Frederick Friedman

Lifestyle modification program decreases pregnancy weight gain in obese women.

We assessed the impact of a lifestyle modification program (LMP) on weight gain in pregnancy and evaluated its effect on adverse pregnancy outcomes. A prospective matched controlled study design was employed. Inclusion criteria consisted of pregnant women with singleton gestations and body mass index (BMI) > or = 30 without underlying medical conditions. In the study group, patients were prospectively enrolled in the first trimester. Through the LMP, women participated in a comprehensive program on nutrition, exercise, and weight control in pregnancy. The control group consisted of matched patients by starting BMI, parity, and socioeconomic status during the same study period cared for at the same institution. The primary outcome evaluated was weight gain in pregnancy. Adverse pregnancy outcomes including preeclampsia, gestational diabetes, gestational hypertension, and various postpartum complications were evaluated between the two groups. Statistical analysis was performed using nonparametric methods, with p < 0.5 considered significant. Twenty-eight patients were recruited for this study and underwent the intervention. Patient compliance with the LMP was 75%, two patients were lost to follow-up, one had a preterm delivery, and four had incomplete data due to various reasons. Twenty-one patients completed their pregnancy and were available for analysis. Twenty matched control patients were identified for analysis. Study participants gained significantly less weight in their pregnancies when compared with controls (mean weight gain 17 versus 34 pounds, respectively; p = 0.008). Secondary outcomes of preeclampsia, gestational diabetes, cesarean section, as well as infant birth weight did not significantly differ between the groups. This study suggests an effective method of reducing prenatal weight gain in the obese population. This type of comprehensive intervention could be an important, cost-effective risk-reduction strategy.

The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents

OBJECTIVE The purpose of this study was to evaluate the effect of acute sleep deprivation on the fine motor coordination in obstetrics and gynecology residents. STUDY DESIGN Twenty-eight obstetrics and gynecology residents completed a series of tasks using the Purdue pegboard standardized protocol for testing fine motor coordination both before and after a 24-hour call. RESULTS Twenty-three participants were women and 5 were men. There was a learning curve demonstrated for performance of the tasks. There was a statistically significant decline in performance of residents after overnight call. When adjusting for the learning curve, effects of sleep deprivation were magnified for all tasks: right (dominant) hand (P = .0005), left hand (P = .0020), both hands (P < .0001), and assembly (P < .0001). There were significant differences in performance when segregated by year of training and sex; female residents appeared to tolerate better lack of sleep. CONCLUSION Acute sleep deprivation has a deleterious effect on fine motor coordination in this group of obstetrics and gynecology residents.

A comparative study of computerized tomography, magnetic resonance imaging, and clinical staging for the detection of early cervix cancer

Sixteen patients with cervical cancer underwent radical surgery following standard clinical staging, MRI, and CT. The sensitivity of the CT scan was 14%, the specificity 100%. MRI had a sensitivity of 28% and a specificity of 64%. The clinical stage was correct in 10 of 16 patients (62%). CT and MRI are not individually or collectively better than clinical staging in predicting extent of disease, and currently should not be included in the FIGO staging for cervix cancer.

Laparoscopic pomeroy tubal ligation in a residency training program

STUDY OBJECTIVE To evaluate the efficacy of the laparoscopic Pomeroy method of tubal ligation as a teaching tool during the initial acquisition of advanced laparoscopic skills by 14 residents in a 28-person, 4-year program. DESIGN A prospective, nonrandomized study. SETTING A metropolitan teaching hospital. PATIENTS Fifty-seven women who desired permanent sterilization, and 56 controls who underwent laparoscopic sterilization by standard coagulation. One refused entry and had standard sterilization by bipolar coagulation. In two women, both with several previous laparotomies, visualization of the pelvic organs was incomplete and the procedure was abandoned at the discretion of the surgeon. One had a minilaparotomy Pomeroy tubal ligation and the other was sterilized by standard two-puncture laparoscopic coagulation. One patient was excluded due to an incomplete data profile. INTERVENTIONS Laparoscopic sterilizations using the Pomeroy technique and standard coagulation were performed by gynecology residents with an attending physician present. First-year residents performed 36 (68%) of the 53 procedures. MEASUREMENTS AND MAIN RESULTS Operative times to teach this technique to house officers rotating on the gynecologic service were recorded by postgraduate year and stratified by the number of cases performed by each operator. The average operative times for residents in postgraduate years 1 through 4 were 18.6, 15.4, 21.7, and 14.8 minutes, respectively. These diminished with experience. A statistically longer time of 7.1 minutes was required to teach residents the Pomeroy technique compared with standard bipolar coagulation (p<0.0003). CONCLUSION Laparoscopic Pomeroy tubal ligation as a method to begin educating residents in advanced operative video-laparoscopy appears to have great potential.

