Fadi Bsat

Comparison of three outpatient regimens in the management of nausea and vomiting in pregnancy.

OBJECTIVE: This study compares pyridoxine–metoclopramide combination therapy to prochlorperazine and promethazine monotherapies in the outpatient treatment of nausea and vomiting in pregnancy.STUDY DESIGN: In total, 174 first trimester, singleton pregnancies were evaluated for nausea and vomiting. Patients were prospectively randomized into three treatment groups: pyridoxine–metoclopramide, prochlorperazine, or promethazine. Prior to, and on the third day, patients recorded their subjective responses to the given treatment and their number of emesis episodes. The three treatment groups were compared for therapy response.RESULTS: There were no differences in the number of emesis episodes prior to treatment. Both subjective and objective responses to treatment differed among the three groups when comparing the combination therapy to the monotherapies (p<0.05).CONCLUSION: Combination therapy with pyridoxine and metoclopramide appears to be superior to either monotherapy in the treatment of nausea and vomiting in pregnancy.

Effectiveness of varicocelectomy in varicoceles diagnosed by physical examination versus Doppler studies.

The purpose of this study is to compare the effectiveness of varicocelectomy for improving the spermogram in treating varicoceles diagnosed by physical examination and those diagnosed by Doppler but with a negative physical examination. The charts of 112 patients were retrospectively analyzed and the patients divided in two groups: group A, where the varicocele was detected by physical examination, and group B, where physical examination was negative but Doppler studies revealed the presence of stasis or backflow in the pampiniform plexus of the spermatic veins. In subjects complaining of infertility, the two groups were similar with regard to age distribution and duration of infertility. After varicocelectomy, 85% of patients in group A had improved spermogram, compared with only 27% in group B. This difference was statistically significant (P less than 0.0001).

Imaging of the Placenta with Pathologic Correlation

The placenta functions to nourish and protect the fetus. Imaging of the placenta can have a profound impact on patient management, owing to the morbidity and mortality associated with various placental conditions. To fully appreciate placental pathology, its physiology, anatomy, and variant anatomy will be outlined. Placental conditions affecting the mother and fetus include molar pregnancies, placental hematoma, abruption, previa, accreta, vasa previa, choriocarcinoma, and retained products of conception. Ultrasonography remains the definitive modality in diagnosing most of these conditions, with magnetic resonance imaging remaining an adjunctive measure. Computed tomography is occasionally used in cases of trauma and tumor staging.

Accuracy of fetal fibronectin to predict preterm birth in twin gestations with symptoms of labor.

OBJECTIVE: To investigate accuracy of fetal fibronectin testing to predict preterm birth in twin gestations with symptoms of preterm labor. METHODS: We reviewed charts of all patients with twin gestations who underwent fetal fibronectin testing and presented with complaints of preterm labor between January 1, 2000, and June 30, 2004. We also reviewed the charts of all singleton gestations with similar complaints that had fetal fibronectin testing between January 1, 2000, and December 31, 2001. All samples were processed using a rapid fetal fibronectin detection system. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of fetal fibronectin testing in singleton and twin gestations in predicting delivery within 14 days of testing. RESULTS: Four hundred twenty-nine singletons and 87 twins met the inclusion criteria. The birth rate before 34 weeks of gestation for singletons was 3.5% compared with the rate of twin pregnancies of 28.7%. Fetal fibronectin predicted delivery within 14 days of testing with a sensitivity, specificity, and positive and negative predictive values in singleton gestations of 82%, 90%, 17%, and 99%, respectively. In twin gestations, fetal fibronectin predicted delivery within 14 days of testing with a sensitivity, specificity, and positive and negative predictive values of 71%, 74%, 19%, and 97%, respectively. CONCLUSION: As noted in singleton pregnancies, fetal fibronectin testing in twins has a high negative predictive value. Fetal fibronectin evaluation may be a useful tool in screening twins with symptoms of preterm labor, because a negative result places these women at a low risk for delivering within 2 weeks of testing. LEVEL OF EVIDENCE: II

Superfetation secondary to ovulation induction with clomiphene citrate: a case report

In conclusion, CC has been associated with an increased rate of multifetal pregnancy; however, after each induction cycle, pregnancy should be ruled out before start of a new induction cycle. This would prevent misinterpretations of the gestational age at delivery, and hence of maturity, and would also help prevent any potential malformation that may be caused by a yet undetected teratogenic effect of CC.

