A systematic review of contaminants in donor human milk.

Donor human milk (DHM) from a milk bank is the recommended feeding method for preterm infants when the mother's own milk (MOM) is not available. Despite this recommendation, information on the possible contamination of donor human milk and its impact on infant health outcomes is poorly characterised. The aim of this systematic review is to assess contaminants present in DHM samples that preterm and critically ill infants consume. The data sources used include PubMed, EMBASE, CINAHL and Web of Science. A search of the data sources targeting DHM and its potential contaminants yielded 426 publications. Two reviewers (S. T. and D. L.) conducted title/abstract screening through Covidence software, and predetermined inclusion/exclusion criteria yielded 26 manuscripts. Contaminant types (bacterial, chemical, fungal, viral) and study details (e.g., type of bacteria identified, study setting) were extracted from each included study during full-text review. Primary contaminants in donor human milk included bacterial species and environmental pollutants. We found that bacterial contaminants were identified in 100% of the papers in which bacterial contamination was sought (16 papers) and 61.5% of the full data set (26 papers), with the most frequently identified genera being Staphylococcus (e.g., Staphylococcus aureus and coagulase-negative Staphylococcus) and Bacillus (e.g., Bacillus cereus). Chemical pollutants were discovered in 100% of the papers in which chemical contamination was sought (eight papers) and 30.8% of the full data set (26 papers). The most frequently identified chemical pollutants included perfluoroalkyl substances (six papers), toxic metal (one paper) and caffeine (one paper). Viral and fungal contamination were identified in one paper each. Our results highlight the importance of establishing standardisation in assessing DHM contamination and future studies are needed to clarify the impact of DHM contaminants on health outcomes.

Perinatal Health Outcomes Across Rural and Nonrural Counties Within a Single Health System Catchment.

Background: Perinatal health outcomes are influenced by a variety of socioeconomic, behavioral, and economic factors that reduce access to health services. Despite these observations, rural communities continue to face barriers, including a lack of resources and the fragmentation of health services. Objective: To evaluate patterns in health outcomes, health behaviors, socioeconomic vulnerability, and sociodemographic characteristics across rural and nonrural counties within a single health system catchment area. Methods: Socioeconomic vulnerability metrics, health care access as determined by licensed provider metrics, and behavioral data were obtained from FlHealthCHARTS.gov and the County Health Rankings. County-level birth and health data were obtained from the Florida Department of Health. The University of Florida Health Perinatal Catchment Area (UFHPCA) was defined as all Florida counties where ≥5% of all infants were delivered at Shands Hospital between June 2011 and April 2017. Results: The UFHPCA included 3 nonrural and 10 rural counties that represented more than 64,000 deliveries. Nearly 1 in 3 infants resided in a rural county, and 7 out of 13 counties did not have a licensed obstetrician gynecologist. Maternal smoking rates (range 6.8%-24.8%) were above the statewide rate (6.2%). Except for Alachua County, breastfeeding initiation rates (range 54.9%-81.4%) and access to household computing devices (range 72.8%-86.4%) were below the statewide rate (82.9% and 87.9%, respectively). Finally, we found that childhood poverty rates (range 16.3%-36.9%) were above the statewide rate (18.5%). Furthermore, risk ratios suggested negative health outcomes for residents of counties within the UFHPCA for each measure, except for infant mortality and maternal deaths, which lacked sample sizes to adequately test. Conclusions: The health burden of the UFHPCA is characterized by rural counties with increased maternal death, neonatal death, and preterm birth, as well as adverse health behaviors that included increased smoking during pregnancy and lower levels of breastfeeding relative to nonrural counties. Understanding perinatal health outcomes across a single health system has potential to not only estimate community needs but also facilitate planning of health care initiatives and interventions in rural and low-resource communities.

Abnormal fetal heart rate patterns caused by pathophysiologic processes other than fetal acidemia.

