improve patient outcomes by decreasing hypertension-related maternal morbidity and mortality.

Longitudinal assessment of obstetrics and gynecology resident perceptions and comfort following cerclage placement simulation.

BACKGROUND: Utilization of simulation training in medical education has increased over time, particularly for less common scenarios and procedures. Simulation allows trainees to practice in a low-stress environment and eliminates patient risk. Cerclage placement has become less frequent, which limits obstetrics and gynecology (OB/GYN) exposure to cerclage placement during training. This exposes an area of training requiring simulation in OB/GYN resident education. OBJECTIVE: To evaluate resident reception to cerclage simulation, their self-reported comfort with and ability to troubleshoot difficult cerclage placement immediately and 12 months following didactic education and simulation. METHODS: In 2019, 18/20 (90%) OB/GYN residents in our university program underwent didactic teaching and simulation in cerclage placement using a pelvic model with removable cervix. Residents completed a survey immediately and 12 months following simulation. Wilcoxon signed-rank test was used to analyze resident self-report of comfort with cerclage placement and skill techniques for navigating difficult placement before and after simulation training. Descriptive statistics were analyzed as means and standard deviations. RESULTS: Eighteen of twenty (90%) residents participated in the education session in cerclage placement. All 18 (100%) completed a postsimulation survey and 17/18 (94%) completed a survey 12 months later. All reported improved comfort with cerclage placement and statistically significant improvement in knowledge on techniques for troubleshooting difficult placement after simulation. All residents reported that the simulation enhanced their learning and recommended the simulation for future educational opportunities. CONCLUSIONS: Cerclage simulation was well-received by OB/GYN residents in learning and practicing cerclage placement. Residents demonstrated improved comfort with placement following simulation.

Hyperparathyroidism in Pregnancy: A Review of the Literature.

IMPORTANCE: Maternal hyperparathyroidism can be associated with significant maternal and fetal morbidity and fetal mortality. Because the maternal symptoms are typically nonspecific, the disorder may not be recognized leading to adverse pregnancy outcomes. OBJECTIVE: The aim of this study was to review the literature on the etiology/prevalence, pathophysiology, diagnosis, management (medical and surgical), and the maternal/neonatal complications associated with pregnancies complicated by hyperparathyroidism. EVIDENCE ACQUISITION: A literature search was undertaken by our university librarian using the search engines PubMed and Web of Science. Search terms used included "hyperparathyroidism" AND "pregnancy" OR "pregnancy complications" OR "maternal." The number of years searched was not limited, but the abstracts had to be in English. RESULTS: There were 309 abstracts identified, 164 of which are the basis of this review. This includes 137 articles of the 269 individual case reports in the literature since the first case report in 1947. The articles and case reports reviewed the etiology, risk factors, diagnosis, management, complications, and maternal/fetal outcomes of pregnancies complicated by hyperparathyroidism. CONCLUSIONS AND RELEVANCE: Undiagnosed maternal hyperparathyroidism can result in critical maternal and fetal outcomes during pregnancy. This review highlights what is currently known about hyperparathyroidism during pregnancy to increase the awareness of this serious pregnancy disorder.

A comparison of maternal and perinatal outcomes with vaginal delivery: indicated induction versus spontaneous labor.

OBJECTIVE: To determine if there is a difference in the maternal and perinatal characteristics and outcomes of women undergoing a medically indicated labor induction and delivering vaginally compared to women in spontaneous labor delivering vaginally. METHODS: This is a planned secondary analysis of previously published data with additional data collected for a case-control design. Maternal and perinatal characteristics and outcomes of women undergoing a medically indicated labor induction of labor and delivering vaginally were compared with the next woman who went into labor spontaneously and delivered vaginally. RESULTS: There were 1097 women in the medically indicated labor group and 1096 women in the spontaneous labor group. The medically indicated induction group was younger (p < .0001), had less women of "other" race (p = .004), were of a lower gravidity and parity (p < .0001), had a lower Bishops' score on admission (p < .0001), had a greater proportion of umbilical arterial cord pH values <7.1 and <7.0 (p < .0001). Additionally, the induction group had longer first and second stages of labor (p < .0001). While the unadjusted rates of post-partum complications and NICU admission were higher in the medically indicated labor induction group, only cord gas pH <7.1 remained statistically significant after adjustment. CONCLUSION: Even with successful vaginal delivery of a medically indicated induction of labor, the risk for adverse outcomes remains elevated.

Maternal features at time of preterm prelabor rupture of membranes and short-term neonatal outcomes.

