Implementing American College of Obstetricians and Gynecologists Outpatient Antepartum Testing Recommendations: Can Your Clinic Handle It?

OBJECTIVE: This study was conducted to determine the difference in the number of pregnancies that would qualify for outpatient fetal testing between our current academic practice and that of the 2021 American College of Obstetricians and Gynecologists (ACOG) antepartum recommendations. STUDY DESIGN: We performed a retrospective study of all pregnancies that delivered and received prenatal care at our institution between January 1, 2019, and May 31, 2021. The timing and amount of outpatient antepartum testing was determined for each patient. Our current antepartum testing guidelines (clinic protocol) were compared with the 2021 ACOG recommendations (ACOG protocol). Statistical analysis was performed with descriptive statistics and z scoring to compare the total amount of antepartum testing utilized with each protocol. RESULTS: A total of 1,335 pregnancies were included in the study. With the ACOG protocol, an additional 310 (23.2%) of pregnancies would qualify for antepartum testing (57.8% with ACOG protocol vs. 34.6% with clinic protocol). Most of the increased testing was due to maternal age with additional risk factors, hypertensive disorders, diabetes, prepregnancy body mass index ≥ 35, and complex fetal anomalies or aneuploidies. Overall, the ACOG protocol would require an additional 570 antepartum tests (z-score = 4.04, p = 0.000005) over the study period, which is equivalent to 19 additional tests per month and 5 per week. Only nine stillbirths occurred during this time, of which two would have had antepartum testing with both protocols, one would have only had testing per ACOG, and two would have had testing individualized per ACOG. CONCLUSION: More pregnancies would require outpatient antenatal testing with adoption of the ACOG protocol. A 23% increase in testing would equate to five additional antepartum tests per week. Although this study cannot assess the clinical impact of additional testing, minimal scheduling resources are needed to accommodate this increase. KEY POINTS: · Most pregnancies have risk factors for stillbirth.. · Most pregnancies qualify for fetal testing per ACOG.. · More resources are needed for this increased testing..

Prevalence and predictors of mother-infant skin-to-skin contact at birth: findings from a U.S. tertiary medical center.

BACKGROUND: Immediate skin-to-skin contact has well-established benefits for both mother and baby. However, its implementation varies widely, with limited data on predictors. OBJECTIVE: This study aimed to investigate prevalence, duration, and maternal and newborn predictors of immediate skin-to-skin contact following vaginal deliveries. STUDY DESIGN: We conducted a retrospective cohort study of vaginal deliveries from May to October 2019 at Albany Medical Center. We abstracted patient demographic and clinical predictor variables from medical records. The primary outcome was prevalence of skin-to-skin contact during the first hour of life, including any and that meeting the World Health Organization standard of care (defined as initiation within 5 minutes lasting for 60 minutes without separation). The secondary outcome was skin-to-skin contact duration in minutes during the first hour of life. Data were analyzed using multivariate logistic and linear regression models as appropriate. RESULTS: Among 635 mother-infant dyads, the prevalence of any skin-to-skin contact was 74% and the prevalence of skin-to-skin contact meeting the World Health Organization standard of care was 43%. Maternal higher education increased odds of any skin-to-skin contact [adjusted odds ratio, 2.34; 95% confidence interval, 1.07, 5.13], while maternal delivery complications were associated with decreased odds [adjusted odds ratio, 0.39; 95% confidence interval, 0.17, 0.91]. Infants with 1-minute Apgar scores of 0-3 were four times less likely to receive any skin-to-skin contact compared with infants with scores of 7-10 [adjusted odds ratio, 0.26; 95% confidence interval, 0.09, 0.75]. Other neonatal factors that decreased odds of skin-to-skin contact were multiple gestation [adjusted odds ratio, 0.06; 95% confidence interval, 0.02, 0.19], preterm delivery [adjusted odds ratio, 0.39; 95% confidence interval, 0.19, 0.78], and neonatal intensive care unit admission [adjusted odds ratio, 0.13; 95% confidence interval, 0.06, 0.29]. All significant neonatal predictors also significantly decreased skin-to-skin contact duration in minutes. CONCLUSION: The practice of immediate skin-to-skin contact after vaginal delivery did not meet the recommended standard. Neonatal complications and lower maternal educational level further reduced prevalence and duration, indicating the need for targeted educational interventions for patients and providers. CONDENSATION: The prevalence and duration of immediate skin-to-skin contact after vaginal delivery are lower than recommended. Staff and patient education could mitigate some barriers.HighlightsSkin-to-skin contact occurs less often and with shorter duration than recommendedNewborn health is a stronger predictor of skin-to-skin contact than maternal healthHigher maternal education increases prevalence of skin-to-skin contact.

