Assessment of lesbian, gay, bisexual, transgender, and questioning experiences within a large southeast training program.

The USA has become increasingly diverse resulting in greater strides to improve workforce diversity and inclusivity. The objective of this study is to compare the experiences of trainees in Graduate Medical Education who identify as Lesbian, Gay, Bisexual, Transgender or Questioning (LGBTQ) to the experiences of non-LGBTQ trainees within the medical workplace. We conducted a cross-sectional, exploratory survey from 1 December 2020 to 14 January 2021 at a single, large teaching institution. We collected data anonymously and stored it in a REDCap database. We excluded surveys in which trainees did not respond to sexual orientation. We used contingency tables and Fisher's exact test to identify outcomes associated with sexual orientation and gender identity particularly with regard to professionalism, well-being, and satisfaction with training. We distributed the survey to 840 trainees. 730 trainees were included (23 (3.2%) LGBTQ and 707 (96%) Straight). LGBTQ trainees were more likely to experience offensive remarks based on race/ethnicity (p = 0.03) and sexual orientation (p = 0.01). Secondary analysis based on race found that Blacks and Other were more likely to report differences based on professionalism and satisfaction with their training program. There was no difference seen among LGBTQ trainees based on race. We found trainees who identified as LGBTQ were more likely to experience discrimination/microaggressions. Also, racial and ethnic groups that are underrepresented in medicine were more likely to encounter discrimination and dissatisfaction with their training. More efforts are needed in academics to promote safe and supportive LGBTQ and minority training experiences.

The effects of offering immediate postpartum placement of IUDs and implants to pregnant patients with heart disease.

OBJECTIVE: To evaluate the effects of offering immediate postpartum long-acting reversible contraception to pregnant patients with heart disease. STUDY DESIGN: Retrospective cohort of pregnant patients with cardiac disease managed by a Comprehensive Pregnancy & Heart Program. Patients were divided into 2 cohorts: pre-immediate postpartum LARC Program implementation (March 2015 to January 2017) and post-implementation (February 2017 to June 2019). The primary outcome was LARC (intrauterine device [IUD] or etonogestrel implant) use postpartum, defined as LARC either immediately postpartum or at the postpartum visit. Secondary outcomes included contraception intent at delivery and IUD expulsion rate of IUDs placed immediately postpartum. RESULTS: Of 159 included patients, 96 (60%) delivered during the post-implementation period. LARC use tripled after program implementation, 11% vs 35%, p < 0.01. Specifically, immediate postpartum IUD use increased from 1 (1.6%) to 10 (10.4%), p = 0.05, and use of immediate postpartum implant increased from 0 to 14 (14.6%), p = 0.002. Rates of women without contraception plans at delivery decreased from 32% to 14%, p < 0.01, as did the number of women using medroxyprogesterone acetate: 16% vs 4%, p = 0.01. Tubal ligation rates were not different before and after program implementation: 24% and 29%, p = 0.46. Postpartum visit rates were similar between Pre and Post groups: 70% and 72%, p = 0.78, respectively. One immediate postpartum IUD expulsion occurred. CONCLUSION: LARC use tripled in pregnant patients in an obstetric heart disease program after implementation of an immediate postpartum LARC Program. Access to immediate postpartum IUDs and implants should be a public health priority for women with heart disease to reduce their disproportionate burden of maternal morbidity and mortality. IMPLICATIONS: Access to immediate postpartum IUDs and implants should be a public health priority for women with heart disease - as well as all people with high-risk health conditions - to reduce their disproportionate burden of maternal morbidity and mortality.

Smartphone Use and the Perception of Professionalism Among Medical Students and Surgical Faculty.

