Jeffrey D. Sperling

Four Residents' Narratives on Abortion Training: A Residency Climate of Reflection, Support, and Mutual Respect

The decision on the part of obstetrics and gynecology residents to opt in or out of abortion training is, for many, a complex one. Although the public debate surrounding abortion can be filled with polarizing rhetoric, residents often discover that the boundaries between pro-choice and pro-life beliefs are not so neatly divided. We present narratives from four residents, training at a 32-resident program in the Northeast, who have a range of views surrounding abortion. Their stories reveal how some struggle with the real-life experience of providing abortions, while others feel angst over lacking the skills to terminate a life-threatening pregnancy. These residents have found that close relationships with coworkers from all sides of this issue, along with a residency program that encourages open conversation, have fostered understanding. Their narratives demonstrate that reasonable providers can disagree fundamentally and still work effectively with one another and that the close relationships formed in residency can allow both sides to see beyond the black and white of the public abortion debate. Our objectives in this commentary are to encourage a more nuanced discussion of abortion among obstetrician-gynecologists, to describe the aspects of our residency program that facilitate open dialogue and respect across diverse viewpoints, and to demonstrate that the clear distinction between being pro-life and pro-choice often breaks down when one is immediately responsible for the care of pregnant women.

The Role of Headache in the Classification and Management of Hypertensive Disorders in Pregnancy.

Hypertensive disorders of pregnancy remain among the leading causes of maternal morbidity and mortality. The onset of headaches in patients with hypertensive disorders of pregnancy has been considered as a premonitory symptom for eclampsia and other adverse maternal outcomes. Headaches are very common symptoms during pregnancy and the postpartum period with a reported incidence of 39%; however, headache is absent in 30-50% of women before the onset of eclampsia and is a poor predictor of eclampsia and adverse maternal outcomes. If included in the definition of cerebral or visual disturbances, headache may be considered a symptom of preeclampsia, a diagnostic feature of preeclampsia with severe features, a premonitory symptom of eclampsia, and an indication for delivery. Inclusion of this nonspecific symptom in the diagnosis and management of hypertensive disorders of pregnancy in the absence of an evidence basis may lead to unintended consequences including excessive testing, visits to outpatient offices or emergency departments, additional hospitalization, and iatrogenic preterm delivery without proven benefit. If a cerebral disturbance such as severe or persistent headache presents for the first time during pregnancy or postpartum, an evaluation should be performed that considers a broad differential diagnosis, including but not limited to hypertensive disorders of pregnancy, and the diagnostic evaluation is similar to that in nonpregnant adults. This commentary draws attention to the implications of considering the cerebral disturbance of headache as a symptom that portends adverse pregnancy outcome in the current recommendations for diagnosing and managing hypertensive disorders of pregnancy.

Cervical Cerclage During Periviability: Can We Stabilize a Moving Target?

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recently published consensus guidelines on periviable birth recommending that obstetric interventions (antenatal corticosteroids, tocolysis, magnesium sulfate, antibiotics for preterm premature rupture of membranes or group B streptococcus prophylaxis, and cesarean delivery for fetal indications) may be considered at 23 0/7 weeks of gestation and neonatal resuscitation at 22 0/7 weeks of gestation. Cervical cerclage significantly decreases preterm delivery and improves perinatal outcomes in women with a singleton pregnancy, prior spontaneous preterm birth, and transvaginal cervical length less than 25 mm before 24 0/7 weeks of gestation or in women who experience painless cervix dilation in the second trimester. Randomized trials assessing ultrasonogram-indicated and physical examination-indicated cerclage report a procedure-related complication rate of 0.3% and 0.9%, respectively. If previability is a requisite for receiving a cerclage, an increasing subset of women may not be afforded an intervention that has known benefit, because obstetric and neonatal interventions are likely to occur at earlier gestational ages. Given the low procedure-related complication rate demonstrated in randomized trials, appropriately selected women should continue to be offered the procedure up to 24 0/7 weeks of gestation. Based on current evidence, cerclage placed after 24 0/7 weeks of gestation cannot be recommended, and future inquiry in the form of a well-designed randomized trial after this gestational age should be considered. The goal of this commentary is to review the history of cerclage and discuss the indications, risks, benefits, and implications on future research of this procedure as it relates to gestational age during periviability.

