bluuebunny/crossref_metadata_2025 huggingface dataset:
Malposition and Expulsion of Immediate Postplacental Intrauterine Devices [3P]
Authors: Bala Shruti
Published: May 2019

INTRODUCTION:

The primary objective was to determine if immediate postpartum placement of intrauterine devices at time of cesarean delivery was associated with increased rates of malpositioned devices compared with placement after vaginal delivery.

METHODS:

This was a retrospective cohort of 126 women who received immediate postpartum intrauterine device placement (either a postplacental levonorgestrel or copper) following vaginal or cesarean delivery over a two year period between May 2015 to May 2017 at a tertiary care center. Women were followed for 12 weeks postpartum.

RESULTS:

A total of 126 women were analyzed in this study (N=63 for vaginal deliveries and N=63 for cesarean delivery). Baseline demographic characteristics between the vaginal delivery and cesarean delivery groups were similar. The total discontinuation of IUD secondary to malposition or expulsion was 33% (N=42; 25% at time of cesarean delivery versus 41% at time of vaginal delivery) at 12 weeks post-partum. Expulsion of the IUD was significantly more common in the vaginal delivery group (31.7% versus 12.7%, p=0.017). There was no difference in malposition between the two groups (9.5% in vaginal delivery group, 14.2% in cesarean delivery group, p=0.58). There was a significant increase in use of ultrasound to determine IUD position amongst the cesarean delivery group (46.0% vs. 12.7%, p=0.00003).

CONCLUSION:

Immediate post-placental IUD placement after vaginal delivery resulted in a higher occurrence of expulsion than following cesarean delivery. We did not observe a significant difference in malposition of intrauterine devices following placement after vaginal delivery compared with cesarean section.
Non-Palpable Contraceptive Implant Removals: Experience From a Referral Center [5P]
Authors: Matulich Melissa Carol , Chen Melissa Joy , Schimmoeller Natasha Rita , Hsia Jennifer K. , Uhm Suji , Creinin Mitchell D.
Published: May 2019

INTRODUCTION:

To describe our experience as a non-palpable contraceptive implant referral center, including office removal of subfascial implants.

METHODS:

We reviewed the charts of 46 patients seen in our Family Planning subspecialty center for non-palpable contraceptive implant removal from March 2015 through August 2018. Non-palpable implants were localized using high-frequency ultrasonography and skin mapping. We extracted information on demographics, implant location, and outcomes. We used Fisher exact testing for dichotomous variables. IRB-approved.

RESULTS:

Five women had palpable implants of which four chose to have removal. Ultrasound localization was performed for the other 41 women; one was not visualized and was identified on computed tomography imaging. Implants were intrafascial (n=1), suprafascial (n=15), and subfascial (n=25). The patient with intrafascial placement chose to continue use. Two patients with a subfascial implant opted to delay removal. We completed all 15 attempted suprafascial implant removals and 19/23 (83%) attempted subfascial removals in the office. Three of the four failures had removal in the operating room with a collaborative orthopedic surgeon; the other patient sought surgical removal elsewhere. Post-procedure neuropathic pain complaints were reported after 7 (30%) subfascial and no suprafascial removals (P=.03). Non-palpable implants were subfascial in 1/8 (12%) obese and 24/33 (73%) non-obese women (P=.003). Eight (32%) subfascially located implants were inserted during a removal-reinsertion procedure through the same incision.

CONCLUSION:

At a specialized referral center, most subfascial implants can be removed in the office; some patients may experience limited post-procedure neuropathic pain. Most non-palpable implants in non-obese women are subfascial and in obese women are suprafascial.
Pain Medication Use in Opiate Dependent Patients During Surgical Abortion [6P]
Authors: Ramanadhan Shaalini , White Katharine O.
Published: May 2019

INTRODUCTION:

There are currently limited guidelines for pain management for patients who are opiate dependent and undergoing minor surgical procedures. We assessed the differences in pain medication use for patients with and without opiate dependence and explored factors associated with need for pain medication during surgical abortion.

METHODS:

We conducted a chart review of patients undergoing surgical abortion from 2012 to 2017 at a single urban university hospital. We compared the doses of administered benzodiazepines and opiates for patients who were opiate dependent to a random sample of non-opiate dependent women undergoing the same procedures. We assessed associations of opiate replacement therapy use and outpatient pain medication.

RESULTS:

We identified 64 women with opiate dependence who met eligibility criteria. The mean fentanyl dose was higher for opiate dependent (n=64) than non-dependent (n=64) patients (110 mg vs 88 mg, p=<0.001). Average midazolam doses were only minimally different between groups (2.7 mg and 2.3 mg, p=0.001). Within the opiate dependent cohort, use of replacement therapies such as methadone (n=17) or buprenorphine (n=28) did not impact pain medication requirements.

CONCLUSION:

Higher doses of fentanyl may be required to achieve adequate pain control for patients with opiate dependence during surgical abortion. The use of replacement therapy does not impact dosing. These findings can inform provider expectations related to doses of narcotics for opiate dependent patients.
Evaluation of Neonatal Resuscitation Program (NRP) Knowledge Among OB/GYN Residents [11P]
Authors: Tonismae Tiffany R. , Slaven James E. , Shanks Anthony L.
Published: May 2019

INTRODUCTION:

NRP training has been utilized to teach birth attendees evidence-based approaches to care for the newborn at birth. OB/GYN trainees undergo NRP training and rotate in the NICU as interns. It is unclear how much NRP knowledge is retained as OB/GYN residents advance in NRP knowledge following their intern NICU rotation and NRP course.

