Rachel G. Sinkey

#37: Diagnosis and management of vasa previa.

Vasa previa occurs when fetal blood vessels that are unprotected by the umbilical cord or placenta run through the amniotic membranes and traverse the cervix. If membranes rupture, these vessels may rupture, with resultant fetal hemorrhage, exsanguination, or even death. Prenatal diagnosis of vasa previa by ultrasound scans is approximately 98%. Approximately 28% of prenatally diagnosed cases result in emergent preterm delivery. Management of prenatally diagnosed vasa previa includes antenatal corticosteroids between 28-32 weeks of gestation, considerations for preterm hospitalization at 30-34 weeks of gestation, and scheduled delivery at 34-37 weeks of gestation.

The GoMo study: a randomized clinical trial assessing neonatal pain with Gomco vs Mogen clamp circumcision

OBJECTIVE Our objective was to compare the pain/stress levels of newborns among the 2 most common circumcision techniques after resident-wide education. STUDY DESIGN The study period of this randomized control trial was October 2012 through March 2014. Following informed consent, full-term males from uncomplicated singleton pregnancies were randomized to Gomco (n=137) or Mogen (n=137) devices. Resident-wide education for an obstetrics and gynecology residency program at a single institution was performed to ensure standardized training. All infants received a subcutaneous ring block before the procedure and oral sucrose intraoperatively. The primary outcome was neonatal pain assessed physiologically by salivary cortisol levels (enzyme-linked immunosorbent assay) and clinically by a validated neonatal pain score (crying, requires increased oxygen administration, increased vital signs, expression, sleeplessness [CRIES]). Secondary outcomes were immediate complications, duration of procedure, and short-term outcomes as reported by mothers and pediatricians. A sample size of 274 (accounting for 20% loss of follow-up) was determined sufficient to detect a mean difference of 1.22 μg/dL in cortisol levels (Gomco, SD±3.34; Mogen, SD±0.81) with 80% power, P=.05 level of significance. RESULTS A total of 251 infants completed the protocol. There were no significant differences in maternal or neonatal demographics including preoperative heart rate and mean arterial pressure. In the Mogen circumcision, the percentage change of cortisol was significantly lower than Gomco (279.1±498.15 vs 167.75±272.22; P=.049). There were no differences in postoperative CRIES scores. Postoperative heart rate was higher in infants undergoing Gomco circumcision than Mogen circumcision (138.7±16.5 vs 133.4±17.5; P=.015) as was mean arterial blood pressure (63.3±9.2 vs 60.4±8.6; P=.012). Mogen circumcisions were shorter (7.00±2.97 vs 3.65±1.84 minutes; P<.001). There were no significant differences in bleeding complications. A total of 168 maternal surveys were completed, with 98.7% maternal satisfaction in Gomco vs 98.9% in Mogen. There were no reports of bleeding after discharge or circumcision revisions in either group to date. CONCLUSION Mogen clamp is associated with less neonatal pain physiologically by significantly lower percentage change in salivary cortisol, lower heart rate, and mean arterial blood pressure. There was no difference in CRIES scores. Mogen clamp circumcision duration is significantly shorter than Gomco clamp. Both methods demonstrate satisfactory maternal and pediatrician short-term follow-up.

A positive association between umbilical cord RBC folate and fetal TL at birth supports a potential for fetal reprogramming

Telomere length (TL) has been studied extensively in adults; however, limited information exists regarding maternal influences on TL in utero. The objective of this study was to investigate the relationship between fetal red blood cell (RBC) folate levels, a surrogate measure for maternal folate levels, and TL. We hypothesized that umbilical cord RBC folate concentrations would positively correlate with fetal TL. Data for this analysis were collected as part of a prospective cohort study that recruited pregnant women upon admission into labor and delivery. Cord blood was collected for 96 maternal-fetal dyads, and DNA analysis was performed using quantitative polymerase chain reaction. The telomere to single copy gene ratio method was used to determine TL, and RBC folate levels were measured. Statistical analysis was conducted by incorporating a bootstrapping approach into generalized linear modeling-based analyses. Consistent significant positive correlations were observed between RBC folate and TL (telomere to single copy gene ratio) with 9880 of the 10000 (98.8%) iterations performed having a P value less than .05. Our study shows a positive association between umbilical cord RBC folate and fetal TL at birth. These findings may provide a pathway of understanding and preventing adult-onset disease and mortality through intrauterine reprogramming.

