RESUMEN
OBJECTIVE: To evaluate whether prenatal care in a specialized diabetes in pregnancy program (DMC) improves compliance with completion of the 2-h 75 g oral glucose tolerance test (2HrOGTT) in GDM women. METHODS: A retrospective cohort study of GDM women delivering in a university health system between January 2011 and March 2014 was performed. Women were divided into two groups: those receiving care in prenatal clinics over an 18-month period prior to the establishment of the diabetes in pregnancy clinic (pre-DMC) and those receiving prenatal care in a specialized diabetes in pregnancy clinic (post-DMC). The primary outcome was completion of the 2HrOGTT postpartum. Clinical characteristics associated with 2HrOGTT completion were evaluated. Time trend analysis was performed to evaluate month to month variation in 2HrOGTT compliance for secular trends. RESULTS: A total of 292 women were analyzed, 147 post-DMC and 118 pre-DMC. The 2HrOGTT was ordered more frequently in the post-DMC compared to pre-DMC (90.0 versus 53.0%, p < 0.0001). Rates of completion of the 2HrOGTT were 49.2% post-DMC and 25.0% pre-DMC, p = 0.007. After adjusting for potential confounders, women who received prenatal care post-DMC were 2.98 times more likely to complete the 2HrOGTT compared to those receiving care pre-DMC (OR 2.98 [1.34, 6.62], p = 0.007). CONCLUSIONS: Providers were 5.9 times more likely to order the recommended testing for GDM women who attended the postpartum visit in the post-DMC period. GDM women who receive prenatal care in a specialized diabetes in pregnancy program are more likely to complete the 2HrOGTT in the postpartum period.
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Prueba de Tolerancia a la Glucosa/estadística & datos numéricos , Cooperación del Paciente , Atención Posnatal/estadística & datos numéricos , Periodo Posparto , Atención Prenatal/métodos , Adulto , Estudios de Casos y Controles , Diabetes Mellitus Tipo 2/prevención & control , Diabetes Gestacional/terapia , Femenino , Humanos , Tamizaje Masivo/estadística & datos numéricos , Embarazo , Atención Prenatal/estadística & datos numéricos , Estudios Retrospectivos , Factores de TiempoRESUMEN
Background Obstetrical hemorrhage is a leading cause of morbidity and mortality, yet is inconsistently defined. In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) reVITALize program redefined postpartum hemorrhage (PPH) as greater than 1,000 mL blood loss regardless of the mode of delivery (MOD). Objective We sought to assess the reVITALize definition's validity by understanding whether the definition of PPH should, as proposed by ACOG, be one value regardless of MOD. Study Design This is a retrospective study of all women who delivered at the hospital of the University of Pennsylvania from October 15, 2013 through December 15, 2013. Results A total of 592 of the 626 (95%) women were included. The average reported estimated blood loss (EBL) for vaginal delivery (VD) was significantly lower than for cesarean delivery (CD) ([350 ±170 mL) and [880 ± 360 mL]; p < 0.001). The average hemoglobin (Hb) drop was only slightly lower for VD compared with CD ([1.4 ± 1.0 g/dL {11.5% drop}] and [1.9 ± 1.2 g/dL {16.2% drop}], respectively, p < 0.001). The association between EBL and observed Hb drop differed in accuracy by MOD. Conclusion Likely based on historic perceptions, obstetric providers estimate blood loss for VD as less than half that of CD. However, using objective measures, blood loss is more similar than perceived between VD and CD, supporting the ACOG reVITALize single definition of PPH regardless of MOD.
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Cesárea , Hemoglobinas/metabolismo , Parto , Hemorragia Posparto/diagnóstico , Adolescente , Adulto , Volumen Sanguíneo , Femenino , Humanos , Variaciones Dependientes del Observador , Embarazo , Estudios Retrospectivos , Terminología como Asunto , Adulto JovenRESUMEN
OBJECTIVE: Total abdominal hysterectomy (TAH) is a common operation performed by obstetrician-gynecologists. Training opportunities for this procedure are declining. Mental practice (MP), the use of mental imagery to rehearse a task symbolically before performance, has been used successfully in sports and music to enhance skill. This strategy demonstrates benefit in existing surgical education literature. We aimed to develop and validate a MP tool (MPT) for resident training in TAH. DESIGN: A prospective survey study was performed in a large, urban, academic medical center in Philadelphia, Pennsylvania, USA. A MPT was developed by guiding expert surgeons through a cognitive walk-through of TAH to identify key procedural cues. For validation, a convenience sample of 22 residents and attendings (N = 11 per group) mentally rehearsed TAH. Motivation, confidence, quality of imagery, and utility of the activity were assessed with a previously validated Mental Imagery Questionnaire (MIQ) before and after exposure to the MPT. RESULTS: Residents, but not attendings, found MP to be useful in preparation for surgery (residents, p = 0.01; attendings, p = 0.34) and had increased confidence following this exercise (residents, p = 0.01; attendings, p = 0.08). Significant improvement in global imagery score after use of the tool was shown by residents (p = 0.01) but not by the attendings (p = 0.08), with residents having lower imagery skills than attendings both pre-MP and post-MP. Reliability testing of the MIQ indicated internal consistency (pre-MPT, 0.91; post-MPT, 0.90). CONCLUSIONS: MP may serve as a potentially effective, portable, and inexpensive resident surgical training tool in preparation for TAH. Attendings may benefit from certain aspects of MP. The MIQ may serve as a measure of imagery skills in future experiments of MP in preparation for surgery.