METHODS:

A survey was distributed amongst the 41 OB/GYN residents at Indiana University during the 2017-2018 academic year following IRB approval from Indiana University School of Medicine. The survey was completed anonymously and included the resident's year in training (PGY1-4) and date of their NRP course and NICU rotation. A 10-question abbreviated NRP quiz was administered to participants. Correlation analysis was performed to test for associations between quiz scores and elapsed time (months) between quiz and the intern NRP course and NICU rotation.

RESULTS:

37 of 41 residents completed the survey. The average test score was 76%. There was no significant difference between abbreviated NRP quiz score and PGY level (p=0.30). There was also no difference between time since NRP course (p=0.21) or time since NICU rotation (p=0.50). Greater time since NICU rotation correlated with lower quiz scores in the PGY2 class (p<0.05). No significant correlation was seen in the other classes.

CONCLUSION:

Overall, there was no significance between test scores based on training year. With this information, OB/GYN residents may be able to do an accelerated certification course while in a training setting instead of the traditional course completion every 2 years.
Residents at Inner-City Academic Centers May Fail to Meet the New Minimally Invasive Hysterectomy Requirements [14P]
Authors: Sidduri Nishanth , Ackroyd Sarah , Hernandez Enrique , Rose Marisa
Published: May 2019

INTRODUCTION:

The ACGME and ACOG promote the use of minimally invasive approaches for hysterectomy. In 2018, the ACGME Ob/Gyn Residency Review Committee increased the number of minimally invasive (MIS) hysterectomies required for trainees to graduate residency. Historically, inner-city black women have higher rates of fibroid disease and other medical co-morbidities that may exclude MIS as the safest mode for hysterectomy.

METHODS:

Retrospective cohort study using the 2016 hysterectomy-specific National Surgical Quality Improvement Program (NSQIP) database. Demographics, comorbidities and surgical characteristics were examined by hysterectomy type. The association between race and hysterectomy type was investigated using one and two-way analysis of variance (ANOVA).

RESULTS:

In 2016, 20,770 hysterectomies for benign indications were identified. Across all races, 25.7% underwent abdominal hysterectomy, 57.4% underwent laparoscopic hysterectomy and 16.9% underwent vaginal hysterectomy. Black women were more likely than white women to undergo open abdominal hysterectomy (41.4% vs 20.1%, respectively, P<0.001). After adjusting for uterine weight (0-100 g, 100-250 g, and >250 g), black women were still more likely to undergo abdominal hysterectomy compared to other races (P<0.001). Additionally, when adjusting for history of prior abdominal or pelvic surgeries, black women were more likely to undergo abdominal hysterectomy compared to other races (P<0.001).

CONCLUSION:

Black women disproportionately undergo higher rates of abdominal hysterectomy compared to other racial groups. Trainees at academic medical centers with a higher proportion of black patients may fail to meet the number of minimally invasive hysterectomies required for graduation. Further efforts to identify the etiology of racial disparities in route of hysterectomy should be pursued.
STEP 1, STEP 2 or CREOG Scores- Which Exam Predicts Successful Passage of the Qualifying Examination? [15P]
Authors: North Ware Jamie L. , Tabatabai Mohammad , Im Wansoo , Fritts Demeka , Looney Kimberly , Aguinaga Maria del Pilar
Published: May 2019

INTRODUCTION:

The Council on Resident Education in Obstetrics and Gynecology (CREOG) is an objective measurement of medical knowledge. A score below 200 may identify those at risk for failing the American Board of Obstetrics and Gynecology (ABOG) Qualifying Exam. The aim of this study is to evaluate if there is a correlation between the Step 1, 2 (CK) and CREOG scores collectively with the passage of the ABOG Qualifying Exam on the first attempt and to identify a threshold score for passage.

METHODS:

IRB approval was waived and data collected from twenty-seven residents over a ten year period. For each resident, the STEP 1, STEP 2, annual CREOG scores and self-reported passage of the ABOG Qualifying Exam were collected. Residents with missing data (n=2) were excluded. Simple logistic regression was used to investigate the effect of a single test score on predicting the likelihood of pass or fail on the ABOG Qualifying Examination. The associations between the examinations were evaluated using Spearman's rank correlation coefficient.

RESULTS:

USMLE Step 1 and Step 2 examinations had no significant effect on the outcome of the ABOG Qualifying examination (P<0.125 and P<0.544) respectively. PGY2 was a better predictor when compared to the PGY1 scores (P<.079) vs (P<.611). The mean score was 178.444 for PGY 3 and was the most significant factor in predicting passage or failure of the Qualifying Examination (P<.031).

CONCLUSION:

A score of 170 or higher on the last two years of residency might be a good indicator of success on the ABOG Qualifying Examination.
Transgender Care Knowledge and Attitudes Amongst Puerto Rico's Gynecologists [18P]
Authors: Carro-Jimenez Maria T. , Ortiz Kevin J. , Rivera Mario , Suárez Gina , Romaguera Josefina
Published: May 2019

INTRODUCTION:

Transgender refers to individuals whose gender identity and/or expression of gender differs from gender assigned at birth. Countless roadblocks prevent access to medical services due to stigmas and prejudices, lack of knowledge and experience in terms of their healthcare needs, and insensitive treatment from their providers. Even though the gynecology field is involved in care of transgender individuals, there is scarce literature and guidelines focused on their care. The aim of this study is to learn about attitudes, disposition and knowledge of transgender medical care amongst gynecologists actively practicing in Puerto Rico (PR).

