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Objective: To identify the current challenges in obstetrics and gynecology residency education and propose solutions to overcome these obstacles., Methods: The American College of Obstetricians and Gynecologists (ACOG) hosted the first National Summit on Women's Health on May 31 and June 1, 2017, with a follow-up meeting December 20-21, 2017, at ACOG headquarters in Washington, DC. Invitees from 20 related societies briefly presented their organizations' perspectives and discussed focused questions about specific challenges, proposed solutions, and anticipated obstacles. Finally, participants summarized their top two recommendations to improve current residency training., Results: Summit participants identified four primary areas of focus: 1) align curriculum with relevant topics to practice, 2) ensure faculty have the necessary resources and time to teach effectively, 3) consider using the final months of medical school to get a jump start on residency fund of knowledge and skills, and 4) use better assessments during the course of residency., Conclusion: Representatives of the Council on Resident Education in Obstetrics and Gynecology, the American Board of Obstetrics and Gynecology, and the Accreditation Council for Graduate Medical Education must work together to address these priorities and reach consensus on the curricular content of core training in obstetrics and gynecology.

Objective: To quantitate the contribution of various demographic factors to the U.S. maternal mortality ratio., Methods: This was a retrospective observational study. We analyzed data from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) from 2005 to 2014 that contains mortality and population counts for all U.S. counties. Bivariate correlations between the maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P<.05) in the univariate analysis to deal with multicollinearity among the existing variables., Results: The United States has experienced an increase in maternal mortality ratio since 2005 with rates increasing from 15 per 100,00 live births in 2005 to 21-22 per 100,000 live births in 2013 and 2014. (P<.001) This increase in mortality was most pronounced in non-Hispanic black women, with ratios rising from 39 to 49 per 100,000 live births. A significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population was demonstrated. Cesarean deliveries, unintended births, unmarried status, percentage of deliveries to non-Hispanic black women, and four or fewer prenatal visits were significantly (P<.05) associated with the increased maternal mortality ratio., Conclusion: The current U.S. maternal mortality ratio is heavily influenced by a higher rate of death among non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability and access or utilization by underserved populations are important issues faced by states seeking to decrease maternal mortality.

Objective: To investigate factors associated with differential state maternal mortality ratios and to quantitate the contribution of various demographic factors to such variation., Methods: In a population-level analysis study, we analyzed data from the Centers for Disease Control and Prevention National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) that contains mortality and population counts for all U.S. counties. Bivariate correlations between maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P<.05) in the univariate analysis to deal with multicollinearity among the existing variables., Results: The United States has experienced a continued increase in maternal mortality ratio since 2007 with rates of 21-22 per 100,000 live births in 2013 and 2014. This increase in mortality was most dramatic in non-Hispanic black women. There was a significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population. Cesarean deliveries, unintended births, unmarried status, percentage of non-Hispanic black deliveries, and four or less prenatal visits were significantly (P<.05) associated with increased maternal mortality ratio., Conclusion: Interstate differences in maternal mortality ratios largely reflect a different proportion of non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability, access, or utilization by underserved populations are an important issue faced by states in seeking to decrease maternal mortality.

Excessive gestational weight gain and obesity have been recognized as independent risk factors for maternal and fetal complications of pregnancy with significant lifelong consequences. These associations call into question the recently released Institute of Medicine (IOM) gestational weight gain recommendations, particularly for obese women. The IOM recommendation of a single standard of weight gain for all obesity classes is also of concern, because higher body mass index levels are associated with more severe pregnancy complications, such as preeclampsia and gestational diabetes. The IOM recommendations retained the 1990 focus on the theoretical association between poor gestational weight gain and low birth weight (LBW). Low gestational weight gain may often be a consequence and not the cause of LBW, and there is a lack of evidence in developed countries that dietary supplementation increases birth weight. Current obstetric practice allows for accurate and timely diagnosis of and intervention for LBW. We submit that gestational weight gain recommendations should be more individualized especially for obese women. Obese pregnant women should not be precluded from partaking in healthy lifestyle modifications in pregnancy that include physical activities, modified, judicious diets, and limited weight gain.

