Faculty Bibliography

CONTEXT/BACKGROUND:Postpartum, diabetes insipidus (DI) can be part of Sheehan's syndrome or lymphocytic hypophysitis in combination with anterior pituitary hormone deficiencies. In contrast, acute onset of isolated DI in the postpartum period is unusual. CASE PRESENTATION/METHODS:This patient presented at 33 weeks gestation with placental abruption, prompting a cesarean delivery of twins. Immediately after delivery, she developed severe DI. The DI could be controlled with the vasopressinase-resistant 1-deamino-8-D-arginine vasopressin (DDAVP), but not with arginine vasopressin (AVP), and it resolved within a few weeks. OBJECTIVE:The aim of this study was to demonstrate that the postpartum DI in this patient was caused by the release of placental vasopressinase into the maternal bloodstream. METHODS AND RESULTS/RESULTS:Cells were transiently transfected with the AVP receptor 2 (AVPR2) and treated with either AVP or DDAVP in the presence of the patient's serum collected postpartum or 10 weeks after delivery. The response to the different treatments was evaluated by measuring the activity of a cAMP-responsive firefly luciferase reporter construct. The in vitro studies demonstrate that the patient's postpartum serum disrupts activation of the AVPR2 by AVP, but not by the vasopressinase-resistant DDAVP. CONCLUSIONS:Placental abruption can rarely be associated with acute postpartum DI caused by release of placental vasopressinase into the bloodstream. This clinical entity must be considered in patients with placental abruption and when evaluating patients presenting with DI after delivery.

OBJECTIVE:To estimate the prevalence of postpartum obsessive-compulsive disorder (OCD) symptoms and to ascertain risk factors for this condition. STUDY DESIGN/METHODS:This is a prospective cohort of postpartum women carried out from June to September 2009. A total of 461 women were recruited after delivery at a tertiary care institution. Demographic, psychiatric, and obstetric information were collected from each participant. Patients were contacted at 2 weeks and at 6 months postpartum and completed screening tests for depression, anxiety, and OCD. RESULTS:Eleven percent of women screened positive for OCD symptoms at 2 weeks postpartum. At 6 months postpartum almost half of those women had persistent symptoms, and an additional 5.4% had developed new OCD symptoms. Concomitant positive screens for anxiety and depression were predictive factors for the development of OCD symptoms. CONCLUSION/CONCLUSIONS:Prior population-based studies estimate the prevalence of OCD to be approximately 2-3%. We found much higher rates among women in the postpartum period. The postpartum period is a high-risk time for the development of OCD symptoms. When such symptoms develop, they have a high likelihood of persisting for at least 6 months.

Female fertility declines dramatically with age, and childbearing at older maternal ages has significant medical consequences for mother and infant that are well-known to health professionals. Despite this, the average maternal age in the United States continues to rise. Many factors likely contribute to this secular trend; to date, no research has examined whether American women are aware of the complications of deferring conception and how this correlates with health literacy. The purpose of this study was to evaluate women's knowledge of the implications of delaying pregnancy. A structured, in-person interview was administered to 300 women between 20 and 50 years of age attending 1 of 2 gynecologic clinics at a single institution. Demographic information, medical history, and gynecologic history were obtained; and participants answered questions about the implications of aging for fertility and pregnancy outcome. Health literacy and numeracy were assessed. Participants demonstrated knowledge deficits about the implications of aging on fertility and pregnancy, and many were unfamiliar with success rates of infertility treatments. Several demographic factors correlated with knowledge; health literacy and numeracy were both important predictive variables. To the authors' knowledge, this is the first study of women's knowledge about fertility, aging, and their health literacy. Awareness of the importance of health literacy and numeracy should inform future educational efforts about fertility.

BACKGROUND:National organizations historically focused on increasing use of effective services are now attempting to identify and discourage use of low-value services. Electronic health records (EHRs) could be used to measure use of low-value services, but few studies have examined this. The aim of the study was to: (1) determine if EHR data can be used to identify women eligible for an extended Pap testing interval; (2) determine the proportion of these women who received a Pap test sooner than recommended; and (3) assess the consequences of these low-value Pap tests. METHODS:Electronic query of EHR data identified women aged 30-65 years old who were at low-risk of cervical cancer and therefore eligible for an extended Pap testing interval of 3 years (as per professional society guidelines). Manual chart review assessed query accuracy. The use of low-value Pap tests (ie, those performed sooner than recommended) was measured, and adverse consequences of low-value Pap tests (ie, colposcopies performed as a result of low-value Pap tests) were identified. RESULTS:Manual chart review confirmed query accuracy. Two-thirds (1120/1705) of low-risk women received a Pap test sooner than recommended, and 21 colposcopies were performed as a result of this low-value Pap testing. CONCLUSION/CONCLUSIONS:Secondary analysis of EHR data can accurately measure the use of low-value services such as Pap testing performed sooner than recommended in women at low risk of cervical cancer. Similar application of our methodology could facilitate efforts to simultaneously improve quality and decrease costs, maximizing value in the US healthcare system.

