Developing an interactive reproductive health equity session for pre-clerkship medical students.

In the United States, sexual, reproductive, and perinatal health inequities are well documented and known to be caused by a history of systemic oppression along many axes, including but not limited to race, ethnicity, gender, socioeconomic position, sexual orientation, and disability. Medical schools are responsible for educating students on systems of oppression and their impact on health. Reproductive justice advocates, including lay persons, medical students, and teaching faculty, have urged for integrating the reproductive justice framework into medical education and clinical practice. In response to medical student advocacy, we developed introductory didactic sessions on social and reproductive justice for preclinical medical students. These were created in a team-based learning format and include pre-course primer materials on reproductive justice. During the sessions, students engaged with hypothetical clinical vignettes in small groups to identify oppressive structures that may have contributed to the health outcomes described and potential avenues for contextually relevant and level-appropriate advocacy. The sessions took place in November 2019 (in-person) and 2020 (virtually) and were well attended by students. We highlight our experience, student feedback, and next steps, including further integration of reproductive health equity into medical school curricula in concert with department-wide education for faculty, residents, nursing, and allied health professionals. This introduction to social and reproductive justice can be adapted and scaled across different medical school curricula, enhancing the training of a new generation of physicians to become critically aware of how oppressive structures create health inequities and able to mitigate their impact through their roles as clinicians, researchers, and advocates.

Improving preparedness of emergency medicine residents in the management of postpartum hemorrhage: A randomized controlled study of two pedagogical approaches.

OBJECTIVE: To evaluate a novel curriculum to enhance knowledge and preparedness of emergency medicine (EM) residents in the management of postpartum hemorrhage (PPH). METHODS: A randomized controlled trial examining two pedagogical approaches. Following baseline testing of knowledge and confidence in respect of PPH management, participants were randomized to receive a didactic lecture on PPH management (group A, n = 14) or a didactic lecture followed by simulation-based training on PPH management and debriefing (group B, n = 16). Post-intervention, proficiency in PPH management was evaluated by clinical skills simulation and post-intervention assessment for participants. The change in the mean test and clinical skills scores were compared using Student's t-test. Linear regression examined the effects of covariates. RESULTS: Both forms of intervention increased participants' knowledge of (group A: mean = 2.50, 95% confidence interval [CI] 1.63-3.37, P < 0.001; group B: mean = 1.56, 95% CI 0.89-2.24, P < 0.001) and confidence in PPH management (group A: mean = 1.00, 95% CI 0.46-1.54, P = 0.003; group B: mean = 1.00, 95% CI 0.52-1.48, P = 0.001), relative to baseline. However, addition of simulation and debriefing to the didactic session did not offer any advantage (knowledge: mean = -0.94, 95% CI -1.97 to 0.10, P = 0.074; confidence: mean = 0.00, 95% CI -0.66 to 0.66, P = 1.000). CONCLUSION: Delivery of a structured curriculum led to improvement of knowledge and confidence with regard to the management of PPH by EM residents.

Teaching obstetric ultrasound at Mulago Hospital - Kampala, Uganda.

BACKGROUND: Mulago Hospital is a high volume referral hospital under the Makerere University School of Medicine and Health Sciences. Basic obstetric ultrasound is a useful skill that can aid patient care. OBJECTIVES: The purpose of the study was to assess the effectiveness of an intervention implemented to teach basic ultrasound skills to medical students and house officers at Mulago Hosptial, Kampala, Uganda. METHODS: Forty participants, including medical students, junior house officers (JHOs), and senior house officers (SHOs) were enrolled in the study. A didactic and practical hands-on teaching session was evaluated using a pre- and post-test that was administered to all participants. RESULTS: Participants included 12 medical students, 23 JHOs, and 5 SHOs. A significant difference in pre- and post-test scores was demonstrated in the medical students and JHOs (34% to 76%, p <0.0001) and this was retained when the results were stratified into the basic definitions and practical sections of the survey (33% to 71%, p<0.0001). The scores for the senior house officers had a mean increase of 2.3 points. CONCLUSION: This original teaching intervention is an effective method to improve knowledge and skills for medical students and house officers at Mulago Hospital in the area of basic obstetric ultrasound.

