Structural Racism and Adverse Pregnancy Outcomes Through the Lens of the Maternal Microbiome.

Microbiome science offers a glimpse into personalized medicine by characterizing health and disease states according to an individual's microbial signatures. Without a critical examination of the use of race as a variable, microbiome studies may be susceptible to the same pitfalls as other areas of science grounded in racist biology. We will examine the use of race as a biological variable in pregnancy-related microbiome research. Emerging data from studies that investigate the intestinal microbiome in pregnancy suggest strong influence of a poor diet on adverse pregnancy outcomes. Differences in the vaginal microbiome implicated in adverse pregnancy outcomes are frequently attributed to race. We review evidence that links systemic racism to pregnancy health outcome differences with a focus on the vaginal and intestinal microbiomes as well as diet. We also review how structural racism ultimately contributes to inequitable access to healthy food and higher risk environmental exposures among pregnant people of lower socioeconomic status and exacerbates common pregnancy comorbidities.

Severely Restricting Abortion Threatens Equitable Health Outcomes for People With Human Immunodeficiency Virus.

Equitable access to abortion is a critical component of reproductive care. Women with human immunodeficiency virus (HIV) in the United States are disproportionately Black and will be disproportionately affected by abortion bans following the Supreme Court's decision to overturn Roe v Wade. We argue that this decision is directly in conflict with the National HIV/AIDS Strategies and Centers for Disease Control and Prevention's goals to eliminate perinatal HIV transmission.

Postpartum hemorrhage: Moving from response to prevention for Alaska Native mothers.

OBJECTIVE: To identify risk factors for postpartum hemorrhage in a population of Alaska Native women. METHODS: A case-control study of 384 women (128 cases, 256 controls) delivering between August 1, 2018, and July 31, 2019, was conducted at a Level III maternal referral center for Alaska Native women in Alaska. Risk factors were assessed via retrospective chart review, and bivariate and conditional regression analyses were conducted to determine odds ratios (ORs) between women with and without postpartum hemorrhage. RESULTS: Body mass index ≥40 (OR 2.6, 95% confidence interval [CI] 1.4-4.5), antepartum bleeding (OR 6.3, 95% CI 1.2-31.6), previous postpartum hemorrhage (OR 5, 95% CI 2.6-9.8), suspected macrosomia (OR 2.7, 95% CI 1.4-5.3), macrosomia with birthweight ≥4000 g (OR 3.1, 95% CI 1.8-5.3), pre-eclampsia with magnesium sulfate (OR 4.0, 95% CI 2.0-8.0), length of third stage of labor >20 min (OR 2.2, 95% CI 1.1-4.4), oxytocin use >12 h (OR 5.4, 95% CI 2.0-14.6), residence in a rural community (OR 2.2, 95% CI 1.4-3.6), and vitamin D supplementation (OR 1.7, 95% CI 1.1-2.6) were associated with greater risk of postpartum hemorrhage. CONCLUSION: Analysis of clinical and geographic risk factors for postpartum hemorrhage in Alaska Native women identified important targets for prevention.

911 EMS Activations by Pregnant Patients in Maryland (USA) during the COVID-19 Pandemic.

INTRODUCTION: In the early phase of the coronavirus disease 2019 (COVID-19) pandemic, United States Emergency Medical Services (EMS) experienced a decrease in calls, and at the same time, an increase in out-of-hospital deaths. This finding led to a concern for the implications of potential delays in care for the obstetric population. HYPOTHESIS/PROBLEM: This study examines the impact of the pandemic on prehospital care amongst pregnant women. METHODS: A retrospective observational study was conducted comparing obstetric-related EMS activations in Maryland (USA) during the pandemic (March 10-July 20, 2020) to a pre-pandemic period (March 10-July 20, 2019). Comparative analysis was used to analyze the difference in frequency and acuity of calls between the two periods. RESULTS: There were fewer obstetric-related EMS encounters during the pandemic compared to the year prior (daily average during the pandemic 12.5 [SD = 3.8] versus 14.6 [SD = 4.1] pre-pandemic; P <.001), although the percent of total female encounters remained unchanged (1.6% in 2020 versus 1.5% in 2019; P = .091). Key indicators of maternal status were not significantly different between the two periods. African-American women represented a disproportionately high percentage of obstetric-related activations (36.2% in 2019 and 34.8% in 2020). CONCLUSIONS: In this state-wide analysis of EMS calls in Maryland early in the pandemic, no significant differences existed in the utilization of EMS by pregnant women. Prehospital EMS activations amongst pregnant women in Maryland only decreased slightly without an increase in acuity. Of note, over-representation by African-American women compared to population statistics raises concern for broader systemic differences in access to obstetric care.

