James Van Hook

Neonatal Organ System Injury in Acute Birth Asphyxia Sufficient to Result in Neonatal Encephalopathy

OBJECTIVE To identify the proportion of major organ system injury in cases of acute intrapartum asphyxia that result in neonatal encephalopathy. METHODS A prospectively maintained database was cross‐referenced using medical record coding to identify diagnoses of acute intrapartum asphyxia, acute birth asphyxia, or neonatal encephalopathy over a 6‐year period. An acute intrapartum asphyxial antecedent was validated with emphasis on excluding long‐standing or chronic conditions where injury likely occurred before presentation. Injury pattern was evaluated using routinely available laboratory and imaging tests. RESULTS Forty‐six cases of acute peripartum asphyxia sufficient to result in the diagnosis of neonatal encephalopathy were identified. Clinical central nervous system injury resulting in encephalopathy was present in 100% of cases as it was an entry criteria; of these, 49% had electroencephalogram and 40% had imaging studies diagnostic of acute injury. Liver injury based on elevated aspartate transaminase or alanine transaminase levels occurred in 80%. Heart injury, as defined by pressor or volume support beyond 2 hours of life or elevated cardiac enzymes, occurred in 78%. Renal injury, defined by an elevation of serum creatinine to greater than 1.0 mg/dL, persistent hematuria, persistent proteinuria, or clinical oliguria, occurred in 72%. An elevation in nucleated red blood cell counts exceeding 26 per 100 white blood cells occurred in 41%. CONCLUSION Using common diagnostic tests as markers of acute asphyxial injury, we noted that multiple organs suffer damage during an acute intrapartum asphyxial event sufficient to result in a neonatal encephalopathy.

Association of reported trimester-specific smoking cessation with fetal growth restriction.

OBJECTIVE: To assess the association of reported smoking cessation at various time points during pregnancy with fetal growth restriction. METHODS: This was a population-based retrospective cohort study of singleton nonanomalous live births using Ohio birth certificates, 2006–2012. Outcomes of women who reported smoking only in the 3 months before conception and women who reported smoking through the first, second, or third trimester were compared with a referent group of nonsmokers. Multivariate logistic regression assessed the association between smoking cessation at various times in pregnancy and fetal growth restriction less than the 10th and 5th percentiles. RESULTS: Of 927,424 births analyzed, 75% of mothers did not smoke. Of smokers, 24% smoked preconception only, 10% quit after the first trimester, 4% quit after the second trimester, and 59% smoked throughout pregnancy. The rate of fetal growth restriction less than the 10th and 5th percentiles among nonsmokers was 8.1% and 3.6%, respectively. Although smoking only in the preconception period did not significantly increase fetal growth restriction risk, smoking in any trimester did. The adjusted odds ratio (95% confidence interval) for fetal growth restriction less than the 10th and 5th percentiles, respectively, of cessation after the first trimester was 1.19 (1.13–1.24) and 1.25 (1.17–1.33) and 1.67 (1.57–1.78) and 1.83 (1.68, 1.99) for cessation after the second trimester. Women who reported smoking throughout pregnancy had the highest risks of fetal growth restriction, 2.26 (2.22–2.31) and 2.44 (2.37–2.51), after accounting for the influence of race, low socioeconomic status, and medical comorbidities. CONCLUSION: Smoking of any duration during pregnancy is associated with an increased risk of fetal growth restriction with decreasing risk the earlier that cessation occurs. Smoking cessation programs should focus on the benefit of quitting as early in pregnancy as possible. LEVEL OF EVIDENCE: II

