Analytical approaches to evaluating hypertensive disorders of pregnancy.

BACKGROUND: Data from the A Randomized Trial of Induction Versus Expectant Management study suggested that low-risk pregnant patients randomized to expectant management at term had a higher risk for developing hypertensive disorders of pregnancy than pregnant patients randomized to elective induction at 39 weeks. In addition, hypertensive disorders of pregnancy were reported to decrease with advancing gestational age when comparing outcomes by gestational age at delivery. OBJECTIVE: This study aimed to verify these contrasting findings by evaluating the relationship between hypertensive disorders of pregnancy at term and gestational age at delivery. STUDY DESIGN: This was a secondary analysis of a multicenter, prospective cohort study of nulliparous pregnant patients with singleton gestations (from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be). Pregnant patients who delivered ≥37+0 weeks' gestation were included. Patients were excluded if they did not provide consent for data release in subsequent studies or if they had missing outcome data. The primary outcome was hypertensive disorders of pregnancy, defined as gestational hypertension or preeclampsia with or without severe features according to the American College of Obstetricians and Gynecologists guidelines. Descriptive statistics were used to evaluate hypertensive disorders of pregnancy in the following 2 ways: analysis (1), incidence of hypertensive disorders of pregnancy by gestational age week among all ongoing pregnancies and analysis (2), the incidence of hypertensive disorders of pregnancy by gestational age week among deliveries at that gestational age week. It was assumed that hypertensive disorders of pregnancy were not expectantly managed at term. RESULTS: Of the 8011 pregnant patients included in this analysis, 1003 (12.5%) had hypertensive disorders of pregnancy: 162 (24.5%) delivered at 37+0 to 37+6 weeks' gestation, 232 (18%) delivered at 38+0 to 38+6 weeks, 310 (12.1%) delivered at 39+0 to 39+6 weeks, 207 (8.7%) delivered at 40+0 to 40+6 weeks, and 92 (8.1%) delivered at ≥41+0 weeks. In analysis 1, the incidence of hypertensive disorders of pregnancy increased with advancing gestational age among all ongoing pregnancies with a hypertensive disorder of pregnancy (2.0% at 37 weeks and 8.1% at 41 weeks). In analysis 2, the incidence of hypertensive disorders of pregnancy decreased with advancing gestational age among deliveries at that gestational age week alone (24.5% at 37 weeks and 8.1% at 41 weeks). CONCLUSION: Our results confirm the findings from the A Randomized Trial of Induction Versus Expectant Management study showing that the risk for hypertensive disorders of pregnancy increases with advancing gestational age, but hypertensive disorders of pregnancy is more common among deliveries at earlier gestational ages. These key differences illustrate how important the study design and analytical approach are to accurately interpret results and apply findings clinically.

Antibiotic Timing in Previable Prelabor Rupture of Membranes Less Than 24 Weeks of Gestation.

OBJECTIVE: This study aimed to compare neonatal and maternal outcomes between immediate and delayed prophylactic antibiotic administration after previable prelabor premature rupture of membranes (PROM) less than 24 weeks of gestation. STUDY DESIGN: Retrospective cohort study of singleton pregnancies with PROM between 160/7 and 236/7 weeks of gestational age conducted at a single tertiary care referral center between June 2011 and December 2015. Patients with multiple gestations, fetal anomalies, those who elected augmentation, or with a contradiction to expectant management, such as suspected intra-amniotic infection or stillbirth, were excluded from the study. We compared pregnancy characteristics, maternal complications, and neonatal outcomes between women who received a course of antibiotics within 24 hours of PROM and women who received antibiotics after 24 hours of PROM. The primary outcome was neonatal survival to hospital discharge. Secondary outcomes included gestational age at delivery, time from PROM to delivery, neonatal birth weight, days in the neonatal intensive care unit (NICU), composite adverse neonatal outcomes, and maternal morbidity. RESULTS: Ninety-four women met inclusion criteria, 57 (61%) received antibiotics within 24 hours of PROM and 37 (39%) received antibiotics 24 hours after PROM. Baseline maternal characteristics were similar in both groups. The mean gestational age at PROM was similar between groups at 20.8 ± 2.3 weeks in the immediate antibiotics group and 20.6 ± 2.1 weeks in the delayed antibiotics group (p = 0.48). Compared with delayed antibiotic administration, immediate antibiotic administration was not associated with a significant difference in latency time from PROM to delivery, rate of stillbirth, days in an ICU, or adverse neonatal outcomes. Maternal outcomes also did not differ significantly between groups. Neonatal birth weight was lower in the immediate antibiotics group (p = 0.012). CONCLUSION: Our data suggest that there is no maternal or neonatal benefit to immediate administration of latency antibiotics compared with delayed administration. KEY POINTS: · Adverse neonatal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Maternal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Neonatal birth weight was lower in infants that received immediate antibiotics after previable PROM..

