Ellen Landsberger

Impact of folic acid fortification in the United States: markedly diminished high maternal serum alpha-fetoprotein values.

OBJECTIVE: Folic acid fortification of breads and grains was implemented in the United States in 1998 in an attempt to reduce the incidence of neural tube defects. Outcome data from birth registries have shown a 20% drop—less than originally predicted. In this study, we ascertain if the impact of folic acid fortification is better seen at the time of midtrimester prenatal diagnosis by looking at incidence of high maternal serum alpha-fetoprotein (MSAFP) values. METHODS: Data regarding MSAFP levels in 61,119 patients undergoing maternal serum screening at a large commercial laboratory were categorized by multiples of the median (MoM). The data were compared between 2 groups: before mandatory supplementation in the United States in 1997 and after mandatory supplementation in 2000. High MSAFP values were further categorized as high (2.75–4.00 MoM) or very high (more than 4.00 MoM). Data were analyzed by χ2 analysis. RESULTS: Comparative data showed a 32% decrease of patients with MoM greater than 2.75 + (2.5% −1.7%). Further categorizations revealed similar decreases. CONCLUSION: The introduction of folic acid fortification has produced a profound decrease in the number of high MSAFP values, reflective of a decreased incidence of neural tube defects. Our results help to validate the decision to fortify food with folic acid, which represents a highly successful public health policy for primary prevention of birth defects. LEVEL OF EVIDENCE: II-2

Re-evaluating the role of the MFM specialist: Lead, follow, or get out of the way

Objective. To assess the effect of sub-specialty prenatal care provided to high-risk obstetrical patients in a community perinatal center as a function of whether consultation and referral to a Maternal–Fetal Medicine (MFM) sub-specialist was at the discretion of the generalist, required by the insurance carrier, or by patient choice. Methods. Demographics, management, and perinatal outcomes for high-risk patients managed exclusively by MFM were compared with those managed by generalists who were later referred to MFM after problems arose. Results. Despite similar demographics, high-risk patients managed exclusively by a single MFM had less prematurity, lower cesarean section rates, fewer low 5-minute Apgar scores (1.3% vs. 5.5%, p < 0.001), and lower perinatal mortality rates (8.0/1000 vs. 47.6/1000, p < 0.001) than those referred at a later date. Conclusions. In this setting, earlier MFM care resulted in better outcomes. These data suggest that the ‘gatekeeper’ model of generalist to MFM might be better the other way around.

Outcome of pregnancy when gestational diabetes mellitus is diagnosed before or after 24 weeks of gestation.

INTRODUCTION: The objective of this study was to compare the outcome of pregnancy in women diagnosed with gestational diabetes mellitus (GDM) before 24 weeks of gestation with those diagnosed after 24 weeks of gestation. METHODS: The records of women with a GDM were reviewed over a 5-year period. All women are routinely screened for GDM at their first prenatal visit before 24 weeks of gestation and if negative, a repeat screening occurs at 24–28 weeks of gestation. Two groups were formed based on gestational age of the diagnosis of GDM, a group diagnosed before 24 weeks of gestation and a group diagnosed after 24 weeks of gestation. Multiple gestations, incomplete records, and delivery before 22 weeks of gestation were excluded. Standard statistics and regression analysis considered P<.05 significant and the study was approved by the institutional review board. RESULTS: There were 305 women diagnosed with GDM before 24 weeks of gestation and 401 women diagnosed after 24 weeks of gestation included in the study. The GDM before 24 weeks of gestation group was older, had more obese women (body mass index greater than 30 kg/m2), delivered earlier, and had a lower birth weight. The groups were similar when comparing cesarean delivery rates, preeclampsia, fetal demise, shoulder dystocia, and macrosomia (birth weight greater than 4,000 g) (Table 1). In multivariate regression analysis, diagnosis of GDM before 24 weeks of gestation was an independent predictor of preterm birth (less than 37 weeks of gestation; Table 2). Table 1 Maternal Demographics and Pregnancy Outcomes (Ngai, p. 162–3S) Table 2 Multivariate Regression Analysis of Independent Predictors of Preterm Birth (Ngai, p. 162–3S) CONCLUSION: The diagnosis of GDM before 24 weeks of gestation is associated with preterm delivery when compared with women diagnosed after 24 weeks of gestation.

