Jennifer K. Durst

Universal cervical length screening: implementation and outcomes

BACKGROUND Transvaginal measurement of cervical length (CL) has been advocated as a screening tool to prevent preterm birth, but controversy remains regarding the overall utility of universal screening. OBJECTIVE We aimed to evaluate the acceptability of a universal CL screening program. Additionally we evaluated risk factors associated with declining screening and subsequent delivery outcomes of women who accepted or declined screening. STUDY DESIGN This was a retrospective cohort study of transvaginal CL screening at a single institution from July 1, 2011, through December 31, 2014. Institutional protocol recommended transvaginal CL measurement at the time of anatomic survey between 17-23 weeks in all women with singleton, viable pregnancies, without current or planned cerclage, with patients able to opt out. Patients with CL ≤20 mm were considered to have clinically significant cervical shortening and were offered treatment. We assessed acceptance rate, risk factors for declining CL screening, and the trend of acceptance of CL screening over time. We also calculated the prevalence of CL ≤25, ≤20, and ≤15 mm, and estimated the association between CL screening and spontaneous preterm birth. RESULTS Of 12,740 women undergoing anatomic survey during the study period, 10,871 (85.3%; 95% confidence interval [CI], 84.7-85.9%) underwent CL screening. Of those, 215 (2.0%) had a CL ≤25 mm and 131 (1.2%) had a CL ≤20 mm. After the first 6 months of implementation, there was no change in rates of acceptance of CL screening over time (P for trend = .15). Women were more likely to decline CL screening if they were African American (adjusted odds ratio [aOR], 2.17; 95% CI, 1.93-2.44), obese (aOR, 1.18; 95% CI, 1.06-1.31), multiparous (aOR, 1.45; 95% CI, 1.29-1.64), age <35 years (aOR, 1.24; 95% CI, 1.08-1.43), or smokers (aOR, 1.42; 95% CI, 1.20-1.68). Rates of spontaneous preterm birth <28 weeks were higher in those who declined CL screening (aOR, 2.01; 95% CI, 1.33-3.02). CONCLUSION Universal CL screening was implemented successfully with 85% of women screened. Overall incidence of short cervix was low and women with significant risk factors for preterm birth were more likely to decline screening. Patients who declined CL screening were more likely to be African American, obese, multiparous, age <35 years, and smokers. Rates of early, but not late, spontaneous preterm birth were significantly higher among women who did not undergo CL screening.

Impact of Gestational Weight Gain on Perinatal Outcomes in Obese Women.

Objective This study aims to evaluate perinatal outcomes, according to gestational weight gain (GWG) in obese women. Study Design A retrospective cohort of perinatal outcomes in obese women who gained below, within, or above the 2009 Institute of Medicine guidelines and delivered ≥ 36 weeks. Additionally, outcomes, according to the rate of GWG (kg/week; minimal [< 0.16], moderate [0.16-0.49], or excessive [> 0.49]) were compared among women delivering preterm. Results Overall, 5,651 obese women delivered ≥ 36 weeks. GWG above guidelines was associated with increased cesarean section (adjusted odds ratio [aOR]: 1.44, 95% confidence interval [CI]: 1.21-1.72), gestational hypertension (aOR: 1.58, 95% CI: 1.21-2.06), and macrosomia (birth weight ≥ 4,000 g) (aOR: 2.08, 95% CI: 1.62-2.67). GWG below recommendations was associated with less large for gestational age infants (aOR: 0.60, 95% CI: 0.47-0.75). A total of 6,663 women delivered ≥ 20 weeks. Minimal weekly GWG was associated with increased spontaneous preterm birth (aOR: 1.56, 95% CI: 1.23-1.98) and more small for gestational age (SGA) infants (aOR: 1.55, 95% CI: 1.19-2.01). Excessive weekly GWG was associated with increased indicated preterm birth (aOR: 1.61, 95% CI: 1.29-2.01), cesarean section (aOR: 1.39, 95% CI: 1.20-1.61), preeclampsia (aOR: 1.83, 95% CI: 1.49-2.26), neonatal intensive care unit admission (aOR: 1.33, 95% CI: 1.08-1.63), and macrosomia (aOR: 2.40, 95% CI: 1.94-2.96). Conclusions Obese women with excessive GWG had worse outcomes than women with GWG within recommendations. Limited GWG was associated with increased spontaneous preterm birth and SGA infants.

Resolution of a Low-Lying Placenta and Placenta Previa Diagnosed at the Midtrimester Anatomy Scan: Resolution of a Low-Lying Placenta and Placenta Previa

To identify the incidence and resolution rates of a low‐lying placenta or placenta previa and to assess the optimal time to perform follow‐up ultrasonography (US) to assess for resolution.

Mode of delivery in nulliparous women with gestational hypertension undergoing early term induction of labor

Abstract Objective: To evaluate perinatal outcomes in nulliparous women undergoing induction of labor for gestational hypertension at term. Study design: Retrospective cohort study of nulliparous women with gestational hypertension undergoing induction of labor ≥37 weeks. Mode of delivery and perinatal outcomes were compared for women who delivered at 370–6/7, 380–6/7, and ≥390/7 weeks gestation. Results: The cohort included 320 women: 67 (21%) at 370–6/7, 76 (24%) at 380–6/7, and 177 (55%) at ≥390/7. There was no increase in cesarean delivery (CD) in women delivering earlier, with 26.9% (370–6/7), 19.7% (380–6/7) and 29.9% (≥390/7) requiring CD (p values = 0.39). Compared to ≥39 weeks, composite maternal morbidity was lowest in women delivering at 380–6/7 (adjusted odds ratio [aOR] 0.45, 95% confidence interval (CI) 0.24–0.84). Composite neonatal morbidity was similar among the groups. When compared to women delivering at ≥390/7 weeks, women delivered at 380–6/7 were less likely to experience any adverse maternal or neonatal outcome (aOR 0.50, 95% CI 0.28–0.90). Conclusions: Compared to induction of labor at ≥39 weeks, early term induction of labor was not associated with an increased risk of CD in nulliparous women with gestational hypertension.

Determining the Minimum Number of Ultrasound Simulations to Establish Competency

Local Mentor: Eric Strand, MD APGO Advisor: Nancy Hueppchen, MD, MSc PURPOSE: To determine the number of simulations that are required to provide the novice learner with comparable ultrasound skills to a PGY1 Intern. BACKGROUND: There is renewed emphasis on training medical students prior to the start of residency. The VIMEDIX OB simulator offers the ability to simulate ultrasound images although the ideal integration into training is unknown. METHODS: Prospective cohort study of OB/GYN residents (n=33) and medical students entering OB/GYN residency (n=12). IRB approval was obtained prior to the start of the study. Each resident took a timed test on US image fetal biometry acquisition (head circumference, abdominal circumference and femur length). Accuracy and mean times (seconds) were established for PGY1, PGY2, PGY3 and PGY4 years. Medical students comprised the intervention cohort. The students performed timed growth scans after completing 1, 5, 10 and 15 simulations. Accuracy was then compared to PGY1, PGY2, PGY3 and PGY4 years. RESULTS: Thirty-three residents completed the study. Resident accuracy in obtaining satisfactory images for growth US decreased with advancing PGY year from 85.7% as a PGY 1 to 50% as a PGY4. Ten medical students completed all simulations for analysis. Accuracy was 41.7% after one simulation and 90.9% after 5. DISCUSSION: The use of an ultrasound simulator demonstrated that novice learners had to perform 5 simulations to demonstrate comparable growth scan accuracy to a PGY 1. Ultrasound accuracy decreased with advancing year in residency suggesting that skills should be maintained during training.