Michael J. Paglia

Outcomes from a labor and delivery team training program with simulation component

We evaluated the implementation of a labor and delivery unit team training program that included didactic sessions and simulation training with an active clinical unit. Over an 18-month follow-up time period, our team training program showed improvements in patient outcomes as well as in perceptions of patient safety including the dimensions of teamwork and communication.

Cytomegalovirus-induced mirror syndrome associated with elevated levels of circulating antiangiogenic factors.

BACKGROUND: We describe a case where Mirror syndrome was characterized by altered levels of antiangiogenic proteins (soluble fms–like tyrosine kinase 1 [sFlt1] and soluble endoglin). CASE: We describe a pregnant patient with severe fetal and placental edema induced by congenital cytomegalovirus (CMV) infection that was associated with preeclampsia. Fetal CMV was confirmed histologically, whereas antiangiogenic factors were demonstrated to be elevated in maternal but not fetal blood. The levels of sFlt1 and soluble endoglin in our patient’s serum before delivery were 116.5 ng/mL (normal pregnancy 19.3 ng/mL and preeclampsia 66.0 ng/mL, representing mean values before delivery) and 107.4 ng/mL (normal pregnancy 18.7 ng/mL and preeclampsia 52.6 ng/mL, representing mean values before delivery), respectively. In contrast, the values of sFlt1 and soluble endoglin in the cord blood were relatively low at 2.1 ng/mL and 8.2 ng/mL, respectively. CONCLUSION: If this observation is confirmed, CMV infection may be cited as a cause of Mirror syndrome and preeclampsia phenotypes associated with this disorder may be related to increased circulating antiangiogenic factors.

Tobacco use and secondhand smoke exposure during pregnancy in low- and middle-income countries: the need for social and cultural research

Tobacco use is a leading cause of death and of poor pregnancy outcome in many countries. While tobacco use is decreasing in many high‐income countries, it is increasing in many low‐ and middle‐income countries (LMICs), where by the year 2030, 80% of deaths caused by tobacco use are expected to occur. In many LMICs, few women smoke tobacco, but strong evidence indicates this is changing; increased tobacco smoking by pregnant women will worsen pregnancy outcomes, especially in resource‐poor settings, and threatens to undermine or reverse hard‐won gains in maternal and child health. To date, little research has focused on preventing pregnant womens tobacco use and secondhand smoke (SHS) exposure in LMICs. Research on social and cultural influences on pregnant womens tobacco use will greatly facilitate the design and implementation of effective prevention programs and policies, including the adaptation of successful strategies used in high‐income countries. This paper describes pregnant womens tobacco use and SHS exposure and the social and cultural influences on pregnant womens tobacco exposure; it also presents a research agenda put forward by an international workgroup convened to make recommendations in this area.

When the heart stops: a review of cardiac arrest in pregnancy.

Cardiac arrest is a rare occurrence in pregnancy and may be related to obstetric or medical causes. Pregnancy is associated with profound physiologic changes that prepare the gravida for the challenges of labor and delivery, and resuscitation of the pregnant patient needs to take these changes into consideration. Cardiac output and plasma volume increase in pregnancy and distribute differently with the uterine circulation receiving approximately 17% of the total cardiac output. On the other hand, cardiac output is sensitive to positional changes in the second half of pregnancy but may improve with a lateral tilt of the gravida. Both oxygen reserve and upper airway size decrease in pregnancy, leading to difficulties surrounding airway management. Changes in the volume of distribution, renal and hepatic clearance may impact drug effects and need to be recognized. This review will discuss an overview of pregnancy physiology that is relevant to cardiac resuscitation, detail the challenges in the various resuscitative steps including a synopsis on perimortem delivery, and describe obstetric and nonobstetric causes of mortality and cardiac arrest in pregnancy.

Gestational diabetes: evolving diagnostic criteria.

Purpose of review Gestational diabetes mellitus (GDM) is a common complication of pregnancy. There has been controversy and debate about how to optimally diagnose GDM and whether treatment modifies outcomes. We review the current controversies in both the screening and diagnosis of GDM and the benefits of treating GDM. Recent findings Three major studies have been published in the past 2 years that have evaluated these issues. The goal of the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study was to determine the level of maternal glycemia at which adverse fetal/neonatal or maternal outcomes are impacted. Rather than a definitive cut-off, the study found that there was a continuous relationship between maternal glycemia and pregnancy outcomes. Two studies evaluated the effect of treating mild GDM on both maternal and neonatal outcomes. Each found a significant benefit with diagnosis and treatment. Summary Ideally, the results of the HAPO study will bring order to the current international confusion surrounding the diagnosis of GDM. Recently, the International Association of Diabetes and Pregnancy Study Groups recommended new screening criteria for GDM based on the HAPO study. Professional organizations around the world are currently considering these recommendations.

Patient and provider perceptions of sleep disordered breathing assessment during prenatal care: a survey-based observational study.

