bluuebunny/crossref_metadata_2025 huggingface dataset:
Reduction of Cesarean Delivery Rates in South Florida: The MSMC Experience [ID: 1370319]
Authors: Kostolias Alessandra , Husnain Zia , James Jane , Lauture Adolphia , Mayrink Maximiliano , Perez Jorge
Published: May 2023

INTRODUCTION:

Mount Sinai Medical Center (MSMC) in Miami Beach, Florida, is home to a diverse and international obstetric population. In 2017, the state of Florida had a cesarean delivery (CD) rate for nulliparous, term, singleton, vertex (NTSV) of 31.1%, the highest in the nation. Mount Sinai Medical Center had a NTSV CD rate of 38.3%. The national rate of NTSV CD in 2017 was 26%. Mount Sinai Medical Center joined PROVIDE (Promoting Primary Vaginal Deliveries), a statewide initiative by the Florida Perinatal Quality Collaborative with the goal of improving maternal and newborn outcomes by applying evidence-based interventions and reducing NTSV CD rates.

METHODS:

The implementation of an obstetrics and gynecology residency program and monthly grand rounds contributed to an effort of evidence-based medicine. The interventions implemented were nurse education of labor positioning from Bundle Births and Spinning Babies, nursing recognition as “Vaginal Queen of the Month,” Bishop score documentation added to H&P, obstetric physicians assigned “Badge Buddies” next to their hospital ID cards disclosing their personal NTSV CD rate, and a pre-cesarean checklist for labor dystocia or failed induction.

RESULTS:

After 2 years of multifaceted interventions, MSMC had decreased its cesarean delivery rate for NTSV patients from 38.3% in 2017 to 27.7% in 2019. The average rate in Florida overall was 29.7% in 2019 and the national rate of CD in NTSV patients was 25.6% in 2019 (data source: FPQC Perinatal Indicator System).

CONCLUSION:

With continued interventions, we hypothesize that we will meet the healthy people 2030 target CD for NTSV rate of 23.6% as the initiative enters its sustainability phase.
Effect of Single-Unit Transfusion Guideline on Red Blood Cell Transfusion for Obstetric Patients [ID: 1375663]
Authors: Triebwasser Jourdan , Bailey Joanne , Carver Alissa , Hyatt David , Logan-Sitko Ashley , Smith Roger
Published: May 2023

INTRODUCTION:

The American Red Cross recently declared a national blood crisis. We aimed to evaluate the effect of a single-unit transfusion guideline on the transfusion rate.

METHODS:

An interdisciplinary quality improvement initiative to reduce blood transfusion for postpartum hemorrhage (PPH) was conducted in a tertiary obstetric hospital with approximately 5,000 births annually. Opportunities for improvement were prioritized including antepartum anemia treatment, early recognition and treatment of PPH, and blood stewardship. The baseline period was January 2019 to December 2020. The intervention period was July 2021 to April 2022. We recommended transfusions begin with an order for a single unit of blood (“Start with One”). Plan-do-check-act cycles were initiated. The clinical outcome was units of blood transfused per 1,000 deliveries. Relative risks, t tests, and control charts were used for analysis. The quality improvement project was IRB exempt (HUM00213652).

RESULTS:

Incidence of PPH decreased between baseline and intervention periods (relative risk 0.83, 95% CI 0.77–0.90). The baseline transfusion rate was 79.3 units of blood per 1,000 births. During the intervention period, this decreased by 32.8% to 53.2 units per 1,000 births (P=.004). Special cause variation was found after introduction of the “Start with One” campaign: 8 consecutive months in the intervention period have been above the mean proportion for single-unit transfusions.

CONCLUSION:

A single-unit transfusion guideline, as part of a multimodal strategy to reduce PPH, was associated with a significant decrease in red cell transfusion. The current national blood shortage should be a call to action for all obstetric providers to safely reduce the volume of blood transfusions.
Adapting Obstetric-Capacity Assessments to a Rural Context to Drive System Improvements [ID: 1375979]
Authors: Glover Annie , Brown Diane , Fertaly Kaitlin , Holman Carly , McCracken Clayton , Nelson Megan
Published: May 2023

INTRODUCTION:

As part of its Health Resources and Services Administration Maternal Health Innovation, Centers for Disease Control and Prevention (CDC) ERASE MM, and the American College of Obstetricians and Gynecologists Alliance for Innovation on Maternal Health (AIM) awards, Montana assessed capacity to provide risk-appropriate care in Montana's hospitals with labor and delivery (L&D) units as well as critical access hospitals (CAHs) without L&D units that serve remote communities in maternity care deserts.

METHODS:

Montana conducted the CDC LOCATe assessment in 96% (N=25) of hospitals with an L&D and adapted an assessment used internationally by the World Health Organization to assess emergency obstetric capacity in 94% of CAHs without an L&D. Surveys were conducted in REDCap, and the research team provided facilities with technical support in their completion of the assessments.

RESULTS:

While half of CAHs without L&D reported an emergency delivery in the last 2 years, just one reported capacity to perform all services necessary to safely manage emergency deliveries. Two-thirds of facilities without L&D units did not have a written transport protocol. In hospitals with L&D who conducted the LOCATe assessment, nearly half (48%) overestimated the level of maternal health care that they were able to provide. Ultrasound and maternal-fetal medicine were the most common capacity insufficiencies.