Restriction of oral intake during labor: whither are we bound?

In 1946, Dr Curtis Mendelson suggested that aspiration during general anesthesia for delivery was avoidable by restricting oral intake during labor. This suggestion proved influential, and restriction of oral intake in labor became the norm. These limitations may contribute to fear and feelings of intimidation among parturients. Modern obstetrics, especially in the setting of advances in obstetric anesthesia, does not mirror the clinical landscape of Mendelson; hence, one is left to question if his findings remain relevant or if they should inform current recommendations. The use of general anesthesia at time of cesarean delivery has seen a remarkable decline with increased use of effective neuraxial analgesia as the standard of care in modern obstetric anesthesia. While the American College of Obstetricians and Gynecologists now endorses clear liquids during labor, current recommendations continue to suggest that solid food intake should be avoided. Recent evidence from a systematic review involving 3130 women in active labor suggests that oral intake should not be restricted in women at low risk of complications, given there were no identified benefits or harms of a liberal diet. Aspiration and other adverse maternal outcomes may be unrelated to oral intake in labor and as such, qualitative measures such as patient satisfaction should be paramount. It is time to reassess the impact of oral intake restriction during labor given the minimal risk of aspiration during labor in the setting of modern obstetric anesthesia practices.

Screening for Preeclampsia and the USPSTF Recommendations

Preeclampsia is a condition characterized by the new onset of hypertension after 20 weeks of gestation, with proteinuria, evidence of organ dysfunction, or both in a previously normotensive woman.1 Preeclampsia and eclampsia complicate up to 10% of pregnancies and remain a leading cause of maternal and neonatal morbidity and mortality in the United States.2 The complications of preeclampsia in part shaped the development of prenatal care in the United States. The timing and frequency of visits were chosen to improve detection of preeclampsia through the measurement of blood pressure at routine prenatal visits.3 In this issue of JAMA, the USPSTF provides a recommendation statement on screening for preeclampsia.4 The current recommendation was based on an updated systematic evidence review by Henderson et al5 conducted on behalf of the task force that evaluated 5 key questions: How effectively does screening for preeclampsia reduce maternal and perinatal morbidity and mortality? What is the effectiveness of risk assessment in early pregnancy for identifying women at high risk for preeclampsia? What are the harms of preeclampsia risk assessment? How effectively do screening tests (eg, blood pressure, proteinuria) identify women with preeclampsia? What are the harms of screening for preeclampsia and do they differ by risk status or screening protocol? Although these questions are all equally important, 3 issues are worthy of discussion: the effectiveness of routine blood pressure measurement for detection of preeclampsia, the evidence of various tests to detect proteinuria, and the value of models to predict preeclampsia before its onset.

Prevention of RhD Alloimmunization: A Comparison of Four National Guidelines

Objective The objective of this study was to compare national guidelines on the prevention of RhD alloimmunization. Study Design We performed a review of four national guidelines on prevention of alloimmunization from the American Congress of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynaecologists, Society of Obstetricians and Gynaecologists of Canada, and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. We compared the indications/contraindications, timing, dosing, formulation and route of anti‐D immune globulin, and management of unique circumstances. The references were compared with regard to the number of randomized control trials, Cochrane Reviews, and systematic reviews/meta‐analyses cited. Results Variation exists in recommendations on the timing and need for consent prior to routine antenatal anti‐D immune globulin administration, prophylaxis for unique circumstances (e.g., threatened abortion < 12 weeks, complete molar pregnancy), and the use of cell‐free fetal DNA testing for fetal RhD genotype. Conclusion These variations in recommendations reflect the heterogeneity of the literature on the prevention of alloimmunization and highlight the need for synthesis of evidence to create an international guideline on prevention of alloimmunization. This may improve safety, quality, optimize outcomes, and stimulate future trials.