OBJECTIVE: To understand the perception of professionalism surrounding smartphone use (wards/educational activities) among medical students and surgical faculty. DESIGN: A prospective cohort study was conducted using an electronic survey and distributed to third- and fourth-year medical students, obstetrics/gynecology, and surgery faculty members. Five cases were randomly presented; participants were asked to review and rate the clinician's behavior on a 5-point Likert scale. SETTING: The study was completed at The Johns Hopkins University School of Medicine, a tertiary care institution, in the departments of gyn/ob and surgery. PARTICIPANTS: A total of 123 medical students (51% response rate) from the class of 2015/2016 along with 73 surgical faculty in the departments of gyn/ob and surgery completed the study. Of the surgical faculty, 48% were ob/gyn (54% response rate) and 52% were surgery (21% response rate). Of note, when quarrying the department of surgery all surgical faculty were included, however, only those with direct student interaction were asked to complete the survey leading to the lower response rate. RESULTS: In 3 of 5 scenarios, students and faculty had significant differences in perception of professionalism (p<0.05). Faculty were more likely to find behaviors unprofessional compared to students. The acceptability of certain behaviors was significantly correlated in some case scenarios with how participants reported using their smartphones. Personal use of technology appears to influence the perception of acceptable behavior in certain scenarios.

Test of integrated professional skills: objective structured clinical examination/simulation hybrid assessment of obstetrics-gynecology residents' skill integration.

BACKGROUND: Assessment of obstetrics-gynecology residents' ability to integrate clinical judgment, interpersonal skills, and technical ability in a uniform fashion is required to document achievement of benchmarks of competency. An observed structured clinical examination that incorporates simulation and bench models uses direct observation of performance to generate formative feedback and standardized evaluation. METHODS: The Test of Integrated Professional Skills (TIPS) is a 5-station performance-based assessment that uses standardized patients and complex scenarios involving ultrasonography, procedural skills, and evidence-based medicine. Standardized patients and faculty rated residents by using behaviorally anchored checklists. Mean scores reflecting performance in TIPS were compared across competency domains and by developmental level (using analysis of variance) and then compared to standard faculty clinical evaluations (using Spearman ρ). Participating faculty and residents were also asked to evaluate the usefulness of the TIPS. RESULTS: Twenty-four residents participated in the TIPS. Checklist items used to assess competency were sufficiently reliable, with Cronbach α estimates from 0.69 to 0.82. Performance improved with level of training, with wide variation in performance. Standard faculty evaluations did not correlate with TIPS performance. Several residents who were rated as average or above average by faculty performed poorly on the TIPS (> 1 SD below the mean). Both faculty and residents found the TIPS format useful, providing meaningful evaluation and opportunity for feedback. CONCLUSIONS: A simulation-based observed structured clinical examination facilitates observation of a range of skills, including competencies that are difficult to observe and measure in a standardized way. Debriefing with faculty provides an important interface for identification of performance gaps and individualization of learning plans.

To the point: reviews in medical education--the Objective Structured Clinical Examination.

This article, the eighth in the To the Point Series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, discusses the effectiveness of the Objective Structured Clinical Examination (OSCE) for assessment of learners' knowledge, skills, and behaviors. The OSCE has also been used for the appraisal of residents and physicians undergoing licensure examinations; herein we focus on its application to undergraduate medical education. We review evidence for best practices and recommendations on effective use of the OSCE and requirements for and challenges to its implementation, including creative ways to design an OSCE program with a limited budget. We discuss its role in providing formative and summative feedback and describe learner performance on the OSCE as the OSCE relates to subsequent testing, including US Medical Licensing Examination step 1. A representative case with assessment used at the authors' medical schools is included.

Midpregnancy vaginal fluid defensins, bacterial vaginosis, and risk of preterm delivery.

