United states medical licensing examination scores as a predictor of performance on the annual council of resident education in obstetrics and gynecology examinations.

OBJECTIVE: To determine how well the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores predict the performance of residents on the annual Council of Resident Education in Obstetrics and Gynecology (CREOG) examination given to the residents at the second and third years of their residency. STUDY DESIGN: USMLE Steps 1 and 2 scores from medical school were compared to the resident CREOG examination scores at the second and third years of training for 61 residents from 2000 to 2011. RESULTS: A strong, statistically significant (p < 0.001) correlation was found between the USMLE and CREOG scores, ranging between r = 0.588 and r = 0.667 for the USMLE 1 scores and r = 0.630 and r = 0.640 for the USMLE 2 scores. CONCLUSION: This observation should be useful for program directors in selecting the future medical students for their residency program since those with high USMLE Steps 1 and 2 scores typically do very well on their objective testing during and after the residency.

The gynecologist's role in preventing overdiagnosis of ectopic molar pregnancy: a case report.

BACKGROUND: Ectopic hydatidiform mole is a rare, yet overdiagnosed, entity. A diagnosis of ectopic molar pregnancy requires close follow-up, has implications on future fertility, and may require chemotherapy. Patients diagnosed with a hydropic abortus do not require hormone surveillance or abstinence from pregnancy for the extended time period generally recommended for patients diagnosed with a complete or partial hydatidiform mole. The correct classification of products of conception is clinically important because each of the three diagnoses has a different potential for malignant transformation. CASE: A 29-year-old woman, G5P2104, with ectopic pregnancy and without clinical or laboratory data suspicious for molar pregnancy required ancillary histopathologic testing for accurate diagnosis. CONCLUSION: This case illustrates the vital role of the gynecologist in assimilating information to prevent over-diagnosis of ectopic molar pregnancy. General gynecologists must therefore understand the histopathologic options available for differentiating hydropic products of conception, partial hydatidiform mole and complete hydatidiform mole.

Cesarean or vaginal delivery for the breech fetus at the threshold of viability: results from a maternal-fetal medicine specialists survey.

OBJECTIVE: To determine how United States Maternal-Fetal medicine specialists recommend delivery of a breech fetus at the threshold of viability. METHODS: U.S. Society for Maternal-Fetal Medicine (SMFM) members were surveyed about; geographic location, practice type, whether they performed deliveries, definition of threshold for viability, recommendations for delivery of a breech fetus at the threshold of viability, and if the current medical-legal climate had any bearing on their decisions. Chi-Square and Fisher's Exact tests were used for analysis. RESULTS: 510 SMFM members responded to the questionnaire. The highest percentage of respondents stated '23 weeks' (31%) as the cutoff for viability, followed by '24 weeks' (21%) and '23 weeks or 500 g' (10%). Seventy percent recommended cesarean delivery for a breech fetus at the threshold of viability. The majority of respondents based their decision on 'published data' or 'expert opinion', however, 58.6% reported they felt current medical evidence was inadequate to support a recommendation. Fifty-three percent stated their recommendations are affected by medical-legal concerns. CONCLUSION: The majority of U.S. maternal fetal-medicine specialists who responded would recommend cesarean delivery for a breech fetus at the threshold of viability, despite the belief that there is inadequate evidence in the literature to support this recommendation.

Increased risk of placental abruption in underweight women.

We sought to determine if there is a relationship between prepregnancy underweight status and placental abruption. We utilized the Missouri maternally linked cohort data files covering the period 1989 through 1997. We estimated the association between prepregnancy underweight subtypes and placental abruption using adjusted odds ratios. Subanalyses were performed to determine whether the amount of weight gained during pregnancy could modify the association. A total of 439,235 singleton pregnancies with 3696 abruptions were analyzed. Underweight mothers had a 40% greater likelihood for placental abruption (odds ratio 1.4; 95% confidence interval 1.3 to 1.5). The risk increased with ascending severity of underweight status ( P for trend <0.01). There was a trend toward decreased risk for placental abruption among underweight women with adequate weight gain in pregnancy. Prepregnancy maternal underweight status is associated with placental abruption. This risk may be reduced with adequate weight gain during pregnancy.

Fetal umbilical cord blood erythropoietin, interleukin-6, pH, pO(2), pCO(2), and base excess levels in histologic and/or clinical chorioamnionitis: is the response only inflammatory?

OBJECTIVE: To determine the correlation of histological chorioamnionitis (CA) with and without clinical CA with umbilical cord blood gases, erythropoietin (EPO), and interleukin-6 (IL-6) levels. METHODS: Umbilical artery blood gas analysis (pH, pO(2), pCO(2), BE) and umbilical vein EPO and IL-6 levels were measured in 202 infants from normal, histological, and no clinical CA and histological plus clinical CA pregnancies. RESULTS: Umbilical artery blood gas analyses were not different between normal controls and histological and clinical CA groups. Blanc Stage 1 histological CA had no abnormal EPO or IL-6 umbilical blood results. EPO in umbilical venous blood was elevated only in those infants with both histological and clinical CA. Umbilical vein IL-6 levels were elevated in all advanced microscopic and clinical CA. High and low EPO groups also have corresponding high and low IL-6 levels suggesting a common stimulus for these substances. CONCLUSIONS: Blanc stage I histological CA is probably clinically insignificant. CA is infrequently associated with abnormal umbilical artery blood gas levels. Advanced histological and clinical CA can elevate both EPO and IL-6 in umbilical blood and these may be key elements of mechanisms that effect fetal brain function.

Placenta increta and cocaine abuse in a grand multipara leading to a second trimester rupture of an unscarred uterus: a case report.

