Michael O. Gardner

Outcome of Very Low Birth Weight Infants Exposed to Antenatal Indomethacin for Tocolysis

OBJECTIVE:Beginning in October 1995, and for several years thereafter, our institution used indomethacin as a first-line tocolytic drug. Our purpose is to compare the outcomes of very low birth weight infants who were exposed to antenatal indomethacin with those who were not exposed to this therapy.STUDY DESIGN:We used our centers component of the NICHD Neonatal Research Networks Generic Data Base which recorded the outcomes of all live born infants weighing less than 1500 g over a 5-year period. We abstracted data concerning neonatal morbidity (death, Grades III to IV intraventricular hemorrhage (IVH), necrotizing enterocolitis and patent ductus arteriosus), as well as other factors including gestational age, birth weight, antenatal corticosteroid treatment and maternal hypertension or pre-eclampsia. Univariate analysis was performed using Fishers exact test. Multivariate analysis using logistic regression was performed to control for confounding factors.RESULTS:A total of 85 infants who were exposed to antenatal indomethacin were compared to 464 infants who were not exposed to the drug. In the univariate analysis, antenatal indomethacin exposure was not associated with a significant increase in the incidence of necrotizing enterocolitis or patent ductus arteriosus. The incidence of Grades III to IV IVH was 17.9% in those infants exposed to antenatal indomethacin compared to 7.1% in the nonexposed infants (p=0.008). The incidence of neonatal death in the exposed infants was 27.7 versus 16.4 in the nonexposed infants (p=0.02).After controlling for antenatal corticosteroids, maternal pre-eclampsia, gestational age and birth weight, antenatal indomethacin was significantly associated with an increased incidence of IVH, but not neonatal death.CONCLUSION:Antenatal indomethacin was associated with significantly higher rates of IVH. Additional studies assessing the potential risks of indomethacin tocolysis are needed before it is used as a first-line tocolytic therapy.

Perceptions toward HIV, HIV screening, and the use of antiretroviral medications: a survey of maternity-based health care providers in Zambia.

Mother-to-child transmission of HIV (MTCT) is a major contributor to Zambias HIV burden. Based on our experience in Zambia, we felt that provider perceptions, knowledge base, and practice patterns toward HIV-positive mothers may pose as significant obstacles to preventing MTCT. Two hundred and twenty-five health care providers throughout Zambia were surveyed in 2002. Providers reported widespread stigma associated with HIV. Physicians (OR = 1.9), providers with research affiliations (OR = 2.3), and those located in Lusaka (OR = 9.0) were more likely to offer HIV testing. Only 30% routinely prescribed antiretroviral treatment (ART) to reduce MTCT. Practitioners from district facilities, those from Lusaka, and those employed at research facilities were more likely to prescribe ART routinely (OR = 2.8, 10.1 and 3.4 respectively). Among those never prescribing ART, most cited a lack of availability (83%). Our results highlight the need for further provider education, critical appraisal of the current system for HIV testing, and widespread distribution of ART.

High false-positive rate of human immunodeficiency virus rapid serum screening in a predominantly hispanic prenatal population.

OBJECTIVE: To identify the characteristics of the gravidas delivering at our birthing center that place them at risk for false-positive human immunodeficiency virus (HIV) enzyme-linked immunosorbent assay (ELISA).STUDY DESIGN: The medical records of all rapid HIV-ELISA-positive gravidas that delivered at our hospital between January 2000 and October 2001 were retrieved, and information was gathered regarding maternal demographics. The results of the Western blot tests were also retrieved and correlated to the ELISA results, across varying maternal characteristics. χ 2, Students t-test and multivariate analysis were performed, as appropriate, using the SAS software; statistical significance was denoted by p<0.05.RESULTS: A total of 69 patients had a positive rapid HIV-ELISA out of 9,781 deliveries. Of those, 26 were confirmed as HIV infected by Western blot (overall HIV prevalence: 0.27%, ELISA-positive predictive value: 37.7%). The subgroup prevalence of HIV and positive predictive value of ELISA were 1.53 and 75% among Caucasians; 2.43 and 82.6% among African-Americans; and 0.05 and 9.8% among Hispanics, respectively (p<0.05 for the comparisons between Hispanics and non-Hispanics only). A history of multiple (≥5 lifetime) sexual partners was elicited in the majority of HIV-infected patients.CONCLUSIONS: The positive predictive value of rapid HIV-ELISA during pregnancy varies widely, depending on maternal race/ethnicity and sexual behavior. The routine disclosure of rapid intrapartum HIV serum screening results prior to Western blot confirmation should be avoided in very low-risk populations.

