Moms in the NICU: developing a pilot to engage and empower women who have delivered a prematurely born infant.

BACKGROUND: Mothers spend long hours at their preterm infant's bedside in the Neonatal Intensive Care Unit (NICU), giving clinicians the opportunity to engage mothers in caring for their own health. OBJECTIVE: To develop a NICU based intervention to reduce the risk of a future premature birth by engaging and empowering mothers to improve their own health and identify barriers to implementing their improvement. DESIGN: Development based on a framework of narrative discourse refined by the Quality Improvement Plan Do Study Act Approach. SETTING: Level II Stepdown Neonatal Intensive Care Unit. PARTICIPANTS: 14 mothers of preterm infants, ages 24-39 years. METHODS: A team of Maternal Fetal Medicine Physicians, obstetricians, neonatologists, neonatal nurses, and parents developed guidelines to elicit the mother's birth story, review the story with a clinical expert to fill in knowledge gaps, identify strategies to improve health to reduce the risk of future preterm birth, and facilitate mother developing an action plan with specific six week goals. A phone interview was designed to assess success and identify barriers to implementing their health plan. The protocol was modified as needed after each intervention to improve the interventions. RESULTS: "Moms in the NICU" toolkit is effective to guide any clinical facilitator to engage, identify health improvement strategies, and co-develop an individualized health plan and its take home summary reached stability after the 5th mother. Mothers reported experiencing reassurance, understanding, and in some cases, relief. Participants were enthusiastic to inform future quality improvement activities by sharing the six week barriers faced implementing their health plan. CONCLUSION: Engaging in the NICU provides an opportunity to improve mothers' understanding of potential factors that may be linked to preterm birth, and promote personally selected actions to improve their health and reduce the risk of a future preterm birth.

Trends in Spontaneous and Medically Indicated Preterm Birth in Twins versus Singletons: A California Cohort 2007 to 2011.

OBJECTIVE: The study aimed to describe preterm birth (PTB) rates, subtypes, and risk factors in twins compared with singletons to better understand reasons for the decline in PTB rate between 2007 and 2011. STUDY DESIGN: This was a retrospective population-based analysis using the California linked birth certificates and maternal-infant hospital discharge records from 2007 to 2011. The main outcomes were overall, spontaneous (following spontaneous labor or preterm premature rupture of membranes), and medically indicated PTB at various gestational age categories: <37, <32, and 34 to 36 weeks in twins and singletons. RESULTS: Among the 2,290,973 singletons and 28,937 twin live births pairs included, overall PTB <37 weeks decreased by 8.46% (6.77-6.20%) in singletons and 7.17% (55.31-51.35%) in twins during the study period. In singletons, this was primarily due to a 24.91% decrease in medically indicated PTB with almost no change in spontaneous PTB, whereas in twins indicated PTB declined 7.02% and spontaneous PTB by 7.39%. CONCLUSION: Recent declines in PTB in singletons appear to be largely due to declines in indicated PTB, whereas both spontaneous and indicated PTB declined in twins. KEY POINTS: · The declines in PTB noted between 2006 and 2014 occurred in both singleton and twins.. · Declines were mostly in medically indicated PTB.. · Interventions proposed as causing the declines in singletons would not apply to twins..

Frequency of cerclage in consecutive pregnancies of women with history of preterm birth.

BACKGROUND: Serial cervical length screening is performed in women with a history of preterm birth to determine indication for cerclage placement. Our aim is to evaluate the frequency of cerclage placement in consecutive pregnancies with preterm birth history to determine whether performing serial cervical length screening for women with a history of late (34-36 6/7 weeks) spontaneous preterm birth (SPTB) should be reconsidered. METHODS: Retrospective evaluation of cerclage frequency and gestational age of delivery for consecutive singleton births for 69,671 women whose first birth was a SPTB. RESULTS: History of late SPTB was associated with a lower frequency of cerclage than history of early SPTB (0.83% vs 4.88%, OR 0.16, 95% CI 0.14-0.18). Rates of recurrent SPTB were lower for women with history of late SPTB than those with history of early SPTB (13.45%, 3.74% early, 9.71% late vs 20.69%, 9.12% early, 11.57% late). CONCLUSION: Women with a history of late PTB have a lower risk of recurrent PTB than those with a history of early PTB but constitute most of those undergoing serial cervical length screening for potential cerclage placement. Practice guidelines for screening women with a history of late PTB should be re-evaluated.