CONCLUSION:

The system assessments revealed specific interventions that can expand capacity for quality obstetric care in a rural state like Montana, such as simulation training, adoption of AIM safety bundles through the perinatal quality collaborative, and enhanced access to ultrasound and maternal-fetal medicine services through telemedicine. National assessments like LOCATe should be adapted for the rural context to facilitate targeted resource investments.
A Simulation Model of the Effects of Tailored Prenatal Care Delivery on Care Access [ID: 1377136]
Authors: Kandiraju Meghana , Bryan Timothy , Cohn Amy , Ghrayeb Leena , Kingston Cole , Peahl Alex
Published: May 2023

INTRODUCTION:

The Michigan Plan for Appropriate Tailored Healthcare in pregnancy (PATH) recommends tailoring prenatal care delivery to patients’ risk factors for visit number (for low risk: 8–9 visits; for high-risk patients: 12–14 visits) and preferences for care modality (in-person only or hybrid with virtual visits). We used simulation to explore how tailored prenatal care recommendations affect care access.

METHODS:

A discrete event simulation was created in C++ to assess the operational effects of tailored recommendations in comparison to standard care. Patients enter the system and are divided into low-risk and high-risk categories based on medical conditions. The simulation models dynamic patient arrivals, varied patient classifications, tailored pathways, heterogeneous durations of total care, and patient flow until each patient's pathway ends (eg, childbirth). Metrics captured include patient delays, overbooked appointments, and unused capacity. The model was run with 1,000 replications during a 52-week period with a 10-year warm-up period to reach steady-state equilibrium within the simulation. The IRB designated this analysis of de-identified data exempt.

RESULTS:

Transitioning to the new prenatal care model reduced mean care delays per patient in all care modalities by 3.5 weeks for low-risk patients (9.79 weeks–6.37 weeks) and 0.4 weeks for high-risk patients (9.8 weeks–9.4 weeks). Tailoring care reduced the percentage of overbooked appointments by an average of 9.4% and the average unused capacity by 7.4%.

CONCLUSION:

Tailored prenatal care models including telemedicine result in improved operational efficiencies.
The Feasibility of Establishing a Canadian Obstetric Survey System (CanOSS) for Severe Maternal Morbidity: Interim Results [ID: 1377349]
Authors: D'Souza Rohan , Ashraf Rizwana , Malhamé Isabelle , Seymour Rebecca
Published: May 2023

INTRODUCTION:

Obtaining granular data on events and circumstances leading to severe maternal morbidity (SMM) could complement large epidemiologic studies and enable targeted interventions to improve maternal health. This study aims to assess the feasibility of gathering such data from maternity units across Canada through a Canadian Obstetric Survey System (CanOSS).

METHODS:

The study is a sequential explanatory mixed-methods study, the first step of which is a nationwide survey of maternity unit leads. Semistructured qualitative interviews are being conducted with unit leads that expressed interest in response to the survey. Responses are reported using proportions and percentages. Interviews are being thematically analyzed. This study was approved by the Hamilton Integrated Research Ethics Board (HiREB) #14002.

RESULTS:

As of October 18, 2022, we have identified 306 maternity units nationally, and sent 218 surveys, with 59 maternity units across 8 provinces completing. Among these, 34 (83%) report having a system in place for reviewing SMM, conducted on an as-needed basis in 61% of units, and most commonly involving a multidisciplinary panel of experts with representation from nursing (85%), maternity unit leadership (79%), and hospital management (74%). A written report is prepared following 76% of meetings. Findings are shared with health care professionals involved in the event and formulated into recommendations in 79% and 82% of units, respectively. Importantly, 78% of respondents would be willing to contribute anonymized data on SMM within a centralized reporting system. Interviews have taken place with 14 unit leads. Interviewed participants unanimously agree that an obstetric survey system is needed. Concerns raised include privacy, resources, funding, and having a clear definition of SMM.

CONCLUSION:

This feasibility study will facilitate future planning, clarify barriers to be addressed, and resource implications for gathering data on SMM at a national level, and lay the foundations for a future CanOSS.
Evaluation of Out-of-Hospital Cardiac Arrests in Births and Neonates: Opportunities to Improve Care [ID: 1377387]
Authors: Guise Jeanne-Marie , Eriksson Carl , Huynh Trang , Meckler Garth , Walker-Stevenson Grace
Published: May 2023

INTRODUCTION:

Home births have increased 77% from 2004 to 2017 and further increased with the COVID-19 pandemic. While the majority of home births are uneventful, some are complicated and require attendance of emergency medical services (EMS). Understanding characteristics of out-of-hospital births and EMS care is increasingly important to improve care.

METHODS:

We conducted a chart review of pediatric out-of-hospital cardiac arrests (POHCAs) from EMS agencies across the United States to evaluate the care provided by first responders. The study was approved by Oregon Health & Science University and respective IRBs.

RESULTS:

Of 1,020 POHCAs, 54 were responses to births and 43 were for other neonates. While most neonatal POHCAs occurred in a home or residence (84%), some births occurred at other locations such as a health care facility, public or commercial building, and street or highway. Bystander cardiopulmonary resuscitation was performed in less than half of births but more than half of other neonates. Return of spontaneous circulation was twice as likely for births as for other neonates (27% versus 13%). Overall, serious adverse safety events were observed in three-fourths of neonatal resuscitations. Births were more likely to be associated with failure to follow the correct resuscitation algorithm and lack of positive pressure ventilation.

