bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of a Lateral Flow Assay Device for Detection of Urine Congophilia [11K]
Authors: Rood Kara M. , Davis Wendy , Locke Megan , Webster Shaylyn , Fowler Aubry , Buhimschi Irina A.
Published: May 2017

INTRODUCTION:

In preeclampsia (PE), protein misfolding results in urinary protein aggregates with affinity for Congo-Red. Quantification of urine congophilia carries diagnostic and prognostic potential for PE. Transitioning this discovery to clinical practice requires converting research assays to standardized and technically reliable diagnostic tools. A newly developed rapid lateral flow chromatography assay (LFA) for urine congophilia addresses several limitations of the earlier generation assays. In this study we evaluated the agreement between the LFA device, the nitrocellulose Congo red Dot Test (CRD) Array and the paper-based CRD Simple Test.

METHODS:

71 urine samples were collected prospectively from women who were evaluated for PE. Fresh urine was applied to the LFA device (GestAssured™ test) and the CRD Simple Test. Results were scored using a chromatic visual aid. The CRD nitrocellulose array was run in the laboratory and the test result (% CRR, Congo Red Retention) was calculated using an automated protocol. A %CRR >15 was considered positive. Correlation and agreement among test results were recorded.

RESULTS:

The nitrocellulose %CRR values ranged from 0-89% with 40/71 measuring positive for urine congophilia (%CRR>15%). There was a significant difference in congophilia level between positive (%CRR: 60.4±3.0) and negative (%CRR: 4.8±0.7) specimens. The LFA device score correlated significantly with %CRR (0.865, P < 0.001) and CRD Simple Test Score (r=0.799, P < 0.001) with “excellent-level” agreement (kappa=0.86).

CONCLUSION:

The LFA test appears to be a reproducible, qualitative, diagnostic aid suitable for the clinic that detects PE-associated congophilia in urine, similarly to the CRD assays .
Venous Thromboembolism: Comparing Risk Assessment Tools for Postpartum Prophylaxis in a Teaching Hospital [12K]
Authors: Davis Brittany , Hadpawat-Lee Anita
Published: May 2017

INTRODUCTION:

During the first 6 weeks postpartum, patients are 2.5 to 84 times more likely to have a venous thromboembolism (VTE). While risk is increased, the overall incidence of VTE is low, making the establishment of consistent VTE prophylaxis recommendations difficult. We identified population-specific risk factors and compared assessment tools and recommendations from the American College of Obstetricians and Gynecologists, American Academy of Chest Physicians, and Royal College of Obstetricians and Gynecologists. We also investigated adherence to our current VTE risk assessment tool and prophylaxis guidelines.

METHODS:

253 postpartum patients from our hospital were randomly selected and their charts reviewed to identify demographics, medical risk factors, hospital management, and postpartum complications.

RESULTS:

The most common risk factors in our population were a body mass index greater than or equal to 30 (59%) and Cesarean delivery (35%). Using the RCOG and ACCP guidelines, pharmacologic prophylaxis was recommended in 59% and 17% of patients, respectively. Appropriate utilization of our current VTE risk assessment tool yielded a recommendation for pharmacologic prophylaxis in 30% of patients. Our tool was only completed in 21-25% of patients and 6% of patients actually received pharmacologic prophylaxis.

CONCLUSION:

Significant variation in recommendations exist when applying published guidelines to our population. Our current assessment tool is underutilized and use of pharmacologic prophylaxis is lower than all available recommendations. Standardizing postpartum pharmacological prophylaxis guidelines may help decrease variations in practice and promote pharmacologic prophylaxis in patients at high risk of VTE, a leading cause of maternal morbidity and mortality.
Variation in Outcome Reporting in Cardiac Arrhythmias and Aortopathies in Pregnancy [17K]
Authors: Thurman Robin , Zaffar Nusrat , Sayyar Parastoo , Silversides Candice , Murphy Kellie , D'Souza Rohan
Published: May 2017

INTRODUCTION:

Variation in outcome reporting undermines the usefulness of research as comparisons cannot be drawn when definitions are not standardized. This study aimed to review outcomes reported in studies on pregnant women with cardiac arrhythmias and aortopathies, with a view to developing a core outcome set for future studies in this area.

METHODS:

A search strategy was designed for MEDLINE, Embase and Cochrane Central databases from 1980 to 2015 to identify studies in pregnant women with arrhythmias and aortopathies. Two reviewers independently assessed titles and abstracts and discrepancies were reviewed by a third reviewer for the final decision on inclusion.

RESULTS:

After removing duplicates, 3118 titles and abstracts were reviewed and 485 articles involving pregnant women with congenital or acquired cardiac disease were identified. Of these, there were 12 studies on aortopathies and ten on arrhythmias. Overall, 77 outcomes were listed in the arrhythmia group, the most common being: cardiac event (7), syncope (4) and spontaneous abortion (3); 83 outcomes were used in studies on aortopathies, preterm delivery (8), increase in aortic root diameter (6), and abortion (6) being the three most common. The definition of outcomes differed significantly between studies.

