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OBJECTIVE: To review data regarding the efficacy of galactogogues available in the US to increase breast milk production in postpartum mothers. DATA SOURCES: Literature was sought using PubMed (1966-June 2012) and EMBASE (1973-June 2012). Search terms included breastfeeding, breast milk, lactation, galactogogue, metoclopramide, oxytocin, fenugreek, milk thistle, silymarin, growth hormone, thyroid releasing hormone, medroxyprogesterone, domperidone, goat's rue, beer, Asparagus racemosus, shatavari, Medicago sativa, alfalfa, Onicus benedictus, blessed thistle, Galega officinalis, brewer's yeast, and herbals. STUDY SELECTION AND DATA EXTRACTION: All studies including humans and published in English with data assessing the efficacy of galactogogues for increasing breast milk production were evaluated. DATA SYNTHESIS: Breast milk is considered the optimal food source for newborns through 1 year of age. Many factors influence overall maternal production, including maternal pain, illness, balance of time when returning to work, anxiety, or emotional stress. Although a variety of herbal and pharmaceutical options have anecdotal evidence of their ability to improve breast milk production, peer-reviewed studies proving their efficacy are lacking. Metoclopramide, oxytocin, fenugreek, and milk thistle have shown mixed results in improving milk production; however, the trials were small and had a variety of limitations. CONCLUSIONS: Nonpharmacologic recommendations should be exhausted before adding therapy. Although anecdotal evidence encourages the use of metoclopramide, fenugreek, asparagus, and milk thistle for their galactogogue properties, efficacy and safety data in the literature are lacking. Oxytocin and domperidone are potentially available for compounding purposes, but safety data are limited. More studies are needed to evaluate the effects of available galactogogues on breast milk production.

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OBJECTIVE: To determine whether survival is different in "early" (23(0/7)-23(3/7) weeks) vs "late" (23(4/7)-23(6/7) weeks) infants. STUDY DESIGN: Records of 126 consecutive liveborn infants delivered at 23(0/7) to 23(6/7) weeks' gestation from 2001-2010 were examined using the Vermont Oxford Network database. Infants born at 23 0/7 to 23 3/7 weeks were grouped into "early" and those at 23 4/7 to 23 6/7 weeks were "late." Clinical characteristics were compared between groups and multivariate analyses were used to predict survival. RESULTS: Seventy-two infants were early and 54 were late. Survival was 25% vs 56%, respectively (P < .001). The early group was less likely to receive steroids (43% vs 65%; P = .016) and had a lower mean birthweight (547 g vs 596 g; P < .001). No difference in other factors was seen between groups. No change in survival was observed during the study period in either group. CONCLUSION: Late 23-week infants have improved survival compared with early infants. Delaying delivery as little as 24-96 hours may improve survival for 23-week infants.

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OBJECTIVE: To evaluate the safety of the human papillomavirus (HPV) bivalent and quadrivalent vaccines in pregnancy. DATA SOURCE: PubMed (1966-August 2010) was searched using the terms human papillomavirus, human papillomavirus vaccine, and pregnancy. References were reviewed for relevant information. STUDY SELECTION AND DATA EXTRACTION: All studies including humans that were published in English with data describing HPV vaccine administration in pregnancy were evaluated. DATA SYNTHESIS: Two combined analyses of 7 Phase 3 efficacy trials have retrospectively evaluated the safety of unintentional administration of either the bivalent (n = 1786) or quadrivalent (n = 2085) HPV vaccine during pregnancy. In addition, postmarketing pregnancy registry surveillance data (prospective, n = 787; retrospective, n = 76) for the quadrivalent HPV vaccine have been published. However, only 279 pregnancies from the studies and 90 pregnancies from the registry occurred within 30 days of receiving the vaccination. Overall, the vaccine does not appear to be associated with an increased risk of spontaneous abortion, fetal malformations, or adverse pregnancy outcomes beyond that found in the general population. Although the data are limited, neither HPV vaccine appears to be associated with an increased risk of adverse pregnancy outcomes. However, limitations of the data include small patient populations, minimal to no adjustments for factors known to influence pregnancy outcomes or malformations, and the majority of the available pregnancy data are from retrospective analysis of Phase 3 efficacy trials. CONCLUSIONS: Neither HPV vaccine should be routinely administered during pregnancy. If a pregnancy occurs midseries, the remaining vaccines should be given after pregnancy completion. Further studies are required to determine actual risk.

