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Objectives: Assess temporal changes, intercenter variability, and birthing person (BP) factors relating to interventions for extremely early deliveries., Methods: Retrospective study of BPs and newborns delivered from 22-24 completed weeks at 13 US centers from 2011-2020. Rates of neonatology consultation, antenatal corticosteroids, cesarean delivery, live birth, attempted resuscitation (AR), and survival were assessed by epoch, center, and gestational age., Results: 2028 BPs delivering 2327 newborns were included. Rates increased in epoch 2-at 22 weeks: neonatology consultation (37.6 vs 64.3%, P < .001), corticosteroids (11.4 vs 29.5%, P < .001), live birth (66.2 vs 78.6%, P < .001), AR (20.1 vs 36.9%, P < .001), overall survival (3.0 vs 8.9%, P = .005); and at 23 weeks: neonatology consultation (73.0 vs 80.5%, P = .02), corticosteroids (63.7 vs 83.7%, P < .001), cesarean delivery (28.0 vs 44.7%, P < .001), live birth (88.1 vs 95.1%, P < .001), AR (67.7 vs 85.2%, P < .001), survival (28.8 vs 41.6%, P < .001). Over time, intercenter variability increased at 22 weeks for corticosteroids (interquartile range 18.0 vs 42.0, P = .014) and decreased at 23 for neonatology consultation (interquartile range 23.0 vs 5.2, P = .045). In BP-level multivariate analysis, AR was associated with increasing gestational age and birth weight, Black BP race, previous premature delivery, and delivery center., Conclusions: Intervention rates for extremely early newborns increased and intercenter variability changed over time. In BP-level analysis, factors significantly associated with AR included Black BP race, previous premature delivery, and center., (Copyright © 2024 by the American Academy of Pediatrics.)

Osmotic demyelination syndrome (ODS) occurs in patients with diabetes and hyponatremia. We herein report a case of ODS with chorea detected on serial magnetic resonance imaging (MRI), despite no prompt hyponatremia correction. A 74-year-old man with cirrhosis and uncontrolled type 2 diabetes developed an altered mental status and chorea during treatment for diabetic ketoacidosis (DKA). Despite no rapid sodium correction and normal initial brain MRI findings, serial MRI revealed ODS-related abnormalities. Clinicians should consider ODS in patients with DKA and a hyperosmolar hyperglycemic state displaying unconsciousness and neurological manifestations, including chorea, even without substantial changes in serum sodium levels. An MRI re-examination can help capture missing ODS complications.

In this report, we describe a unique case of an 80-year-old woman who developed chronic bromine poisoning due to the prolonged ingestion of over-the-counter (OTC) medication containing bromovalerylurea (BVU), thus leading to the onset of drug-induced partial Fanconi syndrome and resultant osteomalacia. The patient's condition improved following the cessation of bromide intake. This case highlights the potential risks of chronic BVU exposure and the importance of caution regarding the use of OTC medications containing BVU.

Objective: This study aimed to compare cesarean delivery (CD) rates and maternal/neonatal outcomes before and after the 2014 ACOG/SMFM Obstetric Care Consensus for Safe Prevention of Primary CD., Study Design: This retrospective study compared unscheduled CD rates and outcomes of singleton, cephalic, term pregnancies at a tertiary-care teaching maternity hospital. Births 5 years before (March 2009-February 2014) and after (June 2014-May 2019) release of the consensus were included. Chi-square and t -test were used to compare outcomes and logistic regression to adjust for confounders., Results: In this study, 44,001 pregnancies were included, 20,887 before and 23,114 after the consensus. Unscheduled CD rates increased after the consensus (12.9 vs. 14.3%, p  < 0.001); however, there was no difference after adjustment (adjusted odds ratio [aOR], 0.97; 95% confidence interval [CI], 0.91-1.03). Vaginal birth after cesarean (VBAC) deliveries increased among multiparas (4.8 vs. 7.2%, p  < 0.001), which remained significant after adjustment (aOR, 1.51; 95% CI, 1.37-1.66). Postpartum hemorrhage, blood transfusion, and chorioamnionitis were modestly increased, while third-degree perineal lacerations decreased. Uterine rupture and neonatal outcomes were unchanged after adjustment., Conclusion: At our tertiary-care maternity hospital, the Safe Prevention of Primary CD Care Consensus was not associated with a change in unscheduled CD, though VBAC deliveries increased. We did not demonstrate improved neonatal outcomes and showed increased maternal morbidity that warrants further study., Key Points: · Consensus did not change unscheduled cesarean rates.. · Consensus associated with increased hemorrhage.. · Institutional outcomes can assist implementing changes.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: To evaluate associations between serum analytes used for genetic screening and obstetric complications among twin pregnancies., Methods: This cohort included twins delivered at a tertiary care hospital from 2009 to 2017. Abnormal levels of pregnancy associated plasma protein (PAPP-A), first and second trimester human chorionic gonadotropin (hCG), alpha fetoprotein (AFP), estriol, and inhibin, reported as multiples of the median (MoM), were defined as <5 %ile or >95 %ile for our cohort. Associations between abnormal analytes and preterm delivery, small for gestational age, and pregnancy-associated hypertension were calculated using Fisher's exact test., Results: A total of 357 dichorionic/diamniotic and 123 monochorionic/diamniotic twins were included. Among dichorionic/diamniotic twins, elevated AFP (>3.70 MoM) was associated with increased preterm delivery <34 weeks (44.4 vs. 16.5 %, p=0.007), while elevated inhibin (>4.95 MoM) was associated with increased preterm delivery<37 weeks (94.1 vs. 58.8 %, p=0.004). For monochorionic/diamniotic twins, elevated inhibin (>6.34 MoM) was associated increased preterm delivery <34 weeks (66.7 vs. 24.8 %, p=0.04) and hypertension (66.7 vs. 21.4 %, p=0.03)., Conclusions: Selected abnormal analyte levels were associated with increased rates of adverse outcomes in twin pregnancies, which differed by chorionicity. Our findings assist providers in interpreting abnormal analyte levels in twin pregnancies and may help to identify those at increased risk for adverse outcomes., (© 2024 Walter de Gruyter GmbH, Berlin/Boston.)