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Educación de Postgrado en Medicina/métodos , Histerectomía/educación , Histerectomía/psicología , Imágenes en Psicoterapia/educación , Procesos Mentales , Competencia Clínica , Femenino , Ginecología/educación , Hospitales Universitarios , Humanos , Internado y Residencia/métodos , Laparotomía/métodos , Masculino , Periodo Preoperatorio , Estudios Prospectivos , Encuestas y Cuestionarios , Estados UnidosRESUMEN
Background Previous studies have shown an association between total excessive gestational weight gain and hypertension in pregnancy. However, this may be a reflection of excessive water retention associated with the pathophysiology of hypertensive disorders of pregnancy. Early excessive weight gain, prior to the third trimester, results in greater maternal fat deposition and inflammation, which has also been associated with the development of hypertension. By focusing on early excessive weight gain, the association between maternal weight gain and the future development of hypertension can be examined. Objective To evaluate the association between early excessive maternal weight gain and the development of hypertension during pregnancy. Study Design This was a secondary analysis of a longitudinal cohort study of 1,441 women without chronic hypertension who were enrolled in a prospective study evaluating maternal angiogenic factors and the prediction of preeclampsia. Initial body mass index (BMI) was calculated by weight and height at the first study visit. Early excessive maternal weight gain was defined as weight gain by 28 weeks that exceeded the Institute of Medicine (IOM) guidelines and was calculated utilizing the maximum amount of weight gain per week recommended by the IOM based on the patient's starting BMI (normal: 0.45 kg; overweight: 0.32 kg; obese: 0.27 kg). Hypertension was defined as a sustained systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg. Logistic regression was used to determine the association between early excessive weight gain, initial BMI, and the development of hypertension, including gestational hypertension and preeclampsia, during pregnancy. Results Of 1,441 women, 767 (53.2%) had weight gain that exceeded the IOM guidelines in the first 28 weeks and 154 (10.8%) developed hypertension during pregnancy. Women whose weight gain exceeded the IOM guidelines were more likely to develop hypertension even after adjusting for relevant confounders (12.5 vs. 8.6%; p = 0.02; adjusted odds ratio [OR] = 1.70; 95% confidence interval [CI]: 1.18-2.44; p < 0.01). Obese women had a 2.4-fold increased risk of developing hypertension, even after controlling for excessive weight gain (adjusted OR = 2.44; 95% CI: 1.66-3.59; p < 0.01) Conclusions Early excessive maternal weight gain and initial BMI are independently associated with the diagnosis of a hypertensive disorder of pregnancy. Women should be counseled regarding the benefits of achieving a normal BMI prior to pregnancy and appropriate weight gain during pregnancy, as well as the potential harms of excessive weight gain related to perinatal outcomes.
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Índice de Masa Corporal , Hipertensión Inducida en el Embarazo/epidemiología , Obesidad/epidemiología , Aumento de Peso , Adulto , Femenino , Guías como Asunto , Humanos , Estudios Longitudinales , Preeclampsia/epidemiología , Embarazo , Primer Trimestre del Embarazo , Segundo Trimestre del EmbarazoRESUMEN
OBJECTIVES: Previous studies have demonstrated an association between adverse obstetric outcomes, such as preterm birth, and in utero inflammation. The fetal thymus, which can be visualized in the anterior mediastinum on obstetric sonography, may involute in response to such inflammation and thus may identify pregnancies at increased risk for these outcomes. We therefore sought to determine whether second-trimester fetal thymus measurements are associated with preterm birth. METHODS: Transabdominal fetal thymus measurements were prospectively obtained in singleton pregnancies at gestational ages of 18 weeks to 23 weeks 6 days during a 5-month period. The transverse and anterorposterior thymus diameters and the thymic-thoracic ratio were measured. Delivery outcomes were collected from our clinical database. The primary outcome was preterm birth, which we defined as delivery between 24 weeks and 36 weeks 6 days. Small for gestational age (SGA) and pregnancy-related hypertension, which are adverse obstetric outcomes that may also be associated with in utero inflammation, were included as secondary outcomes. RESULTS: We included 520 patients with thymus measurements and obstetric outcome data. The prevalence of preterm birth was 12.3% (n = 64). None of the thymus measurements were associated with preterm birth. Similarly, there was no association between thymus measurements and SGA or pregnancy-related hypertension. CONCLUSIONS: Sonographic assessment of the second-trimester fetal thymus did not identify patients at increased risk for preterm birth, SGA, and pregnancy-related hypertension. Routine thymus measurements during the second-trimester anatomic scan are not clinically useful for prediction of preterm birth and other adverse outcomes.