OBJECTIVE: The objective of this study was to assess if maternal and obstetric characteristics other than gestational age at the time of rupture impact short-term neonatal outcomes. METHODS: This is a retrospective observational study from a single tertiary care referral center. This study reviewed women with a singleton pregnancy complicated by preterm prelabor rupture of membranes over a 3-year period from May of 2014 through May of 2017. Maternal characteristics and short term neonatal outcomes were collected. RESULTS: We identified 210 pregnancies complicated by preterm prelabor rupture of membranes. Eighteen of these patients had rupture of membranes prior to viability. Of the maternal characteristics at time of admission studied, gestational age at rupture and race influenced short term neonatal outcomes. Women who identified as race other than white had neonates with lower rates of intubation than neonates born to white patients. Gestational age at rupture significantly influenced the neonatal intensive care unit length of stay. Each additional week gained before rupture occurred was associated with a 17.1% decrease in length of stay. Maternal age, gravidity, parity, body mass index, single deepest pocket, and amniotic fluid index did not influence short term neonatal outcomes. CONCLUSIONS: Gestational age at rupture of membranes is the most predictive factor associated with short term neonatal outcomes. Race may also influence short term neonatal outcomes. Other maternal characteristics do not seem to influence short term neonatal outcomes. This information can assist with patient counseling on admission for preterm prelabor rupture of membranes and expected neonatal course.

Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum.

OBJECTIVE: To compare prophylactic and emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement in the management of placenta accreta spectrum (PAS). STUDY DESIGN: Retrospective chart review of all patients with PAS (January 2018 to January 2020) at a single tertiary center who underwent prophylactic or emergent REBOA for cesarean hysterectomy for PAS. RESULTS: A total of 16 pregnant patients with PAS underwent percutaneous REBOA placement by acute care surgeons in collaboration with a multi-disciplinary PAS team. The REBOA catheter was placed prophylactically in 11 cases and emergently in 5 cases. No complications occurred in the prophylactic placement group. In the emergent placement group, 3 of 4 surviving patients had vascular access site complications requiring intervention. CONCLUSION: A multidisciplinary approach for the management of PAS utilizing REBOA is feasible in the setting of both planned and emergent cesarean hysterectomy and can aid in the control of acute hemorrhage. The risk for vascular access site complications related to REBOA catheter placement is higher in the emergent setting compared to prophylactic placement.

Management of pregnancies complicated by placenta accreta spectrum utilizing a multidisciplinary care team in a rural state.

PURPOSE: To compare maternal and neonatal outcomes following the development of a multidisciplinary care team for the management of pregnancies complicated by placenta accreta spectrum (PAS) in a rural state. METHODS: This is a retrospective cohort study evaluating pregnancies managed before PAS team care management formation (2010-2015) and after (2016-2020) in a university medical center. Maternal and neonatal outcomes were analyzed. Patients were grouped by delivery date to either before or after dedicated PAS team formation. Maternal and neonatal outcomes were analyzed. Frequencies and percentages were reported for categorical measures while means and standard deviations were computed for continuous measures. Wilcoxon rank-sum test was used for continuous variables while Chi-square or Fisher's exact was used for categorical measures. FINDINGS: There were 82 patients with PAS managed at our institution (29 in Pre-PAS team group and 53 in Post-PAS team group). The number of units of packed red blood cells (PRBCS) transfused intraoperatively was significantly higher in the Pre-PAS care team group (6.52 vs. 3.26, p = .0057). The total number of units PRBCS transfused (9.93 vs. 3.51, p = .0014) and total number of cryoprecipitate transfused (0.77 vs. 0.08, p = .0225) during the entire hospital stay were increased in the Pre-PAS team group. Median neonatal 1 min and 5 min APGAR scores were lower in the Pre-PAS care team group (2 vs 6 at 1 min, p = .0035; 6 vs. 7at 5 min, p = .0301). CONCLUSIONS: Management of PAS by a dedicated, multidisciplinary team results in less blood transfusion requirements and improved maternal and neonatal outcomes.

Placental location site and adverse antepartum pregnancy complications: a meta-analysis and review of the literature.

