Medical Specialties Commons^™

Understanding Maternity Care Coordination For Women Veterans Using An Integrated Care Model Approach, Kristin M. Mattocks, Aimee Kroll-Desrosiers, Rebecca L. Kinney, Sara Singer

Kristin M. Mattocks

BACKGROUND: An increasing number of women veterans are using VA maternity benefits for their pregnancies. However, because the VA does not offer obstetrical care, women must seek maternity care from non-VA providers. The growing number of women using non-VA care has increased the importance of understanding how this care is integrated with ongoing VA medical and mental health services and how perceptions of care integration impact healthcare utilization. Therefore, we sought to understand these relationships among a sample of postpartum veterans utilizing VA maternity benefits.

METHODS: We fielded a modified version of the Patient Perceptions of Integrated Care survey among …

An Analysis Of Major Issues For Culturally-Minded Professionals In Women's Health Care, Victoria Clark

Victoria Clark

Nadolol In Pregnancy: A Medical Student’S Reflection On Her Pregnancy, Rebecca King-Mallory, Shawndra Barker, Kaitlin Mcgrogan, Adam M. Franks

Adam M. Franks, MD

Hypertension is a common concern during pregnancy. Beta-blockers are one potential treatment, but third trimester exposure has correlated with an increased risk of perinatal events. Nadolol, a nonselective beta blocker, has properties that differ from those of its selective counterparts, including longer half-life, decreased protein binding, and renal excretion in the unchanged form. There is very limited data on the use of nadolol during pregnancy, and its safety has not been completely evaluated. This case study documents the perinatal outcomes of nadolol use throughout a medical student’s pregnancy and explores the experience in obtaining and undergoing medical care.

Anaemia In Pregnancy: Occurrence In Two Economically Different Clinic Populations Of Karachi, Saadiya Aziz Karim, Mohammad Khurshid, Javed H. Rizvi

Mohammad Khurshid

According to previous WHO standards, anaemia in pregnancy denoted a haemoglobin level of 11.0 gms/dl or less, but this is now considered to be variable1 as it differs from country to country depending on local reference ranges and socio-economic conditions. Each country should “lay down minimal acceptable standards” below which an individual is considered to be anaemic, taking into account the available fmancial and manpower resources and other health needs of the country2. There is a wide divergence in the quoted prevalence of anaemia in Pakistan and neigh­bouring countries.3-6 This study was undertaken to determine a range of haemoglobin levels …

Proyecto Mama: A Lifestyle Intervention In Overweight And Obese Hispanic Women: A Randomised Controlled Trial--Study Protocol, Lisa Chasan-Taber, Bess H. Marcus, Milagros C. Rosal, Katherine L. Tucker, Sheri J. Hartman, Penelope S. Pekow, Edward J. Stanek Iii, Barry Braun, Caren G. Solomon, Joanne Manson, Sarah L. Goff, Glenn Markenson

Sarah L. Goff MD

BACKGROUND: The proportion of women entering pregnancy overweight or obese has been rising and, in turn, is associated with adverse maternal and fetal outcomes. Gestational weight gain (GWG) exceeding Institute of Medicine (IOM) guidelines further increases health risks and has been independently associated with postpartum weight retention. Hispanic women are disproportionately affected by overweight and obesity, but have had limited access to interventions that promote healthy lifestyles due to cultural, socioeconomic, and language barriers. Therefore, the overall goal of this randomized controlled trial is to test the efficacy of a culturally and linguistically modified, individually-tailored lifestyle intervention to reduce excess …

Role Of Multiple Births In Very Low Birth Weight And Infant Mortality, B. Magee

B. Dale Magee

OBJECTIVE: To determine the percentage of very-low-birth-weight (VLBW) infants (g) and infant deaths attributable to multiple births in the general population and in women aged 35+. STUDY DESIGN: The year 2000 Massachusetts birth certificate database with linked births-deaths was examined. Etiologic fractions (EF) for VLBW and infant mortality attributable to multiples were calculated for the general population and the 35+ age group. The percentages of multiples occurring in the 35+ age group were calculated. Infant deaths due to congenital anomalies and "perinatal conditions" were calculated. RESULTS: There were 81,582 resident births in Massachusetts in 2000. Of them 4.3% were multiples. …

