A Patient Interview-Based Needs Assessment and Evaluation of Experiences with Periviable Pregnancies.

Given the complex ethical and emotional nature of births during the periviable period for both health care providers and families, this investigation sought to identify strategies for improved counseling of pregnant patients facing preterm birth at the cusp of viability at a tertiary care center in Hawai'i. As part of a larger quality improvement project on periviability counseling, 10 patients were interviewed during either individual or small focus groups using a progression of hypothetical scenarios. Interviews were analyzed independently by 3 investigators to identify themes of patient experience and potential areas for improvement when counseling patients who are carrying periviable pregnancies. Several common themes emerged from the interviews. Patients expressed the desire for more information throughout the process delivered in a jargon-free manner with unified messaging from the medical teams, and emotional support. These findings add to a limited body of literature which addresses patient perceptions of interactions with health care providers in the face of uncertainty, particularly in a Pacific Islander population. The authors recommend increasing provider training and developing a more structured process to counsel pregnant women facing periviable pregnancy loss to improve the patient experience.

Perceptions Regarding Pediatric and Adolescent Gynecology Training among Obstetrics and Gynecology Residents in Hawai'i.

A pediatric and adolescent gynecology curriculum was implemented for obstetrics/gynecology residents at a single institution in Hawai'i. The primary objective of this study was to evaluate the effectiveness of this pediatric and adolescent gynecology (PAG) formal curriculum in improving knowledge. Twelve residents at the University of Hawai'i completed the curriculum during their second year of training. Of these, 6 residents completed an examination assessing knowledge both before and immediately after the curriculum. Five of these residents completed the examination 1-2 years after completing the curriculum. Average pre-rotation examination scores were 57%, which increased significantly immediately after the curriculum to 87% (P=.003) and remained significantly higher after 1-2 years with average scores of 71% (P=.025). A secondary objective was to assess resident comfort and confidence levels in the subject. All residents who completed the curriculum completed surveys assessing comfort in their pediatric and adolescent gynecology training and both perceived confidence and competence in this area. Despite completing the curriculum, 7 of 12 (58%) did not feel comfortable evaluating pediatric gynecology patients, and 5 of 12 (42%) did not feel prepared nor competent to care for pediatric and adolescent patients. A formal pediatric and adolescent gynecology curriculum increased examination performance, which suggests knowledge retention. However, despite curriculum completion, residents still desired more training in the subject area. Residency programs should consider innovative ways to incorporate inpatient and outpatient educational experiences, periodic testing, and feedback longitudinally throughout residency training to improve long-term retention, confidence, and competence in providing gynecologic care in the pediatric and adolescent gynecology population.

Placentas delivered by pre-pregnant obese women have reduced abundance and diversity in the microbiome.

Maternal pre-pregnancy obesity may have an impact on both maternal and fetal health. We examined the microbiome recovered from placentas in a multi-ethnic maternal pre-pregnant obesity cohort, through an optimized microbiome protocol to enrich low bacterial biomass samples. We found that the microbiomes recovered from the placentas of obese pre-pregnant mothers are less abundant and less diverse when compared to those from mothers of normal pre-pregnancy weight. Microbiome richness also decreases from the maternal side to the fetal side, demonstrating heterogeneity by geolocation within the placenta. In summary, our study shows that the microbiomes recovered from the placentas are associated with pre-pregnancy obesity. IMPORTANCE: Maternal pre-pregnancy obesity may have an impact on both maternal and fetal health. The placenta is an important organ at the interface of the mother and fetus, and supplies nutrients to the fetus. We report that the microbiomes enriched from the placentas of obese pre-pregnant mothers are less abundant and less diverse when compared to those from mothers of normal pre-pregnancy weight. More over, the microbiomes also vary by geolocation within the placenta.

Complications of operative vaginal delivery and provider volume and experience.

