Efficacy of the NICHD vaginal birth after cesarean delivery calculator: a single center experience.

Objective: As the cesarean delivery rate has risen future pregnancy outcomes are impacted including the decision to undergo a repeat cesarean or a vaginal birth after cesarean (VBAC) in the subsequent pregnancy. A calculator was developed by the maternal fetal medicine units (MFMUs) network in 2007 to estimate the chance of successful VBAC and is used widely. The purpose of this study was to investigate the calculator's validity on our obstetric patient population.Study design: This was a retrospective study of patients attempting a VBAC delivery at a single center from January 2012 to June 2014. Chances for success were estimated using the MFMU network VBAC calculator in 201 evaluable patients. We then compared the calculator's results with the outcomes observed. In order to determine if the MFMU VBAC calculator was accurately predicting successful vaginal deliveries, we discretized our dataset by binning into MFMU score deciles. Each decile was then tested for significant deviations from the predicted success rate using an exact binomial test. Significance was determined at 0.05 levels.Results: Two hundred and one patients were included. Our results demonstrated higher actual VBAC success than anticipated by using the MFMU network calculator for patients with scores in the 40-80% decile range. When stratified by race, we found the calculator to be a better predictor of success in African-American patients, as the calculator appears to underestimate success in white and Hispanic patients.Conclusion: Calculators are helpful to facilitate patient counseling and shared decision-making regarding the patient's choice for VBAC. When providing such counseling, the potential for reduced predicted VBAC success in the mid-decile range with the MFMU calculator should be recognized.

A difficult situation - balancing critical anticoagulation versus the risk of permanent neurologic deficit: a case report.

BACKGROUND: Anticoagulation is the mainstay of treatment for pulmonary embolism. However, if bleeding unfortunately occurs, the risks and benefits of anticoagulation present a challenge. Management of one hemorrhagic complication, retroperitoneal hematoma, is rare, difficult, and controversial. CASE PRESENTATION: A 73-year-old white man presented with left lower extremity swelling and dyspnea. He was tachycardic, hypertensive, and demonstrated poor oxygen saturation of 81% on ambient air. A computed tomography angiogram revealed a saddle pulmonary embolus. Tissue plasminogen activator was administered and he was started on a heparin infusion. He was eventually transitioned to enoxaparin. On the day of discharge, however, he had sudden onset of right leg numbness and weakness below his hip. A computed tomography of his head was not concerning for stroke, and neurology was consulted. Neurology was concerned for spinal cord infarction versus hematoma and recommended magnetic resonance imaging of his thoracic and lumbar spine. The magnetic resonance imaging revealed a left psoas hematoma. A computed tomography scan of his pelvis also showed a right psoas and iliacus hematoma. He was transitioned to a low intensity heparin infusion. The following day his left leg exhibited similar symptoms. There was concern of progressive and irreversible nerve damage due to compression if the hematomas were not drained. Interventional radiology was consulted for drainage. The heparin infusion was paused, drainage was performed, and the heparin infusion was reinitiated 6 hours following the procedure by interventional radiology. His blood counts and neurologic examination stabilized and eventually improved. He was discharged home on a novel anticoagulant. CONCLUSIONS: Management of a retroperitoneal hematoma can commence with recognition of the warning signs of bleeding and neurological impairment, and consulting the appropriate services in case the need for intervention arises. A conservative approach of volume resuscitation and blood transfusion can be used initially, with the need for pausing or reversing anticoagulation being assessed on an individual basis with expert consultation. If intervention becomes necessary, other interventional radiology-based modalities can be used to identify and stop the bleeding source, and interventional radiology-guided drainage can be performed to decrease the hematoma burden and relieve neurological symptoms.

Obesity and reproduction: a study to determine how effectively medical education enhances awareness of the reproductive risks related to obesity.

OBJECTIVE: To explore awareness of the reproductive versus the medical risks of obesity in a medical and non-medical college educated population. METHODS: An exploratory prospective research design was used. A 26-question online survey was developed and offered to a sample of medical students/residents (n=325) and non-medical college students (n=102). The data were analyzed using Graph Pad software. RESULTS: 102 non-medical undergraduate students (28% male and 72% female) and 325 resident physicians and medical students (46% male, 47% female, 7% unspecified) responded. Both groups reported higher awareness of the general risks of obesity as compared to the reproductive risks. As expected, lay students reported less awareness of female reproductive issues as compared to the medical group (all p-values <0.01). Over 90% of respondents would be motivated to lose weight before pregnancy if they knew of these risks, with more than half planning to have children in the future. CONCLUSION: This exploratory study found that despite having at least a college education, the populations studied had relatively low levels of awareness of obesity-related reproductive risks. The medical population had much more knowledge about the other health risks of obesity. The survey provided initial data that might be used to consider knowledge gaps and strategies for engaging and educating medical trainees and the public about the reproductive risks of obesity.