Monica Rincon

Use and attitudes of obstetricians toward 3 high-risk interventions in MFMU Network hospitals.

OBJECTIVE We sought to evaluate the frequency of, and factors associated with, the use of 3 evidence-based interventions: antenatal corticosteroids for fetal lung maturity, progesterone for prevention of recurrent preterm birth, and magnesium sulfate for fetal neuroprotection. STUDY DESIGN A self-administered survey was conducted from January through May 2011 among obstetricians from 21 hospitals that included 30 questions regarding their knowledge, attitudes, and practice of the 3 evidence-based interventions and the 14-item short version of the Team Climate for Innovation survey. Frequency of use of each intervention was ascertained from an obstetrical cohort of women between January 2010 and February 2011. RESULTS A total of 329 obstetricians (74% response rate) who managed 16,946 deliveries within the obstetrical cohort participated in the survey. More than 90% of obstetricians reported that they incorporated each intervention into routine practice. Actual frequency of administration in women eligible for the treatments was 93% for corticosteroids, 39% for progesterone, and 71% for magnesium sulfate. Provider satisfaction with quality of treatment evidence was 97% for corticosteroids, 82% for progesterone, and 57% for magnesium sulfate. Obstetricians perceived that barriers to treatment were most frequent for progesterone (76%), 30% for magnesium sulfate, and 17% for corticosteroids. Progesterone use was more frequent among patients whose provider reported the quality of the evidence was above average to excellent compared with poor to average (42% vs 25%, respectively; P < .001), and they were satisfied with their knowledge of the intervention (41% vs 28%; P = .02), and was less common among patients whose provider reported barriers to hospital or pharmacy drug delivery (31% vs 42%; P = .01). Corticosteroid administration was more common among patients who delivered at hospitals with 24 hours a day-7 days a week maternal-fetal medicine specialist coverage (93% vs 84%; P = .046), CONCLUSION: Obstetricians in Maternal-Fetal Medicine Units Network hospitals frequently use these evidence-based interventions; however, progesterone use was found to be related to their assessment of evidence quality. Neither progesterone nor the other interventions were associated with overall climate of innovation within a hospital as measured by the Team Climate for Innovation. National Institutes of Health Consensus Conference Statements may also have an impact on use; there is such a statement for antenatal corticosteroids but not for progesterone for preterm prevention or magnesium sulfate for fetal neuroprotection.

Proteomic analysis of cervical vaginal fluid proteins among women in recurrent preterm labor

Abstract Objective: Proteomic analysis of four cervical-vaginal fluid (CVF) proteins to identify biomarkers of recurrent preterm birth (rPTB) in at-risk women prior to onset of preterm labor. Methods: Nested case control study from 2007 to 2011 of women with prior spontaneous preterm birth(s) (PTB) who underwent serial CVF sampling. Mass spectrometry analysis was used and ELISA analysis was performed to validate candidates. Results: 108 patients were enrolled and 10 cases and 20 gestational age matched controls were analyzed after exclusions. Of 748 CVF proteins identified, 72 had statistically significant (p < 0.05) expression differences and 38 were highly differentially expressed (p < 0.01). Four candidate proteins were abundant and involved in immune/inflammatory response, but ELISA analysis did not confirm altered expression patterns. Conclusion: The lack of confirmation of potential biomarkers identified by mass spectrometry and ELISA demonstrates the challenges of validating PTB biomarkers and suggests that a panel of biomarkers would improve the predictive value of CVF testing.

Persistent ovarian masses and pregnancy outcomes

Abstract Objective: To determine if persistent ovarian masses in pregnancy are associated with increased adverse outcomes. Methods: This is a retrospective cohort of 126 pregnant women with a persistent ovarian mass measuring 5 cm or greater who delivered at two university hospitals between 2001 and 2009. Maternal outcomes included gestational age (GA) at diagnosis, delivery and surgery as well as miscarriage, preterm birth (PTB), ovarian torsion and hospital admission for pain. Neonatal outcomes included birth weight, respiratory distress syndrome (RDS), intra-ventricular hemorrhage (IVH), death and sepsis. Results: A total of 1225 ovarian masses were identified (4.9%) in 24 868 patients. A persistent ovarian mass was found in 0.7%. Average GA at diagnosis was 17.8 weeks. Miscarriage rate was 3.3%. Average GA at delivery was 37.9 weeks. Of the patients, 8.5% had ovarian torsion, 10.3% had admission for pain and 9.3% had PTBs. The mean cesarean delivery rate was 46.3%. The average neonatal weight was 3273 g. There was one neonatal death in this cohort. The rate of RDS was 2.8%, IVH 0.9% and neonatal sepsis 1.9%. The most common surgical pathologic diagnosis was dermoids (37.6%). No overt malignancies were seen. Conclusion: A persistent ovarian mass in pregnancy does not confer an increased risk of adverse pregnancy outcomes.