OBJECTIVE: To assess relations among midpregnancy vaginal defensin levels, a component of the host innate immune response, bacterial vaginosis, and risk of preterm delivery. These relations are compared across race groups because previous studies have repeatedly shown that the prevalence of bacterial vaginosis and the risk of preterm delivery are greater in African-American women compared with that in white women. METHODS: Data are from a prospective study that enrolled pregnant women from 52 clinics in five Michigan communities. In the study subcohort, defensins (human neutrophil peptides 1, 2 and 3) and bacterial vaginosis (Nugent criteria) were measured in vaginal fluid collected at enrollment (15th through 27th week of pregnancy) from 1,031 non-Hispanic white and African-American women (787 term, 244 preterm). Preterm deliveries were categorized by clinical circumstances, ie, spontaneous and medically indicated. RESULTS: Among African Americans, vaginal human neutrophil peptides 1-3 levels greater than or equal to the median were associated with bacterial vaginosis and specifically with spontaneous preterm delivery only (adjusted odds ratio 2.3, 95% confidence interval 1.2-4.3). Once African-American women were stratified by human neutrophil peptide 1-3 levels, bacterial vaginosis added nothing to the prediction of spontaneous preterm delivery risk. None of the above associations were observed in non-Hispanic whites. CONCLUSION: The relations among human neutrophil peptide 1-3 levels, bacterial vaginosis, and preterm delivery vary by race group. In African Americans, midpregnancy human neutrophil peptide 1-3 levels were more informative to preterm delivery risk than was bacterial vaginosis, suggesting an important role for host response. In addition, elevated human neutrophil peptide 1-3 levels may be a marker for particular high-risk vaginal milieus that are not distinguished by the current bacterial vaginosis Nugent scoring system.

To the point: medical education review of the role of simulators in surgical training.

Simulation-based training (SBT) is becoming widely used in medical education to help residents and medical students develop good technical skills before they practice on real patients. SBT seems ideal because it provides a nonthreatening controlled environment for practice with immediate feedback and can include objective performance assessment. However, various forms of SBT and assessment often are being used with limited evidence-based data to support their validity and reliability. In addition, although SBT with high-tech simulators is more sophisticated and attractive, this is not necessarily superior to SBT with low-tech (and lower cost) simulators. Therefore, understanding the types of surgical simulators and appropriate applications can help to ensure that this teaching and assessment modality is applied most effectively. This article summarizes the key concepts that are needed to use surgical simulators effectively for teaching and assessment.

A comprehensive review to establish priority learning objectives for medical students in the obstetrics and gynecology clerkship.

OBJECTIVE: This study was undertaken to describe the process used to identify, externally validate, and establish the priority learning objectives for medical students on the obstetrics and gynecology clerkship. STUDY DESIGN: We conducted a review of the APGO Medical Student Objectives in Obstetrics and Gynecology to establish which of these objectives should be given first priority. We used recommendations from external references to assess the validity of these selected objectives. We compared the distribution of objectives with levels of expected competency from Miller's pyramid. RESULTS: From a list of 267 unique learning objectives we identified 134 (50.2%) Priority 1 objectives students must master by the end of the clerkship. The recommendations from 17 external references were compared with this set of objectives, which demonstrated a significant correlation between the 2 (P < or = .001). Priority 1 objectives were associated with advanced levels of competency. CONCLUSION: External sources validated and helped prioritize the learning objectives.

The Alabama Preterm Birth Study: umbilical cord blood Ureaplasma urealyticum and Mycoplasma hominis cultures in very preterm newborn infants.

OBJECTIVE: This study was undertaken to evaluate the frequency of umbilical cord blood infections with Ureaplasma urealyticum and Mycoplasma hominis in preterm 23- to 32-week births and to determine their association with various obstetric conditions, markers of placental inflammation, and newborn outcomes. STUDY DESIGN: 351 mother/infant dyads with deliveries between 23 and 32 weeks' gestational age who had cord blood cultures for U. urealyticum and M. hominis had their medical records abstracted, other placental cultures performed, cord interleukin-6 levels determined, placentas evaluated histologically, and infant outcomes determined. RESULTS: U. urealyticum and/or M. hominis were present in 23% of cord blood cultures. Positive cultures were more common in infants of nonwhite women (27.9% vs 16.8%; P = .016), in women less than 20 years of age, in those undergoing a spontaneous compared to an indicated preterm delivery (34.7% vs 3.2%; P = .0001), and in those delivering at earlier gestational ages. Intrauterine infection and inflammation were more common among infants with a positive U. urealyticum and M. hominis culture as evidenced by placental cultures for these and other bacteria, elevated cord blood interleukin-6 levels, and placental histology. Infants with positive cord blood U. urealyticum and M. hominis cultures were more likely to have neonatal systemic inflammatory response syndrome (41.3% vs 25.7%; P = .007; adjusted odds ratio, 1.86; 1.08-3.21) and probably bronchopulmonary dysplasia (26.8% vs 10.1%; P = .0001; adjusted odds ratio 1.99; 0.91-4.37), but were not significantly different for other neonatal outcomes, including respiratory distress syndrome, intraventricular hemorrhage, or death. CONCLUSION: U. urealyticum and M. hominis cord blood infections are far more common in spontaneous vs indicated preterm deliveries and are strongly associated with markers of acute placental inflammation. Positive cultures are associated with neonatal systemic inflammatory response syndrome and probably bronchopulmonary dysplasia.