Objectives: Screening for sleep disordered breathing (SDB) remains poor in the general population, despite evidence for association with adverse outcomes and improvement of certain outcomes with therapy. Data from the past decade have suggested an association between snoring and adverse pregnancy outcomes including gestational hypertensive disorders. However, it is unclear how often SDB is screened for in pregnancy. The objective of this study was to evaluate whether, and how, symptoms of SDB are assessed during prenatal care. Methods: This study was designed as a survey-based observational study. Within 48 hours of delivery, English-speaking patients were surveyed regarding prenatal conversations with obstetric providers about symptoms of SDB. During a similar time period, obstetric providers completed an anonymous questionnaire regarding how often they discussed the same symptoms during prenatal visits. Results: A total of 776 patients and 80 providers performing the majority of deliveries at the same hospital answered the survey. Nurse providers asked about sleep quality significantly more often than physician providers; however, responses to questions about snoring were similar in both groups. Resident physicians were the least likely to ask about sleep quality. Less than 3% of providers reported asking about snoring, closely matching patient responses. A total of 44% of patients surveyed were overweight and 21.7% were obese. Although 32% of patients snored, only 5% were asked about snoring during a prenatal visit. Obese women and women with a history of gestational hypertensive disorders were more likely to report being asked about snoring. Conclusions: Based on patient and obstetric provider recollections of discussions, the issue of SDB is poorly assessed during routine prenatal care, despite an increasing prevalence of overweight and obesity in the pregnant population.

Expression and androgen regulation of C-CAM cell adhesion molecule isoforms in rat dorsal and ventral prostate

C-CAM is an epithelial cell adhesion molecule with two major splice variants that differ in the length of the cytoplasmic domain. C-CAM1 (long (L)-form) strongly suppresses the tumorigenicity of human prostate carcinoma cells. In contrast, C-CAM2 (short (S)-form) does not exhibit tumor-suppressive activity. In the present study we have investigated the functional significance of L-form and S-form C-CAM in rat prostate by examining their expression and distribution in different prostate lobes and their response to androgen deprivation. RNase protection assays with a probe for both C-CAM isoforms detected high levels of C-CAM messages in the rat dorso-lateral prostate (DLP). L- and S-form proteins, localized by indirect immunofluorescence using isoform-specific antipeptide antibodies, were co-expressed on the apical surface of prostate epithelial cells in normal DLP. Androgen depletion did not significantly change the steady state levels of C-CAM message and protein expression in the DLP, although there was a change in the pattern of protein expression in these lobes. In contrast, C-CAM isoform messages and proteins were undetectable in normal ventral prostate (VP) but increased markedly in this lobe in response to castration, producing isoform ratios similar to those in DLP. These results demonstrate that coordinate expression of C-CAM isoforms is maintained in the VP following androgen depletion and suggest that androgen suppresses C-CAM expression in VP but not in DLP. These results suggest that balanced expression of L- and S-form C-CAM is important for normal prostate growth and differentiation.

Outcomes of Sleep Disordered Breathing in Pregnancy

Sleep disordered breathing has been linked to adverse cardiovascular outcomes in the general population. In pregnancy, sleep disordered breathing has also been linked to pathologic disorders that have been associated with long term cardiovascular and metabolic outcomes such as gestational hypertensive disorders and gestational diabetes mellitus. Endothelial dysfunction, sympathetic stimulation and inflammation are among the mechanisms proposed to explain the association with adverse outcomes. In addition to mechanistic research, future efforts need to focus on the effect of therapy on such outcomes.

Influenza Vaccination among Pregnant Women: Patient Beliefs and Medical Provider Practices

ACOGs research department recruited four medical centers to participate in a study on the attitudes and practices of medical providers and pregnant patients regarding influenza vaccination. Medical providers and patients were given voluntary surveys and medical record data was collected over two flu seasons, from 2013 to 2015. Discrepancies between self-reports of medical providers and patients and medical records were observed. Nearly 80% of patients self-reported accepting the influenza vaccine, but medical record data only reported 36% of patients accepting the vaccine. Similarly, all medical providers reported giving recommendations for the vaccine, but only 85% of patients reported receiving a recommendation. Age, education, a medical providers recommendation, and educational materials were found to positively influence patient beliefs about the influenza vaccine. Accepting the vaccine was influenced by a patients previous actions, beliefs, and a medical providers recommendation. Patients who reported previously not accepting the vaccine and had negative feelings towards the vaccine but accepted it while pregnant reported concern for the health and safety of their baby. Future research should focus on groups that may be less likely to accept the vaccine and ways to dispel negative myths. Medical provider should continue to strongly recommend the vaccine and provide educational materials.

Compliance with group B streptococcus testing prior to labor and delivery.

We tested whether group B streptococcus (GBS) screening is performed as recommended by the Centers for Disease Control and Prevention (CDC) and evaluated the need for a rapid GBS test for women with full-term pregnancies. A retrospective cohort analysis at a single, large academic institution was performed. Women who delivered full-term (>37 weeks) infants and had documented prenatal care were included. The primary outcome was documented screening. One hundred sixty-five full-term pregnancies were included; 158 women [95.76%; 95% confidence interval (CI), 92.68 to 98.83%] were screened prior to presentation at labor and delivery. This frequency was significantly greater than the a priori hypothesis of 90% ( P = 0.01). Of the 158 women ever screened, 15 had GBS bacteriuria and 143 had genital culture performed. However, only 118 of the 143 (80.61%; 95% CI, 74.57 to 86.64%) were cultured at the appropriate time as recommended by the CDC (between 35 and 37 weeks). This screening frequency was significantly lower than the a priori hypothesis of 90% ( P < 0.001). Most full-term women presenting to labor and delivery have been screened for GBS. However, screening performed at the appropriate gestational age per CDC recommendations was lower than expected. Rapid GBS testing does not appear to be necessary for this population.