Carolina Bibbo

Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial.

BACKGROUND: The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. METHODS: A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 &mgr;g/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 &mgr;g. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ⩽ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the &khgr;2 test with Yates continuity correction. RESULTS: There was no significant difference in the time to NPRS ⩽ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83–2.4, P = .21). DPE achieved NPRS ⩽ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22–0.59, P = .0001). The median times (interquartile range) to NPRS ⩽ 1 were 2 (0.5–6) minutes for CSE, 11 (4–120) minutes for DPE, and 18 (10–120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39–3.28; P < .001), 20 minutes (RR 1.60; 95% CI 1.26–2.03; P < .001), and 30 minutes (RR 1.18; 95% CI 1.01–1.30; P < .034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07–0.51; P < .001) and physician top-up intervention (RR 0.45; 95% CI 0.23–0.86; P = .011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06–0.38; P < .001), hypotension (RR 0.38; 95% CI 0.15–0.98; P = .032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08–0.60; P < .001), and physician top-up intervention (RR 0.45; 95% CI 0.23–0.86; p = .011). CONCLUSIONS: Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.

Routine cervical length and fetal fibronectin screening in asymptomatic twin pregnancies: is there clinical benefit?

Abstract Objective: To determine whether routine cervical length (CL) and fetal fibronectin (fFN) screening is associated with improved clinical outcomes in asymptomatic patients with twin pregnancies. Study design: We compared outcomes between two large cohorts of twin pregnancies who delivered in New York City from 2003 to 2012. One cohort (n = 532) was managed by a single group practice, delivered at one large academic medical center, and underwent routine serial CL and fFN screening. The second cohort (n = 456) delivered at a second large academic center and only underwent CL and fFN testing as clinically indicated. Outcomes measured include cerclage placement, preterm birth (PTB), spontaneous PTB (sPTB), and antenatal corticosteroid (ACS) exposure. Results: Rates of cerclage placement, PTB, and SPTB were similar between the two groups. However, routine CL and fFN screening was associated with improved rates of ACS exposure in patients who delivered <34 weeks (91.3% versus 74.7%, p = 0.005) and 34–36 6/7 weeks (41.3% versus 13.9%, p < 0.001) without increased ACS exposure in women who delivered at term. In patients who delivered <34 weeks, routine CL and fFN screening was significantly associated with improved rates of ACS exposure within 1–14 days of delivery and within 1–7 days of delivery. Conclusion: In twin pregnancies, routine CL and fFN screening does not reduce the risk of PTB or SPTB. However, the routine use of these tests is associated with significantly improved ACS exposure and timing for women who deliver preterm without increasing ACS exposure to women who deliver at term.

Rescue corticosteroids in twin pregnancies and short‐term neonatal outcomes

Objective  To estimate the efficacy of a rescue course of antenatal corticosteroids in twin pregnancies.

In Vivo Quantification of Placental Insufficiency by BOLD MRI: A Human Study

Fetal health is critically dependent on placental function, especially placental transport of oxygen from mother to fetus. When fetal growth is compromised, placental insufficiency must be distinguished from modest genetic growth potential. If placental insufficiency is present, the physician must trade off the risk of prolonged fetal exposure to placental insufficiency against the risks of preterm delivery. Current ultrasound methods to evaluate the placenta are indirect and insensitive. We propose to use Blood-Oxygenation-Level-Dependent (BOLD) MRI with maternal hyperoxia to quantitatively assess mismatch in placental function in seven monozygotic twin pairs naturally matched for genetic growth potential. In-utero BOLD MRI time series were acquired at 29 to 34 weeks gestational age. Maps of oxygen Time-To-Plateau (TTP) were obtained in the placentas by voxel-wise fitting of the time series. Fetal brain and liver volumes were measured based on structural MR images. After delivery, birth weights were obtained and placental pathological evaluations were performed. Mean placental TTP negatively correlated with fetal liver and brain volumes at the time of MRI as well as with birth weights. Mean placental TTP positively correlated with placental pathology. This study demonstrates the potential of BOLD MRI with maternal hyperoxia to quantify regional placental function in vivo.

Spatiotemporal alignment of in utero BOLD-MRI series: Spatiotemporal Alignment of MRI series

To present a method for spatiotemporal alignment of in‐utero magnetic resonance imaging (MRI) time series acquired during maternal hyperoxia for enabling improved quantitative tracking of blood oxygen level‐dependent (BOLD) signal changes that characterize oxygen transport through the placenta to fetal organs.

Management of twins: vaginal or cesarean delivery?

Recent level I evidence from a single randomized-controlled trial has shown that there is no difference in fetal or neonatal outcomes (composite of fetal/neonatal death or serious neonatal morbidity) between planned cesarean delivery and planned vaginal delivery for twins between 32 and 38 6/7 weeks. As long as the presenting twin is vertex, vaginal delivery should be considered regardless of the presentation of the second twin. To avoid unnecessary cesarean deliveries and maternal morbidity, it is important to continue to train residents to perform obstetrics maneuvers necessary for vaginal delivery of twins such as vaginal breech extraction.

Toward a better understanding of gender-based performance in the obstetrics and gynecology clerkship: women outscore men on the NBME subject examination at one medical school.

