Craig M Zelig

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.

Nausea, vomiting, and heartburn in pregnancy: a prospective look at risk, treatment, and outcome

Objective: To examine risk factors, treatment, and outcomes for nausea/vomiting (N/V) and heartburn during pregnancy. Methods: We included 2731 women from a prospective cohort study of gallbladder disease in pregnancy. Subjects completed questionnaires at enrollment, early third trimester, and 4–6 weeks postpartum. We used logistic regression to examine independent predictors of upper gastrointestinal symptoms. Results: Ninety-five percent of pregnant women experienced either heartburn and/or N/V. Independent predictors for heartburn included prepregnancy heartburn (OR 5.28, 95% CI 3.78–7.37), multigravidity, prepregnancy body mass index, and pregnancy weight gain. Independent predictors for N/V included prepregnancy N/V (OR 2.25, 95% CI 1.52–3.31), other digestive problems prepregnancy, younger age, single gestation, and carrying a female fetus. 11% of women with N/V and 47% of women with heartburn used pharmacologic therapy. Infants born to women with heartburn had significantly higher birth weights (p = 0.03), but gestational age at delivery was not significantly different. N/V was not associated with birth weight or gestational age at delivery. 19.7% of women with heartburn during pregnancy reported postpartum heartburn. Conclusions: Heartburn and N/V are common pregnancy symptoms, particularly among women with a history of such symptoms. Neither condition appears to adversely affect the outcome of pregnancy. Pregnancy-related heartburn predisposes to early postpartum heartburn.

Complications from Roux-en-Y gastric bypass mistaken for medical complications in gravid patients.

BACKGROUND: The increased frequency of bariatric surgery has resulted in a growing number of intrapartum surgical emergencies including internal hernia, bowel obstruction, and gastric rupture. CASE: We describe the cases of three gravid women with history of laparoscopic Roux-en-Y gastric bypass surgery who experienced significant complications during subsequent pregnancy. Two patients became hemodynamically unstable and required emergent laparotomy. In both cases, fetal outcomes were poor but the patients ultimately recovered after prolonged hospital courses. In the third patient, early recognition allowed for a minimally invasive surgical correction. CONCLUSION: After bariatric surgery, patients who become pregnant are at risk for serious postoperative complications. Because symptoms can be subtle, a high index of suspicion and early intervention by a multidisciplinary team is necessary to prevent catastrophic outcomes.

Return to military weight standards after pregnancy in active duty working women: comparison of marine corps vs. navy.

Objective: To compare the likelihood of being within weight standards before and after pregnancy between United States Marine Corps (USMC) and Navy (USN) active duty women (ADW). Methods: ADW with singleton gestations who delivered at a USMC base were followed for 6 months to determine likelihood of returning to military weight standards. Odds ratio (OR), adjusted odds ratio (AOR) and 95% confidence intervals were calculated; p < 0.05 was considered significant. Results: Similar proportions of USN and USMC ADW were within body weight standards one year prior to pregnancy (79%, 97%) and at first prenatal visit (69%, 96%), respectively. However, USMC ADW were significantly more likely to be within body weight standards at 3 months (AOR 4.30,1.28–14.43) and 6 months after delivery (AOR 9.94, 1.53–64.52) than USN ADW. Weight gained during pregnancy did not differ significantly for the two groups (40.4 lbs vs 44.2 lbs, p = 0.163). The likelihood of spontaneous vaginal delivery was significantly higher (OR 2.52, 1.20–5.27) and the mean birth weight was significantly lower (p = 0.0036) among USMC ADW as compared to USN ADW. Conclusions: Being within weight standards differs significantly for USMC and USN ADW after pregnancy.