Homocysteine Levels Are not Related to Telomere Length in Cord Blood Leukocytes of Newborns.

Objective Elevated homocysteine (HC) levels and/or shortened telomere length (TL) are associated with adverse medical conditions. Our objective is to investigate the relationship between HC and TL in cord blood leukocytes of newborns. Study Design This is a nested study from a prospective cohort from 2011 to 2012 in pregnant women admitted for delivery at a university-affiliated hospital. Cord blood was collected at delivery and genomic DNA was analyzed using quantitative PCR. The telomere-to-single copy gene ratio method was employed to quantify TL. Newborn HC levels were measured. generalized linear regression modeling (GLM) and bootstrap statistical analyses were performed. Results Seventy-seven maternal-fetal dyads with a mean gestational age of 39 weeks were included. The distribution of the coefficient of homocysteine showed most values greater than zero demonstrating that homocysteine had a positive relationship with TL. In 915 of 10,000 (9.15%) iterations, the p-value was < 0.05 demonstrating a positive effect. Conclusion Increasing newborn concentrations of HC are not associated with decreasing TL. Larger, prospective studies are needed to confirm these findings and long-term implications.

Does adjunctive use of progesterone in women with cerclage improve prevention of preterm birth

Abstract Objective: To evaluate outcomes among pregnancies with cerclage as compared to cerclage and adjunctive progesterone. Methods: A retrospective cohort study was performed from 1 October 2011–30 June 2015 including women with a singleton gestation with vaginal cerclage. Exclusion criteria included multiple gestations, simultaneous 17-alpha hydroxyprogesterone caproate (17-OHPC) and vaginal progesterone (vag-p) use, and patients lost to follow-up. Primary outcome was prevention of preterm birth less than 35 (PTB <35) weeks gestational age (GA). Results: One hundred thirty-six patients met inclusion criteria; 73 women had cerclage only, 53 had cerclage and 17-OHPC, 10 had cerclage and vag-p. GA at cerclage placement was similar across groups (p = 0.068). There was a difference in prevention of PTB <35 weeks GA among groups (p = 0.035) with a trend toward earlier delivery among patients with cerclage and vag-p. Rates of PTB <35 weeks in the cerclage (29%) and cerclage and 17-OHPC groups (34%) were similar (p = 0.533). The odds ratio for risk of PTB <35 weeks among women with cerclage and vag-p as compared to all other patients was 5.21 (95%CI: 1.3–21.2). Conclusion: The combination of cerclage with intramuscular progesterone resulted in similar PTB prevention as compared to cerclage alone. There may be an association between cerclage, vaginal progesterone and higher rates of PTB which may be attributed to characteristics of the group rather than the therapies studied.

Placental Alpha-Microglobulin-1 Test in Resource-Limited Settings: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate whether the use of placental alpha-microglobulin-1 (PAMG-1) for the diagnosis of preterm premature rupture of membranes is cost-effective in resource-limited settings. METHODS: We designed a decision-analytic model from a third-party payers perspective to determine the cost-effectiveness of the PAMG-1 test compared with the traditional diagnostic test of pooling, Nitrazine, and ferning in diagnosing preterm premature rupture of membranes in a resource-limited setting. The primary health outcome of interest is the number of hospital transfers averted by each strategy per 1,000 patients screened. Baseline probabilities and cost assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2015 U.S. dollars. RESULTS: Under our baseline parameters, the use of a PAMG-1 test was the preferred cost-effective strategy. The PAMG-1 test averted hospital transfers of 447 true-negative patients per 1,000 tested at a cost of

Cost-Effectiveness of Old and New Technologies for Aneuploidy Screening

143,407 (

Elective induction of labor at 39 weeks among nulliparous women: The impact on maternal and neonatal risk

320.82 per hospital transfer averted). The traditional test averted hospital transfers of 395 true-negative patients per 1,000 tested at a cost of

142 – Pontocerebellar Disorders

172,652 (

Cornelia de Lange Syndrome

437.40 per hospital transfer averted). In a Monte Carlo simulation of 10 million trials, the PAMG-1 test was selected as the most cost-effective strategy with a frequency of 74%. The traditional test was only selected with a frequency of 26%. The “do-nothing” strategy was not selected throughout the trial. CONCLUSION: Among women presenting at resource-limited settings with a history suspicious of preterm premature rupture of membranes between 24 and 36 weeks of gestation, our analysis provides evidence suggesting that PAMG-1 is the most cost-effective testing strategy.