CONCLUSION:

There are unique challenges in the care of out-of-hospital births for the EMS system. There is an opportunity to improve use of neonatal resuscitation protocols and early ventilation.
Qualitative Evaluations of Patient–Provider Interactions and Experience in Obstetric Transport [ID: 1377912]
Authors: Garcia Eliana , Banwarth-Kuhn Brenna , Hong Emily , McGuire Brenna , Quiner Trevor
Published: May 2023

INTRODUCTION:

Rural patients who require complex obstetric care are dependent on transport services to higher-level facilities. The objective of this study is to describe the efficacy of provider–patient interactions in informed consent, transport processes, and overall quality of care during emergency transport to the University of New Mexico Hospital (UNMH), the only level 1 trauma center receiving complex patients from multiple states.

METHODS:

Participants transported for emergency obstetric indications were recruited at UNMH. Institutional review board approval was obtained for demographic questionnaires, interviews, and surveys graded on a 5-point Likert scale were delivered via in person, telephone, or Zoom software and securely recorded. English interviews were transcribed via Otter.ai. Spanish interviews were manually translated.

RESULTS:

Preliminary results consisted of 10 patients living on average 3 hours from UNMH. While 90% of respondents reported that they had a good overall transport experience, 40% had concerns about personal safety and 50% for their baby's safety during transport. Additionally, 20% felt that their provider did not explain why they required transport and 30% did not understand why they were transported. A strong majority of participants (80%) reported no alternatives to transport being provided.

CONCLUSION:

Overall, rural obstetric patients who required transport to UNMH report a positive experience. However, some patients felt uninformed, did not understand the reason for their transport, and/or had fears about their safety and their baby's safety. Future studies should aim to understand the complex patient and provider factors that contribute to a patient's understanding during the consent process and how this affects patient perceptions and outcomes.
Postpartum Hemorrhage Prevention Quality Improvement Initiatives and Blood Transfusion Utilization [ID: 1378079]
Authors: Berens Michaela , Chisholm Christian , Parsons Laura , Urban Amanda
Published: May 2023

INTRODUCTION:

The universal implementation of active management of the third stage of labor, quantitative assessment of blood loss, and hemorrhage risk assessment on admission is recommended to reduce the incidence and morbidity of postpartum hemorrhage. We evaluated the effect of these quality improvement (QI) initiatives, in addition to an active management protocol for iron deficiency anemia antepartum, on the use of blood transfusion during delivery hospitalization.

METHODS:

We obtained blood transfusion data for the obstetric service at a tertiary care university hospital from January 1, 2017 to July 13, 2022, as well as data for every delivery during that time period (N=11,101). Institutional review board approval was obtained for the study. Patients whose transfusions were administered for nonobstetric indications were excluded. We compared the frequency of blood transfusions and number of units transfused per patient before and after the implementation of QI initiatives.

RESULTS:

There was a significant downward trend in the frequency of blood transfusions (P=.003) and the number of units transfused per patient (P=.000006) during the study period. The transfusion rate was 3.3% in the year prior to any intervention and 1.78% after implementation of all QI initiatives. No differences were observed in the characteristics of the patient population relevant to hemorrhage risk during the study period.

CONCLUSION:

This study provides evidence that in addition to reducing postpartum hemorrhage and its morbidity, these QI initiatives also help reduce blood transfusion utilization.
Prediction of Severe Postoperative Anemia After Low-Risk Cesarean Delivery [ID: 1370554]
Authors: Onishi Kazuma , Kawakita Tetsuya
Published: May 2023

INTRODUCTION:

Postoperative laboratory tests after cesarean delivery are routinely performed. With an accurate prediction of individuals at an increased risk of severe postoperative anemia, we may safely reduce the number of routine postoperative laboratory tests. We aimed to develop a scoring system that predicts severe postoperative anemia (hemoglobin less than 7.0 g/dL) after low-risk cesarean delivery.

METHODS:

This was a retrospective case–control study. Individuals with placental abruption, placenta accrete, placenta previa, preeclampsia, HELLP, and blood loss greater than or equal to 1,000 mL were excluded. Predictive variables with P value less than .05 in simple and multivariate logistic regression models were used in the scoring system. Weighted points based on the logarithm of odds ratio in the multivariate logistic regression model were allocated to each factor, and the score was calculated as a summation of those points. Our IRB approved this analysis.

RESULTS:

Of 1,955 individuals analyzed, 35 (1.8%) had severe postoperative anemia. The predictive factors included preoperative Hb less than or equal to 10.0 g/dL (4.0 points), blood loss greater than or equal to 816 mL (1.0 point), body mass index less than or equal to 30.5 kg/m2 (1.0 point), and preoperative platelet greater than or equal to 194×1,000/mL (1.0 point). The area under a curve of the model was 0.92 (95% CI 0.88–0.97). Using score 3.0 as a cutoff, sensitivity, specificity, and positive and negative predictive values were 91.4%, 83.9%, 9.4%, and 99.8%.

CONCLUSION:

We created a scoring system for severe postoperative anemia with high discriminative ability.
Real-Time Assessment of Symptoms for Postpartum Care via a Smartphone Application: Pilot Evaluation [ID: 1376090]
Authors: Goodin Amie , Dhillon Karamveer , Jennings-Coulibaly Alexis , Roussos-Ross Dikea , Varma Deepthi , Wen Tony
Published: May 2023

INTRODUCTION:

Leading causes of morbidity and mortality in women occur in the postpartum period and include postpartum mood disorders, substance use disorders, hypertensive disorders, and infection. This study pilots Gator MOMitor, a smartphone application utilizing ecological momentary assessment (EMA) technology, which allows clinicians to monitor symptoms in at-risk postpartum women in real time.