Clinical trial of interconceptional antibiotics to prevent preterm birth: subgroup analyses and possible adverse antibiotic-microbial interaction.

OBJECTIVE: The purpose of this study was to explore whether endometrial microbial colonization and plasma cell endometritis are risk factors for adverse pregnancy outcomes, and whether these outcomes are influenced by interactions between interconceptional antibiotics and the micro-flora. STUDY DESIGN: Subgroup analyses of data from a double-blind, randomized, placebo-controlled trial of a course of metronidazole plus azithromycin given every 4 months to women with a prior preterm delivery to prevent recurrent preterm delivery. Endometrial cultures and histology were obtained at randomization and repeated 2 weeks after the first treatment. Fifty-nine on antibiotics versus 65 on placebo had pregnancy outcomes. Prevalence of adverse pregnancy outcomes (pregnancy loss or preterm birth < 37 weeks) was stratified by treatment group and endometrial characteristics. Subgroups were assessed and screened for potential interaction (P values for significance set a priori at < .01), prior to formal statistical testing for interaction (P values < .05). RESULTS: The prevalence of adverse pregnancy outcome was 62.7% in the presence of endometrial microbial colonization at baseline (any microbe) and 50% in the absence of colonization (RR = 1.25; 99% CI 0.42-3.7). Prevalence of adverse pregnancy outcomes was 61.9% with plasma cell endometritis, and 70.8% without; RR = 0.87 (0.50-1.5). There was a nonsignificant reduction in adverse pregnancy outcome in the absence of Gardnerella vaginalis or gram-negative rods with RR (95% CI) = 0.60 (0.3-1.2) and 0.66 (0.4-1.2), respectively. In the presence of these microbes, antibiotics appeared to increase adverse outcomes: RR = 1.5 (1.1-2.0) and 1.5 (1.1-2.1), respectively. This reversal of impact represents a crossover interaction. CONCLUSION: Neither baseline endometrial microbial colonization nor plasma cell endometritis were risk factors for adverse pregnancy outcome. However, colonization with specific microbes interacted with antibiotics to increase adverse outcomes.

The Alabama Preterm Birth Study: diffuse decidual leukocytoclastic necrosis of the decidua basalis, a placental lesion associated with preeclampsia, indicated preterm birth and decreased fetal growth.