The lifestyle modification project: limiting pregnancy weight gain in obese women

Abstract Objective: To assess the impact of a group lifestyle intervention on gestational weight gain in a cohort of obese pregnant women. Methods: A cohort study comparing 60 pregnant women enrolled in an educational intervention with controls from the same institution who receive routine prenatal care. Subjects were matched with controls by pre-pregnancy body mass index, parity and ethnicity. Subjects participated in group and individual counseling sessions focused on diet, exercise and weight goals. The primary outcome was gestational weight gain. Results: A greater number of patients in the intervention group met the Institute of Medicine weight gain recommendations (35 versus 24, p = 0.0446). Mean gestational weight gain of participants was lower than the control group, but this was not statistically significant. Number of sessions attended was associated with a decrease in total weight gained. Conclusion: Educational interventions targeting obese pregnant women may be an effective way to limit gestational weight gain. Participation in educational sessions likely influences total weight gain.

The sequential effect of computerized delivery charting and simulation training on shoulder dystocia documentation.

Objective. To estimate the effects of computerized charting and shoulder dystocia (SD) simulation drills on the documentation of SD. Methods. 180 cases of SD were evaluated in three consecutive time periods: T1: 45 written delivery notes; T2: 48 delivery notes after the implementation of a standardized SD note in the computerized medical record; T3: 87 computerized delivery notes after SD simulation drills. Results. A standardized SD computerized note resulted in a significant improvement in documentation of EFW, diabetic status, time of the body delivery, fetal head position, which shoulder was impacted, anesthesia, the length of each stage of labor, NICU admission, the birth weight, and that a discussion took place with the patient. The implementation of a SD simulation drill was associated with a further increase in the documentation of the instruments used for delivery, whether a cord pH was performed, and that a discussion took place with the patient. Additionally, the implementation of a SD simulation drill increased the rate of documented SD (1.61% vs. 2.37% of vaginal deliveries, p = 0.0275) and the number of obstetricians who documented a SD (32.35% vs. 60.29% of delivering obstetricians, p = 0.0020). Conclusions. Standardized SD notes as well as simulation drills improve documentation of SD events.

Association Between Senior Obstetrician Supervision of Resident Deliveries and Mode of Delivery

OBJECTIVE In December 2012, the Mount Sinai Hospital implemented a program to have senior obstetricians (more than 20 years of experience) supervise residents on labor and delivery during the daytime. The objective of this study was to estimate the association of resident supervision by senior obstetricians with mode of delivery. METHODS This was a retrospective cohort study of all resident deliveries at Mount Sinai from July 2011 to June 2015. We included all patients with live, term, singleton, vertex fetuses. We compared delivery outcomes between patients delivered before December 2012 and patients delivered December 2012 and later using logistic regression analysis to control for age, body mass index, parity, induction, and prior cesarean delivery. During the study period there were no other specific departmental initiatives to increase forceps deliveries aside from having six obstetricians with significant experience in operative deliveries supervise and teach residents on labor and delivery. RESULTS There were 5,201 live, term, singleton, vertex deliveries under the care of residents, 1,919 (36.9%) before December 2012 and 3,282 (63.1%) December 2012 or later. The rate of forceps deliveries significantly increased from 0.6% to 2.6% (adjusted odds ratio [OR] 8.44, 95% confidence interval [CI] 3.1-23.1), and the rate of cesarean deliveries significantly decreased from 27.3% to 24.5% (adjusted OR 0.68, 95% CI 0.55-0.83). There were no statistically significant differences in the rates of third- or fourth-degree lacerations or 5-minute Apgar scores less than 7. Among nulliparous women, the forceps rate increased from 1.0% to 3.4% (adjusted OR 4.87, 95% CI 1.74-13.63) and the cesarean delivery rate decreased from 25.6% to 22.7% (adjusted OR 0.69, 95% CI 0.53-0.89). The increase in forceps deliveries and the decrease in cesarean deliveries were seen only in daytime hours (7 AM to 7 PM), that is, the shift that was covered by senior obstetricians. CONCLUSION Having senior obstetricians supervise resident deliveries is significantly associated with an increased rate of forceps deliveries and a decreased rate of cesarean deliveries.