Physician Barriers and Facilitators for Screening for Congenital Heart Disease With Routine Obstetric Ultrasound: A National United States Survey.

OBJECTIVES: Prenatal detection of congenital heart disease with obstetric screening remains at less than 50% in most population studies, far from what is thought to be achievable. We sought to identify barriers/facilitators for screening from the perspective of interpreting physicians and to understand how these barriers/facilitators may be associated with interpretation of screening images. METHODS: Our mixed-methods studies included 4 focus groups in centers across the United States with obstetric, maternal-fetal medicine, and radiology providers who interpreted obstetric ultrasound studies. Themes around barriers/facilitators for fetal heart screening were coded from transcripts. A national Web-based survey was then conducted, which quantitatively measured reported barriers/facilitators and measured physicians' ability to interpret fetal heart-screening images. Multivariable generalized linear random-effect models assessed the association between barriers/facilitators and the accuracy of image interpretation at the image level. RESULTS: Three main themes were identified in the focus groups: intrinsic barriers (ie, comfort with screening), external barriers (ie, lack of feedback), and organizational barriers (ie, study volumes). Among 190 physician respondents, 104 interpreted ultrasound studies. Perceptions of barriers varied by practice setting, with nontertiary providers having lower self-efficacy and perceived usefulness of cardiac screening. Facilitators associated with the odds of accurate interpretation of screening images were knowledge (odds ratio, 2.54; P = .002) and the volume of scans per week (odds ratio, 1.01 for every additional scan; P = .04). CONCLUSIONS: Some of the main barriers to cardiac screening identified and prioritized by physicians across the United States were knowledge of screening and minimal volumes of scans. Targeting these barriers will aid in improving prenatal detection of congenital heart disease.

Outcome and Treatment of Antenatally Diagnosed Nonimmune Hydrops Fetalis.

INTRODUCTION: The objectives of this study were to evaluate the outcome of nonimmune hydrops fetalis in an attempt to identify independent predictors of perinatal mortality. MATERIAL AND METHODS: A retrospective cohort study was conducted including all cases of nonimmune hydrops from two tertiary care centers. Perinatal outcome was evaluated after classifying nonimmune hydrops into ten etiological groups. We examined the effect of etiology, site of fluid accumulation, and gestational age at delivery on postnatal survival. Neonatal mortality and hospital discharge survival were compared between the expectant management and fetal intervention groups among those with idiopathic etiology. RESULTS: A total of 142 subjects were available for analysis. Generally, nonimmune hydrops carried 37% risk of neonatal mortality and 50% chance of survival to discharge, which varies markedly based on the underlying etiology. Ascites was an independent predictor of perinatal mortality (p value = 0.003). There was nonsignificant difference in neonatal mortality and hospital discharge survival among idiopathic cases that were managed expectantly versus those in whom fetal intervention was carried out. DISCUSSION: The outcome of nonimmune hydrops varies largely according to the underlying etiology and the presence of ascites is an independent risk factor for perinatal mortality. In our series, fetal intervention did not offer survival advantage among fetuses with idiopathic nonimmune hydrops.

Surgical Techniques at Cesarean Delivery: A U.S. Survey.

Objective To assess the frequency of surgical techniques at cesarean delivery (CD) among U.S. obstetricians. Methods Members of the American College of Obstetrician Gynecologists were randomly selected and e-mailed an online survey that assessed surgical closure techniques, demographics, and reasons. Data were analyzed using SPSS (IBM Corp., Armonk, New York, United States), descriptive statistics, and analysis of variance. Results Our response rate was 53%, and 247 surveys were analyzed. A similar number of respondents either "always or usually" versus "rarely or never" reapproximate the rectus muscles (38.4% versus 43.3%, p = 0.39), and close parietal peritoneum (42.5% versus 46.9%, p = 0.46). The most frequently used techniques were double-layer hysterotomy closure among women planning future children (73.3%) and suturing versus stapling skin (67.6%); the least frequent technique was closure of visceral peritoneum (12.2%). Surgeons who perform double-layer hysterotomy closure had fewer years in practice (15.0 versus 18.7 years, p = 0.021); surgeons who close visceral peritoneum were older (55.5 versus 46.4 years old, p < 0.001) and had more years in practice (23.8 versus 13.8 years practice; p < 0.001). Conclusion Similar numbers of obstetricians either reapproximate or leave open the rectus muscles and parietal peritoneum at CD, suggesting that wide variation in practice exists. Surgeon demographics and safety concerns play a role in some techniques.