METHODS:

After Institutional Review Board approval, gynecologists were invited to complete a survey designed to determine knowledge about transgender care, disposition, and experience treating transgender patients. The administered questionnaire was previously used in a study evaluating gynecologists from the continental United States but had yet to be done in PR. Responses were catalogued using Epi Info frequency analysis.

RESULTS:

Fifty-nine participants were recruited. When asked if comfortable taking care of male-to-female transsexuals (MTFT), 59% agreed. In female-to-male transsexuals (FTMT), 47% agreed. Regarding if would perform pap smears on FTMT 81% agreed, whereas 80% felt comfortable performing breast exams on MTFT. Of the respondents 49% are not familiar with hormonal regimens used for gender reassignments. 70% of respondents knew there is a Practice Bulletin on the care of the transgender patient.

CONCLUSION:

There is a willingness to treat transsexual patients amidst PR gynecologists but the lack of knowledge regarding population specific treatments and managements represents a limitation.
Self-Reported Opioid Allergy: Obstetrical Outcomes and Postpartum Pain Management [29P]
Authors: Blitz Matthew J. , Freling Julia L. , Prasannan Lakha , Greenberg Meir , Marchbein Harvey , Rochelson Burton L.
Published: May 2019

INTRODUCTION:

To determine how obstetrical outcomes and inpatient postpartum pain management are affected by self-reported opioid allergy (SROA).

METHODS:

Retrospective cohort study of singleton deliveries at >=37 weeks of gestation at a tertiary hospital from 2013-2016. Patients were excluded for NSAID allergies, drug abuse history, positive urine toxicology, general anesthesia for delivery, and incomplete records. The primary outcomes evaluated were mode of delivery and medications administered for inpatient postpartum analgesia.

RESULTS:

A total of 21,225 deliveries were included: 289 with SROA and 20,936 without SROA. In the SROA group, 29 reported reactions suggestive of true allergies (i.e. severe, life-threatening, hypersensitivity reactions). Among this subgroup, 51.7% (n=15) received opioids from the same chemical class (phenanthrenes) as their stated allergy. Women in the SROA group were older and more likely to be white and multiparous. The SROA group had a higher primary cesarean delivery rate (36.0% vs. 21.7%; P<0.0001) and overall cesarean delivery rate (58.1% vs. 35.3%; P<0.0001). Among cesarean deliveries, there was a small reduction in inpatient postpartum opioid analgesia in the SROA group compared to the non-SROA group (73.8% vs. 80.5%, respectively; P<0.04); no difference was noted among vaginal deliveries. Women in the SROA group who received opioids were more likely to receive multiple opioid medications (15.1% vs. 8.2%; P<0.005).

CONCLUSION:

True opioid allergy is rarely encountered in obstetrics. Women with SROA receive inpatient postpartum opioid analgesia at similar rates to those without SROA. Patients prone to adverse medication effects may be at increased risk for cesarean delivery.
Severe Anemia at Delivery: Can Rigorous Antenatal Identification Prevent It? [30P]
Authors: Fadayomi Ayotunde , Reimers Rebecca Mutascio , Smith Nicole A. , Carusi Daniela A.
Published: May 2019

INTRODUCTION:

Despite routine antenatal hemoglobin (Hb) assessment, severe anemia at delivery remains a problem. We evaluated whether attentiveness to anemia is associated with less severe anemia at delivery.

METHODS:

This is a nested case-control study derived from deliveries at an academic tertiary hospital from January, 2007 to May, 2016. We identified patients with a singleton gestation and Hb ≤10.5 g/dl between 12 and 29 weeks gestational age, excluding suspected accreta, previa, hemoglobinopathies or relevant chronic medical conditions. Severe anemia was defined as Hb ≤9 g/dl at time of delivery. Controls were matched 2 to 1 by delivery year. We compared the use of supplemental lab evaluations and iron prescriptions for the two groups.

RESULTS:

Of 60,274 deliveries, 2,623 patients had second trimester anemia. Of these, 168 (6.4%) presented with severe anemia at delivery. After matching, 504 patients were analyzed. On univariate analysis, cases were more likely to be black (OR 1.76, P=.02) or Hispanic (OR 1.85, P=.02), multiparous (OR 2.76, P<.0001), have lower mean second trimester Hb (9.2 g/dl vs 10.0 g/dl, P<0.0001), have additional Hb (20.8% vs 10.1%, P=.002) and ferritin draws (8.9% vs 2.4%, P=.002), supplemental iron prescriptions (58.3% vs 0.9%, P<.0001), and iron infusions (6% vs 0%, P<0.0001) than were controls. On multivariate analysis, cases still had more supplemental labs (OR 2.60; P=0.0004), and oral/IV iron prescriptions (OR 66.86; P<0.0001).

CONCLUSION:

Severe anemia at delivery was not associated with reduced attentiveness to low antenatal hemoglobin. Prevention should focus on alternative treatment approaches.
Severe Range Blood Pressures and the Association With Hypertension Up to 2 Years Post-Delivery [31P]
Authors: Leftwich Heidi Kay , Weeks Corinne M. , Marcov Lauren J. , Wiese Sarah L. , Chase Gillian , Leung Katherine
Published: May 2019

INTRODUCTION:

While hypertension can normalize soon after delivery, some women experience prolonged periods of hypertension. We sought to determine whether severe range blood pressures on labor and delivery are associated with having hypertension 12 weeks to 2 years after delivery.

METHODS:

Retrospective cohort study of pregnancies with a delivery from 7/2009-7/2016. Inclusion criteria were delivery at our tertiary hospital, presence of hypertensive disorder, and a documented blood pressure 12 weeks-2 years postpartum. Blood pressures were documented for every visit between 12 weeks and 2 years postpartum. A logistic regression model was used to determine the odds of hypertension in the 2 years following delivery. Multivariable logistic regression analysis was used to adjust for confounding factors.

