Department of Obstetrics and Gynecology Medical Student Works
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Item Intrauterine Fetal Demise and Bereavement Care(2022-03-24) Hand, Breanne L.; Gripe, Amanda M.Item IU School of Medicine Correctional Medicine Student Outreach Project(2022-10-22) Nunge, Rebecca A; Gates, Kayla L; Fazle, Trilliah; Garcia, Jennifer; Messmore, Nicole M; Agarwal, NeetaBackground: This project was founded on the basis that correctional medicine is an important component frequently missing from medical education. Opportunities to participate in medical care within correctional facilities, while concurrently engaging in discussions about disproportionate incarceration of certain populations and mass incarceration as a whole, will cultivate empathetic, socially-engaged, and passionate young physicians. This student organization was formed to facilitate clinical opportunities within correctional facilities and host events that focus on the broader socioeconomic and political context and forms of structural and cultural violence that have contributed to mass incarceration in the United States. Methods: In order to facilitate organizational goals, a relationship was fostered between IUSM and Dr. Kristen Dauss, the Chief Medical Officer of the IDOC. Following affiliation agreements, students may now gain clinical exposure at any facility in the state. Since its creation, IUCM has hosted virtual educational lectures, panels, and journal clubs, in collaboration with other student organizations and scholars in the field. The organization encourages engagement with original research in coordination with faculty advisors. We have also worked with administration to incorporate correctional health topics officially into the curriculum. Conclusions: As physicians who will practice medicine in the country with the highest incarceration rate in the world, having a fundamental understanding of topics related to correctional health, adverse health experiences while incarcerated, and longstanding traumatic effects of incarceration is imperative. IUCM’s goal is to create introductory materials and share resources relating to the socioeconomic and political context which has led to mass incarceration and the deficits in care for currently and formerly incarcerated people. Developing a better understanding of the justice system as well as the emotional, mental, and physical impact incarceration has on patients, and will stimulate interest in engaging with these concepts through research, volunteer work, educational events, and in patient care.Item PAS the Salt: A Case of Autoimmune Polyglandular Syndrome Type II(2021-03) d'Arnaud, Lindsey; Owusu, Raiven; Vinze, Sanjna; Vucescu, Raluca I.CASE DESCRIPTION: Here we present the case of a 71 year old female with a decades-long history of Hashimoto thyroiditis and vitiligo who developed Addison Disease (AD). Routine labs showed serum sodium of 124, and the patient reported fatigue and lightheadedness on follow-up with her primary care physician. Despite discontinuation of hydrochlorothiazide, subsequent labs showed Na of 112 and she was sent to the emergency department and found to have hypoosmolar hyponatremia consistent with syndrome of inappropriate antidiuretic hormone secretion. Fluid restriction, saline infusion, and later sodium-chloride tablets failed to improve sodium levels two days after admission. Further investigation revealed low morning cortisol that did not respond to adrenocorticotropic hormone (ACTH) stimulation, demonstrating adrenal insufficiency. Later workup revealed elevated serum ACTH and positive 21-hydroxylase antibodies consistent with autoimmune adrenalitis. CONCLUSION: AD, albeit rare, is important to consider in severely hyponatremic patients with established monoglandular endocrinopathy. CLINICAL SIGNIFICANCE: The patient has autoimmune polyglandular syndrome type II (PAS-II), defined by the presence of AD and either autoimmune thyroid diseases (AITDs) and/or type one diabetes mellitus; patients may also exhibit other autoimmune conditions such as pernicious anemia, premature ovarian failure, alopecia, vitiligo, celiac disease, or multiple sclerosis. PAS-II is a rare diagnosis with a prevalence of 1-2 per 100,000 and a male-to-female ratio of 1:3. It is usually not recommended to routinely screen for other autoimmune diseases in patients with existing AITDs. Autoimmune endocrinopathies pose potential harms to patients, such as life-threatening adrenal crisis, metabolic derangements, infertility, and worsened quality of life; these harms ought to be considered in deciding if and how often to screen for concomitant autoimmune disorders in patients with monoglandular autoimmune endocrinopathies.Item Treatment of Opioid Use Disorder During Pregnancy: Buprenorphine or Methadone?