Association between gestational age and perinatal outcomes in women with late preterm premature rupture of membranes.

OBJECTIVE: ACOG suggests expectant management until 34 weeks for patients with PPROM. New data suggests extending to 37 weeks might enhance neonatal outcomes, reducing prematurity-linked issues. This study aims to assess adverse neonatal outcomes across gestational ages in women with PPROM. STUDY DESIGN: A retrospective cohort study was performed using linked vital statistics and ICD-9 data. Gestational age at delivery ranged from 32 to 36 weeks. Outcomes include NICU admission >24 hours, neonatal sepsis, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. Multivariate regression analyses and chi-squared tests were employed for statistical comparisons. RESULTS: In this cohort of 28,891 deliveries, there was a statistically significant decline in all studied adverse neonatal outcomes with increasing gestational age, without an increase in neonatal sepsis. At 32 weeks, 93% of newborns were in the NICU >24 hours compared to 81% at 34 weeks and 22% at 36 weeks (p<0.001). At 32 weeks, 20% had neonatal sepsis compared to 11% at 34 weeks and 3% at 36 weeks (p<0.001). At 32 weeks, 67% had RDS compared to 44% at 34 weeks and 12% at 36 weeks (p<0.001). CONCLUSION: In the setting of PPROM, later gestational age at delivery is associated with decreased rates of adverse neonatal outcomes without an increase in neonatal sepsis.

Association of perinatal outcomes among pregnant patients with gestational diabetes receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children.

BACKGROUND: Treatment of gestational diabetes mellitus has been demonstrated to improve perinatal outcomes. However, the role of the Special Supplemental Nutrition Program for Women, Infants, and Children in maternal and neonatal outcomes for qualifying patients with gestational diabetes mellitus is less understood. OBJECTIVE: The objective of this study is to observe the relationship of enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children with pregnancy outcomes in patients with gestational diabetes. STUDY DESIGN: This was a retrospective cohort study using National Vital Statistics Birth Data of pregnant persons diagnosed with gestational diabetes mellitus between 2014 and 2018. The study population was composed of patients who had Medicaid coverage for maternity care; patients with Medicaid are automatically qualified for the Special Supplemental Nutrition Program for Women, Infants, and Children. The study groups were defined as those who enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children vs those who did not enroll. In addition, maternal and neonatal outcomes for these groups were analyzed. Univariate and multivariable logistic regression analyses adjusted for significant covariates were performed. RESULTS: Of 460,377 pregnant persons with pregnancies complicated by gestational diabetes mellitus, 73% were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children, and 27% were not. Pregnant persons with gestational diabetes mellitus enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children had decreased odds of preterm delivery before 34 and 37 weeks of gestation. Although the Special Supplemental Nutrition Program for Women, Infants, and Children group had higher odds of large-for-gestational-age neonates and cesarean delivery, the overall rates of these outcomes in both cohorts were high. CONCLUSION: The Special Supplemental Nutrition Program for Women, Infants, and Children provides a resource for perinatal support, supplemental food, and nutritional education. The decrease in the rates of preterm deliveries in pregnant persons with gestational diabetes mellitus that enroll in the Special Supplemental Nutrition Program for Women, Infants, and Children, Infants, and Children relative to those that qualified for the program but did not enroll suggested that having access to available education and food sources may influence perinatal outcomes.

Obstetric management for stillbirth complicated by a prior cesarean delivery: a cost-effectiveness analysis.

BACKGROUND: The primary concern for a trial of labor after cesarean (TOLAC) is a uterine rupture leading to neonatal injury or mortality and maternal mortality. In individuals who have a term stillbirth, the neonatal concern is absent, yet repeat cesarean delivery remains common in this setting. Given the increased maternal risks from cesarean, it is important to evaluate obstetric management options in the population of women who have a term stillbirth and prior cesarean delivery (CD). OBJECTIVES: To examine the outcomes and costs of a TOLAC via induction of labor verses a repeat CD for cases of stillbirth occurring near term. STUDY DESIGN: A decision-analytic model incorporating the current and a subsequent delivery using TreeAge software was designed to compare outcomes in women induced for a TOLAC to those undergoing repeat CD in the setting of stillbirth at 34-41 weeks' gestation. We used a theoretical cohort of 6000 women, the estimated annual number of women a prior cesarean who experience a stillbirth in the United States. Outcomes included quality-adjusted life years (QALY) for both modes of delivery with consideration of future pregnancy risks. Future pregnancy risks included uterine rupture, hysterectomy, placenta accreta, maternal death, neonatal death, and neonatal neurological deficits. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. RESULTS: In our theoretical cohort of 6000 women with a prior CD and current stillbirth, induction of labor resulted in 4836 fewer cesarean deliveries during stillbirth management, 1040 fewer cesarean deliveries in the subsequent pregnancy, and 14 fewer cases of placenta accreta in the subsequent pregnancy, despite 29 additional uterine ruptures across both pregnancies. Induction of labor was found to be the dominant strategy, resulting in decreased costs and increased QALYs. Univariate sensitivity analyses demonstrated that induction of labor was cost effective until the risk of uterine rupture in the first delivery exceeded 0.83% (baseline estimate: 0.38%). Additional univariate sensitivity analyses found that induction of labor was cost effective until the risk of IOL failure in the first delivery exceeded 64% (baseline estimate: 19%). CONCLUSION: In our theoretical cohort, induction of labor for TOLAC in the setting of a stillbirth with a history of prior CD is cost effective compared to a repeat CD. The results of this analysis demonstrate the benefit of induction of labor among women in this scenario who desire a future pregnancy.

