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Connect the Dots—March 2017

Penick, Emily R. MD; Kliethermes, Chris MD; Grimstad, Frances MD; Chescheir, Nancy C. MD

doi: 10.1097/AOG.0000000000001921
Contents: Connect the Dots...

Financial Disclosure The authors did not report any potential conflicts of interest.

“Connect the Dots” begins with a brief comment on an article from an issue of Obstetrics & Gynecology selected by the Editor-in-Chief. The next author “connects” a piece that relates in some way to the synopsis she/he received. She/he then sends her/his “connection” only to the next author. The three authors making connections are members of the ACOG Junior Fellow Congress Advisory Council.

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Assessment of Transvaginal Ultrasound Cervical Length Image Quality

Obstet Gynecol 2017;129:536–41

A PubMed search on December 5, 2016, using the terms, “preterm birth” and “cervical length measurement” identified 341 articles published in the past 10 years. Cervical length measurements are used daily to inform decisions about cerclage and progesterone use, steroid therapy, inductions, and hospital admissions for preterm labor. It is important to standardize all imagining techniques to determine whether a study is normal or not, to follow change in measurements over time and with different ultrasonographers, and to provide evidence-based care.

Boelig et al (see page 536) report the results of almost 4 years of the Cervical Length Education and Review Program, a certification program sponsored by the Society for Maternal-Fetal Medicine and developed by several multidisciplinary organizations to standardize techniques for obtaining this clinically important measurement. Fewer than 700 people had completed Cervical Length Education and Review Program training, and 85% of these passed on the first submission. Failures resulted from very basic errors in image acquisition and measurement, based on submitted views. Among the 15% of first-time failures, 85% passed on repeat submission, suggesting that this skill can be learned.

The take-home messages are several: ultrasound measurements can be standardized and learned, and, as imagers, we underuse the opportunity to develop our skills using standards set by those in obstetrics and gynecology and radiology. The field of quality improvement has shown how important it is to do procedures the same way each time. By studying the educational process of certification in this particular procedure, these authors have provided an excellent example of how research in standardization can be completed and reported.

Nancy C. Chescheir, MD

University of North Carolina, Chapel Hill, North Carolina

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Modifying the Risk of Recurrent Preterm Birth: Influence of Trimester-Specific Changes in Smoking Behaviors

Am J Obstet Gynecol 2016 Nov 18. pii: S0002-9378(16)32058-0. [Epub ahead of print]

As mentioned in the previous Dot, the need to standardize cervical length measurement and develop skills associated with accurate measurements to aid with prediction and prevention of preterm birth cannot be overemphasized, especially in women at risk for recurrent preterm birth. Preterm birth remains the most common cause of neonatal morbidity and mortality in the United States. In addition to a shortened cervix, a combination of maternal, obstetric, and behavioral factors, such as drug, alcohol, and tobacco use, can modify a woman's risk for preterm birth. Women with a history of preterm birth are at increased risk for subsequent preterm birth, which is further increased if they use tobacco. Cessation of tobacco use is an excellent way of preventing cigarette-associated preterm birth. This study by Wallace et al highlights how smoking cessation can modify the risk of recurrent preterm birth.

In this study, mothers aged younger than 20 and those with limited prenatal care or late entry to care were more likely to smoke. Rates of recurrent preterm birth were highest in women who quit smoking in the third trimester or smoked throughout the pregnancy, despite adjusting for concomitant risk factors, whereas women who quit smoking early in the first two trimesters experienced similar preterm birth rates as nonsmokers. As obstetricians, we have the opportunity to screen for many modifiable risk factors and use resources to aid patients with smoking cessation. During pregnancy, patients may have more motivation to quit risky behaviors; thus, we should continue to screen for these risk factors and closely monitor patients who desire to quit.

Emily R. Penick, MD

Walter Reed National Military Medical Center, Bethesda, Maryland

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Quantitative Fetal Fibronectin to Predict Preterm Birth in Asymptomatic Women at High Risk

Obstet Gynecol 2015;125:1168–76

As mentioned in the previous Dot, preterm birth is the most common cause of neonatal morbidity and mortality in the United States. Predicting which patients are at risk is especially challenging, which may involve the maternal risk factors mentioned in the previous Dot. Identifying these patients early to start appropriate treatment, that is, antenatal corticosteroids, will help reduce morbidity and mortality. We use a thorough history and physical examination along with behavioral modification and cervical length measurements to help identify high-risk patients. Another method to determine patients' risk for preterm birth is fetal fibronectin. Typically, this test is used for its negative predictive value, with a negative result reassuring the unlikelihood of delivery within 7 days. The authors set out to determine whether it could be used for its positive predictive value.

In this study, the authors conclude that higher rates of preterm birth (2.5 times the relative risk) were associated with fetal fibronectin concentrations greater than 200. They also confirmed that a negative result was associated with a low likelihood of preterm birth, although quantitative levels of 10–49 ng/mL, which typically result as negative, had increased preterm birth rates. This study may lead to an improved use of a predictive test and reminds us, as scientists, that it is important to continually to look at the tests we perform. We need to identify weaknesses in these tests and ask ourselves how they can be improved and then follow-up on these changes to ensure they improve outcomes.

Chris Kliethermes, MD

Baylor College of Medicine, Houston, Texas

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Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients

AMA J Ethics 2016;18:1147–55

How can we improve? How can we review and improve our current techniques to serve our patients better? One quality improvement suggestion was published in the AMA Journal of Ethics regarding methods used to assess our transgender patients' readiness for hormonal and surgical transition. The current model, from the World Professional Association for Transgender Health, recommends mental health evaluations and psychotherapy, usually including a referral letter indicating the patient's readiness to initiate medical care.

The authors comment that this model can place undue burden on the person who is seeking gender-affirming treatment, requiring the mental health professional to act as gatekeeper. This model was created based on expert consensus on the ethical notion of nonmaleficence (first do no harm). However, contemporary studies suggest hormonal and surgical therapy is relatively safe and can improve a transgender person's quality of life.

The authors suggest the informed consent model as an alternative; it is routinely used in medicine. A risks–benefits discussion is conducted with the patient, and the best care option is chosen using scientific knowledge and an understanding of the patient's goals and expectations, supporting patient autonomy. The authors believe that the patient is best positioned to assess beneficence (what is best for the patient) and nonmaleficence. The model does not remove the awareness of treatment effect on a patient's psychosocial state but dispels the notion that the patient and clinician are incapable of discussing gender variance and its management, promoting supportive psychosocial treatment over gender-evaluating assessments, and enabling patient–clinician discussions regarding individualized treatment goals.

As health care providers seek to improve transgender care, it is important to continually evaluate the guidelines set in place to provide safe, affirming, and respectful care.

Frances Grimstad, MD

University of Kansas Medical Center, Kansas City, Kansas

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.