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Hipertensión Inducida en el Embarazo/diagnóstico por imagen , Recién Nacido Pequeño para la Edad Gestacional , Nacimiento Prematuro/diagnóstico por imagen , Timo/diagnóstico por imagen , Timo/embriología , Ultrasonografía Prenatal/métodos , Adulto , Estudios de Cohortes , Femenino , Humanos , Embarazo , Segundo Trimestre del Embarazo , Estudios RetrospectivosRESUMEN
Objectives Despite limited data, antenatal testing has been initiated in many institutions for women with morbid obesity given their increased risk of stillbirth. Therefore, our objective was to evaluate the obstetrical implications of antenatal testing in the morbidly obese population. Study Design We performed a retrospective cohort study of women undergoing antenatal testing from January 2011 through December 2012 who delivered at our institution. The exposed group was women undergoing antenatal testing with morbid obesity (body mass index [BMI] ≥ 40 kg/m(2)). This group was subdivided into two groups: group 1, which included women undergoing testing for morbid obesity alone, and group 2, which included women undergoing testing for morbid obesity with an additional medical comorbidity. The unexposed group (group 3) comprised nonmorbidly obese women (BMI < 35 kg/m(2)) undergoing antenatal testing for similar medical comorbidities. Our primary outcomes were induction of labor and gestational age at delivery. Results A total of 512 women met inclusion criteria. Group 1 had a lower induction rate as compared with groups 2 and 3 (22.2, 32.5, and 37.6%, respectively; p = 0.003). Additionally, women delivered at a later gestational age in group 1 (39.3 weeks [38.4-40.2]) compared with groups 2 (38.5 weeks [36.1-40.3]) or 3 (37.1 weeks [37.0-38.2]), p = 0.04. There were no significant differences in our secondary outcomes including rate of cesarean delivery (p = 0.11) or rate of nonreactive nonstress test (p = 0.4). Conclusions While it remains unknown whether antenatal testing decreases the stillbirth risk in morbidly obese women, this population does not appear to be at increased risk of induction of labor or delivery prior to 39 weeks secondary to testing. Future studies should evaluate neonatal implications and cost-effectiveness of antenatal testing in this group.
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Cesárea/estadística & datos numéricos , Trabajo de Parto Inducido/estadística & datos numéricos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/epidemiología , Complicaciones del Embarazo/epidemiología , Adulto , Índice de Masa Corporal , Bases de Datos Factuales , Femenino , Edad Gestacional , Humanos , Recién Nacido , Pennsylvania/epidemiología , Embarazo , Diagnóstico Prenatal/métodos , Estudios Retrospectivos , Mortinato/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Cell-free deoxyribonucleic acid (DNA) is increasingly being used to screen for fetal aneuploidy. The majority of fetal cell-free DNA in the maternal blood results from release from the syncytiotrophoblast as a result of cellular apoptosis and necrosis. Elevated levels of fetal cell-free DNA may be indicative of underlying placental dysfunction, which has been associated with preterm birth. Preliminary studies have demonstrated that fetal cell-free DNA is increased in pregnancies complicated by spontaneous preterm birth. There are limited data on the association between fetal cell-free DNA levels and fetal fraction and preterm birth in asymptomatic women in the first and second trimesters. Preliminary studies have failed to find an association between first-trimester cell-free DNA levels and preterm birth, whereas there is conflicting evidence as to whether elevated second-trimester cell-free DNA is associated with a subsequent spontaneous preterm birth clinical event. OBJECTIVE: The objective of the study was to evaluate the association between first- and second-trimester cell-free DNA fetal fraction and preterm birth. STUDY DESIGN: This was a retrospective cohort study of women with singleton pregnancies at increased risk for aneuploidy who had cell-free DNA testing at 10-20 weeks' gestation between October 2011 and May 2014. The cohort was subdivided by gestational age at the time of cell-free DNA testing (10-14 weeks or 14.1-20 weeks). The primary outcome was preterm birth less than 37 weeks' gestation, and the secondary outcomes were preterm birth at less than 34 weeks' gestation and spontaneous preterm birth at less than 37 and 34 weeks' gestation. RESULTS: Among 1349 pregnancies meeting inclusion criteria 119 (8.8 %) had a preterm birth prior to 37 weeks with 49 cases (3.6 %) delivering prior to 34 weeks. Whereas there was no significant association between fetal fraction and the preterm birth outcomes for those who underwent cell-free DNA testing at 10-14 weeks' gestation, there were significant associations among those screened at 14.1-20.0 weeks' gestation. Fetal fraction greater than or equal to the 95th percentile at 14.1-20.0 weeks' gestation was associated with an increased risk for preterm birth less than 37 and 34 weeks' gestation (adjusted odds ratio, 4.59; 95% confidence interval, 1.39-15.2; adjusted odds ratio, 22.0; 95% confidence interval, 5.02-96.9). CONCLUSION: Elevated fetal fraction levels at 14.1-20.0 weeks' gestation were significantly associated with an increased incidence of preterm birth. Our findings warrant future exploration including validation in a larger, general population and investigation of the potential mechanisms that may be responsible for the initiation of preterm labor associated with increased fetal cell-free DNA.