Xk Aprosencephaly And Anencephaly In Sibs, Phillip Townes, Karen Reuter, E. Rosquete, B. Magee

B. Dale Magee

Recent studies have suggested a causal and pathogenetic relationship between holoprosencephaly and anencephaly. In support of the proposed relationship we report a sibship that includes anencephalic male twins and a female infant with a severe form of alobar holoprosencephaly, radial aplasia, and oligodactyly. The upper limb and brain malformations are considered to represent aprosencephaly syndrome. The coexistence of anencephaly and aprosencephaly within a sibship suggests that XK aprosencephaly syndrome may be an autosomal recessive disorder.

Doing The Best With What We Have: We Need Better: Informing Obstetric Policy With Administrative Data, Tiffany Moore Simas, B. Magee, Ellen Delpapa

B. Dale Magee

In this issue of Medical Care, Backes Kozhimannil and colleagues present data from the National Inpatient Sample on differences between rural and urban obstetric care. We applaud their efforts in examining this issue and agree that all women should be afforded safe deliveries, and ideally each woman’s experience would not be different. That being said, there are some practical considerations that must be applied to their analyses and recommendations. We would like to take this opportunity to capitalize on their efforts and speak to 2 other highly related implications for policy and practice.

Role Of Smoking In Low Birth Weight, B. Magee, Dale Hattis, Nancy Kivel

B. Dale Magee

OBJECTIVE: To assess the role of smoking on low birth weight (LBW). STUDY DESIGN: From Massachusetts for 1998, 79,904 birth certificates were reviewed. Birth weight, gestational age, plurality and maternal race were analyzed in relation to the mother's smoking status during the pregnancy. The etiologic fraction (EF) was calculated for smoking and LBW for the group as a whole as well as for various subgroups. RESULTS: A total of 11.7% of women acknowledged smoking during pregnancy. The overall LBW rate was 6.83%. The relative risk (RR) of LBW among smokers was 1.58. For all births the EF for smoking was …

Prenatal Oral Health Education In U.S. Dental Schools And Obstetrics And Gynecology Residencies, Megan Curtis, Hugh Silk, Judith A. Savageau

Judith A. Savageau

Prenatal oral health (POH) is an important health issue, but dental and obstetrical clinicians are not meeting the oral health needs of pregnant patients. This study evaluates how training contributes to this paradox with a national survey of sixty dental school deans and 240 obstetrics and gynecology residency program directors. Response rates were 53 percent and 40 percent for deans and program directors, respectively. According to the respondents, 94 percent of responding dental schools provided POH education, only 39 percent of responding residencies taught POH, and 65 percent of responding deans and 45 percent of responding program directors were aware …

The Association Between Hospital Obstetrical Volume And Maternal Postpartum Complications, Kathy Kyser, Xin Lu, Donna Santillan, Mark Santillan, Stephen Hunter, Alison Cahill, Peter Cram

Stephen K. Hunter

OBJECTIVE: The purpose of this study was to examine the relationship between delivery volume and maternal complications. STUDY DESIGN: We used administrative data to identify women who had been admitted for childbirth in 2006. Hospitals were stratified into deciles that were based on delivery volume. We compared composite complication rates across deciles. RESULTS: We evaluated 1,683,754 childbirths in 1045 hospitals. Decile 1 and 2 hospitals had significantly higher rates of composite complications than decile 10 (11.8% and 10.1% vs 8.5%, respectively; P < .0001). Decile 9 and 10 hospitals had modestly higher composite complications as compared with decile 6 (8.8% and …

Risk Of Early & Late Obstetric Complications In Women With Ivf- Conceived Pregnancies And Polycystic Ovary Syndrome (Pcos), N. A. Bagegni, J. Blaine, Bradley J. Van Voorhis, Anuja Dokras

