Postpartum care: Discussions and counseling for the peripartum period.

BACKGROUND: Traditionally, postpartum care is confined to inpatient care immediately post birth and one appointment approximately six weeks postpartum. Data supports a continuum of care model as best for the health of mother and baby. Despite most women having significant concerns about the postpartum period, these concerns are frequently incompletely addressed by providers. We surveyed prenatal and postpartum patients to understand their concerns and experiences discussing postpartum care with providers. METHODS: Cross sectional surveys were administered between June 2019 and May 2021. Principal component analysis was used to show higher than average (positive) or lower than average (negative) conversations with providers about postpartum care examined by race, education, and parity. Chi squared tests were conducted to examine the significance of specific postpartum concerns. RESULTS: 421/450 patient surveys were analyzed, based on completion. Most patients were White (193), had post graduate degrees (188), privately insured (236), married (248), first time pregnant (152), and used doctors as their primary provider (267). Patients with lower education, higher parity and Black patients without postgraduate degrees reported higher than average postpartum counseling. Additionally, most patients expressed significant concerns about postpartum exhaustion (65.8%), breastfeeding (62.3%), pain (61.2%), physical activity (54.9%) and the baby blues (50.4%). CONCLUSIONS: Postpartum concerns are incompletely and inconsistently addressed amongst patients based on race, parity, and education. A continuum of care approach, beginning in the third trimester, through the postpartum period, may provide better counseling to address all patients' concerns.

Predicting risk of peripartum blood transfusion during vaginal and cesarean delivery: A risk prediction model.

OBJECTIVE: The objective of this study is to develop a model that will help predict the risk of blood transfusion using information available prior to delivery. STUDY DESIGN: The study is a secondary analysis of the Consortium on Safe Labor registry. Women who had a delivery from 2002 to 2008 were included. Pre-delivery variables that had significant associations with transfusion were included in a multivariable logistic regression model predicting transfusion. The prediction model was internally validated using randomly selected samples from the same population of women. RESULTS: Of 156,572 deliveries, 5,463 deliveries (3.5%) required transfusion. Women who had deliveries requiring transfusion were more likely to have a number of comorbidities such as preeclampsia (6.3% versus 4.1%, OR 1.21, 95% CI 1.08-1.36), placenta previa (1.8% versus 0.4%, OR 4.11, 95% CI 3.25-5.21) and anemia (10.6% versus 5.4%, OR 1.30, 95% CI 1.21-1.41). Transfusion was least likely to occur in university teaching hospitals compared to community hospitals. The c statistic was 0.71 (95% CI 0.70-0.72) in the derivation sample. The most salient predictors of transfusion included type of hospital, placenta previa, multiple gestations, diabetes mellitus, anemia, asthma, previous births, preeclampsia, type of insurance, age, gestational age, and vertex presentation. The model was well-calibrated and showed strong internal validation. CONCLUSION: The model identified independent risk factors that can help predict the risk of transfusion prior to delivery. If externally validated in another dataset, this model can assist health care professionals counsel patients and prepare facilities/resources to reduce maternal morbidity.

Practices of sickle cell disease genetic screening and testing in the prenatal population.

BACKGROUND: Genetic screening and testing are technologies historically underutilized in Black populations despite predicting diseases like sickle cell disease (SCD), which is predominantly found in Blacks. We surveyed prenatal patients to understand choices, beliefs and experiences surrounding genetic screening and testing, specifically for SCD. METHODS: In this cross-sectional study, we surveyed 322 women during prenatal visits. Responses were analyzed to identify barriers to care and education about testing and screening for SCD. Patients rated whether they agreed or disagreed with statements regarding sickle cell health behaviors. We used χ2 tests to compare categorical variables by self-reported race. Binary logistic regression was used to determine the odds ratios and confidence intervals for each outcome. RESULTS: Women were a mean (SD) age of 33.3 (6.1). 42.9% of patients self-identified as White while 41.3% of patients self- identified as Black. Screening questions were adjusted for differences in race, insurance, and education levels to show significant differences in responses between Blacks and Whites for screening for SCD (p = 0.047, OR 95% CI = 0.455 [0.210-0.989]) and plans to meet with genetic counselors (p = 0.049, OR 95% CI = 0.299 [0.090-0.993]). The statements "if sickle cell is not in their family, then it is likely not in themselves or their children," was significantly different between Black and White populations (p = 0.011, OR 95% CI = 0.207 [0.081-0.526]). CONCLUSION: Our findings suggest gaps in screening, testing, education, and pregnancy management choices between Black and White patients. Research should focus on decreasing these healthcare gaps and improving education that address concerns about SCD for relevant populations.