OBJECTIVE: Laminar necrosis, a band-like distribution of coagulative necrosis, has been reported at the choriodecidual interface of the free membranes of placentas of women with various adverse neonatal outcomes. Our goal in this study was to evaluate the frequency of an equivalent feature in the decidua basalis, diffuse decidual leukocytoclastic necrosis (DDLN), a diffuse coagulative necrosis admixed with karyorrhectic debris, in preterm births <32 weeks, and to determine its association with various obstetric conditions, markers of placental inflammation, and newborn outcome. STUDY DESIGN: Four hundred and forty-six mother/infant dyads who delivered between 23 and 32 weeks gestational age (GA) had their medical records abstracted, a variety of placental and cord blood cultures performed, cord interleukin-6 (IL-6) levels determined, and the placentas evaluated histologically by a single pathologist (OFP). RESULTS: Women with DDLN (27%) were significantly more likely than other women to have preeclampsia (57.6 vs. 24.8%, p < 0.0001), an indicated preterm birth in this pregnancy (61.9 vs. 26.4%, p < 0.0001), and a prior indicated preterm birth (12.7 vs. 4.1%, p = 0.001), but were not more likely to have an abruption, diabetes, to smoke or be Black. Among DDLN-positive vs. DDLN-negative women, birth weight was significantly lower (1,069 +/- 373 vs. 1,171 +/- 389 g, p = 0.014), despite the GAs being similar (28.6 +/- 2.2 vs. 28.6 +/- 2.3 weeks, p = NS). Women with DDLN were less likely to have a positive placental culture for any organism (50.0 vs. 61.3%p = 0.03), Ureaplasma urealyticum and Mycoplasma hominis in either the placenta or cord blood (29.7 vs. 42.1%, p = 0.02), or an elevated cord blood IL-6 (21.5 vs. 32.9%, p = 0.059). They also were less likely to have acute inflammation of the membranes (27.4 vs. 56.4%, p < 0.0001), chorionic plate (17.0 vs. 48.6%, p < 0.0001) or cord (15.7 vs. 36.6%, p < 0.0001). Decidual necrosis in the free membranes also occurred more frequently in the presence vs. absence of DDLN (25.2 vs. 9.2%, p < 0.0001). Infants whose placentas had DDLN were significantly less likely to have neonatal systemic inflammatory response syndrome (20.7 vs. 35.2%, p = 0.004), but were not significantly different for other neonatal outcomes including respiratory distress syndrome, intraventricular hemorrhage or death. CONCLUSION: DDLN of the decidua basalis is relatively common in placentas of 23-32 week newborns, and, when present, is inversely associated with inflammatory maternal and newborn conditions and positively associated with preeclampsia, indicated preterm birth, and lower birth weight. The positive correlation of DDLN with obstetrical and neonatal conditions associated with underperfusion of the placental bed, suggests that DDLN may be a marker of vascular compromise.

Early second-trimester inflammatory markers and short cervical length and the risk of recurrent preterm birth.

This study aimed to analyze the associations between serum and cervicovaginal inflammatory markers and recurrent spontaneous preterm birth in a cohort study of 62 pregnant women with > or =1 prior early spontaneous birth. Serum samples and cervicovaginal swabs from the women were obtained at enrollment in early second trimester (week 12-25). Cervical length was measured by ultrasound and dicotomized in to short (< or =25 mm) and long cervices (>25 mm). The study endpoints were spontaneous preterm birth before 35 weeks and secondarily<37 weeks. Multiple inflammatory markers in serum (IL-1beta, IL-2, IL-5, IL-6, IL-8, IL-12, IL-18, TNF-alpha, TGF-beta, sTNF-R1, GM-CSF and TREM-1) and cervicovaginal secretions (IL-18, sTNF-RI and sIL-6) were individually associated with spontaneous preterm birth. Short cervical length did not explain associations between inflammatory markers and spontaneous preterm birth. Serum and cervicovaginal inflammatory markers did not correlate. In a combined prediction model using both serum and vaginal inflammatory markers, serum TNF-alpha, cervicovaginal sIL-6Ralpha and cervical length predicted 69% of all recurrent spontaneous preterm birth at a 5% false-positive rate. In conclusion, cervical length, serum TNF-alpha and cervicovaginal sIL-6Ralpha provide a clinically useful prediction of recurrent preterm birth in early second-trimester in women with a prior spontaneous preterm birth.

Impact of interconception antibiotics on the endometrial microbial flora.