Fetofetal Transfusion Syndrome in Monochorionic-Triamniotic Triplets Treated with Fetoscopic Laser Ablation: Report of Two Cases and A Systematic Review.

Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.

Maternal-fetal medicine fellowship 3- and 4-dimensional ultrasound experience: room for improvement.

OBJECTIVES: The purpose of this study was to assess maternal-fetal medicine (MFM) fellowship 3- and 4-dimensional (3D/4D) ultrasound experience and training. METHODS: A 53-item prenatal diagnosis survey was emailed to 458 associate members of the Society for Maternal-Fetal Medicine. Associate members include both MFM fellows and recent graduates who are not yet board certified in MFM. RESULTS: A total of 148 associate members completed the survey (32% response rate); 92% were at least in their second year of a fellowship, and 48.1% had completed a fellowship. About half (50.8%) were capable of performing 3D/4D ultrasound examinations ("performers"), whereas 49.2% were not ("nonperformers"). Among performers, about 80% were capable of only basic image acquisition. Overall, 39.5% of respondents received no official 3D/4D ultrasound training, and 55.5% stated that fewer than 1 in 5 of their MFM faculty routinely performed 3D/4D ultrasound examinations. Compared with performers, nonperformers had less formal 3D/4D ultrasound training (53% versus 26%; P = .018) and fewer MFM faculty who performed 3D/4D ultrasound examinations (43% versus 68%; P = .005), and fewer nonperformers were taught by ultrasound mentors (25% versus 47.8%; P = .011). CONCLUSIONS: Most fellows are not trained in 3D/4D ultrasound. Greater emphasis on ultrasound mentorship and formalized ultrasound training by MFM faculty during fellowships is needed.

Maternal-fetal medicine fellowship obstetrical ultrasound experience: results from a fellowship survey.

OBJECTIVE: To assess maternal-fetal medicine (MFM) fellowship obstetrical ultrasound training, scope of practice and research. METHODS: A 52-item prenatal diagnosis survey was e-mailed to 458 associate members of the Society for Maternal-Fetal Medicine on two separate occasions. Associate members include both MFM fellows and recent graduates who are not yet board certified in MFM. RESULTS: A total of 148 associate members completed the survey (32% response rate), 92% of whom were at least in their second year of fellowship. A total of 58% of fellows spend at least 20% of their fellowship time performing prenatal ultrasounds, and most begin their ultrasound training in their first year. Most fellows describe being comfortable performing routine fetal anatomy surveys, growth ultrasounds and umbilical artery Doppler measurements, but only 48% are nuchal translucency (NT) certified, most through Nuchal Translucency Quality Review. A total of 7% of fellows do not receive structured training in 2D ultrasound, 39% receive no structured training in 3D/4D ultrasound, and 28% receive no structured training in fetal echocardiography. Only 38% can identify an ultrasound mentor during fellowship. CONCLUSION: Most fellows are trained in ultrasound during their first year of fellowship and feel comfortable performing routine exams. However, ultrasound mentorship, structured training and research in prenatal ultrasound are limited in some programs.

Prevention of preterm birth based on short cervix: symptomatic women with preterm labor or premature prelabor rupture of membranes.

The diagnosis of preterm labor (PTL) is challenging, especially in women whose cervical dilatation is <2 cm and who are <80% effaced. In symptomatic women, with threatened PTL in both singletons and twins, transvaginal ultrasound cervical length (CL) identifies a high-risk group that is more likely to be in true PTL, more likely to deliver sooner, and more likely to deliver preterm. The addition of fetal fibronectin improves the predictive accuracy in women whose CL is <30 mm but >15 mm. Transvaginal ultrasound CL can also be performed in the presence of ruptured membranes and predicts latency. Although additional data are needed, the evidence so far suggests that the use of transvaginal ultrasound CL and fetal fibronectin can be used to better identify and manage women with PTL likely to have an imminent preterm delivery, and to avoid interventions in women who would not.

