Department of Obstetrics and Gynecology Works

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Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial
(BioMed Central, 2015-02) Wiecha, John M.; Adams, William G.; Rybin, Denis; Rizzodepaoli, Maria; Keller, Jeremy; Clay, Jayanti M.; Department of Obstetrics and Gynecology, IU School of Medicine
Background Asthma is the most common chronic condition of childhood and disproportionately affects inner-city minority children. Low rates of asthma preventer medication adherence is a major contributor to poor asthma control in these patients. Web-based methods have potential to improve patient knowledge and medication adherence by providing interactive patient education, monitoring of symptoms and medication use, and by facilitation of communication and teamwork among patients and health care providers. Few studies have evaluated web-based asthma support environments using all of these potentially beneficial interventions. The multidimensional website created for this study, BostonBreathes, was designed to intervene on multiple levels, and was evaluated in a pilot trial. Methods An interactive, engaging website for children with asthma was developed to promote adherence to asthma medications, provide a platform for teamwork between caregivers and patients, and to provide primary care providers with up-to-date symptom information and data on medication use. Fifty-eight (58) children primarily from inner city Boston with persistent-level asthma were randomised to either usual care or use of BostonBreathes. Subjects completed asthma education activities, and reported their symptoms and medication use. Primary care providers used a separate interface to monitor their patients’ website use, their reported symptoms and medication use, and were able to communicate online via a discussion board with their patients and with an asthma specialist. Results After 6-months, reported wheezing improved significantly in both intervention and control groups, and there were significant improvements in the intervention group only in night-time awakening and parental loss of sleep, but there were no significant differences between intervention and control groups in these measures. Emergency room or acute visits to a physician for asthma did not significantly change in either group. Among the subgroup of subjects with low controller medication adherence at baseline, adherence improved significantly only in the intervention group. Knowledge of the purpose of controller medicine increased significantly in the intervention group, a statistically significant improvement over the control group. Conclusions This pilot study suggests that a multidimensional web-based educational, monitoring, and communication platform may have positive influences on pediatric patients’ asthma-related knowledge and use of asthma preventer medications.
Using Simulation to Assess the Influence of Race and Insurer on Shared Decision-making in Periviable Counseling
(Lippincott Williams & Wilkins, 2014-12) Edmonds, Brownsyne Tucker; McKenzie, Fatima; Fadel, William F.; Matthias, Marianne S.; Salyers, Michelle P.; Barnato, Amber E.; Frankel, Richard M.; Department of Obstetrics and Gynecology, IU School of Medicine
Introduction: Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision making (SDM) in periviable counseling. Methods: We conducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled 2 consecutive standardized patients diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation. We assessed verisimilitude of the simulation in semistructured debriefing interviews. We coded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework and then compared communication scores by standardized patient race and insurer using analysis of variance. Results: Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% were married, and 75% were parents; 91% of the physicians rated the simulation as highly realistic. Overall, SDM scores were relatively high, with means ranging from 6.4 to 7.9 (of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (P < 0.01 and P = 0.01, respectively). Between-group comparison revealed nonsignificant differences (P = <0.10) between the SDM scores for privately insured black patients versus privately insured white patients, Medicaid-insured white patients versus Medicaid-insured black patients, and privately insured black patients versus Medicaid-insured black patients. Conclusions: This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. Shared decision making may occur differentially based on patients’ sociodemographic characteristics and deserves further study.