A multicenter prospective study of neonatal outcomes at less than 32 weeks associated with indications for maternal admission and delivery.

BACKGROUND: Counseling for patients with impending premature delivery traditionally has been based primarily on the projected gestational age at delivery. There are limited data regarding how the indications for the preterm birth affect the neonatal outcome and whether this issue should be taken into account in decisions regarding management and patient counseling. OBJECTIVE: We performed a prospective study of pregnancies resulting in premature delivery at less than 32 weeks to determine the influence of both the indications for admission and their associated indications for delivery on neonatal mortality and complications of prematurity. STUDY DESIGN: This is a multicenter, prospective study in 10 hospitals where all data from the neonatal intensive care unit routinely was imported to a deidentified data warehouse. Maternal data were collected prospectively at or near the time of delivery. Eligible subjects included singleton deliveries in these hospitals between 23 0/7 and 31 6/7 weeks. The primary hypothesis of the study was to determine whether there was a difference in the primary outcome, which was defined as neonatal composite morbidity, between those neonates delivered after admission for premature labor vs premature rupture of membranes, because these were expected to be the 2 most frequent diagnoses leading to premature birth. The sample size was calculated based on a 10% difference in outcomes for these 2 entities. We based this hypothesis on the knowledge that premature rupture of membranes has a greater incidence of intra-amniotic infection and inflammation than premature labor and that outcomes for premature neonates are worse when delivery is associated with intra-amniotic infection. Additional outcomes were analyzed for all other indications for admission and delivery. Composite morbidity was defined as ≥1 of the following: respiratory distress syndrome (oxygen requirement, clinical diagnosis, and consistent chest radiograph), bronchopulmonary dysplasia (requirement for oxygen support at 28 days of life), severe intraventricular hemorrhage (grades 3 or 4), periventricular leukomalacia, blood culture-proven sepsis present within 72 hours of birth, necrotizing enterocolitis, or neonatal death before discharge from the hospital. A secondary composite of serious neonatal morbidity also was defined prospectively. RESULTS: The study included 1089 mother/baby pairs. Composite morbidity between those with premature labor (77.2%) and premature rupture of membranes (73.2%) was not significantly different (P = .29). A few neonatal complications were associated with indications for admission and delivery, but on logistic regression adjusting for gestational age and other confounders, suspected intrauterine growth restriction was the only indication for admission or delivery associated with an increase in serious morbidity (odds ratio 4.5, [2.1 to 9.8], P < .003). Other factors not related to the indications for admission including cesarean delivery, and low 5-minute Apgar were associated with an increase in morbidity. CONCLUSION: Studies of many single factors related to the indications for preterm delivery have been shown to be associated with adverse neonatal outcome. In this study evaluating all of the most frequent indications, however, we found only suspected intrauterine growth restriction as an indication for admission and delivery was found to be so. Thus, it seems that in almost all situations counseling patients can be based primarily on gestational age along with other factors including estimated fetal weight, sex, race, plurality, and completion of a course of antenatal corticosteroids.

Development of an Automated Column Solid-Phase Extraction Cleanup of QuEChERS Extracts, Using a Zirconia-Based Sorbent, for Pesticide Residue Analyses by LC-MS/MS.

A new, automated, high-throughput, mini-column solid-phase extraction (c-SPE) cleanup method for QuEChERS extracts was developed, using a robotic X-Y-Z instrument autosampler, for analysis of pesticide residues in fruits and vegetables by LC-MS/MS. Removal of avocado matrix and recoveries of 263 pesticides and metabolites were studied, using various stationary phase mixtures, including zirconia-based sorbents, and elution with acetonitrile. These experiments allowed selection of a sorbent mixture consisting of zirconia, C18, and carbon-coated silica, that effectively retained avocado matrix but also retained 53 pesticides with <70% recoveries. Addition of MeOH to the elution solvent improved pesticide recoveries from zirconia, as did citrate ions in CEN QuEChERS extracts. Finally, formate buffer in acetonitrile/MeOH (1:1) was required to give >70% recoveries of all 263 pesticides. Analysis of avocado extracts by LC-Q-Orbitrap-MS showed that the method developed was removing >90% of di- and triacylglycerols. The method was validated for 269 pesticides (including homologues and metabolites) in avocado and citrus. Spike recoveries were within 70-120% and 20% RSD for 243 of these analytes in avocado and 254 in citrus, when calibrated against solvent-only standards, indicating effective matrix removal and minimal electrospray ionization suppression.

