Examining pregnancy-specific smartphone applications: what are patients being told?

OBJECTIVE: The objective of this study is to evaluate the informative content of two free, pregnancy-specific smartphone applications and their accuracy and adherence to prenatal care guidelines. STUDY DESIGN: This is a qualitative analysis of the information delivered through two free, pregnancy-specific smartphone applications (apps): Text4Baby (T4B) and Baby Center's 'My Pregnancy Today' (BC). All information from conception through 2 weeks postpartum were transcribed and coded independently by two physician researchers. Content was analyzed and assigned thematic codes. The proportion of content each app delivered per theme was then calculated and the χ(2)-test was used to compare thematic frequency between apps. RESULTS: A total of 609 pieces of daily content were transcribed; 698 message themes were coded and analyzed. Most information delivered by T4B was about fetal development (23.8%) or prenatal care (16.6%); most content from BC was about normal pregnancy symptoms (20.1%) or maternal well-being (21.1%); the differences between apps for each of these themes were statistically significant (P<0.05). A total of four messages contained incomplete or ambiguous content; neither app delivered overtly incorrect medical information. T4B and BC had a similar proportion of information that was in-line with the American College of Obstetrics and Gynecology Guidelines for Prenatal Care. Neither app delivered any messages about contraception. CONCLUSION: T4B and BC are free, pregnancy-specific apps with different focuses. Neither app delivers comprehensive prenatal information, as evidenced by the absence of information about postpartum contraception. More information is needed to determine the role of such apps in prenatal care.

Does an Electronic Health Record Improve Completeness of Prenatal Studies?

OBJECTIVE: To determine whether implementation of an electronic health record (EHR) would increase the rate of prenatal Human Immunodeficiency Virus (HIV) and purified protein derivative (PPD) testing. METHODS: Eligible participants received prenatal care and delivered at term at a single academic institution in March-April 2011, March-April 2012, and March-April 2013. As part of routine prenatal care, all women were tested for HIV and tuberculosis (via a PPD test) during each pregnancy. The 2011 cohort was charted on paper. The 2012 and 2013 cohorts were charted via EHR. To appear in the prenatal labs display in EHR, PPD results must be manually documented, while HIV results are uploaded automatically. Documentation of PPD and HIV tests were analyzed. RESULTS: The 2011, 2012, and 2013 cohorts had 249, 208, and 190 patients, respectively. Complete PPD and HIV results were less likely to be charted in the 2012 EHR cohort compared to the paper chart cohort (72.1% vs. 80.1%; p=0.03). This was driven by fewer documented completed PPD tests (2011 83.9% vs. 2012 72.6%; p=0.003). PPD test documentation improved non-significantly to 86.2% in the 2013 EHR cohort (p=0.5). HIV documentation rates increased from 95.2% in the paper chart cohort to 98.6% in the 2012 EHR cohort (p=0.04), and to 98.9% in the 2013 EHR cohort (p=0.03). CONCLUSIONS: EHR implementation corresponded with a marked decrease in documentation of PPD test completion. HIV documentation rates improved. PPD results were likely charted incorrectly in provider notes due to training deficiencies and lack of standardization, which did not improve significantly after retraining.

Amniotic fluid index measured with the aid of color flow Doppler.

OBJECTIVE: To determine whether using color flow Doppler to identify the umbilical cord affects amniotic fluid index (AFI) measurements. METHODS: A total of 2236 AFI measurements between 24 and 42 weeks in singleton gestations with no known or suspected fetal anomalies and < 14 days' discrepancy between menstrual and ultrasonographic dating were included. Color flow Doppler was used to identify loops of umbilical cord; these were excluded from the measurement. Polynomial regression was used to generate means and centiles. Data were grouped according to completed weeks of gestation and descriptive statistics were calculated. At each week of gestation, the number and percentage of pregnancies diagnosed as < or = 2.5th, < or = 5th, > or = 95th, and > or = 97.5th centile according to a 'standard' nomogram derived without using color flow Doppler were calculated. RESULTS: The AFI decreased significantly over gestational age, starting at 31 weeks (p < 0.05 by ANOVA). The relationship between AFI and gestational age was best modeled by a second-degree polynomial (p < 0.001). The median and range of the proportion of AFIs that fell outside the ranges of the standard nomogram at each completed gestational age was: 6.0 (2.3-35.4)% for the < or = 2.5th centile, 9.9 (3.1-37.5)% for the < or = 5th centile, 3.8 (0-30)% for the > or = 95th centile, and 1.8 (0-20)% for the > or = 97.5th centile. The 2.5th and 5th centiles using the current data were lower than those of the 'standard', and the difference increased with advancing gestation. Upper centiles were also different. CONCLUSION: The AFI measured using color flow Doppler overestimates oligohydramnios and may underestimate polyhydramnios when a standard AFI table obtained without color flow Doppler is used. Normal values specific for measurement method should be used for reference.

