Magnesium sulfate and risk of hypoxic-ischemic encephalopathy in a high-risk cohort.

BACKGROUND: Hypoxic-ischemic encephalopathy contributes to morbidity and mortality among neonates ≥36 weeks of gestation. Evidence of preventative antenatal treatment is limited. Magnesium sulfate has neuroprotective properties among preterm fetuses. Hypertensive disorders of pregnancy are a risk factor for hypoxic-ischemic encephalopathy, and magnesium sulfate is recommended for maternal seizure prophylaxis among patients with preeclampsia with severe features. OBJECTIVE: (1) Determine trends in the incidence of hypertensive disorders of pregnancy, antenatal magnesium sulfate, and hypoxic-ischemic encephalopathy; (2) evaluate the association between hypertensive disorders of pregnancy and hypoxic-ischemic encephalopathy; and (3) evaluate if, among patients with hypertensive disorders of pregnancy, the odds of hypoxic-ischemic encephalopathy is mitigated by receipt of antenatal magnesium sulfate. STUDY DESIGN: We analyzed a prospective cohort of live births ≥36 weeks of gestation between 2012 and 2018 within the California Perinatal Quality Care Collaborative registry, linked with the California Department of Health Care Access and Information files. We used Cochran-Armitage tests to assess trends in hypertensive disorders, encephalopathy diagnoses, and magnesium sulfate utilization and compared demographic factors between patients with or without hypertensive disorders of pregnancy or treatment with magnesium sulfate. Hierarchical logistic regression models were built to explore if hypertensive disorders of pregnancy were associated with any severity and moderate/severe hypoxic-ischemic encephalopathy. Separate hierarchical logistic regression models were built among those with hypertensive disorders of pregnancy to evaluate the association of magnesium sulfate with hypoxic-ischemic encephalopathy. RESULTS: Among 44,314 unique infants, the diagnosis of hypoxic-ischemic encephalopathy, maternal hypertensive disorders of pregnancy, and the use of magnesium sulfate increased over time. Compared with patients with hypertensive disorders of pregnancy alone, patients with hypertensive disorders treated with magnesium sulfate represented a high-risk population. They were more likely to be publicly insured, born between 36 and 38 weeks of gestation, be small for gestational age, have lower Apgar scores, require a higher level of resuscitation at delivery, have prolonged rupture of membranes, experience preterm labor and fetal distress, and undergo operative delivery (all P<.002). Hypertensive disorders of pregnancy were associated with hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.13-1.40]; P<.001) and specifically moderate/severe hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.11-1.42]; P<.001). Among patients with hypertensive disorders of pregnancy, treatment with magnesium sulfate was associated with 29% reduction in the odds of neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.71 [95% confidence interval, 0.52-0.97]; P=.03) and a 37% reduction in the odds of moderate/severe neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.63 [95% confidence interval, 0.42-0.94]; P=.03). CONCLUSION: Hypertensive disorders of pregnancy are associated with hypoxic-ischemic encephalopathy and, specifically, moderate/severe disease. Among people with hypertensive disorders, receipt of antenatal magnesium sulfate is associated with a significant reduction in the odds of hypoxic-ischemic encephalopathy and moderate/severe disease in a neonatal cohort admitted to neonatal intensive care unit at ≥36 weeks of gestation. The findings of this observational study cannot prove causality and are intended to generate hypotheses for future clinical trials on magnesium sulfate in term infants.

A Case of an Obstructed Delivery by a Large, Lower Uterine Segment Fibroid Interlocked with a Fetal Mentum.

Uterine leiomyomata are associated with many pregnancy complications and will likely become increasingly common as the average age of childbearing increases. We describe a case of an obstructed delivery by a large fibroid. A 37-year-old G2P1001 with a 10-cm anterior, lower uterine segment fibroid presented for labor induction. Labor was complicated by arrest of descent due to suspected obstruction of the fetal body by the fibroid after descent of the fetal head, and delivery during cesarean section was complicated by apparent interlocking of the fetal mentum with the fibroid. Large, anterior lower uterine segment fibroids have the potential to obstruct delivery of the fetal head or of the fetal body, and these patients should be counseled regarding the potential for complications via both vaginal and cesarean deliveries.