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OBJECTIVE: To describe a new placement technique for the transcervical Foley catheter that may succeed when other methods have failed. STUDY DESIGN: Sixteen patients were identified as candidates for placement of a transcervical Foley catheter for cervical ripening, but all had failed attempted placement using the classically described methods. Our new placement technique involved the use of a 5 French rigid catheter guide inserted into the Foley catheter to make the catheter rigid and to ease insertion. RESLLTS: Placement was 100% successful in all 16 patients using the new insertion technique. CONCLUSION: The use of a rigid stylet during insertion increases the chances of success. The ease of insertion using this technique makes the use of a Foley catheter for cervical ripening a valuable option.

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OBJECTIVE: To investigate the relationship between gestational weight gain and adverse pregnancy outcomes among women with normal prepregnancy body mass index. METHODS: We conducted a population-based cohort study of women with normal prepregnancy body mass index who delivered full-term singletons using Missouri birth certificate data for 1999-2001. The cohort was divided into three groups (less than recommended [less than 25 lb], n=16,852; recommended [25-35 lb], n=37,292; more than recommended [more than 35 lb], n=40,552) based on Institute of Medicine gestational weight gain guidelines. Logistic regression was used to adjust for known confounders. RESULTS: Compared with women gaining 25-35 lb, women gaining less than 25 lb during pregnancy had lower odds for preeclampsia (adjusted odds ratio [aOR] 0.56, 95% confidence interval [CI] 0.49-0.64), cephalopelvic disproportion (aOR 0.64, 95% CI 0.55-0.75), failed induction (aOR 0.68, 95% CI 0.59-0.78), cesarean delivery (aOR 0.82, 95% CI 0.78-0.87), and large for gestational age infants (aOR 0.40, 95% CI 0.37-0.44) and increased odds for small for gestational age infants (aOR 2.14, 95% CI 2.01-2.27). Likewise, women gaining more than 35 lb had lower odds for small for gestational age infants (aOR 0.48, 95% CI 0.45-0.50) and increased odds for preeclampsia (aOR 1.88, 95% CI 1.74-2.04), failed induction (aOR 1.51, 95% CI 1.39-1.64), cesarean delivery (aOR 1.35, 95% CI 1.29-1.40), and large for gestational age infants (aOR 2.43, 95% CI 2.30-2.56). CONCLUSION: Our study shows that adherence to the current Institute of Medicine guidelines results in lower risks for adverse pregnancy, labor, and delivery outcomes when comparing all outcomes collectively.

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PURPOSE: This study compares rural and small-city teenage and adult pregnancies, with respect to complication rates and pregnancy outcomes. METHODS: Chart review of Medicaid patients (513 teenage [under 20 years] and 174 adult controls [ages 25-34]) delivered (excluding multiple gestation) in Amarillo, Texas, from January 1999 to April 2001. Demographic data collected included maternal race, gravidity, parity, smoking status, drug usage, presence of antenatally diagnosed sexually transmitted disease(s), county type (rural vs small city) and number of prenatal visits. Outcomes included mode of delivery, primary cesarean section rates, preterm birth (<34 or <37 weeks), birth weight, birth weight <2500 g, preeclampsia, total maternal weight gain, hemoglobin changes after delivery, Apgar scores, and neonatal intensive care unit admissions. Statistical comparisons between groups were made for a number of factors and outcomes (P < .05). RESULTS: Teenagers did not have a significantly higher frequency of either illicit drug or tobacco usage, but teenagers <17 years had a greater incidence of sexually transmitted diseases (19.8% vs 10.4%, P < .008) and preeclampsia (7.1% vs 2.3%, P < .025, odds ratio 3.2 [1.1 to 9.9]) when compared with adults. The total weight gain was highest for teens < or =17 years (36.4 pounds vs adults: 28.2, P < .001). The primary cesarean section rate was higher in adults (all teens 18.5% vs adults 38.6%, P < 001). County rurality had no impact on any of the observed findings or variables tested. CONCLUSIONS: Young teenagers have a higher incidence of sexually transmitted diseases and preeclampsia and also gain significantly more weight with pregnancy than young adults. However, the pregnancy outcomes were no different for rural vs small city teens.

