Brad M. Dolinsky

Persistent Pulmonary Hypertension of the Newborn Is Associated with Mode of Delivery and Not with Maternal Use of Selective Serotonin Reuptake Inhibitors

We sought to determine if maternal use of selective serotonin reuptake inhibitors (SSRIs) in the second half of pregnancy is associated with persistent pulmonary hypertension of the newborn (PPHN). We performed a case-controlled study (1:6 ratio) of infants delivered at Madigan Army Medical Center with primary PPHN from 2003 through 2009. Study and control patients were compared for the following clinical factors: SSRI use after 20 weeks gestation, mode of delivery, maternal disease, body mass index, tobacco use, fetal gender, maternal age, and parity. We identified 20 cases of primary PPHN out of 11,923 births for an incidence of 0.17%. Mode of delivery was the only factor we found to be associated with PPHN. Specifically, cesarean delivery (CD) prior to the onset of labor increased the risk for PPHN: odds ratio (OR) = 4.9, confidence interval (CI) 1.7 to 14.0. Importantly, use of SSRIs in the second half of pregnancy was identified in 5% of the controls but none of the cases (OR = 0, CI 0 to 3). PPHN is associated with CD prior to the onset of labor but not with SSRI use in the second half of pregnancy. Previous studies linking PPHN to SSRI use relied on after-the-fact patient interviews and incomplete records. Additional studies are needed to verify these results.

Effect of Dexamethasone Administered With Magnesium Sulfate on Inflammation-Mediated Degradation of the Blood–Brain Barrier Using an In Vitro Model

Patients at risk for preterm delivery are frequently administered both antenatal steroids for fetal maturation and magnesium sulfate for neuroprotection. In this study, we investigate whether steroids coadministered with magnesium sulfate preserve blood–brain barrier integrity in neuroinflammation. Human umbilical vein endothelial cells were grown in astroglial conditioned media in a 2-chamber cell culture apparatus. Treatment with tumor necrosis factor-α (TNF-α) or catalytically active recombinant matrix metalloproteinase 9 (MMP-9) simulated neuroinflammation. Membrane integrity was assessed by zona occludens 1 (ZO-1) immunoreactivity, permeability to fluorescently conjugated dextran, and transendothelial electrical resistance (TEER). The TNF-α and MMP-9 treatment increased the rate of dextran transit, decreased TEER, and decreased ZO-1 immunoreactivity at junctional interfaces. Dexamethasone pretreatment alone or in combination with 0.5 mmol/L magnesium sulfate preserved monolayer integrity after inflammatory insult. Magnesium sulfate alone was not protective. This study supports a possible interaction between steroids and magnesium in neuroprotection.

The effect of magnesium sulfate on the activity of matrix metalloproteinase-9 in fetal cord plasma and human umbilical vein endothelial cells

OBJECTIVE Clinical evidence suggests that magnesium sulfate may reduce the risk of fetal neurologic injury in preterm delivery. Matrix metalloproteinase-9 (MMP-9) levels are elevated in preterm labor patients. There is evidence that MMP-9 may break down the blood-brain barrier in humans, causing cytokine mediated cell injury. Our objective was to determine whether the addition of magnesium sulfate attenuates activity of MMP-9, a complex zinc-dependent enzyme, in fetal cord plasma. STUDY DESIGN We collected cord plasma in 6 term, unlabored patients. Using enzyme-linked immunosorbent assay, we measured the activity of MMP-9 with varying concentrations of magnesium sulfate added in vitro. Results were verified using a human umbilical cord vein endothelial cell (HUVEC) line. RESULTS Addition of physiologic doses of magnesium sulfate (0.07 mg/mL) resulted in a 25% decrease in active MMP-9 (P = .03). In a HUVEC line, magnesium sulfate resulted in a 32% decrease in MMP-9 activity (P = .00012). CONCLUSION The addition of magnesium sulfate attenuated MMP-9 activity in cord plasma and in a HUVEC line.

Interaction between maternal obesity and Bishop score in predicting successful induction of labor in term, nulliparous patients.

