Treatment for Mild Chronic Hypertension during Pregnancy
BACKGROUND:The benefits and safety of the treatment of mild chronic hypertension (blood pressure, <160/100 mm Hg) during pregnancy are uncertain. Data are needed on whether a strategy of targeting a blood pressure of less than 140/90 mm Hg reduces the incidence of adverse pregnancy outcomes without compromising fetal growth. METHODS:In this open-label, multicenter, randomized trial, we assigned pregnant women with mild chronic hypertension and singleton fetuses at a gestational age of less than 23 weeks to receive antihypertensive medications recommended for use in pregnancy (active-treatment group) or to receive no such treatment unless severe hypertension (systolic pressure, â‰¥160 mm Hg; or diastolic pressure, â‰¥105 mm Hg) developed (control group). The primary outcome was a composite of preeclampsia with severe features, medically indicated preterm birth at less than 35 weeks' gestation, placental abruption, or fetal or neonatal death. The safety outcome was small-for-gestational-age birth weight below the 10th percentile for gestational age. Secondary outcomes included composites of serious neonatal or maternal complications, preeclampsia, and preterm birth. RESULTS:A total of 2408 women were enrolled in the trial. The incidence of a primary-outcome event was lower in the active-treatment group than in the control group (30.2% vs. 37.0%), for an adjusted risk ratio of 0.82 (95% confidence interval [CI], 0.74 to 0.92; P<0.001). The percentage of small-for-gestational-age birth weights below the 10th percentile was 11.2% in the active-treatment group and 10.4% in the control group (adjusted risk ratio, 1.04; 95% CI, 0.82 to 1.31; Pâ€‰=â€‰0.76). The incidence of serious maternal complications was 2.1% and 2.8%, respectively (risk ratio, 0.75; 95% CI, 0.45 to 1.26), and the incidence of severe neonatal complications was 2.0% and 2.6% (risk ratio, 0.77; 95% CI, 0.45 to 1.30). The incidence of any preeclampsia in the two groups was 24.4% and 31.1%, respectively (risk ratio, 0.79; 95% CI, 0.69 to 0.89), and the incidence of preterm birth was 27.5% and 31.4% (risk ratio, 0.87; 95% CI, 0.77 to 0.99). CONCLUSIONS:In pregnant women with mild chronic hypertension, a strategy of targeting a blood pressure of less than 140/90 mm Hg was associated with better pregnancy outcomes than a strategy of reserving treatment only for severe hypertension, with no increase in the risk of small-for-gestational-age birth weight. (Funded by the National Heart, Lung, and Blood Institute; CHAP ClinicalTrials.gov number, NCT02299414.).
Evaluation of classic and novel ultrasound signs of placenta accreta spectrum
OBJECTIVES/OBJECTIVE:Improvements in the antenatal diagnosis of placenta accreta spectrum (PAS) would allow preparations for delivery in centers of excellence, leading to decreased maternal mortality and severe morbidity. Our objectives were to assess the performance of classic ultrasound signs and to determine the value of novel signs in the detection of PAS. METHODS:Cases of second trimester placenta previa who also had third trimester vaginal ultrasound, and all cases of PAS, at seven medical centers had outcome-blinded retrospective image review for signs of PAS by three MFM physicians. Classic signs of PAS were defined as placental lacunae, bladder wall interruption, myometrial thinning, and subplacental hypervascularity. Novel signs were defined as small placental lacunae, irregular placental myometrial interface (PMI), vascular PMI, non-tapered placental edge, and placental bladder bulge. PAS was diagnosed by difficulty in removing the placenta or placental pathologic confirmation. Multivariate regression analyses were performed, and ROC curves generated. RESULTS:A total of 55 cases of PAS were included (28 accreta, 11 increta, 16 percreta) The area under the curve and 95% CI for classic markers, novel markers and a model combining both were 0.82 (95% CI 0.75-0.88), 0.84 (95% CI 0.77-0.90) and 0.88 (95% CI 0.82-0.94) respectively. A model combining classic and novel signs was better than either model alone (p=0.03). An increasing number of signs was associated with greater likelihood of PAS. With the presence of 0, 1, 2, and >3 classic ultrasound signs, PAS was present in 5%, 24%, 57%, and 94% of cases respectively. CONCLUSIONS:We confirmed the value of classic ultrasound signs of PAS. The addition of novel ultrasound signs improves detection of PAS. These findings have clinical implications for the detection of PAS, and may help guide the obstetrical management of patients diagnosed with these placental disorders. This article is protected by copyright. All rights reserved.