Estimated Placental Volume and Gestational Age.

OBJECTIVE: The objective of this study was to validate estimated placental volume (EPV) across a range of gestational ages (GAs). STUDY DESIGN: Three hundred sixty-six patients from 2009 to 2011 received ultrasound scans between 11 + 0 and 38 + 6 weeks GA to assess EPV. An EPV versus GA best fit curve was generated and compared with published normative curves of EPV versus GA in a different population. A subanalysis was performed to explore the relationship between EPV and birth weight (BW). RESULTS: Analysis of EPV versus GA revealed a parabolic curve with the following best fit equation: EPV = (0.372 GA - 0.00364 GA2)3. EPV was weakly correlated with BW, and patients with an EPV in the bottom 50th percentile had 2.42 times the odds of having a newborn with a BW in the bottom 50th percentile (95% confidence interval: 1.27-4.68). Microscopic evaluation of two placentas corresponding to the smallest EPV outliers revealed significant placental pathology. CONCLUSION: Placental volume increases throughout gestation and follows a predictable parabolic curve, in agreement with the existing literature. Further validation is required, but EPV may have the potential for clinical utility as a screening tool in a variety of settings.

Faculty Development for Fostering Clinical Reasoning Skills in Early Medical Students Using a Modified Bayesian Approach.

PROBLEM: Clinical reasoning is a necessary skill for medical students to acquire in the course of their education, and there is evidence that they can start this process at the undergraduate level. However, physician educators who are experts in their given fields may have difficulty conveying their complex thought processes to students. Providing faculty development that equips educators with tools to teach clinical reasoning may support skill development in early medical students. INTERVENTION: We provided faculty development on a modified Bayesian method of teaching clinical reasoning to clinician educators who facilitated small-group, case-based workshops with 2nd-year medical students. We interviewed them before and after the module regarding their perceptions on teaching clinical reasoning. We solicited feedback from the students about the effectiveness of the method in developing their clinical reasoning skills. CONTEXT: We carried out this project during an institutional curriculum rebuild where clinical reasoning was a defined goal. At the time of the intervention, there was also increased involvement of the Teaching and Learning Center in elevating the status of teaching and learning. OUTCOME: There was high overall satisfaction with the faculty development program. Both the faculty and the students described the modified Bayesian approach as effective in fostering the development of clinical reasoning skills. LESSONS LEARNED: Through this work, we learned how to form a beneficial partnership between a clinician educator and Teaching and Learning Center to promote faculty development on a clinical reasoning teaching method for early medical students. We uncovered challenges faced by both faculty and early learners in this study. We observed that our faculty chose to utilize the method of teaching clinical reasoning in a variety of manners in the classroom. Despite obstacles and differing approaches utilized, we believe that this model can be emulated at other institutions to foster the development of clinical reasoning skills in preclerkship students.

Transfer function analysis of dynamic cerebral autoregulation in preeclampsia.

OBJECTIVE: The cerebral circulatory effects of preeclampsia on the latency (phase) and the efficiency (gain) of the cerebral autoregulatory response is unknown. Preeclampsia causes a progressive impairment of the cerebral autoregulatory response. We sought to identify these dynamic cerebral autoregulation changes in preeclampsia. STUDY DESIGN: We simultaneously measured continuously beat to beat outputs of mean arterial pressure (MAP) (Pilot 9200) and beat to beat, systolic, diastolic, and mean cerebral blood flow (MCBFV) (Nicolet Vascular TCD) for 2min with the patient during supine rest. Five preeclamptic and 5 matched normotensive controls were studied. R-R intervals, MAP, and MCBFV were analyzed in the frequency domain. Data sets were fast Fourier transformed and power spectral densities were calculated. We calculated the phase angle (which represents the temporal relationship between the MAP and mean MCBFV) and the transfer function (amplitude or gain between changes in the MCBFV signal and the MAP signal). All continuous data was compared between the two groups using T tests. RESULTS: We identified a significant difference between (1) the gain between the normotensive and preeclamptic groups (.29±.07 vs .10±.04) (p<.01, and (2) the phase angle (59±12 vs 129±31), p<.01. The preeclamptic group showed significant decrease in gain but an increase in phase angle). CONCLUSION: Preeclampsia paradoxically results in a significant improvement in dynamic cerebral autoregulation as demonstrated by an increase in phase and a decrease in gain. Clinical studies that can systematically assess the progression of these dynamic autoregulation changes are needed.