(2020-03) Davis, Elizabeth; Owusu, Raiven; Vinze, Sanjna; Arnaduo, CamillaBACKGROUND: In 2011, 5% of pregnant women 15 to 44 yo reported opioid/illicit drug use during pregnancy, and this percentage is rising. Opioid use disorder (OUD) is a chronic disease associated with adverse effects on maternal and fetal health, such as physiologic withdrawal at birth, low birth weight, congenital abnormalities, and higher relapse rates. Pregnant women treated for OUD with medication-assisted-treatment (MAT) have significantly reduced adverse effects. MAT is the standard treatment of OUD in along with counseling/therapy. Opioid agonists, namely buprenorphine and methadone, are common treatments, as they prevent opioid withdrawal symptoms, improve adherence to prenatal care, and reduce the risk of relapse. CASE: Patient is a 26 year old G2P1 female presenting with buprenorphine, heroin, and methamphetamine use during pregnancy. She had a vaginal delivery of a healthy baby girl at 40+2 weeks (APGARs 8 and 9). She used heroin during the first trimester of pregnancy and started buprenorphine treatment at 5 months’ gestation. Pregnancy complicated by a 3 weeks in a rehab center at 8 months following relapse on methamphetamine. CLINICAL SIGNIFICANCE: Research is being conducted on the risks and benefits of buprenorphine vs methadone as MAT. Buprenorphine overall has better maternal and neonatal outcomes when compared to methadone. Mothers taking buprenorphine during their pregnancy were more likely to start MAT prior to or earlier in pregnancy and had longer gestations compared to methadone. In regards to neonatal outcomes, methadone has been associated with higher rates of neonatal mortality and congenital anomalies when compared to buprenorphine. NAS generally is less severe with buprenorphine, and newborns require treatment significantly less often and for a shorter duration. Newborns exposed to buprenorphine are associated with greater birth weight but more gastrointestinal abnormalities. With the increase in OUD during pregnancy, research regarding the most effective MAT is timely and critical.Item Developing a Minimally Invasive Cell-Based Model to Predict Response to Major Trauma(2020-07-31) Nunge, Rebecca A; Gates, Kayla L; Adom, Jamila; McKinley, ToddBackground. Physical trauma results in a systemic inflammatory response. Preliminary research in orthopedic trauma patients suggests that patients with similar demographics and severity of injury vary in their response to traumatic injury. Analysis of the immunological response post-injury showed a sustained pro-inflammatory response with delayed reparative cytokine expression in trauma sensitive patients, while the trauma tolerant patients had an early inflammatory expression with resolution by 72 hours post-injury. Thus, we hypothesize that differential response to non-traumatic injury might serve as a predictive tool for the identification of trauma tolerant and sensitive patients prior to injury. The goal of this research is to test whether immunological changes to inflammatory stimuli can predict tolerance or sensitivity to trauma using an-vitro cell-based assay. Methods. Splenocytes were isolated from naive C57BL/6 mice and subjected to biological trauma in vitro using LPS (100 ng/mL) or hypoxic trauma using hydrogen peroxide (50 µM, 100 µM, and 200 µM) with or without proinflammatory cytokines, IL-1β (1 ng/mL) , IL-6 (200 ng/mL), and IL-33 (150 ng/mL). Inflammation and hypoxia were assessed using IL-6 and HIF-1ɑ expression respectively via qPCR 24 hours post-treatment. Cell death and pro-inflammatory cytokine production using multiplex analysis were used to measure outcomes. Results. Both types of treatments showed increased cell death compared to the control group. qPCR data is pending. Conclusion. With these studies as a core of the experimental approach, this in vitro cell-based assay will be used to assess immunologic response to inflammatory stimuli across the genetic variation of mouse strains. Findings from this project could enable the development of a clinical test that accurately predicts immunologic response to trauma and related-complications based on patients’ sensitivity to pre-traumatic injury.Item Fatty acid metabolism disorder not found on prenatal testing(2022-03) Nunge, Rebecca A; Grismore, Myranda; Ganapaneni, Sruthi; Waters, Hallie; Rouse, Caroline ECase Description: A 26 year old G3P2001 presented for amniocentesis due to a family history of carnitine palmitoyltransferase 2 (CPTII) deficiency. Her first child developed seizures and passed away soon after birth; CPTII deficiency was diagnosed on the newborn screen. Both parents were confirmed to be carriers. For her second pregnancy, she opted against invasive testing. The newborn was treated proactively. Testing confirmed the child was not affected, and treatment was halted. In the current pregnancy, she opted for amniocentesis, which revealed an affected male. Background: CPT II deficiency is a rare autosomal recessive disease caused by a mutation in a gene encoding carnitine palmitoyltransferase 2, an essential enzyme in fatty acid oxidation. Affected patients are at risk for hypoketotic hypoglycemia, seizures, hepatomegaly, cardiomyopathy, arrhythmias, and other downstream issues. A postnatal diagnosis via the newborn screen does not confer the benefit of advanced awareness of the disease and allow for preemptive treatment. CPT II deficiency can be confirmed prenatally with diagnostic testing. Amniocentesis is an invasive test associated with a low but present risk of pregnancy loss, so some may opt against the test. Conclusion: Carriers of CPT II mutations are counseled that future pregnancies confer a 