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ADN/análisis , Nacimiento Prematuro/diagnóstico , Adulto , Femenino , Edad Gestacional , Humanos , Embarazo , Primer Trimestre del Embarazo , Segundo Trimestre del Embarazo , Nacimiento Prematuro/prevención & control , Estudios Retrospectivos , Medición de Riesgo/métodos , Factores de RiesgoRESUMEN
BACKGROUND: Preterm birth (PTB) remains a significant cause of neonatal morbidity and mortality. Women with a prior PTB are at risk for recurrent PTB. Treatment with 17-alpha hydroxyprogesterone caproate (17OHP-C) has become standard of care for women with prior PTB to help reduce this risk. Factors that affect a woman's decision to use this medication are largely unknown. OBJECTIVE: The objective of our study was to investigate patient-level barriers to 17OHP-C. We studied a cohort of women eligible for 17OHP-C with the hypothesis that 17OHP-C is underutilized and certain patient characteristics, such as obstetrical history, influence its use. STUDY DESIGN: A cross-sectional study of all women seen at a specialty prematurity clinic from 2009 through 2013 was performed. Women with a singleton pregnancy were included if they had a prior spontaneous PTB (sPTB). The χ(2) tests were performed for univariate analyses. Multivariable logistic regression was used to control for confounders. RESULTS: In all, 243 women had 17OHP-C recommended to them based on obstetrical history. There were 218 women with a pregnancy during our study period that were included in our analysis. A total of 163 (74.7%) had documented 17OHP-C use. Women were more likely to accept 17OHP-C if they had a history of a second-trimester loss only (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.17-4.58) or received recommendation for cerclage due to a short cervical length (OR, 4.12; 95% CI, 1.55-10.99). Women with a prior full-term birth were less likely to accept 17OHP-C (OR, 0.48; 95% CI, 0.26-0.89), especially when the prior full-term birth was subsequent rather than prior to the PTB (OR, 0.19; 95% CI, 0.08-0.47). Race, obesity, and insurance status did not impact 17OHP-C use. There was no difference in the rate of sPTB between those who used and did not use 17OHP-C (37.2 vs 34.0%, P = .7). CONCLUSION: Obstetric history impacted 17OHP-C use. This study identifies biases regarding 17OHP-C at the patient level and can be used to develop strategies to increase its use. However, the similarity in the sPTB rate between users and nonusers highlights the importance of identifying specific populations where 17OHP-C is and is not effective in preventing PTB.
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17-alfa-Hidroxiprogesterona/uso terapéutico , Aceptación de la Atención de Salud/estadística & datos numéricos , Embarazo de Alto Riesgo , Nacimiento Prematuro/prevención & control , Progestinas/uso terapéutico , Adulto , Cerclaje Cervical , Estudios Transversales , Femenino , Muerte Fetal , Humanos , Pennsylvania , Embarazo , RecurrenciaRESUMEN
OBJECTIVE: To create a prediction score incorporating both maternal clinical characteristics and sonographic measurements in an effort to more accurately determine the risk of a large for gestational age (LGA) infant in the obese gravida. METHODS: We performed a retrospective cohort study of obese women with singleton pregnancies who had a fetal ultrasound performed between 32 and 36 weeks from 1/2008 to 12/2011. LGA was defined as birth weight (BW) ≥ 90%. Clinical characteristics associated with fetal overgrowth were included in a multivariable logistic model and stepwise backwards regression was performed to identify which risk factors generated the most parsimonious predictive model. Adjusted odds ratios of covariates in the final model were used to estimate weights for each risk factor that were summed to generate a predictive score. RESULTS: Six-hundred and sixty-nine obese women were included. The incidence of LGA infants was 11.8%. Ultrasound estimation of fetal weight alone accurately predicted LGA in 17.7 % of cases (AUC = 0.58). The most parsimonious model to accurately predict LGA at birth included 3rd trimester ultrasound EFW >90th percentile, interval from scan to delivery, and maternal history of diabetes mellitus (DM) (AUC = 0.74). A positive prediction score test result was associated with 92% specificity and 89% negative predictive value. CONCLUSIONS: A clinical prediction rule was developed and internally validated to predict the risk of an LGA infant among obese women. The ability to calculate a prediction score at the time of delivery is appealing to the clinician in order to accurately counsel women regarding the risks surrounding the delivery.