RESULTS:

524 women met inclusion and exclusion criteria. Of these, 127 (24%) women had at least one severe range blood pressure during their hospitalization for delivery. Women with severe blood pressures were more likely to have a history of or current gestational hypertension, but less likely to have IUGR (p<0.05). Other variables were similar. However, women with severe range blood pressures during delivery hospitalization did not show a greater rate of hypertension from 12 weeks - 2 years in either unadjusted (OR 1.24 [0.83-1.85], p=0.30) or adjusted analysis (OR 1.24 [0.80-1.9], p=0.34).

CONCLUSION:

While 24% of women in our cohort had severe range hypertension, this was not associated with hypertension up to 2 years post-delivery. It is important to encourage all women with hypertensive disorders to follow up closely, as this alone does not seem to identify those at highest risk.
The Effect of Chronic Hypertension on Control of Severe Range Blood Pressures in Preeclampsia [36P]
Authors: Cui Yiwen , Litman Ethan , Feustel Paul , Bringley Johanna , Rijhsinghani Asha
Published: May 2019

INTRODUCTION:

We aim to assess the impact of maternal hypertension category on the control and response of urgent hypertension.

METHODS:

This is a retrospective cohort study of patients who required immediate-acting antihypertensive medications outlined by the ACOG Committee Opinion #692 during the peripartum admission between June 2015 to June 2017. The patients were either diagnosed with preeclampsia with severe features (“preSF”) or chronic hypertension with superimposed preeclampsia with severe features (“cHTN+preSF”). We abstracted maternal medical history and medication dosing. Statistical significance was calculated with the Student's t-test or Mann-Whitney test. Multivariable regression analysis was used to adjust for the effect of confounders.

RESULTS:

We identified 326 patients, 211 with preSF and 115 with cHTN+preSF. In the antepartum period, patients with cHTN+preSF received significantly more doses of immediate-acting antihypertensive medications than those with preSF (3 vs 2 doses, p<0.01). The cHTN+preSF group also required more time for blood pressures to exit severe range (55 vs 30 minutes, p<0.01) and more frequent re-dosing of anti-hypertensive medication (2 vs 1 times, p=0.02). The differences remained significant in the multivariable regression model when controlled for age, gravidity and BMI. During the postpartum period, the same parameters were similar between the groups.

CONCLUSION:

While chronic hypertension is recognized as a risk factor for the development of preeclampsia, we demonstrate that it also complicates and prolongs the course of blood pressure management particularly in the antepartum period. Consideration should be given to maternal history when tailoring treatment of severe hypertension in patients with pre-eclampsia.
The Effect of Labor and Delivery Nursing Experience on Labor Progression and Cesarean Section Rates [39P]
Authors: Calo Corinne A. , Elliott John O. , Clifton William D. , Umunnabuike Chioma , Krantz Carl A.
Published: May 2019

INTRODUCTION:

Prevention of the primary cesarean section (PCS) is a quality indicator of both provider and facility performance. Although nurses spend a significant amount of time with patients in labor, data is lacking regarding the influence of nursing labor and delivery experience on PCS rate.

METHODS:

A retrospective, institutional review board approved, cohort study of 3,275 nulliparous, term patients with singleton fetus in vertex presentation was conducted. Labor progression was calculated during the active phase of labor. Nursing experience, categorized into <2 years, 2-5 years, and >5 years, was calculated using a weighted average of years of experience and time spent caring for the patient. Patients who underwent PCS for failure to progress, cephalopelvic disproportion, and arrest of dilation/descent were included. Labor progression and PCS rates were compared via one-way ANOVA, chi-square tests, and logistic regression analysis.

RESULTS:

Labor progressed at a faster rate when nursing experience was >5 compared to 0-2 and 2-5 years (1.3±1.2, 1.0±0.8, and 0.8±0.8 cm/hr, respectively; P<.001). PCS rate was significantly lower for nurses with >5 compared to 0-2 and 2-5 years of experience (10%, 15.9%, and 14.1%, respectively; P<.001). Utilizing >5 years as the reference group translated to an increased odds of PCS in the 0-2 (OR 1.69, 95% CI 1.28-2.23) and 2-5 years experience groups (OR 1.48, 95% CI 1.09-1.99).

CONCLUSION:

This study demonstrates that labor and delivery nursing experience is associated with labor progression and PCS rate. Follow-up studies are needed to determine if differences in practice and more rigorous education/didactics could reduce these differences.
The Effect of the Cost of Professional Liability Insurance on the Ob/Gyn Workforce in the U.S. From 2005 to 2015 [4Q]
Authors: Kim Edward , Rayburn William , Xierali Imam
Published: May 2019

INTRODUCTION:

Professional liability climate is an important factor that can influence the physician workforce and thereby access to healthcare. We sought to investigate the relationship between the cost of professional liability insurance (PLI) and obstetrics and gynecology (Ob/Gyn) workforce in the U.S. from 2005 to 2015.

METHODS:

We obtained the PLI cost data from Medical Liability Monitor and calculated the Ob/Gyn workforce density from the American Medical Association's Physician Masterfile and the U.S. Census for the years 2005 to 2015.

RESULTS:

Nationally, there has been an approximately 21% decrease in the cost of PLI, 10% increase in the absolute number of Ob/Gyns and 0.62% increase in the Ob/Gyn workforce density in this period. A negative binomial regression model showed a significantly positive relationship between these two variables, with an incidence rate ratio (IRR) of 1.005 (p = 0.006). In other words, the Ob/Gyn workforce density increased by 0.5% with every $10,000 increase in the cost of PLI.

