Integrating Public and Population Health Into Medical Education Curricula: Opportunities and Challenges for Reform.

ABSTRACT: In a review of U.S. medical education curricular guidance, from premedical studies through to continuing medical education, Maeshiro and colleagues found limited examples of public and population health topics. In this Commentary, the authors emphasize the importance of including public and population health in the curriculum, pointing to curricular reform efforts to integrate these topics into teaching of basic sciences and clinical studies. In addition, they consider the expectations placed on physicians to meet the needs of the population and argue that policies that support public health funding, infrastructure, and workers are also critical to improving the health of communities.

Institute of Medicine Guidelines for Appropiate Pregnancy Weight Gain for Obese Women May Be Too High.

OBJECTIVE: To investigate how the 2009 Institute of Medicine (IOM) guidelines for pregnancy weight gain for obese women relate to the longer-term outcome of childhood obesity. STUDY DESIGN: Maternal, neonatal, soioeconomic, and nutritional histories were collected for mothers with children age 2-5 years old. Women in each body mass index (BMI) category were categorized based on under, appropriate (AG), and over weight gain per IOM guidelines and compared with rates of childhood obesity in each category. RESULTS: A total of 502 mother-child pairs were enrolled; 36.4% of women were obese at the start of pregnancy. Obese women who were AG by IOM guidelines were more likely than underweight, normal weight, and overweight women to have obese offspring (29.5% vs. 14.2%, p = 0.04). The BMI percentiles of the offspring of obese AG women were 10 percentile points higher than the 55th percentile of the other groups. CONCLUSION: The 2009 IOM pregnancy weight gain guidelines for obese women may still be too high when considering longer-term outcomes such as childhood obesity. Further studies are needed.

Shoulder dystocia: risk factors, predictability, and preventability.

Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16-48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common. The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.

Large for gestational age and long-term cognitive function.

OBJECTIVE: As we have previously published, small-for-gestational-age (<3% birthweight [BW]) newborns exhibit catch-up cognitive functioning by age 2 years. Our objective was to compare cognitive functioning in children born with ≥90% vs 5-89% BW for gestational age (WGA) between 9 months and kindergarten. STUDY DESIGN: Nonanomalous singletons from Early Childhood Longitudinal Study-Birth Cohort with BW ≥90% vs 5-89% were compared. Cognitive and academic functioning was measured at 4 time points: 9 months, and 2, 3.5, and 5.5 years. Associations between WGA and cognitive functioning at each time point was examined using confounder-adjusted general linear model-based methods. RESULTS: Of 2930 cases, 271 (9.2%) were ≥90% WGA. In terms of cognitive performance, children ≥90% WGA were not statistically different (P = .068) from normal WGA at any time point, nor did they change at different rates across early childhood. CONCLUSION: There is no difference in cognitive function in children with BW 5-89% vs ≥90% for GA.

Is maternal diabetes a risk factor for childhood obesity?

OBJECTIVE: Our objective is to determine if there is a relationship between diabetes during pregnancy and childhood obesity, in our inner-city, African-American population. METHODS: Pertinent child, neonatal and maternal pregnancy and delivery data were collected from mothers of children age 2-5 years old. Outcome variable definition was based on children's body mass index (BMI) subgroups; independent variable definition on birthweight subgroups based on customized growth percentiles. Covariates included pre and postnatal factors. Those covariates marginally related to diabetes (p < 0.2) by bivariate analyses, were allowed to compete in logistic regression, with p < 0.05 significant. RESULTS: Four hundred and ninety-three patients were enrolled, of which 35 (7.1%) had diabetes during pregnancy. Children of diabetic mothers were more likely to be obese at age 2-5 years than those of non-diabetics (p = 0.004). Five of 20 covariates had p < 0.2 in bivariate setting. Following stepwise logistic regression, diabetes and maternal prepregnancy BMI were significant determinants of childhood obesity. When large-for-gestational age (LGA) was added into the model, diabetes was no longer significant (p = 0.105); only LGA (p = 0.008) and maternal prepregnancy BMI (p = 0.032) were significantly associated with childhood obesity. CONCLUSIONS: In our inner-city, primarily African-American population, diabetes in pregnancy is significantly related to childhood obesity at age 2-5 years. Well-controlled diabetes during pregnancy that avoids macrosomia may lead to prevention of future childhood obesity as well.

Neonatal brachial plexus injury: obstetrical factors and neonatal management.

Neonatal brachial plexus injury (BPI) is a birth outcome characterized by injury to the brachial plexus identified after delivery. Though uncommon, its potential occurrence following delivery is concerning for both the delivering clinician as well as the pediatric team. Considerable research looking at delivery factors, including forces applied at the time of delivery and management of the BPI after it has occurred, has led to a better understanding, if not a lower rate, of BPI. This information is reviewed below.

Being too large for gestational age precedes childhood obesity in African Americans.

OBJECTIVE: The purpose of this study was to investigate the association between large-for-gestational-age (LGA) infants and the development of childhood obesity in an inner-city primarily African American population. STUDY DESIGN: Maternal, neonatal, socioeconomic, and nutritional histories were collected for mothers with children who were 2-5 years old. Associations between Alexander and customized birthweight percentiles and body mass index for the age of the child were examined. RESULTS: One hundred ninety-five mother-child pairs were enrolled; the childhood obesity rate was 18%. Increasing Alexander and customized birthweight percentiles were related to increasing obesity. LGA newborn infants were 2.5 times more likely to be obese in childhood than average size newborn infants. Maternal smoking was also associated with childhood obesity. CONCLUSION: LGA infants have the highest likelihood of childhood obesity in this inner-city predominantly African American population. Customized growth percentiles perform best in the identification of the highest risk population.