Background: Transient myoclonic (TM) state in older adults is a neurological condition characterised by short-lived, repetitive myoclonus without consciousness disturbance. First reported in 1992, it predominantly affects older individuals with chronic diseases. Despite its clear symptomatology, TM often remains under-recognised, leading to potential misdiagnoses., Case Description: We report a case of a 68-year-old woman with a history of chronic heart failure who developed TM during hospitalisation following medication adjustment for acute heart failure. The patient, who had no history of intracranial disease or epilepsy, experienced acute involuntary movements of the face and limbs three days after diuretic adjustment. She responded well to intravenous diazepam and oral clonazepam, with no recurrence of symptoms post-treatment., Discussion: TM presents with bilateral, irregular, and repetitive myoclonus, mostly affecting the head, neck and upper extremities. Diagnosis is clinical, based on symptomatology and normal laboratory results. This case underscores the importance of recognising TM in differential diagnosis, especially in older patients in the acute or recovery phase of infection, or with medication changes. The potential role of fluid volume changes in TM pathophysiology in patients with underlying conditions such as hypertension or chronic heart failure is also highlighted. This case emphasises the need for heightened awareness and knowledge of TM among healthcare professionals., Conclusions: TM, though rare, requires awareness among clinicians for accurate diagnosis and management. It is crucial to avoid misdiagnosis and unnecessary interventions, and to provide appropriate information during care transitions, particularly in older adults with chronic conditions., Learning Points: Transient myoclonic (TM) state is a rare neurological condition in older adults, characterised by brief and repetitive myoclonus, primarily affecting the head, neck and upper extremities.The distinctive clinical diagnostic feature is myoclonus occurring without disturbances in consciousness, without amnesia or paralysis, while retaining the ability to perform directed movements. This condition can manifest at rest, may worsen with posture or movement, and tends to improve during sleep.Management strategies include ensuring smooth care transitions, avoiding misdiagnosis and educating patients and families about the risk of recurrence., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2024.)

The health of women over the entire span of their reproductive years is crucial - beginning in adolescence and extending through the postpartum period. This paper provides a scoping review of the relevant literature on risk factors for gestational diabetes mellitus (GDM) and progression from GDM to type 2 diabetes mellitus (T2DM), particularly among women of Native Hawaiian and Pacific Islander (NHPI) and Asian racial/ethnic backgrounds in Hawai'i, using the PubMed database (July 2010 to July 2020). NHPI and Asian populations have a greater likelihood of developing GDM compared to their White counterparts. Risk factors such as advanced maternal age, high maternal body mass index, and lack of education about GDM have varying levels of impact on GDM diagnosis between ethnic populations. Mothers who have a history of GDM are also at higher risk of developing T2DM. Common risk factors include greater increase in postpartum body mass index and use of diabetes medications during pregnancy. However, few studies investigate the progression from GDM to T2DM in Hawai'i's Asian and NHPI populations, and no studies present upstream preconception care programs to prevent an initial GDM diagnosis among Hawai'i's women. Thus, updated reports are necessary for optimal early interventions to prevent the onset of GDM and break the intergenerational cycle of increased susceptibility to T2DM and GDM in both mother and child. Further attention to the development of culturally sensitive interventions may reduce disparities in GDM and improve the health for all affected by this condition., (©Copyright 2022 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Objective: To evaluate associations between operative vaginal delivery complications and provider experience (operative vaginal delivery volume and time since residency)., Methods: We included all operative vaginal deliveries between 2008 and 2014 at a tertiary care teaching hospital, stratified into forceps-assisted and vacuum-assisted deliveries. Complications included severe perineal lacerations (3rd and 4th degree) and neonatal injuries (subgaleal/subdural/cerebral hemorrhage, facial nerve injury, and scalp injury), which were identified by International Classification Diagnosis-9 codes. Providers were categorized by operative vaginal delivery volume (mean annual forceps- or vacuum-assisted deliveries over the study interval) and time since residency. Regression analyses were used to compare complication rates by provider volume and time since residency, adjusting for potential confounders, using 0-1 deliveries per year and <5 years since residency as reference groups., Results: Nine hundred and thirty-four forceps and 1074 vacuums occurred. For forceps-assisted deliveries, severe perineal injury was decreased among providers with >10 forceps per year (aOR 0.50 [95%CI 0.30-0.81]) and at 15-19 years (aOR 0.45 [95% CI 0.22-0.94], and ≥25 years (aOR 0.45 [0.27-0.73]) since residency. There were no associations with neonatal injuries. Among vacuum-assisted deliveries, severe perineal injury decreased at ≥25 years since residency (aOR 0.35 [95%CI 0.17-0.74], with no association with provider volume. Neonatal injury decreased at 5-9 years (aOR 0.53 [95%CI 0.30-0.93]), and 15-19 years since residency (aOR 0.53 [95%CI 0.29-0.97]), due to differences in scalp injuries. Neonatal injuries other than scalp injury were rare., Conclusion: Severe perineal lacerations decreased with increasing operative vaginal delivery experience, primarily among forceps-assisted vaginal delivery. Providers >5 years since residency may have lower scalp injury with vacuums, but this cohort was largely underpowered for neonatal injury.