CONCLUSION:

We remain cautiously optimistic for the future of the Ob/Gyn workforce and professional liability climate. Investigation of the effect of the cost of PLI on the Ob/Gyn workforce relocation pattern is an important future direction for research.
The Association Between Smoking and Postoperative Complications in Laparoscopic Hysterectomies [9Q]
Authors: Lababidi Suzanne , Winfrey Olivia K. , Shammout Fadel
Published: May 2019

INTRODUCTION:

Smoking is a known risk factor for complications in major abdominal procedures, however the association has been poorly described in minimally invasive procedures. This project aims to describe the association between smoking and post-operative complications in laparoscopic hysterectomies.

METHODS:

This project utilized the National Surgical Quality Improvement Project database for 2007 and 2016 to examine patients who underwent a laparoscopic hysterectomy. Incomplete data was the only exclusion criterion. Binary logistic regression and Chi-square test were used for data analysis. Significance was set at P=.05.

RESULTS:

A total of 51,699 patients were included in analysis. Of these, 581 (0.8%) developed superficial surgical site infection (SSI), 563 (0.8%) developed organ space SSI, 137 (0.2%) developed a wound dehiscence, 90 (0.1%) developed pneumonia post-operatively, 1,519 (2.2%) required readmission, and 695 (1.0%) required re-operation. When controlling for age, hypertension, and diabetes, smoking was significantly associated with organ space SSI (OR 1.477, 95% CI 1.215-1.794, P=.002), pneumonia (OR 2.021, 95% CI 1.287-3.174, P=.001), and hospital readmission (OR 1.297, 95% CI 1.143-1.472, P<.001). The association between smoking and superficial SSI (P=.065), wound dehiscence (P=.318), or reoperation (P=.756) was not statistically significant.

CONCLUSION:

These data demonstrates the significant association smoking has with important postoperative complications in laparoscopic hysterectomies. When controlling for other risk factors, smoking was still associated with increased risk of infection, pneumonia, and readmission. Smoking cessation is an important preoperative goal and has the potential to significantly improve surgical outcomes.
Uterine Leiomyoma With KAT6B-KANSL1 Fusion: Report of a Rapidly Enlarging Uterine Mass in a Postmenopausal Woman [14Q]
Authors: Ainsworth Alessandra J. , Bakkum-Gamez Jamie , Schoolmeester Kenneth
Published: May 2019

INTRODUCTION:

Leiomyomas are benign uterine smooth muscle tumors. After menopause, most women have a reduction in size and number of leiomyomas. Conversely, uterine sarcomas present as a rapidly enlarging pelvic mass in postmenopausal women. The distinction of uterine leiomyoma from sarcoma is difficult and definitive diagnosis requires pathologic examination.

METHODS:

A 74 year-old multiparous female with a history of ductal carcinoma in situ (DCIS) of the breast presented with significant postmenopausal bleeding, requiring blood transfusion, and a rapidly enlarging pelvic mass. Abdominal imaging including ultrasound and computerized tomography confirmed a 15 cm uterine mass. The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy with concern for uterine sarcoma. Grossly, the uterus contained a 15.5 cm well demarcated intramural mass. Microscopically, the tumor was a spindle cell neoplasm with anastomosing fascicles interrupted by thick-walled blood vessels or fibrous regions. The cells exhibited uniformly mild to moderate cytologic atypia. Immunohistochemically, the tumor strongly and diffusely expressed desmin and h-caldesmon and exhibited patchy, strong expression of CD10. RNA-seq, confirmed by RT-PCR and Sanger sequencing, revealed a gene fusion involving KAT6B and KANSL1. The fusion joins exon 3 of KAT6B to exons 11 and 12 of KANSL1. The final diagnosis was a benign uterine leiomyoma. The patient remains without evidence of disease six months post-operatively.

CONCLUSION:

This is the first case, to our knowledge, that has identified the KAT6B-KANSL1 fusion in a uterine leiomyoma. Further efforts to classify the pathologic characteristics and prevalence of this fusion may contribute to understanding of tumorigenesis of uterine smooth muscle tumors.
Bundled Prevention of Cesarean Surgical Site Infections: The Down and Dirty [20Q]
Authors: Gee Stephen Elliott , Orellana Robert , Kellert Brian Andrew , Mangino Julie , Meyers Carol , Rood Kara M.
Published: May 2019

INTRODUCTION:

Surgical site infections (SSI) following cesarean delivery (CD) are a major cause of morbidity and economic burden. Our tertiary-care hospital implemented a multidisciplinary SSI surveillance system and preventative bundles to reduce rate of SSI after CD. Our objective was to measure the effect of 3 bundles on post-CD SSI.

METHODS:

A retrospective single-center cohort study of all CD July 2012 to December 2017 was performed. Infections were identified via 30-day active surveillance using CDC definitions by one infection preventionist and reviewed by one physician. Patient demographics and procedural details were stored for submission to CDC. Unadjusted and adjusted risk factors were identified using logistic regression. Bundle 1 (2014) included enhanced surgical instrument sterilization, bandage removal POD2, preoperative sage cloth, 3 grams Cefazolin for women >120 kg, recommended patient warming, staples removal POD7, and provided silver dressings. Bundle 2 (2015) included nurses prepping with prolonged prep time using two chlorhexidine applicators. Bundle 3 (2016) included preoperative vaginal prep and 500 mg Azithromycin in unscheduled CD in labor and encouraged post-placental glove change.