Measuring Variation in Interpregnancy Interval: Identifying Hotspots for Improvement Initiatives.

OBJECTIVE: The study aimed to determine if single year birth certificate data can be used to identify regional and hospital variation in rates of short interpregnancy interval (IPI < 6 months). STUDY DESIGN: IPI was estimated for multiparous women ages 15 to 44 years with singleton live births between 2015 and 2016. Perinatal outcomes, place of birth, maternal race, and data for IPI calculations were obtained by using birth certificates. IPI frequencies are presented as observed rates. RESULTS: The cohort included 562,039 multiparous women. Short IPI rates were similar to those obtained with analyses by using linked longitudinal data and confirmed the association with preterm birth. Short IPI rates varied by race and Hispanic nativity. There was substantial hospital (0.8-9%) and regional (2.9-6.2%) variation in short IPI rates. CONCLUSION: IPI rates can be reliably obtained from current year birth certificate data. This can be a useful tool for quality improvement projects targeting interventions and rapidly assessing their progress to promote optimal birth spacing. KEY POINTS: · Near-real time regional and hospital IPI rates can be reliably obtained from current year birth certificate data.. · Substantial variations in rates of short IPI exist between hospital and perinatal regions.. · IPI rates from individual birth certificates can be a tool to target and assess interventions..

A Synoptic Electronic Order Set for Placental Pathology: A Framework Extensible to Nonneoplastic Pathology.

Accurate pathologic assessment in placental pathology is mostly dependent on a complete clinical history provided by a clinical team. However, often, the necessary clinical information is lacking, and electronic order sets (EOSs), if implemented correctly, create an opportunity for entering consistent and accurate clinical data. In this viewpoint piece, we describe a framework for synoptic EOS in placental pathology. We outline the necessary data and create optional clinical data that get entered as a dropdown menu of free text. While EOSs are the best way to approach and diagnose placenta and other nonneoplastic pathologic specimens, the barriers for implementation include paper requisitions and a cultural mindset resistance. The aspiration for our synoptic EOS is to become an effective tool for communication between proceduralists and pathologists for proper diagnosis of placental specimens. Through our EOS, the appropriate and complete clinical context is conveyed from the clinical teams to the pathologist. The pathologist can easily and rapidly extract the necessary information to render an accurate and precise diagnosis. The captured data likewise become a valuable research resource.

Preterm birth outcomes among Asian women by maternal place of birth.

OBJECTIVE: To investigate overall, spontaneous, and medically indicated preterm birth (PTB) rates between US-born and non-US-born Asian women living in California. STUDY DESIGN: Nulliparous women with a singleton livebirth and Asian race in California between 2007 and 2011 were investigated. The prevalence of overall (<37 weeks), spontaneous, and medically indicated PTB was examined by self-reported race and place of birth among ten Asian subgroups. RESULTS: There were marked differences in PTB rates between the individual Asian subgroups. After adjustments, non-US-born Chinese, Japanese, Vietnamese, and Indian women had lower odds of overall PTB and Chinese, Vietnamese, Cambodian, and Indian women had lower odds of spontaneous PTB compared with their US-born counterparts. CONCLUSION: Further investigation of biological and social factors contributing to these lower odds of spontaneous PTB among the non-US-born Asian population could potentially offer clues for reducing the burden of PTB among the US born.

Cerclage Location and Gestational Age at Delivery.

Objective Multiple authors have suggested cerclage position is a determinant of "success." We assessed the interaction between cervical length (CL), cerclage height (cerH), proximal residual length (PRL), gestational age at delivery, and rate of delivery ≤ 34 weeks, in this study. Study Design Present study is a retrospective cohort study of all cerclages placed at Maimonides Medical Center from 2006 to 2016. Outcomes: gestational age at delivery and delivery before 34 weeks; predictors: PRL, cerH, CL; and indications for cerclage: history (Hx), physical exam (PE), and ultrasound (US) indicated cerclage. A general linear model was used to predict power-transformed age at delivery from cerH, CL, and indication for cerclage. Subanalyses by indication were conducted. Logistic regression was used for delivery ≤ 34 weeks. Results The cerH by indication did not reach statistical significance ( p = 0.090). When stratified by indications, the effect of cerH on age at delivery was apparent for Hx (adjusted R 2 = 0.18, p < 0.001) and PE (adjusted R 2 = 0.43, p = 0.004) cerclages but not for US cerclages (adjusted R 2 = 0.08, p = 0.206). Logistic regression predicting delivery ≤ 34 weeks ( n = 29) produced similar results. Conclusions For Hx and PE indicated cerclages, the location of the stitch may influence the timing of delivery. Specifically, the higher the cerclage, the more advanced the gestational age at delivery.

