Maria Hutchinson

Interobserver and intraobserver reliability of the NICHD 3-Tier Fetal Heart Rate Interpretation System

OBJECTIVE Our purpose was to test the reliability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) 3-Tier Fetal Heart Rate (FHR) classification system. STUDY DESIGN Individual 15- to 20-minute FHR segments (n = 154) were independently reviewed without clinical data by 3 maternal-fetal medicine examiners and classified by NICHD category (I, II, III). RESULTS Interobserver reliability was moderate (kappa 0.45) and varied by NICHD category (category I moderate [kappa 0.48], category II moderate [kappa 0.44], and category III poor [kappa 0.0]). The intraobserver agreement ranged from substantial to perfect (kappa 0.74-1.0). CONCLUSION Interobserver agreement of 3-Tier FHR classification System was moderate for NICHD categories I and II. Agreement for category III tracings was poor mainly due to lack of agreement regarding absent vs minimal variability.

A pilot randomized, controlled trial of metformin versus insulin in women with type 2 diabetes mellitus during pregnancy

OBJECTIVE Few studies support oral diabetic treatment in pregnant women with type 2 diabetes mellitus (T2DM). The objective of this study was to compare the effects of metformin versus insulin on achieving glycemic control and improving maternal and neonatal outcomes in pregnant women with T2DM. STUDY DESIGN A pilot randomized, controlled trial was conducted of metformin versus insulin for the treatment of T2DM during pregnancy. The primary outcome was glycemic control measured with hemoglobin A1c < 7% at delivery. Maternal and neonatal outcomes were compared between groups. RESULTS In this study, 8 women received metformin and 11 received insulin. All women in both groups achieved glycemic control by delivery (HgbA1c: metformin 5.96 ± 5.88 vs. insulin 6.34 ± 0.92%). There were similar rates of cesarean delivery, birth weights, neonatal intensive care unit admissions, respiratory distress syndrome, and neonatal dextrose treatment between groups. There was one case of fetal macrosomia in the insulin group, one case of shoulder dystocia in the metformin group and no cases of failed metformin therapy. CONCLUSION In this pilot study, glycemic control was achieved in women who received metformin and insulin. Larger studies are needed to determine whether metformin can be considered a reasonable alternative to insulin in pregnant women with T2DM.

Maternal development experiences of women hospitalized to prevent preterm birth

OBJECTIVE To examine ways that womens experience of hospitalization with bed rest to prevent preterm birth impacts prenatal maternal development. METHOD Interviews based on the Interview Schedules for Dimensions of Maternal Development in Psychosocial Adaptation to Pregnancy were conducted at a hospital in the southwestern United States with a convenience sample of 41 women during confinement to bed rest to prevent preterm birth. The interviews were recorded, and verbatim transcripts were submitted to thematic analysis. RESULTS Five themes were mapped from the womens narratives: (1) acceptance of pregnancy, but with fears specific to elevated risks to self and baby; (2) heightened identification with motherhood and fatherhood protector roles; (3) renewal or deepening of mother-daughter closeness intensified by high-risk pregnancy; (4) enhanced couple support and collaboration; and (5) acceptance of responsibility to perform in remaining pregnant and preparing for labor, but willingness to accept help from doctors and nurses. CONCLUSIONS This study of hospitalization to prevent preterm birth showed that women experience hospitalization as a burden to be endured to meet future goals, but that it also can facilitate prenatal maternal development in psychosocial adaptation to high risk pregnancy. Implications for research and practice are discussed.

Population standards of birth weight underestimate fetal growth abnormalities in diabetic pregnancies.

The objective of this study was to compare the frequency of abnormal fetal growth in women with diabetes mellitus (DM) using population-based birth weight (pop BW) percentiles compared with customized birth weight (cust BW) percentiles, which include adjustments for maternal race, parity, height, weight, and fetal sex. The study design comprised a retrospective cohort of singleton DM pregnancies delivered over a 1-year period (June 2007 to May 2008) from a single tertiary care university-based medical center. Inclusion criteria were gestational age >20 weeks at delivery, live birth, and absence of major chromosomal/structural abnormalities. Small for gestational age (SGA), <10th percentile, and large for gestational age (LGA), >90th percentile pregnancies were categorized based on pop BW or cust BW standards. There were significant differences in the rates of SGA (p < 0.004) and LGA (p < 0.001) between cust BW and pop BW methods. When comparing the two methods, pop BW did not identify 13/16 (81%) of SGA and 23/39 (59%) of LGA babies defined by cust BW methods. The use of cust BW calculation in a diabetic population identified a greater percentage of neonates with pathologic fetal growth compared with pop BW standards, suggesting that the population standard may underdiagnose abnormal fetal growth in diabetic pregnancies.