RESULTS:

Over 5.5 years, 2.2% (176/8150) of women developed post-CD SSI. 79% (138/176) were superficial incisional primary SSI. The first bundle had no significant effect on the odds of post-CD SSI (odds ratio [OR] 0.48, confidence interval [95% CI] 0.15 - 1.61). We observed decreased odd of post-CD SSI for both bundle 2 (OR 0.63, 95% CI 0.45 - 0.87) and bundle 3 (OR 0.61, 95% CI 0.42 - 0.88).

CONCLUSION:

Evidence-based bundles should be considered at institutions experiencing high post-CD SSI rates.
Obstetric Outcomes in Nepali Immigrant Patients: A Retrospective Study Within the Rochester Regional Health System [26Q]
Authors: Lewis Gregory Kirk , Dawkins Josette Camion , Boddu Rohini , Cabral Paul A.
Published: May 2019

INTRODUCTION:

Ethnic minorities particularly immigrants, tend to be at increased risk for poor birth outcomes. Rochester New York is home to many Nepali immigrants with a 56% increase in 2014. These immigrants face many barriers which includes communication, health literacy and accessibility to health services. The purpose of this study was to evaluate the obstetric outcomes of Nepali patients within the Rochester Regional Health System.

METHODS:

Nepali women who delivered between January 1, 2011 and December 31, 2016 were matched with Non-Nepali women who delivered during the same time period. Demographic and obstetric information was extracted from the electronic medical records. Obstetric outcomes between the 2 study groups were then analyzed. Data analysis was done using the SPSS, version 24.

RESULTS:

The final analysis was performed on 194 patients (86 Nepali and 108 Non-Nepali). Nepali patients had prolonged second stage of labor (P<.05) and a higher cesarean section rate (33.7% vs 26.9%) compared to Non-Nepali patients. Nepali patients also had significantly higher rates of chorioamnionitis/endometritis (P<.05) as well as third degree vaginal lacerations (P<.05). More postpartum hemorrhage was seen in the Nepali group of patients, 17.4% vs 12.0%. Babies born to Nepali mothers were more likely to be admitted to the Neonatal Intensive Care unit (P<.05).

CONCLUSION:

Nepali mothers had higher obstetric complications than Non-Nepali mothers. Further ongoing analysis of health outcomes within this particular migrant population is warranted. This will certainly help to inform better reproductive health care practices for these patients, and ultimately minimize disparities in their obstetric care and outcomes.
Opioid Withdrawal During Pregnancy and Rates of Neonatal Abstinence Syndrome (NAS): A Pilot Study [27Q]
Authors: Stephens Angela Jessica , Tibavinsky Bernal Lina Maria , Street Linda , Browne Paul
Published: May 2019

INTRODUCTION:

Opioid dependency in pregnancy has detrimental effects to mother and fetus. Neonatal Abstinence Syndrome (NAS) is a complex disorder caused by the abrupt termination of fetal exposure to opioids. The incidence has risen in the United States (US) during the past decade. Current policies and the paucity of Licensed Narcotic Treatment Programs leaves limited options for opioid-dependent patients.

METHODS:

A retrospective cohort study was conducted to assess the ability to offer opioid withdrawal during pregnancy and the effects of withdrawal on rates of NAS. The NIH's I2B2 software was used to identify patients with opioid dependency seen at our institution from January 1, 2014 to January 31, 2018. Clinical outcomes between opioid maintenance and opioid withdrawal cohorts were then conducted.

RESULTS:

51 pregnancies were identified with opioid dependency from January 2014 to January 2018. 29 patients enrolled in an opioid withdrawal program. 22 patients enrolled in an opioid maintenance program. 3 in the withdrawal and 1 in the maintenance cohort remain pregnant. 2 in the withdrawal cohort were lost to follow up. There was 1 abortion in the maintenance and 1 perinatal death in the withdrawal group. NAS rates were 30.0% (6/20) in the maintenance cohort and 43.5% (10/23) in the withdrawal cohort. Rate of NAS were 18.2% (2/11) in the successful withdrawal and 66.7% (8/12) in the failed withdrawal cohort. 25% (3/12) of failed withdrawal cohort relapsed, and 66.7% (2/3) had infants with NAS.

CONCLUSION:

Successful, supervised opioid withdrawal during pregnancy is possible, and may reduce rates of neonatal abstinence syndrome.
Improving Detection of Surgical Site Infections After Cesarean Delivery: What Are Diagnosis Codes Missing? [28Q]
Authors: Duffy Cassandra , Ross Naima , Messina Maria , Ewing Julie , Saiman Lisa , Goffman Dena
Published: May 2019

INTRODUCTION:

Surveillance for surgical site infections (SSI) following cesarean can be challenging. We sought to identify cases of SSI over two years and describe our methods of case ascertainment.

METHODS:

We queried our hospital's data warehouse for cesareans deliveries from 2016-2017 among women >18 years of age. Three methods for case finding were used: i) ICD-10 diagnoses codes, ii) reporting complications in postoperative notes, and iii) infection control surveillance activities. For ICD-10 codes, we sought endometritis following delivery and infection of obstetrical surgical wound, infection following procedure, cellulitis, and/or peritoneal abscess. We included endometritis as an organ/space SSI by CDC definitions. Chart review was performed for all cases identified by any of the 3 methods to confirm SSI diagnosis as per CDC criteria.

