Katherine E. Debiec

Inadequate prenatal care and risk of preterm delivery among adolescents: a retrospective study over 10 years

OBJECTIVE The aim of this study was to determine whether inadequate prenatal care is associated with increased risk of preterm birth among adolescents. STUDY DESIGN We selected a random sample of women under age 20 years with singleton pregnancies delivering in Washington State between 1995 and 2006. Multivariate logistic regression was used to assess the association between prenatal care adequacy (percent of expected visits attended, adjusted for gestational age) and preterm birth. RESULTS Of 30,000 subjects, 27,107 (90%) had complete data. Women without prenatal care had more than 7-fold higher risk of preterm birth (n = 84 [24.1%]; adjusted odds ratio [aOR], 7.4), compared with those attending 75-100% of recommended visits (n = 346 [3.9%]). Women with less than 25%, 25-49%, or 50-74% of expected prenatal visits were at significantly increased risk of preterm birth; risk decreased linearly as prenatal care increased (n = 60 [9.5%], 132 (5.9%], 288 [5%]; and aOR, 2.5, 1.5, and 1.3, respectively). CONCLUSION Inadequate prenatal care is strongly associated with preterm birth among adolescents.

Labor and delivery outcomes among young adolescents

OBJECTIVE We sought to determine whether young adolescents aged 11-14 years and teens aged 15-17 and 18-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20-24 years. STUDY DESIGN We conducted a retrospective population-based cohort study using Washington State birth certificate data linked to hospital records from 1987 through 2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents aged 11-14 years, young teens aged 15-17 years, and older teens aged 18-19 years to young adults aged 20-24 years. The primary outcome was method of delivery. Secondary outcomes included postpartum hemorrhage, shoulder dystocia, third- and fourth-degree perineal lacerations, chorioamnionitis, prolonged maternal length of stay, gestational age at delivery, birthweight, respiratory distress syndrome, neonatal length of stay, and death. We used multivariate regression to assess associations between age and delivery outcomes. RESULTS Young adolescents aged 11-14 years had a lower risk of cesarean (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.65-0.83) and operative vaginal (RR, 0.87; 95% CI, 0.78-0.97) delivery compared to young adults aged 20-24 years. Compared to young adults, young adolescents had an increased risk of prolonged length of stay for both vaginal and cesarean delivery (RR, 1.34; 95% CI, 1.20-1.49, and RR, 1.71; 95% CI, 1.38-2.12, respectively), with no significant differences in indication for cesarean delivery or other measures of maternal morbidity. Young adolescents had an increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79-2.48), low and very low birthweight (RR, 2.08; 95% CI, 1.73-2.50, and RR, 3.25; 95% CI, 2.22-4.77, respectively), and infant death (RR, 3.90; 95% CI, 2.36-6.44) compared to young adults. CONCLUSION Young adolescents have a decreased risk of cesarean and operative vaginal delivery compared to young adults; however, their neonates face higher risks of preterm delivery, low and very low birthweight, and death. This information can be used to inform clinical care for this population.

Case report: lethal fetal head injury and placental abruption in a pregnant trauma patient

Fetal trauma in blunt abdominal trauma is uncommon, but traumatic fetal head injury is almost universally fatal to the fetus. Placental abruption is the most common injury to the gravid uterus in trauma, and when the mother survives, it is the most common cause of fetal death. The imaging diagnosis of these conditions may be difficult since there are only three cases reported in the literature of intrauterine skull fractures on plain films [3, 8, 10], ultrasound is in sensitive in the diagnosis of placental abruption [24], and the most sensitive test to diagnose placental abruption is external fetal monitoring with devices that measure uterine tone and contractility and fetal heart rate [23]. The diagnosis of fetal trauma and placental abruption may be made on contrast enhanced CT performed through the abdomen and pelvis of pregnant trauma patients. For these reasons, it is useful for the radiologist interpreting the CT scan to recognize fetal head injuries and placental abruption in pregnant trauma patients.Fig. 7 Axial scans through the bony pelvis demonstrate an unstable pelvic fracture with posterior pelvic ring disruption.There is a zone 2 fracture of the left sacrum and a fracture of the left obturator ring (arrowheads)

Primary vaginal dilation for vaginal agenesis: strategies to anticipate challenges and optimize outcomes.