Is obesity an independent barrier to obtaining prenatal care

OBJECTIVE Obesity is a demonstrated barrier to obtaining health care. Its impact on obtaining prenatal care (PNC) is unknown. Our objective was to determine if obesity is an independent barrier to accessing early and adequate PNC. STUDY DESIGN We performed a retrospective cohort study of women who initiated PNC and delivered at our institution in 2005. Body mass index (BMI) was categorized by World Health Organization guidelines: underweight (<18.5 kg/m(2)), normal weight (18.5 to 24.9 kg/m(2)), overweight (25.0 to 29.9 kg/m(2)), and obese (≥30 kg/m(2)). Maternal history and delivery information were obtained through chart abstraction. Differences in gestational age at first visit (GA-1) and adequate PNC were evaluated by BMI category. Data were compared using χ(2) and nonparametric analyses. RESULTS Overall, 410 women were evaluated. The median GA-1 was 11.1 weeks and 69% had adequate PNC. There was no difference in GA-1 or adequate PNC by BMI category (p = 0.17 and p = 0.66, respectively). When BMI groups were dichotomized into obese and nonobese women, there was no difference in GA-1 or adequate PNC (p = 0.41). CONCLUSION In our population, obesity is not an independent barrier to receiving early and adequate PNC. Future work is warranted in evaluating the association between obesity and PNC and the perceived barriers to obtaining care.

Breaking Bad News in obstetrics: a randomized trial of simulation followed by debriefing or lecture

Abstract Objective: Although communication skills represent an increasingly important aspect of medical care, little has been done to assess the best method of teaching these skills. Our study was designed to assess simulation-debriefing compared to lecture in teaching skills for Breaking Bad News (BBN) in obstetrics. Methods: This is a randomized prospective trial of house staff from a large academic medical center. Subjects initially underwent baseline simulation, followed by evaluation on BBN skills by themselves, a faculty observer, and the standardized patient (SP). The subjects were then immediately randomized to a debriefing session by faculty or to a lecture about BBN. Subsequently, both groups underwent a second simulation with the same three assessments, yielding post-intervention data. Results: 35 subjects completed both simulations. Both debriefing and lecture curricula showed improvement in scores by self (p = 0.010) and faculty (p < 0.001). The debriefing group improved significantly more than the lecture group for self-evaluation; additionally, improvements were greater for the debrief group in verbal and nonverbal skills. Long-term follow-up three months after both interventions demonstrated continued improvement in BBN. Conclusions: Simulation training with debriefing is effective for teaching communication skills, and superior to lecture for self-perceived improvement. Long-term follow-up suggested retention of confidence in BBN skills.

Impact of Folic Acid Fortification in the United States

OBJECTIVE Folic acid fortification of breads and grains was implemented in the United States in 1998 in an attempt to reduce the incidence of neural tube defects. Outcome data from birth registries have shown a 20% drop-less than originally predicted. In this study, we ascertain if the impact of folic acid fortification is better seen at the time of midtrimester prenatal diagnosis by looking at incidence of high maternal serum alpha-fetoprotein (MSAFP) values. METHODS Data regarding MSAFP levels in 61,119 patients undergoing maternal serum screening at a large commercial laboratory were categorized by multiples of the median (MoM). The data were compared between 2 groups: before mandatory supplementation in the United States in 1997 and after mandatory supplementation in 2000. High MSAFP values were further categorized as high (2.75-4.00 MoM) or very high (more than 4.00 MoM). Data were analyzed by chi(2) analysis. RESULTS Comparative data showed a 32% decrease of patients with MoM greater than 2.75 + (2.5% -1.7%). Further categorizations revealed similar decreases. CONCLUSION The introduction of folic acid fortification has produced a profound decrease in the number of high MSAFP values, reflective of a decreased incidence of neural tube defects. Our results help to validate the decision to fortify food with folic acid, which represents a highly successful public health policy for primary prevention of birth defects. LEVEL OF EVIDENCE II-2