CONCLUSION:

A large number of inconsistently reported outcomes were identified in studies involving pregnant women with arrhythmias and aortopathies. A core outcome set for cardiac disease in pregnancy, in particularly arrhythmias and aortopathies is in the process of being developed for international use in clinical and research settings.
Expectant Management vs. Induction of Labor in Women With Severe Proteinuria in Preeclampsia [20K]
Authors: Speranza Rosa , Savitsky Leah , Luck Marissa , Burwick Richard , Caughey Aaron B.
Published: May 2017

INTRODUCTION:

A 2013 report from the American College of Obstetricians and Gynecologists (the College) task force removed greater than 5g proteinuria in a 24-hour urine collection from the severe symptoms list for preeclampsia. We sought to determine the perinatal outcomes following implementation of this guideline.

METHODS:

A decision analytic model was created using TreeAge software. Our study compared induction of labor (IOL) at 34 weeks gestation with expectant management from 34-37 weeks gestation. For each week of expectant management, we calculated the rate of spontaneous delivery and risk of developing severe symptoms. Utilities were included with a discounted life expectancy rate of 3% to produce quality adjusted life years (QALYs). Our theoretical population included 100,000 pregnant women with mild gestational hypertension, greater than 5 g protein in a 24-hour urine collection and no other severe symptoms. We analyzed both neonatal and maternal outcomes.

RESULTS:

Expectant management based on the new guidelines resulted in 23,068 cases of progression to or complications of severe disease, 3 additional maternal deaths, and 10 more stillbirths. Conversely, IOL at 34 weeks resulted in 440 more neonatal deaths and 355 more cases of cerebral palsy.

CONCLUSION:

Our model and analysis support the updated College guideline for expectant management of women with mild hypertension, greater than 5 g proteinuria and no other severe symptoms. Although expectant management leads to higher rates of maternal death, stillbirths, and adverse maternal events, the significant rates of cerebral palsy and neonatal death in preterm delivery at 34 weeks support expectant management over IOL at 34 weeks.
Exploring Racial Disparities in Preterm Neonatal Outcomes in the Neonatal Intensive Care Unit (NICU) [21K]
Authors: Townsel Courtney , Keller Rebecca , Kuo Chia-Ling , Campbell Winston , Hussain Naveed
Published: May 2017

INTRODUCTION:

Racial disparities exist in pregnancy outcomes and infant mortality. We explored whether in-hospital morbidity or mortality differed by race for preterm neonates admitted to a single academic institution's NICU.

METHODS:

Retrospective cohort analysis of preterm infants, under 37 weeks, within NIS-3 database from 1994-2009. Anomalies and aneuploidy were excluded. Primary outcome was death before discharge. Secondary outcomes were respiratory distress syndrome (RDS), interventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). Planned sub-analysis of very preterm (VPT) infants, under 28 weeks, was performed. Four racial groups were compared with odds ratio compared to Caucasian neonates (CN). Logistic regression was performed with P-value less than 0.05 significant.

RESULTS:

4,802 neonates were included. There was no difference across racial groups (RGs) in death before discharge (p=0.106). Mixed neonates had a 60% increased risk of in-hospital death (IHD) compared to CNs [OR 1.60 (1.05-2.40), p=0.026]. There was a significant reduction in RDS for all three RGs compared to CNs (p=0.004). There was no difference between RGs for IVH (p=0.280) or NEC (p=0.099). In the VPT cohort IHD, RDS and NEC did not differ across RGs (p=0.151, p=0.538, p=0.905, respectively). There was a significant increase in IVH across VPT RGs (p=0.038). Asian neonates accounted for majority of IVH morbidity compared to CNs [OR 3.21 (1.09-9.07), p=0.029].

CONCLUSION:

IHD does not differ across RGs in preterm neonates admitted to the NICU. CNs have a higher rate of RDS than other RGs.
A Fertility Sparing Surgical Treatment of Cornual Ectopic Pregnancy [22K]
Authors: Sadek Seifeldin , Ravins Claudia , Vallejo Victoria , Dad Nimra
Published: May 2017

INTRODUCTION:

The mainstay of treatment for cornual pregnancy has been laparoscopic cornuostomy versus cornual resection. The purpose of this study was to achieve a safe and accessible treatment option for patients with cornual ectopic pregnancy, without compromising future fertility.

METHODS:

Two pregnant women diagnosed with cornual ectopic pregnancy were identified by ultrasound (US). Both were initially treated using methotrexate (MTX). After the failure of medical treatment, both underwent fertility-preserving surgery. The pelvis was accessed laparoscopically, 100 ml of vasopressin (dilution of 1:20) was injected into the myometrium at the base of the cornual ectopic pregnancy. After blanching of the cornual pregnancy was observed, using the operative hysteroscope, the cornual pregnancy was dislodged with alligator grasping forceps. A suction curettage was then performed, removing products of conception. A Beta-hCG was measured at postoperative day (POD) 1 and 28.