OBJECTIVE: The purpose of this study was to evaluate the impact of an interconception antibiotic regimen on endometrial microbial flora and histologic type. STUDY DESIGN: This was a secondary analysis of a double-blind randomized placebo-controlled trial of prophylactic metronidazole plus azithromycin that was given to 241 women (antibiotics, 118 women; placebo, 123 women) with a previous preterm delivery to prevent recurrent preterm delivery. Endometrial cultures and histologic types were obtained at randomization and 2 weeks after treatment. The prevalence of either the new acquisition or the resolution of individual microbes, categories of microbes, and plasma cell endometritis were compared by chi-square or Fishers' exact tests. RESULTS: Overall, antibiotics were associated with lower acquisition and higher resolution of microbes. Of women without Gardnerella at baseline, 14% of the women who received antibiotics vs 34% of the women who received placebo had positive endometrial culture for the organism after treatment (P < .05); of those women with G. vaginalis at baseline, 57% of the women who received antibiotics vs 33% of the women who received placebo (P < .05) had a negative follow-up culture. Other gram-negative rods, especially aerobes in general, manifested similar patterns. The impact on anaerobes and plasma cell endometritis was not definitive, but there was a trend toward the increased resolution of the former (77% vs 55%) and reduced acquisition of the latter (28% vs 50%). CONCLUSION: The antibiotic regimen prevented the acquisition and promoted the resolution, but not the eradication, of gram-negative rods such as G. vaginalis and the aerobic subcategory.

The Alabama Preterm Birth study: polymorphonuclear and mononuclear cell placental infiltrations, other markers of inflammation, and outcomes in 23- to 32-week preterm newborn infants.

OBJECTIVE: The purpose of this study was to better understand the relationship between placental polymorphonuclear and mononuclear cell infiltrations with bacterial cultures, markers of inflammation, and preterm outcomes. STUDY DESIGN: This was a prospective study in 446 women who were delivered of a singleton infant at <32 weeks of gestational age. Five placental sites were categorized as having polymorphonuclear or mononuclear infiltrations. Results were compared with placental and cord cultures, umbilical cord interleukin-6 levels, and neonatal outcomes. RESULTS: Polymorphonuclear, but not mononuclear, cell infiltrations were more common at the earliest gestational ages and in black women (56.0% vs 39.3%; P < .01). Polymorphonuclear infiltration was associated with spontaneous preterm birth (73.9% vs 8.0%; P < .0001), but not with preeclampsia (9.9% vs 34%; P < .0001). Women with positive cultures, high interleukin-6 levels, and clinical chorioamnionitis all had significantly more polymorphonuclear infiltrations than did women without those conditions (all probability values, <.0001). In all sites, polymorphonuclear infiltration was associated with neonatal systemic inflammatory response syndrome (P < .0001) and in the cord with necrotizing enterocolitis (22.4% vs 13.5%; P = .02). Intraventricular hemorrhage and neonatal death were not associated with polymorphonuclear infiltration. Polymorphonuclear infiltration at all sites was associated with less respiratory distress syndrome (P < .01). Mononuclear cell infiltration, when present in the decidua basalis, was associated with an increase in neonatal intraventricular hemorrhage (23.8% vs 7.4%; P < .0004). Plasmacytic infiltrates were associated with increased intraventricular hemorrhage (29.4% vs 8.3%; P = .01) and neonatal death (27.8% vs 9.2%; P = .02). CONCLUSION: Polymorphonuclear infiltrations of the free membranes, chorionic plate, and umbilical cord were associated with positive intrauterine cultures and elevated cord blood interleukin-6. There was also an association with systemic inflammatory response syndrome and necrotizing enterocolitis, but not with intraventricular hemorrhage or death, and with decreased respiratory distress syndrome. Decidual mononuclear cell infiltration was associated with an increased risk of intraventricular hemorrhage and decidual plasma cell infiltration with increased intraventricular hemorrhage and neonatal death.

The Alabama preterm birth study: corticosteroids and neonatal outcomes in 23- to 32-week newborns with various markers of intrauterine infection.

