The Safety of Low-Dose Aspirin on the Mode of Delivery: Secondary Analysis of the Effect of Aspirin in Gestation and Reproduction Randomized Controlled Trial.

OBJECTIVE: This study aimed to examine whether prenatal low-dose aspirin (LDA) therapy affects risk of cesarean versus vaginal delivery. STUDY DESIGN: This study is a secondary analysis of the randomized clinical effects of aspirin in gestation and reproduction (EAGeR) trial. Women received 81-mg daily aspirin or placebo from preconception to 36 weeks of gestation. Mode of delivery and obstetric complications were abstracted from records. Log-binomial regression models estimated relative risk (RR) of cesarean versus vaginal delivery. Data were analyzed among the total preconception cohort, as well as restricted to women who had a live birth. RESULTS: Among 1,228 women, 597 had a live birth. In the intent-to-treat analysis, preconception-initiated LDA was not associated with risk of cesarean (RR = 1.02; 95% confidence interval [CI]: 0.98-1.07) compared with placebo. Findings were similar in just women with a live birth and when accounting prior cesarean delivery and parity. CONCLUSION: Preconception-initiated daily LDA was not associated with mode of delivery among women with one to two prior losses. KEY POINTS: · Aspirin was not associated with risk of cesarean section.. · Aspirin was not associated with mode of delivery.. · No increased risk of bleeding with use of aspirin..

An alternative to cesarean: a description of external cephalic version in noncephalic presenting twin.

Objective: External cephalic version (ECV) is utilized in breech presenting singleton gestations but ECV of the noncephalic presenting twin has been considered technically unfeasible. We have successfully performed ECVs of the noncephalic presenting twin. Our objective is to describe our experience with this technique.Study design: This is a descriptive case series of our attempted ECVs in twin pregnancies and their outcomes.Results: Of 19 twin A ECV attempts, 10 cases were successful. The overall vaginal delivery rate was 42% (8/19 cases). There were no emergent cesarean deliveries required, and no neonatal injuries were observed.Conclusions: ECV can be achieved in pregnancies complicated by a noncephalic presenting twin. Further study is necessary to assess the safety and generalizability of our finding.

Maternal risk factors and neonatal outcomes in placental abruption among patients with equal access to health care.

INTRODUCTION: Placental abruption complicates 1% of pregnancies, and is associated with significant morbidity and mortality. The objective was to examine risk factors and outcomes in pregnancies complicated by abruption in a health care system with equal access to care. METHODS: This was a retrospective cohort study of all deliveries at Walter Reed National Military Medical Center (WRNMMC) between 1 January 2014 and 1 June 2017. The primary outcome was maternal factors that influenced abruption. The secondary outcome evaluated the neonatal outcomes after abruption. RESULTS: A total of 4351 patients delivered at WRNMMC and met the inclusion criteria. 52 patients (1.2%) had a pathology confirmed abruption. There was an association with smoking (p < .05; OR 4.25) and African American race (p = .005). Neonatal variables demonstrated an association between abruption and gestational age at delivery, low birth weight, Apgar scores, NICU admissions, and fetal demise all with p < .005. CONCLUSIONS: Our results demonstrate an association between both smoking and African American race with placental abruption. Unlike previous studies, there were no barriers to access to care. Further, there was no association with age, hypertension, diabetes, autoimmune disease, or trauma. Results did reaffirm an association between abruption and preterm birth, low birth weight, lower Apgars, NICU admissions, and fetal demise.PrécisIn a medical system with no barriers to access to care, maternal risk factors and neonatal outcomes associated with placental abruptions were investigated in over 4300 deliveries.

Speed Mentoring: An Effective & Efficient Path to Development of Mentor Relationships in a Military Obstetrics & Gynecology Residency.

INTRODUCTION: With a deficit of effective military residency mentorships, a paucity of research on successful mentorship programs, and growing reports on innovative mentoring programs, we developed a "Speed Mentoring" event for the National Capital Consortium OBGYN Residency. MATERIALS AND METHODS: The development, implementation, and follow-up responses through participant surveys were designed as an institutional review board (IRB)-approved evidence-based quality improvement project at our institution. Our event coordinated mentorship opportunities between residents and faculty from a wide range of specialties, leadership roles, and research experiences. Residents were matched with faculty that aligned with self-identified goals. Surveys were distributed prior to the event and at follow-up intervals to demonstrate the lasting impact and areas for improvement. RESULTS: Prior to our first event, every resident reported by survey that they desired more mentorship opportunities. However, only 55% could identify a specific mentor, citing limited time and difficulty establishing a relationship. Immediately following the event, 90% of residents scheduled a follow-up with at least one mentor. Forty-seven percent of residents reported inspiration to initiate a new research project. Meanwhile, faculty felt valued and gained satisfaction by "giving back" to their profession. After 1 month, half of the residents and faculty had already conducted at least one meeting. At 3 months, 76% of meetings centered on research and 23% on quality improvement projects. Fifty-seven percent of participants reported future scheduled meetings. At 6 months, 75% of residents reported meaningful mentorship relationships. CONCLUSIONS: After demonstrating a need for improved mentorship opportunities, we implemented an efficient way to foster mentorship while expanding resident involvement in research, QI projects, and fellowship applications. This "Speed Mentorship" program can be easily adapted to all residency programs.

Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons.

BACKGROUND: We evaluated a novel simulation-based cesarean section training program to teach critical techniques for cesarean section and hemorrhage management.  Methods: This was a prospective educational intervention. After Institutional Review Board approval, we recruited Obstetrics and Gynecology, Family Medicine, and General Surgery residents at three hospitals. All participants received didactic education. Participants were then randomized into two arms with one group to receive task-trainer based training and the other no training. Afterwards, all residents had their performance of a complete cesarean section and management of a post-partum hemorrhage evaluated on a high-fidelity simulator. Evaluators were blinded to randomization. EXPERIENCE: Thirty-three participants were recruited between July 2017 and January 2019. There were 19 trainees in the control group and 14 in the intervention group. The intervention group scored significantly higher on performance of the cesarean delivery (p-value 0.007), hemorrhage management (p-value 0.0002), and overall skill (p-value 0.008). There were no differences in the other categories. CONCLUSION: Participants trained with a combination of didactic education and task-trainers versus didactic education alone performed significantly better on all procedural aspects of a cesarean section and hemorrhage management on a high-fidelity simulator, demonstrating that simulation-based training allows trainees to gain procedural experience while decreasing patient risk.

Recalled maternal lifestyle behaviors associated with anti-müllerian hormone of adult female offspring.

Anti-müllerian hormone (AMH) is an established marker of ovarian reserve that decreases with age. Though the pool of ovarian follicles is established during fetal development, impacts of in utero exposures on AMH are uncertain. Thus, we sought to evaluate associations of in utero exposures with AMH of adult daughters with a prospective cohort study of adult daughters at university medical centers. Women noted their mother's reported use of diethylstilbestrol (DES), vitamins, tobacco, alcohol, and caffeine during pregnancy, and their mother's occupation during pregnancy. All participants were reproductive age women (18-40 years) enrolled in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial. Serum AMH concentrations were measured at baseline prior to conception and categorized using clinical guidelines. Multinomial regression models estimated associations between each exposure and high (>3.5 ng/mL) and low (<1.0 ng/mL) versus normal AMH (1.0-3.5 ng/mL), adjusting for participant's age, mother's age, mother's history of fertility treatment, and mother's use of vitamins. In 1202 women with available data, maternal caffeine use was associated with an increased risk of low AMH, compared to normal (relative risk [RR] 1.90, 95 % confidence interval [CI] 1.09, 3.30). Vitamins were associated with an increased risk of high AMH compared to normal (RR 1.93, 95 % CI 1.24, 3.00). Other exposures were not associated with AMH concentrations in offspring. Maternal caffeine and vitamin use during pregnancy may be associated with ovarian reserve in adult offspring, highlighting the potential importance of pregnancy lifestyle on the reproductive health of daughters.

Risk Assessment and Treatment Guide for Obstetric Thromboprophylaxis: Comprehensive Review of Current Guidelines.

OBJECTIVE: Currently, there are numerous recommendations and often conflicting guidance provided for venous thromboembolism (VTE) prophylaxis in pregnancy. Our objective was to create a one-page risk assessment and treatment guide based on a review of the most recent and evidence-based publications on this subject to simplify the approach and allow all obstetric patients to be properly assessed for risk of VTE and treated if indicated. STUDY DESIGN: We identified studies by completing a PubMed and MEDLINE search from January of 1980 through March 2017 with articles utilizing a specific combination of the selected general keywords (thrombophilia, pregnancy, VTE, prophylaxis, hypercoagulability, antepartum, postpartum, risk, etc.). We completed the search at the saturation point, meaning that all combinations of the relevant words were directing us to the same articles. After collecting the relevant sources and reviewing them, a total of 10 articles/guidelines were selected for inclusion in the analysis. RESULTS: We outlined every recommendation in the identified articles and guidelines and included any recommendation that was cited in at least three different sources in the final guide. We used American College of Obstetrics and Gynecology recommendations as the base for screening and dosing guidelines and utilized known and published absolute risk values and odds ratios to stratify risk factors. This stratification was used for both antepartum and postpartum recommendations and a single-page guideline was created. CONCLUSION: This compilation of guidelines integrates the complicated topic into a simple comprehensive guide where women can be identified early and accurately for appropriate VTE prophylaxis to protect them during and after pregnancy.

Congenital Megaureter Presenting in an Adult as a Vaginal Wall Cyst.

BACKGROUND: Vaginal cysts are a common finding. The differential diagnosis includes epidermal inclusion, Bartholin gland, Gartner duct, and Skene gland cysts and Müllerian anomalies. Rarely, leiomyomas, cancers, or ectopic ureters or megaureters are found. CASE: A 31-year-old woman, gravida 3 para 3, presented with a 12-year history of intermittent abdominal pain and involuntary loss of urine. She was diagnosed with ectopic vaginal megaureter after evaluation and subsequently underwent a nephroureterectomy with a marsupialized distal ureter. She remains asymptomatic. CONCLUSION: Consideration of a rare diagnosis such as an ectopic ureter is important when patients repeatedly present with involuntary urinary incontinence in conjunction with a vaginal cyst and an otherwise negative evaluation. Using magnetic resonance imaging can be useful to assess urinary tract involvement, particularly in patients with known urinary tract malformations.