Melissa March

Circulating Angiogenic Factors and the Risk of Adverse Outcomes among Haitian Women with Preeclampsia

Objective Angiogenic factors are strongly associated with adverse maternal and fetal outcomes among women with preterm preeclampsia (PE) in developed countries. We evaluated the role of angiogenic factors and their relationship to adverse outcomes among Haitian women with PE. Material and Methods We measured plasma antiangiogenic soluble fms-like tyrosine kinase 1 (sFlt1) and proangiogenic placental growth factor (PlGF) levels in women with PE (n=35) compared to controls with no hypertensive disorders (NHD) (n=43) among subjects with singleton pregnancies that delivered at Hospital Albert Schweitzer (HAS) in Haiti. We divided the preeclamptic women into two groups, early onset (≤ 34 weeks) and late onset (>34 weeks) and examined relationships between sFlt1/PlGF ratios on admission and adverse outcomes (abruption, respiratory complications, stroke, renal insufficiency, eclampsia, maternal death, birth weight <2500 grams, or fetal/neonatal death) in women with PE subgroups as compared to NHD groups separated by week of admission. Data are presented as median (25th-75th centile), n (%), and proportions. Results Among patients with PE, most (24/35) were admitted at term. Adverse outcome rates in PE were much higher among the early onset group compared to the late onset group (100.0% vs. 54.2%, P=0.007). Plasma angiogenic factors were dramatically altered in both subtypes of PE. Angiogenic factors also correlated with adverse outcomes in both subtypes of PE. The median sFlt1/PlGF ratios for subjects with early onset PE with any adverse outcome vs. NHD <=34 weeks with no adverse outcome were 703.1 (146.6, 1614.9) and 9.6 (3.5, 58.6); P<0.001). Among late onset group the median sFlt1/PlGF ratio for women with any adverse outcome was 130.7 (56.1, 242.6) versus 22.4 (10.2, 58.7; P=0.005) in NHD >34 weeks with no adverse outcome. Conclusion PE-related adverse outcomes are common in women in Haiti and are associated with profound angiogenic imbalance regardless of gestational age at presentation.

Fetal biometry: Relevance in obstetrical practice

Fetal biometry is the measurement of the fetus and various segments of the fetal anatomy. Every part of the fetal anatomy may be imaged, but fetal head, abdomen, and femur measurements are the most commonly used, as well as the crown-rump length in early gestation. These biometric measurements can be used to estimate gestational age and fetal weight, evaluate interval fetal growth, and identify fetuses who are either growth restricted or macrosomic. These measurements may influence antepartum and intrapartum management and may be used to predict peripartum outcomes. Biometry is therefore an integral and valuable element of obstetrical practice.

Maternal risk factors for neonatal necrotizing enterocolitis

Abstract Objective: This study aimed to investigate the relationship between maternal hypertensive disease and other risk factors and the neonatal development of necrotizing enterocolitis (NEC). Methods: This was a retrospective case–control study of infants with NEC from 2008 to 2012. The primary exposure of interest was maternal hypertensive disease, which has been hypothesized to put infants at risk for NEC. Other variables collected included demographics, pregnancy complications, medications and neonatal hospital course. Data were abstracted from medical records. Results: Twenty-eight cases of singleton neonates with NEC and 81 matched controls were identified and analyzed. There was no significant difference in the primary outcome. Fetuses with an antenatal diagnosis of growth restriction were more likely to develop NEC (p = 0.008). Infants with NEC had lower median birth weight than infants without NEC (p = 0.009). Infants with NEC had more late-onset sepsis (p = 0.01) and mortality before discharge (p = 0.001). Conclusions: The factors identified by this case–control study that increased the risk of neonatal NEC included intrauterine growth restriction and lower neonatal birth weight. The primary exposure, hypertensive disease, did not show a significantly increased risk of neonatal NEC; however, there was a nearly two-fold difference observed. Our study was underpowered to detect the observed difference.

