Should antenatal testing be performed in patients with a pre-pregnancy BMI ≥ 35?

Possibly. Elevated BMI is associated with an increased risk for stillbirth (strength of recommendation [SOR], B; cohort studies and meta-analysis of cohort studies). Three studies found an association between elevated BMI and stillbirth and one did not.

Should we stop prescribing IM progesterone to women with a history of preterm labor?

YES, we should stop the routine prescribing of IM progesterone to prevent preterm delivery. A 2003 randomized controlled trial (RCT) found that weekly intramuscular (IM) 17 hydroxyprogesterone (17-OHP) for women with a singleton pregnancy and a history of spontaneous preterm delivery decreased the preterm delivery rate by 34% (strength of recommendation [SOR]: B, single RCT). However, the follow-up 2020 PROLONG RCT did not find that 17-OHP prevents preterm birth or improves neonatal outcomes.

Does tranexamic acid reduce mortality in women with postpartum hemorrhage?

When used in conjunction with the standard of care, 1 g intravenous (IV) tranexamic acid given 1 to 3 hours after delivery is associated with a significant reduction in maternal mortality from postpartum hemorrhage (PPH) (strength of recommendation: A, randomized controlled trial [RCT] and Cochrane review).

Clinical Inquiries: What are the benefits/risks of giving betamethasone to women at risk of late preterm labor?

Giving betamethasone to women at risk for delivery between 34 weeks 0 days and 36 weeks 6 days can lower by almost 40% the incidence of transient tachypnea of the newborn, severe respiratory distress syndrome, and the use of surfactant (strength of recommendation [SOR]: A, systematic review of randomized controlled trials [RCTs]). Betamethasone may increase neonatal hypoglycemia, but the hypoglycemia isn't associated with a prolonged hospital stay or other negative outcomes.

Hypertensive Disorders of Pregnancy.

Elevated blood pressure in pregnancy may represent chronic hypertension (occurring before 20 weeks' gestation or persisting longer than 12 weeks after delivery), gestational hypertension (occurring after 20 weeks' gestation), preeclampsia, or preeclampsia superimposed on chronic hypertension. Preeclampsia is defined as hypertension and either proteinuria or thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. Proteinuria is not essential for the diagnosis and does not correlate with outcomes.

The impact of Advanced Life Support in Obstetrics (ALSO) training in low-resource countries.

Objective: To examine the effects of the Advanced Life Support in Obstetrics (ALSO) program on maternal outcomes in four low-income countries.

Methods: Data were obtained from single-center, longitudinal cohort studies in Colombia, Guatemala, and Honduras, and from an uncontrolled prospective trial in Tanzania.

Results: In Colombia, maternal morbidity and the number of near misses increased after ALSO training, but maternal mortality decreased.

Management of Spontaneous Vaginal Delivery.

Most of the nearly 4 million births in the United States annually are normal spontaneous vaginal deliveries. In the first stage of labor, normal birth outcomes can be improved by encouraging the patient to walk and stay in upright positions, waiting until at least 6 cm dilation to diagnose active stage arrest, providing continuous labor support, using intermittent auscultation in low-risk deliveries, and following the Centers for Disease Control and Prevention guidelines for group B streptococcus prophylaxis. Most women with a low transverse uterine incision are candidates for a trial of labor after cesarean delivery and should be counseled accordingly.

The effect of prenatal support on birth outcomes in an urban midwestern county.

Objectives: In Dane County, Wisconsin, the black-white infant mortality gap started decreasing from 2000 and was eliminated from 2004 to 2007. Unfortunately, it has reappeared since 2008. This paper examines risk factors and levels of prenatal care to identify key contributors to the dramatic decline and recent increase in black infant mortality and extremely premature birth rates.

Low primary cesarean rate and high VBAC rate with good outcomes in an Amish birthing center.

Purpose: Recent national guidelines encourage a trial of labor after cesarean (TOLAC) as a means of increasing vaginal births after cesarean (VBACs) and decreasing the high US cesarean birth rate and its consequences (2010 National Institute of Health Consensus Statement and American College of Obstetricians and Gynecologists revised guideline). A birthing center serving Amish women in Southwestern Wisconsin offered an opportunity to look at the effects of local culture and practices that support vaginal birth and TOLAC. This study describes childbirth and perinatal outcomes during a 17-year period in LaFarge, Wisconsin.

Cesarean delivery.

