Ivan Ngai

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.

Unilateral adrenal infarction in pregnancy

A 25-year-old pregnant woman at 28 weeks gestational age presented with increasing abdominal pain and was found to have a unilateral adrenal infarction on a CT scan of the abdomen. Her medical history was unremarkable. There was no evidence of adrenal insufficiency with normal cortisol and adenocorticotropic hormone levels for pregnancy. Evaluation of thrombophilia disorders established the patient to be heterozygous for methylenetetrahydrofolatereductase C677T gene mutation as the only finding. The patient was anticoagulated to prevent contralateral thrombosis. At 32 weeks she experienced spontaneous rupture of membranes. One week later she delivered vaginally and remained anticoagulated for the puerperium.

Comparison of Subcuticular Suture Type for Skin Closure after Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE To compare the rate of wound complications among women who underwent cesarean delivery through a Pfannenstiel skin incision followed by subcuticular closure with either poliglecaprone 25 suture or polyglactin 910 suture. METHODS Patients undergoing nonemergent cesarean delivery at or beyond 37 weeks of gestation were randomized to undergo subcuticular skin closure with either poliglecaprone 25 or polyglactin 910. The primary outcome was a wound composite outcome of one or more of the following: surgical site infection, wound separation, hematoma, or seroma within the first 30 days postpartum. To detect a reduction in the primary outcome rate from 12% to 4%, with a power of 0.90 and a two-tailed α of 0.05, 237 women per study group were required. Analysis was performed according to the intent-to-treat principle. RESULTS From May 28, 2015, to August 5, 2016, 275 women were randomized to poliglecaprone 25 and 275 to polyglactin 910, of whom 520 (95%) were included in the final analysis: 263 in the poliglecaprone 25 group [of whom 231 (88%) actually underwent poliglecaprone 25 closure) and 257 in the polyglactin 910 group [of whom 209 (81%) actually underwent polyglactin 910 closure]. The groups were similar in demographic characteristics, medical comorbidities, and perioperative characteristics. Poliglecaprone 25 was associated with a significantly decreased rate of overall wound complications when compared with polyglactin 910, 8.8% compared with 14.4% (relative risk 0.61, 95% CI 0.37-0.99; P=.04). CONCLUSION Closure of the skin after cesarean delivery with poliglecaprone 25 suture decreases the rate of wound complications compared with polyglactin 910 suture. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02459093.

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor

OBJECTIVE The aim of this study was to improve patient handoffs on the labor floor. METHODS A prospective cohort study of obstetrics residents at Montefiore Medical Center was performed between 2012 and 2014. Labor-floor handoffs were recorded before and after didactic sessions as well as after installation of whiteboards formatted with the mnemonic SWIFT (Subject, Why?, Issues, Fetus, Tasks). Handoff transcripts were evaluated by obstetricians blinded to timing and speaker identity. An intraclass correlation coefficient accounted for evaluator differences. Data analysis was by ordinal logistic regression, the generalized estimating equations method (correlated data), and Bonferroni adjustment (multiple comparisons). RESULTS Forty-five handoffs were evaluated (15 each predidactics, postdidactics, and postwhiteboard revision). Higher completeness scores over time were noted for admission reason, labor concerns, and task list (not statistically significant). Comprehensive score increases prelecture to postwhiteboard were seen in handoff clarity (2.81 versus 2.91) and overall quality (2.77 versus 2.81) (not statistically significant). A subanalysis of four residents who gave multiple handoffs over different periods revealed few significant changes over time. Greater interevaluator consistency was noted with more objective elements. CONCLUSIONS The mnemonic SWIFT, with formalized curricula for obstetrical resident training focusing on new learners and increased faculty involvement and reinforcement, may result in improvement of handoffs on the labor floor.

The Effectiveness of 17α-Hydroxyprogesterone Caproate in Obese Women for Prevention of Preterm Delivery

INTRODUCTION: To assess the outcomes of 17&agr;-hydroxyprogesterone caproate in obese women compared with nonobese women. METHODS: Women receiving 17&agr;-hydroxyprogesterone caproate from January 1, 2011, through December 31, 2012, were identified. Demographics including body mass index (BMI) and pregnancy outcomes were obtained. All women received a 250-mg weekly dosage of 17&agr;-hydroxyprogesterone caproate. Obesity was defined as a BMI greater than 30 kg/m2. Statistical analysis considered P<.05 as significant and the study was approved by the institutional review board. RESULTS: There were 79 women using 17&agr;-hydroxyprogesterone caproate caproate identified during the study period with 39 obese women and 40 nonobese women in a control group. When compared the groups had similar mean gestational age at delivery (obese 36.9±2.8 compared with nonobese NOR 36.4±3.9 weeks; P=.48) and similar mean birth weights (obese 2,765±816 compared with nonobese 2,854±597 g; P=.58). More obese women (59%) were delivered by cesarean than nonobese women (23%; P<.01). When dividing the cohort by BMI greater than 35 kg/m2 or greater than 40 kg/m2, the similarities remained. CONCLUSION: There are no differences in pregnancy outcomes for obese women receiving the universal dosage of 17&agr;-hydroxyprogesterone caproate for prevention of preterm birth (Table 1). Cesarean delivery was more common in the obese women. Table 1 Maternal Body Mass Index and Pregnancy Outcomes