Clostridium botulinum toxin A inhibits contractility in pregnant human myometrium in vitro.

Studies were undertaken to evaluate the effect of Botulinum neurotoxin type-A (BoNTA) preparation on oxytocin-induced contractions of pregnant human myometrium in vitro. Human myometrial tissue was exposed to increasing concentrations (1-50 000 U/mL) of BoNT/A. Isometric contractions were measured using a force displacement transducer. The cumulative effect of BoNT/A on myometrial activity (time to half relaxation [TTR50], frequency, and amplitude) was evaluated. The frequency of myometrial contractions was depressed by 40% from baseline (P < .05) and relaxation time was increased by 30% (P < .05) from baseline within a narrow range of concentrations. There was no significant difference in amplitude. The observed effects were rapidly reversed after complete wash out of the tissue. BoNT/A or its analogues with more specific tissue affinity may be of value as future agents for prevention of unwanted uterine contractile activity associated with preterm labor and fetal surgery.

Does knowledge of cervical length and fetal fibronectin affect management of women with threatened preterm labor? A randomized trial.

OBJECTIVE: The purpose of this study was to estimate the effect of sonographic cervical length (CL) and fetal fibronectin (FFN) on length of evaluation and outcomes in women with preterm labor (PTL). STUDY DESIGN: Women with threatened PTL were randomized to either a knowledge group (results of CL and FFN available and used according to study protocol), or a standard group (blinded to CL and FFN). Primary outcome was length of evaluation in triage. RESULTS: One hundred women were randomized. There was no significant difference between groups in length of evaluation, but in women with CL > or = 30 mm, the mean time for evaluation was significantly shorter in the knowledge group (1:58 h +/- 0:50 vs 2:53 h +/- 0:50, P = .004). Incidence of spontaneous preterm birth (SPTB) in the knowledge group was significantly reduced (13.0 vs 36.2%, P = .01). CONCLUSION: The knowledge of CL and FFN was associated with reduction in length of evaluation in women with CL > or = 30 mm and in incidence of SPTB in all women with PTL.

Gestational age at cervical length measurement and incidence of preterm birth.

OBJECTIVE: To estimate the risk of spontaneous preterm birth based on transvaginal ultrasound cervical length and gestational age at which cervical length was measured. METHODS: Women at high risk for spontaneous preterm birth and with transvaginal ultrasound cervical length measurements between weeks 12 and 32 were identified at one institution between July 1995 and June 2005. Inclusion criteria for women at high risk for spontaneous preterm birth were prior spontaneous preterm birth at 14 to 35 weeks, cone biopsy, müllerian anomaly, or two or more dilation and evacuations. Women with multiple gestations, cerclage, indicated preterm birth, or fetal anomalies were excluded. Logistic regression was used to estimate the spontaneous preterm birth risk before 35, 32, and 28 weeks. RESULTS: Seven hundred five women received 2,601 transvaginal ultrasound measurements for cervical length. The incidences of spontaneous preterm birth before 35, 32, and 28 weeks were 17.7, 10.6, and 6.7%, respectively. The risk of spontaneous preterm birth before 35 weeks decreased by approximately 6% for each additional millimeter of cervical length (odds ratio 0.94, 95% confidence interval, 0.92-0.95, P=.001) and by approximately 5% for each additional week of pregnancy at which the cervical length was measured (odds ratio 0.95, 95% confidence interval 0.92-0.98, P=.004). Similar results were obtained for spontaneous preterm birth before 32 and 28 weeks. CONCLUSION: Gestational age at which transvaginal ultrasound cervical length is measured significantly affects the calculation of risk of spontaneous preterm birth. The spontaneous preterm birth risk increases as the length of the cervix declines and as the gestational age decreases. These spontaneous preterm birth risks are important for counseling and management for women with various degrees of short cervical length at different gestational ages. LEVEL OF EVIDENCE: II.

Diagnosis of gestational diabetes mellitus: is it time for a new critical value?