Relationship of trimester-specific smoking patterns and risk of preterm birth

BACKGROUND In 2011, the US national rate of smoking early in pregnancy was 11.5%. Unfortunately, our home state of Ohio had a rate twice as high at 23%. Smoking in pregnancy remains one of the most important modifiable risk factors for pregnancy complications, specifically preterm birth. OBJECTIVE The objective of the study was to quantify the preterm birth risk to various trimester-specific smoking behaviors. STUDY DESIGN The study was a population-based, retrospective cohort study of singleton non-anomalous live births, using Ohio birth records 2006 to 2012. Preterm birth rates were compared between non-smokers and women who smoked in the preconception period only, those who quit smoking after the 1st and 2nd trimesters, and those who smoked throughout pregnancy. Multivariate logistic regression quantified the risk of smoking with cessation at various times in pregnancy and preterm birth risk, adjusted for maternal race, education, age, Medicaid use, marital status, and parity. A stratified analysis was performed on the basis of preterm birth subtype: spontaneous preterm birth versus indicated preterm birth. We also performed an additional analysis stratifying for maternal race using the 2 largest categories of race (non-Hispanic white and non-Hispanic black). RESULTS Of the 913,757 birth records analyzed, nearly 25% of the women reported some smoking behavior on the birth certificate data. Of smokers, less than half quit during pregnancy (38.8% vs 61.2% smoked throughout pregnancy). Early quitters had a similar preterm birth rate compared with non-smokers. Women who smoked through the 1st trimester only did not have a significant increase in their overall preterm birth odds ratio <37 weeks; however, it did increase the odds of extreme preterm birth <28 weeks by 20% (adjusted odds ratio, 1.20; 95% confidence interval [CI], 1.02, 1.40). Quitting late in pregnancy resulted in the highest odds ratio increase: 70% for preterm birth <37 weeks (adjusted odds ratio 1.70; CI, 1.60, 1.80), even after adjustment for the confounding influences. Quitting smoking early in pregnancy after the 1st trimester did not increase the overall risk of spontaneous or indicated preterm birth <37 weeks significantly. However, quitting after the 1st trimester was associated with a significant increase in risk of extreme spontaneous preterm birth <28 weeks, an effect not seen with indicated preterm birth <28 weeks. Delaying cessation until late in pregnancy-after the 2nd trimester-was associated with the highest risk increases, 65% increased odds of spontaneous and 78% increase in odds of indicated preterm births. The rate of preterm births to non-Hispanic black mothers was increased in all categories over those of non-Hispanic white mothers. The relative influence of smoking cessation in pregnancy was similar in black compared with white mothers. The effect modification in the regression model was analyzed and revealed no significant interaction between race and smoking patterns on preterm birth risk. CONCLUSION Smoking throughout pregnancy is associated with an increased risk of preterm birth. However, quitting early in pregnancy negates this risk. Widespread programs aimed at smoking cessation early in pregnancy could have a significant impact on reducing the rate of preterm birth nationally.

The hemodynamic effects of isometric exercise during late normal pregnancy

OBJECTIVE Our study was designed to evaluate the hemodynamic effects of isometric exercise in late normal pregnancy. STUDY DESIGN Study subjects were 10 healthy pregnant volunteers with uncomplicated singleton gestations between 25 and 36 weeks. Doppler methods were used to derive cardiac output, total peripheral resistance, and stroke volume before, during, and after a defined protocol of lower extremity isometric exercise. Hemodynamics and blood pressure were evaluated and compared. RESULTS Mean arterial blood pressure and total peripheral resistance increased during the performance of isometric effort (mean blood pressure +/- SD was 78.9 +/- 7.3 to 97.5 +/- 8.6 mm Hg; total peripheral resistance +/- SD was 924 +/- 148 to 1153 +/- 18.3 dyne.sec.cm-5; p < 0.002 and p < 0.001, respectively). Cardiac output remained unchanged throughout the study period. CONCLUSION In advanced normal pregnancy isometric exercise increases the mean arterial blood pressure by raising the total peripheral resistance.

Giant chorioangiomas: perinatal outcomes and techniques in fetoscopic devascularization.