Role of estrogen and progesterone receptors in neonatal uterine cell proliferation in the mouse
(2015-01) Cooke, P.S.; Nanjappa, M. K.; Medrano, T.I.; Lydon, J.P.; Bigsby, Robert M.; Department of Obstetrics and Gynecology, IU School of Medicine
The major endocrine regulators of the female reproductive tract are 17β-estradiol (E2) and progesterone (P4). This review discusses our recent work related to the roles of E2 and P4 and their receptors, estrogen receptor 1 (ESR1) and progesterone receptor (PR), respectively, in the neonatal uterus. Neonatal uterine cells in mice are mitogenically responsive to estrogens, but neonatal ovariectomy does not inhibit pre-weaning uterine cell proliferation, indicating that this process does not require endogenous estrogens. Neonatal uterine cell proliferation could result from ligand-independent growth factor activation of ESR1, or be independent of ESR1 neonatally despite its obligatory role in adult uterine epithelial proliferation. To determine the role of ESR1 in uterine development, we analyzed cell proliferation and uterine gland development (adenogenesis) in wild-type (WT) and Esr1 knockout (Esr1KO) mice postnatally. Our results indicate that pre-weaning uterine cell proliferation and adenogenesis are independent of ESR1, but these processes become dependent on E2/ESR1 signaling for maintenance and further proliferation and uterine growth during puberty. How pre- weaning uterine cell proliferation and adenogenesis occur independently of E2/ESR1 signaling remains unknown, but ligand-independent activation of ESR1 is not involved in this process. The synthetic glucocorticoid dexamethasone (Dex) inhibits luminal epithelial (LE) proliferation in neonatal mouse uteri, but it has been unclear whether Dex effects were mediated by glucocorticoid receptor (GR) and/or PR. We have used PR knockout (PRKO) mice to test whether PR is required for Dex inhibition of LE proliferation. Our results indicate that maximal inhibitory Dex effects on uterine LE proliferation require PR, possibly reflecting Dex crosstalk with PR. Inhibitory effects of Dex and P4 on LE proliferation may also involve GR binding, as indicated by the small but significant inhibition of LE proliferation by both Dex and P4 in PRKO mice.
Offering induction of labor for 22-week premature rupture of membranes: a survey of obstetricians
(Nature Publishing Group, 2015-08) McKenzie, Fatima; Tucker Edmonds, Brownsyne; Department of Obstetrics and Gynocology, IU School of Medicine
Objective: To describe obstetricians’ induction counseling practices for 22-week preterm premature rupture of membranes (PPROM) and identify provider characteristics associated with offering induction. Methods: Surveyed 295 obstetricians on their likelihood (0–10) of offering induction for periviable PPROM across 10 vignettes. Twenty-two-week vignettes were analyzed, stratified by parental resuscitation preference. Bivariate analyses identified physician characteristics associated with reported likelihood ratings. Results: Obstetricians (N=205) were not likely to offer induction. Median ratings by preference were as follows: resuscitation 1.0, uncertain 1.0 and comfort care 3.0. Only 41% of obstetricians were likely to offer induction to patients desiring comfort care. In addition, several provider-level factors, including practice region, parenting status and years in practice, were significantly associated with offering induction. Conclusions: Obstetricians do not readily offer induction when counseling patients with 22-week ruptured membranes, even when patients prefer palliation. This may place women at risk for infectious complications without accruing a neonatal benefit from prolonged latency.
Documentation of specific mesh implant at the time of midurethral sling surgery in women with stress incontinence
(Lippincott Williams & Wilkins, 2015-01) Kassis, Nadine C.; Thompson, Jennifer C.; Scheidler, Anne M.; Hale, Douglass S.; Department of Obstetrics and Gynecology, IU School of Medicine
Objective: We aimed to assess documentation completeness of the operative record for mesh implanted at the time of midurethral sling surgery and to identify modifiable predictors of documentation completeness. Methods: A retrospective cross-sectional study of women with stress incontinence who underwent midurethral sling placement between January 2009 and December 2011 was conducted. Data from the dictated operative note and nursing operative record were extracted to determine if the specific mesh implanted during surgery was documented. The primary outcome was the rate of documentation of mesh implanted in the physician's dictated operative note and in the nursing record. Logistic regression was used to determine if any characteristics were associated with the rate of documentation while accounting for correlation of patients from the same dictating surgeon. Results: There were 816 surgeries involving the implantation of a midurethral sling during the study period. All surgeries were performed at 6 Indiana University hospitals. Fifty-two surgeons of varying specialties and levels of training dictated the operative notes. A urogynecologist dictated 71% of the operative notes. The rate of documentation completeness for mesh implanted in the physician's note was 10%. The rate of documentation completeness for mesh implanted in the nursing operative record was 92%. Documentation of mesh implanted in the physician's note was not significantly associated with the level of training, specialty, or year of surgery. Conclusions: Documentation completeness for specific mesh implant in the physician's note is low, independent of specialty and level of training. Nursing documentation practices are more rigorous. Postmarket surveillance, currently mandated by the Food and Drug Administration, may not be feasible if only the physician's note is available or if nursing practices are inconsistent. Development of documentation guidelines for physicians would improve the feasibility of surveillance.