METHODS:

Gator MOMitor used a HIPAA-compliant EMA platform to send tailored assessments through the app to postpartum women with health risks in the initial 6 weeks postpartum, including mood disorder (n=401), cesarean infections (n=162), preeclampsia (n=154), and diabetes (n=9). Nonresponsiveness or critical responses submitted by patients in the app generated a trigger based on assessment algorithms, prompting a call from a nurse for follow-up and/or referral.

RESULTS:

A total of 401 participants were enrolled. 60% identified as White race, 22% Black race, and 14% identified as Hispanic ethnicity. Half (52%) were enrolled in Medicaid, and most (84%) had a term delivery. A total of 3,778 assessments were completed in the app: 1,599 for postpartum mood, 620 for cesarean incision, 1,536 for hypertension, and 24 for diabetes. There were 52, 103, and 39 positive screenings, respectively, in mood assessments (≥12 on the Edinburgh Postnatal Depression Scale), hypertension (BP≥140/90), and cesarean incision concerns, and zero positive screens in the diabetes group. The assessment-based triggers from positive screens resulted in 209 nurse follow-ups, 35 face-to-face visits, and 8 hospital admissions.

CONCLUSION:

GatorMOMitor may be an effective tool for extended assessment and monitoring of postpartum women that could reduce maternal mortality and morbidity.
Diagnosis of Fetal Congenital Malformation as Risk Factor for Postpartum Depression [ID: 1377045]
Authors: Doroskin Tatiana , Broome Sidney , Dallas Madison , Kinzer Carly , Roussos-Ross Dikea , Razavi Mehrsa Sadat
Published: May 2023

INTRODUCTION:

Annually, more than 7.9 million children, or 6% of all neonates worldwide, are diagnosed with fetal congenital malformations (FCMs). This diagnosis is the second largest cause of infant mortality and is an important cause of maternal vulnerability during pregnancy. This study aims to determine whether the incidence of postpartum depression (PPD) is increased in mothers with FCM, in comparison to mothers without such diagnosis.

METHODS:

A retrospective chart review was conducted between January 1, 2015, and April 1, 2022. Inclusion criteria required a) at least one prenatal visit, b) a postpartum visit, c) completion of Edinburgh Postpartum Depression Scale (EPDS), and d) prenatal diagnosis of FCM. The control group required a–c with absence of significant perinatal complications. Two hundred FCM and 200 control participants were included. An EPDS score of greater than 12 was considered positive and at risk of PPD. Independent-samples t test and χ2 analysis were conducted.

RESULTS:

Independent-samples t test, comparing the study and control participants, noted a statistically significant difference in at-risk EPDS scores. Mothers with FCM diagnosis scored higher on questions 3, 7, and 8. Chi-square analysis noted a statistically significant difference in risk of PPD between mothers with FCM and those without such diagnosis.

CONCLUSION:

Mothers with a diagnosis of FCM are more likely to score higher on EPDS and be at-risk for PPD, thereby revealing the importance to closely monitor their psychiatric status. Future studies should analyze the incidence of maternal psychiatric diagnoses based on the severity of newborn intervention required postpartum.
Does a Lower Target of Postpartum Blood Pressure Reduce Readmission Rates in Patients With Hypertensive Disorders of Pregnancy? [ID: 1377089]
Authors: Ge Christina , Brathwaite Coryse , Grover Jennifer , Karpman Mitchell
Published: May 2023

INTRODUCTION:

The classification of normal blood pressure in the general population, as determined by multiple organizations including the American Heart Association, American College of Cardiology, and National Institutes of Health, has been evolving. In the pregnant and postpartum population, the threshold of normal blood pressure is higher. Postpartum hypertension has been estimated to affect 20% of women and plays a large role in maternal readmissions. In those with hypertensive disorders of pregnancy, the target postpartum blood pressure should be reevaluated in light of the lower thresholds of the general population.

METHODS:

This study included pregnant patients with singleton fetuses and a diagnosis of chronic hypertension, gestational hypertension, preeclampsia, and eclampsia who delivered at Luminis Health Anne Arundel Medical Center from January 2019 to 2022. The primary outcome was hospital readmission for a hypertensive diagnosis or related sequelae within the first 30 days of delivery. This study was approved by IRB ID 1735193-1.

RESULTS:

Out of 1,433 patients with hypertensive disorders of pregnancy, 55 patients (3.8%) were readmitted because of hypertensive disorders or related complications. Patients with a maximum blood pressure after delivery of greater than or equal to 150/100 mm Hg were significantly more likely to be readmitted (odds ratio 1.99 [1.06, 3.75]). The maximum blood pressure on the day of discharge and oral antihypertensive initiation were not significantly associated with readmission.