Whole-exome sequencing for diagnosis of Peters-plus syndrome after prenatal diagnosis of recurrent low PAPP-A and multiple fetal anomalies in two consecutive pregnancies.

 We report a case of two consecutive pregnancies in the same couple presenting with very low pregnancy-associated plasma protein A (PAPP-A), with both pregnancies affected by multiple anomalies of a similar phenotype identified during mid-trimester ultrasound, and eventual diagnosis of Peters-plus syndrome. This case is important in expanding the differential for very low PAPP-A. It also demonstrates the diagnostic value of whole-exome sequencing (WES) after prenatal diagnosis of recurrent fetal ultrasonographic findings. The importance and complexity of providing patient education to enable informed consent for next generation sequencing technologies is discussed.

Whole-exome sequencing for diagnosis of Peters-plus syndrome after prenatal diagnosis of recurrent low PAPP-A and multiple fetal anomalies in two consecutive pregnancies.

 We report a case of two consecutive pregnancies in the same couple presenting with very low pregnancy-associated plasma protein A (PAPP-A), with both pregnancies affected by multiple anomalies of a similar phenotype identified during mid-trimester ultrasound, and eventual diagnosis of Peters-plus syndrome. This case is important in expanding the differential for very low PAPP-A. It also demonstrates the diagnostic value of whole-exome sequencing (WES) after prenatal diagnosis of recurrent fetal ultrasonographic findings. The importance and complexity of providing patient education to enable informed consent for next generation sequencing technologies is discussed.

Moyamoya disease in pregnancy: management after intracranial bypass grafting.

Moyamoya disease (MD) is a chronic, progressive cerebrovascular disease distinguished by bilateral stenosis or occlusion of the arteries around the circle of Willis with resulting prominent arterial collateral circulation. We describe a pregnant woman in whom this diagnosis was confirmed by cerebral angiogram and treated with bilateral superficial temporal artery-middle cerebral artery (STA-MCA) bypass grafting prior to conception. The patient was managed with strict blood pressure monitoring and low-dose aspirin antepartum, intrapartum, and postpartum. The patient presented in spontaneous labor at term and underwent a spontaneous vaginal delivery without complications.

Effect of meconium on the hemoglobin-oxygen association curve.

OBJECTIVE: Our purpose was to determine the effect of meconium-stained amniotic fluid on the hemoglobin-oxygen association curve of maternal whole blood. METHODS: Whole blood was obtained from term gravidas in active labor. Hemoglobin-oxygen association curves were generated for blood incubated with meconium vs. controls. Oxygen association curves were determined at pH 7.4 and 37 degrees C utilizing an automated device consisting of a spectrophotometer cuvette fitted with a magnetic stirrer, gas exchange line, and a Clark oxygen electrode. The samples were deoxygenated with nitrogen and association curves recorded while reoxygenating. Data was analyzed with Sigma Plot and Sigma Stat software. Analysis included log transformation, linear regression, and paired t-test. RESULTS: Twenty-eight hemoglobin oxygen association curves were generated. In all 14 pairs, meconium shifted the hemoglobin-oxygen association curve to the right. Partial pressures of oxygen required for various degrees of hemoglobin saturation were higher in meconium-exposed samples; P50 (30.1+/-0.6 vs. 27.8+/-0.4 mmHg, P < 0.01); P75 (46.9+/-0.6 vs. 43.1+/-0.5 mmHg, P < .001); P90 (69.2+/-1 vs. 63.3+/-1 mmHg, P < 0.01). CONCLUSIONS: Meconium-stained amniotic fluid causes a statistically significant, but clinically small, right shift in the hemoglobin-oxygen association curve.

Isolated bilateral anophthalmia in a girl with an apparently balanced de novo translocation: 46,XX,t(3;11)(q27;p11.2).

Primary anophthalmos is a heterogeneous condition. In its nonsyndromal form, it is usually considered an autosomal recessive trait. However, other causes such as chromosomal abnormalities and prenatal insults need to be considered. We report on a unique reciprocal translocation 46,XX,t(3;11)(q27;p11.2) in a baby with isolated anophthalmos. Both Chitayat et al. [1996] and Alvarez Arratia et al. [1984] have reported on cases of terminal deletion of the long arm of chromosome 3. In each case the child had multiple anomalies including microphthalmia or anophthalmia. Because our patient appears to have no other anomalies, this break point may indicate that a genetic locus for eye formation exists at chromosome site 3q27. Published 1999 Wiley-Liss, Inc.

