Kinetics of maternal pertussis-specific antibodies in infants of mothers vaccinated with tetanus, diphtheria and acellular pertussis (Tdap) during pregnancy.

BACKGROUND: Kinetics of Tdap-induced maternally-derived antibodies in infants are poorly understood. Pre-Tdap era data suggest that maternal pertussis antibodies in infants have a half-life of approximately 5-6 weeks. METHODS: 34 mother-infant pairs had blood collected before maternal Tdap vaccination, 4 weeks later, at delivery (maternal and cord), and at infant ages 3 and 6 weeks from June 2014-March 2015. Immunoglobulin G (IgG) to pertussis toxin (PT), filamentous hemagglutinin (FHA), fimbrial proteins (FIM) and pertactin (PRN) was quantified by multiplex luminex assay (IU/ml). Geometric mean concentrations (GMCs) with 95% confidence intervals (C.I.) and half-life of pertussis antibodies were calculated. RESULTS: Tdap was administered to 34 women (mean age 31.1 years) at mean gestation 30.7 weeks (28-32.7). Mean neonatal gestation was 39.1 weeks (36-41.1) and mean birthweight was 3379 g (2580-4584). Four weeks post-Tdap vaccination, maternal pertussis-specific IgG GMCs increased ≥4-fold in 59%, 41%, 29% and 44% of women for PT, FHA, FIM and PRN, respectively, and then waned. The transplacental transport ratio of pertussis antibodies was 1.35 for PT, 1.41 for FHA, 1.31 for FIM and 1.36 for PRN. Between birth and age 6 weeks, infant serum GMC for PT-specific IgG decreased from 55.1 IU/mL (38.6-78.6) to 21.1 IU/ml (14.7-30.2), and the proportion of infants with PT levels ≥10 IU/ml fell from 97% to 67%. Half-life of pertussis-specific IgG in infants in days was 29.4 (95% CI 27.3-31.7) for PT, 29.8 (95% CI 27.7-32.2) for FHA, 31.2 (95% CI 28.9-33.7) for PRN, and 35.8 (95% CI 30.1-44.3) for FIM. CONCLUSION: The half-life of pertussis-specific antibodies in infants induced by maternal Tdap vaccination (29-36 days) is shorter than previously reported. Understanding how the durability of passively-acquired antibodies impacts infant susceptibility to pertussis and response to primary vaccination is critical to refine prevention strategies.

Transversus abdominis plane block with liposomal bupivacaine for pain control after cesarean delivery: a retrospective chart review.

BACKGROUND: Adverse effects of opioid analgesics and potential for chronic use are limitations in the cesarean setting. Regional anesthesia using transversus abdominis plane (TAP) block post-cesarean delivery may improve analgesia and reduce opioid consumption. Effectiveness of TAP block using liposomal bupivacaine (LB) to reduce post-cesarean pain is unknown. METHODS: We performed a single-center retrospective chart review of patients aged ≥18 years who underwent cesarean delivery with a multimodal pain management protocol with or without TAP block with LB 266 mg. Assessments included postsurgical opioid consumption; area under the curve (AUC) of numeric rating scale pain scores from 0 to 3 days; proportion of opioid-free patients; discharge- and post-anesthesia care unit (PACU)-ready time; times to ambulation, solid food, and bowel movement; hospital length of stay (LOS); and adverse events (AEs). Data were analyzed in the total population and in first- and repeat-cesarean subgroups using Wilcoxon, chi-squared, and Student's t-tests. RESULTS: Of 201 patients, 101 were treated with LB TAP block (LB-TAPB) and 100 without LB-TAPB. Treatment with LB-TAPB vs without LB-TAPB significantly reduced mean post-surgical opioid consumption (total, 47%; first-cesarean, 54%; repeat-cesarean, 42%; P<0.001 each) and mean AUC of pain scores (total, 46%; first-cesarean, 57%; repeat-cesarean, 40%; P<0.001 each). Patients treated with LB-TAPB had significantly shorter mean discharge-ready times (2.9 vs 3.6 days; P=0.006), PACU-ready times (138 vs 163 minutes; P=0.028), and LOS (2.9 vs 3.9 days; P<0.001). LB-TAPB significantly decreased mean times to ambulation and solid food by 39% and 31% (P<0.01 each), respectively, and numerically reduced mean time to bowel movement (26%; P=0.05). Fewer patients treated with LB-TAPB vs without LB-TAPB reported an AE (34% vs 50%; P=0.026). CONCLUSION: These results suggest multimodal pain management incorporating TAP block with LB 266 mg is an effective approach to reducing opioid requirements and improving analgesia post-cesarean delivery.