Objectives: Early diagnosis of gestational diabetes can lead to greater optimization of glucose control. We evaluated associations between maternal serum analytes (alpha-fetoprotein [AFP], free beta-human chorionic gonadotropin [beta-hCG], inhibin, and estriol) and the development of gestational diabetes mellitus (GDM)., Methods: This retrospective cohort study identified single-ton pregnancies with available second trimester serum analytes between 2009 and 2017. GDM was identified by ICD-9 and -10 codes. We examined the associations between analyte levels and GDM and to adjust for potential confounders routinely collected during genetic serum screening (maternal age, BMI, and race) using logistic regression. Optimal logistic regression predictive modeling for GDM was then performed using the analyte levels and the above mentioned potential confounders. The performance of the model was assessed by receiver operator curves., Results: Out of 5,709 patients, 660 (11.6%) were diagnosed with GDM. Increasing AFP and estriol were associated with decreasing risk of GDM, aOR 0.76 [95% CI 0.60-0.95] and aOR 0.67 [95% CI 0.50-0.89] respectively. Increasing beta-hCG was associated with a decreasing risk for GDM(aOR 0.84 [95% CI 0.73-0.97]). There was no association with inhibin. The most predictive GDM predictive model included beta-hCG and estriol in addition to the clinical variables of age, BMI, and race (area under the curve (AUC 0.75), buy this was not statistically different than using clinical variables alone (AUC 0.74) (p=0.26)., Conclusions: Increasing second trimester AFP, beta-hCG, and estriol are associated with decreasing risks of GDM, though do not improve the predictive ability for GDM when added to clinical risk factors of age, BMI, and race., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: To describe racial/ethnic representation in United States (US) and Australian obstetric research, represented by the Maternal-Fetal Medicine Units Network (MFMU) and Australian Research Centre for Health of Women and Babies (ARCH) trials., Methods: MFMU studies were identified through PubMed and ARCH studies through their online publication listing from 2011 to 2016. Observational and randomized cohorts and primary and secondary data analyses were included. Studies with race-based enrollment were excluded. Racial/ethnic representation was expressed as the mean racial/ethnic percentages of the studies (i.e.,: studies weighted equally regardless of sample size). Racial/ethnic percentages in MFMU studies were compared to US registered births and ARCH compared to Australian census ancestry data., Results: 38 MFMU studies included 580,282 women. Racial/ethnic representation (% [SD]) included White 41.7 [12.3], Hispanic 28.1 [15.4], Black 26.2 [12.3], Asian 3.6 [2.3], and American Indian/Alaskan Native (AI/AN) 0.2 [0.02]. No studies reported Native Hawaiian/other Pacific Islanders (NHOPI) separately. Comparatively, registered US births (%) were White 75.7, Hispanic 28.1, Black 16.1, Asian/Pacific Islander 7.1, and AI/AN 1.1, which differed from the MFMU (P = 0.02). 20 ARCH studies included 51,873 women. The most reported groups were White 76.5 [17.4], Asian 15.2 [14.8], and Aboriginal/Torres Strait Islander 13.9 [30.5], compared to census numbers of White 88.7, Asian 9.4, and Aboriginal/Torres Strait Islander 2.8 (P < 0.01). Two ARCH studies reported African ethnicity., Conclusion: There is racial diversity in studies by MFMU and ARCH, with opportunities to increase enrollment and enhanced reporting of Asian, AI/AN, and NHOPI races in MFMU studies and Black race in ARCH studies.

Introduction: Preeclampsia is a medical condition complicated with hypertension and proteinuria during pregnancy. While preeclampsia affects approximately 5% of pregnancies, it remains without a cure. In addition, women who had preeclampsia during pregnancy have been reported to have an increased risk for cardiovascular disease later in life. However, the disease etiology and molecular mechanisms remain poorly understood. The paucity in the literature on preeclampsia associated maternal cardiovascular risk in different ethnic populations also present a need for more research. Therefore, the objective of this study was to identify cardiovascular/metabolic single nucleotide polymorphisms (SNPs), genes, and regulatory pathways associated with early-onset preeclampsia., Materials and Methods: We compared maternal DNAs from 31 women with early-onset preeclampsia with those from a control group of 29 women without preeclampsia who delivered full-term normal birthweight infants. Women with multiple gestations and/or known medical disorders associated with preeclampsia (pregestational diabetes, chronic hypertension, renal disease, hyperthyroidism, and lupus) were excluded. The MetaboChip genotyping array with approximately 197,000 SNPs associated with metabolic and cardiovascular traits was used. Single nucleotide polymorphism analysis was performed using the SNPAssoc program in R. The Truncated Product Method was used to identify significantly associated genes. Ingenuity Pathway Analysis and Ingenuity Causal Network Analysis were used to identify significantly associated disease processes and regulatory gene networks respectively., Results: The early-onset preeclampsia group included 45% Filipino, 26% White, 16% other Asian, and 13% Native Hawaiian and other Pacific Islanders, which did not differ from the control group. There were no SNPs associated with early-onset preeclampsia after correction for multiple comparisons. However, through gene-based tests, 68 genes and 23 cardiovascular disease-related processes were found to be significantly associated. Associated gene regulatory networks involved cellular movement, cardiovascular disease, and inflammatory disease., Conclusions: Multiple cardiovascular genes and diseases demonstrate associations with early-onset preeclampsia. This unfolds new areas of research regarding the genetic determinants of early-onset preeclampsia and their relation to future cardiovascular disease., Competing Interests: The authors have declared that no competing interests exist.