Impact of genetic counseling on primary and preventive care in obstetrics and gynecology.

OBJECTIVE: To evaluate the utility of the prenatal three-generation pedigree in assessment of the obstetric patient's primary medical risks. STUDY DESIGN: In a case series, 250 charts of patients referred for amniocentesis on the basis of advanced maternal age were reviewed for a significant genetic risk of a primary care disorder. RESULTS: A total of 40 patients (16%) were at significantly increased risk for a primary care disorder. Thirty-eight patients (15.2%) were at increased risk for medical conditions for which early screening, detection and/or intervention are established. CONCLUSION: For the advanced maternal age population, formal genetic risk assessment performed prior to amniocentesis can be beneficial in primary care risk assessment.

Is adrenomedullin a causal agent in some cases of type 2 diabetes?

The study of two populations with a recent onset of type 2 diabetes showed that a subset of the patients had higher levels of adrenomedullin (AM) than the rest of the diabetics. In this subset, physiological elevations of AM might have triggered the disease in predisposed individuals. Diabetics showed higher levels of AM than healthy controls. In addition, glycemia was measured in diabetic rats after injection of saline, AM, or antiAM antibody. AM elevated glycemia, whereas the antibody reduced circulating glucose to normal. These results suggest that manipulation of AM levels could represent a new approach in the management of diabetes for the appropriate individuals.

Expression of adrenomedullin and its receptor in normal and malignant human skin: a potential pluripotent role in the integument.

Adrenomedullin (AM) is a multifunctional peptide involved in a variety of physiological functions, including growth regulation and antimicrobial activity. We have determined by immunohistochemistry and in situ hybridization that AM and its receptor are present in all the epithelial cells of the normal skin, including keratinocytes of the epidermis and hair follicles, as well as cells of the glands and secretory ducts. We also have detected AM in the sweat, by RIA. In addition, AM and its receptor were found in skin tumors of different histologies. The presence of AM and its receptor in normal and neoplastic skin was confirmed by RT-PCR and Western blot analysis performed on cell extracts from human skin cell lines. Radiolabeled AM bound to specific sites in cultured cells with a Kd of 9 nM. This binding was blocked by the addition of cold AM but not by related peptides such as AM 22-52, pro-AM 20 N-terminal peptide, calcitonin gene-related peptide, calcitonin gene-related peptide 8-37, or amylin. Finally, exposure to synthetic AM resulted in an increase of thymidine intake by skin cells. These results implicate AM as a potential player in skin defense against infectious microorganisms and as a possible autocrine growth factor in normal skin physiology and tumor development.

The usefulness of a prenatal genetic questionnaire in genetic risk assessment.

OBJECTIVE: To evaluate a prenatal questionnaire as a genetic screen and as an aid in pre-amniocentesis genetic risk assessment. METHODS: In a retrospective cohort study, charts were reviewed for 158 consecutive women of advanced maternal age referred for genetic counseling. Genetic risks identified by use of a questionnaire completed by 79 consecutive patients were compared with those risks identified by the referring physician, those identified during subsequent three-generation pedigree analysis, and to genetic risks identified by pedigree evaluation of 79 consecutive individuals who underwent genetic counseling without the aid of a questionnaire (controls). RESULTS: Sixteen (20%) of the questionnaires revealed a previously unidentified genetic risk. The sensitivity and specificity of the questionnaire were determined to be 40.0 and 97.4%, respectively. Pedigree analysis alone (control group) identified significantly more at-risk pedigrees than did the questionnaire alone (34 versus 20%, P < .05), but identified significantly fewer at-risk pedigrees than obtained from the study group patients who completed a questionnaire and pedigree evaluation (34 versus 50.6%, P < .05). Of all 158 patients, 15.2% (n = 24) underwent additional testing on the basis of genetic risk assessment. There was no difference between the study and control groups in additional evaluations performed (P = 1.0). CONCLUSION: A three-generation pedigree is superior to a questionnaire in genetic risk assessment. The questionnaire was not sufficiently sensitive to serve independently as an adequate genetic screen or risk assessment tool and did not influence subsequent fetal evaluation. Assessment of the sensitivity and specificity of prenatal genetic questionnaires should be undertaken before their routine clinical use.

Detection of adrenomedullin, a hypotensive peptide, in amniotic fluid and fetal membranes.

