Low- and middle-income countries are underresourced in subspecialist care. This study describes a unique maternal-fetal medicine clinical fellowship training program at Moi University School of Medicine and Moi Teaching and Referral Hospital in Eldoret, Western Kenya. The first of its kind in Eastern Africa, it has met with success in the retention of highly qualified practitioners providing complex pregnancy care to a population that has been heretofore underserved.
TikTok has increasingly become a source of information about reproductive health. Patients seeking health information about oral contraception on TikTok may be influenced by videos containing misinformation or biased information.
This social media infodemiological study aims to provide a descriptive content analysis of the quality and reliability of oral contraceptive health information on TikTok.
Researchers screened 1,000 TikTok videos from December 2022 to March 2023 retrieved under various search terms related to oral contraceptives. Data, including engagement metrics such as views, likes, comments, saves, and shares, were recorded. Video content including contraceptive methods discussed, efficacy, tolerability, and side effects were recorded. Two reviewers independently used a modified DISCERN criteria and Global Quality Scale (GQS) to assess the quality and reliability of information for each video.
Five hundred seventy-four videos were analyzed after applying exclusion criteria. Videos had a median length of 27 seconds (Q1=13sec, Q3=57sec) and received a median of 35,000 total views (Q1=4856 views, Q3=411,400 views) and 166 views per day (Q1=28 views per day, Q3=2021 views per day). Video creators were 83.3% female and 58.7% white. The mean modified DISCERN score was 1.63 (SD=1.06) and the mean GQS score was 2.28 (SD=1.37). Video creators were 83.3% female and 58.7% white. The mean modified DISCERN score was 1.63 (SD=1.06) and the mean GQS score was 2.28 (SD=1.37). The most common topic discussed in the videos was the effects of contraception. Healthcare professionals had significantly higher DISCERN and GQS scores (p<.001) than non-healthcare professionals. However, they received fewer views, likes, and comments on their videos (p<.001). Healthcare professionals were 86 times more likely than non-healthcare professionals to post educational videos (p<.001). However, non-educational content received significantly more views, likes, and comments than educational content (p<.001).
TikTok videos related to oral contraceptive health had low quality and reliability of information. The majority of videos were made by non-healthcare providers, and the most common topic discussed was the effects of contraception. Videos made by healthcare professionals contained more reliable contraceptive information, but received less engagement than videos made by non-healthcare professionals. Healthcare providers should consider the prevalence of poor-quality information about oral contraceptives on social media when counseling and educating patients about reproductive health.
Preterm birth from intrauterine infection is a leading cause of neonatal neurologic morbidity. Likewise, maternal obesity is associated with intra-amniotic infection and inflammation. Whether maternal obesity is a risk factor for fetal brain injury that occurs with premature birth remains unknown. This study hypothesized that maternal obesity intensifies fetal neuroinflammation in the setting of premature delivery.
This study aimed to examine the influence of maternal obesity on perinatal neuroinflammatory responses that arise with preterm birth using a murine model.
Dams with obesity were generated via a high-fat diet that was maintained throughout pregnancy. In parallel, dams without obesity (normal) received a control diet. All dams were paired with males on normal diet. Pregnant dams were randomized to receive an intrauterine administration of bacterial endotoxin (lipopolysaccharide) or the vehicle (phosphate-buffered saline) on embryo day 15.5 of what is typically a 19- to 21-day gestation. Fetal brains were harvested 6 hours after intrauterine administrations, and the expressions of key inflammatory cytokines (Il1b, Il6, and Tnf) and panels of metabolic, immune, and inflammatory genes were analyzed.
With the phosphate-buffered saline, there was no difference in gene expression related to maternal obesity. There were substantial differences in Il6 and immune/inflammatory expression profiles in fetal brains from dams with obesity vs normal dams that received lipopolysaccharide. Few differences were observed among the metabolic genes examined under these conditions. The gene expression pattern associated with maternal obesity correlated with pathways related to white matter injury.
The expression of neuroinflammatory markers instigated by bacterial endotoxin via intrauterine lipopolysaccharide was greater in embryo brains obtained from dams with obesity. Expression profiles suggest that in combination with intrauterine inflammation, maternal obesity may increase the risk of fetal white matter injury. Further investigation is warranted to understand the relationship between maternal health and neurologic outcomes associated with prematurity.
