Linda R. Chambliss

Noninvasive uterine electromyography for prediction of preterm delivery

OBJECTIVE Power spectrum (PS) of uterine electromyography (EMG) can identify true labor. EMG propagation velocity (PV) to diagnose labor has not been reported. The objective was to compare uterine EMG against current methods to predict preterm delivery. STUDY DESIGN EMG was recorded in 116 patients (preterm labor, n = 20; preterm nonlabor, n = 68; term labor, n = 22; term nonlabor, n = 6). A Student t test was used to compare EMG values for labor vs nonlabor (P < .05, significant). Predictive values of EMG, Bishop score, contractions on tocogram, and transvaginal cervical length were calculated using receiver-operator characteristics analysis. RESULTS PV was higher in preterm and term labor compared with nonlabor (P < .001). Combined PV and PS peak frequency predicted preterm delivery within 7 days with area under the curve (AUC) of 0.96. Bishop score, contractions, and cervical length had an AUC of 0.72, 0.67, and 0.54. CONCLUSION Uterine EMG PV and PS peak frequency more accurately identify true preterm labor than clinical methods.

Use of uterine electromyography to diagnose term and preterm labor

Current methodologies to assess the process of labor, such as tocodynamometry or intrauterine pressure catheters, fetal fibronectin, cervical length measurement and digital cervical examination, have several major drawbacks. They only measure the onset of labor indirectly and do not detect cellular changes characteristic of true labor. Consequently, their predictive values for term or preterm delivery are poor. Uterine contractions are a result of the electrical activity within the myometrium. Measurement of uterine electromyography (EMG) has been shown to detect contractions as accurately as the currently used methods. In addition, changes in cell excitability and coupling required for effective contractions that lead to delivery are reflected in changes of several EMG parameters. Use of uterine EMG can help to identify patients in true labor better than any other method presently employed in the clinic.

A Randomized Controlled Study of Brief Interventions To Teach Residents about Domestic Violence.

PURPOSE To test an educational intervention regarding domestic violence. METHOD Residents beginning their training in 1995 or 1996 were randomly assigned to attend, at their hospital orientation, either a 20-minute session emphasizing the importance of screening for domestic violence or a session on an unrelated topic. RESULTS Seventy-one percent of the residents in the experimental group diagnosed domestic violence; 52% in the control did so (RR, 1.35; 95% CI, 0.96-1.90; p = .07) in the nine to 12 months following the intervention. Rates of diagnosis differed by specialty (p <.01): 100% family practice, 90% emergency medicine, 80% obstetrics-gynecology, 63% pediatrics, 47% internal medicine, 0% surgery. Change in knowledge was assessed in 1996; significant improvement was noted (p = .002). CONCLUSION An intervention about domestic violence conducted at orientation for residents improved the rate of diagnosis of domestic violence. While the improvement was not statistically significant in this case, the intervention was brief and harmless. Other institutions should consider this kind of brief intervention.

Progestin treatment for the prevention of preterm birth

Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α‐hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long‐term progestin supplementation mostly studied so far. However, progesterone (but not 17α‐hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.

Paper gestational age wheels are generally inaccurate

OBJECTIVE To compare the estimated date of confinement of paper gestational wheels to the estimated date of confinement of APPs wheels using a standard last menstrual period. METHODS Obstetric providers were asked for their gestational wheels. The last menstrual period was set at Jan. 1, 2013, and the estimated date of confinement obtained was compared with the estimated date of confinement of Oct. 8th if the pregnancy completed 280 days. The process was performed on 20 electronic APPs downloadable to cell phones. The process was repeated for both for the leap year of 2012. RESULTS Thirty-one paper wheels from a variety of sources were collected. Ten wheels (35%) were consistent with the standard pregnancy duration of 280 days. Among the wheels surveyed, the largest discrepancy was 4 days short of 280 days. Two wheels gave an estimated date of confinement that differed from each other by 7 days. Wheels from the same source did not agree with each other. Twenty electronic gestational age calculators were examined. All 20 gave an estimated date of confinement of Oct. 8 consistent with 280 days. None of the paper gestational wheels but all of the APPs corrected for a leap year. CONCLUSION In contrast to APPs gestational age calculators, the estimated date of confinement of the majority of paper wheels deviated from the standard pregnancy duration of 280 days. Precision in gestational age assessment is critical in a variety of clinical settings and heightened by the focus by payers and reporting agencies on elective deliveries before 39 weeks. The use of paper gestational age wheels should be abandoned.

Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations.

BACKGROUND Management of rhinosinusitis during pregnancy requires special considerations. OBJECTIVES 1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations. METHODS The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea. RESULTS Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations. CONCLUSIONS The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.

Additive Inhibitory Effects of Progesterone and Sodium Nitroprusside on Uterine Contractility During Pregnancy

Progesterone (P4) and nitric oxide (NO) suppress uterine contractility (CTX). This study compares the effects of P4 to sodium nitroprusside (SNP, an NO donor) and their combination on human CTX of term/preterm and labor/nonlabor tissues. Uterine tissues (n = 128) from women (n = 28) undergoing Cesarean were suspended in organ baths. Tissues (n ≥ 6/group) were treated with vehicle, P4, SNP, or combinations. A subset of tissues (n ≥ 2/group) from term/preterm ± labor and nonpregnant patients was analyzed with P4 alone. Analysis of variance (ANOVA) was used for statistical differences (P < .05). The combination of P4 with SNP significantly suppresses CTX (% inhibition of −127.1 ± 14.5) to the levels lower than with either P4 (−20.1 ± 8.6) or SNP alone (−72.0 ± 11.2). Suppression of P4 is similar in term, preterm, and nonpregnant tissues, with increased sensitivity in laboring tissues. This indicates that P4 or SNP alone may be used for preterm labor and their combination may be more successful.

Development of an Advanced Womenʼs Imaging Fellowship in Obstetrics and Gynecology [21E]

INTRODUCTION: The role of ultrasound in diagnosis has led to its increased use in the everyday practice of obstetrics and gynecology. There is a need for individuals with advanced training to perform and interpret studies, as well as educate residents and medical students in medical imaging. Well trained physicians can also benefit their patients by performing an ultrasound, providing results, and initiating further treatment planning in the same visit. METHODS: A one year curriculum was developed with input from expert ultrasound faculty in the departments of Radiology, Emergency Medicine, Obstetrics/Gynecology and Maternal Fetal Medicine. The curriculum was approved by the hospitals Department of Graduate Medical Education. It included lectures, assigned readings, and direct supervision of ultrasounds by experienced clinicians and registered sonographers. An emphasis was placed on understanding ultrasound technology and performance and interpretation of gynecologic, first trimester, and basic anatomical fetal ultrasound. Additional training was provided in ultrasound procedures, and the integration of MRI and CT in diagnosis. The fellow was required to complete the Registered Diagnostic Medical Sonographer certification in Ob/Gyn. RESULTS: Over 600 scans were completed by the fellow. The learner demonstrated proficiency in ultrasound techniques, including guided procedures and 3D volume manipulation. The fellow earned the ultrasound certification. He is currently employed as academic faculty; teaching gynecologic ultrasound, interpreting routine fetal scans, and providing interdepartmental instruction. CONCLUSION: The training curriculum is a means of training physicians in advanced ultrasound techniques in Ob/Gyn. The curriculum may be further refined to maximize the fellows skill set and knowledge of the ultrasound literature.

Use of Real-Time Ultrasonography to Diagnose Pseudolabor

Pseudolabor has been reported in a handful of cases over the past 20 years and has been proposed as a subtype of conversion disorder. Pseudolabor is not well understood and remains a challenge for obstetrical providers to diagnose early enough so as to prevent unnecessary use of tocolytics and other unnecessary care for preterm labor. Contraction patterns observed in pseudolabor patients have classically been described with 2 different morphologies, both caused by prolonged abdominal skeletal muscle contraction. One morphology is described as “spiked,” abrupt in onset, and abrupt in descent. The second is described as an abrupt onset, plateau or flattop phase, followed by an abrupt descent. Here we describe a case of a 30-yearold woman who presented with signs suspicious for pseudolabor whose contraction patterns were convincing for uterine smooth muscle contractions. In this case, real-time ultrasound was used to demonstrate that the uterus was not contracting, thus confirming a diagnosis of pseudolabor.