OBJECTIVE: Our purpose was to determine whether adrenomedullin, a multifunctional regulatory peptide involved in blood flow regulation and growth stimulation and with antimicrobial activity, was a component of amniotic fluid from second-trimester human fetus and to determine the source of this peptide. STUDY DESIGN: A prospective descriptive study was performed on 134 patients undergoing amniocentesis after genetic counseling, ultrasonography, and informed consent. Adrenomedullin expression was determined by immunocytochemical analysis, Western blot analysis, reverse transcriptase-polymerase chain reaction, and in situ reverse transcriptase-polymerase chain reaction in fetal membranes and with radioimmunoassay in amniotic fluids. RESULTS: Radioimmunoassay of the 134 amniotic fluid specimens revealed adrenomedullin-like immunoreactivity in all of them, ranging in concentration from 10 to 300 fmol/25 microliters (170 +/- 62 fmol/25 microliters). Immunocytochemical analysis, Western blot analysis, reverse transcriptase-polymerase chain reaction, and in situ reverse transcriptase-polymerase chain reaction further established the expression of adrenomedullin protein and messenger ribonucleic acid in fetal amniotic membranes, suggesting that this organ is the source of amniotic adrenomedullin. CONCLUSIONS: Our results clearly demonstrate the presence of adrenomedullin in second-trimester human amniotic fluid and adrenomedullin messenger ribonucleic acid and protein in amniotic membranes, suggesting that adrenomedullin is a hormone involved in the maintenance of normal pregnancy. Further studies with these molecular tools are in progress to determine the precise role of this hormone and whether adrenomedullin plays a role in the pathogenesis of various disorders of pregnancy.

Femoral hypoplasia and maternal diabetes: consider femoral hypoplasia/unusual facies syndrome.

Femoral hypoplasia/unusual facies syndrome (FH/UFS) is a rarely considered clinical entity that has a strong association with maternal diabetes. A case that demonstrates the prenatal morphologic and biometric abnormalities, and postnatal findings are presented. The pathogenesis and natural history of FH/UFS is discussed and contrasted with the caudal dysplasia syndrome.

The importance of genetic counseling before amniocentesis.

OBJECTIVE: To determine the adequacy of genetic risk assessment among primary care providers and to evaluate the efficacy of genetic counseling before "routine" genetic amniocentesis. STUDY DESIGN: A retrospective cohort study was undertaken. Charts of 275 consecutive patients referred for genetic counseling and amniocentesis on the basis of advanced maternal age (AMA) were compared with charts of 103 consecutive patients referred for an abnormal maternal serum alpha-fetoprotein (MSAFP) finding. Pedigree information obtained during counseling of these patients was compared with the family histories charted by the referring physician. RESULTS: In 35.6% of pedigrees evaluated, a significant genetic risk was discovered during genetic consultation that had not been noted by the referring physician. Furthermore, 9.8% of AMA patients and 10.7% of patients with abnormal MSAFP results underwent additional genetic testing or screening on the basis of genetic counseling. Additional genetic testing of 0.8% of amniotic fluid specimens was done on the basis of the genetic risk assessment elicited during counseling. Although a significant difference in increased genetic risk was observed between the AMA and abnormal MSAFP groups (AMA 30.8% positive, MSAFP 48.5% positive; relative risk 0.81, confidence limit 0.70 to 0.93), no significant difference was observed between the two groups with regard to patient interventions (relative risk 0.97, confidence limit 0.79 to 1.21) or amniotic fluid testing (p = 0.57, not significant). CONCLUSIONS: The data support the importance of genetic counseling before amniocentesis. Furthermore, the findings support the relevancy and usefulness of genetic counseling in more accurately ascertaining genetic risk and in maximizing the benefits of genetic evaluation of patients seemingly at low risk for other genetic diseases.

Fetal oculocerebrorenal syndrome of Lowe associated with elevated maternal serum and amniotic fluid alpha-fetoprotein levels.