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OBJECTIVE: To determine if a student's subjective clinical evaluation score (CES) correlates with United States Medical Licensing Examination (USMLE) Step 1 or Step 2, obstetrics/gynecology clerkship final examination or Medical College Admission Test (MCAT) scores. STUDY DESIGN: The test scores for all students rotating at Texas Tech Health Sciences Center at Amarillo from 1994 to 2002 were obtained. Regression models were used to compare the CES and examination scores. The 10th percentile of the CES was statistically compared with each examination score as well as its 10th percentiles. RESULTS: The mean scores for the 285 students were USMLE Step 1, 204.4; USMLE Step 2, 205.0; MCAT, 29.1; obstetrics/gynecology final, 86.0; CES, 88.5. Linear correlations were found between the CES and USMLE Step 2 (r = 0.26, p < 0.001) and the obstetrics/gynecology final (r=0.25, p<0.001). Students with a poor CES (<10th percentile) had lower USMLE Step 2 scores, (188.2 vs. 206.3, p < 0.001) and more examination failures (odds ratio [OR] 8.9 [2.3-33.9]) as well as both lower obstetrics/gynecology final examination scores (81.1 vs. 86.3, p < 0.001) and more clerkship failures (OR 14.2 [1.9-107.4]). CONCLUSION: Students' subjective CESs correlate linearly with performance on both the USMLE Step 2 and obstetrics/gynecology final examinations. Poor CESs (< 10th percentile) predicted lower scores on the future standardized examinations studied.

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OBJECTIVE: To determine if either a shorter third-year obstetrics and gynecology (Ob/Gyn) student clerkship or the semester of rotation results in differences in a student's objective or subjective performance. STUDY DESIGN: Five hundred twenty-one students from 1995-1998 (8-week clerkship) and 112 students from 1998-1999 (6 weeks) in their third year of medical school were included. Final examination scores, subjective assessments for the Ob/Gyn clerkship, final grades and United States Medical Licensure Examination (USMLE) Step 1 scores were obtained (first attempts only). Student t tests, chi2 and univariate analysis (using USMLE Step 1 scores as a control) were used (P <. 05) to compare the Ob/Gyn clerkship scores/grades by both clerkship length and semester of rotation. RESULTS: The 8-week and 6-week clerkship mean final examination scores were 69.5 and 69.7, respectively; the USMLE Step 1 scores were 205.1 and 215.1, respectively (P < .001). After univariate analysis, lower examination scores were seen for students clerking on the 6-week rotation (P < .001) as well as for those clerking in the first semester (first semester, 68.1; second, 71.3; P < .001). Based upon these results, the 8-week clerkship scores were calculated to be approximately 3.4 points higher than those of the 6-week clerkship, potentially lowering the final grades of 15.2% of the 6-week students. No significant differences were seen with the comparisons of a student's subjective assessments. CONCLUSION: A shorter third-year Ob/Gyn student clerkship appears to lower Ob/Gyn final examination scores. Lower examination scores are also seen for students with a first-semester clerkship. These lower scores could lead to lower final grades.

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OBJECTIVE: To estimate whether variations in intrapartum management and complications exist with regard to the time of delivery within the academic year. METHODS: The delivery records of 7814 patients were separated by both term half year and quarter. Statistical comparisons were made using chi2 tests of association (P < .05) with respect to the academic time of the year and perineal trauma (third- or fourth-degree tear), episiotomy usage, cesarean delivery, postpartum hemorrhage, chorioamnionitis, shoulder dystocia, neonatal intensive care unit admission, 1- or 5-minute Apgar scores less than 7, and low umbilical cord pH. RESULTS: There were 4082 deliveries in the first half and 3732 in the second half of the year from April 1996 through March 1999. The first half-year overall cesarean rate was higher (15.8% versus 14.3%, P < .03). Primary cesarean rates were similar. No other differences were found by term half year. More perineal trauma was noted in the fourth quarter (first 3.3%, second 4.5%, third 3.7%, fourth 5.5%, P < .037). Episiotomy usage was higher in both the first and fourth quarters (13.0%, 11.3%, 10.6%, and 14.8%, P < .002). More cases of chorioamnionitis occurred in the fourth quarter (first 3.4%, second 3.1%, third 2.6%, fourth 4.0%, P < .038, third versus fourth quarter). Chorioamnionitis occurred more frequently in July (July 5.0% versus August-June 3.1%, P < .005). There were no other clinically significant differences. Neonatal outcomes were not affected by academic time of year. CONCLUSION: Although small differences in outcome exist with respect to the academic time of the year, the timing of these differences indicates that there is not a "July phenomenon" in obstetrics at our institution.