Evidence-Based Cesarean Delivery for the Nonobstetrician

Cesarean delivery (CD) is one of the most common major surgeries performed in the United States and worldwide. Surgical techniques evaluated in well-designed randomized controlled trials (RCTs) that demonstrate maternal benefit should be incorporated into practice. The objective of this review is to provide a summary of surgical techniques of the procedure and review the evidence basis for them for the nonobstetrician. The following techniques with the strongest evidence should be commonly performed, when feasible: (1) prophylactic antibiotics with a single dose of ampicillin or first-generation cephalosporin prior to skin incision; (2) postpartum hemorrhage prevention with oxytocin infusion of 10 to 40 IU in 1 L crystalloid over 4 to 8 hours; (3) low transverse skin incision; (4) blunt or sharp subcutaneous and fascial expansion; (5) blunt, cephalad-caudad uterine incision expansion; (6) spontaneous placental removal; (7) blunt-tip needle usage during closure; (8) subcutaneous suture closure (running or interrupted) if thickness is ≥2 cm; and (9) skin closure with suture. Although the number of RCTs designed to optimize maternal and neonatal outcomes of this common procedure is encouraging, further work is needed to minimize surgical morbidity. Optimal methods for postpartum hemorrhage prevention, adhesion prevention, and venous thromboembolism prophylaxis remain ongoing areas of active research, with outcomes that could markedly improve maternal morbidity and mortality. If evidence of a surgical technique appears preferred over another, clinicians should be comfortable adopting the evidence-based technique when performing and teaching CD.

Immediate vs Delayed Pushing During the Second Stage of Labor

Efforts to optimize cesarean delivery rates have prompted research regarding the optimal approach to the management of labor.1,2 The second stage of labor, defined as the interval from complete cervical dilation until delivery of the fetus, is a critical period in labor management. Whether the mother should push immediately or delay pushing for 1 or more hours has been the subject of debate and several observational studies and randomized clinical trials. Although the data may be mixed as a result of efforts to control for mode of delivery and insufficient sample size,3,4 prolonged duration of the second stage of labor is associated with both adverse maternal4 and neonatal outcomes.5 Delayed pushing (also known as laboring down, passive descent, or rest and descend) has not been studied in a highquality, adequately powered, contemporary randomized clinical trial.6 In this issue of JAMA, Cahill et al7 compared the effect of immediate vs delayed pushing during the second stage of labor (spontaneous or induced) among nulliparous women at or beyond 37 weeks’ gestation receiving neuraxial analgesia. The primary outcome was the rate of spontaneous vaginal delivery with secondary outcomes of maternal and neonatal morbidity. This pragmatic, multicenter randomized clinical trial performed between 2014 and 2017 recruited 2414 women with a mean age of 26.5 years. The rate of spontaneous vaginal delivery did not differ between groups (85.9% in the immediate pushing group vs 86.5% in the delayed pushing group; relative risk, 0.99 [95% CI, 0.96-1.03]). Patients in the immediate pushing group had decreased duration of the second stage of labor (31.8 minutes less) and increased duration of active pushing (9.2 minutes more). Although the study was not powered to fully evaluate the additional outcomes that were assessed, certain events were more likely to occur in each study group. In the immediate pushing group, thirdor fourth-degree perineal lacerations were more common, whereas in the delayed pushing group, chorioamnionitis and postpartum hemorrhage were more common. There was no significant difference between groups in a composite measure of neonatal morbidity, although suspected neonatal sepsis and acidemia were less common in the immediate pushing group. Importantly, the data and safety monitoring board terminated this study after a planned interim analysis (following enrollment of 2414 women of a planned sample of 3184) due to futility and concern for increased morbidity in the delayed pushing group. Although previous data have suggested that delayed pushing reduces the risk of cesarean delivery,8 the data in this study as well as more recent observational data suggest that delayed pushing does not reduce the risk of cesarean delivery and lengthens the duration of the second stage of labor without evidence of benefit to mother or infant.9,10 The authors acknowledged several limitations of their investigation including lack of blinding and the associated possibility of bias, lack of adjustment for multiple comparisons, and lack of power for some secondary outcomes. It is important to note that 4238 of the 12 088 patients (35.1%) assessed for eligibility declined to participate in the trial and that several confounders that may have contributed to the primary outcome were not assessed, including rotation of the malpositioned head and maternal positioning.11 The other interventions not evaluated that may have changed the frequency of the maternal and neonatal outcomes include the use of warm compresses and perineal massage for perineal care12 and the performance of episiotomy.13 Moreover, an adjusted model for potential confounders that could affect the primary and secondary outcomes was not performed. Nonetheless, this study suggests the potential harms of delayed pushing and the reduced risks for some maternal and neonatal outcomes with immediate pushing. This study presents the only contemporary level 1 evidence available on this topic. As optimal labor management strategies are evaluated, it is exciting to consider how technology could contribute to improving perinatal outcomes. The International Society of Ultrasound in Obstetrics and Gynecology recently published guidelines on the intrapartum use of ultrasonography.14 Such a tool could be an objective method to assess fetal head descent (progression), station, position, attitude (ie, the posture of the fetus, with flexion of the fetal head on the chest), synclitism (ie, the sagittal suture of the fetal head is in line with the transverse diameter of the pelvis inlet), and accurately assess feasibility of an operative vaginal delivery. This technique could also minimize unnecessary clinical examinations and improve maternal satisfaction. Novel models of collaborative care using both midwives and obstetric laborists has been shown to decrease cesarean delivery rates, improve rates of vaginal birth after cesarean delivery, but require further research.15 The data from the report by Cahill et al7 contribute to a growing body of literature on how to optimally manage labor in an evidenced-based fashion and improve perinatal outcomes without compromising maternal satisfaction. Almost 4 million births occur in the United States each year, of which approximately 68% involve vaginal delivery, so additional Related article page 1444 Opinion