Prediction of pregnancy outcome in preterm premature rupture of membranes using vaginal pool amniotic fluid markers

Abstract Objective: To determine whether there is an association between levels of interleukin-6 (IL-6), lactate dehydrogenase (LDH), and glucose in vaginal pool amniotic fluid specimens and pregnancy outcome in preterm premature rupture of membranes (PPROM). Methods: Vaginal pool amniotic fluid samples from 49 patients at between 27 and 36 weeks of gestation with PPROM and no evidence of clinical chorioamnionitis were tested for IL-6, LDH, and glucose. Results were compared with respect to collection-to-delivery interval, histologic chorioamnionitis, and neonatal sepsis. Results: The mean collection-to-delivery interval was 67 hours (3 to 420 hours). There was no difference between IL-6, LDH, or glucose with respect to collection-to-delivery interval. The prevalence of histologic chorioamnionitis was 36% (18 of 49). The prevalence of neonatal sepsis was 26% (13 of 49); six of the 13 also had histologic chorioamnionitis. The mean LDH level was significantly greater (107.6 U/L) for women with histologic chorioamnionitis than for those without (9.8 U/L; P = 0.0004). A receiver operating curve found that an LDH level greater than 25 U/L predicted histologic chorioamnionitis (PPV, 80%). Conclusion: Vaginal pool amniotic fluid LDH greater than 25 U/L was shown to predict histologic chorioamnionitis in PPROM, whereas IL-6 and glucose were not shown to be clinically useful.

The use of high-frequency oscillatory ventilation in a patient with H1N1 pneumonia

A 32-year-old multigravida was admitted at 33.9 weeks with respiratory distress. Community-acquired pneumonia was suspected and antimicrobial treatment initiated with ceftriaxone sodium and azithromycin. However, despite these therapies her respiratory status deteriorated. She was subsequently diagnosed with Swine-origin Influenza A (H1N1) Virus pneumonia and treated with oseltamivir. After failing conventional ventilation, high-frequency oscillatory ventilation (HFOV) was utilized. In pregnant patients who fail to respond to conventional ventilation techniques, HFOV should be considered.

Coding Education in Obstetrics [22B]

INTRODUCTION: Healthcare is continuously evolving and very few trainees understand the principles of ICD diagnosis and procedure coding. Few academic programs incorporate documentation, coding and reimbursement training into medical education. We sought to characterize those trainees with self-reported familiarity and understanding of billing and coding in obstetrics. We also identify challenges and strategies for implementing coding education during residency and fellowship. METHODS: Maternal Fetal Medicine fellows, identified through the Society for Maternal Fetal Medicine, were asked to complete an electronic, web-based survey. RESULTS: Of 72 respondents, 36 (50%) were currently in their third year or were recent graduates of fellowship training. 23 (32%) received formal training during their residency or fellowship, however 30% of fellows reported unfamiliarity with E&M and ICD coding. A significant number of trainees (63%) were unaware of the use of modifiers and how they influence acceptance or rejection of medical claims. 93% (67/72) reported an interest in coding education. Challenges cited include lack of awareness during training, time constraints and financial limitations in participating in additional courses. CONCLUSION: With the universal implementation of electronic medical records and the adoption of ICD-10 in the United States, it is imperative that knowledge of appropriate coding and billing practices be upheld. Despite increased utilization of electronic medical records and professional coders, it is important for physicians to have a keen understanding of documentation and coding in clinical practice. These preliminary findings suggest that the current generation of trainees would benefit from coding and billing education during their residency or fellowship curriculum.

OP08.14: Utility of the fetal echocardiogram after a normal fetal cardiac evaluation by detailed fetal anatomy ultrasound

Objectives: To evaluate the performance of 3D software that allows retrieving standard diagnostic planes of the fetal heart from a 3D volume and estimate inter-observer reproducibility of fetal cardiac views in the second trimester of pregnancy. Methods: 73 fetal cardiac volumes were acquired in pregnant women between 20–32 weeks of gestation using Accuvix XQ (MEDISON, Korea). Seven diagnostic planes of the fetal heart, according to standardization of 3D fetal echocardiography: 4-CH view, LVOT, RVOT, 3 vessel view, aortic & ductal arches, venous connection (SVC & IVC) have been retrieved from 3D volumes of the fetal chest using software 3D XI PC Viewer that is composed of Multi-Slice View (MSV) and Oblique View (OBV) modes. The off-line fetal cardiac study was performed by 2 specialists not involved in the volume acquisition, with similar skills in 2D fetal cardiac scanning, but different degree of skills in 3D US examination. 4-CH view was set as an acquisition plane. 25–35 degree of volume sweep was appropriate to capture the stomach and upper mediastinum levels. Results: In our study identification rate and reproducibility of main cardiac landmarks, such as LVOT, RVOT and 3 vessels view were substantial. However, the visualization rate and reproducibility of diagnostic planes of the fetal heart not included into the ‘basic’ 2D cardiac ultrasound, such as ductal arch and venous connection, were lower in less experienced in 3D US hands (Observer 1).