Use of Cervical Elastography at 18 to 22 Weeks Gestation in the Prediction of Spontaneous Preterm Birth
OBJECTIVES/OBJECTIVE:To develop standard cervical elastography nomograms for singleton pregnancies at 18-22 weeks gestation using the E-cervix ultrasound application; assess intra-observer reliability of the E-cervix elastography parameters; and determine if these cervical elastography measurements can be used in the prediction of spontaneous preterm birth. METHODS:This was a prospective cohort study of pregnant women undergoing cervical length screening assessment via transvaginal ultrasound examination at 18 - 22 weeks gestation. A semi-automatic, cervical elastography application (E-cervix) was utilized during the transvaginal examination to calculate five quantitative parameters (Internal Os Stiffness, External Os Stiffness, Internal to External Os Stiffness Ratio, Hardness Ratio, Elasticity Contrast Index) and create a standard nomogram for each one of them. The intra-observer reliability was calculated using Shrout-Fliess reliability. Cervical elastography parameters were compared between those who delivered preterm (<37 weeks) spontaneously versus full term. A multivariable logistic regression model was performed to determine the ability of the cervical elastography parameters to predict spontaneous preterm birth. RESULTS:742 women were included of which 49 (6.6%) had a spontaneous preterm delivery. A standard nomogram was created for each of the cervical elastography parameters from those who had a full term birth in the index pregnancy (n=693). Intra-observer reliability was good or excellent (intraclass correlation (ICC) = 0.757 - 0.887) for each of the cervical elastography parameters except External Os Stiffness which was poor (ICC = 0.441). In univariate analysis, none of the cervical elastography parameters were associated with a statistically significant increased risk of spontaneous preterm birth. In a multivariable model adjusting for history of preterm birth, gravidity, ethnicity, cervical cerclage and vaginal progesterone use, increasing Elasticity Contrast Index was significantly associated with an increased risk of spontaneous preterm birth (OR 1.15, 95%CI [1.02, 1.30]; P=0.02). CONCLUSIONS:Cervical elastography parameters are reliably measured and are stable across 18-22 weeks gestation. Based on our findings, the Elasticity Contrast Index was associated with an increased risk for spontaneous preterm birth and may be the parameter useful for future research.
Correction to: Experiences of early graduate medical students working in New York hospitals during the COVID-19 pandemic: a mixed methods study
Experiences of early graduate medical students working in New York hospitals during the COVID-19 pandemic: a mixed methods study
BACKGROUND:The coronavirus disease 2019 (COVID-19) pandemic presented the world with a sudden need for additional medical professionals. Senior medical students were identified as potential workers and many worldwide graduated early to serve as Junior Physicians in hospitals. The authors sought to identify factors that informed the decision to work, describe experiences in this capacity, and elucidate benefits for trainees. METHODS:The investigators conducted a mixed-methods observational cohort study of early medical graduates eligible to work as Junior Physicians at two New York medical centers in April/May 2020 during an initial surge in COVID-19 hospitalizations. Graduates were surveyed, and a sample of Junior Physicians participated in a focus group. Survey responses of those who worked were compared to those who did not. Focus group responses were transcribed, coded, and thematically analyzed. RESULTS:Fifty-nine graduates completed the study methods and 39 worked as Junior Physicians. Primary reasons for working included duty to help (39 [100%]), financial incentive (32 [82%]), desire to learn about pandemic response (25 [64%]), and educational incentive (24 [62%]). All had direct contact with COVID-19 patients, believed working was beneficial to their medical training, and were glad they worked. None contracted a symptomatic infection while working. Compared with non-Junior Physicians, Junior Physicians reported increased comfort levels in completing medical intern-level actions like transitions of care functions, such as writing transfer notes (Pâ€‰<â€‰0.01), writing discharge orders (Pâ€‰=â€‰0.01), and providing verbal sign out (Pâ€‰=â€‰0.05), and they reported more comfort in managing COVID-19 patients. Sixteen themes emerged from the focus group and were placed into four categories: development of skills, patient care, safety, and wellness. CONCLUSIONS:Senior medical students chose to work as Junior Physicians for both personal and educational reasons. Experiences were beneficial to trainees and can inform future innovations in medical education.
Novel application assessing cervical stiffness heterogeneity [Meeting Abstract]
Novel application assessing cervical stiffness in second trimester [Meeting Abstract]
An evaluation of classic versus novel ultrasound signs of Placenta Accreta Spectrum [Meeting Abstract]
Term Cesarean Delivery in the First Pregnancy is Not Associated with an Increased Risk for Preterm Delivery in the Subsequent Pregnancy
BACKGROUND:Prior studies have reported an increased risk for preterm delivery following a term cesarean delivery. However, these studies did not adjust for high risk conditions related to the first cesarean delivery and are known to recur. OBJECTIVE:To determine if there is an association between term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated preterm delivery. STUDY DESIGN/METHODS:This was a retrospective cohort study of women with the first two consecutive singleton deliveries (2007-2014) identified through a linked pregnancy database at a single institution. Women with a first pregnancy that resulted in cesarean delivery at term were compared to women whose first pregnancy resulted in vaginal delivery at term. Exclusion criteria were known to recur medical or obstetrical complications during the first pregnancy. A propensity score analysis was performed by matching women that underwent a cesarean delivery with those that underwent a vaginal delivery in the first pregnancy. The association between cesarean delivery in the first pregnancy and preterm delivery in the second pregnancy in this matched set was examined using conditional logistic regression. The primary outcome was overall preterm delivery <37 weeks in the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous versus indicated), late preterm delivery (34-36 6/7 weeks), early preterm delivery (< 34 weeks), and small for gestational age (SGA) birth. RESULTS:percentile for gestational age (3.6% versus 2.2%; aOR 1.26, 95% CI 0.52 - 3.06). CONCLUSION/CONCLUSIONS:After robust adjustment for confounders through a propensity score analysis related to the indication for the first cesarean delivery at term, cesarean delivery is not associated with an increase in preterm delivery, spontaneous or indicated, in the subsequent pregnancy.
Does educational intervention improve sonographer awareness of ultrasound safety? [Meeting Abstract]