Anna M. Modest

The effects of umbilical cord milking in extremely preterm infants: a randomized controlled trial

Objective:Delayed cord clamping has been shown to decrease the need for transfusion in preterm neonates, but may delay resuscitation. The aim of this study was to determine whether umbilical cord milking compared with immediate cord clamping in extremely preterm deliveries reduces the need for neonatal red blood cell transfusion.Study design:Women admitted to a tertiary care center and expected to deliver between 24 to 28 completed weeks of gestation were randomized to cord milking before clamping or immediate cord clamping. The primary outcome was the risk of neonatal transfusion, reported as risk ratio (RR) and 95% confidence interval (CI).Result:Of 113 women who were enrolled and randomized, 56 were assigned to cord milking with 36 remaining eligible and completing the study and 57 were assigned to the control group with 39 remaining eligible and completing the study. Albeit not statistically significant, neonates in the cord milking group were less likely to require transfusion compared with those in the control group (RR: 0.86; 95% CI: 0.73 to 1.0). Neonates whose cords were milked had higher hematocrits at birth (P=0.004) and were less likely to develop an intraventricular hemorrhage (P=0.0195).Conclusion:Milking the umbilical cord of a preterm neonate is an easy intervention with the potential to improve perinatal outcomes. Our results suggest that milking of the cord increases the neonate’s initial hematocrit and may lessen the need for transfusion in the neonatal period. The observed reduction in the incidence of intraventricular hemorrhage may have important long-term implications that warrant further study.

Circulating Angiogenic Factors and Risk of Adverse Maternal and Perinatal Outcomes in Twin Pregnancies With Suspected Preeclampsia

To evaluate whether angiogenic factor levels correlate with preeclampsia-related adverse maternal and perinatal outcomes in women with twin pregnancy, we studied 79 women with suspected preeclampsia in the 3rd trimester. Antiangiogenic soluble fms-like tyrosine kinase-1 (sFlt-1) and proangiogenic placental growth factor (PlGF) were measured at presentation on an automated platform. An adverse outcome was defined as hemolysis, elevated liver enzymes, and low platelets syndrome; disseminated intravascular coagulation; abruption; pulmonary edema; cerebral hemorrhage; maternal, fetal, and neonatal death; eclampsia; acute renal failure; small for gestational age; and indicated delivery. All outcomes were ascertained 2 weeks after initial evaluation. Comparing the 52 women (65.8%) who experienced an adverse outcome with the 27 women (34.2%) without an adverse outcome, the median sFlt-1 was elevated (11461.5 pg/mL [8794.0–14847.5] versus 7495.0 pg/mL [3498.0–10482.0; P=0.0004]), PlGF was reduced (162.5 pg/mL [98.0–226.5] versus 224.0 pg/mL [156.0–449.0]; P=0.005), and sFlt-1/PlGF ratio was elevated (74.2 [43.5–110.5] versus 36.2 [7.1–71.3]; P=0.0005). Among those presenting <34 weeks (n=40), the difference in sFlt-1/PlGF ratio was more striking (97.7 [76.6–178.1] versus 31.7 [6.5–48.7]; P=0.001). Addition of sFlt-1/PlGF to the highest systolic blood pressure and proteinuria improved prediction of adverse outcomes. We conclude that in women with twin pregnancy and suspected preeclampsia, the sFlt-1/PlGF ratio at the time of initial evaluation is associated with subsequent adverse maternal and perinatal outcomes. These findings are similar to those in singleton pregnancies and may implicate common pathogenic pathways.

Botulinum Toxin Type A (botox) for Refractory Myofascial Pelvic Pain

Objective To assess intralevator botulinum toxin type A (Botox) injections for refractory myofascial pelvic pain with short tight pelvic floor. Methods Retrospective cohort study of all women with intralevator Botox injection (100–300 Units) from 2005 through 2010 for refractory myofascial pelvic pain. Primary outcomes were self-reported pain on palpation and symptom improvement. Secondary outcomes included postinjection complications and a second injection. Pain was assessed during digital palpation of the pelvic floor muscles using a scale of 0 to 10, with 10 being the worst possible pain. Follow-up occurred at less than 6 weeks after injection and again at 6 weeks or more. Data are presented as median (interquartile range) or proportion. Results Thirty-one patients met eligibility criteria; 2 patients were lostto follow-up and excluded. The median age was 55.0 years (38.0–62.0 years). Before Botox injection, the median pain score was 9.5 (8.0–10.0). Twenty-nine patients (93.5%) returned for the first follow-up visit; 79.3% reported improvement in pain, whereas 20.7% reported no improvement. The median pain with levator palpation was significantly lower than before injection (P<0.0001). Eighteen women (58.0%) had a second follow-up visit with a median pain score that remained lower than before injection (P<0.0001). Fifteen (51.7%) women elected to have a second Botox injection; the median time to the second injection was 4.0 months (3.0–7.0 months). Three (10.3%) women developed de novo urinary retention, 2 patients (6.9%) reported fecal incontinence, and 3 patients (10.3%) reported constipation and/or rectal pain; all adverse effects resolved spontaneously. Conclusions Intralevator injection of Botox demonstrates effectiveness in women with refractory myofascial pelvic pain with few self-limiting adverse effects.