Diabetes mellitus in pregnancy.

This article reviews normal and abnormal carbohydrate metabolism in pregnancy, with an emphasis on the challenges that are faced by those who care for the pregnant woman who has hyperglycemia. The growing problem of type 2 diabetes in pregnancy, the controversial use of oral antihyperglycemic agents for the treatment of gestational diabetes, and the long-term issue of diabetes prevention in those whose hyperglycemia resolves postpartum are also addressed.

Comparison of intrapartum fetal heart rate tracings in patients with neonatal seizures vs. no seizures: what are the differences?

OBJECTIVE: To determine which intrapartum fetal heart rate parameters in the presence of severe neonatal acidosis (pH < 7.0) appropriately predicts the development of neonatal seizures in the context of hypoxic ischemic encephalopathy (HIE). METHODS: The intrapartum fetal heart rate tracings of 25 neonates who developed neonatal seizures secondary to HIE were compared with 25 matched neonates with similar pH and gestational age who did not develop seizures. All patients had at least 2 hours of intrapartum fetal heart rate patterns available for review. We compared the fetal heart rate parameters of prolonged deceleration, variable and late decelerations, variability, accelerations, fetal heart rate baseline and duration of the fetal heart rate abnormality. Comparison between the groups was done using chi-square for nominal data and student t-tests for continuous data. RESULTS: Neonates with seizures 2 degrees HIE had a significantly longer duration of abnormal fetal heart rate patterns (72 +/- 12 minutes vs 48 +/- 12 minutes, p < 0.001). DISCUSSION: This study demonstrated that in the setting of neonatal acidosis the development of seizures is related to the period of stress (duration of the abnormal fetal heart rate pattern).

Screening for fetal well-being in a high-risk pregnant population comparing the nonstress test with umbilical artery Doppler velocimetry: a randomized controlled clinical trial.

OBJECTIVE: The purpose of this study was to evaluate the ability of two different modes of antepartum fetal testing to screen for the presence of peripartum morbidity, as measured by the cesarean delivery rate for fetal distress in labor. STUDY DESIGN: Over a 36-month period, all patients who were referred to the Fetal Assessment Unit at BC Women's Hospital because of a perceived increased fetal antepartum risk at a gestational age of > or =32 weeks of gestation were approached to participate in this study. Fetal surveillance of these women was allocated randomly to either umbilical artery Doppler ultrasound testing or nonstress testing as a screening test for fetal well-being. If either the umbilical artery Doppler testing or the nonstress testing was normal, patients were screened subsequently with the same technique, according to study protocol. When the Doppler study showed a systolic/diastolic ratio of >90th percentile or the nonstress testing was equivocal (ie, variable decelerations), an amniotic fluid index was performed, as an additional screening test. When the amniotic fluid index was abnormal (<5th percentile), induction and delivery were recommended. When the Doppler study showed absent or reversed diastolic blood flow or when the nonstress test result was abnormal, induction and delivery were recommended to the attending physician. Statistical comparisons between groups were performed with an unpaired t test for normally distributed continuous variables and chi(2) test for categoric variables. RESULTS: One thousand three hundred sixty patients were assigned randomly to groups in the study; 16 patients were lost to follow up. Six hundred forty-nine patients received Doppler testing and 691 received nonstress testing. The mean number of visits for the Doppler test and nonstress test groups was two versus two, respectively. The major indications for fetal assessment included postdates (43%), decreased fetal movement (22%), diabetes mellitus (11%), hypertension (10%), and intrauterine growth restriction (7%). The incidence of cesarean delivery for fetal distress was significantly lower in the Doppler group compared with the nonstress testing group (30 [4.6%] vs 60 [8.7%], respectively; P <.006). The greatest impact on the reduction in cesarean deliveries for fetal distress was seen in the subgroups in which the indication for testing was hypertension and suspected intrauterine growth restriction. CONCLUSION: Umbilical artery Doppler as a screening test for fetal well-being in a high-risk population was associated with a decreased incidence of cesarean delivery for fetal distress compared to the nonstress testing, with no increase in neonatal morbidity.