Limitations of Cohort Studies with Historic Controls

TO THE EDITORS: We read with interest the study “17-alpha Hydroxyprogesterone caproate did not reduce the rate of recurrent preterm birth in a prospective cohort study” by Nelson et al. The authors did a thorough job of collecting and analyzing their data and summarizing their findings. The applicability of their results may be limited by the retrospective study design that used historic controls. Practice patterns have changed significantly since the non17P era of their control group, 1988e2011. For example, a patient in the control group with a history of spontaneous preterm birth who, in their next pregnancy, experienced preterm premature rupture of membranes may have been managed expectantly until 36 weeks gestation in 1988. However, in the 17P cohort (2012e2016), a patient with preterm premature rupture of membranes would most likely have been delivered at 35 weeks gestation and thus would be counted a treatment failure. Furthermore, given vast improvements in neonatal care from 1988e2016, the risk and benefit ratio consideration favors earlier delivery for the same clinical circumstances in patients with pregnancy complications in the 17P-exposed group, since the neonatal risks for preterm delivery have decreased over the years of this study. The accuracy of gestational age determination is critical for this study. Determination of gestational age in the later years of this study would have included ultrasound data in essentially all subjects, whereas gestational age determination of many control subjects would have been without the benefit of ultrasound scanning. As described by McIntire et al, gestational age determination in patients delivered at Parkland from 1988e1996 was based on last menstrual period, obstetric ultrasound scans, and fundal height. However, the accuracy of gestational age determination at that time cannot be considered to be nearly as accurate as the case cohort, where one may expect essentially universal ultrasound usage. In the 1988e1996 Parkland obstetrics patients described by McIntire et al, it appears that approximately 34,475 of 122,754 patients received an ultrasound scan (28%). The confounding effect of changes in medical practice over time illustrates a principle limitation of retrospective cohort studies that use historic controls; the longer the difference in epochs (23 years in this case), the greater the likelihood for confounders to bias the results. Given the presence of a welldone, randomized control trial that reached the opposite conclusion of this study, we feel it important to consider the limitations of this cohort study when evaluating the evidence for the clinical benefit of 17P in reducing the risk of recurrent preterm birth. -

Adverse pregnancy outcomes in hypertensive patients: predictive value of protein concentration versus total protein.

Abstract Objectives: To compare the predictive value of protein concentration in a twenty-four hour urine collection to the conventional total protein in a twenty-four hour urine collection for adverse pregnancy outcomes in hypertensive patients. Study design: Retrospective cohort study. Hypertensive patients ≥20 weeks estimated gestational age (EGA) who completed twenty-four hour urine protein collections were identified; antepartum and delivery data were examined. For study patients who met criteria for adverse pregnancy outcome, multi-variable analysis was performed and summary receiver operating characteristic (ROC) curves were generated for each model (total protein compared to protein concentration). The models were compared by analyzing the area under the curve (AUC). Results: A total of 150 patients were analyzed. Mean gestational age at delivery was 36.7 weeks. Analysis of the ROC curves showed no significant difference between the models (AUCs of 0.668 versus 0.656, p = 0.715). Optimal thresholds were 299.2 mg for total protein and 0.1 mg/ml for protein concentration. Conclusion: A protein concentration of 0.1 mg/ml on a twenty-four hour urine collection appears equivalent to the traditional 300 mg total protein. If confirmed by prospective studies, this finding would be clinically important in cases where collections fall short of the 300 mg threshold but exceed the 0.1 mg/ml concentration.

The use of middle cerebral artery Doppler ultrasonography to guide delivery of a viable pregnancy complicated by metastatic gestational chroriocarinoma

Background: Choriocarcinoma is a rare, aggressive subtype of gestational trophoblastic neoplasia. The diagnosis of metastatic choriocarcinoma in the setting of a viable intrauterine pregnancy is exceedingly rare and often associated with feto‐maternal hemorrhage.

Reports to the Navy's Family Advocacy Program: impact of removal of mandatory reporting for domestic violence.

The impact of mandatory reporting laws on domestic violence reports is unclear. In 2006, the Department of Defense removed its requirement for mandatory reporting of domestic violence against adults. Our objective was to determine if there was a change in the incidence of domestic violence reports to the Navys Family Advocacy Program after the shift from mandatory reporting to a policy allowing restricted reporting. Reports of domestic violence to the Navy Central Registry between fiscal year (FY) 2000 and 2010 were studied. Frequencies and rates of domestic violence reports, type of abuse, and victim and offender gender were studied. Over the past 11 years, the total number of unrestricted domestic violence reports to the Navy Central Registry has decreased by just over a third. In addition, the number of substantiated reports has decreased by approximately 50%. Since the collection of data on restricted reports in 2008, the aggregated reporting rate of substantiated reports is significantly smaller, 0.87% for FYs 2008 to 2010 compared to 1.34% for FYs 2000 to 2005, p < 0.01. Domestic violence reports to the Navy Central Registry have declined over the past 11 years, even with the removal of the requirement for mandatory reporting of domestic violence.