RESULTS:

Among 3,507 cesareans, ICD-10 codes identified 76 confirmed cases of endometritis and 31 SSI. The positive predictive value for endometritis was 88.0% (95% CI 80.2-93.1) and for SSI codes, 53.5% (95% CI 43.0-63.6). Adding puerperal sepsis produced one additional SSI case, and searching the postoperative note yielded another 26 cases of endometritis and one wound infection. Six SSI were identified by infection control not identified by other methods. In total, we identified 141 SSI, including 98 endometritis-only cases. The incidence of all SSI, endometritis, and SSI excluding endometritis was 4.02%, 2.79%, and 1.23%.

CONCLUSION:

Improved ascertainment methods are needed to inform and assess performance improvement efforts for cesarean SSI. Reliance on diagnosis codes may miss a significant number of cases and is poorly predictive of SSI other than endometritis.
Oral Carbohydrate Intake Impact on Cesarean Delivery Perioperative Well-Being: A Randomized Interventional Study [29Q]
Authors: Wendling Adam , Byun Sharon Y. , Koenig Megan , Vasilopoulos Terrie , Wishin Judith
Published: May 2019

INTRODUCTION:

Oral carbohydrates (CHO) prior to a variety of surgical procedures has been found to attenuate the postoperative catabolic state with an improvement in well-being insulin sensitivity, cardiac output and shortened hospital stays without adverse effect. Previous work has compared oral CHO to water or flavored water and excluded pregnant women. Our primary aim was to determine if preoperative oral consumption of higher dose CHO would improve patient well-being (WB-VAS) prior to cesarean section compared to a widely available rehydration beverage with a lower CHO dose and fasted controls.

METHODS:

Low risk women undergoing scheduled cesarean deliveries under spinal anesthesia were recruited. Participants were randomized to either: Clearfast® (group CHO), Gatorade Thirst Quencher® (group R) or fasting control (group F). Participants in groups CHO and R received 710 mL of either beverage the night before and 355 mL two hours prior to surgery. Participants in Group F fasted after midnight the night before surgery. Two hours before surgery, baseline WB-VAS was recorded, followed by beverage consumption for groups CHO and R. One hour later, WB-VAS was repeated. Additional recorded measures included umbilical blood glucose, intraoperative variables, breastfeeding success, and quality of recovery one day after surgery.

RESULTS:

Group differences in change in WB-VAS were analyzed using linear regression. Both group CHO and R showed significant improvements in WB-VAS while fasted patients showed no change. There were no differences in other outcomes.

CONCLUSION:

Either the common oral rehydration or higher dose CHO beverage resulted in superior well-being compared to fasting with no difference in other outcomes.
Postoperative Opioids After Laparoscopic Hysterectomy With Transversus Abdominis Plane Block [2D]
Authors: Krajick Kayla Ann , Sullivan Margaret Hancock
Published: May 2019

INTRODUCTION:

Chronic pelvic pain after hysterectomy affects many women, predisposing them to opioid dependence. The amount of opioids consumed postoperatively can also predispose opioid dependence. Transversus abdominis plane (TAP) block is a non-opioid method to reduce postoperative pain. This study seeks to demonstrate the effectiveness of TAP block for total laparoscopic hysterectomy (TLH) patients in reducing postop pain and opioid consumption.

METHODS:

This retrospective cohort study of women undergoing TLH at a single hospital was given exempt status by the Institutional Review Board. Chronic opioid users were excluded. Primary outcomes were opioid consumption within 24 hours postoperatively and amount of opioids prescribed at discharge. Secondary outcomes included pain scores averaged over 6-hour intervals within 24 hours postoperatively. T-test and chi-square analyses were performed.

RESULTS:

This study included 49 women with TLH of whom 26 received a TAP block. The two groups were demographically similar. Women who received TAP block needed significantly less opioids within the first 24 hours postop (38.4 vs 65.9 morphine equivalents, P=.02). No significant differences were seen between the two groups in postoperative pain scores at 6-hour intervals, or in the amount of opioids prescribed at discharge.

CONCLUSION:

Women undergoing TLH who received a TAP block required approximately half the amount of opioids for pain control within the first postoperative day. TAP block should be considered an effective adjunct for pain control after TLH to decrease the amount of postoperative opioid consumption, ultimately aiding in the prevention of chronic opioid use and opioid dependence.
Retrospective Chart Review of an Adolescent Hematology Clinic [4D]
Authors: Mulvaney Kylie , Nelson Anita L. , Borzutzky Claudia , Escovedo Michelle , Jaffray Julie
Published: May 2019

INTRODUCTION:

To investigate the causes of and treatments for heavy menstrual bleeding (HMB) among adolescent females referred for hematologic evaluation, focusing on tolerance of first line methods.

METHODS:

A retrospective chart review was conducted of patients seen in Children Hospital Los Angeles' combined Hematology-Adolescent Medicine clinic between January 2015 and May 2018 for HMB and evaluation for underlying bleeding disorders (BD). Upon approval from the CHLA Institutional Review Board, de-identified data was collected and analyzed on a password-protected spreadsheet.

RESULTS:

Of 115 patients referred to the Hematology-Adolescent clinic, 41 were diagnosed with underlying BD, 66 were found to be free of such disorders, and 8 patients had history of thrombosis or beta thalassemia. Of the 41 women diagnosed with DB, 21 were initially prescribed combined oral contraceptives (COC); 12 had reduced blood loss and the remaining 9 were offered a second line treatment due to either failure of COC to control bleeding, or to intolerable side effects. 17 women with bleeding disorders were initially treated with antifibrinolytic agents; 12 responded to these, while 5 patients were prescribed different agents or hormonal methods. The remaining 3 patients with BD did not receive treatment. The 66 patients without underlying BD were typically prescribed iron supplementation and/or oral contraception.