Intrapartum influences on cesarean delivery in multiple gestation.

OBJECTIVE: To evaluate which intrapartum factors influence the method of delivery in a group of twin pregnancies eligible for vaginal delivery. STUDY DESIGN: Over a 10-year period, 967 consecutive twin pregnancies at gestational age >/=32 weeks with twin A presenting as a vertex and eligible for vaginal delivery were reviewed. Excluded were 40 (4.1%) patients who underwent a repeat and elective cesarean section. All patients who underwent a cesarean section were placed into one of two groups according to the method of delivery of both twins: group 1, cesarean section/cesarean section delivery; and group 2, vaginal/cesarean section delivery. The impact of the following intrapartum factors on the type of delivery were assessed: (1) presentation of the 2nd twin: vertex vs. breech vs. other; (2) experience of the obstetrician: 10 years in practice; (3) multiparity: nulliparous vs. multiparous; (4) incidence of epidural usage; (5) induction vs. spontaneous labor; and (6) difference in fetal weight between twin B and twin A: /= 25% difference. The chi-square statistic was used to compare differences in the incidence of cesarean section between the groups. RESULTS: Total incidence of cesarean section was 266/927 (28.7%). Risk of delivering by a combined vaginal delivery and cesarean section was reduced if the presentation of twin B was vertex or breech (RR: 0.114; 95% confidence interval: 0.049-0.266) or if an epidural was used (RR: 0.380; 95% confidence interval: 0.163-0.883). In twin gestations eligible for vaginal delivery the risk of requiring delivery by cesarean section for both twins is reduced if the presentation of twin B was vertex (RR: 0.782; 95% confidence interval; 0.631-0.968), if an epidural was used (RR: 0.461; 95% confidence interval: 0.375-0.566), or if the birthweight discrepancy was

Intrapartum fetal heart rate patterns in the prediction of neonatal acidemia.

OBJECTIVE: This study was undertaken to correlate changes in the intrapartum electronic fetal heart rate patterns with the development of significant neonatal acidemia. STUDY DESIGN: We identified 488 fetuses at a gestational age of >37 weeks' gestation who had continuous electronic fetal monitoring during labor for the last 2 hours and umbilical artery cord gas analysis performed at delivery. One investigator blinded to the cord gas outcome reviewed all 488 tracings using the National Institute of Child Health and Human Development guidelines for fetal heart rate monitoring. All fetal heart rate tracings with bradycardia were removed from further analysis. The patients were placed in six groups, depending on the absence or presence of normal variability (amplitude >5 beats) during the last hour of monitoring combined with the absence of decelerations or the presence of variable or late decelerations. The relationship between changes in variability and the outcome variables of pH and base deficit in the six groups was assessed with analysis of variance and chi(2) test. Significance was set at the P <.05 level. RESULTS: Patients with normal variability and accelerations, even in the presence of late decelerations or variable decelerations, maintained an umbilical artery pH 7.0 or greater in more than 97% of cases. In the presence of minimal/absent variability (amplitude <5) for at least an hour, the incidence of significant acidemia (pH <7.0) ranged from (12%-31%). CONCLUSION: The most significant intrapartum fetal heart rate parameter to predict the development of significant acidemia is the presence of minimal/absent variability for at least 1 hour as a solitary abnormal finding or in conjunction with late decelerations in the absence of accelerations. Urgent delivery should be considered in these cases after appropriate ancillary testing.