Physician Work-Life Integration: Challenges and Strategies for Improvement.

Increasing evidence shows that physician well-being is linked to patient outcomes, patient and physician satisfaction, and workforce retention. Physician well-being is a broad construct that includes various dimensions of distress (stress, anxiety, fatigue, burnout) and professional fulfillment (meaning in work, engagement). Work-life integration (WLI) is one important component of physician well-being. We will review the current state of WLI among physicians as well as some strategies to improve this aspect of physician well-being. We address this topic through the lens of obstetrics and gynecology, including a discussion of specialty-specific characteristics that present unique challenges and opportunities to improve WLI.

Human Metapneumovirus Infection and Acute Respiratory Distress Syndrome During Pregnancy.

BACKGROUND: Human metapneumovirus has recently been recognized as an important cause of severe respiratory viral infections and of viral infections in patients admitted to intensive care units. Little is known about the course of this infection in pregnancy. CASE: A late-preterm primigravid woman was admitted to the intensive care unit for acute respiratory distress syndrome and subsequently diagnosed with human metapneumovirus. Because of worsening maternal respiratory status, she was intubated and a primary cesarean delivery was performed. The patient's respiratory status continued to decline postpartum, and she ultimately required extracorporeal membrane oxygenation. She was treated supportively until her respiratory status improved, at which time she was extubated and weaned off extracorporeal membrane oxygenation and subsequently discharged home. CONCLUSION: Human metapneumovirus can lead to severe respiratory illness during pregnancy.

Fetal proximal humeral epiphysis as an indicator of term gestation in different ethnic groups.

OBJECTIVES: Accurate pregnancy dating is critical for appropriate clinical management. Our aim was to determine the time of appearance of proximal humeral epiphysis (PHE), consistency of its appearance among ethnic groups and whether 3D imaging helps with its visualization. METHODS: A cross-sectional study was done on 360 patients with 563 scans in different ethnic groups between August 2013 and July 2015. Inclusion criteria were singleton pregnancies (34-40+ weeks of gestation), well dated by <20 weeks sonogram. RESULTS: PHE was not seen at 34 (n = 44) or 35 weeks (n = 36) and was present at gestational ages 36 (n = 3), 37 (n = 126), 38 (n = 96), 39 (n = 100) and 40 weeks (n = 28) in 2%, 12%, 51%, 75% and 100%, respectively. PHE was seen in 20 of 50 (60%) African-Americans, 22 of 61 (64%) south Asians, 41 of 72 (57%) Caucasians, 45 of 86 (48%) Hispanics and 41 of 80 (49%) Asians. CONCLUSION: Appearance of PHE did increase with gestational age, prior to 40 weeks, it was not uniformly present and was seen as early as 36 weeks independent of ethnic group.

Please put on your own oxygen mask before assisting others: a call to arms to battle burnout.

Burnout among healthcare workers has reached epidemic proportions. Obstetrician/Gynecologists are not exceptions. Burnout is a phenomenon that can be difficult to distinguish from other entities, but one that has far-reaching consequences that can be deleterious both to physicians and to their patients. Most worrisome are its insidious nature, its contagiousness, and its relationship to depression. To date there has been a paucity of solutions proven to effectively fight burnout, and the implementation of those that may be helpful has been fragmented. An aggressive and multi-pronged approach is warranted that focus at the individual, departmental, institutional and national levels. Potential solutions should take into account external and internal factors, as well as issues of feasibility, impact and cost. Interventions that may play a role include cognitive-behavioral therapy, enhanced communication, physician wellbeing programs, improving work conditions, and advocacy efforts.

Patterns of Internet Use by Pregnant Women, and Reliability of Pregnancy-Related Searches.