CONCLUSION:

Among 115 patients presenting with HMB, 36% were found to have underlying BD. The first line of treatment across this study population was COC with variable efficacy in reducing symptoms, supporting existing literature and its call for more formalized diagnosis and treatment of HMB.
Self Screening as an Alternative Method of Cervical Screening [5D]
Authors: Manglardi Erin E. , Lendore Jessica , Balhotra Kimen , Fields Paul J. , Bahadoor-Yetman Avi , McGill Frances Mary
Published: May 2019

INTRODUCTION:

The Papanicolaou smear, an accessible screening tool for cervical cancer worldwide is often underutilized. Caribbean cervical cancer incidence is higher than in developed countries. A self-sampling device created with the goal of increasing screening in developing regions. was evaluated in Grenada. Goals of this study included evaluating self screening for accuracy and comfort when compared to a standard Pap smear.

METHODS:

Following IRB approval we conducted a randomized controlled study involving 101 women in April 2017 at St. Georges University, Grenada. Informed consent was obtained. Two liquid based cervical specimens were obtained from each woman: one via physician collected specimen and one via SelfPap (i Self screen) device. Women were randomized as to which specimen was obtained first. Laboratory technicians were blinded to the sampling technique. The first sample from each woman was also tested for HPV (Human Papillomavirus). Participants completed a questionnaire assessing ease and comfort of self screening.

RESULTS:

Of 101 women, 90 (89%) reported the self screening device was easy to use; 79 (78%) reported mild discomfort, while 94 (93%) indicated they would recommend the it for future use. There was strong agreement in the adequacy and accuracy of the samples obtained by the self screening and physician obtained cervical cytology. (Gwet's AC1 = 0.906). HPV was detected in 49/101 samples, and genotyping was performed. Women with abnormal results were appropriately evaluated.

CONCLUSION:

Comparison of cytology results from both samples, our study deemed self screening as an accurate and acceptable alternative method to standard cervical sampling.
The Effect of Bariatric Surgery on Post-Operative Outcomes After Hysterectomy [6D]
Authors: Whitley Julia , Voltzke Kristin , Louie Michelle Yee
Published: May 2019

INTRODUCTION:

Bariatric surgery is common and has been associated with an improvement in obesity-related medical co-morbidities. However, outcomes after hysterectomy for women who have had bariatric surgery is unknown. Our objective was to compare post-hysterectomy outcomes between patients who had bariatric surgery before hysterectomy and obese patients without prior bariatric surgery.

METHODS:

We performed an IRB-approved study of patients who had hysterectomy by any route between 1/2000 and 3/2018 at a large academic medical center. Patients with malignancy were excluded. Multivariable logistic regression was used for analysis.

RESULTS:

223 patients with bariatric surgery before hysterectomy were compared to 225 patients with body mass index (BMI) >40 kg/m2 and no previous bariatric surgery. The average BMI in the bariatric surgery group was 35 kg/m2, compared to 46 kg/m2 in the no bariatric surgery group. We observed a lower proportion of patients with diabetes, hypertension, and hyperlipidemia in the bariatric surgery group compared to the no bariatric surgery group. We found no significant difference in the odds of intraoperative (visceral injury, blood transfusion, conversion to laparotomy) or postoperative complications including major complications (transfusion, cuff dehiscence, surgical site complication, venous thromboembolism, bowel obstruction), minor complications, re-hospitalization, and re-operation within 30 days of hysterectomy, even after adjusting for confounding factors between groups.

CONCLUSION:

Despite a significantly higher BMI and higher proportion of obesity-related co-morbidities, there was no difference in the odds of intraoperative or postoperative complications after hysterectomy in morbidly obese women, compared to women with a history of bariatric surgery prior to hysterectomy.
Maternal HIV Diagnosis Timing and Use of Guideline-Based Antiretroviral Therapies on Infant Outcomes [8D]
Authors: Cohn Ellery , Lazenby Gweneth B.
Published: May 2019

INTRODUCTION:

The primary aim was to evaluate differences in antiretroviral therapy (ART) use in pregnant women living with HIV (WLWH) according to timing of maternal HIV infection, including perinatal (PHIV). The secondary aim was to evaluate the effects of guideline-based maternal ART, including mono-, dual, and combination antiretrovirals (mARV, dARV, cART), on preterm delivery (PTD).

METHODS:

Data were obtained from the state Department of Health (SCDHEC) for WLWH delivering from 2004-2014. Perinatal outcomes were compared according to timing of maternal HIV diagnosis and maternal use of mARV, dARV, cART, and no ART. Bivariate outcomes were compared using Ï‡2 or Fischer's exact tests. Continuous variables were compared using Wilcoxon Rank Sum Tests or Kruskal-Wallis tests.

RESULTS:

663 WLWH delivered 885 infants. 26 (3%) of infants were born to PHIV WLWH, 683 (77%) to WLWH diagnosed before pregnancy, and 185 (21%) to WLWH diagnosed during pregnancy. PTD was less likely among PHIV-exposed infants (4% vs. 24% vs. 16%, P=0.006). PHIV mothers were more likely to use cART (88% vs. 65% vs. 54%, P=0.001). PTD rates were similar among infants exposed to any ART (mARV 21% vs. dARV 20% vs. cART 21%, P=0.93), while infants not exposed to ART had higher PTD rates (38% vs. 31%, P=0.02).

CONCLUSION:

PTD was not increased by maternal PHIV or ART exposure. HIV-exposed infants not exposed to ART had higher PTD rates. These findings support maternal cART use for improved infant outcomes and challenge previous reports of worsened perinatal outcomes among PHIV WLWH.