Fetal heart rate parameters predictive of neonatal outcome in the presence of a prolonged deceleration.

OBJECTIVE: To correlate the presence of baseline variability and the duration of a prolonged deceleration/bradycardia in intrapartum fetal heart rate (FHR) tracings with the development of neonatal acidemia. METHODS: We identified 186 patients with term gestations who had continuous electronic fetal monitoring for at least 2 hours before delivery, with an identified bradycardia during that period. Each patient had umbilical artery cord analysis done and delivery within 30 minutes of that bradycardia. One investigator blinded to the cord gas outcome reviewed the last 2 hours of the tracing using the National Institute of Child Health and Human Development guidelines for FHR monitoring. We assessed the presence or absence of variability before the bradycardia and recovery or no recovery of the bradycardia and placed the patients into four groups. Group 1 (128 patients) with normal variability and recovery, group 2 (40 patients) with normal variability and no recovery, group 3 (nine patients) with decreased variability and recovery, and group 4 (nine patients) with decreased variability and no recovery. We compared the incidence of neonatal acidosis defined as a pH of less than 7.0 at birth among the four groups. The relationship between the various groups was assessed using analysis of variance and the chi(2) test. In addition, a multiple logistic regression model was developed with the parameters of amplitude and recovery used to predict pH at birth. RESULTS: The presence of decreased variability and no recovery of the FHR of a bradycardia was associated with the lowest pH 6.83 +/- 0.16 and a 78% incidence of significant acidosis. Decreased variability before FHR bradycardia was the FHR parameter significantly correlated with low pH. CONCLUSION: The most significant factor predicting the development of pathologic neonatal acidemia and indicating the need for urgent delivery in the presence of a bradycardia is decreased variability before the bradycardia.

The role of serum uric acid as a prognostic indicator of the severity of maternal and fetal complications in hypertensive pregnancies.

OBJECTIVE: To examine whether an elevated serum uric acid level in hypertensive pregnant women is a useful prognostic indicator of severe hypertension; hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome; and small for gestational age (SGA) infants. METHODS: A total of 459 women newly diagnosed with hypertension in pregnancy were categorized into "gestational hypertension" and "hypertension with proteinuria (preeclampsia)" groups. Their serum uric acid levels were correlated with the development of HELLP syndrome, severity of hypertension, and incidence of SGA newborns (< 10th percentile birth weight). HELLP syndrome was divided into 3 classes depending on the severity of the thrombocytopenia. Prior to this study, serum uric acid levels had been measured in a group of normotensive women. Mean and standard deviation of serum uric acid levels for each group were compared using analysis of variance and student t-tests, where necessary. RESULTS: Significant elevation in serum uric acid levels over normotensive pregnant women (285 +/- 72 micromol/L) was observed in both the gestational hypertensive group (341 +/- 83 micromol/L) and the preeclamptic group (384 +/- 93 micromol/L) of women (p < 0.001 and p < 0.05 respectively). Serum uric acid levels were also significantly elevated (p < 0.001) in women with gestational hypertension with HELLP syndrome (382 +/- 78 micromol/L) compared to those without HELLP syndrome (330 +/- 80 micromol/L). Preeclamptic women with HELLP syndrome (412 +/- 99 micromol/L) also demonstrated elevated uric acid levels (p < 0.05) over those without HELLP syndrome (374 +/- 87 micromol/L). However, the level of uric acid did not predict the severity of HELLP syndrome. The presence of SGA infants in the gestational hypertensive group was not associated with increased uric acid levels. CONCLUSION: Uric acid levels, although significantly elevated in women with gestational hypertension and preeclampsia as compared to normotensive pregnant women, are not good prognostic indicators of the severity of the maternal or fetal complications.