Prolonged labor is the commonest indication for intrapartum cesarean section, but definitions are inconsistent and some common definitions were recently found to overestimate the speed of physiological labor. The objective of this review is to establish an overview of synonyms and definitions used in the literature for prolonged labor, separated into first and second stages, and establish types of definitions used.
A systematic search was conducted in PubMed, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier.
All articles in English that (1) attempted to define prolonged labor, (2) included a definition of prolonged labor, or (3) included any synonym for prolonged labor, were included.
Data on study design, year of publication, country or region of origin, synonyms used, definition of prolonged first and/or second stage, and origin of provided definition (if not primarily established by the study) were collected into a database.
In total, 3402 abstracts and 536 full-text papers were screened, and 232 papers were included. Our search established 53 synonyms for prolonged labor. Forty-three studies defined prolonged labor and 189 studies adopted a definition of prolonged labor. Definitions for prolonged first stage of labor were categorized into: time-based (n=14), progress-based (n=12), clinician-based (n=5), or outcome-based (n=4). For the 33 studies defining prolonged second stage, the majority of definitions (n=25) were time-based, either based on total duration or duration of no descent of the presenting part.
Despite efforts to arrive at uniform labor curves, there is still little uniformity in definitions of prolonged labor. Consensus on which definition to use is called for, in order to safely and respectfully allow physiological labor progress, ensure timely management, and assess and compare incidence of prolonged labor between settings.
In high-resource settings, biomarkers of angiogenic balance, such as the soluble fms-like tyrosine kinase-1 (sFlt1)/placental growth factor (PlGF) ratio, have been studied extensively to aid in evaluation of patients with suspected preeclampsia (PE), and have been incorporated into the 2021 International Society for the Study of Hypertension in Pregnancy definition of PE. The utility in under-resourced settings has not been as well characterized.
This analysis sought to identify the role of the sFlt1/PlGF ratio in the evaluation of patients with or without hypertension who are suspected of having PE without other diagnostic information.
This is a secondary analysis of a prior prospective study of patients who were presented with suspected PE at ≥20+0 weeks’ gestation at a single academic tertiary care center. Patients were recruited in the parent study from July 2009 to June 2012. In the original study, clinicians were masked to biomarker results, and patients were followed by chart review. In this analysis, the performance of the sFlt1/PlGF ratio (≤38, >38, or >85) was assessed alone in identifying both hypertensive and non-hypertensive patients at risk of evolving into PE with severe features (PE-SF; American College of Obstetricians and Gynecologists’ definition) within two weeks of the triage visit (PE-SF2). Hypertension was defined as a blood pressure (BP)≥140/90 mmHg.
There were 1043 patients included in the analysis; of whom, 579 (55.5%) and 464 (44.5%) presented with or without hypertension, respectively. In triage, 332 (75.4%) of hypertensive patients presented due to BP concerns, and the remainder were evaluated due to other features (new-onset headache, proteinuria, or edema). On triage evaluation, 66.8% of all patients had a normal sFlt1/PlGF ratio ≤38, and 17.0% had an elevated ratio >85. Among hypertensive patients, a sFlt1/PlGF ratio ≤38 was a good rule-out test for PE-SF2 (negative likelihood ratio [LR-] of 0.15), and a ratio >85 was a good rule-in test (positive likelihood ratio [LR+] of 5.75). Among normotensive patients, sFlt1/PlGF was useful as a rule-in test for ratio >38 (LR+ 5.13) and >85 (LR+ 12.80). Stratified by gestational age, sFlt1/PlGF continued to be a good rule in and good rule out test at <35 weeks among those with hypertension but did not have good test performance ≥35 weeks. sFlt1/PlGF had a good test performance as a rule in test for >85 regardless of gestational age. In triage, 4.3% (30/693) of patients with sFlt1/PlGF ratio <38 had concurrent laboratory evidence of PE, compared with 15.9% (28/176) patients with ratio >85.