Fetal acidemia is a common final pathway to fetal death, and in many cases, to fetal central nervous system injury. However, certain fetal pathophysiological processes are associated with significant category II or category III fetal heart rate changes before the development of or in the absence of fetal acidemia. The most frequent of these processes include fetal infection and/or inflammation, anemia, fetal congenital heart disease, and fetal central nervous system injury. In the presence of significant category II or category III fetal heart rate patterns, clinicians should consider the possibility of the aforementioned fetal processes depending on the clinical circumstances. The common characteristic of these pathophysiological processes is that their associated fetal heart rate patterns are linked to increased adverse neonatal outcomes despite the absence of acidemia at birth. Therefore, in these cases, the fetal heart rate patterns may provide more insight about the fetal condition and pathophysiology than the acid-base status at birth. In addition, as successful timing of intrapartum interventions on the basis of evolution of fetal heart rate patterns aims to prevent fetal acidemia, it may not be logical to continue to use the fetal acid-base status at birth as the gold standard outcome to determine the predictive ability of category II or III fetal heart rate patterns. A more reasonable approach may be to use the umbilical cord blood acid-base status at birth as the gold standard for determining the appropriateness of the timing of our interventions.

Safety of deep brain stimulation in pregnancy: A comprehensive review.

Introduction: Deep brain stimulation (DBS) is increasingly used to treat the symptoms of various neurologic and psychiatric conditions. People can undergo the procedure during reproductive years but the safety of DBS in pregnancy remains relatively unknown given the paucity of published cases. We thus conducted a review of the literature to determine the state of current knowledge about DBS in pregnancy and to determine how eligibility criteria are approached in clinical trials with respect to pregnancy and the potential for pregnancy. Methods: A literature review was conducted in EMBASE to identify articles involving DBS and pregnancy. Two reviewers independently analyzed the articles to confirm inclusion. Data extracted for analysis included conditions treated, complications at all stages of pregnancy, neonatal/pediatric outcomes, and DBS target. A second search was then conducted using www.clinicaltrials.gov. The same two reviewers then assessed whether each trial excluded pregnant individuals, lactating individuals, or persons of childbearing age planning to conceive. Also assessed was whether contraception had to be deemed adequate prior to enrollment. Results: The literature search returned 681 articles. Following independent analysis and agreement of two reviewers, 8 pregnancy related DBS articles were included for analysis. These articles described 27 subjects, 29 pregnancies (2 with subsequent pregnancies), and 31 infants (2 twin pregnancies). There was 1 preterm birth at 35 weeks, and 3 patients who experienced discomfort from the DBS battery (i.e., impulse generator) placement site. All 27 patients had a DBS device implanted before they became pregnant, which remained in use throughout their pregnancy. There was exclusion of pregnant individuals from 68% of 135 interventional trials involving DBS. Approximately 44% of these trials excluded persons of childbearing age not on "adequate contraception" or wishing to conceive in the coming years. Finally, 22% excluded breastfeeding persons. Conclusion: The data from 29 pregnancies receiving DBS treatment during pregnancy was not associated with unexpected pregnancy or post-partum complication patterns. Many clinical trials have excluded pregnant individuals. Documentation of outcomes in larger numbers of pregnancies will help clarify the safety profile and will help guide study designs that will safely include pregnant patients.

Outcomes of pregnancies at high-risk for placenta accreta spectrum following negative diagnostic imaging.

OBJECTIVES: To assess the pretest and negative post-test probability for placenta accreta spectrum (PAS) in a group of patients with high-risk clinical factors. METHODS: We included patients with suspected and/or confirmed PAS at our institution over 8 years. Sonography performed by maternal-fetal medicine specialists, and selected patients underwent MRI. Imaging was considered positive if either sonography or MRI suggested PAS. Histopathology was the gold standard for diagnosis of PAS. We assessed the pretest and negative imaging-test probability, and resources required. RESULTS: We identified 82 high-risk patients with the following: (1) a history of ≥1 cesarean section and/or intrauterine gynecologic procedure and placenta previa in the index pregnancy; (2) a history of >3 cesarean deliveries and/or gynecologic procedures regardless of placental location; (3) prior PAS disorder, or retained placenta requiring manual extraction and/or curettage, complicated by postpartum hemorrhage; and (4) suspected cesarean section scar pregnancy. Histopathology confirmed PAS in 52 patients, with pretest probability of 63%. Imaging correctly identified 44/50 cases with PAS, and excluded this condition in 24/30 cases. Thus, the positive and negative post-test probability for PAS following negative imaging was 88 and 20%, respectively. Of the six patients with false-negative imaging, all had either surgical complications or required care beyond that for routine cesarean section. CONCLUSIONS: Although diagnostic imaging is sensitive, the negative posttest probability remains high in women with high pretest probability for PAS. Therefore, women at high risk for PAS should be managed in experienced centers by a multidisciplinary team even if imaging is negative.