RESULTS:

Both patients tolerated the procedure well, with an estimated blood loss of less than 50 ml and an average OR time of 1H40 min. Both patients had a decrease in β-hCG by greater than 15% on POD 1 and were discharged the same day. On POD 28, Beta-hCG was less than 5 mIU/ml in both patients.

CONCLUSION:

The simultaneous use of laparoscopic and operative hysteroscopy in the treatment of a cornual ectopic pregnancy have been reported. The use of this technique reduces intra-operative bleeding and theoretically decreases the risk of rupture in future pregnancies. This modality, however, may not be used in all cornual pregnancies, especially in patients who already have hemoperitoneum.
Expression and Regulation of Anti-angiogenic Genes and Pro-angiogenic Genes in Human Trophoblast [23K]
Authors: Amezquita Fernando Aguirre , Smith Trenae , Schroeder Mark , Ismaeel Haneen , Torry Donald
Published: May 2017

INTRODUCTION:

Placental hypoxia during preeclampsia contributes to high expression of anti-angiogenic genes like sFlt-1 (Soluble fms-related tyrosine kinase-1) and inhibition of pro-angiogenic genes: PGF (Placental growth factor) and VEGF (Vascular endothelial growth factor). Recent studies suggest choline supplementation during pregnancy could decrease levels of sFlt-1 in maternal serum. The aim of this study is to evaluate angiogenic gene expression of human trophoblast under hypoxic conditions and determine if choline supplementation could modify aberrant gene expression.

METHODS:

Human trophoblast cell lines and placental villus explants collected from normal term placentae were cultured under normoxic and hypoxic conditions. Expression of sFlt-1, VEGF, PGF, and GCM1 (Glial cell missing homolog 1) was evaluated with real-time polymerase chain reaction. 5-Aza-2-deoxycytidine (5-AZA) was used to determine the effects of de-methylation on Flt-1 gene expression in the cell lines. Increasing concentrations of choline from 32 µM to 132 µM were used to treat explants.

RESULTS:

Expression of sFlt-1 in human trophoblast cell lines was lower than in primary trophoblast. Culturing cell lines in 5-AZA increased their expression of sFlt1. Treatment of explants with different choline concentrations under hypoxic conditions had limited effects on the expression of sFlt-1, VEGF, PGF and GCM1.

CONCLUSION:

These results suggest that trophoblast cell lines may regulate sFlt-1 gene expression differently than normal tissue. Hypoxic conditions tended to increase sFlt-1 and VEGF expression and inhibited PGF and GCM1 expression in explants. Choline supplementation seems to have limited effect on reversing hypoxic expression patterns of these genes in vitro. Further studies in primary trophoblast are needed.
Does IVF Treatment (Autologous and Donor Oocyte) Improve Pregnancy Outcomes in Women 40 Years and Older? [24K]
Authors: Savasan Zeynep Alpay , Heasley Emily , Abdulahad Aseel , Zeb Amna
Published: May 2017

INTRODUCTION:

Determine perinatal outcomes in women older than 40 years with IVF treatment (autologous and donor oocyte) compared with spontaneous pregnancy (SP).

METHODS:

Retrospective case control study of singleton pregnancies with maternal age 40 years and older between 2012-2014. Adverse perinatal outcomes included preterm delivery (PTD), hypertensive disorders of pregnancy (HDP), cesarean section (CS), gestational diabetes (GDM), intrauterine growth restriction (IUGR) and fetal loss (IUFD). Composite neonatal outcomes (CNO) included respiratory distress, intraventricular hemorrhage, necrotizing colitis, jaundice, NICU admission and neonatal death.

RESULTS:

Among 249 patients, 102 were IVF conceptions. Median maternal age (years) was 41 (40-50) for SP and 43 (40-52) for IVF (p>0.05). Logistic regression showed OR for PTD 2.3 (95% CI:1.1-4.7; p=0.024), HDP 2.5 (95% CI:1.2-5.1; p=0.016), CS 2.8 (95% CI:1.7- 4.7; p < 0.0001), CNO 3.1 (95% CI:1.7-5.8; p < 0.0001) in IVF pregnancies. These remained statistically significant after adjusting for maternal age. The risk of GDM, IUGR and IUFD was not significantly different between the two groups. Out of 102 IVF conceptions, 47 used donor eggs. These outcomes were not significantly different between donor and autologous oocyte pregnancies.

CONCLUSION:

IVF treatment is associated with adverse maternal and neonatal outcomes whereas oocyte donation does not improve these outcomes in women 40 years and older.
Does HgA1C Correlate With Birth Weight and Other Neonatal Outcomes in Gestational Diabetics? [28K]
Authors: Dinglas Cheryl , Muscat Jolene , Heo Hye , Boryushkina Varvara , Islam Shahidul , Vintzileos Anthony
Published: May 2017

INTRODUCTION:

Gestational diabetes has been associated with adverse neonatal outcomes. The objective of the study was to determine if third trimester glucose control, determined by HgA1C, is correlated with birth weight or other adverse neonatal outcomes.