An Initiative to Reduce the Episiotomy Rate: Association of Feedback and the Hawthorne Effect With Leapfrog Goals.

OBJECTIVE: To assess the association of education, performance feedback, and the Hawthorne effect with a reduction in the episiotomy rate in a large academic institution. METHODS: We describe a prospective observational study of a project conducted between March 2012 and February 2017 to assist clinicians in meeting the Leapfrog Group (www.leapfroggroup.org) target rates for episiotomy. Phases of this project included preintervention (phase 1, March 2012 to April 2014), education and provision of collective department episiotomy rates (phase 2, May 2014 to December 2014), ongoing education with emphasis on a revised Leapfrog target rate (phase 3, January 2015 to February 2016), and provision of individual episiotomy rates to practitioners on a monthly basis (phase 4, March 2016 to February 2017). We analyzed the department episiotomy rates before, during, and after these efforts. Cases of shoulder dystocia were excluded from this analysis. Statistical analysis was performed using a two-tailed Student t test and χ test with P<.05 considered significant. RESULTS: During the study period 1,176 episiotomies were performed in 16,441 vaginal deliveries (7.2%). In phase 2 (2,352 vaginal deliveries), there was a nonsignificant drop in the episiotomy rate with education alone (9.0-8.2%, P=.21). In phase 3 (4,379 vaginal deliveries), the episiotomy rate demonstrated an additional, significant drop to 5.9% (P<.001), but this reduction did not reach the new Leapfrog goal of 5%. In phase 4 (3,160 vaginal deliveries), the hospital episiotomy rate again dropped significantly from 5.9% to 4.37% (P=.007) and met the target rate of 5%. This reduction was sustained over a 12-month time period. During this same time period, the rate of operative vaginal delivery among vaginal births increased (4.5-5.4%, P=.003) and there was no significant change in the rates of third- and fourth-degree perineal laceration (3.8-3.3%, P=.19). CONCLUSION: Education, performance feedback, and the Hawthorne effect were associated with a reduction in the episiotomy rate in a large academic institution without a reduction in the rate of operative vaginal delivery or an increase in the rate of third- and fourth-degree lacerations.

The limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia.

BACKGROUND: Despite intensive efforts directed at initial training in fetal heart rate interpretation, continuing medical education, board certification/recertification, team training, and the development of specific protocols for the management of abnormal fetal heart rate patterns, the goals of consistently preventing hypoxia-induced fetal metabolic acidemia and neurologic injury remain elusive. OBJECTIVE: The purpose of this study was to validate a recently published algorithm for the management of category II fetal heart rate tracings, to examine reasons for the birth of infants with significant metabolic acidemia despite the use of electronic fetal heart rate monitoring, and to examine critically the limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia. STUDY DESIGN: The potential performance of electronic fetal heart rate monitoring under ideal circumstances was evaluated in an outcomes-blinded examination fetal heart rate tracing of infants with metabolic acidemia at birth (base deficit, >12) and matched control infants (base deficit, <8) under the following conditions: (1) expert primary interpretation, (2) use of a published algorithm that was developed and endorsed by a large group of national experts, (3) assumption of a 30-minute period of evaluation for noncritical category II fetal heart rate tracings, followed by delivery within 30 minutes, (4) evaluation without the need to provide patient care simultaneously, and (5) comparison of results under these circumstances with those achieved in actual clinical practice. RESULTS: During the study period, 120 infants were identified with an arterial cord blood base deficit of >12 mM/L. Matched control infants were not demographically different from subjects. In actual practice, operative intervention on the basis of an abnormal fetal heart rate tracings occurred in 36 of 120 fetuses (30.0%) with metabolic acidemia. Based on expert, algorithm-assisted reviews, 55 of 120 patients with acidemia (45.8%) were judged to need operative intervention for abnormal fetal heart rate tracings. This difference was significant (P=.016). In infants who were born with a base deficit of >12 mM/L in which blinded, algorithm-assisted expert review indicated the need for operative delivery, the decision for delivery would have been made an average of 131 minutes before the actual delivery. The rate of expert intervention for fetal heart rate concerns in the nonacidemic control group (22/120; 18.3%) was similar to the actual intervention rate (23/120; 19.2%; P=1.0) Expert review did not mandate earlier delivery in 65 of 120 patients with metabolic acidemia. The primary features of these 65 cases included the occurrence of sentinel events with prolonged deceleration just before delivery, the rapid deterioration of nonemergent category II fetal heart rate tracings before realistic time frames for recognition and intervention, and the failure of recognized fetal heart rate patterns such as variability to identify metabolic acidemia. CONCLUSIONS: Expert, algorithm-assisted fetal heart rate interpretation has the potential to improve standard clinical performance by facilitating significantly earlier recognition of some tracings that are associated with metabolic acidemia without increasing the rate of operative intervention. However, this improvement is modest. Of infants who are born with metabolic acidemia, only approximately one-half potentially could be identified and have delivery expedited even under ideal circumstances, which are probably not realistic in current US practice. This represents the limits of electronic fetal heart rate monitoring performance. Additional technologies will be necessary if the goal of the prevention of neonatal metabolic acidemia is to be realized.