COVID-19: changing the care process for women's health-the patient's perspective.

OBJECTIVE: Assess women's perceptions of the impact of COVID-19 on their health care and well-being, access to and satisfaction with medical care due to the changes in delivery of care triggered by the pandemic. METHODS: An online survey of women having health care appointments in the outpatient facilities across all divisions of a Department of Obstetrics and Gynecology at a tertiary care referral center in North Central Florida. Patients had outpatient appointments that were scheduled, canceled or rescheduled, in person or by telemedicine, between 11 March 2020 and 11 May 2020, a time during which a COVID-19 stay-at-home order was enacted across our state. A total of 6,697 visits were planned. Patients with multiple visits were unified, leaving 6,044 unique patients to whom the survey was emailed between 20 July 2020 and 31 July 2020. The survey was closed on 21 August 2020. Analyses were focused on simple descriptive statistics to assess frequency of responses. Analyses of variance and chi-square analyses were conducted to compare outcomes when all cells were ≥ 10, based on sub-specialty and insurance status; otherwise, frequencies were examined for the entire sample only. Missing data were excluded listwise. RESULTS: A total of 6044 patients were contacted. Completed surveys numbered 1,083 yielding a response rate of 17.9%. The most common sub-specialty visit was gynecology (56.7%) followed by obstetrics (31.5%,), pelvic floor disorders (4.8%), gynecological oncology (2.9%,), and reproductive endocrinology (0.5%). A substantial percentage of women had visits canceled (19.2%), rescheduled (32.8%) or changed (42.1%) to telemedicine. In our patient population, 32.6% were worried about visiting the clinic and 48.1% were worried about visiting the hospital. COVID-19 triggered changes were perceived to have a negative impact by 26.1% of respondents. Refusal of future telemedicine visits was by 17.2%, however, 75.2% would prefer to use both in-person and telemedicine visits. CONCLUSION: During the initial COVID-19 surge with lockdown, the majority of survey respondents were following public health precautions. However, there were significant concerns amongst women related to obstetric and gynecologic medical appointments scheduled during that period. During pandemics, natural disasters and similar extreme circumstances, digital communication and telemedicine have the potential to play a critical role in providing reassurance and care. Nevertheless, given the concerns expressed by survey respondents, communication and messaging tools are needed to increase comfort and ensure equity with the rapidly changing methods of care delivery.

Timing intrapartum management based on the evolution and duration of fetal heart rate patterns.

One of the most important challenges in obstetrics is to determine the appropriate time to deliver the fetus without exposing the mother to unnecessary operative interventions. The use of continuous cardiotocography (cCTG) during labor has resulted in dramatic reductions in intrapartum fetal deaths, but fetal central nervous system (CNS) injury and cerebral palsy (CP) rates have remain relatively unchanged as related to the use of cCTG . In our view, this is due to continuing inability to recognize progressive fetal deterioration and intervene promptly prior to the development of fetal CNS injury. Although the 2008 NICHD workshop proposed a 3-tier classification system, most fetuses born with severe (pathologic) acidemia (cord artery pH < 7.00), as well as those who eventually develop CP, will never reach the stage of NICHD Category III fetal heart rate (FHR) pattern. In the present "Clinical Opinion," we promote a concept derived from observations, that the evolution of the FHR changes of the deteriorating fetus can be visually defined by three color "zones" that are clinically recognizable and, therefore, are actionable. In addition, we will review information regarding how long the fetus may be able to tolerate an abnormal FHR pattern before it suffers an adverse perinatal outcome, an area of investigation that has been rarely addressed before. Based on the available evidence, Category III FHR patterns should not be used as screening criteria because of low sensitivity for either fetal CNS injury (45%) or severe (pathologic) fetal acidemia (36-44%). In addition, the duration of the Category III pattern required for the development of severe fetal acidemia is extremely short to allow for a timely preventative operative intervention. On the contrary, the use of our proposed "red" zone, which includes the most advanced stages in the progressive deterioration of Category II patterns and Category III, will identify the overwhelming majority of fetuses who develop severe (pathologic) acidemia (96%) and/or CNS injury during labor (100%); moreover, the detection of fetal jeopardy by the use of the "red" zone occurs much earlier, as compared to using Category III, thus allowing reasonable amount of time for a timely obstetrical intervention. Further research is needed to determine the false positive rate and positive predictive value for a pre-determined period of time in the red zone.