METHODS:

A prospective cohort trial was performed at a single institution from 2/2013 to 1/2016. Gestational diabetics were enrolled and had a HgA1C within 4 days postpartum as an indicator of glucose control in the third trimester. Exclusion criteria included multiple gestations, delivery before 34 weeks, and chronic steroid use. Fetal growth was determined by a ratio of observed to expected birth weight (90th %) for gestational age, (O/E BW ratio). Linear regression analysis determined association between HgA1C and O/E BW ratio. Wilcoxon rank sum test assessed the correlation between HgA1C and neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), hypoglycemia, and hyperbilirubinemia.

RESULTS:

Sixty-eight women enrolled had an immediate postpartum HgA1C drawn. Mean pre-pregnancy BMI was 29 +/-6 kg/m2 and mean HgA1C was 5.6% +/- 0.6%. There was a statistically significant correlation between HgA1C values and O/E BW ratio, r= 0.509, p < 0.001. The optimal HgA1C cutoff, corresponding to an O/E BW ratio of 1, was 5.77%. HgA1C did not differ among neonates admitted to the NICU, or with a diagnosis of RDS, hypoglycemia, or hyperbilirubinemia.

CONCLUSION:

In a cohort of well-controlled gestational diabetic women with a normal mean HgA1C, a positive correlation was found between HgA1C and O/E BW ratio. Strict diabetic control with HgA1C less than 5.77% may prevent fetal overgrowth.
Factors Associated With Enhanced Availability of Zika Virus Testing Information on Health Department Websites [29K]
Authors: Rivera Joshua O. , Page-Ramsey Sarah , Rodriguez Emma , Menchaca Ryan , Ireland Kayla , Ramsey Patrick
Published: May 2017

INTRODUCTION:

Our objective was to evaluate factors associated with increased Zika virus testing information on health department websites in the United States and its territories.

METHODS:

We reviewed each US state, District of Columbia, and territory (Puerto Rico, Guam, US Virgin Islands, American Samoa, North Marianas Islands) health department websites for information on Zika virus testing. Websites were grouped as either having Zika testing information or not. Factors potentially associated with the presence of testing information on websites were compared between groups, including birth rates, presence of the Aedes mosquito, presence of Zika cases in the state/territory, and designation as a border state/territory.

RESULTS:

71% of 56 state/territory websites had Zika testing information. Mean birth rates were similar between those states with testing information and those without (12.2/1000 vs 13.8/1000, p=0.06). Websites with Zika testing information were more likely to be in areas with Aedes mosquitoes (92.5% vs 62.5%, p=0.01) and to have documented Zika cases (97.5% vs 68.8%, p=0.006) compared to those without information. Designation as a border state/territory did not impact likelihood of Zika testing information on the website (12.5% vs 25.0%, p=0.26).

CONCLUSION:

Zika testing information is more likely to found on state/territory websites where the Aedes mosquito is present and where Zika cases have occurred. Birth rate and border status do not impact the presence of Zika testing information on the state/territory website.
Factors Associated With Induction of Labor Among Primiparous Women Delivering at Term in the LTM III Study [30K]
Authors: Patel Divya , Davidson Christina , Salahuddin Meliha , Lakey David
Published: May 2017

INTRODUCTION:

Induction of labor (IOL) is an increasingly common obstetrical procedure in the U.S., yet characteristics associated with IOL among primiparous women delivering at term are not well understood.

METHODS:

Data from the Listening to Mothers III study, a survey of women ages 18-45 who delivered singleton babies in U.S. hospitals in 2011-12, were utilized. Weighted logistic regression models examined predictors of IOL among 924 primiparous women with term deliveries. Associations of maternal characteristics with delivery route (cesarean and vaginal delivery) were examined among primiparous women induced at term.

RESULTS:

423 (45.8%) primiparous women who delivered at term underwent IOL; subjective/non-medical reasons were reported by 53% of induced women. Women who were married (OR=1.8), felt pressure from a provider for IOL (OR=3.5), and whose provider was concerned about size of the baby (OR=1.9) were significantly more likely to undergo IOL. Nearly 30% of primiparous women who underwent IOL at term had cesarean delivery. Among induced women, those who were overweight/obese (OR=4.9), felt pressure from a provider for cesarean delivery (OR=9.0), believed that childbirth should only be interfered with if medically necessary (OR=2.2), and whose provider suspected the baby might be getting large near end of pregnancy (OR=2.9) were significantly more likely to have cesarean delivery.