Adverse maternal and fetal outcomes and deaths related to preeclampsia and eclampsia in Haiti

OBJECTIVE The purpose of this study was to define the prevalence and clinical characteristics of preeclampsia and eclampsia at a hospital in rural Haiti. METHODS This is a retrospective review of women presenting to Hôpital Albert Schweitzer (HAS) in Deschapelles, Haiti with singleton pregnancy and diagnosis of preeclampsia or eclampsia from January 1, 2011 through December 31, 2012. Hospital charts were reviewed to obtain medical and prenatal history, hospital course, delivery information, and fetal/neonatal outcomes. The outcomes included placental abruption, antepartum eclampsia, postpartum eclampsia, maternal death, birthweight <2500g and stillbirth. Data are presented as median (quartile 1, quartile 3) or n (%) and risk ratios. RESULTS During the study period, 1743 women were admitted to the maternity service at HAS and 290 (16.6%) were diagnosed with preeclampsia or eclampsia. Only singleton pregnancies were analyzed (N=270). Nearly all (95.0%) patients admitted with preeclampsia had severe preeclampsia. There were 83 patients with eclampsia (30.7%) of which 61 (73.4%) had antepartum eclampsia. There were 48 stillbirths (17.8%) and 5 maternal deaths (1.9%). Patients with antepartum eclampsia were younger, more likely to be nulliparous and had less prenatal care compared to women with antepartum preeclampsia. Antepartum eclampsia was associated with placental abruption and maternal death. CONCLUSIONS The rates of preeclampsia and its associated complications, such as eclampsia, placental abruption, maternal death and stillbirth, are high at this facility in Haiti. Such data are essential to developing region-specific systems to prevent preeclampsia-related complications.

Maternal outcomes following the initiation of an institutional delayed cord clamping protocol: an observational case–control study

Abstract Objective: The objective of this study is to evaluate maternal outcomes before and after implementation of an institutional delayed cord clamping (DCC) protocol. Study design: We performed a secondary analysis of a retrospective cohort study of deliveries occurring at <34 weeks at a tertiary care center in 2013–2014. About 139 women who underwent early cord clamping were compared with 130 women delivered after DCC protocol implementation. Maternal estimated blood loss (EBL) was the primary outcome of interest. Operative times, post-Cesarean decrease in hemoglobin (Hgb), and rates of post-partum hemorrhage and transfusion were also examined in bivariate and multivariable analyses. Results: About 75% of post-guideline deliveries had actual DCC. In regression analyses, only Cesarean delivery and multifetal gestation increased EBL. No trends were identified in EBL over time. In post-hoc analysis, the study had over 80% power to detect a difference in post-partum hemorrhage rates of 20%. Conclusion: An institutional DCC protocol for deliveries <34 weeks was not associated with an identifiable increase in adverse maternal outcomes.

The effect of adopting the IADPSG screening guidelines on the risk profile and outcomes of the gestational diabetes population

Abstract Objective: To compare characteristics and outcomes of women diagnosed with gestational diabetes mellitus (GDM) by the newer one-step glucose tolerance test and those diagnosed with the traditional two-step method. Research design and methods: This was a retrospective cohort study of women with GDM who delivered in 2010–2011. Data are reported as proportion or median (interquartile range) and were compared using a Chi-square, Fishers exact or Wilcoxon rank sum test based on data type. Results: Of 235 women with GDM, 55.7% were diagnosed using the two-step method and 44.3% with the one-step method. The groups had similar demographics and GDM risk factors. The two-step method group was diagnosed with GDM one week later [27.0 (24.0–29.0) weeks versus 26.0 (24.0–28.0 weeks); p = 0.13]. The groups had similar median weight gain per week before diagnosis. After diagnosis, women in the one-step method group had significantly higher median weight gain per week [0.67 pounds/week (0.31–1.0) versus 0.56 pounds/week (0.15–0.89); p = 0.047]. In the one-step method group more women had suspected macrosomia (11.7% versus 5.3%, p = 0.07) and more neonates had a birth weight >4000 g (13.6% versus 7.5%, p = 0.13); however, these differences were not statistically significant. Other pregnancy and neonatal complications were similar. Conclusions: Women diagnosed with the one-step method gained more weight per week after GDM diagnosis and had a non-statistically significant increased risk for suspected macrosomia. Our data suggest the one-step method identifies women with at least equally high risk as the two-step method.