Objective: To evaluate the intrauterine management and perinatal outcome of pregnancies complicated by giant placental chorioangioma (>4 cm) and elaborate on various devascularization techniques. Materials and Methods: Retrospective review of 10 cases of giant placental chorioangioma evaluated between January 2005 and August 2012. Maternal demographics, prenatal imaging, response to fetoscopic treatment, obstetrical complications, and perinatal outcomes were evaluated. Results: Overall survival was 80%. Seven (70%) cases were associated with obstetrical complications, including polyhydramnios (n = 7), non-immune hydrops (n = 3), and high cardiac output state (n = 5). Five patients underwent fetoscopic devascularization at a mean gestational age of 24.03 weeks with 80% survival. The tumors were devascularized by bipolar coagulation (n = 1), combination of bipolar and diode laser (n = 2), bipolar and radiofrequency ablation (n = 1), and surgical clip application (n = 1). Postoperatively, all survivors had resolution of hydrops and high cardiac output states with survival beyond 60 days of life. Discussion: Fetoscopic devascularization is indicated for high cardiac output states or non-immune hydrops and may require multiple techniques including bipolar coagulation, clip application, and/or laser to interrupt arterial inflow and devascularize the mass.

Use of an Amnioport to Maintain Amniotic Fluid Volume in Fetuses with Oligohydramnios Secondary to Lower Urinary Tract Obstruction or Fetal Renal Anomalies.

Objective: We describe a technique to maintain amniotic fluid in fetuses with severe oligo-/anhydramnios secondary to lower urinary tract obstruction or fetal renal disease when urine production is inadequate to maintain a normal amniotic fluid volume (AFV). Methods: An amnioport was inserted into the amniotic space. The catheter was secured to prevent dislodgment and tunneled to a subcutaneous reservoir. The reservoir was accessed as necessary, infusing normal saline to maintain AFV. Pregnancy continued until term or indicated delivery. Results: Since 2010, 15 patients in this category were considered for an amnioport. Six chose comfort care and one elected percutaneous amnioinfusions. Nine amnioport procedures were performed in eight patients. There were no fetal deaths. All eight had successful restoration and maintenance of amniotic fluid. Delivery ranged from 9 to 96 days after placement (mean 63.7 days). One died due to unrecognized laryngeal web and another one died of pulmonary hypoplasia after preterm premature rupture of membranes. None of the remaining six had pulmonary hypoplasia. Three remain alive. Discussion: Severe oligo-/anhydramnios in the second trimester secondary to fetal anomalies is almost uniformly lethal due to pulmonary hypoplasia without restoration of amniotic fluid. The amnioport procedure may allow pulmonary survival but commits families to postnatal care decisions regarding pulmonary and renal complications.

Factors Associated with Smoking Cessation in Pregnancy

Objective The objective of this study was to quantify the influence of various patient characteristics on early smoking cessation to better identify target populations for focused counseling and interventions. Study Design This study was a population-based retrospective cohort study of 1,003,532 Ohio live births more than 7 years (2006-2012). Women who quit smoking in the first trimester were compared with those who smoked throughout pregnancy. Logistic regression estimated the strength of association between patient factors and smoking cessation. Results The factors most strongly associated with early smoking cessation were non-white race and Hispanic ethnicity, at least some college education, early prenatal care, marriage, and breastfeeding. Numerous factors commonly associated with adverse perinatal outcomes were found to have a negative association with smoking cessation: low educational attainment, limited or late prenatal care, prior preterm birth, age < 20 years, age ≥ 35 years, and indicators of low SES. In addition, the heaviest smokers (≥ 20 cigarette/day) were least likely to quit (adjusted relative risk [RR], 0.35; 95% confidence interval 0.34, 0.36). Conclusion Early prenatal care and initiation of breastfeeding before discharge from the hospital are associated with increased RR of quitting early in pregnancy by 52 and 99%, respectively. Public health initiatives and interventions should focus on the importance of early access to prenatal care and education regarding smoking cessation for these particularly vulnerable groups of women who are at inherently high risk of pregnancy complications.