CONCLUSION:

For postpartum patients with mild hypertension, a target blood pressure of below 150/100 mm Hg should be considered. Next steps include examining the effect of magnesium sulfate, furosemide, and discharge medication compliance in this population.
Subjective Versus Objective Pain Assessment in the Postpartum Period: Improving Pain Control After Vaginal Delivery [ID: 1378006]
Authors: Stewart Kali , Hincker Alexander , Holroyd Lauren , Rimsza Rebecca , Veade Ashley
Published: May 2023

INTRODUCTION:

The numerical pain rating scale (NPRS) is a validated measure to quantify acute pain; however, its utility after vaginal delivery is unclear. Poorly controlled postpartum pain can increase rates of complications; therefore, pain control is paramount. We investigated how subjective pain relates to objective pain in the postpartum period.

METHODS:

A prospective, observational study at a single academic hospital included patients with vaginal deliveries February to October 2021. Women with opioid use disorder, wound complication, hysterectomy, or readmission were excluded. Subjective pain assessment and NPRS were completed 2 weeks postdischarge. Subjective pain was recorded as “well controlled” versus “poorly controlled.” The numerical pain rating scale was scored 0–10.

RESULTS:

Two hundred thirty-eight patients were included, and 174 (73%) followed up. One hundred twenty (69%) reported “well-controlled” pain, and 54 (31%) reported “poorly controlled.” There was no significant difference in delivery mode, laceration, or nonopioid medication use (P>.05). Patients who used oxycodone were significantly more likely to report “poorly controlled” pain (P=.02). “Poorly controlled” pain was associated with higher median NPRS score (5 [interquartile range (IQR) 4–6] versus 2 [IQR 0–3], P<.001). Among patients with “poorly controlled” pain, 11 (20.4%) had NPRS scores of 0–3. Of those who reported “well-controlled” pain, 22 (18.3%) had NPRS scores of 4–10.

CONCLUSION:

While NPRS scores were higher for patients with “poorly controlled” pain, this was not universal. It is critical to accurately respond to postpartum pain for the nearly 20% of patients whose subjective experience did not correlate with their objective score. Titrating pain control to subjective and objective goals may improve patient experience and outcomes.
Postpartum Maternal Echocardiography and Its Effect on Hospital Management in Patients With Severe Preeclampsia [ID: 1378829]
Authors: Rekawek Patricia , Akerman Meredith , Corbo Anthony , Gubernikoff George , Kinzler Wendy , Vintzileos Anthony
Published: May 2023

INTRODUCTION:

Maternal echocardiography has demonstrated cardiac changes in the setting of preeclampsia; however, its effect on hospital management has not been well studied. The objective of this study was therefore to determine whether abnormal postpartum echocardiography is associated with a change in hospital management in patients with severe preeclampsia.

METHODS:

This was a retrospective cohort study of patients with severe preeclampsia (20–42 weeks) who received postpartum echocardiogram before discharge at a single academic institution from 2019 to 2021. The decision to obtain an echocardiogram was made by the primary physician. Patients with clinical indications for echocardiography (suspicion of heart failure and cardiomyopathy) were excluded. Hospital management outcomes included length of hospital stay, diuretic use, increasing antihypertensives, hospital readmission, and cardiology consultation. Patients with normal versus abnormal echocardiograms were compared using the chi-square test or Fisher’s exact test for categorical data and the two-sample t test or Mann-Whitney test for continuous data, with a value of P<.05 considered significant.

RESULTS:

One hundred forty five patients with preeclampsia who received maternal echocardiograms were included. Twenty-one (14%) had an abnormal echocardiogram, including left ventricle hypertrophy (n=9, 6%), pulmonary hypertension (n=5, 3.4%), moderate pericardial effusion (n=4, 2.7%), and enlarged atrial size (n=3, 2%). Patients with abnormal maternal echocardiograms were more likely to have a longer hospital stay (median stay of 7 days [5, 10] versus 5 days [4, 6], P=.003) and were more likely to receive diuretics (19.1% versus 4%, P=.03). There was no difference in adjustment of antihypertensives (61.9% versus 49.2%, P=.3), cardiology consultation (9.5% versus 6.5%, P=.6), or hospital readmission (4.8% versus 6.5%, P=1).

CONCLUSION:

Abnormal echocardiograms were associated with change in hospital management including longer hospital stay and more diuretic use. Abnormal postpartum echocardiography may be used to identify patients with more severe disease and adverse clinical outcomes. Further clinical utility of abnormal echocardiograms in severe preeclampsia should be evaluated.
What Is the Most Cost-Effective Timing for Postpartum IUD Insertion? [ID: 1379571]
Authors: Leonetti Alexis , Caughey Aaron , Chaiken Sarina , Doshi Uma , Hersh Alyssa
Published: May 2023

INTRODUCTION:

Postpartum intrauterine device (IUD) insertion is an effective contraception choice for reducing rates of unplanned and short-interval pregnancies. However, timing of placement is controversial, and risk of perforation and expulsion vary with timing. We aim to analyze the cost-effectiveness of postpartum IUD insertion intervals when considering risk of perforation or expulsion.

METHODS:

A decision-analytic model compared four intervals of postpartum IUD insertion: between 0 and 3 days, 4 days and 6 weeks, 6 and 14 weeks, or 14 and 52 weeks postpartum. A theoretical cohort of 600,000 was calculated using the estimate that 15.3% of postpartum people receive a long-acting reversible contraceptive. Probabilities, costs, and utilities were procured from the literature. Primary outcomes included IUD-related uterine perforation, expulsion, unplanned short-interval pregnancy, termination, stillbirth, ectopic pregnancy, and preterm delivery. The cost-effectiveness threshold was $100,000/quality-adjusted life-year (QALY).