This retrospective cohort study examined associations between maternal body mass index (BMI), race, and obstetric anal sphincter injury (OASI) (3rd/4th degree perineal lacerations). Obstetric anal sphincter injury may lead to significant maternal morbidity, and a more thorough understanding of risk factors for this complication may guide providers in patient counseling and procedures such as episiotomy or operative vaginal delivery. Vaginal deliveries performed at Kapi'olani Medical Center for Women and Children from 2008-2015 were included. Maternal body mass index at delivery was used and OASIs identified through International Classification of Diseases codes. Demographic/clinical variables were summarized through descriptive statistics. Adjusted odds ratios were calculated using multiple logistic regression. Of the 25,594 deliveries included, 1,198 (4.7%) involved an OASI. OASI prevalence differed by BMI (P < .0001). The prevalence was highest in women with BMI < 30 kg/m 2 (5.3%) and then decreased as BMI increased with women with BMI ≥ 50 demonstrating the lowest prevalence (1.7%). Compared to women with BMI < 30 kg/m 2 , women with BMI > 50 kg/m 2 had a lower odds of OASI (OR 0.31 [95%CI 0.11 - 0.83]), which persisted after adjustment (aOR 0.28 [95%CI 0.08-0.96]). OASI also differed by race (P < .0001), with Native Hawaiian and other Pacific Islanders (NHOPI) demonstrating the lowest prevalence (3.0%) and Asians the highest (5.6%). After adjustment, compared to White women, NHOPI women had lower OASI prevalence that met the borderline of statistical significance (aOR 0.79 [95%CI 0.62-1.01]), while Asian women continued to demonstrate increased prevalence (aOR 1.50 [95% CI 1.22-1.85]). We conclude that obese women, including those with BMI ≥ 50 kg/m 2 , have lower OASI prevalence. Race is also a significant factor, with Asians almost double the prevalence of NHOPIs. These findings contribute to evidence-based, individualized patient counseling on OASI., Competing Interests: None of the authors identify any conflict of interest.

We conducted this study to compare outcomes for pregnancies conceived ≤6 months after dilation and evacuation (D&E) with those conceived >6 months after D&E. This retrospective cohort study included women who underwent D&E (14-26 weeks) and were readmitted with a subsequent pregnancy. The primary outcome was the rate of preterm birth (<37 weeks). We identified 737 D&Es with 214 subsequent pregnancies. Outcomes were available for 85.5% of these pregnancies. Preterm birth <37 weeks occurred in 9.4% (3/32) of patients with an interpregnancy interval ≤6 months and 20.7% (12/58) of patients with an interpregnancy interval >6 months (p = .17). No differences in preterm birth <34 weeks, postpartum haemorrhage, placentation abnormalities, intrauterine growth restriction, cervical insufficiency or mode of delivery were noted. Adverse pregnancy outcomes were not higher in the group of women who conceived ≤6 months after D&E compared to those who waited longer than 6 months. IMPACT STATEMENT What is already known on this subject: A small number of studies have noted an increased risk of adverse pregnancy outcomes with an interpregnancy interval of 6 months or fewer after a spontaneous or an induced abortion. What the results of this study add: We present the first study exploring pregnancy outcomes after dilation and evacuation for termination of pregnancy at 14 weeks or greater. Our results do not support an increased rate of adverse events with an interpregnancy interval of 6 months or fewer following dilation and evacuation. What the implications are of these findings for clinical practice and/or further research: Because of limitations in sample size, our results should be interpreted in the context of other studies.

The aim of this review is to discuss three dimensional (3D) power Doppler of the placenta and its clinical applications. There is a strong clinical need to develop noninvasive, simple and widely available methods of evaluating in vivo placental function to assess fetal wellbeing. While conventional ultrasound is a proven tool in the evaluation of fetal structural anomalies and health, its ability to assess placental function, especially prior to the onset of fetal compromise, is the subject of ongoing investigation. Three dimensional power Doppler has the ability to detect vascularity and blood flow with greater detail than conventional ultrasound, which has led to its investigation in preeclampsia, fetal growth restriction, and other placental vascular abnormalities. While more data are needed on the optimal imaging protocol and its predictive ability for clinical outcomes, 3D power Doppler is emerging as a promising new technology that will improve the evaluation of placental function.

Objective: To evaluate B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac structure and function in normal women through pregnancy and the postpartum., Methods: In this prospective observational study, we obtained serial transthoracic echocardiograms, BNP, and NT-proBNP at seven intervals from 6 weeks' gestation through 12 months postpartum. Women with hypertension or cardiac disease were excluded. Using 6-12 months postpartum as reference for non-pregnant levels, echocardiogram measurements and BNP/NT-proBNP were compared over time using linear mixed models with Tukey-Kramer adjustment for multiple comparisons., Results: Of 116 patients, data was available for 78-114 healthy pregnant or postpartum women within each time interval, and 102 patients provided data for ≥4 intervals. Compared to 6-12 months postpartum, BNP and NT-proBNP remained stable through pregnancy and delivery, increased within 48 h postpartum (P<0.0001), then returned to baseline. Left ventricular volume increased within 48 h postpartum (P=0.021) while left atrial volume increased at 18-24 weeks (P=0.0002), 30-36 weeks (P<0.0001) and within 48 h postpartum (P=0.002). The transmitral early/late diastolic velocity (E/A) ratio, transmitral early/peak mitral annulus diastolic velocity (E/E') ratio, isovolumic relaxation times, and mitral valve deceleration times were similar within 48 h and 6-12 months postpartum., Conclusion: In normal women, BNP/NT-proBNP, left atrial, and left ventricular volumes increase within 48 h postpartum without indications of altered diastolic function.