These findings support the potential for the use of sFlt1/PlGF and BP measurement alone in resource-limited settings where other laboratory tests or clinical expertise are u
Intrahepatic cholestasis of pregnancy has been linked to sudden stillbirth. The suddenness of the stillbirths in these cases have led clinicians to suspect that the pathogenesis of stillbirth in women with intrahepatic cholestasis of pregnancy is not related to asphyxia but rather to an undefined etiology. One leading hypothesis relates certain bile acid metabolites to myocardial injury.
The purpose of this study was to determine whether cord blood troponin I levels are increased in fetuses born to mothers with a diagnosis of intrahepatic cholestasis of pregnancy.
A prospective, case-control study was performed at a single institution between 2017 to 2019 in which 87 pregnant patients with a diagnosis of intrahepatic cholestasis of pregnancy (total bile acids ≥10 μmol/L) were enrolled as cases and 122 randomly selected pregnant patients (asymptomatic with intrapartum total bile acids <10 μmol/L) were enrolled as controls. Cord blood troponin I levels were measured at delivery in both groups using a commercially available chemiluminescent immunoassay. Values ≤0.04 ng/mL were considered negative. Values >0.04 ng/mL were considered positive. The primary outcome was the presence of elevated troponin levels in both cases and controls as a surrogate marker for cardiac status. Our secondary outcomes included neonatal intensive care unit stay, low Apgar scores, neonatal acidosis, and hypoxia indicated by cord blood pH and base excess levels at the time of birth. Chi square and t tests were performed to compare social and obstetrical variables. A P value of <.05 was considered significant. A stratification by total bile acids range of <40 μmol/L, 40 to 100 μmol/L, and >100 μmol/L was performed to assess the relationship between the different severities of intrahepatic cholestasis of pregnancy (by risk of fetal demise with those with total bile acids of >100 μmol/L considered at greatest risk) and the likelihood of a positive troponin I result. Finally, a logistic regression analysis was performed to determine if levels of ≥10 μmol/L were associated with elevated troponin levels.
The mean gestational age at delivery was 38.96±1.47 and 37.71±1.59 weeks of gestation in the controls and cases respectively (P<.001). The mean total bile acids values were 5.2±1.28 ng/mL and 43.2±40.62 ng/mL in the controls and cases respectively (P<.001). Cord blood troponin I was positive in 15 of 122 (12.30%) controls and in 20 of 87 (22.99%) cases. (P<.001). When further stratified by total bile acids levels of <40, 40 to 100, and >100 μmol/L, we found a positive correlation between higher total bile acids levels and a positive troponin I test (P=.002). When controlling for gestational age at delivery, maternal age, and body mass index, higher total bile acids
Rates of maternal mortality are highest in low-resource settings. Family members are often involved in the critical periods surrounding a maternal death, including transportation to health centers and financial and emotional support during hospital admissions. Maternal death has devastating impacts on surviving family members, which are often overlooked and understudied.
Our study aimed to explore the hospital experiences of family members surrounding a maternal death, and to define their access to and need for institutional and psychosocial support.
This mixed methods cross-sectional study was conducted at an urban tertiary hospital in Ghana. Maternal mortalities from June 2019 to December 2020 were identified using death certificates. Participants, defined as husbands or other heads of households in families affected by maternal mortality, were purposively recruited. An interview guide was developed using grounded theory. In-person semi‐structured interviews were conducted in English or Twi to explore impacts of maternal mortality on family members, with a focus on hospital experiences. Surveys were administered on types of and needs for institutional support. Interviews were audio recorded, translated, transcribed, coded with an iteratively-developed codebook, and thematically analyzed. Survey data was descriptively analyzed.
Fifty-one participants included 26 husbands of the deceased woman, 5 parents, 12 siblings, and 8 second-degree relatives. Interviews revealed an overall negative hospital experience for surviving family members, who expressed substantial dissatisfaction and distress. Four themes regarding the hospital experience emerged from the interviews: 1) poor communication from healthcare workers and hospital personnel, which contributed to 2) limited understanding of the patient's clinical status, hospital course, and cause of death; 3) maternal death perceived as avoidable; and 4) maternal death perceived as unexpected and shocking. Survey data revealed that only 10% of participants were provided psychosocial support following the maternal death event, yet 93.3% of those who did not receive support desired this resource.
The hospital experience was overall negative for family members and a lack of effective communication emerged as the root cause of this negative perception. Strategies to improve communication between healthcare providers and families are essential. In addition, there is an unmet need for formal mental health resources for families who experience a maternal death.