RESULTS:

IUD insertion between 6 and 14 weeks postpartum was the cost-effective strategy despite having 1,978 and 1,982 additional perforations in intervals between 0–3 days and 14–52 weeks, respectively. All other outcomes were reduced. When compared to the intervals of 0–3 days, 4 days–6 weeks, and 14–52 weeks postpartum, this strategy resulted in 3,054, 282, and 3,816 more QALYs and decreased costs by $91 million, $22 million, and $316 million, respectively.

CONCLUSION:

Intrauterine device insertion between 6 and 14 weeks postpartum is the cost-effective strategy despite increased risk of perforation. Appropriately counseling patients on the risks and benefits associated with timing of IUD insertion is an important component of postpartum care.
Implementation of a Postpartum Furosemide Protocol in Patients With Hypertensive Disorders of Pregnancy (HDP) [ID: 1381582]
Authors: Foy Melissa , O'Reilly Geralyn
Published: May 2023

INTRODUCTION:

Increasing evidence has shown benefits with the use of furosemide for patients with hypertensive disorders of pregnancy (HDP) in the postpartum period. We compared outcomes of patients diagnosed with HDP who received a standard protocol of postpartum furosemide versus those who had routine postpartum care.

METHODS:

In February 2022, a standardized, multidisciplinary postpartum furosemide protocol was instituted for patients with HDP. Exclusion criteria included hypokalemia, receiving concomitant diuretics, creatinine greater than 1.2 mg/dL, stenotic valvular cardiac disease, hemodynamic instability, or body mass index less than 18. We compared patients prior to routine furosemide use (June 2020 to January 2022) to patients treated under the protocol (February 2022 to July 2022). Outcomes included hypertension defined as systolic blood pressure (BP) greater than 139 or diastolic BP greater than 89 at 6–14 days postpartum, need for additional antihypertensive medications, readmissions, and show-rate for postpartum outpatient visits. Nonparametric tests were used to compare outcomes between the groups. Study was exempt from the IRB.

RESULTS:

A total of 129 patients were identified who met inclusion criteria. 80 patients met criteria prior to protocol implementation, and 49 patients met criteria after implementation. The furosemide group had a significant reduction in hypertension at 6–14 days postpartum (22.86% versus 55.26%, odds ratio 0.24, 95% CI 0.09–0.66) compared to the group who did not receive furosemide. No adverse events were noted in the furosemide group.

CONCLUSION:

Administration of a short course of furosemide to postpartum patients with HDP appears to improve BP recovery in the days immediately after delivery. Further studies examining hemodynamic changes after furosemide use are needed.
Prepregnancy Plant-Based Diets and Risk of Hypertensive Disorders of Pregnancy [ID: 1377112]
Authors: Mitsunami Makiko , Chavarro Jorge , Ortiz-Panozo Eduardo , Rich-Edwards Janet , Souter Irene , Wang Siwen
Published: May 2023

INTRODUCTION:

Plant-based diets have been associated with a lower risk of cardiovascular disease in adults. Specific evidence for their relationship with the risk of hypertensive disorders in pregnancy (HDP) is scarce.

METHODS:

We followed 11,535 healthy women (16,892 singleton pregnancies) participating in the Nurses' Health Study II (1999–2009). Diet was assessed every 4 years using a validated food questionnaire, from which we calculated a plant-based diet index (PBDI; a higher score indicates higher adherence). The women self-reported HDP including preeclampsia and gestational hypertension (GHTN). We estimated the relative risk (RR) of HDP and PBDI (in quintiles) with log-binomial regression using generalized estimating equations with adjustments for potential confounders while considering pregnancies from the same woman.

RESULTS:

The mean age of women at their first in-study pregnancy was 35 years. We identified 495 cases of preeclampsia (2.9%), and 561 cases of GHTN (3.3%). Women in the highest quintile of PBDI had a 28% lower risk of HDP compared to women in the lowest quartile (95% CI: −11%, −42%; P-trend=.007). The association was stronger for GHTN (RR 0.63 [0.47, 0.84], P-trend<.001) than for preeclampsia (RR 0.73 [0.53, 1.02], P-trend=.23). Mediation analysis suggested that body mass index self-reported between dietary assessment and pregnancy explained 39% (95% CI 14–70%) of the relation between PBDI and HDP and 46% (95% CI 12–84%) of the relation between PBDI and GHTN.

CONCLUSION:

Higher adherence to plant-based diets was associated with a lower risk of developing HDP. Much of the benefit appears to be related to improved weight control.
Undetected Maternal Cell Contamination in Products of Conception Analysis May Mask Recurrence Risks for Future Pregnancies: A Case Report and Discussion [ID: 1377203]
Authors: Merrion Katrina , Campbell Lindsey , Hovanes Karine , Jelsema Russel , Maisenbacher Melissa
Published: May 2023

INTRODUCTION:

Maternal cell contamination (MCC) in products of conception (POC) tissue is common; some studies report 59% of 46,XX results represent MCC.

METHODS:

Products of conception tissue and maternal blood samples were shipped to a laboratory for genotyping using Illumina CytoSNP-12b microarrays and bioinformatics (IRB E&I 19040-03A). Patient informed consent was obtained for submission of a case report.

