James B. Hill

Association of Birth Weight With Polymorphisms in the IGF2, H19, and IGF2R Genes

There is a substantial genetic component for birth weight variation. We tested 18 single nucleotide polymorphisms (SNPs) in the IGF2, H19, and IGF2R genes for associations with birth weight variation in 342 mother-newborn pairs (birth weight 2.1–4.7 kg at term) and 527 parent-newborn trios (birth weight 2.1–5.1 kg) across three localities. SNPs in the IGF2R (rs8191754; maternal genotype), IGF2 (rs3741205; newborn genotype), and 5′ region of the H19 (rs2067051, rs2251375, and rs4929984) genes were associated with birth weight. Detailed analyses to distinguish direct maternal, direct newborn, and parent of origin effects for the most strongly associated H19 SNP (rs4929984) determined that the association of maternal genotype with newborn birth weight was due to parent of origin effects not direct maternal effects. That SNP is located near the CTCF binding sites that influence expression of the maternally imprinted IGF2 and paternally imprinted H19 locus, and there are statistically significant and independent opposite effects of the same rs4929984 allele, depending on the parent from which it was inherited.

Hypertensive crisis during pregnancy and postpartum period

Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1-2% will undergo a hypertensive crisis at some point during their lives. Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia. Pregnancy may be complicated by hypertensive crisis, with lower blood pressure threshold for end-organ damage than non-pregnant patients. Maternal assessment should include a thorough history. Fetal assessment should include heart rate tracing, ultrasound for growth and amniotic assessment, and Doppler evaluation if growth restriction is suspected. Initial management of hypertensive emergency (systolic BP >160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia) generally includes the rapid reduction of blood pressure through the use of intravenous antihypertensive medications, with goal systolic blood pressure between 140 mmHg and 150 mmHg and diastolic pressure between 90 mmHg and 100 mmHg. First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside. Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents. The objective of this article is to review the current understanding, diagnosis, and management of hypertensive crisis during pregnancy and the postpartum period.

Implementation of a Protocol to Reduce Occurrence of Retained Sponges After Vaginal Delivery

BACKGROUND Retained sponges (gossypiboma) following vaginal delivery are an uncommon occurrence. Although significant morbidity from such an event is unlikely, there are many reported adverse effects, including symptoms of malodorous discharge, loss of confidence in providers and the medical system, and legal claims. OBJECTIVE To report a protocol intended to reduce the occurrence of retained sponges following vaginal delivery. METHODS After identification of limitations with existing delivery room protocols, we developed a sponge count protocol to reduce occurrence of retained vaginal sponges. We report our experience at Naval Medical Center Portsmouth, a large tertiary care military treatment facility with our efforts to implement a sponge count protocol to reduce retained sponges following vaginal delivery. CONCLUSIONS With appropriate pre-implementation training, protocols which incorporate post-delivery vaginal sweep and sponge counts are well accepted by the health care team and can be incorporated into the delivery room routine.

Oligohydramnios, Small for Gestational Age and Pregnancy Outcomes: An Analysis Using Precise Measures

Background/Aim: Marginal or decreased amniotic fluid volume by ultrasound estimate and fetal growth restriction have been shown to be significantly associated with perinatal mortality. The association of fetal growth restriction and precisely measured amniotic fluid volume is unknown. The purpose of this study was to determine if adverse pregnancy outcomes are more likely in pregnancies complicated by small-for-gestational-age (SGA) neonates and dye-determined oligohydramnios. Methods: Admissions to neonatal intensive care unit (NICU) and other pregnancy outcomes were analyzed in parturients with known amniotic fluid volume, calculated by the dye-dilution technique. The pregnancy outcomes of those with oligohydramnios and SGA were compared with pregnancies complicated by just one of these two conditions and pregnancies with normal fluid and birth weight. Results: Of 202 patients, oligohydramnios was present in 26% (53), SGA in 15% (30) and both conditions in (5%) (11). Logistic regression, controlling for gestational age, demonstrated that the combination of oligohydramnios and SGA, compared to normal growth and fluid strongly predicted NICU admission (OR 11.1; 95% CI 2.1–59.2) but not other complications. (OR 4.8; 95% CI 0.3–62.9). Conclu sions: SGA with oligohydramnios significantly increases the likelihood of a NICU admission, but not other morbidity.