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Peso al Nacer , Obesidad/diagnóstico por imagen , Complicaciones del Embarazo/diagnóstico por imagen , Adulto , Algoritmos , Femenino , Edad Gestacional , Humanos , Recién Nacido , Embarazo , Tercer Trimestre del Embarazo , Estudios Retrospectivos , Ultrasonografía Prenatal , Adulto JovenRESUMEN
OBJECTIVE: Metabolomics has the potential to reveal novel pathways involved in the pathogenesis of preterm birth (PTB). The objective of this study was to investigate whether the cervicovaginal (CV) metabolome was different in asymptomatic women destined to have a PTB compared with term birth. STUDY DESIGN: A nested case-control study was performed using CV fluid collected from a larger prospective cohort. The CV fluid was collected between 20-24 weeks (V1) and 24-28 weeks (V2). The metabolome was compared between women with a spontaneous PTB (n = 10) to women who delivered at term (n = 10). Samples were extracted and prepared for analysis using a standard extraction solvent method. Global biochemical profiles were determined using gas chromatography/mass spectrometry and ultra-performance liquid chromatography/tandem mass spectrometry. An ANOVA was used to detect differences in biochemical compounds between the groups. A false discovery rate was estimated to account for multiple comparisons. RESULTS: A total of 313 biochemicals were identified in CV fluid. Eighty-two biochemicals were different in the CV fluid at V1 in those destined to have a PTB compared with term birth, whereas 48 were different at V2. Amino acid, carbohydrate, and peptide metabolites were distinct between women with and without PTB. CONCLUSION: These data suggest that the CV space is metabolically active during pregnancy. Changes in the CV metabolome may be observed weeks, if not months, prior to any clinical symptoms. Understanding the CV metabolome may hold promise for unraveling the pathogenesis of PTB and may provide novel biomarkers to identify women most at risk.
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Cuello del Útero/metabolismo , Metaboloma , Nacimiento Prematuro/metabolismo , Vagina/metabolismo , Adolescente , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Estudios Prospectivos , Adulto JovenRESUMEN
OBJECTIVE: MicroRNAs (miRNAs), which are highly conserved single-stranded noncoding RNAs that play a crucial role in gene regulation, have now been identified as important players in many diseases states. MiRNAs have also been demonstrated to be reliable and useful biomarkers to identify those women who are at risk for specific adverse outcomes. The objective of this study was to determine whether miRNA profiles in maternal blood are different in women who are destined to have a preterm, compared with a term, birth. STUDY DESIGN: A nested case-control study was performed with maternal serum that was collected as part of a larger prospective cohort. MiRNA expression profiles in maternal serum were compared between women who ultimately had a preterm birth (n = 40) compared with term birth (n = 40). MiRNA expression profiles were created with the use of the Affymetrix GeneChip miRNA Array. The data were analyzed with the significance of analysis of microarrays and principle components analyses. A false discovery rate of 20% was used to determine the most differentially expressed miRNAs. RESULTS: Of the 5640 miRNAs that were analyzed on the array, 4 miRNAs were significantly different between cases and control subjects. Two of the 4 miRNAs were mature miRNAs. The fold difference in expression was <2 for all 4 miRNAs. CONCLUSION: MiRNA profiles in maternal blood were not significantly different in women who were destined to have a preterm, compared with a term, birth. MiRNAs in maternal blood are unlikely to become clinically useful biomarkers for the prediction of preterm birth.
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MicroARNs/sangre , Nacimiento Prematuro/sangre , Nacimiento Prematuro/epidemiología , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Valor Predictivo de las Pruebas , Embarazo , Estudios Prospectivos , Medición de Riesgo , Adulto JovenRESUMEN
OBJECTIVE: Standardized oxytocin protocols have been used to improve the safety and quality of obstetric care. We examined rates of chorioamnionitis and labor dystocia requiring cesarean delivery as unintended consequences of the implementation of a low-dose, checklist-based oxytocin protocol. STUDY DESIGN: We performed a retrospective cohort study of live singleton deliveries that underwent a trial of labor in two 15-month periods, comparing outcomes in those who delivered before to after protocol implementation. Patients and outcomes were identified using a combination of electronic medical records and International Classification of Diseases, 9th Revision, Clinical Modification codes. Time trend analysis was performed to evaluate for secular trends. RESULTS: A total of 8,717 women were included; 5,077 received oxytocin. Despite an unchanged rate of cesarean deliveries from before to after initiation of the protocol (15.15 vs. 14.75%, p = 0.60), deliveries after protocol implementation were generally characterized by higher rates of chorioamnionitis (7.48 vs. 5.97%, p < 0.001), longer median time from admission to delivery (524 vs. 462 minutes, p < 0.001), more cesarean deliveries performed for labor dystocia (50.62 vs. 40.92%, p < 0.001), and fewer cesarean deliveries performed for fetal distress (32.52 vs. 38.67%, p = 0.02). CONCLUSION: Low-dose oxytocin protocols are intended to increase safety, but they may have unintended consequences related to prolonged labor, and should be studied before widespread use.