A comparison of reasons for choosing obstetrician/gynecologist subspecialty training.

Recently, applications for subspecialty fellowship positions in obstetrics and gynecology have increased dramatically. A survey completed by fellows in Maternal-Fetal Medicine (MFM), Reproductive Endocrinology (REI), Gynecologic Oncology (Gyn Onc), and Urogynecology (Urogyn) training programs in the United States between January and March 2006 was aimed at determining why this trend was occuring. Of 449 fellows in 2006, 192 (42.8%) responded. The two most influential factors in all four subspecialties were interest and lifestyle (P < .001). Although these factors were similar throughout all subspecialties, variations exist in how fellows rated each factor by subspecialty. An overwhelming majority (99%) of fellows were either "very satisfied" or "satisfied" with their decisions to pursue fellowship training. The majority of fellows believe that when compared to a generalist Obstetrician/Gynecologist (OB/GYN) they will have a reduced workload, decreased liability, and a higher salary. The recent increase in the number of fellowship applicants is most likely due to a complex interplay of multiple factors.

Isolation of three diterpenoid acids from sunflowers, as oviposition stimulants for the banded sunflower moth, Cochylis hospes.

The banded sunflower moth (BSFM), Cochylis hospes Walshingham (Lepidoptera: Cochylidae) is a specialist insect, the larvae of which feed on sunflowers, Helianthus spp., and a few other species of Compositae. It is one of the most important pests of sunflower in the USA. Previous work on H. annuus, the cultivated sunflower, revealed two diterpenoids that function as oviposition stimulants for female BSFM, and that other, more polar compounds also stimulated oviposition. Using a bioassay-guided approach, we isolated three additional diterpenoids, grandifloric acid (1), 15beta-hydroxy-ent-trachyloban-19-oic acid (2), and 17-hydroxy-16alpha-ent-kauran-19-oic acid (3), from polar fractions of pre-bloom sunflower head extracts. In laboratory bioassays, purified natural samples of each of these compounds stimulated oviposition by female BSFM. Structure-activity relationships of the five diterpenoids known to stimulate oviposition by female BSFM are discussed.

The relationship between utilization of prenatal care and Down syndrome live births.

OBJECTIVE: This study evaluated whether utilization of prenatal care, as measured by the Kessner index, affects the number of Down syndrome live births. METHODS: A retrospective analysis of birth certificate data of Down syndrome live births comparing 1989 to 2001 by year, maternal age, gestational age at first prenatal visit, and adequacy of prenatal care according to Kessner categories of adequacy of prenatal care. RESULTS: Down syndrome live births were inversely correlated with adequacy of prenatal care. Reductions in Down syndrome live births were seen in all categories of prenatal care in all age groups. In 2001 a minimum 30% reduction was seen in any category rising to a 58% reduction in women > or =35 years with adequate prenatal care. The largest reductions were seen in women > or =35 years of age. CONCLUSIONS: Reductions in Down syndrome live births occurred in all age groups between 1989 and 2001. Utilization of prenatal care as measured by the Kessner index was associated with reductions in Down syndrome live births, with a greater reduction in women > or =35 years of age.

Isolation of the diterpenoids, ent-kauran-16alpha-ol and ent-atisan-16alpha-ol, from sunflowers, as oviposition stimulants for the banded sunflower moth, Cochylis hospes.

Two diterpenoid alcohols, ent-kauran-16alpha-ol (1) and ent-atisan-16alpha-ol (2), were isolated from pre bloom (R3-R4 stage) sunflower heads as oviposition stimulants for the banded sunflower moth, Cochylis hospes. Fractionation of a sunflower head extract, by normal-phase flash column chromatography, resulted in an early eluting fraction exhibiting significant activity in an egg-laying bioassay. Compounds 1 and 2, along with ent-trachyloban-19-oic acid (3) and ent-kaur-16-en-19-oic acid (4), were isolated as the major components of this fraction and identified by their NMR and mass spectra. The purified compounds were individually tested for ovipositional activity in dose-response bioassays. In these bioassays, compounds 1 and 2 gave linear dose responses, with increasing numbers of eggs laid as the dosage of either increased. Compounds 3 and 4 failed to stimulate significant egglaying at any of the dosages tested. A factorial design bioassay, using compounds 1 and 2, showed that 1 was relatively more stimulatory than 2, and that there was no synergistic effect on oviposition when the two compounds were combined.

