Bradley D. Holbrook

Umbilical Cord Prolapse

Umbilical cord prolapse is an obstetric emergency that can have negative outcomes for the fetus. It is diagnosed by a palpable or visible cord and is often accompanied by severe, rapid fetal heart rate decelerations. Cases of cord prolapse should be delivered as soon as possible, usually by cesarean section. While awaiting delivery, the fetal presenting part should be elevated off the cord either manually or by filling the bladder. Although an untreated case of umbilical cord prolapse can lead to severe fetal morbidity and mortality, prompt and appropriate management leads to good overall outcomes.

Teratogenic Risks from Exposure to Illicit Drugs

Substance use is prevalent in the United States, especially in the reproductive age population. Even though a reduction in substance use may occur during pregnancy, some women may not alter their drug use patterns until at least pregnancy is confirmed. For these reasons, a large number of fetuses are exposed to illicit substances, including during critical stages of organogenesis. Associating illicit drug use with eventual pregnancy outcome is difficult. This article presents issues pertaining to limitations with published investigations about fetal risks and describes the most current information in humans about fetal effects from specific illicit substances.

The effects of nicotine on human fetal development

Maternal smoking during pregnancy continues to represent a major public health concern. Nicotine is extremely harmful to the developing fetus through many different mechanisms, and the harms increase with later gestational age at exposure. Pregnancies complicated by maternal nicotine use are more likely to have significant adverse outcomes. Nicotine-exposed children tend to have several health problems throughout their lives, including impaired function of the endocrine, reproductive, respiratory, cardiovascular, and neurologic systems. Poor academic performance and significant behavioral disruptions are also common, including ADHD, aggressive behaviors, and future substance abuse. To diminish the adverse effects from cigarette smoking, some women are turning to electronic cigarettes, a new trend that is increasing in popularity worldwide. They are largely perceived as being safer to use in pregnancy than traditional cigarettes, although there is not adequate evidence to support this claim. At this time, electronic cigarette use during pregnancy cannot be recommended. Birth Defects Research (Part C) 108:181-192, 2016.

Abdominal Circumference Alone versus Estimated Fetal Weight after 24 Weeks to Predict Small or Large for Gestational Age at Birth: A Meta-Analysis

Objective We compared the sensitivity and specificity of abdominal circumference (AC) alone versus estimated fetal weight (EFW) to predict small for gestational age (SGA) or large for gestational age (LGA) at birth. Study Design We searched the literature for studies assessing an ultrasonographic AC or EFW after 24 weeks to predict SGA or LGA at birth. Case series or studies including anomalous fetuses or multiple gestations were excluded. We computed the sensitivity, specificity, and positive and negative predictive values of any AC or EFW cutoff analyzed by at least two studies. Results We identified 2,460 studies, of which 40 met inclusion criteria (n = 36,519). Four studies assessed AC alone to predict SGA (n = 5,119), and six assessed AC to predict LGA (n = 6,110). Sixteen assessed EFW to predict SGA (n = 13,825), and 22 evaluated EFW to predict LGA (n = 18,896). To predict SGA, AC and EFW < 10th percentile have similar ability to predict SGA. To predict LGA, AC cutoffs were comparable to all EFW cutoffs, except that AC > 35 cm had better sensitivity. Conclusion After 24 weeks, AC is comparable to EFW to predict both SGA and LGA. In settings where serial EFWs are inaccessible, a simpler screening method with AC alone may suffice.

Reported Experience With Intracervical Ripening Bulb for Outpatient Induction of Labor at Term [18I]

INTRODUCTION: Outpatient cervical ripening using an intracervical balloon catheter offers promise for outpatient preinduction of labor. Published studies are limited by small sample sizes. METHODS: We searched Medline, Web of Science™, Cochrane database, and clinicaltrials.gov for meta-analysis of studies evaluating outpatient cervical ripening with intracervical balloon catheters. We included randomized, controlled trials comparing outpatient intracervical balloon versus inpatient cervical ripening. Outcomes of interest were time spent hospitalized before delivery, total induction time, cesarean delivery rate, need for oxytocin, and 5-minute APGAR score. Our search yielded three studies for inclusion. All three were performed at different institutions and met the following criteria: gestational age 37 weeks or more and suitable for outpatient cervical ripening, initial Bishop score less than 7, no intrauterine growth restriction, intact membranes, and reassuring initial fetal heart rate tracing. All groups were analyzed in an intention-to-treat fashion. RESULTS: The three studies totaled 260 women who were randomized into outpatient (n=144) and inpatient (n=116) groups. Maternal age, parity, and gestational age did not differ between groups. The total induction time, mean total time on oxytocin, rate of epidural use, 5-minute APGAR scores, rate of delivery within 24 hours of induction, and rate of post-partum hemorrhage did not differ between groups. The outpatient group spent an average of 8.6 fewer hours in the hospital before delivery (P=.001) but were more likely to require oxytocin (OR 2.74, P=.032). CONCLUSION: Outpatient cervical ripening with an inflatable bulb catheter appears to be acceptable in a low-risk, term population with an unfavorable cervix.

Retirement Age Ranges from Clinical Practice of Maternal–Fetal Medicine Physicians

Objectives Retirement of “baby boomer” physicians is a matter of growing concern in light of the shortage of certain physician groups. The objectives of this investigation were to define what constitutes a customary retirement age range of maternal‐fetal medicine (MFM) physicians and examine how that compares with other obstetrician‐gynecologist (ob‐gyn) specialists. Study Design This descriptive study was based on American Medical Association Masterfile survey data from 2010 to 2014. Data from the National Provider Identifier were used to correct for upward bias in reporting retirement ages. Only physicians engaged in direct patient care between ages 55 and 80 years were included. Primary outcomes involved comparisons of retirement ages of male and female physicians with other ob‐gyn specialties. Results Interquartile ranges of retirement ages were similar between specialists in MFM (64.1‐71.1), gynecologic oncology (62.1‐68.9), reproductive endocrinology and infertility (64.1‐71.7), and general ob‐gyn (61.5‐67.9). In every specialty, women retired earlier, while males in MFM were most likely to retire at the oldest age (median 70.0). Conclusion MFM physicians usually retired from clinical practice between ages 64 and 71 years, which is similar to other ob‐gyn specialists. Females retired earlier, however, which may impact the overall supply as more females pursue MFM careers.