OBJECTIVE: To identify the value for the 1-hour glucose tolerance test (GTT) that would maintain 100%, 90% and 75% sensitivity for identifying abnormal 3-hour GTT results in prenatal patients from an East Coast, urban, university hospital setting. STUDY DESIGN: Two hundred forty-two women who underwent the 3-hour GTT during pregnancy between January 1, 2004, and February 1, 2005, at a university hospital laboratory and private laboratories were included. The preceding 1-hour GTT results were obtained from these women, and a receiver operating characteristic (ROC) curve was constructed to identify a 1-hour GTT cutoff value that would maintain 100%, 90% and 75% sensitivity. A subgroup analysis was performed of patients of Asian ethnicity. This study was approved by the institutional review board. RESULTS: To maintain 100% sensitivity of the 1-hour GTT in predicting an abnormal 3-hour GTT, the 1-hour GTT cutoff value could be raised to 144 mg/dL in our population. For 90% and 75% sensitivities, the values were 150 and 156 mg/dL, respectively. There was no clinically significant difference in ROC curve evaluation between Asian and non-Asian groups. CONCLUSION: Raising the current level of 135 mg/dL for a 1-hour GTT to potentially decrease the need for the 3-hour GTT should be considered if larger patient series yield findings similar to those in our population.

Very-low-birthweight neonates: do outcomes differ in multiple compared with singleton gestations?

The purpose of this study is to determine if outcomes for very-low-birthweight (VLBW) neonates differ in multiple versus singleton gestations. This is a retrospective cohort study of neonates weighing less than 1500 g admitted to a neonatal intensive care unit from 1993 to 2004. Outcome variables were necrotizing enterocolitis, death, and/or severe intraventricular hemorrhage (IVH). Statistical analysis included univariate and multivariate analysis. During the study period, 1769 VLBW infants including 465 multiples and 1304 singletons were identified. Gestational age and birthweight were similar; conversely white race (68% multiples versus 43% singletons), maternal age (28.7 +/- 5.7 versus 26.1 +/- 6.5 years), born at facility (95% versus 86%), antenatal steroids (74% versus 58%), preeclampsia (14% versus 24%), and preterm labor (74% versus 62%) were significantly different. Correcting for these, VLBW multiples had a higher odds ratio (OR) of death and/or severe IVH, OR 1.4 (1.03-1.95). In our population, VLBW multiple gestations were at elevated odds for death and/or severe IVH compared with VLBW singletons.

Impact of the recent randomized trials on the use of progesterone to prevent preterm birth: a 2005 follow-up survey.

OBJECTIVE: The purpose of this study was to determine whether current attitudes regarding the use of progesterone to prevent preterm birth have changed since our last survey in 2003. STUDY DESIGN: We mailed a 20 question survey to 1264 board certified Maternal-Fetal Medicine specialists in the United States between February and March of 2005 asking about their use and attitudes regarding progesterone to prevent preterm birth. RESULTS: Five hundred and seventy-two surveys were returned (response rate of 45%). In 2005, 67% of respondents used progesterone to prevent SPTB, compared to 38% in 2003 (P < .001). Among users, 38% recommended progesterone for indications other than previous SPTB. Users were more concerned about lack of insurance coverage compared to nonusers but nonusers were more concerned about safety, efficacy, need for more data, and long-term neonatal effects. CONCLUSION: Although the use of progesterone to prevent PTB has increased significantly since our last survey, there remain a substantial number of nonusers. Among users, many are using it for indications not yet proven in clinical trials. Current nonusers have higher levels of concerns compared to nonusers in the first survey and their major concern is the need for more data.

Progesterone for preventing premature birth: practice patterns of board-certified maternal-fetal medicine specialists in the United States.

OBJECTIVE: To determine the current prescription of progesterone to prevent preterm birth (PTB) among board-certified maternal-fetal medicine (MFM) specialists in the United States. STUDY DESIGN: A survey of the board-certified MFM specialists in the United States examining their prescription of and attitudes regarding progesterone to prevent PTB 6 months following publication of a National Institute for Child Health and Human Development trial. RESULTS: Of 1,264 questionnaires sent, 526 were returned (response rate, 42%). After exclusions, 522 surveys remained. One hundred ninety-eight (38%) respondents prescribed progesterone, and 324 (62%) did not. Most nonprescribers were awaiting more data and were more concerned than prescribers about long-term effects (p < 0.0001). Twenty percent of prescribers prescribed progesterone for women with current signs or symptoms of preterm labor. CONCLUSION: As a result of recent evidence, over one third of MFM specialists surveyed have begun prescribing progesterone to prevent PTB. Of these specialists, 20% are using it for indications other than a prior PTB.