Relaxin, a systemic and placental hormone, has potential roles in fetoplacental growth. Human placenta expresses two RLN genes, RLNH1 and RLNH2 Maternal obesity is common and is associated with abnormal fetal growth. Our aims were to relate systemic and cord blood RLNH2, placental RLNs and their receptor (RXFP1) with fetoplacental growth in context of maternal body mass index, and associations with insulin-like growth factor 2 (IGF2) and vascular endothelial growth factor A (VEGFA) in the same placentas. Systemic, cord blood and placental samples were collected prior to term labor, divided by prepregnancy body mass index: underweight/normal ( N  = 25) and overweight/obese ( N  = 44). Blood RLNH2 was measured by ELISA; placental RLNH2, RLNH1, RXFP1, IGF2 and VEGFA were measured by quantitative immunohistochemistry and mRNAs were measured by quantitative reverse transcription PCR. Birthweight increased with systemic RLNH2 only in underweight/normal women ( P  = 0.036). Syncytiotrophoblast RLNH2 was increased in overweight/obese patients ( P  = 0.017) and was associated with placental weight in all subjects ( P  = 0.038). RLNH1 had no associations with birthweight or placental weight, but was associated with increased trophoblast and endothelial IGF2 and VEGFA, due to female fetal sex. Thus, while systemic RLNH2 may be involved in birthweight regulation in underweight/normal women, placental RLNH2 in all subjects may be involved in placental weight. A strong association of trophoblast IGF2 with birthweight and placental weight in overweight/obese women suggests its importance. However, an association of only RLNH1 with placental IGF2 and VEGFA was dependent upon female fetal sex. These results suggest that both systemic and placental RLNs may be associated with fetoplacental growth., (© 2017 Society for Reproduction and Fertility.)

Objective: Pregnant patients receiving hemodialysis (HD) have long hospital stays for the purpose of electronic fetal monitoring (EFM) during HD, which allows for monitoring of fetal well-being. However, more frequent dialysis allows for smaller fluid shifts, preventing maternal hypotension. Our aim was to determine differences in rates of EFM abnormalities during HD versus non-stress testing (NST) off dialysis for gravid women with renal failure., Methods: Retrospective cohort study over a 13-year period (2000-2013) identified five patients with renal failure in pregnancy. EFM tracings were reviewed during HD (cases) and routine inpatient NST off HD (controls). Standardized nomenclature was used to identify EFM abnormalities. The rate of abnormalities per hour of EFM was calculated. Kruskal-Wallis test was used and statistical significance was set at p < 0.05., Results: There were no significant differences in late decelerations (p = 0.2) between cases and controls. Significantly fewer variable decelerations (p = 0.01) and contractions (p ≤0.001) were noted during dialysis compared to controls. Significantly more prolonged decelerations (p = 0.02) were noted during HD compared to controls., Conclusion: There may be no fetal benefit of EFM during HD for gravid women with renal disease attributed to hypertensive and diabetic nephropathy. There may be cost savings by shifting HD to the outpatient setting.

Objective: To compare cesarean complication rates between women with body mass index (BMI) 40-49.9 kg/m(2) and BMI ≥ 50 kg/m(2) and associations with surgical techniques., Methods: This retrospective cohort study from 2009 to 2014 included women who underwent cesarean with delivery BMI ≥ 50 and an equal number with BMI 40-49.9. Wound infections and/or separations were compared. We also examined wound complication rates between skin closure techniques and self-retaining retractor use., Results: Among 498 patients (249 with BMI ≥ 50 and 249 with BMI 40-49.9) there were no differences in estimated blood loss >1000 mL, blood transfusion, deep vein thrombosis or endometritis. Among those with outpatient follow-up (144 with BMI ≥ 50 and 162 with BMI 40-49.9), those with BMI ≥ 50 had a significantly higher rate of wound separations (p = 0.01) but not infections. There were no differences in wound complication rates between skin closure techniques or self-retaining retractor use, though the study was not powered for these comparisons., Conclusion: Wound complications, particularly separations, increase with BMI ≥ 50 compared to a lesser degree of morbid obesity. Skin closure techniques and self-retaining retractor use were not associated with cesarean wound complications in patients with morbid obesity.

Elective delivery from 37 to 39 weeks gestation (early-term deliveries) is a Joint Commission National Quality Measure, and hospitals report on early-term elective delivery rates through Outcome Research Yields Excellence (ORYX) vendors. The objective of this study was to compare early-term elective deliveries, identified through ORYX vendors with those identified through manual chart review, the traditional method of medical record review. We reviewed early-term labor inductions and cesarean deliveries at a single hospital from June 1, 2010 to May 31, 2012. Rates of early-term elective deliveries identified by the data vendor were compared to physician chart review. Overall, the rate of elective deliveries by ORYX was 3% compared to 2% by physician chart review (RR 1.51 [95% CI 1.12-2.03], P < .001). Of the 116 elective early-term deliveries identified by vendor and/or chart review, vendors classified significantly more inductions and cesareans as elective ( P < .001) and missed nine elective deliveries. Of the 107 deliveries identified as elective by ORYX, 62 (57.9%) were verified by chart review, including 69.0% of cesareans and 36.1% of inductions. Findings from this study suggest substantial discrepancy between identification of early-term elective deliveries by data vendors and physician chart review, and indicate that vendor-derived data may overestimate the number of electively delivered patients.

