Peter S. Bernstein

First- and second-trimester thyroid hormone reference data in pregnant women: a FaSTER (First- and Second-Trimester Evaluation of Risk for aneuploidy) Research Consortium study

OBJECTIVE The purpose of this study was to calculate first and second trimester reference ranges and within-woman correlations for TSH, free T4, and thyroid antibodies. STUDY DESIGN TSH, free T4, and thyroid antibodies were measured in paired sera from 9562 women in the FaSTER trial of Down syndrome screening. RESULTS The median first trimester TSH (1.05 mIU/L) is lower than the second (1.23 mIU/L); and 98th centile is higher (4.15 vs 3.77 mIU/L). Within-woman paired TSH correlations are moderately strong (r(2) = 0.64). Among women with first trimester TSH values above the 98th centile, second trimester values are over the 95th centile in 68%. Median first trimester free T4 values (1.10 ng/dL) are higher than second (1.01 ng/dL). Paired free T4 measurements correlate weakly (r(2) = 0.23). Among women with first trimester free T4 values below the 2nd centile, second trimester values are below the 5th centile in 32%. Antibody measurements correlate strongly between trimesters (thyroperoxidase r(2) = 0.79, thyroglobulin r(2) = 0.83). CONCLUSION TSH and free T4 measurements require gestation-specific reference ranges.

The national partnership for maternal safety

Recognition of the need to reduce maternal mortality and morbidity in the United States has led to the creation of the National Partnership for Maternal Safety. This collaborative, broad-based initiative will begin with three priority bundles for the most common preventable causes of maternal death and severe morbidity: obstetric hemorrhage, severe hypertension in pregnancy, and peripartum venous thromboembolism. In addition, three unit-improvement bundles for obstetric services were identified: a structured approach for the recognition of early warning signs and symptoms, structured internal case reviews to identify systems improvement opportunities, and support tools for patients, families, and staff that experience an adverse outcome. This article details the formation of the National Partnership for Maternal Safety and introduces the initial priorities.

Etiologies of fetal growth restriction.

We have presented here are a long list of conditions associated with an increased incidence of fetal growth restriction. Missing from much of the literature on FGR are data that would allow more informed counseling of patients in terms of predicting their risk of carrying a pregnancy complicated by FGR. For example, very little has been published on the chances of having an infant with FGR in a woman suffering from SLE or chronic hypertension. Future studies of FGR should address these issues so that clinicians may counsel their patients properly.

Variability in Thyroid-Stimulating Hormone Suppression by Human Chronic Gonadotropin during Early Pregnancy

OBJECTIVE The objective of the study was to further explore relationships between human chorionic gonadotropin (hCG), TSH, and free T4 in pregnant women at 11 through 18 wk gestation. STUDY DESIGN The design of the study was to analyze hCG in comparison with TSH and free T4, in paired first- and second-trimester sera from 9562 women in the First and Second Trimester Evaluation of Risk for Fetal Aneuploidy trial study. RESULTS hCG is strongly correlated with body mass index, smoking, and gravidity. Correlations with selected maternal covariates also exist for TSH and free T4. As hCG deciles increase, body mass index and percent of women who smoke both decrease, whereas the percent of primigravid women increases (P < 0.0001). hCG/TSH correlations are weak in both trimesters (r2 = 0.03 and r2 = 0.02). TSH concentrations at the 25th and fifth centiles become sharply lower at higher hCG levels, whereas 50th centile and above TSH concentrations are only slightly lower. hCG/free T4 correlations are weak in both trimesters (r2 = 0.06 and r2 = 0.003). At 11-13 wk gestation, free T4 concentrations rise uniformly at all centiles, as hCG increases (test for trend, P < 0.0001), but not at 15-18 wk gestation. Multivariate analyses with TSH and free T4 as dependent variables and selected maternal covariates and hCG as independent variables do not alter these observations. CONCLUSIONS In early pregnancy, a womans centile TSH level appears to determine susceptibility to the TSH being suppressed at any given hCG level, suggesting that hCG itself may be the primary analyte responsible for stimulating the thyroid gland. hCG affects lower centile TSH values disproportionately.