Patient compliance and satisfaction using web-based glucose monitoring for the management of pregnant women with pregestational diabetes.

BACKGROUND: Optimal glycemic control is vital in decreasing the risk of congenital birth defects and perinatal complications in women with diabetes. Although frequent blood glucose (BG) monitoring is essential during pregnancy, studies have highlighted poor compliance and falsification of glucose readings. We designed this study to assess whether a web-based glucose monitor improves compliance, glycemic control, and patient satisfaction. METHODS: This was a prospective study of 30 women with pre-gestational diabetes. After 4 weeks of using paper logs, patients were given a web-based glucose monitor. The primary outcome of interest was the average number of BG readings prior to and during web-based implementation. Secondary outcomes included glycemic control and patient satisfaction as determined by a pre- and post-study survey. RESULTS: The number of BG readings after 2 months using the web-based meter was similar to baseline. Hemoglobin A1c (HbA1c) significantly improved and there was a trend toward improved overall glycemic values. Survey results demonstrated satisfaction with the new system, although 20% of patients felt uncomfortable with glucose values being available to providers in real time. CONCLUSIONS: Compliance with BG monitoring was similar when comparing a web-based system with written logs. Since other studies have highlighted that some glucose data from written logs are falsified, actual compliance using the web-based monitor may be improved. This study demonstrates potential patient concerns using a web-based system. Further studies should explore patient reactions to providers having real-time access to online glycemic data given our survey results.

Educational Attainment of Grandmothers and Preterm Birth in Grandchildren.

BACKGROUND: Maternal education has been shown repeatedly to be inversely associated with preterm birth. Both preterm birth and educational level of families are correlated across generations, but it is not clear if educational level of grandparents affects the risk of preterm delivery of their grandchildren, and, if so, if the association with grandmother's education is independent of mother's education. METHODS: We used New Jersey birth certificates to create a transgenerational dataset to examine the effect of grandmother's education on risk of PTB in White, Black and Hispanic grandchildren. We matched birth certificates of girls born in 1979-1983 to mothers listed on NJ birth certificates for the years 1999-2011. Thus, grandmothers were the women delivering in 1979-1983, and mothers were those born to the grandmothers who in turn delivered grandchildren in 1999-2011. We performed descriptive tabulations and multivariate logistic regression to develop risk estimates. RESULTS: Overall, maternal education was associated inversely with PTB in each of the demographic groups. There was a substantial inter-generational increase in education between grandmothers and mothers in each group, which was most striking in Hispanics After adjusting for maternal age and education, grandmother's education continued to be associated with preterm birth of her grandchildren. CONCLUSIONS: Grandmother's education was an additional, independent predictor of PTB in her grandchildren. This result supports the idea that mother's childhood and preconception socioeconomic environment, including the educational level of her childhood household affect her reproductive health.

Coronavirus disease 2019 pandemic: staged management of surgical services for gynecology and obstetrics.

The coronavirus disease 2019 pandemic warrants an unprecedented global healthcare response requiring maintenance of existing hospital-based services while simultaneously preparing for high-acuity care for infected and sick individuals. Hospitals must protect patients and the diverse healthcare workforce by conserving personal protective equipment and redeployment of facility resources. While each hospital or health system must evaluate their own capabilities and surge capacity, we present principles of management of surgical services during a health emergency and provide specific guidance to help with decision making. We review the limited evidence from past hospital and community responses to various health emergencies and focus on systematic methods for adjusting surgical services to create capacity, addressing the specific risks of coronavirus disease 2019. Successful strategies for tiered reduction of surgical cases involve multidisciplinary engagement of the entire healthcare system and use of a structured risk-assessment categorization scheme that can be applied across the institution. Our institution developed and operationalized this approach over 3 working days, indicating that immediate implementation is feasible in response to an unforeseen healthcare emergency.

Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know.