CONCLUSION:

In this study, nearly half of primiparous women with term deliveries underwent IOL, with a sizeable proportion reporting subjective or non-medical reasons for induction. A better understanding of characteristics associated with IOL at term may help reduce unnecessary intrapartum interventions and, ultimately, primary cesarean delivery.
Factors Associated With Multiple Organ Dysfunction Syndrome in Patients With Obstetric Hemorrhage in Critical Care [31K]
Authors: Eliana Montoya , Carrizosa Jorge , Nino Reinaldo , Castro Alejandro
Published: May 2017

INTRODUCTION:

Obstetric hemorrhage is one of the leading causes of death in obstetric patients in developing countries. Every year, 14 million cases of obstetric hemorrhage occur globally, 1% of them dies. Multiple organ dysfunction syndrome (MODS) occurs between 7% to 15% of patients and has a 90% mortality when three or more organs are affected.

METHODS:

The aim of this study was to determine the risk to develop MODS in patients with obstetric hemorrhage using laboratory results at critical care unit admission. A retrospective case-control study was conducted in four university hospitals in Bogota, Colombia, between 2008 and 2014. Logistic regression analysis was conducted.

RESULTS:

We collected information from 277 cases and 558 controls. Of them, 84.9% was pregnant and 15.1% in the puerperium. The mean age was 27.8 years old (SD 7.3) and mean gestational age was 32.1 weeks (SD 7.1). Hemorrhage was the second most frequent diagnosis (12.2%). Multivariate analysis of hemorrhage diagnosis identified factors associated with MODS: creatinine levels equal or greater than 0.65 mg/dL (OR 1.8 95%CI 1.4-5.3; p < 0.003), platelets equal or less than 200.000 mm3 (OR 2.1 95%CI 1.4-3.2; p < 0.000), aspartate aminotransferases equal or greater than 80 (OR3.3 95%CI 1.7-6.6; p < 0.001), alanine aminotransferase equal or greater than 40 (OR 1.9 95%CI 1.1-3.3; p < 0.019) and total bilirubin equal or greater than 0.8 (OR 1.8 95%CI 1.1-3.0; p < 0.016).

CONCLUSION:

In patients with obstetric hemorrhage, platelet count, serum creatinine, and liver function test can be associated with MODS, even at values considered as normal.
Does Delivery Method Affect Neonatal Outcomes in Diabetic Women? [32K]
Authors: Varvoutis Megan , Shepherd Megan , Borgstadt Ashley , Leaphart Lynn , Baker Arthur
Published: May 2017

INTRODUCTION:

Prior studies have provided valuable findings regarding neonatal outcomes of diabetic mothers. Research has evaluated delivery methods and neonatal outcomes in the general population. Few studies have combined these factors and analyzed the association between delivery method and neonatal morbidity in pregnancies complicated by diabetes mellitus. We sought to determine whether a difference in neonatal outcome exists in the glucose intolerant patient by the type of delivery method.

METHODS:

This is a retrospective cohort study of glucose intolerant women comparing neonatal morbidity based on delivery method. Inclusion criteria were singleton, ≥37 weeks EGA pregnancies with glucose intolerance (pregestational and gestational). Patients diagnosed with congenital fetal anomalies were excluded. Patients were placed into two primary groups: vaginal delivery and cesarean delivery. The primary outcome was a composite of neonatal complications including hyperbilirubinemia, hypoglycemia, NICU admission, respiratory distress syndrome and birth trauma.

RESULTS:

The analysis included 413 eligible women (NSVD, n= 175; CS, n=238). The composite outcome of neonatal morbidity was not significantly increased in women delivered by cesarean section (33.1% vs. 33.2%; p=0.99). Subgroup analysis showed no significant difference in neonatal outcomes in spontaneous and induced vaginal delivery (40.7% vs 29.9%, p=0.15) or scheduled and failed IOL cesarean section (30.4% vs 37.0%, p=0.29).

CONCLUSION:

No significant increase in neonatal morbidity was observed in a particular delivery method. Failed induction of labor was not associated with worse neonatal outcomes. This information may be used for improved patient counseling. Further prospective studies evaluating delivery methods, failed induction of labor and neonatal outcomes are warranted.
Utilization of Placenta Examination in Extremely Obese Pregnant Women; Would It Assist in Improving Prenatal Care? [33K]
Authors: Mariona Federico , Plymel Tryston , Zoma Melody
Published: May 2017

INTRODUCTION:

Maternal obesity is associated with suboptimal perinatal outcome. Abnormal placenta structure and function have been reported in association with an inflammatory response present in maternal obesity. Our study explores the clinicians' use of placenta pathology in extremely obese pregnant women (body mass index ≥ 50 Kg/m2 BMI) to improve future prenatal care.

METHODS:

Post-hoc analysis of a limited patient cohort. Prenatal care was provided by Obstetrician Gynecologists and Resident physicians. Institutional Review Board approval was obtained. The placenta was examined at the time of delivery and submitted to the pathology laboratory. Macroscopic and microscopic evaluation was conducted by Board certified pathologists.