Purpose To better understand why women outperform men in the obstetrics and gynecology (Ob/Gyn) clerkship. Method The authors conducted a retrospective cohort study of students who rotated in the Ob/Gyn clerkship from 2008 to 2011 and graduated by May 2012 from the Icahn School of Medicine at Mount Sinai in New York City. They compared female and male students’ performance on preclerkship standardized tests (the Medical College Admission Test [MCAT] and United States Medical Licensing Examination [USMLE] Step 1) and on Ob/Gyn clerkship components (clinical skills achievement, oral and written case presentations, clinical evaluations, and National Board of Medical Examiners [NBME] subject examination). Results The study included 163 (53.4%) women and 142 (46.6%) men. Among students who took the MCAT, women scored lower than men with a mean (standard deviation) of 33.2 (3.2) versus 34.6 (3.3) (P = .001). Similarly, among all students, women scored lower than men on the USMLE Step 1: 227 (19.1) versus 232.5 (18.8) (P = .012). There were no significant gender differences on most clerkship components. However, women scored higher than men on the Ob/Gyn NBME subject examination: 78.0 (7.5) versus 74.8 (8.4) (P = .001). Consequently, female students achieved higher overall clerkship scores than men: 88.5 (5.6) versus 87.1 (5.1) (P = .024). Analysis of covariance confirmed that gender is associated with NBME subject examination score (P < .001). Conclusions Women outscored men on the NBME subject examination in Ob/Gyn and thereby outperformed men in the Ob/Gyn clerkship.

The Relationship Between Intertwin Membrane Separation and Pregnancy Outcome.

OBJECTIVE: To evaluate the association of intertwin membrane separation and pregnancy outcome. METHODS: This is a retrospective cohort study of women with dichorionic twins who were diagnosed with spontaneous intertwin membrane separation between 2004 and 2013 at a large tertiary care maternity hospital. Control participants were selected as the next two sets of dichorionic twins that delivered at the study institution after a case participant delivered and that did not have an intrauterine procedure. Maternal, fetal, and delivery characteristics were compared using Wilcoxon rank-sum tests. Logistic regressions were used to assess the association of membrane separation and preterm delivery. RESULTS: Among the 27 cases of spontaneous intertwin membrane separation, the median gestational age at diagnosis was 28 weeks (interquartile range 25.5–28.8) and the median gestational age at delivery was 37 weeks (interquartile range 35.3–37.0). The rate of preterm delivery, our primary outcome, was 48% for the case group and 76% for the control group (odds ratio [OR] 0.29, P=.01). The rate of spontaneous preterm delivery was also lower for the case group (19% compared with 44%; OR 0.25, P=.26) as was the rate of neonatal intensive care unit admission (37% compared with 61%; OR 0.37, P=.04). CONCLUSION: Our retrospective cohort study demonstrates that intertwin membrane separation is not associated with adverse outcomes in dichorionic twin pregnancies. Thus, it is reasonable to manage these pregnancies expectantly. LEVEL OF EVIDENCE: II

Angle of Progression on Ultrasound in the Second Stage of Labor and Spontaneous Vaginal Delivery

Objective The objective of this study was to assess the association between the angle of progression (AoP) measured by transperineal ultrasound and mode of delivery and duration of the second stage. Study Design This is a prospective observational study of nulliparous women with a singleton gestation at term in which serial transperineal ultrasound examinations were obtained during the second stage of labor. Multivariable logistic regression and adjusted survival models were used for the analysis. Results A total of 137 patients were included in the analysis and median AoP for the study group was 153 degrees. The adjusted odds ratio (aOR) of requiring an operative delivery was 2.6 times higher for those patients who had an AoP < 153 degrees and the aOR of requiring a cesarean delivery was almost six times higher when compared with those patients who had an AoP ≥ 153 degrees (95% confidence interval [CI]: 1.0, 6.2; p = 0.04; aOR: 5.8, 95% CI: 1.2‐28.3; p = 0.03, respectively). Those patients with an AoP < 153 degrees were at a higher hazard of staying pregnant longer (adjusted hazard ratio: 1.8, 95% CI: 1.2‐2.8, p = 0.005). Conclusion The AoP has the potential to predict spontaneous vaginal delivery and the duration of the second stage of labor which may be useful in counseling patients and managing their labor.

Does the Addition of a Specialized Postpartum Clinic Improve the Care of Women With Preeclampsia

INTRODUCTION: Women with antepartum preeclampsia are at higher risk of developing cardiovascular disease. We sought to assess if the introduction of a specialized postpartum clinic decreases the rate of readmission and triage visits and increases the rate of primary care provider follow-up for women who had antepartum preeclampsia. METHODS: This is a retrospective comparative cohort study of women who had antepartum preeclampsia: 69 women who delivered in 2008 were compared with 69 women who followed in a specialized postpartum clinic from October 2011 to March 2013. &khgr;2 testing was used to compare the rate of readmission, triage visits, and primary care provider follow-up. RESULTS: There was no difference in the baseline characteristics between the two groups. There was a higher combined rate of readmission and triage visits after the introduction of the clinic, 8.7% compared with 21.7% (P<.039). A total of 85.7% of the readmissions and 62.5% of the triage visits occurred before the specialized postpartum clinic appointments. Furthermore, 66.7% of the readmissions and triage visits occurred within 10 days from delivery. There was a trend toward better primary care provider follow-up, 37.7% compared with 46.4% (P<.302). CONCLUSIONS: Our study shows that after the introduction of a specialized postpartum clinic, the rate of readmission and triage visits increased. This likely reflects a growing awareness surrounding preeclampsia and its associated long-term cardiovascular risks. Our study supports that earlier access to postpartum care, within 10 days, may reduce the rate of hospitalization and provide better access to clinical care. A trend toward increased primary care provider follow-up requires further investigation.