Nutrition and pregnancy.

The importance of nutrition during pregnancy with regard to pregnancy outcome has long been acknowledged. This importance has only been further emphasized by the recent changes in food quality and availability, lifestyle changes, and a new understanding of fetal programming on adult outcomes. The impact of the recent obesity epidemic has had a profound effect on the field of medicine, and nowhere may that impact be more critical than the field of obstetrics. We are only beginning to understand how maternal obesity may impact not only immediate pregnancy outcomes, but also life and health course of the offspring. The financial and societal costs will likely be enormous. Much research is needed to understand how these problems can be ameliorated.

Shoulder dystocia and the next delivery: outcomes and management.

OBJECTIVE: To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia. STUDY DESIGN: We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described. RESULTS: Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048). CONCLUSION: In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high--approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.

The levels of leptin, adiponectin, and resistin in normal weight, overweight, and obese pregnant women with and without preeclampsia.

OBJECTIVE: The purpose of this study was to compare adipokines' levels between women with and without preeclampsia based on maternal body mass index (BMI). STUDY DESIGN: This was a cross-sectional study among third-trimester pregnancies with preeclampsia (PIH) compared with normotensive controls. Serum levels of adiponectin, leptin, and resistin were measured before delivery by radioimmunoassay or enzyme-linked immunosorbent assay (ELISA). RESULTS: The study included 22 normotensive and 77 PIH women. Leptin levels increased with maternal BMI. In patients with severe preeclampsia, overweight, and obese women had increased leptin levels (33.4 +/- 14.8 vs 23.0 +/- 10.8 ng/mL respectively, P = .02), and decreased adiponectin levels (8.4 +/- 5.3 vs 12.6 +/- 6.0 ng/mL, P = .03) compared with normal weight women. In women with BMI <25 kg/m2, adiponectin levels increased in patients with preeclampsia compared with controls (11.5 +/- 5.6 vs 9.6 +/- 4.6 and 7.0 +/- 3.2 ng/mL, respectively, P = .005). There was no association between resistin levels and preeclampsia or maternal BMI. CONCLUSION: Women with severe preeclampsia and BMI > or = 25 kg/m2 have decreased adiponectin and increased leptin levels, while normal weight women with preeclampsia have increased adiponectin levels.

Accuracy of estimated fetal weight in shoulder dystocia and neonatal birth injury.

OBJECTIVE: This study was undertaken to determine whether there is any difference in the rate of error of estimated fetal weight (EFW) in cases of shoulder dystocia compared with controls. STUDY DESIGN: Women whose delivery was complicated by shoulder dystocia were studied and compared with a control group matched for parity, race, labor type (spontaneous or induced), and birth weight (BW). Accuracy (%) was defined as [(EFW-BW)/BW] x 100. The primary outcome of the study was rate of EFW underestimation error 20% or greater. RESULTS: During the 5-year study period, there were 206 cases of shoulder dystocia that met all study criteria. There was no difference in the number of patients that had EFW underestimation error 20% or greater (shoulder dystocia 9.8% vs control 12.8%; P = .38). There was also no difference in the number of patients that had EFW underestimation error 20% or greater between shoulder dystocia with and without injury (injury 8.3% vs no injury 7.1%; P = .79). CONCLUSION: EFW underestimation error in cases of shoulder dystocia is an infrequent event and does not occur more often than in deliveries without shoulder dystocia.

Is abnormal labor associated with shoulder dystocia in nulliparous women?

OBJECTIVE: This study was undertaken to examine the relationship between labor abnormalities and shoulder dystocia in nulliparous women. STUDY DESIGN: Nulliparous women whose delivery was complicated by shoulder dystocia were studied and compared with a control group selected based on the best possible match for race, labor type (spontaneous or induced), and birth weight. The duration of first and second stage of labor, as well as the rates of labor progress, were calculated and compared between groups. RESULTS: During this 4-year study period, there were 8010 nulliparous singleton deliveries of which 65 (0.8%) were complicated by shoulder dystocia. Compared with controls, there was no difference in the rate of cervical dilation in the active phase of the first stage of labor. In the shoulder dystocia group, more patients had a second stage of labor greater than 2 hours (22% vs 3%; P <.05) and had operative vaginal deliveries (26% vs 1.5%; P <.001). In shoulder dystocia cases with birth weight greater than 4000 g, 33% had a second stage of labor greater than 2 hours. CONCLUSION: In our population, the combination of fetal macrosomia, second stage of labor longer than 2 hours and the use of operative vaginal delivery were associated with shoulder dystocia in nulliparous women.

Interdelivery interval and uterine rupture.

OBJECTIVE: The purpose of this study was to measure the impact of the interdelivery interval on uterine rupture during subsequent delivery. STUDY DESIGN: An observational cohort study was performed to assess the rate of uterine rupture in women with a previous low transverse cesarean delivery and no previous vaginal delivery who undergo a trial of labor from 1988 to 2000 in a tertiary care center. The rate of uterine rupture was measured for each of the following interdelivery intervals: 36 months of gestation. Multivariate logistic regression analysis was used to adjust for selected confounding variables. RESULTS: Of the 1527 women who met the study criteria, the rate of uterine rupture was 4.8% for patients with an interdelivery interval of 36 months of gestation (P =.04). After adjustment for the confounding variables, the odds ratio for uterine rupture in women with an interdelivery interval of 24 months of gestation.