Risk Factors for a Prolonged Length of Stay in Women Hospitalized for Preeclampsia in Texas

Objectives. To identify correlates of a prolonged length of stay (PLOS) in women hospitalized for preeclampsia/eclampsia in Texas, USA. Methods: Statewide hospital data were obtained, and the records of women who were discharged in 2004 and/or 2005 with a principal discharge diagnosis of preeclampsia or eclampsia were extracted using ICD-9-CM codes. PLOS was defined as a stay greater than 5 days. Odds ratios (OR) for PLOS were calculated. Generalized estimating equations were used to account for a small group of women who were hospitalized multiple times during the study period for preeclampsia. A total of 21,203 records were analyzed. Results: The crude incidence of PLOS was 17.5%. Advancing maternal age was positively associated with PLOS: for every 10-year increase, there was a 20% increase in the odds of PLOS (adjusted OR = 1.20,95% confidence interval (CI): 1.13, 1.28). The strongest risk factor for PLOS was the presence of renal disease: adjusted OR 5.81 (95% CI: 3.97, 8.50). Protective factors included Medicaid beneficiary status, and being admitted from the emergency department. Conclusions: The strongest correlate of PLOS in a large cohort of women hospitalized for preeclampsia was the presence of renal disease.

Influence of Trimester-Specific Smoking Cessation on Fetal Growth Restriction Risk [267]

INTRODUCTION: Cigarette smoking is one of the most important modifiable risk factors for adverse birth outcomes. This study aims to assess the influence of smoking cessation at various time points during pregnancy on the risk of fetal growth restriction (FGR). METHODS: Population-based retrospective cohort study of singleton nonanomalous live births using Ohio birth records, 2006–2012. Outcomes of women who smoked in the 3 months preconception only and women who smoked through the first, second, or third trimesters were compared with a referent group of nonsmokers. Multivariate logistic regression assessed the association between smoking cessation at various times in pregnancy and FGR less than the 10th and fifth percentiles. RESULTS: Of 927,424 births analyzed, 75% did not smoke. Of smokers, 24% smoked preconception only, 10% quit after the first trimester, 4% quit after the second trimester, and 59% smoked throughout pregnancy. Although smoking in the preconception period only did not significantly increase FGR risk, smoking in any trimester did. The adjusted odds ratio (OR) (95% confidence interval [CI]) of cessation after the first trimester was 1.2 (1.1–1.2) and 1.3 (1.2–1.3) and after second trimester was 1.7 (1.6–1.8) and 1.8 (1.7–2.0), respectively, for FGR less than the 10th and fifth percentiles. The highest FGR risks were with smoking throughout pregnancy (adjusted OR [95% CI] 2.2 [2.2–2.3] and 2.4 [2.4–2.5]) after accounting for coexistent influences of race, low socioeconomic status, and medical comorbidities. CONCLUSION: Smoking of any duration during pregnancy is associated with an increased risk of FGR with decreasing risk the earlier that cessation occurs. Smoking cessation programs should focus on the benefit of quitting as early in pregnancy as possible.

The central and renal hemodynamic effects of amino acid infusion in the study of renal reserve in the baboon

Abstract: Normal human renal function is characterized by a large renal reserve. Recruitment of this reserve is a compensatory and pathological response to renal injury. This study was designed to assess the renal reserve and central hemodynamics of young female baboons and, in doing so, the appropriateness of the use of these animals in a model of human renal disease. Eight female baboons completed the protocol. PAH and inulin clearances were measured before and after an amino acid infusion. Central hemodynamics were measured with arterial and pulmonary artery catheters. Effective renal plasma flow and glomerular filtration rate increased by 42%% after amino acid infusion (P = .025). Expansion of renal function was not consistent among individual baboons; two of the eight animals did not demonstrate renal reserve. Central hemodynamics were unaffected by the protocol.