Association between insurance type and pregnancy outcomes in women diagnosed with hypertensive disorders of pregnancy

Abstract Objective: Hypertension in pregnancy is associated with adverse maternal and neonatal outcomes. Previous studies have demonstrated disparities in the risk of preeclampsia based on race, educational attainment, census tract income level and household income. Yet, data on the association of insurance type, classification of hypertension in pregnancy and outcomes have not been well described. We sought to compare outcomes in women with hypertensive disorders of pregnancy, by private versus public insurance. Study design: This was a retrospective cohort study of subjects with a hypertensive disorder of pregnancy that delivered ≥23-week gestation at Oregon Health & Science University (October 2013–December 2017). The cohort began with the 2013 American College of Obstetricians and Gynecologists Executive Summary on Hypertension in Pregnancy, which advised surveillance for severe features of disease in women with hypertension. Utilizing ICD-9 and ICD-10 discharge codes, followed by individual chart review, subjects were stratified into two groups by insurance status: Medicaid (public insurance), or individual or group health insurance (private insurance). As primary outcomes, we assessed severe features of preeclampsia, adverse maternal or neonatal outcomes (composite), and final hypertensive diagnosis: (i) chronic hypertension; (ii) gestational hypertension; (iii) preeclampsia without severe features and, (iv) preeclampsia with severe features. Differences in demographic and outcome data were analyzed by chi-square, t-test, and logistic regression. Results: Among 10 132 deliveries, 1335 (13.2%) were delivered with a hypertensive disorder of pregnancy. Medicaid covered 54.1% (722) of these deliveries; 44.1% (589) were covered by private insurance, and 1.8% (24) had unknown insurance. There was a similar percentage of subjects with Medicaid or private insurance in each hypertensive group (p = .08). However, compared to subjects with private insurance, those with Medicaid had more severe blood pressure (BP) elevations (systolic BP ≥160 mmHg, p = .001) and more cases of eclampsia (p = .04), while neonates of subjects with Medicaid had more intensive care unit admissions (p = .02), and preterm births (p < .001). The association between Medicaid insurance and severe BP elevation, or adverse neonatal outcomes, persisted after multivariable adjustment. Conclusion: Medicaid was not associated with a particular hypertensive disorder in pregnancy, yet those with Medicaid experienced more severe BP elevations and higher rates of adverse neonatal outcomes. More research is needed to understand potential risk factors and ways to improve outcomes for those with publicly funded insurance.

Evaluation of Hemolysis as a Severe Feature of Preeclampsia

Hemolysis predisposes to adverse pregnancy outcomes. Yet, there are limited data on hemolysis in hypertensive disorders of pregnancy other than hemolysis, elevated liver enzymes, and low platelet count syndrome. To evaluate the prevalence and impact of hemolysis in hypertensive disorders of pregnancy, we performed a retrospective cohort study at a single center (October 2013–May 2017), among women screened for hemolysis using lactate dehydrogenase (LDH) levels. We compared LDH levels by hypertensive disorder (chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia with severe features) and evaluated impact on adverse pregnancy outcomes. Data were analyzed by &khgr;2 or t test, ANOVA, test of medians, and logistic regression. Among 8645 deliveries, 1188 (13.7%) had a hypertensive disorder. Of these, 812 (68.4%) had LDH measurement before delivery: chronic hypertension (n=152); gestational hypertension (n=209); preeclampsia (n=216); and preeclampsia with severe features (n=235). LDH ≥400 U/L (≥1.6× normal) was more common in preeclampsia with severe features compared with other hypertensive disorders of pregnancy (9.8% versus 2.3%; P<0.001); adjusted odds ratio 4.52 (95% confidence interval, 2.2–9.2; P<0.001). LDH ≥400 U/L was associated with adverse maternal outcomes (41.7% versus 15.3%; P<0.001), adjusted odds ratio 3.05 (95% confidence interval, 1.4–6.7; P=0.006), and adverse neonatal outcomes (eg, preterm birth 59.4% versus 22.5%; P<0.001). We find that elevated LDH levels are associated with adverse maternal and neonatal outcomes in hypertension and preeclampsia, independent of hemolysis, elevated liver enzymes, and low platelet count syndrome. Therefore, elevated LDH levels (≥1.6× normal or ≥400 U/L) may be considered a severe feature of preeclampsia.