Expectant management of preterm premature rupture of membranes at 34 weeks: a cost effectiveness analysis.

OBJECTIVE: To examine the outcomes and cost effectiveness of expectant management versus immediate delivery of women who experience preterm premature rupture of membranes (PPROM) at 34 weeks. METHODS: A cost-effectiveness model was built using TreeAge software to compare outcomes in a theoretical cohort of 37,455 women with PPROM at 34 weeks undergoing expectant management until 37 weeks versus immediate delivery. Outcomes included fetal death, neonatal sepsis, neonatal death, neonatal neurodevelopmental delay, healthy neonate, maternal sepsis, maternal death, cost, and quality-adjusted life years. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000 per quality-adjusted life year. RESULTS: In our theoretical cohort of 37,455 women, expectant management yielded 58 fewer neonatal deaths and 164 fewer cases of neonatal neurodevelopmental delay. However, it resulted in 407 more cases of neonatal sepsis and 2.7 more cases of maternal sepsis. Expectant management resulted in 3,531 more quality-adjusted life years and a cost savings of $71.9 million per year, making it a dominant strategy. Univariate sensitivity analysis demonstrated expectant management was cost effective until the weekly cost of antepartum admission exceeded $17,536 (baseline estimate: $12,520) or the risk of maternal sepsis following intraamniotic infection exceeded 20%. CONCLUSION: Our model demonstrated that expectant management of PPROM at 34 weeks yielded better outcomes on balance at a lower cost than immediate delivery. This analysis is important and timely in light of recent studies suggesting improved neonatal outcomes with expectant management. However, individual risks and preferences must be considered in making this clinical decision as expectant management may increase the risk of adverse perinatal outcomes when the risk of puerperal infection increases.

Effect of a small-group, active learning, tutorial-based, in-course enrichment program on student performance in medical physiology.

Physiology is one of the major foundational sciences for the medical curriculum. This discipline has proven challenging for students to master due to ineffective content acquisition and retention. Preliminary data obtained from a survey completed by "low-performance" students (those maintaining a grade average below the passing mark of 70%) at Morehouse School of Medicine reported that students lacked the ability to adequately recognize and extract important physiological concepts to successfully navigate multiple-choice assessments. It was hypothesized that a specially designed, small-group, active learning, physiology in-course enrichment program would minimize course assessment failure rates by enhancing the ability of low-performance students to effectively identify important course content, successfully perform on multiple-choice assessments, and, thereby, improve overall course performance. Using self-report surveys, study skills and test-taking deficiencies limiting successful comprehension of course material and examination performance were identified. Mini-quiz assessments and assignments in formulating multiple-choice examination questions were given to help students recognize and solidify core concepts and improve test-taking ability. Lastly, self-report surveys evaluated the effectiveness of the enrichment program on overall course performance. Results showed a marked improvement in student confidence levels with regards to approaching multiple-choice assessments, and a significant improvement in grades achieved in the physiology component of the first-year curriculum, as 100% of participants achieved a final passing grade average of ≥70%. It was concluded that students became more proficient in identifying, understanding, and applying core physiological concepts and more successful in mastering multiple-choice questions.

The effects of dehydroepiandrosterone (DHEA) on in vitro spleen cell proliferation and cytokine production.

Dehydroepiandrosterone (DHEA), a weak androgenic steroid, has been associated with enhancing immune responses and upregulating resistance against viral, parasitic, and bacterial infections. The objective of this study was to assess the effects of DHEA on murine spleen cell viability, proliferation, and cytokine production following in vitro stimulation with the mitogens concanavalin A (ConA) and lipopolysaccharide (LPS). Results showed that exposure to 6 microM DHEA significantly decreased the viability and proliferation of murine spleen cells stimulated with LPS, whereas no effect was seen on murine spleen cells stimulated with ConA. DHEA did influence the production of both ConA-induced and LPS-induced cytokines. DHEA also significantly reduced the mitogen-induced production of the proinflammatory cytokine interleukin-1 (IL-1) as well as the Th1 cytokines IL-2 and interferon-gamma (IFN-gamma). Increasing concentrations of DHEA significantly increased the production of the Th2 cytokine IL-10 but had no effect on the production of the Th2 cytokine IL-4, the proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha), or IL-6. These results suggest that DHEA may be an important factor for increasing Th2 cytokine production and decreasing Th1 and proinflammatory cytokine production. This study provides a more comprehensive understanding of the effects of DHEA on the rates of cell proliferation, cell viability, and cytokine production.