Does hypoglycemia following a glucose challenge test identify a high risk pregnancy

ObjectiveAn association between maternal hypoglycemia during pregnancy with fetal growth restriction and overall perinatal mortality has been reported. In a retrospective pilot study we found that hypoglycemia was linked with a greater number of special care/neonatal intensive care unit admissions and approached significance in the number of women who developed preeclampsia. That study was limited by its retrospective design, a narrow patient population and the inability to perform multivariate analysis because of the limitations in the data points collected. This study was undertaken to compare the perinatal outcome in pregnancies with hyoglycemia following a glucose challenge test (GCT) to pregnancies with a normal GCT.MethodsObstetric patients (not pre-gestational diabetics or gestational diabetes before 24 weeks were eligible. Women with a 1 hour glucose ≤ 88 mg/dL (4.8 m/mol) following a 50-gram oral GCT were matched with the next patient with a 1 hour glucose of 89–139 mg/dL. Pregnancy outcomes were evaluated.ResultsOver 22 months, 436 hypoglycemic patients and 434 normal subjects were identified. Hypoglycemia was increased in women < 25 (p = 0.003) and with pre-existing medical conditions (p < 0.001). Hypoglycemia was decreased if pre-pregnancy BMI ≥ 30 (p = 0.008).Preeclampsia/eclampsia was more common in hypoglycemic women. (OR = 3.13, 95% CI 1.51 – 6.51, p = 0.002) but not other intrapartum and perinatal outcomes.ConclusionHypoglycemic patients are younger, have reduced pre-pregnancy weight, lower BMIs, and are more likely to develop preeclampsia than normoglycemic women.

Vaginal birth after cesarean delivery: comparison of ACOG practice bulletin with other national guidelines.

Evidence-based guidelines regarding vaginal birth after cesarean from 3 countries (United States, Canada, and United Kingdom) were reviewed. The similarities in the 3 national guidelines (trial of labor after 1 previous cesarean, informed consent, delivery facility and available resources, epidural analgesia, continuous fetal monitoring, and induction and augmentation of labor) are understandable. Differences in recommendations (uterine rupture risk, success rate, intrauterine pressure catheter, and mechanical cervical ripening) are not explained. The likelihood of recommendations being categorized as level A differed: United States, 27% (3/11); Canada, 32% (6/19); and United Kingdom, 0% (0/17). Only 6 publications were cited by all 3 guidelines.

Severe small size for gestational age and cognitive function: catch-up phenomenon possible

OBJECTIVE We sought to compare cognitive functioning in children born with birthweight <3% vs ≥3% for gestational age (GA) between 9 months and kindergarten. STUDY DESIGN Nonanomalous singletons from the Early Childhood Longitudinal Study-Birth Cohort were included. Associations between weight for GA and cognitive functioning were examined using a series of confounder-adjusted general linear models. RESULTS Of 3633 cohorts, 585 (16%) were <3% for GA. At 9 months, cognitive performance of newborns <3% was about 12 percentile points lower than their normal counterparts (P < .001). By 2 years, however, no significant cognitive differences between these groups were observed (P = .668). Academic performance at preschool age (around 3.5 years) was not different for reading (P = .245) or math (P = .880), nor different at kindergarten age. CONCLUSION Newborns <3% for GA exhibit catch-up cognitive functioning by 2 years, with relatively no decrements in academic functioning observed by kindergarten.

Intrapartum fetal surveillance: review of three national guidelines.

Evidence-based guidelines regarding intrapartum fetal surveillance from three countries (United States, Canada, and Australia/New Zealand) were reviewed. The similarities in the three national guidelines (purported etiology, management of periodic changes, and intermittent auscultation for low-risk women) are understandable. Differences in recommendations (role of fetal admission test, amnioinfusion for variable decelerations, scalp pH, umbilical arterial acid-base status, and education in interpretation of fetal heart tracing) are not explained. The likelihood of recommendations being categorized as level A differed for the countries: United States, 41% (7/17); Canada, 18% (3/17); and Australia and New Zealand, 17% (2/12). Only one publication was cited by all three guidelines. To avoid confusion and possibly enhance their quality, national guidelines should acknowledge the presence of others on the same topic, and if there are differences then provide explanations for dissimilarities.

Maintenance tocolytics for preterm symptomatic placenta previa: a review.

The purpose of the review article is to determine if prolonged (≥48 hour) tocolytics with symptomatic preterm placenta previa improves perinatal outcome. OVID MEDLINE and Cochrane Databases were searched from January 1950 to January 2009. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. We identified two retrospective studies ( N = 217) and one randomized clinical trial (RCT; N = 60), and they were analyzed separately. Results of the RCT indicated that pregnancy is prolonged for more than 7 days with continued tocolytics (OR 3.10, 95% CI 1.38 to 6.96) but combined results of two retrospective studies did not confirm the prolongation (OR 1.19, 95% CI 0.63 to 2.28). The RCT was inadequately compliant with Consolidated Standards of Reporting Trials statement. While awaiting an appropriately designed RCT to determine the duration of tocolytics with placenta previa and preterm labor, it should be limited to 48 hours.

Indications for caesarean sections at ≥34 weeks among nulliparous women and differential composite maternal and neonatal morbidity

To compare composite maternal and neonatal morbidities (CMM, CNM) among nulliparous women with primary indications for caesarean section (CS) as acute clinical emergency (group I; ACE), non‐reassuring fetal heart rate (group II) and arrest disorder (group III).