ACES: Accurate Cervical Evaluation With Sonography

Transvaginal sonographic cervical length screening is an important tool for the evaluation of preterm labor. However, a structured curriculum is lacking in obstetrics and gynecology residency programs. The Accurate Cervical Evaluation with Sonography (ACES) program was developed to address this deficiency and combines an online didactic course with a standardized performance assessment of live scans. We sought to evaluate the effectiveness of the ACES program to teach residents sonographic cervical length assessment.

Impaired Ultrasonographic Cervical Assessment After Voiding: A Randomized Controlled Trial

OBJECTIVE: To estimate whether the timing of bladder emptying affects focal myometrial contraction development and image adequacy. METHODS: Women at 14 0/7–32 0/7 weeks of gestation undergoing a transvaginal ultrasound examination from January 1, 2012, to September 1, 2012, were eligible for this blinded randomized controlled trial. Participants were randomly assigned to undergo transvaginal imaging immediately after urination (within 5 minutes) or to defer the imaging by at least 15 minutes. The primary outcome was focal myometrial contraction development as determined by two independent blinded reviews of the images. Secondary outcomes included image adequacy and the diagnosis of placenta previa. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated using repeated-measures log binomial regression. RESULTS: Two hundred twenty-one women provided 335 randomized encounters for analysis. Women in the deferred scan group were 30% less likely to experience a focal myometrial contraction (28.1% compared with 40.5%, RR 0.70, 95% CI 0.52–0.93) and 41% less likely to have inadequate images (18.6% compared with 31.5%, RR 0.59, 95% CI 0.40–0.86). The two groups were equally likely to be diagnosed with placenta previa (P=.13). However, participants in the deferred scan group were 76% less likely to have images demonstrating a placenta previa and focal myometrial contraction (3.0% compared with 12.5%, RR 0.24, 95% CI 0.09–0.62) than participants in the immediate scan group. Eight women would need to defer imaging for 15 minutes from bladder voiding to prevent one focal myometrial contraction of the lower uterine segment or inadequate imaging. CONCLUSIONS: A brief interval (at least 15 minutes) between voiding and transvaginal cervical evaluation is associated with decreased risk for focal myometrial contractions and improved imaging. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01513395. LEVEL OF EVIDENCE: I

Racial differences in neonatal hypoglycemia among very early preterm births

Objective:To determine whether the prevalence of neonatal hypoglycemia differs by race/ethnicity.Study design:A retrospective cohort study using prospectively collected data from 515 neonates born very preterm (<32 weeks) to normoglycemic women and admitted to the neonatal intensive care unit (NICU) at a major tertiary hospital in Boston, MA, between 2008 and 2012.Results:A total of 61%, 12%, 7%, 7%, and 13% were White, Black, Hispanic, Asian, and Other, respectively. Among the 66% spontaneous preterm births, 63% of the black neonates experienced hypoglycemia (blood glucose level < 40 mg/dL), while only 22–30% of the other racial/ethnic neonates did so (Black vs. White RR 2.15; 95% CI: 1.54–3.00). After adjusting for maternal education, maternal age, multiple gestations, delivery type, gestational age, birth weight, and neonates’ sex, this association remained significant (adjusted Black vs. White RR: 1.61, 95% CI: 1.13–2.29). An increased risk of infant hypoglycemia was not seen in infants of other racial/ethnic groups, nor in any racial/ethnic group with a medically indicated preterm birth.Conclusions:Black neonates delivered for spontaneous (but not medical) indications at <32 weeks had a higher risk of hypoglycemia, which could provide critical information about mechanisms of preterm birth and adverse postnatal outcomes in this high-risk group.