Sarah Poggi

Prioritizing posterior arm delivery during severe shoulder dystocia.

BACKGROUND Delivery of the posterior arm, or the Barnum maneuver, is at times used late in shoulder dystocia management algorithms, and is not often a first- or second-line management protocol. CASE A multiparous, diabetic patient, who was morbidly obese and had a residual obstetric brachial plexus injury, experienced a precipitous second stage of labor and severe shoulder dystocia. Attempts at the McRoberts maneuver with traction failed to deliver the fetus. In lieu of alternative maneuvers or continued attempts at traction, the posterior arm was delivered and the fetal trunk followed easily. CONCLUSION A geometric analysis reveals that using posterior arm delivery reduces the obstruction by more than a factor of two, relative to the McRoberts maneuver. We recommend earlier use of this maneuver during shoulder dystocia management.

Additional training with an obstetric simulator improves medical student comfort with basic procedures.

Objective: To determine if an obstetric birthing simulator can improve medical student understanding of and comfort with basic obstetric procedures. Study Design: Medical students were surveyed at the end of their obstetrics rotation regarding their knowledge and comfort with basic obstetric procedures. A group of students was trained on basic procedures utilizing an obstetric simulator. Survey results were compiled and analyzed with the Mann-Whitney U test. Results: In all, 60 untrained students and 18 simulator trained students completed surveys. Trained students were significantly more comfortable with fundal height measurements (P = 0.003), Leopold maneuvers (P < 0.001), fetal scalp electrode placement (P < 0.001), intrauterine pressure catheter placement (P < 0.001), and artificial rupture of membranes (P = 0.001) and reported better understanding of the indications for placement of a fetal scalp electrode (P = 0.01) and intrauterine pressure catheter (P = 0.03). Conclusions: Additional training with an obstetric simulator improved medical student self-reported comfort with and understanding of basic procedures compared with standard resident and staff-directed instruction.

The role of activity-dependent neuroprotective protein in a mouse model of fetal alcohol syndrome

OBJECTIVE Fetal alcohol syndrome (FAS) is the most common nongenetic cause of mental retardation. Peptides NAPVSIPQ (NAP) and SALLRSIPA (SAL), related to activity-dependent neuroprotective protein (ADNP), prevent alcohol-induced damage in a mouse model of FAS. Our objective was to characterize ADNP in this model to relate this protein to the mechanisms of damage and peptide neuroprotection. STUDY DESIGN Timed, pregnant C57Bl6/J mice were treated on day 8. Groups were control, alcohol, peptide pretreatment, or peptide alone. Embryo and decidua were harvested at 6 and 24 hours and 10 days. To evaluate ADNP expression, real-time polymerase chain reaction was performed with results presented as the ratio of ADNP-to-glyceraldehyde-3-phosphate dehydrogenase (GAPDH) concentration. Analysis of variance was performed for overall comparisons with P<.05 considered significant. RESULTS At 6 hours, there was no difference in ADNP between alcohol-exposed embryos compared with control embryos. At 24 hours, there was an increase in ADNP in alcohol-exposed embryos compared with controls (P<.001); these findings persisted at 10 days (P<.001). In the decidua at 6 hours, there was no difference between alcohol and control. At 24 hours, there was greater ADNP in alcohol-exposed decidua compared with controls (P<.001), which did not persist at 10 days (P=.97). Peptide pretreatment did not prevent the alcohol-induced increase in ADNP in embryo or decidua. CONCLUSION Alcohol increased embryonic and decidual ADNP expression at 24 hours and it persisted in the embryo for 10 days. Because ADNP is a known neuroprotectant, these findings suggest that it may be released as a protective mechanism in FAS. Changes in the embryo were persistent suggesting that the embryo is more vulnerable to alcohol-induced damage than the mother.

Triplet Morbidity and Mortality in a Large Case Series

OBJECTIVE: A significant increase in the triplet birth rate has occurred recently. This rise is of concern, as these infants are historically reported to be at risk of adverse outcome. Thus, we examined the outcome of triplet births in a large contemporary case series.STUDY DESIGN: Since 1993, detailed clinical data have been collected on all patients admitted to our Neonatal Intensive Care Unit. We retrospectively analyzed this database to examine triplet outcome.RESULTS: A total of 51 consecutive sets of triplets were born over a 9-year period. The mean birth weight for triplets was 1789±505 g, mean gestational age was 32.6±2.7 weeks, with discordancy present in 17.6% of neonates. Complications of prematurity were infrequent. Triplet survival to discharge was 96%.CONCLUSIONS:This large contemporary case series of triplets demonstrates excellent survival with low associated morbidity. These data suggest that there may no longer be medical justification for offering selective fetal reduction to parents with triplet pregnancies.