Potential of Metformin to Improve Cardiac Risk in Postpartum Women with Gestational Diabetes

Objective Pregnancy is associated with an increase in total cholesterol, high density lipoproteins (HDL), and low-density lipoproteins (LDL). Postpartum, HDL and LDL decrease over the first 12 weeks postpartum. Oxidized LDL (ox-LDL) is a marker of oxidative stress-related inflammation, which is associated with obesity and also with development of cardiovascular disease. Cardiovascular protection and weight loss are benefits from metformin, especially in women with diabetes. The objective of this study was to compare changes in lipid profiles and biomarkers for obesity during the initial 6 weeks postpartum between women with gestational diabetes mellitus (GDM) treated with metformin versus placebo. Methods This was a planned ancillary study of a randomized controlled trial compares metformin versus placebo in women with GDM for postpartum weight loss. Two 3 mL blood samples were collected within 24 h of delivery and 6 weeks postpartum immediately processed after collection then stored at −20°C until completion of clinical trial prior to analysis. Change in the median plasma concentrations of total cholesterol, HDL, ox-LDL, glucose, insulin, leptin, and unacylated ghrelin were compared between study groups. Results Of the 77 postpartum women were included, 35 received metformin and 42 received placebo. There was less of a reduction in HDL in the metformin group compared to placebo (−2.3 versus −7.5 mg/dL, p = 0.019). In addition, there was a greater reduction in ox-LDL in those receiving metformin (−12.2 versus −3.8 mg/dL, p = 0.038). No other differences were observed in the selected biomarkers evaluated. Conclusion Biomarker levels of HDL and ox-LDL were positively affected during the initial 6 weeks postpartum in GDM women treated with metformin. Additional studies with a longer duration of metformin treatment in the postpartum period are warranted to evaluate long-term potential benefits.

Intravenous Acetaminophen versus Morphine for Analgesia in Labor: A Randomized Trial

Objective To compare the effectiveness of intravenous acetaminophen with that of morphine in reducing pain in the first stage of labor. Methods An open‐label, randomized controlled trial of women ≥ 34 weeks gestation in the first stage of labor, assigned to either intravenous acetaminophen or morphine. The primary outcome was improved analgesia measured by difference of visual analog scale (VAS) score at 120 minutes from baseline. Secondary outcomes were request for rescue analgesia, maternal side effects, and fetal heart rate changes. Statistical analyses performed were chi‐square, Students t‐test, and Kaplan‐Meier survival analysis. Results Of 40 women randomized, 18 received acetaminophen (2 did not receive study drug), and 20 received morphine. Because of difficulties in recruitment, the sample size of 88 was not achieved. The primary outcome was similar between groups (p = 0.53). Within 120 minutes of initial treatment, more women receiving intravenous acetaminophen required rescue analgesia (acetaminophen: 52.9% vs. morphine: 17.6%, p < 0.01). Maternal and fetal side effects were similar between groups. Conclusion There was no difference in VAS scores between groups. However, as half of women receiving intravenous acetaminophen required rescue analgesia within 120 minutes of treatment, intravenous acetaminophen may be less effective for analgesia in early labor compared with intravenous morphine.

Excessive Gestational Weight Gain in Women with Gestational and Pregestational Diabetes

We sought to determine the frequency of excessive gestational weight gain (GWG) and its impact on perinatal outcomes in women with gestational (GDM) and pregestational diabetes mellitus (DM). A retrospective cohort of diabetic women was studied. GWG was categorized by the 2009 Institute of Medicine guidelines. Perinatal outcomes were compared between those women with and without excessive GWG. There were 153 women who met study criteria. There was no difference in excessive GWG between women with GDM and pregestational DM (44.4% versus 38.5%, P = 0.51) or based on Whites class ( P = 0.17). After adjusting for confounders, excessive GWG was not associated with an increased rate of adverse perinatal outcomes (odds ratio 1.49, 95% confidence interval 0.56 to 2.35) and had similar associations with both pregestational DM and GDM. Although excessive GWG was common in our diabetic population, it was not associated with an increased rate of adverse perinatal outcomes.