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Protocolos Clínicos , Distocia/epidemiología , Complicaciones del Trabajo de Parto/epidemiología , Oxitócicos/uso terapéutico , Oxitocina/uso terapéutico , Adulto , Cesárea/estadística & datos numéricos , Lista de Verificación , Corioamnionitis/epidemiología , Distocia/tratamiento farmacológico , Registros Electrónicos de Salud , Femenino , Sufrimiento Fetal , Monitoreo Fetal , Humanos , Clasificación Internacional de Enfermedades , Trabajo de Parto Inducido , Complicaciones del Trabajo de Parto/tratamiento farmacológico , Oxitocina/efectos adversos , Embarazo , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: To examine whether variation in neighborhood context is associated with preterm birth (PTB) outcomes and gestational age (GA) at delivery in Philadelphia, and to determine whether these associations might persist when considering relevant individual-level variables. STUDY DESIGN: We analyzed individual-level data collected for a prospective cohort study of singleton pregnancies with preterm labor. We merged block-group level data to each individual's home address. Unadjusted analyses were performed to determine the association between block-group variables and individual-level outcomes. Block-group variables identified as potential risk factors were incorporated into multivariable individual-level models to determine significance. RESULTS: We analyzed data for 817 women. The prevalence of PTB <37 weeks was 41.5%. Although in unadjusted analyses several block-group variables were associated with PTB and GA at delivery, none retained significance in individual-level multivariable models. CONCLUSION: Block-group level data were not associated with PTB outcomes or GA at delivery in Philadelphia.
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Ambiente , Nacimiento Prematuro/epidemiología , Características de la Residencia/estadística & datos numéricos , Crimen/estadística & datos numéricos , Femenino , Humanos , Renta/estadística & datos numéricos , Philadelphia , Embarazo , Atención Prenatal/estadística & datos numéricos , Estudios Prospectivos , Factores de Riesgo , Factores Socioeconómicos , Estadística como AsuntoRESUMEN
OBJECTIVE: Maternal morbidity is increasing in the United States. Our objectives were to examine whether a labor and delivery (L&D) provider model with regular maternal-fetal medicine (MFM) coverage decreases the rates of maternal morbidity during delivery hospitalizations and has an impact on obstetrician-gynecologist residents' perceptions of safety and education. STUDY DESIGN: We performed a retrospective cohort study to compare the rates of maternal morbidity before and after the implementation of an MFM-centered coverage model on L&D. Outcomes were identified using International Classification of Diseases, ninth revision, codes. The primary outcome was a composite of severe maternal morbidity. Additionally, obstetrician-gynecologist residents completed an anonymous survey asking them to compare coverage models, and their Council on Resident Education in Obstetrics and Gynecology examination scores were compared. RESULTS: Data from 4715 deliveries were included. There were no differences in composite morbidity or individual adverse outcomes. Most residents (81.3%) preferred the new provider model, with median 5-point Likert scores indicating perceived increases in safety and education. Mean Council on Resident Education in Obstetrics and Gynecology scores improved in the 18 residents exposed to both models. CONCLUSION: Although the MFM-centered provider model appears to have had a positive impact on residents' perceptions of safety and education, it was not associated with significant changes in severe maternal morbidity.
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Servicios de Salud Materna/organización & administración , Cuerpo Médico de Hospitales , Modelos Organizacionales , Complicaciones del Trabajo de Parto/prevención & control , Admisión y Programación de Personal , Complicaciones del Embarazo/prevención & control , Adulto , Actitud del Personal de Salud , Betametasona/administración & dosificación , Estudios de Cohortes , Parto Obstétrico , Utilización de Medicamentos , Evaluación Educacional , Femenino , Glucocorticoides/administración & dosificación , Ginecología/educación , Humanos , Unidades de Cuidados Intensivos , Internado y Residencia , Trabajo de Parto Inducido/estadística & datos numéricos , Complicaciones del Trabajo de Parto/epidemiología , Obstetricia/educación , Admisión del Paciente/estadística & datos numéricos , Pennsylvania , Embarazo , Complicaciones del Embarazo/epidemiología , Nacimiento Prematuro/prevención & control , Estudios Retrospectivos , Esfuerzo de Parto , Parto Vaginal Después de Cesárea/estadística & datos numéricos , Adulto JovenRESUMEN
OBJECTIVE: Although premature cervical remodeling is involved in preterm birth (PTB), the molecular pathways that are involved have not been elucidated fully. MicroRNAs (miRNAs) that are highly conserved single-stranded noncoding RNAs that play a crucial role in gene regulation have now been identified as important players in disease states. The objective of this study was to determine whether miRNA profiles in cervical cells are different in women who are destined to have a PTB compared with a term birth. STUDY DESIGN: A nested case-control study was performed. With the use of a noninvasive method, cervical cells were obtained at 2 time points in pregnancy. The cervical cell miRNA expression profiles were compared between women who ultimately had a PTB (n = 10) compared with a term birth (n = 10). MiRNA expression profiles were created with the Affymetrix GeneChip miRNA Array. The data were analyzed with the Significance of Analysis of Microarrays and Principle Components Analyses. A false-discovery rate of 20% was used to determine the most differentially expressed miRNAs. Validation was performed with quantitative polymerase chain reaction. In vitro studies were performed to confirm expression and regulation of select miRNAs. RESULTS: With a false-discovery rate of 20% of the 5640 miRNAs that were analyzed on the array, 99 miRNAs differed between those with a PTB vs a term birth. Qualitative polymerase chain reaction validated the array findings. In vitro studies confirmed expression of select miRNAs in cervical cells. CONCLUSION: MiRNA profiles in cervical cells may distinguish women who are at risk for PTB months before the outcome. With the large downstream effects of miRNAs on gene expression, these studies provide a new understanding of the processes that are involved in premature cervical remodeling and allow for the discovery of new therapeutic targets.