Predictive value of transvaginal cervical length in triplet pregnancies for spontaneous preterm delivery at ≤ 32 weeks

Objective: To establish whether cervical length is a predictor of spontaneous preterm delivery at ≤ 32 weeks in triplet pregnancies. Methods: This was a case-control study of all triplet pregnancies followed with more than three sonographic assessments of cervical length at 4-week intervals from 1995 to 2000. Cervical length in women delivered spontaneously at ≤ 32 weeks (cases) was compared with that of the remaining women (controls). Statistical analysis included Fishers exact test, χ2 test, one-way analysis of variance, logistic regression and receiver operating characteristic (ROC) curve to determine optimal cervical length thresholds for spontaneous preterm delivery at ≤ 32 weeks. Results: Of the 58 women included in the study, 17 (29%) delivered spontaneously at ≤ 32 weeks. The preterm delivery group had similar demographic and obstetric variables, but a higher rate of cerclage placement (65% vs 17%, p < 0.001) than controls. Mean ± standard deviation cervical length was significantly shorter among cases than controls at 16-20.0 weeks (3.0 ± 1.2 vs. 3.9 ± 0.8 cm, p = 0.01), but not at 20.1-24.0 weeks (3.5 ± 1.1 vs. 3.8 ± 1.0 cm, p = 0.76). Logistic regression analysis determined that cervical length at 16-20 weeks had an odds ratio of 0.43 (95% CI = 0.23, 0.80) for the prediction of spontaneous preterm delivery at ≤ 32 weeks. ROC curve analysis identified a cervical length of ≤ 2.6 cm as the optimal threshold for the prediction of spontaneous preterm delivery at ≤ 32 weeks (sensitivity 41%, specificity 92%). Conclusions: In a population of triplet gestations with a 29% rate of preterm delivery, cervical length at 16-20.0 weeks, but not at 20.1-24.0 weeks, was inversely correlated with the probability of preterm delivery at ≤ 32 weeks.

Differential expression of c-fos in a mouse model of fetal alcohol syndrome ☆

OBJECTIVE Fetal alcohol syndrome (FAS) results in stillbirth, fetal growth restriction, and mental retardation with injury attributed to oxidative stress. Our objective was to identify signal transduction pathways expressed in a model of FAS and to quantify expression of c-fos, a gene in the stress signal pathway. STUDY DESIGN Timed, pregnant C57Bl6/J mice were injected on E8 with saline solution or alcohol. RNA was extracted from decidua and embryo 6 and 24 hours later. Microarray analysis was used to screen gene pathways. Differential gene expression was confirmed using real-time polymerase chain reaction with results presented as the ratio of c-fos concentration to that of glyceraldehyde-3-phosphate dehydrogenase (GAPDH). RESULTS Differential gene expression between alcohol and control was noted for stress signal pathway genes including c-fos. Real-time polymerase chain reaction demonstrated that c-fos messenger RNA expression was greater in the alcohol than control decidua at 6 hours after injection (P<.01). This effect persisted at 24 hours (P<.01). There was no difference in c-fos expression in embryos whose mothers received alcohol versus control after 6 hours (P=.12) or 24 hours (P=.89). CONCLUSION Alcohol administration during pregnancy results in differential gene expression in the stress signal pathway, particularly in c-fos. C-fos expression in the decidua increases from 6 to 24 hours after alcohol injection, but does not change in the embryo, which may contribute to alcohol-induced damage in FAS.

Risk Factors for Pulmonary Edema in Triplet Pregnancies

OBJECTIVE: Multiple gestations are known to be at increased risk for pulmonary edema. Our objective was to characterize this morbidity in a cohort of triplet pregnancies.STUDY DESIGN: Charts from triplet pregnancies managed by the Georgetown University Hospital Maternal–Fetal Medicine service were abstracted for demographic information and complications. Cases who developed pulmonary edema were compared with those who did not using Fisher exact test, χ2 and Students t-test with p<0.05 considered significant.RESULTS: Of 66 triplet pregnancies with complete records, 15 (22.7%) were complicated by pulmonary edema. Patients developing this condition were more likely to be receiving magnesium sulfate therapy than those who did not [14/15 (93.3%) vs 32/51 (62.7%) p=0.049]. There was no difference between patients developing pulmonary edema and those who did not in terms of maternal age (mean±SD: 34.5±6.8 vs 34±4.3 years, p=0.8) or gestational age at delivery (33.3±2.3 vs 32.8±3.5 weeks, p=0.6), but the former group had smaller babies than the latter (1739± 369 vs 1891±538 g, p=0.04). Among the patients treated with magnesium sulfate, those who developed the more severe form of pulmonary edema were more likely than those who did not to have been treated for pre-eclampsia than preterm labor (6/10 (60%) vs 7/33 (21.2%), p=0.04).CONCLUSIONS: Pulmonary edema is a common complication of triplet pregnancy. Patients receiving magnesium sulfate, having pre-eclampsia or fetal growth restriction are at increased risk for pulmonary edema, particularly in its worst clinical presentation.