Intrahepatic Cholestasis of Pregnancy: Review of Six National and Regional Guidelines

Intrahepatic cholestasis of pregnancy (ICP) is a poorly understood disease of the late second or third trimester of pregnancy, typically associated with rapid resolution following delivery. It is characterized by pruritis, elevated serum bile acids, and abnormal liver function tests and has been linked to stillbirth, meconium passage, respiratory distress syndrome and fetal asphyxial events. The incidence is highly variable, dependent both on the ethnic makeup of the population as well as the diagnostic criteria being used. Management is challenging for clinicians, as laboratory abnormalities often lag behind clinical symptoms making diagnosis difficult. The American Congress of Gastroenterology, Government of Western Australia Department of Health, the Royal College of Obstetricians and Gynaecologists, Society for Maternal Fetal Medicine, European Association for the Study of the Liver, and South Australia Maternal and Neonatal Community of Practice have all released guidelines to address the risks, diagnosis and management of ICP. We performed a descriptive review of these guidelines along with a literature search to address conflicting recommendations and highlight new evidence. The variations in the guidelines reflect the heterogeneity of the literature and the challenges of diagnosing and managing ICP.

Prenatal Care Adherence and Neonatal Intensive Care Unit Admission or Stillbirth among Women with Gestational and Preexisting Diabetes Mellitus

Objective To determine if there was an association between prenatal care adherence and neonatal intensive care unit (NICU) admission or stillbirth, and adverse perinatal outcomes in women with preexisting diabetes mellitus (DM) and gestational DM (GDM). Materials and Methods This is a retrospective cohort study among women with DM and GDM at a Diabetes in Pregnancy Program at an academic institution between 2006 and 2014. Adherence with prenatal care was the percentage of prenatal appointments attended divided by those scheduled. Adherence was divided into quartiles, with the first quartile defined as lower adherence and compared with the other quartiles. Results There were 443 women with DM and 499 with GDM. Neonates of women with DM and lower adherence had higher rates of NICU admission or stillbirth (55 vs. 39%; p = 0.003). A multivariable logistic regression showed that the lower adherence group had higher likelihood of NICU admission (adjusted odds ratio: 1.61 [1.03‐2.5]; p = 0.035). Those with lower adherence had worse glycemic monitoring and more hospitalizations. Among those with GDM, most outcomes were similar between groups including NICU admission or stillbirth. Conclusion Women with DM with lower adherence had higher rates of NICU admission and worse glycemic control. Most outcomes among women with GDM with lower adherence were similar.