Randomized Quality Improvement Trial of Opting-In Versus Opting-Out to Increase Influenza Vaccination Rates during Pregnancy

Introduction  Despite strong recommendations, only 40.6% of pregnant women attending two prenatal clinics were vaccinated against influenza during the 2009 pandemic. We tested whether an opting-out approach would improve vaccine uptake. Methods  We conducted a randomized quality improvement (QI) trial to compare opting-out with conventional opting-in consent for influenza immunization. Women age ≥ 18 years attending the University of Texas Health Science Center at Houston (UTHealth) or UT-Medical Branch (UTMB) prenatal clinics during the 2010–2011 influenza season, were eligible. Results  We enrolled 280 women (140 UTHealth, 140 UTMB). Both groups had similar mean age (26.0 ± 5.5 years), mean gestational age (19.4 ± 9.5 weeks), and percent with underlying health conditions (20.7%). Vaccination rates with opting-in and opting-out were similar among all (83 vs. 84%), UTHealth (87 vs. 93%), and UTMB patients (79 vs.76%) ( p  > 0.05). In subsamples of patients assessed, consent strategy did not significantly affect maternal recall of information provided. Conclusion  While prenatal influenza vaccination uptake doubled from the 2009–2010 influenza season, opting-out did not perform better than opting-in, a conclusion opposite that we would have reached had this been a nonconcurrent trial. Vaccination rates dropped posttrial; hence, continued research is needed to increase the prenatal influenza immunizations.

Liberal versus Indicated Maternal Oxygen Supplementation in Labor: A Before-and-After Trial

Background Although supplemental oxygen (SO2) is routinely administered to laboring gravidas, benefits and harms are not well studied. Objective This article compares strategies of liberal versus indicated SO2therapy during labor on cesarean delivery (CD) rate and neonatal outcomes. Study Design A controlled, before‐and‐after trial of laboring women with term, singleton pregnancies. During an initial 8‐week period, maternal SO2was administered at the discretion of the provider followed by an 8‐week period where SO2was to be given only for protocol indications. Results Our study included 844 women. There was no difference in number of women receiving SO2(53% liberal vs. 50% indicated; p = 0.33). For those receiving SO2, there was no difference in SO2duration (median, 89 minutes [interquartile range, 42‐172] vs. 87 minutes [36‐152]; p = 0.42). There were no differences in overall CD rate (20% vs. 17%; p = 0.70), CD for nonreassuring fetal status, or use of intrauterine resuscitative measures. There were more 5‐minute APGAR < 7 in the indicated group, but no difference in umbilical artery pH < 7.1 or neonatal intensive care unit (NICU) admission. Conclusion Approximately half of women receive SO2intrapartum regardless of a strategy of liberal or indicated oxygen use. There were no clinically significant differences in outcomes between strategies.

Families at Risk: Home and Car Smoking Among Pregnant Women Attending a Low-Income, Urban Prenatal Clinic

INTRODUCTION Secondhand smoke exposure (SHSe) has been identified as a distinct risk factor for adverse obstetric and gynecological outcomes. This study examined the prevalence of SHSe reduction practices (i.e., home and car smoking bans) among pregnant women in a large U.S. prenatal clinic serving low-income women. METHODS Pregnant women (N = 820) attending a university-based, urban prenatal clinic in Houston, Texas, completed a prenatal questionnaire assessing bans on household and car smoking and a qualitative urine cotinine test as part of usual care. Data were collected from April 2011 to August 2012. RESULTS Nearly one-third (n = 257) of the sample reported at least 1 smoker living in the home. About a quarter of the women in the full sample did not have a total smoking ban in their home and car. Within smoking households, 44% of the pregnant women reported smoking, 56% reported smoking by another household member, and in 26% of smoking households both the pregnant woman and at least one other person were smoking. Only 43% of women with a household smoker reported a total ban on smoking, with higher rates among Hispanic women. Smoking bans were less common when the pregnant women smoked, when more than 1 smoker resided in the home, and when pregnant with her first child. CONCLUSIONS SHSe among low-income pregnant women is high, and interventions to raise awareness and increase the establishment of smoking bans in homes and cars are warranted.