Simulation training improves medical students' learning experiences when performing real vaginal deliveries.

Objective: To determine the relationship between simulation training for vaginal delivery maneuvers and subsequent participation in live deliveries during the clinical rotation and to assess medical students’ performance and confidence in vaginal delivery maneuvers with and without simulation training. Methods: Medical students were randomized to receive or not to receive simulation training for vaginal delivery maneuvers on a mannequin simulator at the start of a 6-week clerkship. Both groups received traditional didactic and clinical teaching. One researcher, blinded to randomization, scored student competence of delivery maneuvers and overall delivery performance on simulator. Delivery performance was scored (1–5, with 5 being the highest) at weeks 1 and 5 of the clerkship. Students were surveyed to assess self-confidence in the ability to perform delivery maneuvers at weeks 1 and 5, and participation in live deliveries was evaluated using student obstetric patient logs. Results: Thirty-three students were randomized, 18 to simulation training [simulation group (SIM)] and 15 to no simulation training [control group (CON)]. Clerkship logs demonstrated that SIM students participated in more deliveries than CON students (9.8 ± 3.7 versus 6.2 ± 2.8, P < 0.005). SIM reported increased confidence in ability to perform a vaginal delivery, when compared with CON at the end of the clerkship (3.81 ± 0.83 versus 3.00 ± 1.0, respectively, P < 0.05). The overall delivery performance score was significantly higher in SIM, when compared with CON at week 1 (3.94 ± 0.94 versus 2.07 ± 1.22, respectively, P < 0.001) and week 5 (4.88 ± 0.33 versus 4.31 ± 0.63, P < 0.001) in the simulated environment. Conclusions: Students who receive simulation training participate more actively in the clinical environment during the course of the clerkship. Student simulation training is beneficial to learn obstetric skills in a minimal risk environment, demonstrate competency with maneuvers, and translate this competence into increased clinical participation and confidence.

Thyroperoxidase and thyroglobulin antibodies in early pregnancy and preterm delivery.

OBJECTIVE: To further evaluate the relationship between thyroid antibodies and preterm births. METHODS: This is a prospective study of pregnancy outcome and demographic data combined with retrospective measurement of thyroperoxidase and thyroglobulin antibodies. Sera were obtained at 11–13 and 15–18 weeks of gestation from 10,062 women with singleton viable pregnancies (a subset from the First- and Second-Trimester Risk of Aneuploidy [FaSTER] trial). RESULTS: Women with elevated levels of thyroperoxidase, thyroglobulin antibodies, or both in the first trimester have a higher rate of preterm delivery before 37 weeks of gestation than antibody-negative women (7.5% compared with 6.4%, odds ratio [OR] 1.18; 95% confidence interval [CI] 0.95–1.46). This is also the case for very preterm delivery before 32 weeks of gestation (1.2% compared with 0.7%, OR 1.70; 95% CI 0.98–2.94). Preterm premature rupture of membranes is also increased (2.0% compared with 1.2%, OR 1.67; 95% CI 1.05–2.44). These associations are less strong for second-trimester antibody measurements. CONCLUSION: The present data do not confirm strong associations between thyroid antibody elevations and preterm birth found in three of five previously published reports. Preterm premature rupture of membranes appears to contribute to the thyroid antibody-associated early deliveries, possibly as a result of inflammation. LEVEL OF EVIDENCE: II

