Christian A. Chisholm

Cerebral arteriovenous malformation in pregnancy: Presentation and neurologic, obstetric, and ethical significance☆☆☆★

Cerebral arteriovenous malformations infrequently complicate pregnancy. We sought to determine the neurologic, obstetric, and ethical significance of such malformations. We present the clinical course of 2 pregnant women with arteriovenous malformations who experienced cerebral hemorrhage and a loss of capacity for decision making. We also review the neurologic and obstetric significance of arteriovenous malformations in pregnancy. Various treatment options with concern for pregnancy and the prognosis for arteriovenous malformations are outlined. The ethical issues involved for pregnant patients whose decisional capacity is compromised as a result of cerebral injury are explored. A review of persistent vegetative state and brain death (death by neurologic criteria) occurring in pregnancy allows us to explore many issues that are applicable to decisionally incapacitated but physiologically functioning pregnant women. We outline a document, the purpose of which is to obtain advance directives from pregnant women regarding end-of-life decisions and to appoint a surrogate decision maker. We believe that evaluation and treatment of the arteriovenous malformation may be undertaken without regard for the pregnancy and that the pregnancy should progress without concern for the arteriovenous malformation.

Communicating bad news

The need to communicate bad news to patients and their families is common in the practice of obstetrics and gynecology. Although this is one of the most important interactions between caregivers and their patients, most physicians receive little or no formal education on the process of communicating bad news. Recipients for bad news favor being informed by a physician familiar to them, in the presence of support persons, and with provision of adequate medical information and referrals. The physician who imparts bad news should approach this communication directly and with a caring attitude, sensitive to both the informational content and emotional reaction. The objectives of this article are to review the literature regarding the process of communicating bad news and to set forth a set of general guidelines by which practitioners can communicate bad news more effectively and compassionately.

A guide to the safety of CNS-active agents during breastfeeding.

SummaryFor most agents with CNS activity, there are limited data regarding their safety in breastfeeding. Any decision to institute treatment for a neurological or psychiatric disorder must weigh the benefits of maternal treatment against the potential harm to the breastfeeding mother of withholding medication which may improve her illness. For the neonate, one must balance the risk of medication exposure against the benefit of receiving breast milk.Most tricyclic antidepressants can be used in lactating women. Because of the limited data, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors should only be used with due consideration of the potential adverse effects. Breastfeeding is best avoided by women who require lithium therapy, because of both the immature excretory systems in the infant and relatively high doses received by the infant. There is little information about the safety of antipsychotic medications in breastfeeding. Concerns include toxicity and abnormal neurological development in the infant. These agents may be used with caution.Most agents which cause depression of the CNS, including opiates and sedatives, can be used in small doses and for short courses in breastfeeding mothers. Most anticonvulsants can be used in lactating women. Reference texts and consultation with experts are useful adjuncts to discussion of the risks and benefits of therapy with the patient. The scope of this review is limited to drugs with therapeutic uses, thus drugs of abuse are not discussed, nor are caffeine and alcohol (ethanol).

Nulliparity and duration of pregnancy in multiple gestation

OBJECTIVE: We sought to test the hypothesis that nulliparous women with multiple gestations would be more likely to have shorter gestational durations, a higher frequency of previable deliveries, and fewer pregnancy complications when compared with parous women. METHODS: We reviewed the medical records of women who delivered a multiple gestation at 15 or more weeks at 2 institutions between January 1, 1990 and June 30, 2002 (n = 1,035). We recorded demographic data, medical complications, and pregnancy outcomes and analyzed these using paired t tests for continuous variables, χ2 for categorical variables, and linear regression analysis for the effect of multiple variables on the primary outcome variable, gestational age at delivery. RESULTS: There was a statistically significant difference in mean gestational age at delivery (34 versus 34.9 weeks, P = .006) between the nulliparous and multiparous groups after excluding women with a history of previous preterm birth and/or midtrimester loss. There were no differences between groups in the likelihood of delivering before 20, 24, or 28 weeks. In linear regression analysis, ongoing fetal number (P < .001), premature rupture of membranes (PROM; P < .001), cerclage (P = .002), and death of 1 or more fetuses (P < .001) were associated with shorter gestation. Cesarean delivery was associated with longer gestation (P < .001). Nulliparous women were significantly more likely to have a pregnancy complicated by hypertension (20.8% versus 9.2%, P < .001), diabetes (7% versus 4%, P = .03), or PROM (24.4% versus 17.3%, P = .006). CONCLUSION: Nulliparous women with a multiple gestation deliver their pregnancies, on average, 0.9 weeks earlier than parous women and more frequently experience hypertension, diabetes, and PROM. They are not, however, more likely to deliver before 24 weeks of gestation. LEVEL OF EVIDENCE: II-3

Catheter Ablation of Arrhythmia During Pregnancy.