Using Simulation to Define the Learning Curve for the Digital Cervical Examination.

INTRODUCTION: To assess how skill in the digital cervical examination is acquired in medical students. METHODS: In a longitudinal study, medical students completed 200 simulated cervical examinations. We performed regressions of each student's cumulative accuracy using the linear, power, and sigmoidal models to determine best fit. We also constructed multilevel models to determine the influence of dilation and effacement on accuracy and to determine whether the starting level and rate of learning varied between individuals. To assess skill decay, we assessed accuracy at 1, 2, and 5 months after training. We defined the amount of sustained accuracy needed to achieve competence using cumulative summation analyses and determined the amount of practice needed to reach this level of skill. RESULTS: Twenty-five medical students participated. The median (interquartile range) of cumulative accuracy at the end of the study was 69% (65-78) for dilation and 80% (76-91) for effacement. The sigmoidal model had the best fit. All students achieved competence during the study. The multilevel models showed that accuracy decreased with higher dilation and lower effacement and found that starting level and rate of learning varied between individuals. Maximal accuracy in both dilation and effacement was seen after 150 repetitions. Accuracy of the medical students persisted for 1 month for dilation and 2 months for effacement. The average±SD number of repetitions needed to achieve competence was 89±46 (range 35-195) for dilation and 48±38 (range 11-174) for effacement. DISCUSSION: Based on the variability in skill between individuals and the rate of skill acquisition and decay, we feel that a competence-based rather than time-based approach is most appropriate, that trainee performance should be monitored both during and after training, and that 150 repetitions, or more, should be included in any digital cervical examination simulation regimen.

Effectiveness of Vaginal Delivery Simulation in Novice Trainees.

OBJECTIVE: Simulation training has been demonstrated to increase medical student confidence with vaginal deliveries; however, effect on skill performance is still lacking. To determine if integration of simulation training into the OB/GYN clerkship improves performance of vaginal deliveries, we assessed the effectiveness of simulation in third-year medical students. METHODS: During the OB/GYN clerkship, third-year students were assigned to receive vaginal delivery simulation (n=54) or cervical exam simulation (n=56), with each group serving as a simulation naïve control for the other skill. As a final assessment of their skill, students performed a simulated vaginal delivery scored by a blinded observer using a procedural checklist (score 0-30). A satisfactory score was considered 26 or greater. The individual scores and percentage of satisfactory scores were compared between both groups using a Mann-Whitney U test and chi-square test, respectively. RESULTS: Vaginal delivery students had a significantly higher mean score (27 +/- 3.2) and percentage of students achieving a passing score (85%) than the cervical exam students (22 +/- 3.5 and 15%). There were no differences in vaginal delivery performance based on gender, nor was there any difference in the number of real-life deliveries performed between vaginal delivery and cervical exam students. CONCLUSIONS: Even though medical students had an equivalent clinical rotation experience, a short period of simulation training had a marked effect on their end-of-rotation performance. During initial resident or midwife training more than 5 hours of simulation will likely be required to properly prepare 100% of trainees.