Video compared to conversational contraceptive counseling during labor and maternity hospitalization in Colombia: A randomized trial

OBJECTIVE Assess if video-based contraceptive education could be an efficient adjunct to contraceptive counseling and attain the same contraceptive knowledge acquisition as conversation-based counseling. STUDY DESIGN This was a multicenter randomized, controlled trial examining contraceptive counseling during labor and maternity hospitalization regarding the options of immediate postpartum contraception. At two urban public hospitals, we randomized participants to a structured conversation with a trained counselor or a 14-min video providing the same information. Both groups received written materials and were invited to ask the counselor questions. Our primary outcome was to compare mean time for video-based education and conversational counseling; secondary outcomes included intended postpartum contraceptive method, pre- and postintervention contraceptive knowledge, and perceived competence in choosing a method of contraception. RESULTS We enrolled 240 participants (conversation group=119, video group=121). The average time to complete either type of counseling was similar [conversational: 16.3 min, standard deviation (SD) ±3.8 min; video: 16.8 min, SD ±4.6 min, p=.32]. Of women intending to use nonpermanent contraception, more participants intended to use a long-acting reversible contraceptive (LARC) method after conversational counseling (72/103, 70% versus 59/105, 56%, p=.041). Following counseling, mean knowledge assessment scores increased by 2 points in both groups (3/7 points to 5/7 correct). All but two participants in the video group agreed they felt equipped to choose a contraceptive method after counseling. CONCLUSIONS Compared to in-person contraceptive counseling alone, video-based intrapartum contraceptive education took a similar amount of time and resulted in similar contraceptive knowledge acquisition, though with fewer patients choosing LARC. IMPLICATIONS Video-based contraceptive education may be useful in settings with limited personnel to deliver unbiased hospital-based, contraceptive counseling for women during the antepartum period.

Maternal prenatal depression predicts infant negative affect via maternal inflammatory cytokine levels

Maternal depressive symptoms during pregnancy are associated with risk for offspring emotional and behavioral problems, but the mechanisms by which this association occurs are not known. Infant elevated negative affect (increased crying, irritability, fearfulness, etc.) is a key risk factor for future psychopathology, so understanding its determinants has prevention and early intervention potential. An understudied yet promising hypothesis is that maternal mood affects infant mood via maternal prenatal inflammatory mechanisms, but this has not been prospectively examined in humans. Using data from a pilot study of women followed from the second trimester of pregnancy through six months postpartum (N = 68) our goal was to initiate a prospective study as to whether maternal inflammatory cytokines mediate the association between maternal depressive symptoms and infant offspring negative affect. The study sample was designed to examine a broad range of likely self-regulation and mood-regulation problems in offspring; to that end we over-selected women with a family history or their own history of elevated symptoms of attention-deficit/hyperactivity disorder. Results supported the hypothesis: maternal pro-inflammatory cytokines during the third trimester (indexed using a latent variable that included plasma interleukin-6, tumor necrosis factor-alpha and monocyte chemoattractant protein-1 concentrations as indicators) mediated the effect, such that higher maternal depressive symptoms were associated with higher maternal inflammation, and this mediated the effect on maternal report of infant negative affect (controlling for maternal affect during the infant period). This is the first human study to demonstrate that maternal inflammatory cytokines mediate the association between prenatal depression and infant outcomes, and the first to demonstrate a biological mechanism through which depressive symptoms impact infant temperament.

Ambulatory management of preterm labor.

The majority of patients with preterm labor will deliver at term, and universal treatment of preterm labor with tocolytics and antenatal corticosteroids results in widespread overtreatment while benefitting a minority of patients. Ambulatory strategies for preventing preterm birth and identifying at-risk patients are discussed. These include consideration of obstetric history, serial cervical length sonography, digital examination, and selective use of biomarker tests. Ambulatory therapies to reduce preterm birth include different formulations of progesterone and cerclage. Optimal use of antenatal corticosteroids is discussed, and a review of ambulatory management strategies for patients who are discharged home after tocolysis is conducted.