OBJECTIVE Determine the Bishop score most predictive of induction of labor (IOL) success for different maternal weight groups. STUDY DESIGN Retrospective cohort study. Prospectively collected database utilized to determine the optimum Bishop score within each prepregnancy body mass index (BMI) category of term, nulliparous patients undergoing IOL. RESULTS For the total group (n = 696), Bishop score ≥ 5 was most predictive of success (75% versus 56%, p < 0.0001). Within each BMI category, Bishop score ≥ 5 remained most predictive: normal weight (79% versus 64%, p < 0.01); overweight (72% versus 58%, p = 0.03); and obese (73% versus 45%, p < 0.0001). Overall, nonobese patients had more success than obese patients (70% versus 59%, p < 0.01). The nonobese group had more success than the obese group when the Bishop score was < 3 (57% versus 39%, p < 0.05) but not when it was ≥ 3 (72% versus 65%, p = 0.1). Also, there was a higher fraction of patients with Bishop score < 3 in the obese group compared with the nonobese group (25% versus 14%, p < 0.001). CONCLUSION The optimum Bishop score for predicting successful IOL in nulliparous patients was 5 regardless of BMI class. The higher IOL failure rate observed in obese women was associated with lower starting Bishop scores and was compounded by higher failure rates in obese women with Bishop scores < 3.

Transversus abdominis plane block for postoperative analgesia after cesarean delivery

Objective: The transversus abdominis plane (TAP) block is the ultrasound-guided placement of a peripheral nerve block in the abdominal wall for pain control. Our objective was to compare postoperative adjunctive oral narcotic use in women who underwent cesarean delivery and received the TAP block vs. those who received neuraxial narcotics. We hypothesize a decrease in narcotic use in women who received the TAP block. Methods: Retrospective cohort study of women who received a TAP block for postoperative analgesia after cesarean compared to women who did not. The primary outcome was the total number of oral narcotic tablets administered between 24 and 48 h after surgery. An independent t-test and an analysis of covariance were employed to determine significant differences (P < 0.05) between the cohorts and to adjust for confounders. Results: The TAP block cohort utilized 30% less oral narcotic analgesia than the control cohort (3.8 ± 0.5 tablets, P < 0.001). After adjusting for confounders and the presence of antecedent labor, there remained a significant reduction in the total oral narcotic doses given to women who underwent a TAP block compared to other forms of analgesia. Conclusion: The TAP block is associated with decreased oral narcotic usage 24–48 h following cesarean delivery

The pregnancy “super-utilizer”: how does a high-risk depression screen affect medical utilization?

Abstract Objective: Our objective was to determine whether a score of  >11 on the Edinburgh postnatal depression scale (EPDS) at the initial prenatal visit was associated with an increased use of acute medical visits when compared to pregnant women with an initial EPDS score of ≤11. Methods: This was a retrospective cohort study comparing the utilization of acute medical care during pregnancy and the first eight weeks after delivery amongst 200 women with an EPDS score >11 at their initial prenatal visit compared with 200 women with an EPDS score ≤11. “Super-utilization” was defined as ≥4 acute or unscheduled medical visits during pregnancy and the first eight weeks after delivery (90th percentile). Logistic regression was used to control for confounders. Results: Women with an initial EPDS score >11 were significantly more likely to engage in super-utilization of acute medical care compared with those women scoring ≤11 (adjusted odds ratio [aOR], 2.12; 95% confidence interval [CI], 1.53–3.90). Conclusions: Pregnant women scoring >11 on the EPDS at their initial prenatal visit are more likely to super-utilize acute medical care in the perinatal period. This subset of patients at-risk for increased utilization can be identified early during prenatal care. Interventions to better meet the medical and psychosocial needs of these women warrant future research.

Micronized progesterone reduces vasoconstriction in the placenta.

Abstract Objective: To investigate if micronized progesterone (P4) has the ability to attenuate thromboxane mimetic U46619-mediated fetoplacental artery vasoconstriction. Methods: Paired cotyledons obtained from the same placenta of five-term subjects were analyzed. The fetal artery and maternal intervillous space of one cotyledon was infused with P4 while another cotyledon was infused with control perfusate. After 30 min, a bolus dose of U44619 was administered to both cotyledons. Results: The change in the measured fetoplacental vascular pressure caused by bolus administration of U46619 was less in the cotyledons infused with P4 (p = 0.009). Conclusion: Continuous treatment with P4 significantly attenuates the U46619-mediated fetoplacental vasoconstriction.