RESULTS:

A 25-year-old woman with a family history of recurrent pregnancy loss (RPL) was first offered POC analysis after her second loss. The result was normal female; however, MCC could not be ruled out because a maternal sample was not provided. Thus, the result was presumed normal, and the patient was informed her testing did not identify a genetic cause for her loss. The patient's third miscarriage was sent for POC analysis with a parental sample, which identified a maternally derived 26.8-Mb terminal deletion and 39.3-Mb terminal duplication of chromosome 4. The submitted maternal sample allowed for reanalysis of the second loss confirming MCC. Maternal karyotype analysis revealed an abnormal result: 46,XX,inv(4)(p15.2q31.3). The patient was referred to reproductive endocrinology for discussion of options, including in vitro fertilization with preimplantation genetic testing.

CONCLUSION:

Undetected MCC can lead to erroneous normal female results, masking fetal findings that could affect recurrence risks. Since 5% of couples with RPL have a balanced chromosome rearrangement, almost six couples for every 1,000 losses are at risk for undetected MCC masking recurrence risks (calculated using a 50% expected aneuploidy rate and 59% of 46,XX results actually representing MCC).
Provider Preferences for Utilization of Video Visits for Prenatal Care During the COVID-19 Pandemic [ID: 1375554]
Authors: Hersh Alyssa , Kernberg Annessa , Rincon Monica , Sarker Minhazur , Thirunagaru Koumudi , Valent Amy
Published: May 2023

INTRODUCTION:

The objective of this study was to assess providers' perceived advantages and disadvantages of prenatal care provision via video visits.

METHODS:

This was a cross-sectional survey of prenatal care providers in four academic institutions and their surrounding community sites across wide geographic areas of the United States in 2021–2022. Institutional review board approval was obtained by Oregon Health & Science University. The survey was distributed online via REDCap and consisted of 15 questions, which collected information about telehealth availability to patients, advantages and disadvantages of telehealth visits, and basic provider demographics. Analyses were conducted in STATA 17.

RESULTS:

There were 214 (42%) providers who completed the survey. The majority were female (82%), MD/DO (83%), older than 35 years (55%), and not trainees (61%). 155 (72%) providers reported they were conducted fewer than 10% of their visits via telehealth and 148 (69%) providers reported they had chosen not to offer a telehealth visit to a patient at least one time. The top three advantages of telehealth visits cited by providers included that patients can be located wherever is convenient for them, do not need to coordinate childcare for the appointment, and do not have to worry about exposure to infections like COVID-19. The top three disadvantages cited included inability to perform a physical exam, inability to obtain in-office urine or other point-of-care testing, and connection difficulties.

CONCLUSION:

During the pandemic, relatively few academic providers utilized telehealth visits to deliver prenatal care despite the potential advantages perceived. Addressing providers' perceived disadvantages of prenatal care provision via telehealth may combat the low utilization.
Virtual Antenatal Group Contraception Counseling: A Pilot Study [ID: 1346753]
Authors: Ereme Keemi , Akullo Kaidee , Class Quetzal A. , Hinz Erica
Published: May 2023

INTRODUCTION:

This pilot study examines the feasibility, patient satisfaction, and knowledge after a novel virtual Group Contraception Counseling (GCC) session.

METHODS:

At an urban academic hospital, we recruited English-speaking pregnant women aged 15–49 who had access to a video-enabled electronic device. Participants engaged in a standardized 45-minute educational session about contraceptive methods in groups of two to five persons conducted over a video conferencing platform. The primary outcome was patient satisfaction measured by the Person-Centered Contraception Counseling (PCCC) scale. The secondary outcome was knowledge change before and after counseling. We used a nonparametric test of ranks to analyze satisfaction scores. A paired-sample t test and independent t tests were used to compare knowledge scores.

RESULTS:

Nineteen participants completed the study. Participants identified primarily as Black (47%), in a partnership (52%), having completed college (61%), and having an annual income of less than $50,000 (78%). The mean PCCC score was 19.21 out of 20 (SD 1.12, range 13–20) with no difference in satisfaction based on demographics or knowledge change score (r−0.296, P=.218). There was a significant difference between knowledge test scores pre- and post-GCC sessions (t
18=−3.229, P<.01), with post scores being 12% higher than pre scores (range 16–40%). Age, race, partnership status, and employment did not differentiate scores, whereas education was predictive of mean change of score after the GCC session (t
15=−2.93, P<.01).

CONCLUSION:

Our preliminary findings suggest antenatal contraception counseling in small virtual groups is a feasible option with high satisfaction and increased contraceptive knowledge for postpartum contraception choices.
Universal Transvaginal Ultrasounds: Does It Really Make a Difference? [ID: 1369458]
Authors: Grubman Olivia , Hussain Farrah , Mitchell Mackenzie , Owens Thomas , Strauss Tirtza
Published: May 2023

INTRODUCTION:

There are no universal guidelines for transvaginal ultrasound (TVUS) at time of anatomy scan. TVUS can provide valuable information on placental location and cervical length (CL). As a quality assurance initiative, universal TVUS (UTVUS) protocol was started. The aim of this study was to evaluate differences in diagnoses and interventions in the 6 months prior to UTVUS protocol to 6 months after implementation.

METHODS:

This was an institutional review board-approved retrospective cohort study performed on singleton gestations from February 2021 to January 2022. The pre-group underwent TVUS for history of preterm birth, if the cervix appeared short or if the placenta appeared low lying on transabdominal scan. In the post-group, all patients underwent TVUS.