OBJECTIVE: To report an association between fetal oculocerebrorenal syndrome of Lowe and elevations in maternal serum alpha-fetoprotein (MSAFP) and amniotic fluid alpha-fetoprotein (AFAFP). METHODS: Case 1 was identified during routine MSAFP screening. Cases 2-5 were identified through review of a data base of individuals with oculocerebrorenal syndrome enrolled at the National Institutes of Health. To estimate the frequency of this association, only those whose mothers would have been in the early second trimester from February 1987 to August 1993 were enumerated. The MSAFP was assumed to be normal unless explicitly reported or unless information outside the data base confirmed that MSAFP was not determined. RESULTS: An elevated MSAFP (2.5 multiples of the median [MoM] or greater) was detected in five of 20 pregnancies with a fetus affected by oculocerebrorenal syndrome. Maternal serum alpha-fetoprotein was greater than 5.0 MoM in three pregnancies undergoing amniocentesis, and all had an elevated AFAFP without significant acetylcholinesterase activity. No abnormalities were found by ultrasound, and there was no other cause of elevated AFP identified postnatally. Family history was positive in three of the five cases. The mothers were carriers in four of the five cases, whereas the fifth case appeared to be a spontaneous mutation. CONCLUSIONS: Elevated MSAFP and AFAFP appear to occur at a higher than expected frequency in pregnancies carrying an oculocerebrorenal syndrome fetus. The mechanism of elevation of AFP may be related to fetal renal tubular dysfunction. A directed interview, focusing on a maternal family history of male relatives with unexplained mental retardation, early institutionalization, or congenital rubella, is appropriate with unexplained MSAFP elevations and, particularly, with unexplained AFAFP elevations without acetylcholinesterase activity.

Amnioinfusion does not affect the length of labor.

OBJECTIVE: Our objective was to determine whether amnioinfusion prolongs or shortens the length of labor in patients who have an accepted indication for amnioinfusion. STUDY DESIGN: We performed a retrospective post hoc analysis of the length of labor of 437 patients who were enrolled in three prospective, randomized, controlled studies of amnioinfusion. RESULTS: The length of labor was not significantly different for patients who received amnioinfusion compared with those who did not receive amnioinfusion (control group). Among the subgroup with vaginal delivery, the duration of labor after amnioinfusion did not differ from the duration of labor among the controls. The length of labor (mean +/- SD, in hours) for the amnioinfusion group was 9.3 +/- 6.3 versus 10.6 +/- 6.9 for the control groups (p not significant). Among the subgroup that required cesarean delivery, the duration of labor after amnioinfusion did not differ from the duration of labor among the controls. The length of labor (mean +/- SD, in hours) in patients requiring cesarean delivery in the amnioinfusion group was 11.1 +/- 6.3 versus 13.0 +/- 7.5 for the control group (p not significant). CONCLUSION: Amnioinfusion does not prolong or shorten the length of labor among patients who have an accepted indication for the treatment.

Prophylactic amnioinfusion improves outcome of pregnancy complicated by thick meconium and oligohydramnios.

OBJECTIVE: The null hypothesis is that the use of intrapartum amnioinfusion in labors complicated by the presence of thick meconium and oligohydramnios will not decrease the incidence of fetal distress, cesarean delivery, meconium aspiration, or meconium aspiration syndrome. STUDY DESIGN: One hundred seventy term and postterm patients with thick meconium and oligohydramnios were randomly chosen to receive amnioinfusion or standard obstetric care without amnioinfusion. The frequency of fetal distress, cesarean section, meconium aspiration, and meconium aspiration syndrome were subject to chi 2 analysis, Student's t test, or Fisher's exact test. RESULTS: The rate of fetal distress was significantly reduced in the amnioinfusion group compared with controls (three of 85 vs 19 of 85, relative risk 0.15, 95% confidence interval 0.06 to 0.42). The rate of cesarean section for fetal distress was significantly reduced in the amnioinfusion group (two of 85 vs 17 of 85, relative risk 0.118, confidence interval 0.03 to 0.49). The rates of meconium aspiration (four of 85 vs 33 of 85, relative risk 0.12, confidence interval 0.0449 to 0.327) and meconium aspiration syndrome (0 of 85 vs five of 85, relative risk 0.09, confidence interval 0.009 to 0.872) were significantly reduced by amnioinfusion. CONCLUSIONS: Amnioinfusion improves the outcome in pregnancies complicated by thick meconium and oligohydramnios.

Prophylactic amnioinfusion as a treatment for oligohydramnios in laboring patients: a prospective, randomized trial.

Prophylactic amnioinfusion was studied in a randomized sample of 305 patients with oligohydramnios in labor. One hundred seventy-five patients underwent amnioinfusion with the remainder serving as controls. Amniotic fluid was titrated to an amniotic fluid index greater than 10.0 cm in the treatment group. Patients receiving amnioinfusion had significantly less operative intervention for fetal distress (p = 0.0001) and fewer cesarean sections (p = 0.0001). Umbilical artery pH at the time of delivery also was increased (p = 0.0001). Rates of amnionitis and endometritis were not significantly different between infused patients and controls, although the length of hospital stay was significantly decreased (p = 0.002) in the treatment group. Our data support earlier reports in the literature that amnioinfusion is a useful technique for decreasing intrapartum morbidity for both mother and fetus.