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Cuello del Útero/metabolismo , MicroARNs/metabolismo , Nacimiento Prematuro/metabolismo , Adulto , Estudios de Casos y Controles , Femenino , Perfilación de la Expresión Génica , Regulación de la Expresión Génica , Humanos , Recién Nacido , MicroARNs/genética , Embarazo , Nacimiento Prematuro/genéticaRESUMEN
OBJECTIVE: The purpose of this study was to determine whether prenatal inflammation (as assessed by clinical chorioamnionitis, maternal temperature >38°C, or histologic chorioamnionitis) is associated with a composite adverse neonatal outcome. STUDY DESIGN: We performed a prospective cohort study of women at 22 weeks to 33 weeks 6 days' gestation with symptoms of labor (April 2009 to March 2012). Relevant maternal and neonatal exposures and outcomes were recorded. Multivariable logistic regression was performed to determine the association between prenatal inflammation and neonatal outcomes that were controlled for potential confounders. RESULTS: We analyzed 871 mother-infant pairs. The preterm birth rate was 42.0%. When we controlled for infant sex and modified the data by gestational age at delivery, prenatal inflammation remains a significant risk factor for adverse neonatal outcomes, despite advancing gestational age: clinical chorioamnionitis at 32 weeks' gestation (odds ratio [OR], 3.12; 95% confidence interval [CI], 1.02-9.52], at 36 weeks' gestation (OR, 8.88; 95% CI, 4.32-18.25), and at 40 weeks' gestation (OR, 25.30; 95% CI, 9.25-69.19); maternal temperature >38°C at 32 weeks' gestation (OR, 3.18; 95% CI, 0.66-15.42), at 36 weeks gestation (OR, 8.40; 95% CI, 3.60-19.61), and at 40 weeks gestation (OR, 22.19; 95% CI, 8.15-60.44); histologic chorioamnionitis at 32 weeks gestation (OR, 1.25; 95% CI, 0.64-2.46), at 36 weeks gestation (OR, 2.56; 95% CI, 1.54-4.23), and at 40 weeks gestation (OR, 5.23; 95% CI, 1.95-13.99). CONCLUSION: The protective association with advancing gestational age is diminished when prenatal inflammation is present.
Asunto(s)
Corioamnionitis/epidemiología , Inflamación/epidemiología , Resultado del Embarazo/epidemiología , Adulto , Área Bajo la Curva , Femenino , Edad Gestacional , Humanos , Modelos Logísticos , Embarazo , Estudios Prospectivos , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVES: To determine whether (1) isolated fetal abdominal circumference < 5% (AC5) in absence of growth restriction (estimated fetal weight < 10% [EFW10]) or (2) borderline fetal growth 10 to 19% (EFW10-19) predicts subsequent fetal and/or neonatal growth restriction. STUDY DESIGN: The authors performed a retrospective cohort study (January 2008 to December 2011) of women with singleton pregnancies between 26 and 36 weeks who had ≥ 1 growth ultrasound. Univariable and multivariable analyses were performed to determine the association between isolated AC5 or EFW10-19 with both subsequent sonographic diagnosis of EFW10 and neonatal diagnosis of small for gestational age (SGA). Test characteristics were calculated. RESULTS: Out of the 10,642 pregnancies, prevalence of isolated AC5, EFW10-19, EFW10, and SGA were as follows: AC5, 5.31%; EFW10-19, 13.30%; EFW10, 7.95%; and SGA, 17.63%. While screening for SGA using EFW10 alone would miss 68.34% of SGA neonates, using isolated AC5 would identify an additional 16.15% of SGA neonates with a 3.7% false positive rate. Using EFW10-19 would identify an additional 40.20% of SGA neonates with a 9.0% false positive rate. CONCLUSION: Fetuses with isolated AC5 or EFW10-19 are at an increased risk of growth restriction. Using isolated AC5 or composite EFW10-19 would identify SGA neonates that are missed using conventional sonographic definitions of growth restriction alone.