Bradley J Van Voorhis

There is conflicting evidence on the association between PCOS and early and late obstetric complications. It is unclear if the reported risks are independent of BMI, preexisting hypertension and diabetes. We performed a retrospective chart review to examine the risk of early and late obstetrical complications after IVF in women with PCOS (n=130) compared to controls (n=130). The miscarriage rate was 17.7% in PCOS women and 15.4% in controls. PCOS was not associated with miscarriage independent of age and BMI. The prevalence of gestational DM (GDM) was similar in both groups (12% PCOS versus 11% controls). BMI was independently associated …

Defining Normal Igg Changes Throughout Pregnancy, Jena Taylor, Jona Conklin, Stephen K. Hunter, Ryan Empey, Eric M. Tyler, Ashley Christensen, Katelyn M. Talcott, Zuhair K. Ballas, Donna A. Santillan, Mark K. Santillan

Stephen K. Hunter

Immunoglobulin G (IgG) is the major serum immunoglobulin, accounting for roughly 75% of all immunoglobulin. IgG is the only class of immunoglobulin that crosses the placenta and it serves as the main immunologic barrier between the fetus and external environments. There has not been a clear consensus on what the normal values of IgG are throughout pregnancy. The aim of this study is to measure serum immunoglobulin G in each trimester of the pregnant female to determine a normal IgG profile throughout all trimesters in normal pregnancy.

Cell Encapsulation As A Potential Nondietary Therapy For Maternal Phenylketonuria, Donna Santillan, Mark Santillan, Stephen Hunter

Stephen K. Hunter

OBJECTIVE: The objective of this work was to determine whether cells overexpressing phenylalanine (Phe) hydroxylase (PAH) can significantly reduce Phe in vitro for potential use as a therapy for preventing maternal phenylketonuria. STUDY DESIGN: Human 293T and WRL68 cell lines were transiently and stably transfected to overexpress PAH. Cells were encapsulated within microspheres of sodium alginate. Timed measurements of Phe in media were performed using tandem mass spectrometry. RESULTS: Both nonencapsulated and encapsulated transiently transfected cells overexpressing PAH significantly reduced the Phe concentration in media by approximately 50% in comparison to mock-transfected cells. Cell line clones stably expressing PAH significantly …

The Association Between Hospital Obstetrical Volume And Maternal Postpartum Complications., Kathy L Kyser, Xin Lu, Donna Santillan, Mark Santillan, Stephen Hunter, Alison G Cahill, Peter Cram

Donna A. Santillan

OBJECTIVE: The purpose of this study was to examine the relationship between delivery volume and maternal complications.

STUDY DESIGN: We used administrative data to identify women who had been admitted for childbirth in 2006. Hospitals were stratified into deciles that were based on delivery volume. We compared composite complication rates across deciles.

RESULTS: We evaluated 1,683,754 childbirths in 1045 hospitals. Decile 1 and 2 hospitals had significantly higher rates of composite complications than decile 10 (11.8% and 10.1% vs 8.5%, respectively; P < .0001). Decile 9 and 10 hospitals had modestly higher composite complications as compared with decile 6 (8.8% and 8.5% vs 7.6%, respectively; P < .0001). Sixty percent of decile 1 and 2 hospitals were located within 25 miles of the nearest greater volume hospital.

CONCLUSION: Women who deliver at very low-volume hospitals have higher complication rates, as do women who deliver at …

From Molecules To Medicine: A Future Cure For Preeclampsia?, Mark Santillan, Donna Santillan, Curt Sigmund, Stephen Hunter

Donna A. Santillan

In the United States, preeclampsia (PreE) affects 5-7% of all pregnancies, yet represents 15% of all maternal-fetal morbidity and mortality. PreE causes fetal growth restriction, oligohydramnios, fetal death, and maternal seizures, stroke, cerebrovascular hemorrhage and death. It has immediate and potentially long-term effects on both the fetus and mother. To date, the molecular pathogenesis of PreE is largely unknown. Multiple pathways, including dysfunctional angiogenesis, inappropriate placentation, oxidative stress and an altered immunological milieu have been proposed as key players in the development of PreE. In addition, genetic factors in all of these pathways are essential components in the etiology of …

