Torri D. Metz

Genome-Wide Significance and Replication of the Chromosome 12p11.22 Locus Near the PTHLH Gene for Peripartum Cardiomyopathy

Background— Peripartum (PP) cardiomyopathy (CM) is a rare condition of unknown etiology that occurs in late pregnancy or early postpartum. Initial evidence suggests that genetic factors may influence PPCM. This study evaluated and replicated genome-wide association of single nucleotide polymorphisms with PPCM. Methods and Results— Genome-wide single nucleotide polymorphisms in women with verified PPCM diagnosis (n=41) were compared separately with local control subjects (n=49 postmenopausal age-discordant women with parity ≥1 and no heart failure) and iControls (n=654 women ages 30 to 84 years with unknown phenotypes). A replication study of independent population samples used new cases (PPCM2, n=30) compared with new age-discordant control subjects (local2, n=124) and with younger control subjects (n=89) and obstetric control subjects (n=90). A third case set of pregnancy-associated CM cases not meeting strict PPCM definitions (n=29) was also studied. In the genome-wide association study, 1 single nucleotide polymorphism (rs258415) met genome-wide significance for PPCM versus local control subjects (P=2.06×10−8; odds ratio [OR], 5.96). This was verified versus iControls (P=7.92×10−19; OR, 8.52). In the replication study for PPCM2 cases, rs258415 (ORs are per C allele) replicated at P=0.009 versus local2 control subjects (OR, 2.26). This replication was verified for PPCM2 versus younger control subjects (P=0.029; OR, 2.15) and versus obstetric control subjects (P=0.013; OR, 2.44). In pregnancy-associated cardiomyopathy cases, rs258415 had a similar effect versus local2 control subjects (P=0.06; OR, 1.79), younger control subjects (P=0.14; OR, 1.65), and obstetric control subjects (P=0.038; OR, 1.99). Conclusions— Genome-wide association with PPCM was discovered and replicated for rs258415 at chromosome 12p11.22 near PTHLH. This study indicates a role of genetic factors in PPCM and provides a new locus for further pathophysiological and clinical investigation.

Cannabinoid hyperemesis syndrome: a cause of refractory nausea and vomiting in pregnancy.

BACKGROUND: Cannabinoid hyperemesis syndrome is a condition present among chronic cannabis users resulting in abdominal pain, intractable nausea and vomiting, and compulsive bathing behaviors. Given the recent legalization of marijuana in certain areas of the United States, the incidence of this condition may increase among pregnant women. CASE: We report the case of a pregnant 28-year-old woman with multiple admissions for episodic nausea and vomiting resulting in Mallory-Weiss esophageal tears, dehydration, and abdominal pain who was noted to be showering compulsively during her hospitalizations. After an extensive workup for the etiology of her intractable nausea and pain, she was diagnosed with cannabinoid hyperemesis syndrome, which is treated simply with abstinence from marijuana use. CONCLUSION: Cannabinoid hyperemesis syndrome should be considered in pregnant women with intractable nausea relieved by frequent hot bathing. By considering this diagnosis, extensive diagnostic testing can be avoided and the correct therapy, abstaining from cannabis use, can be recommended.

Factors Influencing Residency Program Selection by Medical Students Pursuing Obstetrics and Gynecology

BACKGROUNDnLittle is known about the factors that influence medical student selection of obstetrics and gynecology (ob-gyn) residency programs.nnnOBJECTIVEnWe assessed the factors influencing residency program selection by fourth-year medical students pursuing ob-gyn training.nnnMETHODSnA voluntary, anonymous, 19-question survey of residency selection factors was distributed to all fourth-year medical students interviewing at 1 of 5 academic ob-gyn departments for a residency position during the 2013-2014 interview season. Participants were surveyed about the relative importance (not important, somewhat important, important) of various residency selection factors, including operative experience, exposure to subspecialties, curricular experience, access to fellowships, and administrative aspects of residency, including adherence to duty hour restrictions.nnnRESULTSnOf 322 potential respondents, 262 (81%) completed the survey. Surgical training and training in laparoscopic surgery were deemed important by nearly all respondents (98%, 258 of 262, and 97%, 253 of 262, respectively). Factors that were considered not important by a significant group of respondents included maternity/paternity leave policies (22%, 58 of 259); opportunity for international rotations/electives (20%, 51 of 259); exposure to quality and safety initiatives (13%, 34 of 259); and training in abortion (13%, 34 of 262).nnnCONCLUSIONSnFourth-year medical students identified surgical training as the most important factor in selecting an ob-gyn residency, a finding that is particularly relevant as decreasing and changing surgical volumes affect residency training in this specialty.

Pregnancy After Uterine Rupture

A 28-year-old woman, gravida 3 para 2, with two previous cesarean deliveries presents for prenatal care. Her second pregnancy was complicated by a uterine rupture at 36 weeks of gestation. She asks, When should I be delivered during the current pregnancy?

Factors Influencing Delivery Mode in Candidates for Operative Vaginal Delivery in Modern Practice

INTRODUCTION: The rate of operative vaginal delivery is on the decline with forceps use declining faster than vacuums. We aimed to determine which clinical factors influence delivery mode (forceps, vacuum, or cesarean) among candidates for operative vaginal delivery in modern practice. METHODS: Cross-sectional cohort of candidates for operative vaginal delivery (reached complete and +2 station but did not deliver spontaneously) greater than 34 weeks of gestation from 14 hospitals over 8 years (January 2000 to December 2007). Clinical characteristics were compared between delivery mode groups overall and pairwise between forceps and vacuums. Probability of forceps compared with vacuum, adjusting for clustering within a hospital and physician, was estimated using hierarchical logistic modeling. RESULTS: Six thousand six hundred forty-four women delivered by forceps (3,999 [60%]), vacuum (1,926 [29%]), or cesarean 719 [11%]). Women undergoing cesarean delivery without an attempted operative vaginal delivery were more likely to have gestational diabetes, body mass index greater than 25 kg/m2, and oxytocin during labor. From multivariable modeling, odds of forceps compared with vacuum were greater with induction of labor: odds ratio (OR) 2.24 (95% confidence interval 1.85–2.71), nulliparity: 1.93 (1.52–2.44), presence of an epidural: 2.19 (1.34–3.58), longer duration of second stage: 1.14 (1.05–1.24/h), higher maternal age: 1.18 (1.07–1.30/5 y), and maternal indication for intervention: 1.46 (1.12–1.89). Odds of forceps were less with management by family medicine: OR 0.15 (0.09–0.27). CONCLUSIONS: Clinical factors differ between operative vaginal delivery candidates who underwent forceps, vacuum, or cesarean delivery after adjusting for health care provider and hospital. These differences suggest that patient-level factors drive the choice of delivery mode in a given clinical scenario.