Cardiac arrhythmia as a complication of pregnancy can be problematic to maternal health and fetal life and development. Catheter ablation of tachyarrhythmias during pregnancy has been successfully performed in selected patients with limited experience. Techniques to limit maternal and fetal radiation exposure, including intracardiac echo and electroanatomic mapping systems, are particularly important in this setting. Specific accommodations are necessary in the care of the gravid patient during catheter ablation.

Intimate partner violence and pregnancy: epidemiology and impact

Intimate partner violence is a significant public health problem in our society, affecting women disproportionately. Intimate partner violence takes many forms, including physical violence, sexual violence, stalking, and psychological aggression. While the scope of intimate partner violence is not fully documented, nearly 40% of women in the United States are victims of sexual violence in their lifetimes and 20% are victims of physical intimate partner violence. Other forms of intimate partner violence are likely particularly underreported. Intimate partner violence has a substantial impact on a womans physical and mental health. Physical disorders include the direct consequences of injuries sustained after physical violence, such as fractures, lacerations and head trauma, sexually transmitted infections and unintended pregnancies as a consequence of sexual violence, and various pain disorders. Mental health impacts include an increased risk of depression, anxiety, posttraumatic stress disorder, and suicide. These adverse health effects are amplified in pregnancy, with an increased risk of pregnancy outcomes such as preterm birth, low birthweight, and small for gestational age. In many US localities, suicide and homicide are leading causes of pregnancy-associated mortality. We herein review the issues noted previously in greater depth and introduce the basic principles of intimate partner violence prevention. We separately address current recommendations for intimate partner violence screening and the evidence surrounding effectiveness of intimate partner violence interventions.

Intimate partner violence and pregnancy: screening and intervention

In the first part of this review, we provided currently accepted definitions of categories and subcategories of intimate partner violence and discussed the prevalence and health impacts of intimate partner violence in nonpregnant and pregnant women. Herein we review current recommendations for intimate partner violence screening and the evidence surrounding the effectiveness of intimate partner violence interventions. Screening for intimate partner violence may include exclusively identification of victims of intimate partner violence or both the identification of and intervention for victims. Until recently, many professional organizations did not recommend universal screening for intimate partner violence because of a lack of evidence of effectiveness of screening, lack of evidence demonstrating that screening is not harmful, and/or a lack of consensus regarding the most effective screening tool. The lack of evidence supporting an intervention posed an additional barrier to screening. The American College of Obstetricians and Gynecologists has been a staunch advocate for universal intimate partner violence screening, even when other groups either did not endorse screening or recommended it only for high-risk women. Recent published data confirm that screening is more reliable than usual care in identifying victims of intimate partner violence, both during pregnancy and in nonpregnant women. Likewise, recent published data show that there are no apparent harms of screening for intimate partner violence and that the act of screening may have an empowering effect on women and improve their relationship with and trust in their health care providers. Despite these findings, the implementation rate of intimate partner violence screening remains low. Most encouraging are the recent data showing that interventions performed after screening for intimate partner violence are effective in reducing depression symptoms and episodes of violence as well as improving some outcomes of pregnancy. Although there remains a lack of consensus regarding which screening tool may be the most effective, we exhort all obstetrician-gynecologists to screen all women for intimate partner violence at regular intervals and to familiarize themselves with available community resources to assist those women who have been identified as experiencing intimate partner violence through screening.

Perinatologists and Advanced Practice Nurses Collaborate to Provide High‐Risk Prenatal Care in Rural Virginia Communities