Noninvasive Whole-Genome Sequencing Of A Human Fetus, J. Kitzman, M. Snyder, M. Ventura, A. Lewis, R. Qiu, L. Simmons, H. Gammill, C. Rubens, Donna Santillan, J. Murray, H. Tabor, M. Bamshad, E. Eichler, J. Shendure

Donna A. Santillan

Analysis of cell-free fetal DNA in maternal plasma holds promise for the development of noninvasive prenatal genetic diagnostics. Previous studies have been restricted to detection of fetal trisomies, to specific paternally inherited mutations, or to genotyping common polymorphisms using material obtained invasively, for example, through chorionic villus sampling. Here, we combine genome sequencing of two parents, genome-wide maternal haplotyping, and deep sequencing of maternal plasma DNA to noninvasively determine the genome sequence of a human fetus at 18.5 weeks of gestation. Inheritance was predicted at 2.8 x 10(6) parental heterozygous sites with 98.1% accuracy. Furthermore, 39 of 44 de novo …

Cell Encapsulation As A Potential Nondietary Therapy For Maternal Phenylketonuria, Donna Santillan, Mark Santillan, Stephen Hunter

Donna A. Santillan

OBJECTIVE: The objective of this work was to determine whether cells overexpressing phenylalanine (Phe) hydroxylase (PAH) can significantly reduce Phe in vitro for potential use as a therapy for preventing maternal phenylketonuria. STUDY DESIGN: Human 293T and WRL68 cell lines were transiently and stably transfected to overexpress PAH. Cells were encapsulated within microspheres of sodium alginate. Timed measurements of Phe in media were performed using tandem mass spectrometry. RESULTS: Both nonencapsulated and encapsulated transiently transfected cells overexpressing PAH significantly reduced the Phe concentration in media by approximately 50% in comparison to mock-transfected cells. Cell line clones stably expressing PAH significantly …

The Influence Of Fetal Sex On Patterns Of Change In Anti-Mullerian Hormone During Pregnancy, Ryan Empey, Donna A. Santillan, Mark Santillan, Eric M. Tyler, Stephen K. Hunter, Elaine M. Smith, Barbara J. Stegmann

Donna A. Santillan

Maternal anti-mullerian hormone declines sharply between 13-15 weeks, likely as a result of feto-placental signaling. Fetal AMH levels are known to be widely disparate after the first trimester, with high levels in male and absent levels in female. However, it is unclear as to whether differing fetal AMH levels influence the pattern of change of maternal AMH. Our objective was to examine AMH throughout gestation to determine if the maternal concentration varies according to the gender of the fetus.

Anti-Müllerian Hormone Concentration Levels In Maternal Plasma During The First, Second And Third Trimester Of Pregnancy, Kelin Schultz, Barbara Stegmann, Mark Santillan, Donna Santillan, Elaine Smith, Bradley J. Van Voorhis

Donna A. Santillan

Follicle-Stimulating Hormone (FSH) drops rapidly in pregnancy but Anti-Mullerian Hormone (AMH) has not been shown to drop until about 12 weeks. Since the follicles that secrete AMH are thought to be FSH independent, AMH levels should slowly decline in the absence of FSH because when the follicles reach FSH dependence, they would die off. A study has presented data that suggests a decline in AMH levels suddenly starts at 12 weeks gestation. The present study agrees with a decline in AMH after the first trimester. There is a sharp decline in AMH at 12-16 weeks gestation indicating that the follicular …

Cell Encapsulation As A Potential Nondietary Therapy For Maternal Phenylketonuria, Donna Santillan, Mark Santillan, Stephen Hunter