OBJECTIVE: Intrauterine inflammation/infection is cited as a contraindication to the use of corticosteroids (CS). Our goal was to determine if CS given prenatally to enhance fetal maturity were harmful to infants with various indications of intrauterine infection. STUDY DESIGN: This was a retrospective analysis of data obtained from 457 consecutively enrolled infants delivered between 23 and 32 weeks. Cultures and a histologic examination of the placenta, and cord blood interleukin (IL)-6 levels were obtained. Neonatal outcomes included periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH), respiratory distress syndrome (RDS), chronic lung disease (CLD), necrotizing enterocolitis (NEC), systemic inflammatory response syndrome (SIRS), and infant death. RESULTS: Of the 457 pregnancies, 57.6% had a positive placental culture, 49.8% had histologic chorioamnionitis/funisitis, 28.8% had elevated cord IL-6 levels, and 12.5% had clinical chorioamnionitis. With intrauterine infection/inflammation, none of the neonatal outcomes were significantly worse if mothers were treated with CS. For those with histologic chorioamnionitis/funisitis, of the outcomes historically improved with CS, RDS (59.9 vs 72.2% P = .16), IVH (9.7 vs 14.7% P = .38), and neonatal death (9.9 vs 11.1% P = .82) all occurred less frequently with CS treatment, but differences were not significant. Similar results were seen for women with a positive placental culture. For women with an elevated IL-6, RDS was significantly reduced (59.4 vs 84.2 %, P = .045). Neonatal SIRS was significantly reduced with CS in women with histologic chorioamnionitis/funisitis (39.7 vs 65.7%, P = .005), positive placental cultures (32.7 vs 56.3%, P = .01), and elevated IL-6 levels (42.7 vs 73.7%, P = .02). CONCLUSION: In women with intrauterine infection/inflammation, CS use was not associated with significant worsening in any neonatal outcome, and was associated with significant reductions in RDS and SIRS. These data suggest that CS use may not be contraindicated in the presence of intrauterine inflammation/infection.

The Alabama Preterm Birth Project: placental histology in recurrent spontaneous and indicated preterm birth.

OBJECTIVE: For unknown reasons, a previous preterm birth (PTB) is a major risk factor for PTB in the current pregnancy. Our goal is to evaluate placental histology for clues related to the recurrent nature of PTB. STUDY DESIGN: Four hundred fifty-seven mother/infant dyads delivering between 23 and 32 weeks were first classified as having a spontaneous (S) or indicated (I) PTB, and then sorted into the following mutually exclusive categories by pregnancy history: 1) nulliparous; 2) having no previous PTB; 3) having any previous IPTB; or 4) having a previous SPTB. The placentas were evaluated for acute inflammation in the free membranes, umbilical cord, and chorionic plate, chronic inflammation in the membranes and decidua basalis, thrombosis in the chorionic plate and umbilical cord, and diffuse decidual leukocytoclastic necrosis (DDLN), a lesion associated with decreased placental perfusion. RESULTS: Women who had a SPTB were far more likely (85.5 vs 14.4 P < .0001) to have a SPTB in the previous pregnancy, while women with an IPTB were significantly more likely to have had a previous IPTB (89.7 vs 10.3 P < .0001). Nulliparas and women with previous term births each had about 64% SPTB and 36% IPTB. Acute inflammation at any site was present in 73.9% of SPTB versus 8.0% of IPTB (P < .0001). Chorionic plate thrombosis was also more common in SPTB than IPTB (16.2 vs 7.6, P = .01). Chronic inflammation at any site was more common in IPTB than SPTB (21.0 vs 12.7%, P = .02), as was DDLN (46.5 vs 16.1, P < .0001). When classified by SPTB and IPTB in the current pregnancy, the histologic results were not further influenced by the previous pregnancy history. CONCLUSION: SPTB and IPTB are strongly repetitive. Women with SPTB are significantly more likely to have acute inflammation in the free membranes, chorionic plate, and cord, and chorionic plate thrombosis, while women with an IPTB are significantly more likely to have chronic inflammation and especially DDLN. Past obstetric history does not further influence the placental histology.

The Alabama Preterm Birth Study: intrauterine infection and placental histologic findings in preterm births of males and females less than 32 weeks.