OBJECTIVE: To evaluate associations between operative vaginal delivery complications and provider experience (operative vaginal delivery volume and time since residency). METHODS: We included all operative vaginal deliveries between 2008 and 2014 at a tertiary care teaching hospital, stratified into forceps-assisted and vacuum-assisted deliveries. Complications included severe perineal lacerations (3rd and 4th degree) and neonatal injuries (subgaleal/subdural/cerebral hemorrhage, facial nerve injury, and scalp injury), which were identified by International Classification Diagnosis-9 codes. Providers were categorized by operative vaginal delivery volume (mean annual forceps- or vacuum-assisted deliveries over the study interval) and time since residency. Regression analyses were used to compare complication rates by provider volume and time since residency, adjusting for potential confounders, using 0-1 deliveries per year and <5 years since residency as reference groups. RESULTS: Nine hundred and thirty-four forceps and 1074 vacuums occurred. For forceps-assisted deliveries, severe perineal injury was decreased among providers with >10 forceps per year (aOR 0.50 [95%CI 0.30-0.81]) and at 15-19 years (aOR 0.45 [95% CI 0.22-0.94], and ≥25 years (aOR 0.45 [0.27-0.73]) since residency. There were no associations with neonatal injuries. Among vacuum-assisted deliveries, severe perineal injury decreased at ≥25 years since residency (aOR 0.35 [95%CI 0.17-0.74], with no association with provider volume. Neonatal injury decreased at 5-9 years (aOR 0.53 [95%CI 0.30-0.93]), and 15-19 years since residency (aOR 0.53 [95%CI 0.29-0.97]), due to differences in scalp injuries. Neonatal injuries other than scalp injury were rare. CONCLUSION: Severe perineal lacerations decreased with increasing operative vaginal delivery experience, primarily among forceps-assisted vaginal delivery. Providers >5 years since residency may have lower scalp injury with vacuums, but this cohort was largely underpowered for neonatal injury.

Racial/Ethnic Representation in United States and Australian Obstetric Research.

OBJECTIVE: To describe racial/ethnic representation in United States (US) and Australian obstetric research, represented by the Maternal-Fetal Medicine Units Network (MFMU) and Australian Research Centre for Health of Women and Babies (ARCH) trials. METHODS: MFMU studies were identified through PubMed and ARCH studies through their online publication listing from 2011 to 2016. Observational and randomized cohorts and primary and secondary data analyses were included. Studies with race-based enrollment were excluded. Racial/ethnic representation was expressed as the mean racial/ethnic percentages of the studies (i.e.,: studies weighted equally regardless of sample size). Racial/ethnic percentages in MFMU studies were compared to US registered births and ARCH compared to Australian census ancestry data. RESULTS: 38 MFMU studies included 580,282 women. Racial/ethnic representation (% [SD]) included White 41.7 [12.3], Hispanic 28.1 [15.4], Black 26.2 [12.3], Asian 3.6 [2.3], and American Indian/Alaskan Native (AI/AN) 0.2 [0.02]. No studies reported Native Hawaiian/other Pacific Islanders (NHOPI) separately. Comparatively, registered US births (%) were White 75.7, Hispanic 28.1, Black 16.1, Asian/Pacific Islander 7.1, and AI/AN 1.1, which differed from the MFMU (P = 0.02). 20 ARCH studies included 51,873 women. The most reported groups were White 76.5 [17.4], Asian 15.2 [14.8], and Aboriginal/Torres Strait Islander 13.9 [30.5], compared to census numbers of White 88.7, Asian 9.4, and Aboriginal/Torres Strait Islander 2.8 (P < 0.01). Two ARCH studies reported African ethnicity. CONCLUSION: There is racial diversity in studies by MFMU and ARCH, with opportunities to increase enrollment and enhanced reporting of Asian, AI/AN, and NHOPI races in MFMU studies and Black race in ARCH studies.

Prepregnant Obesity of Mothers in a Multiethnic Cohort Is Associated with Cord Blood Metabolomic Changes in Offspring.

Maternal obesity has become a growing global health concern that may predispose the offspring to medical conditions later in life. However, the metabolic link between maternal prepregnant obesity and healthy offspring has not yet been fully elucidated. In this study, we conducted a case-control study using a coupled untargeted and targeted metabolomic approach from the newborn cord blood metabolomes associated with a matched maternal prepregnant obesity cohort of 28 cases and 29 controls. The subjects were recruited from multiethnic populations in Hawaii, including rarely reported Native Hawaiian and other Pacific Islanders (NHPI). We found that maternal obesity was the most important factor contributing to differences in cord blood metabolomics. Using an elastic net regularization-based logistic regression model, we identified 29 metabolites as potential early-life biomarkers manifesting intrauterine effect of maternal obesity, with accuracy as high as 0.947 after adjusting for clinical confounding (maternal and paternal age, ethnicity, parity, and gravidity). We validated the model results in a subsequent set of samples (N = 30) with an accuracy of 0.822. Among the metabolites, six metabolites (galactonic acid, butenylcarnitine, 2-hydroxy-3-methylbutyric acid, phosphatidylcholine diacyl C40:3, 1,5-anhydrosorbitol, and phosphatidylcholine acyl-alkyl 40:3) were individually and significantly different between the maternal obese and normal-weight groups. Interestingly, hydroxy-3-methylbutyric acid showed significantly higher levels in cord blood from the NHPI group compared to that from Asian and Caucasian groups. In summary, significant associations were observed between maternal prepregnant obesity and offspring metabolomic alternation at birth, revealing the intergenerational impact of maternal obesity.