How to Approach Intrapartum Category II Tracings.

Since its inception, many have questioned the utility of electronic fetal heart rate (FHR) monitoring. However, it arrived without the benefit of clear, standard nomenclature, leading to difficulty interpreting studies regarding its benefit. In 2008, the National Institute of Child Health and Human Development (NICHD) developed standard nomenclature for interpreting eFHR tracings. Understanding what drives the tracings is key to managing them. Category II FHR patterns are by far the most common and most diverse patterns, leading to broad variation in care. Presented here is an algorithm for standardization of management of category II FHR tracings, based on the pathophysiology of decelerations, that can be followed in any labor unit.

A multi-institutional effort for temporary training of residents displaced by disaster: lessons from Katrina.

OBJECTIVE: This study was undertaken to describe a comprehensive, collaborative temporary residency training curriculum after disaster. STUDY DESIGN: The Texas Southeast Alliance was created in response to the Katrina Disaster by regional obstetric/gynecology programs. Principles were devised to guide development of a temporary training curriculum. Learning opportunities were identified and pooled. Affected program directors were contacted who expressed interest in the curriculum which had been approved by institutional officials and appropriate regulatory bodies. RESULTS: In total, 41 different training opportunities were made available to the Tulane residents. Twenty-four residents completed 92 rotations in total. Residents met weekly with their program director. Free psychiatric consultative services were provided through resident counseling services. Housing was facilitated wherever possible. CONCLUSION: Consolidation of resources by the Texas Southeast Alliance provided temporary training experiences for Tulane obstetric and gynecology residents displaced by Hurricane Katrina. Effective training can be maintained after disaster by coordinating institutional efforts and establishing governing principles.

Does a minimally invasive surgery fellowship impact surgical experience among gynecology residents?

STUDY OBJECTIVE: To examine the impact of a minimally invasive surgery (MIS) fellowship on resident experience and to survey the general attitude toward effects of fellowship programs on resident education. DESIGN: Survey (Canadian Task Force classification III). SETTING: An accredited obstetrics and gynecology program in the United States. SUBJECTS: Obstetrics and gynecology residents. INTERVENTION: Residents received a survey regarding the potential impact of a MIS surgery fellowship on resident experience. MEASUREMENTS AND MAIN RESULTS: One year after creation of a MIS fellowship at our institution, we conducted an anonymous survey among residents. We also compared total number of surgical procedures and laparoscopic procedures performed before and after the fellowship commenced. We had a response rate of 70%. The overall impact of the newly established fellowship was regarded as positive. The median approval rating of endoscopic training before and after institution of the fellowship was 3.0 and 4.0, respectively (p < .001). There were no statistically significant changes in caseload between the two periods. CONCLUSION: A fellowship in MIS at an academic institution does not detract from resident experience in gynecologic surgery, with most residents viewing the fellowship positively.