Nora M. Doyle

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.

Role of ultrasound in screening patients at risk for preterm delivery

The ultrasound assessment of the cervix has contributed to the understanding of the pathways to preterm birth. Transvaginal ultrasound measurement of the cervix provides an objective and noninvasive tool for the evaluation of cervical status. Despite widespread use of this procedure, standardization of measurement indications, technique, and interval between examinations has not been achieved. The American College of Radiology has recently recommended that the cervix and lower uterine segment be imaged as part of every obstetric ultra-sound examination in the second trimester. These guidelines specifically suggest a search for a short cervix (less than 30 mm) or funneling. The expert panel on womens imaging further recommended evaluating the cervix sonographically on both the initial examination and all follow-up examinations for twin gestations. The American Institute of Ultrasound in Medicine guidelines indicate that evaluation of the uterus, including cervix, should be performed, but does not indicate specifically that the cervix should be measured. In contrast, the American College of Obstetricians and Gynecologists, although recognizing that cervical length assessment may be helpful in predicting the risk of preterm delivery (particularly from a negative predictive value), does not recommend routine use of cervical length measurement because of the lack of proved treatment or intervention methods. A review of the literature suggests that at the time of this writing the role of routine screening of low-risk women with cervical length assessment by ultrasound is not supported. In contrast, in women at risk for preterm delivery(eg, women with a prior history of preterm birth or women with multiple gestations) cervical length assessment may be useful for its negative predictive value. At present, however, there is no therapeutic intervention that has been proved to decrease the risk of preterm delivery in women with a documented cervix on ultrasound.

Prenatal cystic fibrosis screening in Mexican Americans: an economic analysis.

OBJECTIVE We evaluated the cost benefit of cystic fibrosis screening in Mexican American gravid women. STUDY DESIGN With the use of decisions analysis techniques, a cost-benefit analysis was performed. Baseline assumptions were based on published references. Sensitivity analyses were performed. RESULTS Under the baseline assumptions, screening was not cost beneficial. Threshold analysis showed that, if the test was priced under 53.00 dollars, screening became cost beneficial. Sensitivity analysis demonstrated that lower acceptance rates of amniocentesis or termination made the screening strategy less attractive. If the test sensitivity was raised to 90%, which required testing of >60 mutations, the cost of screening would need to be <100.00 dollars for the program to be cost beneficial. CONCLUSION Cystic fibrosis screening is not cost beneficial in Mexican American women over a wide range of assumptions. This is principally due to the poor sensitivity of the test in this population. Cultural factors, such as lower acceptance of amniocentesis and pregnancy termination of affected fetuses, further lower the cost-benefit ratio of screening.

Perinatal pseudocoarctation: echocardiographic findings in vein of Galen malformation.

Vein of Galen aneurysmal malformations (VGAMs) are rare congenital malformations thought to develop during weeks 6 to 11 of fetal life. Although they represent less than 1% of all cerebral vascular malformations, they constitute up to 30% of all pediatric vascular malformations. Vein of Galen aneurysmal malformations cause high‐output heart failure in the fetus and neonate secondary to the decreased resistance and high blood flow in the lesion. We describe 2 cases, 1 prenatal and 1 postnatal, in which unusual aortic Doppler flow patterns and substantial brachiocephalic vessel dilation contributed to the discovery of a VGAM.

Job satisfaction among program directors in obstetrics and gynecology: a national portrait.

OBJECTIVES The purpose of this study was to determine job satisfaction among program directors in obstetrics and gynecology with the use of a validated tool and to identify specific sources of dissatisfaction that might lead to job change. STUDY DESIGN The program director satisfaction and a global job satisfaction survey were sent to all program directors in the United States. Motivators for seeking a job change were assessed. The chi(2) test, Kruskal-Wallis test, correlation analysis, and multiple linear regression were used. RESULTS Seventy percent of 254 surveys were completed. Global job satisfaction (minimum, 4; maximum, 16) was 11.9+/-2.9; mean program director satisfaction score was 135+/-25.8 (minimum, 54; maximum, 200). Job satisfaction was highest in chairs, full professors, those whose age was >50 years, and those with >5 years of experience (P=.02) and in facets that were related to work with residents, colleagues, and patients. Dissatisfaction was highest with regard to salary, promotion opportunities, and resources. Forty-six percent of those who responded were considering a job change in 3 years; the most common reason for a job change that was cited was administrative hassles. CONCLUSION Although job satisfaction is high among program directors, administrative hassles may lead to high rate of rapid turnover.

Arrhythmogenic right ventricular cardiomyopathy with implantable cardioverter defibrillator placement in pregnancy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a disorder that predominantly affects the right side of the heartand causes ventricular arrhythmias. In many patients the disease is familial. ARVC may account for as many as 5% ofunexpected sudden deaths. We report a case of ARVC diagnosed at 21 weeks gestation treated with an implantable cardiacdefibrillator. The remainder of her pregnancy was uneventful and the patient underwent induction of labor at 39weeks gestation with a passive second stage forceps-assisted delivery resulting in delivery of a normal infant. In the gravidawith cardiac arrhythmias, defibrillator placement may offer a safe, life-preserving treatment and should be considered.

Antenatal corticosteroids for fetal maturation in women at risk for preterm delivery

The available data unambiguously support the beneficial, short-term fetal effects of antenatal corticosteroids in women at risk for preterm delivery. There are still several incompletely addressed questions, including the use of corticosteroids in women with preterm premature rupture of membranes, the optimal corticosteroid preparation to be used, and the impact of repeated dosing. These issues are discussed in this review from the perspective of recent scientific evidence on the mechanisms responsible for positive short-term effects on survival and possible harmful long-term effects.

Placental alpha-microglobulin-1 and combined traditional diagnostic test: a cost-benefit analysis.

OBJECTIVE: To evaluate whether the placental alpha-microglobulin-1 test (PAMG-1) compared with the combined traditional diagnostic test of pooling, nitrazine, and ferning (CTDT) would be a cost-beneficial screening strategy in the setting of potential preterm premature rupture of membranes (PROM). METHODS: A decision analysis model was constructed to estimate the cost benefit of PAMG-1 compared with CTDT on preterm delivery costs from a societal perspective. Our primary outcome was the net cost benefit per person tested in the setting of potential preterm PROM at 34 to less than 37 weeks of gestation. Baseline probabilities and cost assumptions were derived from published literature. We conducted sensitivity analyses. Cost estimates reflect 2013 U.S. dollars. RESULTS: The estimated annual net benefit from PAMG-1 was

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

12,215 per person tested, whereas CTDT had a net benefit of

Robotic Surgery: Resident Friend or Foe?

4,737 per person tested. If the probability of rupture is less than 42%, PAMG-1 will be cost-beneficial, with a net savings of