Impact of antenatal corticosteroid therapy in very low birth weight infants on chronic lung disease and other morbidities of prematurity.

OBJECTIVE:To assess the effect of antenatal corticosteroids on very low birth weight (VLBW) infants through 36 weeks’ postconceptional age.STUDY DESIGN:Data were collected prospectively on all VLBW (≤1500 gm) infants (n = 670) admitted to a single newborn intensive care unit from 1991 to 1996. Mortality rate and the frequency of medical morbidities attributable to prematurity were compared between VLBW infants who received antenatal corticosteroid therapy and those who did not.RESULTS:Antenatal steroid therapy was associated with a significantly lower rate of mortality (p = 0.02) and of mortality due to respiratory causes (p = 0.01). Although the frequency of chronic lung disease (oxygen requirement at 36 weeks’ postconceptional age) was not significantly different between the groups (p = 0.48), the frequency of infants surviving without chronic lung disease was significantly greater in the steroid-exposed group (p = 0.02). There were no significant differences between the groups in the frequency of sepsis, necrotizing enterocolitis, length of hospital stay, or retinopathy of prematurity requiring surgery.CONCLUSION: In our study, antenatal corticosteroid therapy was associated with a beneficial effect on mortality and respiratory morbidity for VLBW infants and was not associated with any known increased risks.

The Effects of Amnioinfused Solutions for Meconium-Stained Amniotic Fluid on Neonatal Plasma Electrolyte Concentrations and pH

OBJECTIVE: To determine if amnioinfused normal saline or lactated Ringers solution in cases of meconium-stained amniotic fluid is associated with significant changes on neonatal plasma electrolyte concentrations or pH.STUDY DESIGN: This was a prospective randomized study using normal saline or lactated Ringers solution for amnioinfusion in women with thick meconium in the amniotic fluid. The control group was composed of women with clear amniotic fluid not receiving amnioinfusion. Cord blood arterial sampling was analyzed for sodium, potassium, and chloride plasma concentrations and pH. The sample sizes allowed for an α of 0.05 and power of 0.80.RESULTS: We evaluated 61 cases (20 normal saline solution, 20 lactated Ringers solution, and 21 control). No significant differences in cord blood arterial plasma concentrations of sodium (p=0.43), potassium (p=0.21), chloride (p=0.68), and pH (p=0.11) were noted.CONCLUSION: Use of normal saline or lactated Ringers solution for amnioinfusion in meconium-stained amniotic fluid is not associated with changes on neonatal plasma electrolyte concentrations or pH.

USE OF ANTENATAL CORTICOSTEROIDS FOR FETAL MATURATION

Corticosteroids used to enhance fetal maturation are one of the best studied interventions in perinatal medicine. The treatment has been shown to reduce neonatal morbidity and mortality. The intervention is also highly cost-effective. In this article, we review the evidence supporting the benefits of corticosteroids, controversial issues concerning their use, and current practice recommendations. The review will highlight the research presented at the recent National Institutes of Health Consensus Conference concerning corticosteroids. This research led the National Institutes of Health to advocate clinical practice guidelines on the appropriate use of corticosteroids.

Robotic surgery training in gynecologic fellowship programs in the United States.