OBJECTIVE:Multiple scoring systems exist to identify inpatients who are at risk for clinical deterioration. None of these systems have been evaluated in an obstetric population. We examined the Systemic Inflammatory Response syndrome (SIRS) and Modified Early Warning score (MEWS) criteria in pregnant women with chorioamnionitis. STUDY DESIGN/METHODS:This was an 18-month retrospective analysis of patients with chorioamnionitis. SIRS and MEWS scores were calculated; clinical outcomes were ascertained, and test characteristics were calculated for the primary outcome of sepsis, intensive care unit transfer, or death. RESULTS:Nine hundred thirteen women with chorioamnionitis were identified. Five women experienced sepsis; there was 1 death. Five hundred seventy-five of the 913 women (63%) met SIRS criteria (95% confidence interval, 59.8-66.2%; positive predictive value, 0.9%). Ninety-two of the 913 women (10.3%) had a MEWS score of ≥ 5 (95% confidence interval, 8.3-12.2%; positive predictive value, 0.05%). CONCLUSION/CONCLUSIONS:SIRS and MEWS criteria do not identify accurately patients who are at risk for intensive care unit transfer, sepsis, or death among pregnant women with intrauterine infection and should not be used in an obstetric setting.

PURPOSE/OBJECTIVE:Routine neonatal circumcision is one of the most commonly performed procedures in a neonate. Residents are expected to acquire the skills to properly evaluate the neonate and gain proficiency in performing circumcision despite significant variability in training. We performed a needs assessment to evaluate obstetric-gynecology residency training in neonatal circumcision. MATERIALS AND METHODS/METHODS:We performed an online self-assessment survey of obstetric-gynecology residents at Prentice Hospital, Chicago, from November 2008 to February 2009. Using images of uncircumcised penises residents were asked to identify which patients were candidates for routine neonatal circumcision. RESULTS:Of 36 obstetric-gynecology residents 27 responded to the survey. Most respondents planned to perform neonatal circumcision when in practice, 44% had no formal training in circumcision and most were comfortable performing routine neonatal circumcision. Overall respondents were less comfortable evaluating whether the a newborn penis could undergo circumcision safely. When presented with 10 pictures of penises and asked to determine whether the neonate should undergo circumcision, 0% of respondents correctly identified all contraindications to neonatal circumcision with an average of 42% of contraindications identified correctly. Of the respondents 77% listed practical experience as the first choice to learn a procedure with an online module preferred by 55% as the second choice. CONCLUSIONS:Although most residents feel competent to technically perform the procedure, they are not confident in their ability to judge the appropriate contraindications to neonatal circumcision. This needs assessment highlights the necessity for further curriculum development and formalized training in this domain.

OBJECTIVE:To estimate the prevalence of epistaxis among pregnant women and to investigate if epistaxis of pregnancy is associated with an increased risk of postpartum hemorrhage. METHODS:A cohort of 1,475 pregnant women presenting to labor and delivery at term were asked to complete a survey about epistaxis and other traditional risk factors for bleeding. Results were compared with those from a cohort of 275 nonpregnant women presenting for routine gynecologic care to estimate the effect of pregnancy on the prevalence of epistaxis. The association between epistaxis of pregnancy and risk of bleeding was estimated by comparing rates of postpartum hemorrhage between pregnant women with and without epistaxis. RESULTS:Final data analysis was performed on 1,470 pregnant women and 275 nonpregnant women. The prevalence of epistaxis was significantly increased in pregnant women compared with nonpregnant women (20.3% compared with 6.2%; P<.001). Women with epistaxis of pregnancy were at increased risk of postpartum hemorrhage compared with women without epistaxis (10.7% compared with 6.7%; P=.02). The increased risk of hemorrhage remained after controlling for cesarean delivery and after exclusion of women who reported epistaxis before pregnancy. Other traditional risk factors for bleeding such as gingival bleeding, O blood type, and easy bruising were not associated with increased risk of postpartum hemorrhage. CONCLUSION/CONCLUSIONS:Epistaxis is a common problem during pregnancy that may be associated with an increased risk of postpartum hemorrhage. As in the nonpregnant population, eliciting a history of epistaxis may help to identify women at risk of disordered hemostasis. LEVEL OF EVIDENCE/METHODS:II.

OBJECTIVE:Episiotomy practice in the United States has changed dramatically over the past 20 years, and recent studies have questioned the utility of routine episiotomy. Our objective was to evaluate current episiotomy practice in a community hospital. STUDY DESIGN/METHODS:We reviewed vaginal deliveries at a community hospital from January 1, 2004, to December 31, 2005. Maternal,fetal, labor and provider data were collected. Data were analyzed with t test, chi2 and logistic regression. RESULTS:A total of 2,959 deliveries by 17 practitioners were evaluated. The episiotomy rate increased for younger patients, with estimated fetal weight > 4,000 g, when presentation was not occiput anterior and with decreasing parity. Provider characteristics, such as a greater number of years in practice or when the delivering physician was not the outpatient physician, increased episiotomy rates. The overall episiotomy rate declined from 20.6% to 17.7% during the study; however, this did not reach statistical significance, and some practitioners had unchanged or increased rates. CONCLUSION/CONCLUSIONS:Practitioner characteristics were the strongest predictors of episiotomy. Overall, the rate at this community hospital was within published recommendations, but wide variations in practice (range, 2-43%) suggest that education needs to target community physicians remote from training to ensure that all women receive optimal, evidence-based delivery care.