Cesarean delivery rates rose from 20 to 33% of births in the United States from 2006-2009 without an accompanying improvement in neonatal outcomes. The cesarean rate may be safely decreased by increasing vaginal birth after cesarean, encouraging external cephalic version for breech presentation, maintaining operative vaginal delivery skills, and applying stricter criteria for operative intervention in labor dystocia. A variety of cesarean operative techniques are supported by randomized controlled trials.

Culturally specific maternity care in Wisconsin.

There are significant health disparities in maternity care in the United States. One way to decrease these disparities may be to improve prenatal care among underserved minority women. This article reviews cultural and ethnic issues that may impact maternity care within 5 different groups of women commonly seen by maternity care providers in Wisconsin: African American, Latina, Hmong, Amish, and immigrant women.

Venous thromboembolism during pregnancy.

Venous thromboembolism is the leading cause of maternal death in the United States. Pregnancy is a risk factor for deep venous thrombosis, and risk is further increased with a personal or family history of thrombosis or thrombophilia. Screening for thrombophilia is not recommended for the general population; however, testing for inherited or acquired thrombophilic conditions is recommended when personal or family history suggests increased risk.

Advanced life support in obstetrics (ALSO) international development.

Background: The Advanced Life Support in Obstetrics (ALSO) program helps pregnancy care providers learn the information and skills necessary to deal with urgent and emergent conditions that arise during pregnancy and delivery by using mannequins, mnemonics, and evidence-based approaches. Since its origin, the program has been disseminated internationally. Outside of North America, more than 18,000 clinicians have taken the ALSO course, and more than 1,200 ALSO individuals have been approved as ALSO instructors.

Prenatal ultrasound: a tale of two cities.

At the beginning of the 21st century, community-based physicians have a technology which is safe, noninvasive and relatively inexpensive. It allows immediate access to visual data inside the body for the evaluation of health and disease. Prenatal ultrasound is vital for the efficient provision of preventive care even in community health centers, where physicians may not be the delivering physicians.

A molar pregnancy detected by following beta-human chorionic gonadotropin levels after a first trimester loss.

This case report summarizes the sequence of events that led to the detection of a molar pregnancy missed by ultrasound and initial pathology examinations. This patient illustrates that following serial quantitative beta-human chorionic gonadotropin (B-hCG) levels after spontaneous, therapeutic, and elective abortions will help detect potentially life-threatening molar and ectopic pregnancies. Further research is needed to determine the optimal frequency of B-hCG testing.

Colposcopy: an evidence-based update.

Colposcopy is a diagnostic procedure, most commonly used in the diagnosis of cervical intraepithelial neoplasia and lower genital tract carcinoma. In this article, evidence-based management strategies are updated with discussion of the 2001 American Society for Colposcopy and Cervical Pathology Consensus Guidelines. Practice management issues include methods to improve cervical cancer screening rates, coding and billing, and telemedicine.

The Advanced Life Support in Obstetrics (ALSO) program: fourteen years of progress.

Background: The Advanced Life Support in Obstetrics (ALSO) program is a highly structured, evidence-based, two-day course designed to provide healthcare professionals with the knowledge and skills to manage the emergency conditions that can occur during childbirth.

Objectives: To document the number of ALSO-trained clinicians and instructors in the United States and internationally and to promote ALSO training among prehospital and disaster medicine professionals.

Methods: Records maintained by the American Academy of Family Physicians (AAFP) for each country where ALSO is taught were reviewed for: (1) the years and locations of the ALSO courses; (2) the number of ALSO-trained caregivers; and (3) the number of ALSO instructors.

Family medicine in Cuba: community-oriented primary care and complementary and alternative medicine.

Family physicians in Cuba and the United States operate within very different health systems. Cuba's health system is notable for achieving developed country health outcomes despite a developing country economy. The authors of this study traveled to Cuba and reviewed the literature to investigate which practices of Cuban family physicians might be applicable for US family physicians wishing to learn from the Cuban experience.

Advanced life support in obstetrics in Ecuador: teaching the teachers.

The advanced life support in obstetrics (ALSO) course is designed to help maternity care providers prepare for obstetrical emergencies. A team of 12 US physicians and a medical interpreter recently taught the ALSO course in Ecuador, with the goal of addressing Ecuador's high maternal and infant mortality rates. To have a greater impact, a teach-the-teacher model was used so that Ecuadorian physicians can now hold their own ALSO courses.

Teaching prenatal ultrasound to family medicine residents.

Prenatal ultrasound is a powerful diagnostic tool, but there has been little research on how to teach ultrasound to family physicians. The available evidence supports teaching through didactics followed by supervised scanning. Didactic topics include physics and machine usage, indications, fetal biometry, anatomic survey, practice management, ethical issues, and resources.