Evidence-based protocol decreases time to vaginal delivery in elective inductions.

BACKGROUND: Labor induction accounts for over 1 in 5 births in the United States. There is large variability in practices of induction of labor. Standardizing aspects of induction of labor has been shown to have beneficial maternal and fetal effects. OBJECTIVE: This study aimed to investigate the impact of the implementation of an evidence-based labor induction protocol on maternal and neonatal outcomes. STUDY DESIGN: In February 2018, a contemporary labor induction protocol composed of standardized cervical ripening and early amniotomy was implemented in the labor and delivery unit at a large academic center along with comprehensive training of staff. Maternal and fetal outcomes were compared between patients undergoing induction over a 9 month period following the implementation of the protocol and those undergoing induction 9 months earlier, excluding a 2 week washout period while training occurred. RESULTS: We studied 887 patients who underwent induction of labor of a live singleton at >24 weeks' gestation during our study period (387 patients before the implementation of the protocol and 500 patients after the implementation of the protocol). Baseline characteristics of maternal age, previous vaginal deliveries, and birthweight were similar in patients before and after the implementation of the protocol. There was a significant increase in the number of elective inductions occurring after the implementation of the protocol. There was a significant decrease in time from start of induction to rupture of membranes in all women under the protocol (13.3 hours before the implementation of the protocol vs 10.4 hours after the implementation of the protocol; P≤.001) and decrease in time from start of induction to delivery (21.2 hours before the implementation of the protocol vs 19.7 hours after the implementation of the protocol; P=.04). When the analysis was stratified by elective and nonelective inductions of labor, we found that time from induction of labor initiation to vaginal delivery was shortened after the implementation of the protocol for those undergoing elective induction (18.5 hours vs 14.6 hours; P=.03). There was no difference in cesarean delivery rate (P=.7), chorioamnionitis (P=.3), postpartum hemorrhage (P=.7), or newborn intensive care unit admission (P=.3). CONCLUSION: The implementation of an evidence-based labor induction protocol was associated with decreased time to delivery, primarily driven by decreased time to vaginal delivery among those undergoing elective inductions of labor, without compromise of maternal or neonatal outcomes.

An Undergraduate Surgery Interest Group: Introducing Premedical Students to the Practice of Surgery.

PURPOSE: Early exposure and surgical mentorship can augment interest in surgery. We evaluate the effect and feasibility of offering education and mentorship opportunities in surgery to premedical students at our institution through an undergraduate surgery interest group (USIG). MATERIALS AND METHODS: We conducted a 1-year assessment of our USIG and reviewed its organizational structure, funding resources, media promotion, and educational activities. Our USIG hosted introductory-level surgical skills workshops, guest lectures by surgeons, and various facility tours. To assess participants' interests, as well as the influences on them to pursue a surgical profession, we analyzed pre- and post-event questionnaires. Similar questionnaires were completed by medical students in our medical student surgery interest group to compare any differences in perception between premedical and medical students. RESULTS: Our USIG currently has 378 undergraduate student members, with a higher proportion of women than in our medical student surgery interest group (P < 0.003). Neurosurgery was the most popular career choice among undergraduate participants. Participants reported the highest satisfaction with suturing and high-fidelity trauma surgery skills workshops. Undergraduate participants indicated that their intrinsic interest in the sciences is the highest motivation to pursue a surgical profession. Resident lifestyle and social obligations of a surgical career were actually positive influences for undergraduate participants; in contrast, medical students viewed those variables as negative factors. CONCLUSION: Our USIG was met with enthusiasm by premedical students and faculty alike. Participation strengthened premedical students' interest in pursuing surgery and increased their understanding of the surgical profession. Early mentorship may positively influence premedical students' perception of surgical careers. USIG is economically feasible and time-efficient; we encourage other academic institutions and educators to consider investing in similar interest groups.