Purpose of review Primary vaginal dilation is patient controlled, safe, less painful, and much lower cost compared with operative vaginoplasty and is considered first-line treatment for vaginal agenesis for women with Mayer–Rokitansky–Küster–Hauser syndrome and androgen insensitivity syndrome. Recent findings This review will highlight studies that assess the optimal methods of primary vaginal dilation and clarify ideal counseling, frequency of dilation, management of side-effects, and long-term physical and psychological outcomes. Summary Providers who care for women with vaginal agenesis should be prepared to not only teach the technical skill of dilation, but also to assess readiness and troubleshoot symptoms associated with dilation.

Randomized Trial of Smartphone-Based Evaluation for an Obstetrics and Gynecology Clerkship

OBJECTIVE We hypothesized that compared to paper evaluations, a smartphone-based quick response (QR) evaluation tool would improve timeliness of feedback, enhance efficacy of giving and receiving feedback, and be as easy to use. DESIGN We performed a randomized controlled trial of student and instructor experience with two evaluation tools in the OB/GYN clerkship at University of Washington School of Medicine (UWSOM). Sites were randomized to the QR or paper tool; students at QR sites received individualized QR codes at the beginning of the clerkship. Instructors and students completed postintervention surveys regarding the evaluation tool and associated feedback. We compared responses between groups using chi-squared tests. SETTING Participating clerkship sites included primary, tertiary, private practice and institutional settings affiliated with the University of Washington in the Washington, Wyoming, Alaska, Montana and Idaho region. PARTICIPANTS Of the 29 OB/GYN UWSOM clerkship sites, 18 agreed to participate and were randomized. Of 29 eligible instructors, 25 (86%) completed the survey, with n = 18 using QR and n = 7 using paper. Of 161 eligible students, 102 (63%) completed the survey, with n = 54 using QR and n = 48 using paper. RESULTS Compared to those using paper evaluations, instructors using QR evaluations were significantly more likely to agree that the evaluation tool was easy to understand (100% QR vs 43% paper, p = 0.002), the tool was effective in providing feedback (78% QR vs 29% paper, p = 0.002), and they felt comfortable approaching students with the tool (89% QR vs 43% paper, p = 0.002). Compared to those using paper evaluations, students using QR evaluations were less likely to agree the tool was effective in eliciting feedback (QR 43% vs paper 55%, p = 0.042). CONCLUSION Instructors found QR evaluations superior to paper evaluations for providing feedback to medical students, whereas students found QR evaluations less effective for feedback.

Beyond the Ivory Tower: A Comparison of Grades Across Academic and Community OB/GYN Clerkship Sites

abstract Construct: Decentralized clinical education is the use of community facilities and community physicians to educate medical students. The theory behind decentralized clinical education is that academic and community sites will provide educational equivalency as determined by objective and subjective performance measures, while training more medical students and exposing students to rural or underserved communities. One of the major challenges of decentralized clinical education is ensuring site comparability in both learning opportunities and evaluation of students. Background: Previous research has examined objective measures of student performance, but less is known about subjective performance measures, particularly in the field of obstetrics and gynecology (OB/GYN). This study explores the implications of clinical site on the adequacy of subjective and objective performance measures. Approach: This was a retrospective cohort study of 801 students in the University of Washington School of Medicine OB/GYN clerkship from 2008 to 2012. Academic sites included those with OB/GYN residency programs (n = 2) and community sites included those without residency programs (n = 29). The association between clerkship site and National Board of Medical Examiners (NBME) grade was assessed using linear regression and clinical and final grade using multinomial regression, estimating β coefficient and relative risks (RR), respectively, and 95% confidence intervals (CIs), adjusting for gender, academic quarter of clerkship, and year of clerkship. Results: There were no differences in NBME exam grades of students at academic sites (76.4 (7.3) versus 74.6 (8.0), β = –0.11, 95% CI [1.35, 1.12] compared to community sites. For clinical grade, students at community sites were 2.4 times more likely to receive honors relative to high pass (RR 2.45), 95% CI [1.72, 3.50], and for final grade, students at community sites were 1.9 times more likely to receive honors relative to pass (RR 1.98), 95% CI [1.27, 3.09], and 1.6 times more likely to receive honors relative to high pass (RR 1.62), 95% CI [1.05, 2.50], compared to those at academic sites. Conclusions: Students at community sites receive higher clinical and final grades in the OB/GYN clerkship. This highlights a significant challenge in decentralized clinical education—ensuring site comparability in clinical grading, Further work should examine the differences in sites, as well as improve standardization of clinical grading. This also underscores an important consideration, as the final grade can influence medical school rank, nomination into honor societies, and ranking of residency applicants.