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Abdomen/patología , Retardo del Crecimiento Fetal/diagnóstico , Retardo del Crecimiento Fetal/epidemiología , Peso Fetal , Recién Nacido Pequeño para la Edad Gestacional , Abdomen/diagnóstico por imagen , Reacciones Falso Negativas , Reacciones Falso Positivas , Femenino , Edad Gestacional , Humanos , Tamaño de los Órganos , Valor Predictivo de las Pruebas , Embarazo , Prevalencia , Estudios Retrospectivos , Ultrasonografía PrenatalRESUMEN
Objectives. To investigate whether early artificial amniotomy (AROM) <4 cm in nulliparous women admitted for induction of labor was associated with an increased rate of chorioamnionitis and cesarean section or a decreased time to vaginal delivery. Study Design. A retrospective cohort study was performed on nulliparous women with a term, singleton gestation and intact membranes who presented for induction of labor (January 2008 to December 2011). Chorioamnionitis was defined using ICD9 codes. Results. 1,567 women were enrolled; 25.4% underwent early AROM. Overall, the prevalence of chorioamnionitis was 12.4%, the rate of cesarean section was 32.2%, and the time from 4 cm cervical dilation to vaginal delivery was 413 min. Compared to women without AROM < 4 cm, early AROM did not affect overall chorioamnionitis rates (10.2 versus 13.2%, P = 0.12) but was associated with an increased cesarean section rate (40.2 versus 29.5%, P < 0.001). However, among those who delivered vaginally, AROM < 4 cm decreased the rate of chorioamnionitis (8.4 versus 14.6%, P = 0.01), which persisted when controlling for potential confounders (OR 0.55, 95% CI 0.33-0.92), and decreased the time from 4 cm dilation to vaginal delivery (329 versus 472 min, P < 0.001). Conclusions. Our findings do not suggest that early AROM is associated with an increased rate of clinical chorioamnionitis.
RESUMEN
Preeclampsia is characterized by hypertension and proteinuria in pregnant women. Its exact cause is unknown. Preeclampsia increases the risk of maternal and fetal morbidity and mortality. Although delivery, often premature, is the only known cure, early targeted interventions may improve maternal and fetal outcomes. Successful intervention requires a better understanding of the molecular etiology of preeclampsia and the development of accurate methods to predict women at risk. To this end, we tested the role of miR-210, a miRNA up-regulated in preeclamptic placentas, in first-trimester extravillous trophoblasts. miR-210 overexpression reduced trophoblast invasion, a process necessary for uteroplacental perfusion, in an extracellular signal-regulated kinase/mitogen-activated protein kinase-dependent manner. Conversely, miR-210 inhibition promoted invasion. Furthermore, given that the placenta secretes miRNAs into the maternal circulation, we tested if serum expression of miR-210 was associated with the disease. We measured miR-210 expression in two clinical studies: a case-control study and a prospective cohort study. Serum miR-210 expression was significantly associated with a diagnosis of preeclampsia (P = 0.007, area under the receiver operator curves = 0.81) and was predictive of the disease, even months before clinical diagnosis (P < 0.0001, area under the receiver operator curve = 0.89). Hence, we conclude that aberrant expression of miR-210 may contribute to trophoblast function and that miR-210 is a novel predictive serum biomarker for preeclampsia that can help in identifying at-risk women for monitoring and treatment.
Asunto(s)
Movimiento Celular , MicroARNs/sangre , Preeclampsia/sangre , Preeclampsia/genética , Trofoblastos/metabolismo , Trofoblastos/patología , Adulto , Biomarcadores/sangre , Estudios de Casos y Controles , Estudios de Cohortes , Demografía , Quinasas MAP Reguladas por Señal Extracelular/metabolismo , Femenino , Humanos , Sistema de Señalización de MAP Quinasas , MicroARNs/genética , Preeclampsia/enzimología , Embarazo , Segundo Trimestre del Embarazo/genética , Trofoblastos/enzimología , Regulación hacia Arriba/genéticaRESUMEN
OBJECTIVE: To investigate whether biomarkers from different pathways of spontaneous preterm birth (cervical membrane degradation [fetal fibronectin], cervical remodeling [soluble E-cadherin], and inflammation (elafin, surfactant protein-D, interleukin-6 [IL-6]) were superior to one biomarker alone in predicting preterm birth. Our secondary objective was to examine the association of these biomarkers with cervical length in predicting preterm birth. METHODS: We performed a single-center, prospective cohort study from August 2011 to November 2012 of asymptomatic women at risk for spontaneous preterm birth as a result of obstetric and gynecologic history. Cervicovaginal fluid and cervical length measurements were collected at two time points (20-23 6/7 weeks and 24-27 6/7 weeks of gestation). RESULTS: Among the 104 women with complete data, the preterm birth rate was 24.5%. Prior preterm birth (P=.006) and cervical length at visit 1 (P=.003) were significantly associated with preterm birth, whereas fetal fibronectin and median biomarker levels (elafin, soluble E-cadherin, IL-6) were not. Median surfactant protein-D levels at visit 1 by preterm birth status were statistically but not clinically different (0.44 ng/mL compared with 0.40 ng/mL, P<.001). Analyses of biomarkers from more than one pathway were not superior to single biomarker analyses in predicting prematurity. Neither inclusion of biomarkers nor fetal fibronectin improved the predictive ability of cervical length alone. CONCLUSION: Cervical length assessment and obstetric history but not fetal fibronectin or biomarkers were useful in the risk stratification of women identified to be at greatest risk for spontaneous preterm birth. LEVEL OF EVIDENCE: II.