Protecting reproductive health information in the post-Roe era: interoperability strategies for healthcare institutions.

On June 24, 2022, the US Supreme Court ended constitutional protections for abortion, resulting in wide variability in access from severe restrictions in many states and fewer restrictions in others. Healthcare institutions capture information about patients' pregnancy and abortion care and, due to interoperability, may share it in ways that expose their providers and patients to social stigma and potential legal jeopardy in states with severe restrictions. In this article, we describe sources of risk to patients and providers that arise from interoperability and specify actions that institutions can take to reduce that risk. Institutions have significant power to define their practices for how and where care is documented, how patients are identified, where data are sent or hosted, and how patients are counseled, and thus should protect patients' privacy and ability to receive medical care that is safe and legal where it is performed.

Perinatal neuroprotection update.

Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.

The Exclusion of Sperm Donation on the Basis of Sexual Practices: Time for a Policy Update.

Currently, both the U.S. Food and Drug Administration and American Society for Reproductive Medicine exclude sperm donation from men who have sex with men. The recommended screening includes questioning donors about their sexual practices and performing a physical examination to look for signs of anal intercourse in addition to standard human immunodeficiency virus (HIV) laboratory testing. The rationale cited is concern over increased risk of HIV transmission in this higher prevalence population. We were unable to find evidence that excluding men who have sex with men or those with signs of anal intercourse on physical examination decreases the false-negative rate of laboratory testing. Current policy allows for men who have sex with men to be prohibited from donating sperm for the use of gestational carriers and therefore discriminates against this population for whom assisted reproductive technology may be their only means of genetic reproduction. We suggest policy revision to include the most advanced HIV laboratory tests and eliminating exclusionary demographics as part of screening.

A Benign Anomalous Umbilical Vein: Not All Umbilical Veins That Wander Are Lost.

A rare case of an anomalous umbilical vein with a previously unreported outcome is described. Most reported cases of anomalous umbilical veins are associated with significant concurrent fetal anomalies and poor outcomes. Fetal magnetic resonance imaging was used in this case to confirm normal portal and hepatic venous vasculature. No other fetal anomalies were identified on ultrasound. The infant was delivered at term and is healthy at the age of 8 months. Parental anxiety regarding the diagnosis was the only adverse consequence of this incidental finding.

Gestational Diabetes Testing: Making Sense of the Controversy.

Evidence has demonstrated that even mild increases in maternal blood sugar are associated with worsening pregnancy outcomes, particularly macrosomia, and that reducing blood sugar improves outcomes. Euglycemia can often be achieved with dietary modification and exercise without a need for medication. Despite this evidence, there continues to be controversy over exactly who, when, and how to test for gestational diabetes mellitus (GDM), with various professional organizations and experts in the field suggesting different strategies or not making specific recommendations at all. Potential sources of this controversy may include differences in opinion about the clinical importance of the consequences of GDM and the benefits of available interventions. Further, dichotomously diagnosing disease when the disease-defining characteristic is linear requires drawing a somewhat arbitrary line in the sand for diagnosis, which is likely to fall in a different place for different providers. Finally, given the resources and effort needed by both women and providers to address GDM, the availability of resources is likely to impact providers' perspectives on the ideal testing strategy. Given the differences among patient characteristics and available resources that exist in different health care settings, identifying one best strategy for GDM testing is not necessarily appropriate. However, given the potential benefits of identifying pregnant women with hyperglycemia, providers should use the most sensitive testing strategy that their patient population and resources allow.

Maternal Hypercalcemia Due to Failure of 1,25-Dihydroxyvitamin-D3 Catabolism in a Patient With CYP24A1 Mutations.

CONTEXT: Calcium metabolism changes in pregnancy and lactation to meet fetal needs, with increases in 1,25-dihydroxyvitamin D [1,25-(OH)2D] during pregnancy playing an important role. However, these changes rarely cause maternal hypercalcemia. When maternal hypercalcemia occurs, further investigation is essential, and disorders of 1,25-(OH)2D catabolism should be carefully considered in the differential diagnosis. CASE: A patient with a childhood history of recurrent renal stone disease and hypercalciuria presented with recurrent hypercalcemia and elevated 1,25-(OH)2D levels during pregnancy. Laboratory tests in the fourth pregnancy showed suppressed PTH, elevated 1,25-(OH)2D, and high-normal 25-hydroxyvitamin D levels, suggesting disordered vitamin D metabolism. Analysis revealed low 24,25-dihydroxyvitamin D3 and high 25-hydroxyvitamin D3 levels, suggesting loss of function of CYP24A1 (25-hydroxyvitamin-D3-24-hydroxylase). Gene sequencing confirmed that she was a compound heterozygote with the E143del and R396W mutations in CYP24A1. CONCLUSIONS: This case broadens presentations of CYP24A1 mutations and hypercalcemia in pregnancy. Furthermore, it illustrates that patients with CYP24A1 mutations can maintain normal calcium levels during the steady state but can develop hypercalcemia when challenged, such as in pregnancy when 1,25-(OH)2D levels are physiologically elevated.

Perspectives on anticipated quality-of-life and recommendations for neonatal intensive care: a survey of neonatal providers.