The effect of fetal neck position on nuchal fold thickness.

OBJECTIVE: Our purpose was to determine whether ultrasonographic measurements of nuchal fold thickness are affected by the position of the fetal neck. STUDY DESIGN: Fetal nuchal fold thickness was prospectively measured in 258 women undergoing routine ultrasonography at 15 to 21 completed weeks of gestation. Patients with fetal structural or chromosomal anomalies were excluded. At the time of examination the position of the fetal head was noted as being extended or flexed on the basis of the angle between the spine and the base of the skull. Gestational age was based on menstrual dates or ultrasonographic biometric parameters. Data were tested for normality. Mann-Whitney U test and analysis of covariance were used (significance was considered to be P <.05). Data are presented as median and range. RESULTS: A total of 258 fetuses were examined with 167 (65%) in the flexed and 91 (35%) in the extended neck position. Gestational age was not significantly different between the flexed and extended groups (median, 19.1 weeks; range, 15.5-21.6 weeks; vs median, 19.1 weeks; range, 15.6-22 weeks; P =.23). Nuchal fold thickness was significantly lower in the flexed group than in the extended group (median, 3.5 mm; range, 1.3-6.2 mm; vs median, 3.9 mm; range, 2.2-4.9 mm; P =.0097). Nuchal fold thickness increased significantly with gestational age in both groups. The difference in nuchal fold thickness between the 2 groups persisted even after the increase in nuchal fold thickness was adjusted for with gestational age (P =.002, analysis of covariance). The difference between the 2 groups was higher at earlier gestations. CONCLUSION: Nuchal fold thickness is affected by gestational age and fetal neck position. Correction for these variables may improve the accuracy of nuchal fold thickness measurements in screening for fetal chromosomal anomalies.

Functional oxytocin receptors in a human endometrial cell line.

OBJECTIVE: Our goal was to demonstrate expression and functionality of oxytocin receptors in a human endometrial cell line. This cell line could then be used for further investigation of the role of oxytocin in reproductive function at the cellular level. STUDY DESIGN: Oxytocin receptor messenger ribonucleic acid expression was determined by reverse transcriptase-polymerase chain reaction deoxyribonucleic acid amplification with ribonucleic acid from confluent Ishikawa cells. Ligand binding to whole cells was evaluated by nonlinear regression analysis with an iodinated oxytocin antagonist. The coupling of the oxytocin receptor to signaling pathways was evaluated by measuring oxytocin-stimulated increases in intracellular calcium concentration, phosphorylation of ERK2 (extracellular-regulated protein kinase 2) mitogen-activated protein kinase, and prostaglandin E(2) release. RESULTS: Polyacrylamide gel electrophoresis of the reverse transcriptase-polymerase chain reaction products demonstrated the presence of oxytocin receptor messenger ribonucleic acid in Ishikawa cells. Ligand-binding analysis of these cells demonstrated a single class of noninteracting sites, with a B(max) (maximal number of binding sites) of 77.7 fmol/mg deoxyribonucleic acid and an apparent dissociation constant of 8.3 x 10(-11) mol/L. Stimulation with 100-nmol/L oxytocin caused a rapid transient increase in intracellular free calcium concentration, which was blocked by 1-micromol/L oxytocin antagonist. Treatment of cells with oxytocin for 10 minutes resulted in a marked increase in the phosphorylation of ERK2, as determined by Western blot analysis, and a 5-fold increase in prostaglandin E(2) release. CONCLUSION: This study is the first to demonstrate functional oxytocin receptors in an established human endometrial cell line. This cell line will be useful in elucidating the mechanisms of action of oxytocin in the reproductive tract at the molecular level.

The effect of indomethacin and prostacyclin agonists on blood pressure in a rat model of preeclampsia.