Background and Objectives: The increasing use and acceptance of robotic platforms calls for the need to train not only established surgeons but also residents and fellow trainees within the context of the traditional residency and fellowship program. Our study aimed to clarify the current status of robotic training in gynecologic fellowship programs in the United States. Methods: This was a Web-based survey of four gynecology fellowship programs in the United States from November 2010 to March 2011. Programs were selected based on their geographic areas. A questionnaire with 43 questions inquiring about robotic surgery performance and training was sent to the programs and either a fellow or the fellowship director was asked to complete. Participation was voluntary. Results: We had 102 responders (18% respond rate) with an almost equal response rate from all four gynecologic fellowships, with a median response rate of 25% (range 21–29%). Minimally Invasive Surgery (MIS) and Gynecologic Oncology (Gyn Onc) fellowships had the highest rate of robotic training in their fellowship curriculum—95% and 83%, respectively. Simulator training was used as a training tool in 74% of Female Pelvic Medicine and Reconstructive Surgery (FPMRS); however, just 22% of Reproductive Endocrinology and Infertility fellowships had simulator training. Eighty-seven percent of Gyn Onc fellows graduate with >50 robotic cases, but this was 0% for Reproductive Endocrinology Infertility fellows. Conclusion: Our study showed that the use of a robotic system was built into fellowship curriculum of >80% of MIS and Gyn Onc fellowship programs that were entered in our study. Simulator training has been used widely in Ob&Gyn fellowship programs as part of their robotic training curriculum.

The impact of maternal age on pregnancy outcome in singleton pregnancies

Abstract Objective: To identify the impact of maternal age on pregnancy outcome in singleton gestations without a maternal history of previous preterm delivery. Study design: We retrospectively identified women who presented with preterm labor in the current pregnancy andsubsequently delivered between July 1995 and February 2000. Included were those with documented pregnancy outcome who delivered at ≥24 weeks of gestation. Data were analyzed as four age groups: Results: Pregnancy outcome was analyzed in 22,975 women. Overall, 38.4% experienced preterm delivery. There were no significant differences across the groups in the incidence of delivery because of spontaneous labor at >37 weeks of gestation. Significant findings are summarized in the table (all P 2 ). 20–34 35–39 ≥40 n = (2,061) 17,362) (2,961) (591) Delivery 46.5% 37.6% 36.6% 37.1% Delivery 6.1% 4.4% 5.9% 7.1% PTL @ delivery 36.0% 26.8% 23.4% 23.5% Cesarean delivery 11.3% 21.9% 32.3% 35.8% Conclusion: Our findings suggest that maternal age

Robotic Surgery: Resident Friend or Foe?

INTRODUCTION: Hysterectomy is the most common major operation for women in the United States and an integral component of resident training. Recently, robotic-assisted hysterectomy has been introduced. We sought to measure the effect of robotic surgery on obstetrics–gynecology resident surgical experience. METHODS: After institutional review board approval, a retrospective cohort of all graduating residents during the time period 2009–2012 was analyzed for total number of surgical cases and resident role as primary surgeon using data from Accreditation Council for Graduate Medical Education Oplogs and electronic medical records and billing codes. Sixteen residents were identified and stratified by year of graduation, 2009–2010–2011–2012 and compared knowing robot introduction occurred in approximately 2011. Statistical analyses performed using NCSS software with P<.05 considered significant. RESULTS: Total number of hysterectomies with the resident as primary surgeon decreased over the study period 1,171–1,426–1,407–781 (P=.02). A decrease in abdominal approach was seen: 1,152–892–834–385 (P=.001). Vaginal numbers remained stable. Other laparotomy cases decreased 1,035–905–562–388 (P=.001). A trend increase for laparoscopic cases coincided with the laparotomy decrease. CONCLUSIONS: The introduction of the robotic-assisted hysterectomy has changed the resident surgical experience, arguably for the worse. Laparotomy experience at our institution reflects national decreasing trends. Resident as primary surgeon may decrease with robot use as attending surgeons are learning the skill set. The decrease in total numbers, coupled with the increase in the variety of hysterectomies, may affect resident surgical skills. Along with the limitations of resident work hours, these changes may require a more rigorous assessment of surgical competency before graduation.