Purpose: There is relatively little information on episiotomies in the context of restricted episiotomy use. This study sought to examine maternal and neonatal injuries with restricted episiotomy use., Methods: We performed a retrospective database analysis of vaginal deliveries at a tertiary care maternity hospital from June 2010 to June 2015. Maternal injuries (third- or fourth-degree lacerations) and neonatal injuries (birth trauma) were identified through the International Classification of Diseases, Ninth Revision, codes. Vaginal deliveries were classified as spontaneous, vacuum-assisted, or forceps-assisted. The associations between episiotomy and maternal and neonatal injuries were examined with stratification by parity, type of vaginal delivery, and type of episiotomy (midline or mediolateral). Adjusted-odds' ratios were calculated for maternal and neonatal injuries using a multiple logistic regression model to adjust for potential confounders., Results: 22,800 deliveries occurred during the study interval involving 23,016 neonates. The episiotomy rate was 6.7 % overall and 22.9 % in operative vaginal deliveries. Episiotomies, both midline and mediolateral, were associated with increased risks of maternal and neonatal injuries regardless of parity (p < 0.0001). Upon stratification by the type of delivery, the association with maternal injury remained only for spontaneous vaginal deliveries (p < 0.0001). Adjusted-odds' ratios demonstrated a continued association between episiotomy and maternal [aOR 1.67 (1.39-2.05)] and neonatal injuries [aOR 1.43 (1.17-1.73)]., Conclusion: Episiotomy continues to be associated with increased third- and fourth-degree lacerations with restricted use, particularly in spontaneous vaginal deliveries.

Phylogenetic and taxonomic characterization was performed for a bacterium, designated strain Q-192T, isolated from the surface of the green macroalga Halimeda sp., collected from the subtropical Ishigaki Island, Japan. The isolate was a polysaccharide-producing, Gram-stain-negative, aerobic, rod-shaped, motile bacterium with a polar flagellum. The isolate was slightly halophilic, required Na+, Mg2+ and Ca2+ ions for growth, but did not require growth factors. The only isoprenoid quinone was ubiquinone-8.The major cellular fatty acids were C18 : 1ω7c, C16 : 0 and C14 : 0. The main hydroxy fatty acid was C10 : 0 3-OH. The DNA G+C content was 45.9 mol%. Phylogenetic analysis of 16S rRNA gene sequences placed the isolate in the class Gammaproteobacteria. The phylogenetically closest relatives with validly published names were Pseudomaricurvus alkylphenolicus KU41GT, Teredinibacter turnerae T7902T, Pseudoteredinibacter isoporae SW-11T and Simiduia agarivorans SA1T with sequence similarities of 94.5, 94.1, 93.7 and 93.6 %, respectively. The isolate was distinguished from members of these genera by a combination of DNA G+C content, chemotaxonomic characteristics (respiratory quinone system, fatty acid profile and polar lipid composition) and other phenotypic features. Based on phylogenetic, genotypic, chemotaxonomic and phenotypic characteristics, strain Q-192T is considered to represent a novel species of a new genus, for which the name Marinibactrum halimedae gen. nov., sp. nov. is proposed. The type strain of Marinibactrum halimedae is Q-192T ( = NBRC 110095T = NCIMB 14932T).

Aim: Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates., Methods: A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness., Results: Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted., Conclusions: Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate., (© 2015 The Authors. Journal of Obstetrics and Gynaecology Research © 2015 Japan Society of Obstetrics and Gynecology.)

The purpose of this study was to assess induction rates, maternal, and neonatal outcomes following adoption of a policy prohibiting elective inductions at less than 39 weeks gestation and inductions between 39 and 41 weeks with an unfavorable cervix. A retrospective cohort study of all deliveries greater than or equal to 37 weeks gestation was conducted 1 year prior to through 1 year after implementation of the induction policy. Induction rates before and after the policy were calculated as the primary outcome while maternal and neonatal conditions were assessed as secondary outcomes. Elective inductions (p = 0.016), elective inductions less than 39 weeks gestation (p = 0.020), and elective inductions 39-40 weeks and 6 days gestation with an unfavorable cervix (p = 0.031) decreased significantly following adoption of the policy. Maternal and neonatal outcomes, including rates of cesarean deliveries, postpartum hemorrhage, chorioamnionitis, and neonatal intensive care unit admissions remained unchanged, though this study was not adequately powered to detect differences in these outcomes. An institutional induction policy was associated with a reduction in elective inductions prior to 39 weeks and up to 40 weeks and 6 days with an unfavorable cervix. These reductions were not accompanied by change in maternal or neonatal outcomes at our institution.

Aim: To describe the effects of nifedipine tocolysis on blood pressure and heart rate in non-hypertensive women., Methods: This was a retrospective study from 2001 to 2011 to compare blood pressures and heart rates among non-hypertensive women on nifedipine tocolysis up to 8 h after nifedipine initiation. Measurements at 20-60 and 61-120 min were compared to assess the differential effects of dosing on hemodynamics and reflected the effects of the initial and complete loading doses, respectively. Charts were reviewed for hypotension-related emergent delivery., Results: One hundred and thirty-eight patients were included. Over the 8-h study interval, mean systolic blood pressure (P < 0.001) and mean diastolic blood pressure (P < 0.001) decreased by 5 mmHg and heart rate increased by 4 b.p.m. (P < 0.001). Systolic and diastolic blood pressures were unchanged from baseline up to 120 min at all doses. Heart rate increased at both 20-60 and 61-120 min when all doses were considered (P < 0.001), but differential dosing effects were not observed. Rates of tachycardia increased (P < 0.001), but rates of hypotension were unchanged. No hypotension-related emergent deliveries occurred., Conclusion: Nifedipine tocolysis was associated with hemodynamic changes in non-hypertensive women. Tachycardia was increased but hypotension was unaffected, supporting the general safety of nifedipine in this setting., (© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.)

Purpose: To compare leak point volumes and cost-effectiveness of a variety of adult incontinence products., Methods: Adult incontinence products were purchased from local retail stores and categorized into moderate absorbency pads, moderate absorbency briefs, maximum absorbency pads, and maximum absorbent briefs. The leak point for each product was determined by applying fluid to the pad until the first drop of leakage from the pad or brief occurred. Cost-effectiveness was calculated by dividing the cost per product by the amount of fluid absorbed prior to the leak point. The leak points and cost-effectiveness of incontinence products were compared within and between categories., Results: Significant differences in leak point volumes were present within all product categories except moderate absorbency pads. When comparing product categories, moderate absorbency pads were the least cost-effective, followed by maximum absorbency pads and absorbent briefs (P < .01)., Conclusions: As a group, absorbent briefs are more cost-effective than incontinence pads, although products of similar absorbency category and design demonstrated varying leak points and cost-effectiveness. These findings may influence physician assessment of urinary incontinence as well as patient selection of incontinence products.