Maternal mortality in the United States is rising and many deaths are preventable. Emergencies, such as postpartum hemorrhage, occur less frequently in non-teaching, rural, and urban low-birth volume hospitals. There is an urgent need for accessible, evidence-based, and sustainable inter-professional education that creates the opportunity for clinical teams to practice their response to rare, but potentially devastating events.
To assess the feasibility of virtual simulation training for the management of postpartum hemorrhage in low-to-moderate-volume delivery hospitals.
The study occurred between December 2021 and March 2022 within 8 non-academic hospitals in the United States with low-to-moderate-delivery volumes, randomized to one of two models: direct simulation training and train-the-trainer. In the direct simulation training model, simulation faculty conducted a virtual simulation training program with participants. In the train-the-trainer model, simulation faculty conducted virtual lessons with new simulation instructors on how to prepare and conduct a simulation course. Following this training, the instructors led their own simulation training program at their respective hospitals. The direct simulation training participants and students trained by new instructors from the train-the-trainer program were evaluated with a multiple-choice questionnaire on postpartum hemorrhage knowledge and a confidence and attitude survey at 3 timepoints: prior to, immediately after, and at 3 months post-training. Paired t-tests were performed to assess for changes in knowledge and confidence within teaching models across time points. ANOVA was performed to test cross-sectionally for differences in knowledge and confidence between teaching models at each time point.
Direct simulation training participants (n=22) and students of the train-the-trainer instructors (n=18) included nurses, certified nurse midwives and attending physicians in obstetrics, family practice or anesthesiology. Mean pre-course knowledge and confidence scores were not statistically different between direct simulation participants and the students of the instructors from the train-the-trainer course (79%+/-13 versus 75%+/-14, respectively, P-value=.45). Within the direct simulation group, knowledge and confidence scores significantly improved from pre- to immediately post-training (knowledge score mean difference 9.81 [95% CI 3.23–16.40], P-value<.01; confidence score mean difference 13.64 [95% CI 6.79–20.48], P-value<.01), which were maintained 3-months post-training. Within the train-the-trainer group, knowledge and confidence scores immediate post-intervention were not significantly different compared with pre-course or 3-month post-course scores. Mean knowledge scores were significantly great
The increasing global prevalence of cesarean scar endometriosis necessitates a thorough understanding of the risk factors for postoperative recurrence, as this is crucial for developing preventive strategies and informed decision-making.
To obtain insight into the clinical risk factors for postoperative recurrence of cesarean scar endometriosis following open lesion resection.
The cohort for this study comprised 272 women, including 26 patients with postoperative recurrence and 246 without recurrence. Various parameters, including baseline characteristics, preoperative, intraoperative, and postoperative conditions, and follow-up information, were analyzed. A comparison of these parameters was made between patients with and without postoperative recurrence. Time-to-recurrence analyses were conducted using Cox's univariate and multivariate proportional hazard analyses, the Kaplan-Meier method, and the log-rank test.
The results revealed significant differences between patients with and without postoperative recurrence in terms of visual analog scale for abdominal pain (P=.008), method of surgery (P<.001), and incision length (P=.002). The Cox proportional hazard model identified the visual analog scale for abdominal pain ≥4 as a significant risk factor for postoperative recurrence (hazard ratio, 3.72 [95% confidence interval, 1.65–8.43]; P=.002). In addition, patients who received removal of scar, excision of mass, and exploration underneath the scar (named as integrated excision) had a lower risk of recurrence than those who received local excision of mass (hazard ratio, 0.14 [95% confidence interval, 0.04–0.48]; P=.002). Furthermore, older patients (aged ≥35 years) were found to have a lower risk of postoperative recurrence than those <35 years (hazard ratio, 0.35 [95% confidence interval, 0.12–1.04]; P=.058). In addition, the depth of involvement was identified as a meaningful factor in postoperative recurrence for patients with local excision of mass, as determined by the log-rank test (P=.018).
The study highlights that the visual analog scale for abdominal pain ≥4 is a risk factor for the recurrence of cesarean scar endometriosis after open lesion resection. Furthermore, the surgical method of integrated excision was identified as a protective factor.
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