RESULTS:

The study was conducted between July 1, 2015 and July 31, 2016 included 4,527 live births; 797 placentas were submitted for evaluation (17.6 %). Two percent (n=58) were in the extreme obese class and 23 placentas of this group were submitted (39.6%). Mean maternal age 29.6 years, mean BMI 56.3 Kg/m2. Gestational age at delivery 27 6/7 to 40 6/7 weeks' gestation. Cesarean delivery 95.6 %. 52% of the placentas were large and 43.7 % small for gestational age. Hypertension in 43% and diabetes in 21.7 %. Preterm birth occurred in 43.4 % where 60% of the placentas were between the 5th and 25th percentile for gestational age. 22 % showed histologic chorioamnionitis. No predominant placenta histologic pathology was reported in the cohort.

CONCLUSION:

The findings reported to the clinicians provided no useful information to modify the prenatal care in a future pregnancy.
Patient Perception of Mammographic Breast Density Notification Laws [37K]
Authors: Metcalfe-Klaw Robin , Woodman Sarah , Fenimore Emily , Copit Debra , Jaspan David , Goldberg Jay
Published: May 2017

INTRODUCTION:

50% of women undergoing screening mammography will be diagnosed with increased breast density. These women may have slightly increased risk for and decreased detection of breast cancer (RR 1.2 – 2.1). Many states have passed laws requiring patient notification of increased breast density and offering additional breast imaging. Few states, however, require insurance coverage of additional imaging.

METHODS:

After IRB approval, a survey study of asymptomatic women undergoing screening mammography was performed. Data collected included patient demographics and patient knowledge of and perception towards breast density notification laws. Patients were additionally queried regarding if they would undergo additional breast imaging if notified of increased breast density on mammography. Statistical analysis was performed using Chi-squared, Fisher's exact test, and Student's t-test.

RESULTS:

18% of women were aware of breast density notification laws. 40% of women reported they would be worried if notified of increased breast density. 84% of women would choose to undergo additional breast imaging if the cost was completely covered by insurance compared to only 44% paying out of pocket.98% of women believed insurance coverage for additional imaging should be required. 88% believed breast density notification laws were economically discriminatory.

CONCLUSION:

If notified of increased breast density on their mammogram, women are twice as likely to undergo additional breast imaging when fully covered by insurance. However, approximately only half of these women would be willing to pay for additional breast imaging out of pocket. Breast density notification laws are economically discriminatory as they require offering additional breast imaging without mandating insurance coverage.
Increased Breast Density on Screening Mammography: Laws Leading to Confusion Amongst Providers [38K]
Authors: Mirghani Sara , Goldberg Jay , Jaspan David , Copit Debra , Scaven Christopher
Published: May 2017

INTRODUCTION:

The breast density notification act is a law that mandates that providers notify patients with increased breast density on screening mammography and offer these patients additional breast imaging. The American College of Obstetricians and Gynecologists has concluded that no studies have demonstrated improved prognosis when additional imaging is obtained, however they state that physicians should comply with their state laws. The aim of this project is to assess providers' knowledge of and management of increased breast density.

METHODS:

An anonymous nine question survey was administered to obstetrician gynecologist residents and attending physicians and primary care physicians. It was sent to providers via email through a Survey Monkey link. Data was collected over a two-month period with a total of 64 responses.

RESULTS:

Only 32% of providers understand the clinical significance of increased breast density on mammography. Only 21% of providers discuss the option of additional imaging with patients who have increased breast density. Sixty-one percent of providers are unaware of the Breast Density Notification Act. Approximately, 47% of providers stated that they would now change their management of increased breast density on mammogram, after having read the Breast Density Notification Act.

CONCLUSION:

There is a lack of provider knowledge regarding the finding of increased breast density on screening mammography. Most providers do not comply with state breast density laws. Simple interventions, such as clinician education and reformatting screening mammography result letters to both patients and providers can improve compliance with breast density notification laws and limit legal liability.
The Effect of Hypertensive Disorders in Pregnancy on Preterm Birth Rates Among African-American Women [4L]
Authors: Premkumar Ashish , Baer Rebecca J. , Jelliffe-Pawlowski Laura L. , Norton Mary E.
Published: May 2017

INTRODUCTION:

To investigate the role gestational and chronic hypertension (HTN) play in rates of preterm birth (PTB) among African-American women.

METHODS:

The study population was drawn from singleton, non-anomalous live births delivered between 20 and 44 weeks' among African-American Women from 2007-2011 in the birth cohort file maintained by the California Office of Statewide Health Planning and Development. Poisson logistic regression was used to calculate the risk of PTB by gestational age and type of PTB among women with a diagnosis of chronic or gestational HTN. Relative risks (RR) and 95% confidence intervals (CI) were calculated for PTB, adjusting for maternal age; payment for delivery; level of education; body mass index; pre-gestational diabetes mellitus; smoking; location of mother's birth; urban or rural residence; previous PTB; and inter-pregnancy interval less than 6 months.