RESULTS:

Of the 1,197 patients, 148 underwent TVUS in the pre-group and 1,049 received UTVUS in the post-group. A greater proportion of patients had short CL identified in the post-group compared to the pre-group (2.2% versus 0.9%, P<.01). Additionally, CL was shorter in the post-group compared to the pre-group (median 1.6 versus 2.2 cm, P=.03). A greater proportion of patients in the post-group received vaginal progesterone (3.1% versus 0.7%, P<.01) and cerclage (2.3% versus 0.7%, P<.01) compared to those in the pre-group, and had a later gestational age at cerclage placement (median 17 weeks 2 days versus 13 weeks 6 days, P=.04). Patients in the pre-group had a higher rate of prior preterm birth (P<.01), delivered at an earlier gestational age (P<.01), and were more likely to have neonatal intensive care unit admission compared to patients in the post-group (P=.02). The overall preterm birth rate in both time periods was not significantly different (11.4% versus 11.2%, P=.82).

CONCLUSION:

UTVUS identifies shorter CL, which leads to increased use of vaginal progesterone and cerclage as compared to abdominal ultrasound with targeted TVUS. UTVUS may lead to increased intervention. However, the cost-effectiveness and clinical significance need to be further evaluated.
Application of Hematologic Indices for Diagnosis of Iron Deficiency Anemia in Pregnancy [ID: 1378030]
Authors: Vigh Richard , Gray Celia , Mackeen A. Dhanya , Paglia Michael , Young Amanda
Published: May 2023

INTRODUCTION:

Prenatal care providers may omit iron studies if the complete blood count is suggestive of mild or moderate iron deficiency anemia (MMIDA). We investigated how sensitive the mean corpuscular volume (MCV) or red blood cell distribution width (RDW) are in identifying MMIDA that is diagnosed by ferritin measurement.

METHODS:

This IRB-approved retrospective cohort study from October 15, 2007 to October 14, 2021, included singleton pregnancies diagnosed with MMIDA and treated with iron for at least 4 weeks prior to delivery. Patients with comorbidities that predispose to anemia (eg, thalassemia) were excluded. The primary outcome was the percentage of patients whose MMIDA could be identified by low MCV or elevated RDW. Secondary outcomes included changes in hemoglobin, MCV, and RDW, and were assessed by persistence versus correction of MMIDA by delivery.

RESULTS:

Eight thousand eight hundred thirty-three patients met criteria; 1,141 (12.9%) had MMIDA diagnosed by low ferritin. The MCV or RDW was concordant with MMIDA diagnosis in 259 (22.7%). Hemoglobin significantly improved from 10.6 to 11.8 g/dL in the corrected group and did not change in the persistent group. Treatment with concurrent oral and IV iron resulted in greater hemoglobin increase (persistent, +0.4, versus corrected, +1.9 g/dL) versus oral iron alone (−0.1 versus +1.3 g/dL). The MCV decreased and RDW increased in both persistent (−2.7 fL, +1.0%) and corrected groups (−0.8 fL, +0.7%).

CONCLUSION:

Thirteen percent of providers ordered iron studies when MMIDA was suspected. Low MCV or elevated RDW are insensitive surrogates of ferritin. Iron studies remain the gold standard for diagnosis. Concurrent IV iron results in superior improvement of hemoglobin versus oral iron alone.
Maternal and Neonatal Outcomes After Monoclonal Antibody Use [ID: 1376620]
Authors: Storm Andrew , Gilley Annemarie , Greiner Andrea
Published: May 2023

INTRODUCTION:

The study aimed to evaluate whether the administration of monoclonal antibodies (MABs) in mildly symptomatic unvaccinated COVID-19-positive pregnant patients reduced the need for maternal hospitalization and to evaluate whether this medication affected the rate of adverse neonatal outcomes and severe maternal disease. We hypothesized that MAB use would reduce the need for hospitalization.

METHODS:

This retrospective cohort study was completed by obtaining electronic medical record data of all pregnant patients between August 2020 and January 2022 who met criteria for MAB therapy. The two comparison groups were patients who received outpatient MAB therapy during pregnancy and those who were eligible for therapy but declined. Demographic and hospitalization data were obtained. Exclusion criteria included severe illness upon diagnosis requiring hospitalization, or patients for whom delivery and neonatal data were not available.

RESULTS:

During the study period, 49 patients qualified for MAB therapy, of which delivery data were available for 39 patients. Twenty patients (51%) elected to receive MAB therapy and 19 (49%) declined. Among those who received MAB therapy, 10 (26% of the population) were vaccinated, and among those who declined, 6 (15% of the population) were vaccinated. The two groups were similar in gestational age at delivery (38 weeks 4 days versus 37 weeks 5 days) and gestational age at diagnosis (19 weeks 0 days versus 22 weeks 6 days). Among patients who did not receive MABs, both absolute and relative maternal hospitalization rate was higher (26.3% versus 5%, 12.8% versus 3%, P>.05). When stratified by vaccination status, those who were vaccinated had a 5% probability of hospitalization regardless of MAB therapy. The probability of hospitalization was highest among unvaccinated women who did not receive MAB therapy (67%) and lowest among unvaccinated women who received MAB therapy (0%).

CONCLUSION:

Unvaccinated patients who declined MAB therapy had a higher rate of hospitalization, although not statistically significant. These preliminary findings warrant further study with a larger cohort.