Vittatalactone, a beta-lactone from the striped cucumber beetle, Acalymma vittatum.

A novel beta-lactone, vittatalactone (1), was isolated from collections of airborne volatile compounds from feeding male striped cucumber beetles, Acalymma vittatum. The structure of 1 was determined to be (3R,4R)-3-methyl-4-(1,3,5,7-tetramethyloctyl)oxetan-2-one by microderivatization, GC-MS, and NMR studies. The absolute configurations at C-2 and C-3 on the beta-lactone ring were assigned by use of the modified Mosher method, applied to the beta-hydroxy acid methyl ester resulting from methanolysis of 1. Biological activity of 1, possibly as an aggregation pheromone for A. vittatum, was indicated by electrophysiological studies using beetle antennae and by the production of 1 by feeding male, and not female, beetles.

L-leucine methyl ester: the female-produced sex pheromone of the scarab beetle, Phyllophaga lanceolata.

The female-produced sex pheromone of the scarab beetle Phyllophaga lanceolata was identified as the methyl ester of an essential amino acid, L-leucine. During field testing, 239 male P. lanceolata were caught in traps baited with L-leucine methyl ester. L-Isoleucine and L-valine methyl esters, similar in structure to L-leucine methyl ester and previously identified as female-produced sex pheromone compounds employed by other Phyllophaga species, were also tested. Addition of L-valine or L-isoleucine methyl esters to the L-leucine methyl ester in 1:1 ratios completely inhibited attraction of P. lanceolata males. Males of P. squamipilosa were also captured using L-leucine methyl ester. This is the first record of P. squamipilosa from Kansas.

Identification of host fruit volatiles from hawthorn (Crataegus spp.) attractive to hawthorn-origin Rhagoletis pomonella flies.

Solid-phase microextraction (SPME) and gas chromatography coupled with electroantennographic detection (GC-EAD) were used to identify volatile compounds from hawthorn fruit (Crataegus spp.) acting as behavioral attractants for hawthorn-infesting Rhagoletis pomonella flies. Consistent EAD activity was obtained for six chemicals: ethyl acetate (94.3%), 3-methylbutan-1-ol (4.0%), isoamyl acetate (1.5%), 4,8-dimethyl-1,3(E),7-nonatriene (0.07%), butyl hexanoate (0.01%), and dihydro-beta-ionone (0.10%). In a flight-tunnel bioassay, there was a dose-related increase in the percentage of flies flying upwind to the six-component mixture. Hawthorn-origin flies also made equivalent levels of upwind flight with the synthetic blend and an adsorbent extract of volatiles collected from whole fruit, each containing the same amount of the 3-methylbutan-1-ol compound. Significantly lower levels of upwind flight occurred to a previously identified volatile blend of ester compounds that attracts R. pomonella flies infesting domestic apples, compared with the hawthorn volatile mix. Selected subtraction assays showed further that the four-component mixture of 3-methylbutan-1-ol, 4,8-dimethyl-1,3(E),7-nonatriene, butyl hexanoate, and dihydro-beta-ionone also elicited levels of upwind flight equivalent to the six-component mix. Removal of 3-methylbutan-1-ol from the four-component blend resulted in complete loss of upwind flight behavior. Removal of dihydro-beta-ionone, 4,8-dimethyl-1,3(E),7-nonatriene, or butyl hexanoate from the four-component mixture resulted in significant decreases in the mean number of upwind flights compared to the four- or six-component mixtures.

Male-specific EAD active compounds produced by female European chafer Rhizotrogus majalis (Razoumowsky).

Chemical investigation of a female balloon-like organ of the European chafer, Rhizotrogus majalis (Razoumowsky), with GC-EAD has resulted in the identification of female-specific compounds, (R)-3- hydroxybutan-2-one, (2R,3R)-2,3-butanediol, and meso-2,3-butanediol that are specifically EAD-active with male antennae. No behavioral role for any of the EAD active compounds could be discerned with this species.