PURPOSE: The purpose to the study was to determine the relationship, if any, between the placental location site and antepartum complications of pregnancy. METHODS: A University research librarian conducted a comprehensive literature search using the search engines PubMed and Web of Science. The search terms were "placental location" AND "pregnancy complications" OR "perinatal complications. There were no limits put on the years of the search. RESULTS: The search identified 110 articles. After reviewing all the abstracts, relevant full articles, and references of full articles, there were 22 articles identified specific to antepartum complications. Central + fundal locations compared to all lateral were associated with a lower risk of hypertension during pregnancy RR = 0.47, 95% CI: 0.31-0.71]. Central location compared to all lateral was also associated with lower risk of hypertension during pregnancy [RR = 0.39, 95% CI: 0.26-0.59]. Placenta locations in the lower uterine segment were associated with greater risk of antepartum hemorrhage (APH) [RR = 2.99, 95% CI: 1.16-7.75] compared to above the lower uterine segment. No differences were observed in placental locations and gestational diabetes (GDM), preterm prelabor rupture of membranes (PPROM), preterm delivery (PTD) or on a placental abruption. CONCLUSION: Central and fundal location sites and central location alone decreased the risk of hypertension during pregnancy. Low uterine segment location sites increased the risk for APH. There were no effects of placenta location sites on the development of GDM, PPROM, PTD or abruption.

Detection of Fetal Anomalies by Remotely Directed and Interpreted Ultrasound (Teleultrasound): A Randomized Noninferiority Trial.

OBJECTIVE: To determine the accuracy and reliability of remotely directed and interpreted ultrasound (teleultrasound) as compared with standard in-person ultrasound for the detection of fetal anomalies, and to determine participants' satisfaction with teleultrasound. STUDY DESIGN: This was a single-center, randomized (1:1) noninferiority study. Individuals referred to the maternal-fetal medicine (MFM) ultrasound clinic were randomized to standard in-person ultrasound and counseling or teleultrasound and telemedicine counseling. The primary outcome was major fetal anomaly detection rate (sensitivity). All ultrasounds were performed by registered diagnostic medical sonographers and interpretations were done by a group of five MFM physicians. After teleultrasound was completed, the teleultrasound patients filled out a satisfaction survey using a Likert scale. Newborn data were obtained from the newborn record and statewide birth defect databases. RESULTS: Of 300 individuals randomized in each group, 294 were analyzed in the remotely interpreted teleultrasound group and 291 were analyzed in the in-person ultrasound group. The sensitivity of sonographic detection of 28 anomalies was 82.14% in the control group and of 20 anomalies in the telemedicine group, it was 85.0%. The observed difference in sensitivity was 0.0286, much smaller than the proposed noninferiority limit of 0.05. Specificity, negative predictive value, positive predictive value, and accuracy were more than 94% for both groups. Patient satisfaction was more than 95% on all measures, and there were no significant differences in patient satisfaction based on maternal characteristics. CONCLUSION: Teleultrasound is not inferior to standard in-person ultrasound for the detection of fetal anomalies. Teleultrasound was uniformly well received by patients, regardless of demographics. These key findings support the continued expansion of telemedicine services. KEY POINTS: · For detection of major anomalies, teleultrasound is comparable to standard ultrasound.. · Teleultrasound was well accepted by patients.. · Teleultrasound use should be expanded..

Placental changes in diabetic pregnancies and the contribution of hypertension.

OBJECTIVE: To evaluate placental abnormalities in pregnancies affected by diabetes compared to unaffected pregnancies from a single academic center. METHODS: This is a retrospective cohort study of women with singleton gestations delivered at the University of Arkansas for Medical Sciences from 2007 to 2016. Pathologic examination of placentas from pregestational and gestational diabetic pregnancies were compared to placentas from patients without diabetes using 12 histologic elements. Maternal and neonatal outcomes were extracted from the medical record and compared between groups. Findings were adjusted for hypertensive disorders of pregnancy. Placental lesions were also correlated with diabetic control. RESULTS: Pathology reports of 590 placentas along with corresponding medical records were reviewed. The diabetic group (N = 484) consisted of 188 patients with pregestational diabetes and 296 patients with gestational diabetes. The nondiabetic group consisted of 106 patients. The diabetic group was older, had a higher average BMI, and more hypertensive disorders (p < .0001). Out of the 12 histologic elements investigated, accelerated villous maturation (aOR = 8.45, 95%CI (1.13-62.95)) and increased placental weight (aOR = 3.131, 95% CI (1.558-6.293)) were noted to be significantly increased in placentas from diabetic pregnancies after controlling for hypertension. Intervillous thrombi were not significantly increased in pregnancies affected by diabetes. Neonates of the diabetic group were more likely to be large for gestational age (p < .0001) and had a higher rate of preterm delivery (p < .0001). CONCLUSIONS: Accelerated villous maturation was found to be more frequent in pregnancies complicated by pregestational diabetes, even after controlling for hypertension. In pregnancies complicated by gestational diabetes, the placental findings were not significant after controlling for hypertension. In contrast with prior studies, there was no increase in thrombotic lesions of the placenta in patients with diabetes.