Barriers to Exercise for Urban Parturients

INTRODUCTION: The objective of this study was to identify unique barriers to exercise during pregnancy in an underserved urban population. METHODS: Pregnant patients at scheduled prenatal appointments were given survey forms to fill out regarding willingness to exercise and preferred type of exercise while waiting to be seen. Verbal announcements and published flyers were also given to the patients about a novel weekly prenatal Zumba exercise program organized through the office, tutored by a licensed Zumba instructor. Patients who did not participate were queried by phone as to reasons for nonparticipation. Access to DVD players and willingness to exercise if provided with an exercise DVD were ascertained. RESULTS: Fifty-two patients completed surveys. All 52 women expressed an interest in participating in regular physical activity and (27/52 [52%]) noted an interest in the Zumba class. However, only three patients participated in the Zumba program. Thirty-one patients were reached by telephone (31/49 [63.3%]). The reasons for nonparticipation elucidated were: employment obligation (8/31 [25.8%]); child care responsibilities (5/31 [16.1%]); lack of awareness of class schedule (5/31 [16.1%]); pregnancy complications (3/31 [9.7%]); and inadequate access to transportation (2/31 [6.4%]). Despite the low class participation rate, 93.5% (29/31) of women reported access to audiovisual equipment and indicated that they would do exercise if provided with a DVD exercise video for home use. CONCLUSION: In our urban population, there are multiple barriers that prevented pregnant patients from participating in this structured outside exercise program. However, identifying previously unappreciated barriers to exercise in an urban population encourages us to provide an alternative home-based exercise regimen that may increase participation.

OP23.01: Trends in the timing and rate of diagnosis of major congenital anomalies after introduction of the routine first trimester screen (FTS)

Objectives: To determine the angle between the four-chamber view and left ventricular outflow tract (LVOT) using live xPlane imaging and to study the reproducibility of this technique. Methods: Live xPlane is a technology available on xMatrix transducers that allows simultaneous imaging of two different planes of section of the same structure, in real time and with the same twodimensional resolution. We attempted real time visualization of the LVOT in the second imaging plane by rotating a reference line along the Y-axis from 0◦ at a step of 5◦ while the 4-chamber view was being imaged in the primary imaging plane. We recorded the rotation angle necessary to begin visualizing the LVOT (first appearance angle) as well as the rotation angle at which, with continuing rotation of the secondary plane, the LVOT was no longer visualized (last appearance angle). The difference between these two angles was denominated ‘angle span’ of the LVOT. Results: Of 100 fetuses being examined at 11–37 weeks’ gestation (by ultrasound), 30 had cardiac defects. Postnatal outcomes were known in 85 of them. The mean ± SD maternal body mass index was 21.8 ± 2.9 kg/m2. Using xPlane imaging, the LVOT was visualized at a rate of 95.1% after 14 weeks. Both intraand inter-class correlation coefficients for the first and last appearance angles were high (0.876–0.980). These angles significantly varied with the cardiac position (P = 0.001 and < 0.001). The first appearance angle was smaller when the normal fetal heart was examined using the subcostal approach than the apical view (25◦ vs 60; P = 0.001). Besides, there was a significant difference in the last appearance angle and the angle span between fetuses with and without LVOT abnormality (P = 0.038 and 0.010). Conclusions: We described a novel method of using xPlane imaging to examine the angle between the four-chamber and LVOT. The results of present and future studies may lead to improved methods for standardizing 4D examinations of the fetal heart.