Coronavirus disease 2019 is an emerging disease with a rapid increase in cases and deaths since its first identification in Wuhan, China, in December 2019. Limited data are available about coronavirus disease 2019 during pregnancy; however, information on illnesses associated with other highly pathogenic coronaviruses (ie, severe acute respiratory syndrome and the Middle East respiratory syndrome) might provide insights into coronavirus disease 2019's effects during pregnancy. Coronaviruses cause illness ranging in severity from the common cold to severe respiratory illness and death. Currently the primary epidemiologic risk factors for coronavirus disease 2019 include travel from mainland China (especially Hubei Province) or close contact with infected individuals within 14 days of symptom onset. Data suggest an incubation period of ∼5 days (range, 2-14 days). Average age of hospitalized patients has been 49-56 years, with a third to half with an underlying illness. Children have been rarely reported. Men were more frequent among hospitalized cases (54-73%). Frequent manifestations include fever, cough, myalgia, headache, and diarrhea. Abnormal testing includes abnormalities on chest radiographic imaging, lymphopenia, leukopenia, and thrombocytopenia. Initial reports suggest that acute respiratory distress syndrome develops in 17-29% of hospitalized patients. Overall case fatality rate appears to be ∼1%; however, early data may overestimate this rate. In 2 reports describing 18 pregnancies with coronavirus disease 2019, all were infected in the third trimester, and clinical findings were similar to those in nonpregnant adults. Fetal distress and preterm delivery were seen in some cases. All but 2 pregnancies were cesarean deliveries and no evidence of in utero transmission was seen. Data on severe acute respiratory syndrome and Middle East respiratory syndrome in pregnancy are sparse. For severe acute respiratory syndrome, the largest series of 12 pregnancies had a case-fatality rate of 25%. Complications included acute respiratory distress syndrome in 4, disseminated intravascular coagulopathy in 3, renal failure in 3, secondary bacterial pneumonia in 2, and sepsis in 2 patients. Mechanical ventilation was 3 times more likely among pregnant compared with nonpregnant women. Among 7 first-trimester infections, 4 ended in spontaneous abortion. Four of 5 women with severe acute respiratory syndrome after 24 weeks' gestation delivered preterm. For Middle East respiratory syndrome, there were 13 case reports in pregnant women, of which 2 were asymptomatic, identified as part of a contact investigation; 3 patients (23%) died. Two pregnancies ended in fetal demise and 2 were born preterm. No evidence of in utero transmission was seen in severe acute respiratory syndrome or Middle East respiratory syndrome. Currently no coronavirus-specific treatments have been approved by the US Food and Drug Administration. Because coronavirus disease 2019 might increase the risk for pregnancy complications, management should optimally be in a health care facility with close maternal and fetal monitoring. Principles of management of coronavirus disease 2019 in pregnancy include early isolation, aggressive infection control procedures, oxygen therapy, avoidance of fluid overload, consideration of empiric antibiotics (secondary to bacterial infection risk), laboratory testing for the virus and coinfection, fetal and uterine contraction monitoring, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, and a team-based approach with multispecialty consultations. Information on coronavirus disease 2019 is increasing rapidly. Clinicians should continue to follow the Centers for Disease Control and Prevention website to stay up to date with the latest information (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

Is there a role for cardiac magnetic resonance imaging during pregnancy?

Purpose: To assess the role of cardiac magnetic resonance imaging (CMR) for the evaluation and management of women with cardiac disorders in pregnancy and postpartum.Methods: Retrospective record review of women at a university-affiliated, single institution referred for CMR without contrast due to known or suspected cardiac disorders between January 2010 and December 2015. Medical records, echocardiogram and CMR reports were reviewed. Instances where clinical management was changed based on CMR findings were identified.Results: There were 17 peripartum CMR studies performed without contrast in 17 pregnancies from 16 women. Indications for CMR included congenital heart disease (N = 8, 47.1%), Marfan syndrome or strong family history of Marfan syndrome (N = 5, 29.4%), cardiomyopathy (N = 1, 5.9%), cardiac mass (N = 1, 5.9%), persistent dyspnea with a normal echocardiogram (N = 1, 5.9%), and hypertension with suspected aortic root dilation (N = 1, 5.9%). CMR confirmed the echocardiogram diagnosis in eight (47.1%) and improved the diagnosis in five (29.4%). Availability of CMR findings changed the delivery management in 2/17 (11.8%) women. CMR was especially helpful in assessing the size of the aortic root in women at risk for dilation.Conclusions: Although echocardiogram imaging of the heart is considered the first-line method for assessing the maternal cardiac status, CMR can provide information about cardiac anatomy and function in pregnant women with complex cardiac disease or suspected aortic pathology. Management may be changed based on results.

Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy.