Response to Brosch et al.
(Elsevier, 2012-03-07) Pihlajamäki, Jussi; Lerin, Carles; Kaminska, Dorota; Venesmaa, Sari; Itkonen, Paula; Boes, Tanner; Floss, Thomas; Schroeder, Joshua; Dearie, Farrell; Crunkhorn, Sarah; Burak, Furkan; Jimenez-Chillaron, Josep C.; Kuulasmaa, Tiina; Miettinen, Pekka; Park, Peter J.; Nasser, Imad; Zhao, Zhenwen; Zhang, Zhaiyi; Xu, Yan; Wurst, Wolfgang; Ren, Hongmei; Morris, Andrew J.; Stamm, Stefan; Goldfine, Allison B.; Laakso, Markku; Patti, Mary Elizabeth; Department of Obstetrics and Gynecology, IU School of Medicine
We would like to respond to Brosch et al. regarding our manuscript “Expression of the Splicing Factor Gene SFRS10 Is Reduced in Human Obesity and Contributes to Enhanced Lipogenesis” (Pihlajamäki et al., 2011b). Brosch performed RT-PCR in liver samples from 13 lean and 34 obese individuals, finding no differences in SFRS10 or LPIN1 expression. We wish to address points raised by Brosch, including experimental strategy and analysis of human SFRS10 expression.
Glucose and lipopolysaccharide regulate proatherogenic cytokine release from mononuclear cells in polycystic ovary syndrome
(Elsevier, 2014-06) González, Frank; Kirwan, John P.; Rote, Neal S.; Minium, Judi; O’Leary, Valerie B.; Department of Obstetrics and Gynecology, IU School of Medicine
Women with polycystic ovary syndrome (PCOS) have chronic low-grade inflammation, which can increase the risk of atherogenesis. We examined the effect of glucose ingestion and lipopolysaccharide (LPS) on markers of proatherogenic inflammation in the mononuclear cells (MNC) and plasma of women with PCOS. Sixteen women with PCOS (8 lean, 8 obese) and 15 weight-matched controls (8 lean, 7 obese) underwent a 3-h oral glucose tolerance test (OGTT). Interleukin-6 (IL-6) and interleukin-1β (IL-1β) release from MNC cultured in the presence of LPS and plasma IL-6, C-reactive protein (CRP), and soluble vascular adhesion molecule-1 (sVCAM-1) were measured from blood samples drawn while fasting and 2 h after glucose ingestion. Truncal fat was measured by dual-energy absorptiometry (DEXA). Lean women with PCOS and obese controls failed to suppress LPS-stimulated IL-6 and IL-1β release from MNC after glucose ingestion. In contrast, obese women with PCOS suppressed these MNC-derived cytokines under the same conditions. In response to glucose ingestion, plasma IL-6 and sVCAM-1 increased and CRP suppression was attenuated in both PCOS groups and obese controls compared with lean controls. Fasting plasma IL-6 and CRP correlated positively with percentage of truncal fat. The absolute change in plasma IL-6 correlated positively with testosterone. We conclude that glucose ingestion promotes proatherogenic inflammation in PCOS with a systemic response that is independent of obesity. Based on the suppressed MNC-derived cytokine responses suggestive of LPS tolerance, chronic low-grade inflammation may be more profound in obese women with PCOS. Excess abdominal adiposity and hyperandrogenism may contribute to atherogenesis in PCOS.