RESULTS:

61,561 African-American women were included; 2,276 had chronic HTN and 5,861 had gestational HTN. Women with chronic HTN progressing to preeclampsia were at 43-fold higher risk of a medically-indicated PTB less than 32 weeks compared with women without chronic HTN. When comparing women with the diagnosis of chronic HTN progressing to preeclampsia versus those with gestational HTN progressing to preeclampsia, those with chronic HTN had higher risks of spontaneous and medically-indicated PTB, especially less than 32 weeks (aRR 2.5 and 3.4, respectively).

CONCLUSION:

Among African-American women, chronic HTN progressing to preeclampsia increased the risk for spontaneous and medically-indicated PTB, especially less than 32 weeks. Further inquiry into the pathophysiology of hypertensive disorders and evaluation of inequality should accompany research on PTB.
Maternal Outcomes and Management of the Third Stage of Labor Following Midtrimester Delivery [6L]
Authors: Sweat Haylea , Zuber Matthew , Cotton-Caballero Amaya , Wakefield Brian , Pettit Kate , Chisholm Christian
Published: May 2017

INTRODUCTION:

Preterm delivery is associated with a prolonged third stage of labor. Our objective was to evaluate the risk of maternal morbidity associated with duration of the third stage after midtrimester delivery.

METHODS:

We performed a retrospective cohort study examining vaginal deliveries between 14-24 weeks gestation. Univariate logistic regression was used for statistical analysis. A receiving operating characteristics (ROC) curve was generated to estimate sensitivity and specificity of the composite outcome (PPH, maternal infection, D&C) at 60 minutes. The proportion of undelivered placentas and risk of PPH or infection were plotted over length of third stage of labor.

RESULTS:

Of 131 participants, 38.2% had a third stage duration greater than or equal to 60 minutes. The risk of PPH was significantly higher among women with a third stage of labor greater than 60 minutes (OR=4.85, 95% CI: 2.11-11.11). This group was also more likely to undergo a post-delivery D&C (OR=18.6, 95% CI: 5.15-67.04). There was no difference in infection risk (OR=0.76, 95% CI: 0.17-3.30). The AUROC was 0.70 (sensitivity 67.0%, specificity 71.0%) for the composite outcome at 60 minutes. The proportion of undelivered placentas demonstrated exponential decay over time, while the risk of PPH and/or infection increased after 90 minutes.

CONCLUSION:

Maternal risk of PPH and need for post-delivery D&C at the time of midtrimester delivery increases with a third stage of labor greater than 60 minutes. Our data suggest that if the placenta is undelivered after 90 minutes, manual extraction or D&C is indicated to mitigate the increasing risk of maternal morbidity.
Genetic Approaches Reveal a Non-Hormonal Etiology for Hyperemesis Gravidarum [7L]
Authors: Fejzo Marlena S. , MacGibbon Kimber W. , Schoenberg Frederic P. , Sazonova Olga , Vacic Vladimir , Mullin Patrick
Published: May 2017

INTRODUCTION:

While very common, the cause of nausea and vomiting in pregnancy (NVP) remains elusive. Evidence suggests a genetic predisposition to the most severe form of NVP, hyperemesis gravidarum (HG). An understanding of the molecular mechanism behind HG will lead to targeted therapies to predict, diagnose, treat, and even prevent HG.

METHODS:

Using a novel approach to study NVP, we performed both a genome-wide association study (GWAS) on 1,306 cases with HG treated with intravenous fluids and 15,766 cases without NVP, and a whole-exome sequencing (WES) study of five families with HG to identify common and rare predisposing genes.

RESULTS:

WES identified RYR2, an intracellular calcium release channel that signals vomiting. GWAS identified a gene in the same pathway as RYR2 as well as genes that appear to play major roles in pregnancy and nausea. Neither method identified mutations or associations between HG and pregnancy hormones.

CONCLUSION:

This study suggests a possible paradigm shift away from a hormonal etiology for NVP. The genes linked to HG play roles in pregnancy and in nausea and vomiting. Treatments that affect some of these new targets are already under investigation. New avenues for prediction, diagnosis, and treatment should follow.
Frequency of Peripartum Gestational Hypertension and Associated Adverse Outcomes [8L]
Authors: Codsi Elisabeth , Garovic Vesna D. , Borowski Krist S. , White Wendy W.
Published: May 2017

INTRODUCTION:

Criteria for gestational hypertension (GH) include only 2 systolic blood pressures (BP) equal or greater than 140 or diastolic BP equal or greater than 90 at least 4 hours apart after 20 weeks gestation. We sought to determine the frequency of previously-normotensive patients meeting criteria for GH when presenting for delivery, and its association with adverse maternal/fetal outcomes.

METHODS:

We performed a retrospective cohort study of consecutive term deliveries without a diagnosis of hypertensive disorder of pregnancy (HDP) prior to admission. Characteristics of BP elevations, evaluations for and diagnosis of HDP; and associations with adverse composite maternal (seizure, pulmonary edema, unplanned ICU admission, emergent treatment of HTN, stroke, death) or fetal adverse events (5 minute Apgar more than 7, death or unplanned NICU admission) were determined.

