Faculty Bibliography

Pregnancy-associated cardiomyopathy can present earlier in gestation than traditionally defined peripartum cardiomyopathy. Management and optimal delivery timing for these patients are not well defined. We present the case of a 30-year-old primigravid at 26 weeks who presented with new onset ventricular tachycardia, biventricular cardiac failure, and severe mitral regurgitation. She was medically stabilized for two weeks prior to delivery with modest improvement in her condition. Due to concern for life-threatening cardiac failure and pulmonary edema at the time of delivery, a percutaneous left ventricular assist device was inserted immediately prior to cesarean delivery. She remained on mechanical circulatory support for 36 h. We discuss considerations regarding use of a percutaneous left ventricular assist device as a novel therapy to support the hemodynamic changes following delivery in parturients with decompensated heart failure.

INTRODUCTION: Hypertensive disorders play a significant role in maternal morbidity and mortality. Limited data on prehypertension (preHTN) in pregnancy exists. We examine the risk of adverse outcomes in patients with preHTN in early (< 20 weeks) versus late pregnancy (> 20 weeks). MATERIALS AND METHODS: Retrospective cohort study of singleton gestations between August 2013 and June 2014. Patients were divided based on when they had the highest blood pressure in pregnancy, as defined per the Joint National Committee 7 (JNC-7). Groups were compared using Chi2, Fisher's exact, Student t-test and Mann-Whitney U test with p < 0.05 used as significance. RESULTS: There were 125 control, 95 early preHTN, 136 late preHTN and 21 chronic hypertension (CHTN). Early preHTN had an increased risk of pregnancy related hypertension (PRH) (OR 12.26, p < 0.01), and composite adverse outcomes (OR 2.32, p < 0.01). Late preHTN had an increased risk for PRH (OR 4.39, p = 0.02) compared to normotensive and decreased risk for PRH (OR 0.26, p = 0.02), and composite adverse outcomes (OR 0.379, p = 0.04) compared to CHTN. Compared to late preHTN, early preHTN had more PRH (OR 2.85, p < 0.01), and composite adverse outcomes (OR 1.68, p = 0.04). CONCLUSIONS: Early prehypertension increases the risk of adverse obstetrical outcomes. Other than an increased risk of PRH, patients with late prehypertension have outcomes similar to normotensive women.

Background: HIV infected (HIV+) Veterans 50+ years of age are more likely to fall than uninfected comparators. Whether they are at greater risk for serious injury after the fall is not known.
Method(s): We used data from the Veterans Aging Cohort Study (VACS). The primary exposures were HIV and falls. The outcome was serious injury as identified by ICD9 codes (hip fracture, fragility fracture, joint dislocation, traumatic brain injury (TBI), and head injury). We identified medically significant falls using Ecodes and a machine learning algorithm applied to radiology reports. After verifying that associations between HIV and each type of serious injury were similar, all injuries were merged into a composite outcome. An interaction term between HIV and falls assessed whether falls had a differential impact on the risk of injury among HIV+ and uninfected participants. The analytic unit was a six-month person-interval. Covariates assessed at the beginning of the interval were evaluated for associations with occurrence of a serious injury in that interval. Multivariable logistic regression was used to evaluate the associations of HIV and falls with serious injury with adjustment for risk factors for fall-related injury identified among older adults and for disease severity with the VACS Index.
Result(s): Our analysis included 73,283 Veterans who were 50+ years of age, 31% of whom were HIV+. Fall incidence was 46 per 1000 person-years (95% CI 45-47 per 1000 person-years) for HIV+ and 40 per 1000 person-years (95% CI 40-41 per 1000 person-years) for uninfected. In bivariate analyses, relative touninfected Veterans, joint dislocation and TBI were less common among HIV+ (1.2% vs 1.7%, p<0.001; and 1.2% vs 1.4%, p<0.001, respectively) whereas hip fracture and fragility fractures were more common (hip fractures: 1.3% vs 0.7%, p<0.001; fragility fractures: 8.0% vs 7.4%, p<0.001, respectively). In fully adjusted models, relative to those who did not fall, those who fell had a substantially increased risk of serious injury: HIV+ (OR 4.14; 95% CI 3.86, 4.44) and uninfected (OR 1.42; 95% CI 1.35, 1.49).
Conclusion(s): Among those 50+ years of age, HIV+ are more likely to fall and more likely to experience serious injury, commonly in the form of fracture, after they fall compared to uninfected individuals

OBJECTIVE: To evaluate the clinical utility of a novel means of assessing the cervix by measuring the angle of the curvature and to evaluate the performance of this technique as well as two other commonly used techniques of cervical length assessment in predicting spontaneous preterm birth (SPTB). METHODS: This was a retrospective cohort analysis of singleton gestations with a history of SPTB. Transvaginal ultrasound images of cervical length obtained between 20-23 6/7 weeks were re-measured using 3 techniques: (1) straight linear distance between the internal and external os, (2) sum of two contiguous linear segments tracing the internal to the external os, and (3) measurement of the angle of the curve within the cervix using an electronic protractor. A short cervical length was defined as