The influence of resuscitation preferences on obstetrical management of periviable deliveries
(Nature Publishing Group, 2015-03) Edmonds, Brownsyne Tucker; McKenzie, Fatima; Hendrix, Kristin S.; Perkins, Susan M.; Zimet, Gregory D.; Department of Obstetrics & Gynecology, IU School of Medicine
Objective Determine the relative influence of patient's resuscitation preferences on periviable delivery management. Methods Surveyed 295 obstetrician-gynecologists about managing periviable preterm premature rupture of membranes. Across 10 vignettes, we systematically varied gestational age; occupation; method of conception; and resuscitation preference. Physicians rated their likelihood (0-10) of proceeding with induction, steroids, and cesarean. Data were analyzed via conjoint analysis. Results 205 physician responses were included. Median ratings for management decisions were: induction 1.89; steroids 5.00; cesarean for labor 3.89; cesarean for distress 4.11. Gestational age had the greatest influence on physician ratings across all decisions (importance values ranging from 72.6-86.6), followed by patient's resuscitation preference (range= 9.3-21.4). Conclusion Gestational age is weighted more heavily than patients’ resuscitation preferences in obstetricians’ decision-making for periviable delivery management. Misalignment of antenatal management with parental resuscitation preferences may adversely affect periviable outcomes. Interventions are needed to facilitate more patient-centered decision-making in periviable care.
Psychotropic Medications in Pregnancy and the Postpartum Period
(Libertas Academia, 2015-07) Haas, David M.; McHugh, Katherine W.; Durst, Paula J.; Rose, Sarah M.; Patil, Avinash S.; Department of Obstetrics & Gynecology, IU School of Medicine
Many pregnant women suffer from mental health conditions while pregnant. As providers and patients make decisions about risks of the conditions and treatments during pregnancy, information to populate those discussions is needed. Taking into account the physiologic changes in pregnancy, we may need to optimize medication therapy. This article reviews and summarizes some of the most common mental health conditions suffered in pregnancy: depression, bipolar disorder, anxiety, and psychosis. It further discusses the different medications used to treat them, as well as risks associated with these medications.
A retrospective comparison of antibiotic regimens for preterm premature rupture of membranes
(Ovid Technologies (Wolters Kluwer) - Lippincott Williams & Wilkins, 2014-09) Pierson, Rebecca C.; Gordon, Sashana S.; Haas, David M.; Department of Obstetrics & Gynecology, IU School of Medicine
OBJECTIVE: To evaluate whether the use of ampicillin and azithromycin leads to a similar latency period in preterm premature rupture of membranes as ampicillin and erythromycin and whether the substitution of azithromycin for erythromycin effects rates of other outcomes. METHODS: We performed a retrospective cohort study of women with preterm premature rupture of membranes between 24 and 34 completed weeks of gestation and compared two groups: those who received ampicillin and erythromycin and those who received ampicillin and azithromycin. Primary outcome was length of latency (defined as time from first antibiotic dose to delivery) and secondary outcomes were rates of chorioamnionitis, cesarean delivery, Apgar scores, birth weight, neonatal death, neonatal sepsis, and neonatal respiratory distress syndrome. RESULTS: Of 168 women who met inclusion criteria, 75 received ampicillin and erythromycin and 93 received ampicillin and azithromycin. There was no difference in latency between groups: 9.6±13.2 days (erythromycin) compared with 9.4±10.0 (azithromycin) days (P=.40). Secondary outcomes did not differ between groups. We had 80% power to detect a difference of 5 days. CONCLUSION: Among women with preterm premature rupture of membranes between 24 and 34 completed weeks of gestation, substitution of azithromycin for erythromycin in the recommended antibiotic regimen did not affect latency or any other measured maternal or fetal outcomes. LEVEL OF EVIDENCE: III.

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