The Effect of a Targeted Educational Activity on Obstetrics and Gynecology Resident In-Training Examination Scores.

The objective of this study was to compare the examination scores before and after implementation of a study program based on high yield topics on the Council of Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination. This prospective cohort study compared scores from academic years 2012 to 2014 of University of Hawai'i obstetrics and gynecology residents who participated in a directed study program based on selected high yield topics from the CREOG Test Item Summary Booklet. Topics were considered high yield if more than 75% of the program residents answered the topic questions incorrectly during the immediately preceding CREOG In-Training Examination administration. Residents were assigned topics to research and present at monthly teaching sessions. The presentations were made accessible in a wiki website. The intervention was initiated in 2012 and discontinued in 2013. The primary outcome was the difference among CREOG In-Training Examination scores before the study program, during the study program, and after the study program was discontinued. Only scores of residents who sat for all three exams were included. Eleven residents were present during the duration of the study period and sat for all three CREOG examinations. During the year of the educational activity, paired individual resident CREOG exams scores increased significantly from the 2012 CREOG administration (mean = 194.7) to the 2013 CREOG administration (mean = 208.2). These findings demonstrate that the CREOG Test Item Summary Booklet and the wiki platform can be used to effectively direct educational efforts resulting in improvements in CREOG examination performance.

Risk factor for first-incident hip fracture in Taiwanese postmenopausal women.

OBJECTIVE: The variation in hip fracture risk between countries is greater than 10-fold. The present study aimed at identifying risk factors that resulted in the first occurrence of hip fracture in Taiwanese postmenopausal women. MATERIALS AND METHODS: A case-control study with a patient group of 50 postmenopausal women, who were admitted to Keelung Chang Gung Hospital, Keelung, Taiwan due to the first incident of accidental hip fracture, was used to examine potential risk factors, including bone mass. Fifty women without hip fracture, selected from those undergoing general health evaluation at the Gynecology Outpatient Clinic at Keelung Chang Gung Hospital, were used as the control group and were matched to the case patients according to age. Evaluation consisted of a questionnaire, interview to document risk factors, physical examination (to record body height and body weight), and examination [dual-energy X-ray absorptiometry used to measure bone mineral density (BMD) of the hip and spine]. RESULTS: The average age of participants of both groups was 79.6 years. Lower level of education, younger age at menopause, increased body height, weight-bearing exercise less than three times per week, and lower BMD were associated with first-incident hip fracture. Total hip BMD was a stronger predictor than the BMD of different sites. Participants in the control group had a significantly higher prevalence of chronic diseases and a history of cataracts or glaucoma compared with those in the patient group. CONCLUSION: While total hip BMD is the strongest predictor of hip fracture, increasing awareness of osteoporosis prevention by educating people about good lifestyle habits and how to maintain BMD is prioritized for preventing the first-incident hip fracture in Taiwanese women.

Impact of low concentrations of phthalates on the effects of 17ß-estradiol in MCF-7 breast cancer cells.

OBJECTIVE: To explore whether lower concentrations of phthalates interfere with the effects of 17ß-estradiol on the growth of MCF-7 breast cancer cells. MATERIALS AND METHODS: MCF-7 cells were treated with 17ß-estradiol (E2), phthalates, including butyl benzyl phthalate (BBP), di(n-butyl) phthalate (DBP), and di(20ethylhexyl) phthalate (DEHP), or with both E2 and phthalates, all at 10nM. After incubation for 48 hours, the cells were harvested and extracted for MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. The proteins involving proliferative and apoptotic pathway were then evaluated using Western blot analysis. RESULTS: In MCF-7 cell cultures, the MTT assay revealed a significant increase in cell viability with E2 and these three phthalates, and significantly more cell proliferation with the combination of E2 and phthalates. Proliferating cell nuclear antigen, as well as phosphatidylinositide 3-kinase (PI3K) and p-Akt, were all substantially increased in cultures with E2, phthalates, and the two combined. An additive effect of phthalates on the obvious increase of Bcl-2 and ER α expression was also noted in the presence of E2. CONCLUSION: The present study demonstrates that even at a very low concentration, BBP, DBP, and DEHP were not only still capable of displaying estrogenic activity, but also of inducing an additive proliferative effect through the PI3K/Akt signaling pathway and preventing apoptosis in the presence of E2. Therefore, the effects of current reference doses for phthalates defined by the government, especially for premenopausal women, should be further considered.