Study Objective: To compare the surgical approach used for hysterectomy at 2 teaching hospitals before and after introduction of the robotic surgical system., Design: Retrospective cohort study (Canadian Task Force classification II-3)., Setting: Two gynecologic training sites at the University of Hawaii., Patients: Women who underwent hysterectomy between January 1, 2005, and December 31, 2011., Measurements and Main Results: ICD-9 procedural codes were used to identify hysterectomies performed between January 1, 2005, and December 31, 2011. Hysterectomies were categorized according to surgical approach: abdominal, vaginal, laparoscopic-assisted vaginal/total laparoscopic, and robotic. Each hysterectomy was also categorized according to primary preoperative diagnosis as general gynecology, gynecologic oncology, and urogynecology. The rates and numbers of hysterectomies performed during 2005-2006 (2 years before acquisition of the robot), 2007-2008 (first 2 years with the robot), and 2009-2011 (3-5 years after acquiring the robot) were compared using χ(2) tests and analysis of variance. The numbers of hysterectomies reported in resident case logs were also collected and compared. A total of 5894 hysterectomies were performed between 2005 and 2011. The total number of hysterectomies performed at Hospital A, which acquired the robotic surgical system, increased over time (p = .04) but remained stable at Hospital B, which did not acquire the robotic surgical system. At Hospital A, the number of robotic hysterectomies increased as the number of abdominal hysterectomies decreased (p < .001), a trend consistent across all diagnostic categories. The number of vaginal and laparoscopic hysterectomies remained stable. Resident case logs also reflected a decrease in the number of abdominal hysterectomies (p = .002) and an increase in the number of combined laparoscopic/robotic hysterectomies (p < .001) performed. The total number of hysterectomies performed by residents was unchanged., Conclusion: Introduction of the robotic surgical system was associated with significant changes in the numbers and types of hysterectomies performed in both general and subspecialty gynecology. Although abdominal hysterectomies decreased as robotic hysterectomies increased, other hysterectomies did not. These trends mirror reported resident surgical experience and have implications for resident education., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Nine novel strains of halophilic and alkaliphilic lactic acid bacteria isolated from European soft and semi-hard cheeses by using a saline, alkaline medium (7 % NaCl, pH 9.5) were taxonomically characterized. The isolates were Gram-stain-positive, non-sporulating and non-motile. They lacked catalase and quinones. Under anaerobic cultivation conditions, lactate was produced from D-glucose with the production of formate, acetate and ethanol with a molar ratio of approximately 2 : 1 : 1. Under aerobic cultivation conditions, acetate and lactate were produced from D-glucose. The isolates were slightly halophilic, highly halotolerant and alkaliphilic. The optimum NaCl concentration for growth ranged between 2.0 % and 5.0 % (w/v), with a growth range of 0-1 % to 15-17.5 %. The optimum pH for growth ranged between 8.5 and 9.5, with a growth range of 7.0-7.5 to 9.5-10.0. Comparative sequence analysis of the 16S rRNA genes revealed that the isolates occupied a phylogenetic position within the genus Alkalibacterium, showing the highest sequence similarity (98.2 %) to Alkalibacterium kapii T22-1-2(T). The isolates constituted a single genomic species with DNA-DNA hybridization values of 79-100 % among the isolates and <29 % between the isolates and other members of the genus Alkalibacterium, from which the isolates were different in motility and flagellation, growth responses to NaCl concentrations and pH, and profiles of sugar fermentation. The DNA G+C contents were between 36.0 and 37.6 mol%. The cell-wall peptidoglycan was type A4β, Orn-D-Asp. The major components of cellular fatty acids were C14 : 0, C16 : 0 and C16 : 1ω9c. Based on the phenotypic characteristics and genetic distinctness, the isolates are classified as a novel species within the genus Alkalibacterium, for which the name Alkalibacterium gilvum sp. nov. is proposed. The type strain is 3AD-1(T) ( = DSM 25751(T) = JCM 18271(T)).

Two non-motile, rod-shaped gammaproteobacteria were isolated from marine sponges collected from the coast of Japan at Numazu. The isolates were oxidase- and catalase-positive facultative anaerobes that fermented carbohydrates. They required sodium ions for growth and were slightly halophilic, growing in the presence of 1.0-5.0 % (w/v) NaCl (optimum of 2.0 % NaCl). Under aerobic conditions, the major isoprenoid quinones were ubiquinone-9 and menaquinone-9 and the minor quinones were ubiquinone-8 and menaquinone-8. The major cellular fatty acids were C(18 : 1)ω7c, C(16 : 1)ω7c and C(16 : 0) and the hydroxy acids were C(10 : 0) 3-OH and C(12 : 0) 3-OH. The DNA G+C content was 48.3-48.7 mol%. Phylogenetic analysis of 16S rRNA gene sequences placed the isolates within the radiation of the genus Endozoicomonas in a broad clade of uncultured clones recovered from various marine invertebrates. The isolates exhibited 96.5-96.9 % 16S rRNA gene sequence similarity with Endozoicomonas elysicola MKT110(T) and Endozoicomonas montiporae CL-33(T), with which the isolates formed a monophyletic cluster with 100 % bootstrap support. The phenotypic features (carbohydrate fermentation, quinone system and some major cellular fatty acids) differed from those of members of the genus Endozoicomonas, which are aerobic, produce little or no menaquinone under aerobic conditions and possess different amounts of C(14 : 0) and C(18 : 1)ω7c. Although some phenotypic differences were identified, the isolates should be assigned to the genus Endozoicomonas on the basis of congruity of phylogeny and should be classified as representatives of a novel species, for which the name Endozoicomonas numazuensis sp. nov. is proposed. The type strain is HC50(T) ( = NBRC 108893(T)  = DSM 25634(T)). An emended description of the genus Endozoicomonas is presented.