An assessment of gender inequitable norms and gender-based violence in South Sudan: a community-based participatory research approach

BackgroundFollowing decades of conflict, South Sudan gained independence from Sudan in 2011. Prolonged conflict, which included gender-based violence (GBV), exacerbated gender disparities. This study aimed to assess attitudes towards gender inequitable norms related to GBV and to estimate the frequency of GBV in sampled communities of South Sudan.MethodsApplying a community-based participatory research approach, 680 adult male and female household respondents were interviewed in seven sites within South Sudan in 2009–2011. Sites were selected based on program catchment area for a non-governmental organization and respondents were selected by quota sampling. The verbally-administered survey assessed attitudes using the Gender Equitable Men scale. Results were stratified by gender, age, and education.ResultsOf 680 respondents, 352 were female, 326 were male, and 2 did not provide gender data. Among respondents, 82% of females and 81% of males agreed that ‘a woman should tolerate violence in order to keep her family together’. The majority, 68% of females and 63% of males, also agreed that ‘there are times when a woman deserves to be beaten’. Women (47%) were more likely than men (37%) to agree that ‘it is okay for a man to hit his wife if she won’t have sex with him’ (p=0.005). Agreement with gender inequitable norms decreased with education. Across sites, 69% of respondents knew at least one woman who was beaten by her husband in the past month and 42% of respondents knew at least one man who forced his wife or partner to have sex.ConclusionThe study reveals an acceptance of violence against women among sampled communities in South Sudan. Both women and men agreed with gender inequitable norms, further supporting that GBV programming should address the attitudes of both women and men. The results support promotion of education as a strategy for addressing gender inequality and GBV. The findings reveal a high frequency of GBV across all assessment sites; however, population-based studies are needed to determine the prevalence of GBV in South Sudan. South Sudan, the world’s newest nation, has the unique opportunity to implement policies that promote gender equality and the protection of women.

Screening for pain in pediatric brain tumor survivors using the pain thermometer.

Numerous instruments have been developed to measure pain within various populations; however, there remains limited understanding of how these tools are applicable to childhood cancer survivors. This study compared a single-item screening measure, the Pain Thermometer (PT), with a more in-depth measure, the Brief Pain Survey (BPS), in a cohort of childhood brain tumor survivors. Ninety-nine survivors (aged 13-32 years) with a median time from diagnosis of 9.9 years (range = 2-18 years) completed the 2 instruments. Thirty-seven survivors (37.4%) were identified on the BPS as having clinically significant pain, but the PT was not found to be an accurate tool for identifying these pain cases. Application of receiver operating characteristic curve analysis of PT ratings against BPS criterion indicated overall concordance between measures. No cutoff score on the PT were identified that resulted in acceptable sensitivity, meaning pain cases identified on the BPS would be missed on the PT. Findings suggest that a multi-item screening measure may better identify clinically significant pain in childhood brain tumor survivors compared with a 1-item screening measure alone.

Developing an Objective Structured Assessment of Technical Skills for Laparoscopic Suturing and Intracorporeal Knot Tying

OBJECTIVE To develop a teaching and assessment tool for laparoscopic suturing and intracorporeal knot tying. DESIGN AND SETTING We designed an Objective Structured Assessment of Technical Skills (OSATS) tool that includes a procedure-specific checklist (PSC) and global rating scale (GRS) to assess laparoscopic suturing and intracorporeal knot-tying performance. Obstetrics and Gynecology residents at our institution were videotaped while performing a laparoscopic suturing and intracorporeal knot-tying task at a surgical simulation workshop. A total of 2 expert reviewers assessed resident performance using the OSATS tool during live performance and 1 month later using the videotaped recordings. OSATS scores were analyzed using the Wilcoxon rank-sum test. Data are presented as median scores (interquartile range [IQR]). Intrarater and interrater reliabilities were assessed using a Spearman correlation and are presented as an r correlation coefficient and p value. An r ≥ 0.8 was considered as a high correlation. After testing, we received feedback from residents and faculty to improve the OSATS tool as part of an iterative design process. PARTICIPANTS In all, 14 of 21 residents (66.7%) completed the study, with 9 junior residents and 5 senior residents. RESULTS Junior residents had a lower score on the PSC than senior residents did; however, this was not statistically significant (median = 6.0 [IQR: 4.0-10.0] and median = 13.0 [IQR: 10.0-13.0]; p = 0.09). There was excellent intrarater reliability with our OSATS tool (for PSC component, r = 0.88 for Rater 1 and 0.93 for Rater 2, both p < 0.0001; for GRS component, r = 0.85 for Rater 1 and 0.88 for Rater 2, both p ≤ 0.0002). The PSC also has high interrater reliability during live evaluation (r = 0.92; p < 0.0001), and during the videotape scoring with r = 0.77 (p = 0.001). CONCLUSIONS Our OSATS tool may be a useful assessment and teaching tool for laparoscopic suturing and intracorporeal knot-tying skills. Overall, good intrarater reliability was demonstrated, suggesting that this tool may be useful for longitudinal assessment of surgical skills.