A case of a uterine rupture in a grand multiparous patient with an unscarred uterus at 19 weeks' gestation secondary to placenta increta and cocaine abuse is presented. This was a diagnostically difficult case where abnormal implantation of the placenta, grand multiparity, and cocaine abuse were all contributors to the uterine rupture.

Placental pathology in trap sequence: clinical and pathogenetic implications.

Twin reversed arterial perfusion sequence (TRAP) resulting in an acardiac twin is a rare occurrence. Acardia requires the presence of arterial-arterial anastomosis, with retrograde perfusion of poorly oxygenated blood from the normal twin to the acardiac twin, venous-venous anastomosis carrying blood back from the acardiac to the normal twin, and circulatory failure of the acardiac twin. Although vascular anastomoses in cases of TRAP have been well described, there is little published literature on the microscopic changes in the placenta in TRAP sequence. We report a case of monochorionic monozygotic twins with an acardiac twin, large arterial-arterial anastomosis, and direct continuity of the umbilical cord veins. The placenta showed villous immaturity, striking villous calcifications, and extensive fetal thrombotic vasculopathy of the umbilical vein of the donor twin and the chorionic plate vessels. Thrombi in the umbilical vessels of the acardiac twin have been reported, and trombi in donor twin organs have been seen after fetal demise in utero. But to our knowledge there is no previously reported thrombi in the donor twin umbilical vessels or the chorionic plate veins. This may have implications not only as a possible factor in the etiology of TRAP, but also and more important as a possible risk factor for thrombotic events in the donor twin. Further studies with clinico-pathological correlation are needed to explore this issue.

Obstetric practice in the United States of America may contribute to the obesity epidemic.

The recommended weight gain of pregnancy in women over the past years has increased from 17.6 lb in 1945 to 25-35 lb in 1990. This has been associated with larger infant birth weights, more difficult deliveries and increased obesity in children and adults, with little benefit in reducing perinatal morbidity. It may be time to reevaluate the amount of weight normal pregnant women should gain.

Ultrasound to identify cord knotting in monoamniotic monochorionic twins.

This case report demonstrates the use of ultrasound and doppler flow in the management of mono-amniotic monochorionic (M/M) twins. M/M twinning is a rare but significant event. It is associated with high rates of fetal mortality, most commonly cited at anywhere from between 30% and 70%. A common cause of death is cord entanglement. The case presented is that of a 19-year-old gravida 1 at 30 weeks with M/M twins in which multiple cord knots were found by ultrasound color doppler flow after variable fetal heart rate decelerations occurred. This prompted a decision for immediate cesarean delivery with normal fetal outcomes. Improvements in perinatal imaging systems are therefore beneficial in the management of M/M twins.

Are placental chorionic capillary nucleated red blood cell counts useful compared to umbilical cord blood tests?

OBJECTIVE: To compare measurement of fetal nucleated red blood cell (NRBC) counts in paired histologic samples of the placenta and umbilical cord bloods. METHOD: Forty-five randomly selected pregnancies had two determinations of the NRBC count. A sample of umbilical venous blood had a NRBC count measured and sections of the placenta were examined for their villous capillary NRBC counts. RESULTS: Umbilical venous blood had NRBC/100 white blood cell counts ranging from 0 to 67. Paired evaluation of placental tissue had NRBC counts of 0-5 with 60% being zero compared to 8% zero counts in cord blood. There was no correlation between the paired counts (R(2) = 0.04). CONCLUSION: Umbilical cord blood provides different information on fetal NRBC count than does histologic study of the placenta.

Prediction of ABOG written examination performance from the third-year CREOG in-training examination results.

OBJECTIVE: To study the ability of the Council on Resident Education in Obstetrics and Gynecology (CREOG) in-training examination score to predict American Board of Obstetrics and Gynecology (ABOG) written examination performance. STUDY DESIGN: Twenty-six physicians took the CREOG examination during the third year of their residency and the ABOG written examination during their fourth year. These 2 test scores were compared. RESULTS: There was a statistically significant correlation between the 2 examination scores (r = 0.69, p < 0.001). CONCLUSION: The CREOG in-training examination at the third year of the residency correlates well with the ABOG written examination score and can be used to identify residents who need remedial study before finishing the program.

The correlation between automated hematology and manually read smears for the determination of nucleated red blood cells in umbilical cord blood.

OBJECTIVE: To determine the correlation between automated hematology nucleated red blood cell counts and manual counts in umbilical cord blood. METHODS: Umbilical cord venous blood was obtained after cord clamping at the time of delivery. The number of nucleated red blood cells per one hundred white blood cells was measured using an automated hematology analyzer and compared with direct microscopic visualization of prepared slides by experienced hematology technicians. RESULTS: The umbilical cord blood from 128 women was studied. The mean, median and standard deviations of nucleated red blood cell counts were not significantly different between the automated reading and the manual reading (mean 9.3+/-11.2 versus 9.1+/-13.1, respectively, P=0.76; median 5.9 versus 5.0, P=0.95; range 0-77, 0-105). Automated derived nucleated red blood cell counts and manual numbers were highly correlated with a correlation coefficient of 0.794. CONCLUSION: The automated hematology analyzer readings of nucleated red blood cell counts correlate well with readings by laboratory hematologists.

Escherichia coli septic shock following second-trimester amniocentesis.

BACKGROUND: Genetic amniocentesis is considered a safe procedure with a low incidence of complications including infection. CASE REPORT: A case of genetic amniocentesis followed by Escherichia coli sepsis is presented. CONCLUSION: Intra-amniotic infection after genetic amniocentesis should be treated aggressively with antibiotics and uterine evacuation.