Mark K. Santillan

OBJECTIVE: The objective of this work was to determine whether cells overexpressing phenylalanine (Phe) hydroxylase (PAH) can significantly reduce Phe in vitro for potential use as a therapy for preventing maternal phenylketonuria. STUDY DESIGN: Human 293T and WRL68 cell lines were transiently and stably transfected to overexpress PAH. Cells were encapsulated within microspheres of sodium alginate. Timed measurements of Phe in media were performed using tandem mass spectrometry. RESULTS: Both nonencapsulated and encapsulated transiently transfected cells overexpressing PAH significantly reduced the Phe concentration in media by approximately 50% in comparison to mock-transfected cells. Cell line clones stably expressing PAH significantly …

Semen Quality In Fertile Men In Relation To Psychosocial Stress, A. Gollenberg, F. Liu, C. Brazil, E. Drobnis, D. Guzick, J. Overstreet, J. Redmon, Amy Sparks, C. Wang, S. Swan

Amy E.T. Sparks

OBJECTIVE: To examine the association between stressful life events and semen parameters. DESIGN: Cross-sectional analysis in a pregnancy cohort study. SETTING: Prenatal clinics in five U.S. cities. PATIENT(S): Fertile men (n = 744) in the Study for Future Families, a cohort study of pregnant women and their partners. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Sperm concentration, percent motile, and percent normal morphology and classification above/below World Health Organization (WHO) cutoffs for semen quality. RESULT(S): After adjusting for confounders, men reporting 2+ recent stressful life events had an increased risk of being classified below WHO thresholds for "normal" defined by concentration, motility, …

Gene Transfer Efficiency During Gestation And The Influence Of Co-Transfer Of Non-Manipulated Embryos On Production Of Transgenic Mice, R. Canseco, Amy Sparks, R. Page, C. Russell, J. Johnson, W. Velander, R. Pearson, W. Drohan, F. Gwazdauskas

Amy E.T. Sparks

Litter size of DNA microinjected zygotes is lower than for non-manipulated zygotes. The rate of embryonic and fetal survival in early, mid and late gestation was determined to assess whether DNA integration was responsible for embryonic losses. Also, the effect of including non-microinjected embryos with injected embryos on pregnancy rate and transgenic pup production was determined. In Experiment 1, one-cell embryos from immature CD-1 mice were microinjected with a whey acidic protein promoter-human protein C gene construct. One hour after microinjection embryos were transferred to pseudopregnant recipients (45 transfers of 30 embryos each). Fifteen recipients were sacrificed on day 4, …

Culture Systems: Embryo Culture And Monozygotic Twinning, Amy Sparks

Amy E.T. Sparks

The incidence of monozygotic twinning in pregnancies achieved with assisted reproductive technologies (ART) is significantly higher than spontaneously conceived pregnancies. The factors associated with ART that predispose the embryos to splitting are not well-characterized. Assisted hatching and extended embryo culture are two ART laboratory methods that have been risk factors for monozygotic twinning. The methods and strategies that may be employed to avoid monozygotic twinning are discussed in this chapter.

Comparison Of Microscopic Epididymal Sperm Aspiration And Intracytoplasmic Sperm Injection/In-Vitro Fertilization With Repeat Microscopic Reconstruction Following Vasectomy: Is Second Attempt Vas Reversal Worth The Effort?, J. Donovan, M. Dibaise, Amy Sparks, J. Kessler, J. Sandlow

Amy E.T. Sparks

Since 1986, we have performed microscopic reconstruction in 18 men following failed microscopic vasectomy reversal. Between 1994 and 1996, nine couples have undergone microscopic epididymal sperm aspiration (MESA)/ intracytoplasmic sperm injection (ICSI) treatment for male infertility due either to congenital absence of the vas deferens (CAVD) or inoperable excurrent duct obstruction. We compared the cost efficiency of repeat vasectomy reversal to that for MESA combined with ICSI/in-vitro fertilization (ICSI/IVF). The cost of male partner procedures (vasectomy reversal, MESA) was based on physician and hospital charges, while the cost of ICSI/IVF included preparation of the female partner (medications and physician charges) …