BACKGROUND: Prior studies have reported an increased risk for preterm delivery following a term cesarean delivery. However, these studies did not adjust for high-risk conditions related to the first cesarean delivery and are known to recur. OBJECTIVE: The objective of the study was to determine whether there is an association between term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated preterm delivery. STUDY DESIGN: This was a retrospective cohort study of women with the first 2 consecutive singleton deliveries (2007-2014) identified through a linked pregnancy database at a single institution. Women with a first pregnancy that resulted in cesarean delivery at term were compared with women whose first pregnancy resulted in a vaginal delivery at term. Exclusion criteria were known to recur medical or obstetrical complications during the first pregnancy. A propensity score analysis was performed by matching women who underwent a cesarean delivery with those who underwent a vaginal delivery in the first pregnancy. The association between cesarean delivery in the first pregnancy and preterm delivery in the second pregnancy in this matched set was examined using conditional logistic regression. The primary outcome was overall preterm delivery <37 weeks in the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous vs indicated), late preterm delivery (34-36 6/7 weeks), early preterm delivery (<34 weeks), and small-for-gestational-age birth. RESULTS: Of a total of 6456 linked pregnancies, 2284 deliveries were matched; 1142 were preceded by cesarean delivery and 1142 were preceded by vaginal delivery. The main indications for cesarean delivery in the first pregnancy were dystocia in 703 (61.5%), nonreassuring fetal status in 222 (19.4%), breech presentation in 100 (8.8%), and other in 84 (7.4%). The mean (SD) gestational ages at delivery for the second pregnancy was 38.8 (1.8) and 38.9 (1.7) weeks, respectively, for prior cesarean delivery and vaginal delivery. The risks of preterm delivery in the second pregnancy among women with a previous cesarean and vaginal delivery were 6.0% and 5.2%, respectively (adjusted odds ratio, 1.46, 95% confidence interval, [CI] 0.77-2.76). In an analysis stratified by the type of preterm delivery in the second pregnancy, no associations were seen between cesarean delivery in the first pregnancy and spontaneous preterm delivery (4.6% vs 3.9%; adjusted odds ratio, 1.40, 95% confidence interval, 0.59-3.32) or indicated preterm delivery (1.6% vs 1.4%; adjusted odds ratio, 1.21, 95% confidence interval, 0.60-2.46). Similarly, no significant differences were found in late preterm delivery (4.6% vs 4.1%; adjusted odds ratio, 1.13, 95% confidence interval, 0.55-2.29), early preterm delivery (1.6% vs 1.2%; adjusted odds ratio, 1.25, 95% confidence interval, 0.59-2.67), or neonates with birthweight less than the fifth percentile for gestational age (3.6% vs 2.2%; adjusted odds ratio, 1.26, 95% confidence interval, 0.52-3.06). CONCLUSION: After robust adjustment for confounders through a propensity score analysis related to the indication for the first cesarean delivery at term, cesarean delivery is not associated with an increase in preterm delivery, spontaneous or indicated, in the subsequent pregnancy.

Length of the second stage of labor and preterm delivery risk in the subsequent pregnancy.

BACKGROUND: Cervical injury is regarded as an important risk factor for preterm delivery. A prolonged second stage of labor may increase the risk of cervical injury that, in turn, may be associated with increased risk of spontaneous preterm delivery in the subsequent pregnancy. OBJECTIVE: We sought to evaluate whether the duration of the second stage of labor in a term primiparous singleton delivery is associated with an increased risk of singleton spontaneous preterm delivery (<37 weeks) in the second pregnancy. STUDY DESIGN: We carried out a retrospective cohort analysis of women with 2 consecutive pregnancies: a first term (≥37 weeks) delivery and second birth. Data were derived from a single institution's prospectively collected obstetrical database from January 2005 through January 2015. Duration of the second stage of labor was examined as a continuous variable, modeled based on nonparametric restricted cubic regression spline with 4 degrees of freedom. Second-stage duration was also examined as short (<30 minutes), normal (30-179 minutes), and prolonged, defined as ≥180 minutes. The association between the duration of the second stage of labor in the first term pregnancy and the risk for spontaneous preterm delivery in the second pregnancy was evaluated before and after adjusting for potential confounders based on the Cox proportional hazards regression model. Associations were expressed based on the adjusted hazard ratio and 95% confidence interval. RESULTS: In all, 6715 women met inclusion criteria. The hazard of spontaneous preterm delivery in the second pregnancy trended higher with both shorter and longer second-stage labors. The length of the second stage of labor in the first term delivery was categorized as short (<30 minutes) in 1749 (26.0%), normal (30-179 minutes) in 4551 (67.8%), and prolonged (≥180 minutes), in 415 (6.2%) women. Of these 6715 women with a first term delivery, 4.2% (n = 279) delivered spontaneously preterm in the second pregnancy. The risks of spontaneous preterm delivery among women with prolonged (≥180 minutes) second stage of labor and normal labor duration (30-179 minutes) were 5.4% (n = 22) and 3.5% (n = 158), respectively (adjusted hazard ratio, 1.81; 95% confidence interval, 1.15-2.84). This increased risk for prolonged second stage of labor was primarily seen among women who underwent a cesarean (hazard ratio, 3.38; 95% confidence interval, 1.09-10.49), but was imprecise among women who delivered vaginally (hazard ratio, 1.52; 95% confidence interval, 0.62-3.74). The risk of spontaneous preterm delivery among women with short second stage of labor (<30 minutes) in their first term pregnancy was 5.8% (n = 99; hazard ratio, 1.28; 95% confidence interval, 0.99-1.67). CONCLUSION: The risk of spontaneous preterm delivery in the second pregnancy was increased in women with a prolonged (≥180 minutes) second stage in the first term pregnancy. This risk was even greater among women who were delivered by cesarean in the first pregnancy.