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OBJECTIVE: To determine risk factors for a prolonged second stage of labor and evaluate the maternal and neonatal outcomes of such pregnancies. METHODS: We reviewed all 7818 patients who delivered at the University of Illinois at Chicago from 1996 to 1999. Excluding nonvertex and multiple gestations, 6791 reached the second stage. Group 1 (n = 6259) consisted of patients with a second stage of 120 minutes or less; group 2, greater than 120 minutes (n = 532 [7.8%]); group 2A, 121-240 minutes (n = 384 [5.7%]); and group 2B, greater than 240 minutes (n = 148 [2.2%]). We compared pregnancy outcomes for these groups with respect to maternal and neonatal morbidity factors using chi(2), Student t, and Wilcoxon rank-sum tests (significance, P <.05). RESULTS: Vaginal delivery rates were 98.7% (group 1), 84.0% (group 2), 90.2% (group 2A), and 65.5% (group 2B). Group 2 had higher rates of perineal trauma, episiotomy usage, chorioamnionitis, postpartum hemorrhage, and operative vaginal delivery than group 1 (P <.001, all comparisons). Group 2B had higher rates of episiotomy usage, operative vaginal deliveries, and perineal trauma than group 2A (P <.001, all comparisons). The neonatal morbidity rates were similar for the three groups. Diabetes, preeclampsia (P <.023), macrosomia, nulliparity, chorioamnionitis, oxytocin usage, and labor induction were each independently associated with an increased risk of a prolonged second stage (all but preeclampsia, P <.001). CONCLUSION: A prolonged second stage is associated with a high rate of vaginal delivery, but a high rate of maternal, though not neonatal, morbidity was observed. Certain antenatal and intrapartum conditions are associated with a prolonged second stage of labor.

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OBJECTIVE: To determine the normal values of the deepest vertical amniotic fluid pocket (DVP) in term pregnancies and whether a similar relationship to birth weight (BW) exists. STUDY DESIGN: Two hundred thirty-one term patients (37-42 weeks) with intact membranes and a normal amniotic fluid index (AFI) were included. DVP was identified and compared to BW, BW > 4,000 g (large for gestational age [LGA]) and BW < 2,500 g (small for gestational age [SGA]). Statistical comparisons and linear regression models were made. RESULTS: The mean gestational age was 39.6 weeks, and mean BW 3,284 g. Mean DVP was 4.5 cm. This did not vary significantly by gestational age. A positive linear correlation was observed between DVP and BW. DVP was greater for pregnancies with LGA (5.2 vs. 4.3 cm [P < .003]). No difference was observed for SGA. The relative risk for a fetus > 4,000 g when the DVP was > 6 was 4.0 (1.6-9.5) and 15.8 (1.6-157.6) if maternal diabetes was also present. No difference was determined for SGA using a DVP < 2. CONCLUSION: Higher DVP is associated with delivery of an LGA infant, particularly in diabetic women.