Breastfeeding and Delivery Room Neonatal Collapse

Sudden unexpected neonatal collapse in the delivery room is a rare occurrence in healthy term infants. Upper airway obstruction may occur from improper positioning of the newborn even while breastfeeding. Such occlusion may have dire consequences if not recognized immediately. We report 2 healthy term neonates who suffered respiratory arrest while in the mother’s arms and attempting breastfeeding. In each case, rapid response by the delivery room nurse averted tragedy. Metabolic and infectious evaluations were unremarkable. Both babies have been well on subsequent examinations. We conclude that proper education of mothers and safe positioning of neonates is critical during the initiation of breastfeeding.

Manchester Procedure Vs. Vaginal Hysterectomy for Uterine Prolapse: A Comparison

The Manchester procedure (MP) was compared with vaginal hysterectomy (VH) to determine whether any differences regarding patient demographics or operative or postoperative outcome could be found between the two techniques. A retrospective chart analysis was done comparing data from 88 consecutive MP to 105 randomly selected VH patients. All the operations were performed for uterine prolapse at Mount Sinai Hospital between 1984 and 1988. MP patients, when compared to VH patients, were more likely to be older and postmenopausal at the time of surgery and to have a private physician. MP patients were less likely to have significant medical illnesses than were VH patients. Statistically significant differences between MP and VH were found for operative time (100 vs 130 minutes, respectively) and blood loss (200 vs. 300 mL, respectively) (P < .001). This difference was not dependent on the performance of anterior or posterior repair. MP was associated with shorter operative time and less blood loss when compared to VH. This, coupled with apparently similar operative outcomes, suggests the use of MP as an alternative to VH in the absence of uterine pathology in appropriate candidates with uterine prolapse. Prospective, controlled, long-term studies comparing the operative results of these two procedures are needed.

Analysis of Morphology of Single-Embryo Transfers and Correlation With Antepartum Biomarkers and Obstetric Outcomes [353].

INTRODUCTION: Embryo morphology during in vitro fertilization has previously been studied in association with rates of implantation and live birth rates. The objective of this project is to evaluate the effect of embryo morphology on antepartum biomarkers and obstetric outcomes after single-embryo transfer. METHODS: At a single reproductive endocrinology and infertility center, 17,768 embryo transfers were performed between July 1, 2001, and June 30, 2013. Of those, 2,882 were single-embryo transfers performed on day 3, 5, or 6. After obtaining institutional review board consent to correlate embryo morphology with perinatal outcomes, we identified 78 patients who delivered at a single institution. We compared embryo morphology, using the Garner and Schoolcraft system of grading including embryo expansion, inner cell mass, and trophectoderm to antepartum biomarkers and pregnancy outcomes. Statistical analysis was performed using t tests for parametric data and Kruskal-Wallis, as indicated. RESULTS: Complete embryologic, serologic, and obstetric outcomes were available for fresh (n=55) and frozen (n=23) single-embryo transfers. Standard biomarkers and obstetric outcomes were correlated with cleavage stage (n=23) and blastocyst (n=55) morphology scores. Embryos with a higher quality inner cell mass demonstrated higher second-trimester maternal serum &agr;-fetoprotein (P<.044). No other differences in standard biomarkers (first and second trimesters) or perinatal outcomes were observed. CONCLUSION: In this retrospective pilot study we demonstrated that embryo morphokinetics did not correlate with perinatal outcome or the majority of placental biomarkers. Patients should be reassured that embryos of lower morphologic quality that implant result in comparable biomarkers and obstetric outcomes similar to those from higher quality embryos.