Acute traumatic injury during pregnancy is a significant contributor to maternal and fetal morbidity and mortality in the United States. Motor vehicle accidents are the leading cause of injury-related maternal death, followed by violence and assault. Lack of seat belts or other restraints increases the risks of both maternal and fetal morbidity and mortality. The American College of Obstetricians and Gynecologists recommends proper seat belt use by all pregnant women and screening for domestic abuse. Maternal injury and death from physical abuse is prevalent, and in some communities, homicide is a major cause of pregnancy-associated maternal death. Blunt trauma most often occurs as a result of motor vehicle accidents, whereas penetrating trauma results from gunshots or stabbings. Blunt trauma to the abdomen increases the risk for placental abruption, and direct fetal injury is more likely with penetrating trauma. Management strategies in acute maternal trauma must focus on a thorough assessment of the mother. A coordinated team effort that includes the obstetrician is essential to ensure optimal maternal and fetal outcomes. Imaging studies should not be delayed because of concerns of fetal radiation exposure, because the risk is minimal with usual imaging procedures, especially in mid-to-late pregnancy. The obstetrician should serve in a consultative role if nonobstetric surgical care is required and must also be prepared to intervene on behalf of the mother and the fetus if trauma care is compromised by the pregnancy. Perimortem cesarean delivery should be considered early in the resuscitation of a pregnant trauma victim, especially when fetal viability is a concern. Once the mother is stabilized in the emergency setting, she should be transported for appropriate maternal and fetal observation until both mother and fetus are clear of danger. It is essential that the clinician and staff maintain thorough and accurate documentation and recording of the chronology of events, the maternal and fetal assessment, and the management and outcome of the pregnancy.

Objective: Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced., Methods: The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995-1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented., Results: Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women., Conclusion: Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer.

A modified biophysical profile was assessed serially in 47 patients with premature rupture of membranes who were not in labor. This profile included fetal movement, fetal tone, fetal breathing, amniotic fluid volume, and placental grade. The most recent study, obtained within 2 days of delivery, was compared with pregnancy outcome as reflected by the development of chorioamnionitis and/or neonatal sepsis. No study patient received antibiotics, steroids, or tocolytics before labor. Neither the composite biophysical profile nor any of its components were found to be different between patients with and without clinical chorioamnionitis. Neonatal sepsis was not observed. These data do not support the use of the biophysical profile as a predictor of maternal infection.

Umbilical cord arterial and venous blood gas values were compared in 63 twin pairs, of which 57 pairs had birth weights of 1500 g or more each. Small differences between the first and second twins existed for PO2, PCO2, and pH. However, bicarbonate values did not differ significantly. These cord gas differences represent minor respiratory aberrations, as reflected by a tendency toward carbon dioxide retention by the second twin. Route of delivery, time interval between deliveries, and nonvertex presentations were not associated with significant deviations from these observed acid-base patterns.

Sonar biparietal diameter, femur length, abdominal circumference, femur length/abdominal circumference ratio, ponderal index, and estimated fetal weight were obtained within ten days of delivery of small-for-gestational-age (SGA) (N = 102) and non-SGA (N = 204) newborns. The effectiveness of each ultrasound variable in the antenatal recognition of the SGA fetus was assessed. An abnormal abdominal circumference was the best predictor, confirming SGA in 98% of cases. Other variables (biparietal diameter, femur length, femur length/abdominal circumference ratio, ponderal index, or estimated fetal weight) were less accurate for predicting SGA. When we determined expected results based on a 10% prevalence of SGA, negative predictive value was greater than 92% for all variables studied; however, with the exception of estimated fetal weight and femur length, positive predictive values were disappointing, including abdominal circumference (21%). This report establishes the limits of ultrasound-derived growth variables in the antenatal identification of the SGA fetus.

Ultrasonographic examinations, including placental grading, were done in 145 smoking and 100 nonsmoking low-risk obstetric patients at 37 weeks' gestation. Extensive calcification--grade III changes--occurred significantly more often in smokers than in nonsmokers (36 versus 14%; P less than .0001). Two groups of smokers, consuming five to 15 cigarettes per day or one or more packs per day, also had significant differences in grade III placenta when compared with nonsmokers. Smokers under age 20 years were more likely to have premature grade III changes; however, parity did not influence premature placental calcification in smokers and nonsmokers. The incidence of small for gestational age infants delivered was not significantly higher in smokers, and grade III placental changes appeared to occur no more often in SGA infants of smokers than of nonsmokers. Our findings suggest that the smoking gravida is at increased risk for premature placental calcification.