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OBJECTIVE: We studied the correlations between both Step 1 and Step 2 of the United States Medical Licensure Examination (USMLE) and the National Board of Medical Examiners Obstetrics and Gynecology Examination (NBME-OB/GYN). METHODS: From July 1994 until June 2001, all third-year medical students at Texas Tech University Health Center at Amarillo were studied. The scores from the first attempts for the three examinations were obtained. We investigated for correlations between the examination scores and the score extremes. RESULTS: A total of 258 students were evaluated. The mean USMLE Step 1 score was 203.7; mean score for Step 2 was 205.0. The NBME-OB/GYN final examination was 86.0. We found linear correlations between the NBME-OB/GYN and the USMLE Step 1 (r =.463, P <.001) and USMLE Step 2 (r =.595, P <.001), as well as between the USMLE Steps 1 and 2 (r =.666 P <.001). Students failing the USMLE Step 1 were more likely to fail their USMLE Step 2 (relative risk [RR] 9.3 [95% confidence interval (CI) 2.1, 41.0]) and/or the NBME-OB/GYN (RR 3.3 [95% CI 1.03, 10.8]). Students scoring in the lowest 25th percentile of the NBME-OB/GYN were more likely to fail the USMLE Step 2. CONCLUSION: Both USMLE Steps 1 and 2 correlated with the NBME-OB/GYN scores, as well as with each other. Students failing either the USMLE Step 1 or NBME-OB/GYN were more likely to fail the USMLE Step 2. The use of this information could predict students at risk for low scores on future examinations.

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OBJECTIVE: Our purpose was to evaluate obesity (body mass index greater than 30.0) as an independent risk factor for infectious morbidity in women having elective or nonelective cesarean deliveries. METHODS: Charts of 611 patients undergoing cesarean were reviewed. After exclusion of those with pre-existing chorioamnionitis, 574 cases were separated into two groups (elective or nonelective cesarean) and then subdivided based on the presence or not of postdelivery infectious morbidity. Estimated blood loss, operative time, number of vaginal examinations, labor length, use of internal monitors, body mass index (BMI), and obesity (BMI greater than 30.0) were then recorded. Student t test, chi(2), multivariate analysis, and receiver operating characteristics curves were used where appropriate (significance: P <.05). RESULTS: The mean gestational age at delivery was 38.3 weeks. Three hundred sixty patients had nonelective cesareans, and 214 had elective cesareans. Prophylactic antibiotics were used for 86.6% of the nonelective group and 75.2% of the elective group. In the nonelective group and after multivariate analysis, significant risk factors for postoperative infections were as follows: labor length (18.4 hours versus 10.9, P <.003), number of vaginal examinations (6.1 versus 4.5, P <.001), BMI (36.6 versus 32.3, P <.001), and obesity (81.8% versus 57.3%, P <.001). For the elective group, a higher BMI (38.9 versus 32.2, P <.003), and black race (63.2% versus 11.5%, P <.001) were found to be significant. CONCLUSION: Our data suggest that obesity is a independent risk factor for postcesarean infectious morbidity and endomyometritis, even if the cesarean is elective and prophylactic antibiotics are given.

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OBJECTIVE: To study women at the time of admission to the labor and delivery unit to determine which type of ultrasonographic assessment of the amniotic fluid--amniotic fluid index (AFI), single deepest vertical pocket (DVP) or amniotic fluid distribution (AFD)--had the greatest clinical utility in predicting labor complications. STUDY DESIGN: Patients not at term, with a nonvertex presentation, or with ruptured membranes, polyhydramnios, or known maternal or congenital abnormalities were excluded. We included 266 low-risk pregnant women admitted for labor. Medical charts were reviewed for documentation of meconium-stained amniotic fluid (Mec), cesarean section (C/S) for fetal indications and admissions to the neonatal intensive care unit (NICU). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for AFI, DVP and AFD were calculated in relation to the three outcome variables. Positive findings were defined as: AFI < 5.0, DVP < 2.5 cm and AFD, sum of the two lower quadrants of the AFI with a lower value than the sum of the two upper quadrants. RESULTS: Mec was documented in 56 patients (21%), 13 patients (4.8%) had a C/S for fetal indications, and 4 infants (1.5%) were admitted to the NICU. Abnormal AFI was detected in 35 patients (13%), abnormal DVP in 38 patients (14%) and abnormal AFD in 117 patients (44%). PPV and NPV for prediction of Mec, C/S and NICU were: Mec 31% and 80% for AFI, 26% and 80% for DVP; 31% and 91% for AFD; C/S 8.6% and 95% for AFI, 5% and 95% for DVP; 8.6% and 100% for AFD and NICU, 0% and 98% for AFI, 0% and 95% for DVP, and 2.7% and 99% for AFD. CONCLUSION: Normal ultrasonographic values for AFI and AFD are associated with a very low risk of labor complications.

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