25% risk of having an affected child. Prenatal diagnostic testing is recommended for prenatal diagnosis, which allows for planning of immediate treatment in the NICU. However, opting to forgo invasive testing and preemptively treat potentially affected child until newborn screening results return, as occurred in this patient’s second pregnancy, is also an option. Clinical Significance: CPT II deficiency is a rare disease that can have devastating effects in newborns without a known diagnosis. Parents with known carrier status must be extensively counseled on their options regarding prenatal and postnatal screening as well as immediate newborn care.Item The Importance of Newborn Screening in the Detection of Congenital Hypothyroidism in Females(2019-11) Husain, Mahera; Nunge, Rebecca A; Rose, Maggie; Bittar, Julie; Zimmerman, Michelle KTitle: The importance of the newborn screen in detection of congenital hypothyroidism in females Authors: Mahera Husain, Rebecca Nunge, Maggie Rose, Julie Bittar. Michelle Zimmerman, MD Case: A nine-day-old female infant presented to the pediatric endocrinology clinic to establish care for congenital hypothyroidism. She was born vaginally at 36 weeks and 6 days, without complications to a 15-year-old mother with no past medical history or family history of chronic illnesses, including thyroid disease. At birth, she weighed 5 lb 10 oz, and was 19" long. Newborn screen showed TSH >1000 mcU/mL (reference 0.72-4.77) and free T4 of 0.3 ng/dL (reference 0.9-1.7). Exam revealed slightly indented anterior fontanelle, overriding sutures and a palpable posterior fontanelle. She had no palpable thyroid. Thyroid ultrasound showed no thyroid tissue in the neck. She was started on 37.5 mcg (16 mcg/kg) daily of levothyroxine. At two-month follow-up, TSH had decreased to 17 mcU/mL and free T4 1.1 ng/dL. Accordingly, her levothyroxine dose was increased. Two months later, her TSH was 25 mcU/mL and free T4 1.2 ng/dL. She will require lifelong thyroid supplementation and close follow-up. Conclusions: Newborn screening for thyroid defects is crucial to detect congenital hypothyroidism and prevent lifelong neurocognitive deficits and developmental delay. Clinical Significance: Congenital hypothyroidism has an incidence of 1:2000 in the United States. Females are twice as likely to be diagnosed with congenital hypothyroidism. Thyroid hormones are necessary for physical and neurological development, especially brain development. The prognosis for congenital hypothyroidism is excellent as long as medication is started early (as in this patient’s case). The severity of neurodevelopmental defects is related to the severity of the case, as well as how long the hypothyroidism is left untreated. The longer an infant goes without treatment, the more severe the deficit is, as demonstrated by lower IQ values. This case illustrates the need for comprehensive newborn screening for thyroid deficits. Newborn screening is a public health program whose recommendations vary by state, region, and country.Item Improving Health in Incarcerated Women(Indiana State Medical Association, 2022-06-06) Nunge, Rebecca A; Brown, Lucy; Clark, Sydney; Fazle, Trilliah; Cooper, Siena; Darroca, RobertWhereas, research often uses gendered language such as “women” or “woman” to describe patients; however, the authors of this resolution recognize that individuals of all gender identities can become pregnant; and Whereas, between 1980 and 2020, the number of incarcerated women in federal and state prisons and county jails has increased by more than 475%; and Whereas, though more men are incarcerated than women, the rate of growth for incarceration of women has been twice that of men since 1980; and Whereas, the imprisonment rate for Black women was 1.7 times the rate of imprisonment for White women, and the rate of imprisonment for Latinx women was 1.3 times the rate of White women in 2020; and Whereas, in 2020, Indiana had the 12th highest female imprisonment rate nationally, at 64 per 100,000, while the national average was 42 per 100,000; and Whereas, the number of women incarcerated in Indiana’s jails has increased more than 25-fold from 1970 to 2015, while the number of women in Indiana prisons has increased more than 19-fold from 1978 to 2017; and Whereas, a 1999 report by the Federal Bureau of Justice Statistics, which is the most recent report to study abuse prior to incarceration, found that 57% of women in state facilities had experienced sexual or physical abuse prior to their incarceration; and Whereas, the link between domestic violence and incarceration of women is evidenced by the fact that the crimes for which women are incarcerated are often directly related to domestic abuse; and Whereas, a 2008 report from the Bureau of Justice found 4% of state and 3% of federal inmates to be pregnant at the time of admission, while only 54% received some type of prenatal care; and Whereas, Indiana does not provide screening and treatment for high-risk pregnancies and only recently passed legislation to limit the use of restraints; and Whereas, a 2016-2017 survey conducted by the Pregnancy in Prison Statistics Project found 3.8% of newly admitted women and 0.6% of all women were pregnant in December 2016, with 92% of