Does increasing body mass index affect cerclage efficacy

Objective:To study the relationship between body mass index (BMI) and gestational age (GA) at delivery in patients with cervical insufficiency (CI) undergoing cerclage.Study Design:We accessed a database of patients with singleton gestations undergoing cerclage (N=168) for a well-characterized history of CI, shortened cervix <2.5 cm with a history of prior preterm delivery or prolapse of membranes through the external os. Univariate and multivariate logistic regression analysis were performed to compare obstetrical outcomes between obese and normal-weight patients.Result:Prior preterm delivery <35 weeks in obese vs normal-weight patients was significantly higher (44% vs 9%), odds ratio=6.9 (95% CI: 2.5, 18.5), with lower mean GA at delivery (32.6±7.0 vs 37.2±3.4 weeks, P<0.001). After controlling for confounders, BMI remained significantly predictive of prematurity (coefficient: −0.12, adjusted R 2=0.24), such that every additional 1 unit of BMI was associated with a 1-day reduction in GA at delivery (P=0.03).Conclusion:An inverse correlation exists between BMI and GA at delivery in patients with CI receiving cerclage. The findings are unexpected given the protective effect of obesity on spontaneous preterm delivery.

Gender differences in amniotic fluid cytokine levels.

Objective: Placental trophoblast invasion and amniotic fluid cytokine receptor levels have been reported to vary with fetal gender. We investigated whether fetal gender affects amniotic fluid levels of the inflammatory cytokines interleukin (IL)-6 and IL-10 and the pro-angiogenesis cytokine angiogenin. Methods: Specimens from singleton gestations undergoing mid-trimester amniocentesis for genetic indications were used. Inclusion criteria were (1) outcome information available, (2) no structural or chromosomal anomaly and (3) no conditions associated with preterm delivery. Amniotic fluid IL-6, IL-10 and angiogenin levels were measured by immunoassay. Statistical analysis included the Mann–Whitney U test and Fishers exact test with p < 0.05 indicating significance. Results: A total of 74 samples were analyzed. Angiogenin levels were significantly lower in amniotic fluid samples from pregnancies with a male than with a female fetus (median (range): 22.2 (5.9–66.4) vs. 32.0 (11.4–159.2) ng/ml, p = 0.007), in contrast to no differences in amniotic fluid IL-6 and IL-10 levels (p = 0.4 and p = 0.1, respectively). In pregnancies with male fetuses delivering preterm (< 37 weeks), angiogenin was also detected at lower levels (p = 0.02). There were no gender differences with respect to race, nulliparity or maternal age. Conclusion: Angiogenin levels, but not IL-6 or IL-10 levels, are significantly lower in second-trimester amniotic fluid of women with male compared with female fetuses, including those women delivering preterm.

Therapeutic cerclage may be more efficacious in women who develop cervical insufficiency after a term delivery.

OBJECTIVE Our objective was to determine whether obstetric history affects the efficacy of therapeutic cerclage. STUDY DESIGN Data were gathered prospectively on patients receiving therapeutic cerclage, defined as midtrimester presentation with a cervical length less than 2.5 cm and prior preterm delivery or cervical dilatation with visible membranes on sterile speculum exam. Delivery outcomes based on cerclage type were compared between women with (n = 31) vs without prior term birth (n = 33). RESULTS Patients with a history of a term birth were older than those without such history (P = .05) but otherwise similar with regard to ethnicity, body mass index, prior preterm birth, genitourinary infection, prior cervical surgery, gestational age at cerclage placement, and cerclage indication. Women with a therapeutic cerclage and a history of a prior term delivery were significantly more likely to deliver after 35 weeks (90% vs 48%, P < .001) and their babies were significantly larger (2942 +/- 812 g vs 1966 +/- 1069 g, P < .001) than women with no prior term delivery. CONCLUSION Patients who develop cervical insufficiency after a term delivery may have better perinatal outcomes following therapeutic cerclage than those without a history of term delivery.