Dextrose intravenous fluid therapy in labor reduces the length of the first stage of labor.

The aim of this systematic review with meta-analysis was to evaluate the effect on length of labor when patients receive IVF with or without dextrose. Searches were performed in electronic databases from inception of each database to May 2018. Trials comparing intrapartum IVF containing dextrose (i.e. intervention group) with no dextrose or placebo (i.e. control group) were included. Only trials examining low-risk pregnancies in labor at ≥36 weeks were included. Studies were included regardless of oral intake restriction. The primary outcome was the length of total labor from randomization to delivery. The meta-analysis was performed using the random effects model. Sixteen trials (n = 2503 participants) were included in the meta-analysis. Women randomized in the IVF dextrose group did not have a statistically significant different length of total labor from randomization to delivery compared to IVF without dextrose (MD -38.33 min, 95% CI -88.23 to 11.57). IVF with dextrose decreased the length of the first stage (MD -75.81 min, 95% CI -120.67 to -30.95), but there was no change in the second stage. In summary, use of IVF with dextrose during labor in low-risk women at term does not affect total length of labor, but it does shorten the first stage of labor.

Postpartum Testing to Detect Persistent Dysglycemia in Women With Gestational Diabetes Mellitus.

The rate of gestational diabetes has doubled, and identifying the 30% with persistent postpartum dysglycemia (prediabetes or diabetes mellitus) is important because low-cost interventions have been proven to prevent overt diabetes mellitus, improve health for women, and potentially decrease the risk for birth defects in future pregnancies. Consensus guidelines continue to recommend a 4- to 12-week postpartum 2-hour oral glucose tolerance test (OGTT) despite persistent reports that only 35% of women complete the test. Physician ordering rates can improve, but the largest barriers to postpartum testing are clearly patient-related. Initiatives to improve OGTT testing rates have been only moderately effective and required allocation of staff time, diverting resources from other clinical areas. Alternative testing models using single-draw tests that bypass patient barriers show promise for improving the diagnosis of postpregnancy dysglycemia. Specifically, evidence is emerging in the pregnant and nonpregnant populations that, compared with the OGTT, the single-draw hemoglobin A1C test may identify more patients with prediabetes, bypasses patient barriers to testing such as the need for fasting, and has less laboratory variation compared with the OGTT or fasting plasma glucose. The risk-benefit focus should shift from comparing individual test performance statistics presuming the OGTT to be the "gold standard" to data reporting the ability of a test to facilitate identification of patients. We review the evidence regarding postpregnancy testing and make recommendations for strategies to improve the identification of dysglycemia and postpregnancy health.

A Multicenter Investigation of Factors Influencing Women's Participation in Clinical Trials.