OBJECTIVE: The objective of the study was to determine whether there are differences in the placental histology and various markers of infection/inflammation between preterm male and female fetuses. STUDY DESIGN: The placentas and umbilical cords of 446 infants born at 23 to 32 weeks were examined histologically, cultured for aerobic and anaerobic bacteria and mycoplasmas, and the interleukin-6 levels in cord blood determined. RESULTS: Male infants were significantly more likely to have positive placental cultures than female infants (63.4% versus 51.8%, P = .01, odds ratio 1.5, 1.0 to 2.4). Cord blood Mycoplasma hominis and Ureaplasma urealyticum infections were marginally more common in male than female fetuses (27.6% versus 19.2%, P = .06, odds ratio 1.7, 0.9 to 2.9), but cord blood interleukin-6 levels were not different between male and female fetuses. The only significant histologic difference between male and female placentas was in decidual lymphoplasmacytic cell infiltration (6.3% versus 0.9%, P = .003, odds ratio 8.3, 1.8 to 39.0). Males had a higher percentage of decidual lymphohistiocytic cell infiltration, but the differences were not significant (11.3% versus 7.4%, P = .160, odds ratio 1.6, 0.8 to 3.2). CONCLUSION: Male infants were significantly more likely to have positive placental membrane cultures than female infants. Decidual lymphoplasmacytic cell infiltrations were more common in male versus female placentas, confirming a previous observation and suggesting that a maternal immune reaction to fetal tissue may be more common in male fetuses.

Association of asymptomatic bacterial vaginosis with endometrial microbial colonization and plasma cell endometritis in nonpregnant women.

OBJECTIVE: This study was undertaken to determine whether asymptomatic bacterial vaginosis (BV) is associated with an increased risk of endometrial microbial colonization or plasma cell endometritis in nonpregnant women. STUDY DESIGN: In this observational cohort study conducted between August 1995 and August 2001, microbial cultures (n = 769) and histopathology (n = 482) were performed on endometrial specimens obtained from women with a recent preterm or term delivery (83 +/- 16 days). Endometritis was defined as the presence of plasma cells. BV was defined using Amsel and Nugent criteria. RESULTS: The study population was 71% black, 29% white, 69% single, and 31% had 12 years or more of education. Endometrial cultures were positive for at least 1 microorganism in 83% (n = 637/769) of the women and plasma cell endometritis was present in 39% (n = 190/482). BV was present in 26% (n = 191/722) by Amsel and 38% (n = 289/769) by Nugent criteria. Women with Nugent-BV (RR [relative risk] = 1.12, 95% CI 1.05-1.19) but not Amsel-BV (RR = 1.06, 95% CI 1.00-1.13) were significantly more likely to have a positive endometrial culture. A consistent and significant association was observed between BV (by Amsel or Nugent criteria) and an increased frequency of endometrial colonization with BV-associated microorganisms grouped and defined in various ways (RR ranged from 1.96-4.22). No association between BV and plasma cell endometritis was observed. CONCLUSION: Asymptomatic BV is associated with a modest increased likelihood of endometrial microbial colonization and colonization by BV-associated bacteria but is not associated with plasma cell endometritis in nonpregnant women.

Early mid-trimester serum relaxin, soluble CD163, and cervical length in women at high risk for preterm delivery.

OBJECTIVE: The purpose of this study was to evaluate the relationship between serum concentrations of relaxin and soluble CD163 with cervical length and preterm delivery in women with previous spontaneous preterm delivery. STUDY DESIGN: Sixty-one of 69 pregnant women with a previous spontaneous preterm had serum relaxin and soluble CD163 measured at week 16 (range, 12-25 weeks). End points were cervical length and gestational age at delivery. RESULTS: Of the 61 women, 26% had >1 previous spontaneous preterm delivery; 84% were black; 87% were unmarried; 13% were smokers, and 39% were delivered before 37 weeks of gestation. Neither relaxin (median, 368 ng/L; range, 83-1493 ng/L) nor soluble CD163 (2.4 mg/L; range, 0.86-6.85 mg/L) correlated with cervical length or gestational age at delivery. Black women had higher relaxin levels (436 vs 205 ng/L; P = .002), but soluble CD163 levels were similar among racial groups. CONCLUSION: Relaxin and soluble CD163 measured at 16 weeks of gestation are not clinically useful predictors of short cervical length or preterm delivery in women with a previous spontaneous preterm delivery.