Poster Presentation Purpose for the Program The specific intent was to assess the effect of a telemedicine‐based high‐risk prenatal clinic on maternal‐child health outcomes for low‐income women in rural communities. Proposed Change Adequate and early access to risk‐appropriate prenatal care can reduce the incidence of adverse outcomes. Limited access disproportionately affects women of low socioeconomic status and with limited English proficiency in rural communities. Distance and costs associated with frequent travel and the limited number of perinatologists are barriers to high‐risk care. Telemedicine can reduce barriers through collaboration of perinatologists and advanced practice nurses. Telemedicine has shown favorable results in a variety of clinical disciplines. Prenatal care is a relative newcomer to the spectrum of health care provided via telemedicine. Implementation, Outcomes, and Evaluation Collaborative high‐risk obstetric (OB) telemedicine clinics were implemented in five rural locations between 2009 and 2013. Local clinics serving the targeted population were solicited as partners. Hands‐on prenatal care and examinations at the local site were provided by nurse practitioners. Video telemedicine visits were in real time with the patient, local practitioner, and remote perinatologist. The telemedicine clinics served 374 patients. With Institutional Review Board (IRB) approval, charts were reviewed to compare patient access measures and pregnancy outcomes before and after initiation of telemedicine. The comparison group consisted of 181 patients. Demographic, patient access, and pregnancy outcome data for women referred before and after the initiation of the telemedicine clinics were compared using two‐sample t test and chi‐square test. Women who received care before telemedicine had a higher rate of missing one or more prenatal visits compared with the telemedicine group (57.1% vs. 21.3%, p = .000). The overall missed visit rate decreased from 0.71% to 0.53% per patient ( p = .086). There was no difference in the groups for gestational age at first visit (13.6 vs. 14.0 weeks of gestation). Deliveries after 37 weeks of gestation were similar (84% pretelemedicine vs. 83% telemedicine). The telemedicine group had a higher mean birth weight (3,226 vs. 3,137 g, p = not significant). There was no difference in the neonatal intensive care unit (NICU) admission rate (12.0% vs. 10.8%); mean NICU days were reduced in the telemedicine group (22.11–13.42, p Implications for Nursing Practice Collaborative care through telemedicine is an effective method for providing high‐risk prenatal care to women who live in rural communities. When compared with traditional care, telemedicine is associated with improved access to care and similar rates of important outcomes.

Missed opportunities: screening and brief intervention for risky alcohol use in women's health settings

BACKGROUND Although womens health settings could provide access to women for screening, brief intervention, and referral to treatment (SBIRT) for risky alcohol use, little is known about rates of alcohol use or associated risk for alcohol-exposed pregnancy (AEP) among womens health patients, receipt of SBIRT services in these settings, or patient attitudes towards SBIRT services. METHODS This study reports the results of a self-administered survey to a convenience sample of womens health patients attending public clinics for family planning or sexually transmitted infection visits. RESULTS Surveys were analyzed for 199 reproductive-aged women who had visited the clinic within the past year. The rate of risky drinking among the sample was (44%) and risk for AEP was (17%). Despite this, many patients did not receive SBIRT services, with more than half of risky drinking patients reporting that they were not advised about safe drinking limits (59%) and similar rates of patients at risk for AEP reporting that their medical provider did not discuss risk factors of AEP (53%). Patient attitudes towards receipt of SBIRT services were favorable; more than 90% of women agreed or strongly agreed that if their drinking was affecting their health, their womens health provider should advise them to cut down. CONCLUSIONS Womens health clinics may be an ideal setting to implement SBIRT and future research should address treatment efficacy in these settings.

Targeted delivery at 34 versus 35 weeks in women with preterm prelabor rupture of membranes.

Abstract Objective: To compare planned delivery at 34 versus 35 weeks for women with preterm prelabor rupture of membranes (PPROM). Materials and methods: We performed a retrospective cohort study of singleton pregnancies with PPROM after 24 weeks delivered from 2006 to 2014. In 2009, an institutional practice change established 35 weeks as the target gestational age before induction of labor was initiated after PPROM. Demographic and outcome measures were compared for two cohorts: women delivered 2006–2008 – target 34 weeks (T34) and women delivered 2009–2014 – target 35 weeks (T35). The primary outcome was neonatal intensive care unit (NICU) admission. Results: Of the 382 women with PPROM, 153 (40%) comprized the T34 cohort and 229 (60%) comprized the T35 cohort. Demographic characteristics were similar between groups. There were no differences between groups in gestational age at PPROM (31.0 ± 3.3 weeks versus 31.2 ± 3.1 weeks; p = .50) or maternal complications. The mean gestational age at delivery was earlier in the T34 group (31.8 ± 3.2 weeks versus 32.4 ± 2.7 weeks; p = .04). The median predelivery maternal length of stay (LOS) was 1 day longer in the T35 group (p = .03); the total and postpartum LOS were similar between groups (p > .05). There were no differences in the rate of NICU admission (T34 89.5% versus T35 92.1%; p = .38) or median neonatal LOS (T34 14 days versus T35 17 days; p = .15). In those patients who reached their target gestational age, both maternal predelivery LOS and total LOS were longer in the T35 group (p > .05). The frequency of NICU admission in those reaching their target gestational age was similar between groups (T34 83.37% versus T35 76.19%; p = .46). Conclusions: A 35-week target for delivery timing for women with PPROM does not decrease NICU admissions or neonatal LOS. This institutional change increased maternal predelivery LOS, but did not increase maternal or neonatal complications.