OBJECTIVE: To identify factors that influence women's participation in clinical research. METHODS: We administered a survey in outpatient and inpatient populations of Obstetrics and Gynecology facilities of six institutions located in four states. The survey included questions regarding any of the participant's past experiences in clinical research and the factors that would influence their participation in clinical research. Analyses included descriptive statistics and a Principal Component Analysis. RESULTS: The analysis included 3,773 respondents; 2,477 (68.1%) were pregnant. The majority of participants were Caucasian (1,453, 40.2%), followed by Hispanic (933, 25.8%), African American/black (744, 20.6%), other minorities (270, 7.5%), and multiracial (212, 5.9%). Ten potential motivating factors and 10 potential barriers were assessed. The greatest motivating factor was "how well research is explained" (mean = 2.87) while "risk of unknown side effects" was the greatest barrier (mean = 3.07) for women's participation in clinical trials. Among six helpful resources assessed, "material in my own language" was scored as the highest (mean = 2.8) in facilitating women's decision to participate. For "risk to the fetus/future fertility" as a barrier, pregnant women's score (mean = 3.25) was significantly higher than nonpregnant women's score (mean = 2.37). CONCLUSIONS: Overall, the risk of unknown side effects discourages women in general, and the risk to the fetus/future fertility discourages pregnant women the most from participating in clinical trials. However, explaining a study well and providing written material in the patients' own language may increase their willingness to participate.

Impact of Race Versus Education and Race Versus Income on Patients' Motivation to Participate in Clinical Trials.

Our study investigates whether levels of motivation and barriers to participation in clinical trials vary with patients' education and income. A self-administered survey asked outpatients to rank potential influential factors on a "0" to "4" significance scale for their motivation to participate in clinical trials. Principal component analysis (PCA), analysis of variance (ANOVA), Kruskal-Wallis, and Mann-Whitney U tests analyzed the impact of race, education, and income on their motivation to participate. Analysis included 1841 surveys; most respondents had a high school education or some college, and listed annual income < $30,000. There was a significant interaction between race and income on our motivation scale 1 scores (p = .0261). Compared with their counterparts, subjects with less education/lower income ranked monetary compensation (p = .0420 and p < .0001, respectively) as a higher motivator. Minorities and patients with less education and lower income appear to be more influenced by their desire to please the doctor, the race and sex of the doctor, and the language spoken by the doctor being the same as theirs. For all races, education appeared to have a direct relationship with motivation to participate, except for African-Americans, whose motivation appeared to decline with more education. Income appeared to have an inverse relationship with motivation to participate for all races.

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties.

INTRODUCTION: This study investigated factors that influence emergency medicine (EM) patients' decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties. METHODS: A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants' responses. RESULTS: A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient's gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285-2.389}], ID [OR:3.281, 95% CI{2.293-4.695}], and OB/GYN [OR:2.408, 95% CI{1.741-3.330}]). EM's rankings of "how well the research was explained" and whether "the knowledge learned would benefit others" as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated "risk of unknown side effects" as their strongest barrier. Regardless of the patients' race, "time commitment" was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218-2.136}], ID [OR:1.340, 95% CI{1.006-1.784}], or OB/GYN [OR:1.901, 95% CI{1.431-2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked "having all material provided in my own language" as the most helpful resource. CONCLUSION: There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient's own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials.

Invasive placental disease: the impact of a multi-disciplinary team approach to management.

PURPOSE: To determine the impact of a structured multi-disciplinary management strategy on clinical outcomes in women with invasive placental disease (IPD). MATERIALS AND METHODS: This was a retrospective cohort study of consecutive women having peripartum hysterectomies with IPD over seven years. For the most recent three years, a structured multidisciplinary team (MDT) reviewed each suspected case, created a management plan, and implemented that plan. Outcomes were compared between cases delivered prior to and after the MDT process was started. RESULTS: There were 47 pregnancies with IPD, of which 31 (66.0%) were suspected antenatally and 40 (85.1%) had a prior uterine surgery. An MDT approach was performed in 19 (40.4%) cases. In the MDT group, there were longer operative times (260 min versus 181 min, p = 0.0001), less blood loss (1200 mL versus 2500 mL, p = 0.009), less administration of blood products (47.4% versus 85.7%, p = 0.005), and higher intraoperative lowest mean arterial pressures (MAPs) (57 mmHg versus 48 mmHg, p = 0.002, when compared to the No-MDT (n = 28) approach. No differences were found for other outcomes. CONCLUSION: Clinically meaningful improvements of less blood loss, fewer transfusions, and higher intraoperative MAPs suggest that MDT cases were more stable intraoperatively, which over a larger number of patients, should translate into improved outcomes.