Two novel strains of marine lactic acid bacteria, isolated from decaying marine algae collected from a subtropical area of Japan, are described. The isolates, designated O24-2(T) and O25-2, were Gram-positive, non-sporulating and non-motile. They lacked catalase and quinones. Under anaerobic cultivation conditions, lactate was produced from glucose with the production of formate, acetate and ethanol in a molar ratio of approximately 2:1:1. Under aerobic cultivation conditions, acetate and lactate were produced from carbohydrates and related compounds. The isolates were slightly halophilic, highly halotolerant and alkaliphilic. They were able to grow in 0-17.0% (w/v) NaCl, with optimum growth of strains O24-2(T) and O25-2 at 1.0-3.0 and 1.0-2.0% (w/v) NaCl, respectively. Growth of strain O24-2(T) was observed at pH 7.5-9.5, with optimum growth at pH 8.0-8.5. Comparative 16S rRNA gene sequence analysis revealed that the isolates occupied a phylogenetic position within the genus Alkalibacterium, showing highest similarity (99.6%) to Alkalibacterium putridalgicola T129-2-1(T). Although sequence similarity was high, the DNA-DNA relatedness value between strain O24-2(T) and A. putridalgicola T129-2-1(T) was 27%, indicating that they are members of distinct species. The DNA G+C contents of O24-2(T) and O25-2 were 43.7 and 44.4 mol%, respectively, and DNA-DNA relatedness between the isolates was 89%. The cell-wall peptidoglycan was type A4β, Orn-d-Asp. The major cellular fatty acid components were C(14:0), C(16:0) and C(16:1)ω9c. Based on phenotypic characteristics and genetic distinctiveness, the isolates were classified as representatives of a novel species within the genus Alkalibacterium, for which the name Alkalibacterium subtropicum sp. nov. is proposed; the type strain is O24-2(T) (=DSM 23664(T)=NBRC 107172(T)).

Eleven novel strains of marine-inhabiting lactic acid bacteria that were isolated from living and decaying marine organisms collected from a temperate area of Japan are described. The isolates were motile with peritrichous flagella and non-sporulating. They lacked catalase, quinones and cytochromes. Fermentation products from glucose were lactate, formate, acetate and ethanol. Lactate yield as percentage conversion from glucose was affected by the pH of the fermentation medium: approximately 55 % at the optimal growth pH of 8.0, greater than approximately 70 % at pH 7.0 and less than approximately 30 % at pH 9.0. The molar ratio of the other three products was the same at each cultivation pH, approximately 2 : 1 : 1. Carbohydrates and related compounds were aerobically metabolized to acetate and pyruvate as well as lactate. The isolates were slightly halophilic, highly halotolerant and alkaliphilic. The optimum NaCl concentration for growth was 2.0-3.0 % (w/v), with a range of 0-25.5 %. The optimum pH for growth was 8.0-9.5, with a range of 6.0-10.0. The G+C content of the DNA was 38.5-40.7 mol%. The isolates constituted two genomic species (DNA-DNA relatedness of less than 41 %) each characterized by sugar fermentation profiles. The cell-wall peptidoglycan of both phenotypes contained meso-diaminopimelic acid. The major cellular fatty acids were C(16 : 0) and a-C(13 : 0). Comparative sequence analysis of the 16S rRNA genes revealed that these isolates represent novel species constituting a phylogenetic unit outside the radiation of typical lactic acid bacteria and an independent line of descent within the group composed of the halophilic/halotolerant/alkaliphilic and/or alkalitolerant species in Bacillus rRNA group 1, with 94.8-95.1 % similarity to the genus Paraliobacillus, 93.7-94.1 % to the genus Gracilibacillus and 93.8-94.2 % to Virgibacillus marismortui. On the basis of possession of physiological and biochemical characteristics common to typical lactic acid bacteria within Bacillus rRNA group 1, chemotaxonomic characteristics and phylogenetic independence, a new genus and two species, Halolactibacillus halophilus gen. nov., sp. nov. and Halolatibacillus miurensis sp. nov., are proposed. The type strains are Halolactibacillus halophilus M2-2T (=DSM 17073T=IAM 15242T=NBRC 100868T=NRIC 0628T) (G+C content 40.2 mol%) and Halolactibacillus miurensis M23-1T (=DSM 17074T=IAM 15247T=NBRC 100873T=NRIC 0633T) (G+C content 38.5 mol%).

A novel glutamyl aminopeptidase (aminopeptidase A, EC 3.4.11.7) was purified from chicken meat by ammonium sulfate fractionation, ethanol fractionation, heat treatment, and successive column chromatographies of DEAE-Sepharose CL-6B and Sephadex G-200. The purified enzyme migrated as a single band on SDS-PAGE. The molecular weight of this enzyme was found to be 55,000 and 550,000 by SDS-PAGE and Sephadex G-200 column chromatographies, respectively. This enzyme hydrolyzed Glu- and Asp-, but not Leu-, Arg-, and Ala-2-naphthylamide (-2NA) at all. The optimum pH and temperature for hydrolysis of Glu-2NA was 7.5. and 70°C, respectively. Reducing agents such as cysteine and dithiothreitol inhibited the activity of this enzyme at concentrations of 1 mM. However, the activation by Ca(2+) and the inhibition by amastatin were not observed.