Using Simulation Training to Improve Shoulder Dystocia Documentation

OBJECTIVE: To estimate whether shoulder dystocia documentation could be improved with a simulation-based educational experience. METHODS: Obstetricians at our institution (n=71) participated in an unanticipated simulated shoulder dystocia followed by an educational debriefing session. A second shoulder dystocia simulation was completed at a later date. Delivery notes were a required component of each simulation. Notes were evaluated using a standardized checklist for 16 key components. One point was awarded for each element present. Wilcoxon signed rank tests were used to compare documentation between simulations. RESULTS: Participants consisted of 43 (61%) attending and 28 (39%) resident physicians. Ages ranged from 25–63 years (mean±standard deviation 37.0±9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5±8.1). Documentation scores were significantly improved after training. Attendings’ baseline documentation scores were 8.5±2.2 and improved to 9.4±2.3, P=.03. Residents’ documentation scores also improved (9.0±2.1 compared with 10.6±2.2, P=.001). In particular, improvement was seen in two components of documentation: 1) providers present for shoulder dystocia (P=.007) and 2) which shoulder was anterior (P<.001). No improvement was seen in standard delivery note components (eg, date, time) or infant characteristics (eg, weight, Apgar scores). CONCLUSION: Although we showed a significant improvement in the quality of documentation through this simulation program, notes were still suboptimal. Use of standardized forms for shoulder dystocia delivery notes may provide the best solution to ensure appropriate documentation. LEVEL OF EVIDENCE: II

First-trimester 3-dimensional power Doppler of the uteroplacental circulation space: a potential screening method for preeclampsia

OBJECTIVE The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC. STUDY DESIGN This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program. RESULTS Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively. CONCLUSION Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC.

Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers

OBJECTIVES We compared an evidence-based model of group prenatal care to traditional individual prenatal care on birth, neonatal, and reproductive health outcomes. METHODS We performed a multisite cluster randomized controlled trial in 14 health centers in New York City (2008-2012). We analyzed 1148 pregnant women aged 14 to 21 years, at less than 24 weeks of gestation, and not at high obstetrical risk. We assessed outcomes via medical records and surveys. RESULTS In intention-to-treat analyses, women at intervention sites were significantly less likely to have infants small for gestational age (< 10th percentile; 11.0% vs 15.8%; odds ratio = 0.66; 95% confidence interval = 0.44, 0.99). In as-treated analyses, women with more group visits had better outcomes, including small for gestational age, gestational age, birth weight, days in neonatal intensive care unit, rapid repeat pregnancy, condom use, and unprotected sex (P = .030 to < .001). There were no associated risks. CONCLUSIONS CenteringPregnancy Plus group prenatal care resulted in more favorable birth, neonatal, and reproductive outcomes. Successful translation of clinical innovations to enhance care, improve outcomes, and reduce cost requires strategies that facilitate patient adherence and support organizational change.

Using an electronic medical record to improve communication within a prenatal care network.

OBJECTIVE: In 2002, the Institute of Medicine called for the introduction of information technologies in health care settings to improve quality of care. We conducted a review of hospital charts of women who delivered before and after the implementation of an intranet-based computerized prenatal record in an inner-city practice. Our objective was to assess whether the use of this record improved communication among the outpatient office, the ultrasonography unit, and the labor floor. METHODS: The charts of patients who delivered in August 2002 and August 2003 and received their prenatal care at the Comprehensive Family Care Center at Montefiore Medical Center were analyzed. Data collected included the presence of a copy of the prenatal record in the hospital chart, the date of the last documented prenatal visit, and documentation of any prenatal ultrasonograms performed. RESULTS: Forty-three charts in each group were available for review. The prenatal chart was absent in 16% of the charts of patients from August 2002 compared with only 2% in August 2003 charts (P < .05). Among charts with prenatal records available, the median length of time between the last documented prenatal visit and delivery was significantly longer for August 2002 patients compared with August 2003 patients (36 compared with 4 days, respectively, P < .001). All patients received prenatal ultrasonograms, but documentation of the ultrasonogram was missing from 16% of the August 2002 charts compared with none of the August 2003 charts (P = .01). CONCLUSION: The use of a paperless, hospital intranet–based prenatal chart significantly improves communication among providers. LEVEL OF EVIDENCE: II-3