Maternal risk factors for neonatal necrotizing enterocolitis

Abstract Objective: This study aimed to investigate the relationship between maternal hypertensive disease and other risk factors and the neonatal development of necrotizing enterocolitis (NEC). Methods: This was a retrospective case–control study of infants with NEC from 2008 to 2012. The primary exposure of interest was maternal hypertensive disease, which has been hypothesized to put infants at risk for NEC. Other variables collected included demographics, pregnancy complications, medications and neonatal hospital course. Data were abstracted from medical records. Results: Twenty-eight cases of singleton neonates with NEC and 81 matched controls were identified and analyzed. There was no significant difference in the primary outcome. Fetuses with an antenatal diagnosis of growth restriction were more likely to develop NEC (p = 0.008). Infants with NEC had lower median birth weight than infants without NEC (p = 0.009). Infants with NEC had more late-onset sepsis (p = 0.01) and mortality before discharge (p = 0.001). Conclusions: The factors identified by this case–control study that increased the risk of neonatal NEC included intrauterine growth restriction and lower neonatal birth weight. The primary exposure, hypertensive disease, did not show a significantly increased risk of neonatal NEC; however, there was a nearly two-fold difference observed. Our study was underpowered to detect the observed difference.

Adverse maternal and fetal outcomes and deaths related to preeclampsia and eclampsia in Haiti

OBJECTIVE The purpose of this study was to define the prevalence and clinical characteristics of preeclampsia and eclampsia at a hospital in rural Haiti. METHODS This is a retrospective review of women presenting to Hôpital Albert Schweitzer (HAS) in Deschapelles, Haiti with singleton pregnancy and diagnosis of preeclampsia or eclampsia from January 1, 2011 through December 31, 2012. Hospital charts were reviewed to obtain medical and prenatal history, hospital course, delivery information, and fetal/neonatal outcomes. The outcomes included placental abruption, antepartum eclampsia, postpartum eclampsia, maternal death, birthweight <2500g and stillbirth. Data are presented as median (quartile 1, quartile 3) or n (%) and risk ratios. RESULTS During the study period, 1743 women were admitted to the maternity service at HAS and 290 (16.6%) were diagnosed with preeclampsia or eclampsia. Only singleton pregnancies were analyzed (N=270). Nearly all (95.0%) patients admitted with preeclampsia had severe preeclampsia. There were 83 patients with eclampsia (30.7%) of which 61 (73.4%) had antepartum eclampsia. There were 48 stillbirths (17.8%) and 5 maternal deaths (1.9%). Patients with antepartum eclampsia were younger, more likely to be nulliparous and had less prenatal care compared to women with antepartum preeclampsia. Antepartum eclampsia was associated with placental abruption and maternal death. CONCLUSIONS The rates of preeclampsia and its associated complications, such as eclampsia, placental abruption, maternal death and stillbirth, are high at this facility in Haiti. Such data are essential to developing region-specific systems to prevent preeclampsia-related complications.

Mycoplasma genitalium and preterm delivery at an urban community health center

To determine the prepartum prevalence of cervical Mycoplasma genitalium colonization and evaluate prospectively whether colonization is associated with preterm delivery among women from a racial/ethnic minority background with a high risk of delivering a low birth weight newborn and a high prevalence of sexually transmitted infections.

Influences of sex, age and education on attitudes towards gender inequitable norms and practices in South Sudan

Prolonged conflict in South Sudan exacerbated gender disparities and inequities. This study assessed differences in attitudes towards gender inequitable norms and practices by sex, age and education to inform programming. Applying community-based participatory research methodology, 680 adult respondents, selected by quota sampling, were interviewed in seven South Sudanese communities from 2009 to 2011. The verbally administered survey assessed attitudes using the Gender Equitable Men scale. Data were stratified by sex, age and education. Of 680 respondents, 352 were female, 326 were male and two did not report their sex. The majority of respondents agreed with gender inequitable household roles, but the majority disagreed with gender inequitable practices (i.e., early marriage, forced marriage and inequitable education of girls). Respondents who reported no education were more likely than those who reported any education to agree with gender inequitable practices (all p < 0.03) except for forced marriage (p = 0.07), and few significant differences were observed when these responses were stratified by sex and by age. The study reveals agreement with gender inequitable norms in the household but an overall disagreement with gender inequitable practices in sampled communities. The findings support that education of both women and men may promote gender equitable norms and practices.