these pregnancies resulting in live births, meaning that policymakers and public health practitioners can optimize outcomes for incarcerated pregnant women and their newborns; and Whereas, a 2008 report from the Bureau of Justice found a statistically significant difference between reported specific medical problems among females (57% in state prisons, 52% in federal prisons) compared to their male counterparts (43% in state prisons, 36% in federal prisons), with arthritis, asthma, and hypertension being the most commonly reported problems; and Whereas, three fourths of incarcerated women are of childbearing age (18-44 years old), and therefore are still menstruating but must pay for their own feminine hygiene products if they do not have the means to afford necessary hygiene products; and Whereas, the AMA (H-525.974) recognizes the financial burden of feminine hygiene products, classifies them as medical necessities, and advocates they be provided free of charge to all incarcerated women; and Whereas, women have specific health needs, including reproductive, gynecologic, and prenatal care, trauma- informed mental health care, and substance abuse care; and Whereas, prisons remain ill-equipped to provide adequate mental and physical healthcare for women inmates; and Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; therefore, be it 78 RESOLVED, that ISMA seek and support legislation that improves access to comprehensive reproductive and physical health care services to women throughout their incarceration from intake to re-entry into the community; and be it further, RESOLVED, that ISMA seek and support legislation that increases allocation of healthcare for women’s prisons within the Indiana Department of Corrections and local county jails in Indiana; and be it further, RESOLVED, that the ISMA adopt AMA H-525.974, as amended, as follows: AMA ISMA: (1) recognizes encourages the Internal Revenue Service to classify feminine hygiene products as medical necessities; (2) will work with federal, local, state, and specialty medical societies, and other relevant stakeholders to advocate for the removal of barriers to feminine hygiene products in state and local prisons and correctional institutions to ensure incarcerated women be provided free of charge, the appropriate type and quantity of feminine hygiene products including tampons for their needs; and (3) encourages the American National Standards Institute, the Occupational Safety and Health Administration, and other advocates and seeks legislation for the state to provide access to free, readily-available feminine hygiene products to all incarcerated women. relevant stakeholders to establish and enforce a standard of practice for providing free, readily available menstrual care products to meet the needs of workers.Item Prevalence and Risk Factors of Gestational Diabetes in Twin Pregnancies: Population Based Study(2022-07-31) Mustafa, Hiba J.; Heydari, Mohammad H.; Nunge, Rebecca A.; Khalil, Asma; Habli, MouniraObjective: To assess the prevalence and risk factors of gestational diabetes (GDM) in twin compared with singleton pregnancies. Methods: Population-based study using CDC birth data from 2016-2020. Higher order pregnancies and pre-pregnancy diabetes were excluded. A Chi-square test of independence was performed to identify significant factors associated with GDM in twin versus singleton pregnancies and within each group independently. Multivariable regression analyses were performed first to assess risk factors that are significantly associated with GDM in twins and second to assess the risk of GDM in twin compared with singletons, adjusted for the significant risk factors. P value<0.01 was considered statistically significant Results: Total of 18,173,365 singleton and 611,043 twin pregnancies were included during the study period. Following the regression model, maternal age≥30 years, nulliparous, IVF, chronic hypertension, Hispanic and Non-Hispanic (NH) Asian, foreign-born, overweight and obesity class I/II/II remained significantly associated with GDM in twins. However, maternal age<25 years, NH Black, and W.I.C program reduced that risk. Factors that more than doubled the risk in twins were maternal age≥40 years (OR 2.06 (1.97 – 2.14), P<0.001), NH Asian (OR 2.12 (2.04 – 2.20), P<0.001), and obesity class I, II, and III (OR: 2.22 (2.16 – 2.29), P<0.001, OR:3.01 (2.92 – 3.11), P<0.001, OR: 3.80 (3.67 – 3.93), p<0.001, respectively). Following adjustment for all the significant risk factors, twin pregnancy remained significantly associated with increasing the risk of GDM in twin compared to singleton pregnancies (OR 1.22 (1.21 – 1.23), P<0.001). Conclusion: Of the significant risk factors, maternal age≥40 years, NH Asian, and obesity class I, II, and III more than doubled the risk of GDM in twins. Regardless of maternal demographics, obstetric history, and endocrine factors, twin pregnancy remained significantly associated with GDM compared to singleton pregnancies. These factors can be used in risk prediction models to better counsel and manage twin pregnancies.Item Hypoglossal Nerve Injury from LMA Placement in a 10 year old(2019-02-07) Hand, Breanne L.; McNeil-Masuka, Janelle K.; Hendrickson, Michele; Horn, Nicole; Boyer, Tanna J.