In Vitro Fertilization Is Associated With An Increase In Major Birth Defects, C. Olson, K. Keppler-Noreuil, P. Romitti, W. Budelier, Ginny Ryan, Amy Sparks, Bradley Van Voorhis

Amy E.T. Sparks

OBJECTIVE: To determine the risk of major birth defects in cohorts of children conceived through IVF or through IUI as compared with naturally conceived children. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): Children conceived by IVF or IUI at the University of Iowa from 1989 through 2002, compared with a matched cohort of naturally conceived children. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Outcome data were obtained from Iowa state birth and fetal death certificates and from the Iowa Birth Defects Registry. RESULT(S): Ninety of 1,462 IVF-conceived children (6.2%) and 17 of 343 IUI-conceived children (5.0%) had a major birth …

Computational Models For Prediction Of Ivf/Icsi Outcomes With Surgically Retrieved Spermatozoa, M. Wald, Amy Sparks, J. Sandlow, Bradley Van Voorhis, Craig Syrop, C. Niederberger

Amy E.T. Sparks

IVF/intracytoplasmic sperm injection (ICSI) using surgically retrieved spermatozoa (SRS) is a key option in the treatment of severe male infertility. It was aimed to develop a computational model for the prediction of this modality's outcome. A dataset of 113 exemplars, derived from patients who underwent IVF/ICSI with SRS, was retrospectively analysed. The dataset, containing input features maternal age, sperm retrieval technique, type of spermatozoa used, type of male factor and output intrauterine pregnancy, was randomized into a modelling ('training') set of 83 and cross-validation ('test') set of 30. neUROn++, a set of C++ programs, was used to model the dataset …

Oral Ovulation Induction Agents Combined With Low-Dose Gonadotropin Injections And Intrauterine Insemination: Cost- And Clinical Effectiveness, Ginny Ryan, V. Moss, W. Davis, Amy Sparks, A. Dokras, Bradley Van Voorhis

Amy E.T. Sparks

OBJECTIVE: To compare the efficacy and cost-effectiveness of different induction protocols involving gonadotropins with intrauterine insemination (IUI). STUDY DESIGN: We performed a retrospective chart review of 648 IUI cycles. Some patients had gonadotropin injections alone before human chorionic gonadotropin (hCG) and IUI (human menopausal gonadotropin protocol); others were given oral medications, then gonadotropins before hCG and IUI (combination protocol). Outcomes included pregnancy rates, multiple birth rates, endometrial thickness, number of ovarian follicles, injection days, ampules of gonadotropins and cost. RESULTS: The combination protocol was more cost-effective. In first cycles, pregnancy rates, multiple birth rates, number of large follicles produced and …

Cost-Effectiveness Of Infertility Treatments: A Cohort Study, Bradley Van Voorhis, Amy Sparks, B. Allen, D. Stovall, Craig Syrop, F. Chapler

Amy E.T. Sparks

OBJECTIVE: To determine the cost-effectiveness of infertility treatments. DESIGN: Retrospective cohort study. SETTING: Academic medical center infertility practice. PATIENT(S): All patients treated for infertility in a 1-year time span. INTERVENTION(S): Intrauterine inseminations, clomiphene citrate and IUI (CC-IUI), hMG and IUI (hMG-IUI), assisted reproductive techniques (ART), and neosalpingostomy by laparotomy. MAIN OUTCOME MEASURE(S): All medical charges and pregnancy outcomes associated with the treatments were obtained. Cost-effectiveness ratios defined as cost per delivery were determined for each procedure. The effects of a woman's age and the number of spermatozoa inseminated on cost-effectiveness of the procedures was also determined. RESULT(S): Intrauterine inseminations, CC-IUI, …

A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis

Amy E.T. Sparks

OBJECTIVE: To reduce the twin rate in our IVF program. DESIGN: A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING: University-based infertility center. PATIENT(S): One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S): A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S): Knowledge of twin risks and desired number of embryos …