Wear of different materials for total hip replacement under adverse stop-dwell-start in vitro wear simulation conditions.

Hip simulation is a common technique for pre-clinical evaluation of wear performance of total hip arthroplasty. Standard techniques replicate kinematics of walking patterns of a typical patient. Attention has focussed in developing simulations of other typical patient daily activities to improve accuracy of wear predictions. A method for simulating stop-dwell-start motion during patient walking and the effect on 36-mm metal-on-metal total hip arthroplasty was previously presented by the authors. This study sought to extend the previous work to look at the effect of these conditions on ceramic-on-ceramic, metal-on-polyethylene and ceramic-on-polyethylene bearings. Two stop-dwell-start protocols were used: one reproducing average patient movement patterns and one examining more severe conditions. For all materials tested, no significant increase in wear was observed under average stop-dwell-start conditions, suggesting the bearing types tested are robust to this type of activity. A significant increase in wear was observed for metal-on-metal, metal-on-polyethylene and ceramic-on-polyethylene bearings under severe stop-dwell-start conditions, this was attributed to depletion of lubricant in the bearing during the dwell period. A greater relative increase in wear was observed for metal-on-metal bearings compared with metal-on-polyethylene and ceramic-on-polyethylene bearings. This may be explained by the contributions of the different lubrication mechanisms in each bearing type. Wear of ceramic-on-ceramic was very low in all tests, suggesting normal measurement variation was masking any effect of the adverse conditions. It was not possible to determine any effect of the different activities. These results emphasise the importance of exploring adverse patient activity simulations. The increase in wear rate associated with an adverse activity such as seen in stop-dwell-start motion, has to be considered in the context of the frequency of the adverse activity cycle relative to other activities such as standard continuous walking, to determine the impact on the total wear in a given time period.

Assessment and Improvement Strategies for a Breast Cancer Early Detection Program in Rural South Africa.

Purpose To assess and develop solutions for an ultrasound-based breast cancer early detection program in rural South Africa 1 year after implementation. Methods A WHO-endorsed RAD-AID Radiology Readiness Assessment was used to evaluate clinic resources. In addition, 5 weeks of observation identified resource deficiencies and reviewed existing documentation methods. On the basis of stakeholders' input and the BI-RADS, we developed new documentation systems. Training was followed by a survey that assessed feasibility and provider acceptance. Results Resource limitations included lack of computers, unpredictable electrical supply, and inconsistent Internet. The assessment revealed incomplete documentation of breast clinical examinations and history, breast lesions, and follow-up. Furthermore, limitations negatively affected communication among providers. Three solutions were developed: a paper patient history form, a paper clinical findings form, and a computerized patient-tracking data base compliant with BI-RADS. Three nurses, three nursing assistants, and one counselor completed the survey. Seventy-one percent indicated positive general attitudes, and 100% agreed that the documentation system is easy and useful and improves overall quality of care, follow-up, decision making; access to clinical information; and communication between clinicians and patients. Five of the seven providers reported that the system increased visit time, but three of those five believed that the process was valuable. Conclusion Implementation of a breast cancer early detection program in resource-limited regions is challenging, and continual assessment is essential. As a result of identified needs, we developed a documentation system that was broadly accepted. Future steps should focus on increasing efficiency, evaluation of provider attitudes long term, and clinical effect.