Objective To assess patterns of e-health use in pregnancy in an underserved racially diverse inner-city population, and to assess the accuracy of pregnancy-related information obtained from the Internet. Methods A cross sectional study of 503 pregnant/postpartum women belonging to an underserved racially diverse inner-city population who completed a survey regarding e-health use. To assess accuracy, four independent expert-reviewers rated the first 10 webpages on Google searches for each of five questions based upon those in ACOG bulletins. Results 70.8 % of pregnant/postpartum women belonging to an underserved racially diverse inner-city population were e-health users. E-health users were younger (mean age 29.4 vs. 31.2, P = 0.009), more likely to be nulliparous (50.3 vs. 21.3 %, P < 0.001), have English as their primary language (62.3 vs. 49.1 %, P = 0.014) and have a college/graduate education (78 vs. 26.6 %, P < 0.001). While 60 % of these women said e-health influenced decision making, only 71.3 % of them discussed their searches with their provider. Expert reviewers determined that the online information was fairly accurate (mean score: +1.48 to +4.33 on a scale of -5 to +5) but not uniformly accurate, and there was at least one webpage with inaccurate information for every question. Conclusions for practice Pregnant women frequently use e-health resources but do not routinely share their findings with their providers. Most, but not all, information obtained is accurate. Therefore it is important for providers to discuss their patients' use, and help to guide them to reliable information.

Resolution of superimposed pre-eclampsia, and improvement in umbilical artery flow in a surviving twin after intrauterine demise of its co-twin.

Pre-eclampsia has a progressive clinical course, and is only cured by delivery of the placenta. We report a 30-year-old G1P0 with dichorionic twins, discordant growth and chronic hypertension who developed superimposed pre-eclampsia in her 21st week of gestation. After intrauterine demise of the severely growth-restricted twin, the superimposed pre-eclampsia resolved. The surviving twin initially had absent end diastolic flow, which resolved after the demise. A healthy 1935-g neonate with Apgar 9/9 was delivered at 34 weeks. Antenatal resolution of pre-eclampsia is extremely rare and resolution of superimposed pre-eclampsia has not, to our knowledge, been reported.

Bilateral internal carotid artery dissection in the postpartum period.

BACKGROUND: Bilateral internal carotid artery dissection is a rare event associated with pregnancy, especially in a patient without any predisposing risk factors. CASE: A 34-year-old woman presented with postpartum unilateral weakness, headaches, and blurry vision 14 days after vaginal delivery. Radiologic imaging revealed bilateral cervical internal carotid artery dissections and cerebral infarctions. She was treated with anticoagulation and showed radiographic and clinical improvement. CONCLUSION: The pathophysiology of cervical artery dissection appears multifactorial, with evidence suggesting environmental and genetic contributions. Intimal injury related to the Valsalva maneuver during labor as well as hemodynamic and hormonal changes related to pregnancy are presumed causes of peripartum spontaneous carotid artery dissection. Antithrombotic therapy for at least 3 to 6 months after dissection and follow-up neuroimaging are suggested.

Diabetes in pregnancy: glycemia control guidelines and rationale.

PURPOSE OF REVIEW: Little consensus exists on the definition of gestational diabetes (GDM), how the condition should be diagnosed, and if interventions for mild maternal hyperglycemia are of any benefit to the mother or fetus. Today, after several large multicenter clinical trials, we are closer than ever to a national and international consensus. RECENT FINDINGS: Glucose tolerance in pregnancy is a continuum, which has a fundamental link to fetal growth. The relationship between maternal glycemia and adverse outcomes is continuous, with no distinct inflection point for increased risk. As a result, any cut-off for the diagnosis of GDM is somewhat arbitrary. Treatment for GDM, even mild cases, significantly reduces the rate of certain adverse perinatal and maternal outcomes, warranting intervention. SUMMARY: Clinical guidelines for the diagnosis of GDM are expected to change in the near future provided that recommendations from the International Association of Diabetes and Pregnancy Study Group are accepted by professional organizations. The criteria for the diagnosis will likely be based on a single 75 g, 2-h oral glucose tolerance test with at least one abnormal value. The proposed threshold values are based on an international consensus regarding risk of adverse pregnancy outcomes. The public health implications for these changes are anticipated to be significant.