OBJECTIVE: This study was designed to determine the effects of cyclooxygenase inhibition and prostacyclin agonists on the hypertension induced by nitric oxide synthase blockade in a previously characterized rat model of preeclampsia. STUDY DESIGN: A condition similar to preeclampsia was induced by infusing pregnant rats with the nitric oxide synthase inhibitor N G -nitro- L -arginine methyl ester through subcutaneously implanted osmotic minipumps. Blood pressure was measured with the tail cuff method. In the first experiment the rats received either vehicle alone (control group), N G -nitro- L -arginine methyl ester (50 mg/d), indomethacin (0.1 mg/d), or N G -nitro- L -arginine methyl ester plus indomethacin beginning on day 17 of pregnancy. In the second experiment the rats received vehicle alone (control group), N G -nitro- L -arginine methyl ester (50 mg/d), or N G -nitro- L -arginine methyl ester plus iloprost (31 microgram/d). In a third experiment cicaprost (15 microgram/d) was substituted for iloprost. RESULTS: Except for an increase on the day after insertion of the pump indomethacin had no significant effect on the hypertension induced by N G -nitro- L -arginine methyl ester. Both prostacyclin agonists (iloprost and cicaprost), however, attenuated the rise in blood pressure usually seen after N G -nitro- L -arginine methyl ester administration. CONCLUSIONS: Nonselective inhibition of the cyclooxygenase enzymatic system does not influence the hypertension seen in the rat preeclampsia model induced by chronic nitric oxide deficiency. The hypertension in this model can be partially reversed with prostacyclin analogs.

The effect of amniotic fluid on the human omental artery in vitro.

OBJECTIVE: The aim of the study was to determine the effect of amniotic fluid on the in vitro contractility of the human omental artery. STUDY DESIGN: Amniotic fluid and a segment of omentum were obtained from each of 5 patients at the time of planned cesarean delivery at normal term gestation for the indication of previous cesarean delivery. The omental artery was cleaned and cut into 3-mm rings, which were placed in 10-mL organ chambers for isometric tension recording. The chambers were filled with Krebs-Henseleit solution bubbled with 5% carbon dioxide in air and maintained at 37 C, pH 7.4. The rings were then equilibrated at 1 g passive tension for 90 minutes. The amniotic fluid was centrifuged for 10 minutes at 3000 rpm to remove all debris. Increasing volumes of supernatant (10-2000 microL) were added to the omental artery rings at baseline tone or after contraction with U46619 (10(-7) mol/L) or potassium chloride (60 mmol/L) to detect contractile and relaxant effects, respectively. Time-solvent control preparations were also run in parallel. RESULTS: Amniotic fluid had no effect on the basal tone of omental artery rings. Amniotic fluid had no effect on the tension in rings previously contracted with either U46619 or potassium chloride. CONCLUSIONS: Amniotic fluid has no direct effect on isolated human omental artery. The catastrophic hemodynamic changes associated with the syndrome of amniotic fluid embolism are not due to a direct effect of circulating amniotic fluid on vascular tone but rather may be due to secondary responses

Dermatofibrosarcoma protuberans of the vulva: report of two new cases and review of the literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP), a low-grade sarcoma of dermal origin, rarely is found on the vulva. Only 16 cases of DFSP of the vulva have been described. CASES: Two patients with long histories of primary vulvar dermatofibrosarcoma protuberans are presented. Both required multiple excisions to resect the tumor completely. The patients remain without evidence of disease after long-term follow-up. One patient is among the youngest recorded. All published cases of vulvar DFSP are reviewed. CONCLUSIONS: Both our experience and that reported in previous cases indicate that wide local excision is required in the treatment of vulvar DFSP.

Pulmonary edema: etiology and treatment.

Pulmonary edema, a serious complication of pregnancy and the puerperium, can result in maternal and fetal morbidity and mortality. Pulmonary edema in pregnancy can be categorized by the primary mechanisms from which it results. An analysis of lung physiology using the Starling equation suggests that increased hydrostatic pressure, increased permeability, and osmotic imbalance can all lead to the development of pulmonary edema. These factors explain many of the common settings of pulmonary edema, including preeclampsia, tocolysis, and cardiac disease. This article will discuss the etiology and pathophysiology of pulmonary edema, how pregnancy influences it, and issues in its management.