OBJECTIVE: Explore associations between neonatal providers' perspectives on survival, quality of life (QOL) and treatment recommendations. METHODS: Providers attending a workshop on neonatal viability were surveyed about survival, perceived QOL and treatment recommendations for marginally viable infants. We assessed associations between estimated survival and perceived QOL and treatment recommendations. RESULTS: In the 44 included surveys, estimates of survival and QOL varied widely. Maximum care was recommended 80% of the time when anticipated QOL was high, versus 20% when anticipated QOL was low (p < 0.001). Adjusted for confounders, odds of recommending maximum intervention were 4.4 times higher when anticipated QOL was high (95% CI 1.9 - 10.2, p = 0.001). CONCLUSIONS: The perspectives of practitioners who provide care to critically ill neonates regarding potential survival and QOL vary dramatically and are associated with the treatments those practitioners recommend. Practitioners should take care to avoid basing treatment recommendations on their own perspectives if they are not well aligned with those of the parents.

Perinatal neuroprotection.

Fetal or neonatal brain injury can result in lifelong neurologic disability. The most significant risk factor for perinatal brain injury is prematurity; however, in absolute numbers, full-term infants represent the majority of affected children. Research on strategies to prevent or mitigate the impact of perinatal brain injury ("perinatal neuroprotection") has established the mitigating roles of magnesium sulfate administration for preterm infants and therapeutic hypothermia for term infants with suspected perinatal brain injury. Banked umbilical cord blood, erythropoietin, and a number of other agents that may improve neuronal repair show promise for improving outcomes following perinatal brain injury in animal models. Other preventative strategies include delayed umbilical cord clamping in preterm infants and progesterone in women with prior preterm birth or short cervix and avoidance of infections. Despite these advances, we have not successfully decreased the rate of preterm birth, nor are we able to predict term infants at risk of hypoxic brain injury in order to intervene prior to the hypoxic event. Further, we lack the ability to modulate the sequelae of neuronal cell insults or the ability to repair brain injury after it has been sustained. As a consequence, despite exciting advances in the field of perinatal neuroprotection, perinatal brain injury still impacts thousands of newborns each year with significant long-term morbidity and mortality.

Time from consent to cesarean delivery during labor.

OBJECTIVE: The objective of the study was to describe the time from consent to incision (consent time) when informed consent (IC) for cesarean delivery (CD) is obtained during labor and identify risk factors for especially short consent times. STUDY DESIGN: The study was a retrospective chart review of 90 cases of CD during labor. Medians and interquartile ranges for times were reported. Multivariable linear and logistic regressions were used to adjust for confounders. A Kaplan-Meier survival analysis was performed to compare consent time among women undergoing CD for fetal heart rate (FHR) indications with other women. RESULTS: The median consent time was 48 minutes (interquartile range, 25-72); 28.9% of patients delivered less than 30 minutes after consent. When adjusted for potential confounders, the odds of delivering less than 30 minutes after consent were 4.7 times higher (95% confidence interval, 1.4-15.2, P = .01) among women who underwent CD for FHR indications than for women who underwent CD for other indications. CONCLUSION: This study demonstrates that when IC for CD is obtained during labor, consent time is brief, particularly among women undergoing CD for FHR indications. Although time is not necessarily a proxy for quality, an especially short consent time is likely to reduce the quality of the conversation and limit a patient's opportunity to understand and recall information. Additional research regarding the optimal approach to IC for CD in labor is needed; however, this study suggests that the practice of obtaining IC at the time the decision for CD is reached is unlikely to provide optimal time for a complete IC discussion.

The oldest gravidas: a review of pregnancy risks in women over 45.

UNLABELLED: As a result of delayed childbearing and increasingly sophisticated assisted reproductive technologies, pregnancy in women aged ≥45 years is becoming more common. Women in this age-group should receive thorough preconception evaluation and counseling about their specific risks in pregnancy. Although many pregnancies in women >45 years old are achieved via assisted reproductive technologies with associated preconception counseling, as many as 45% may be spontaneously conceived. It is therefore important for obstetrician-gynecologists to incorporate education for older women about the risks of pregnancy into routine office visits, and to ask women in this age-group about pregnancy planning. Additionally, many pregnancies in women aged >45 years may be safely managed in a nontertiary care center, avoiding the need for referral and transfer of care to an unfamiliar setting. This review addresses preconception evaluation and counseling, real and perceived risks in older mothers, common pregnancy complications and management of pregnancy in women >45 years old. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be better able to counsel women about the risks of pregnancy for women aged ≥45, evaluate older women for common risk factors that may further increase risk in pregnancy, assess pregnancy complications that are more common in women aged >45, and manage otherwise uncomplicated pregnancies in women in this age-group.

Sepsis after bipolar radiofrequency endometrial ablation.

BACKGROUND: Endometrial ablation offers an alternative to hysterectomy for the treatment of menorrhagia. The literature suggests low rates of complications for this procedure. CASE: A perimenopausal woman underwent an endometrial ablation using a bipolar radiofrequency device. She presented 36 hours postoperatively with sepsis. Her condition worsened despite 18 hours of intravenous antibiotics and aggressive fluid resuscitation, and she underwent exploratory laparotomy and hysterectomy. Blood cultures and uterine tissue cultures grew Escherichia coli. The patient improved quickly after hysterectomy. CONCLUSION: This case demonstrates that life-threatening infection can occur after endometrial ablation.