RESULTS:

Of 185 patients, 140 (76%) had at least 1 BP elevation and 55 (30%) met formal criteria for HDP. Most elevated BPs occurred from admission to 1 hour postpartum (73%). Of those meeting GH criteria, only 18 (10%) underwent evaluation and 16 (9%) were formally diagnosed with HDP. A higher rate of fetal composite outcomes (7% vs 1%) was found in patients meeting criteria for HDP.

CONCLUSION:

BP elevations during admission for delivery were common, and though 30% met the strict definition for GH, only 9% were formally diagnosed reflecting low clinical suspicion. BP elevations through 1 hour postpartum appear to be most often a normal physiologic response to stress rather than a manifestation of HDP, yet GH is associated with risk for poor fetal outcomes.
Parity and Foley Catheter Using Tension or No Tension: A Randomized Controlled Trial [12L]
Authors: Fruhman Gary , Gavard Jeffrey , Amon Erol , Flick Kathleen , Gross Gilad
Published: May 2017

INTRODUCTION:

A secondary analysis of a randomized controlled trial was performed to determine the effects of parity on the use of a Foley transcervical balloon catheter for cervical ripening and the effects of tension on each group.

METHODS:

73 nulliparous and 67 multiparous women underwent cervical ripening with a Bishop score ≤ 6. Tension was created by securing the catheter to the thigh and replacing tension in 30 minute increments. Major outcomes included time from insertion to delivery, time from insertion to catheter expulsion, and mode of delivery. A p value of < 0.05 denoted statistical significance.

RESULTS:

Nulliparous patients had a higher rate of Cesarean delivery (CD) (39.7% vs 22.4%, p = 0.027). They had a longer median time to delivery (17.5 vs 14.6 hours, p=0.054). Applied tension did not shorten times from catheter insertion to delivery or to expulsion. A significantly shorter median time from catheter insertion to expulsion was found in the tension group in multiparous women (2.88 vs 4.61 hours, p= 0.003). Multiparous women in the no tension group had a higher rate of CD than women in the tension group (31.6 % vs 10.3%, p= 0.039).

CONCLUSION:

Within multiparous patients, applied tension decreased the time to expulsion of the catheter, whereas no tension may increase the likelihood of CD. Further studies to evaluate these findings are needed. As expected, nulliparity increased the risk of CD and there was a trend towards longer delivery times compared to multiparous patients.
The Impact of Labor and Delivery Unit Management on Long Childbirth Length of Stay [27L]
Authors: Plough Avery C. , Galvin Grace E. , Li Zhonghe , Declercq Eugene R. , Caughey Aaron B. , Shah Neel T.
Published: May 2017

INTRODUCTION:

The link between operational management of clinical services and quality of patient care has not been well characterized in obstetrics. We aimed to assess the impact of labor and delivery unit management practices on hospital length of stay (LOS) for low-risk patients during childbirth.

METHODS:

Using a validated instrument, we assessed the management practices of 51 diverse labor and delivery units across the United States. We constructed a patient-level relative risk regression model using all 226,463 low-risk patients discharged from these hospitals during 2013 and 2014. The model controlled for patient and hospital characteristics and accounted for clustering within hospitals. We defined our low-risk sample based on the AHRQ IQI#33 denominator specifications and excluded patients with ICD-9 codes indicating antepartum care. We defined long LOS as greater than 3 days for vaginal deliveries and greater than 5 days for cesarean deliveries.

RESULTS:

Delivering at a hospital with one standard deviation better patient flow management was associated with a 15% lower risk of long LOS (P=.004), and delivering at a hospital with one standard deviation better nursing management was associated with a 20% lower risk of long LOS (P < .001). In contrast, delivering at a hospital with one standard deviation better unit culture management was associated with a 30% higher risk of long LOS (P < .001).

CONCLUSION:

The management practices of labor and delivery units appear to independently influence the likelihood that a patient will experience prolonged hospitalization. Further research is needed to understand how optimal management can improve quality of care.
Maternal and Neonatal Outcomes of African-American Women in a Suburban Community Setting [34L]
Authors: May Carissa , Jovanovski Andrew , Ogunyemi Dotun
Published: May 2017

INTRODUCTION:

To evaluate the maternal and neonatal outcomes of African-American women delivering in a suburban community setting.

METHODS:

This is a retrospective study of 16,980 term, singleton deliveries from a single hospital system from 2013-2014. Obstetrical data was extracted from the electronic record, and obstetrical factors for African-American women (1625, 9.6%) were compared to non-African-American women, the majority of whom were Caucasian. For factors that were significant on univariate analysis, independent associations were ascertained using logistic regression.

RESULTS:

Compared to a primarily Caucasian suburban population, African-American women were more likely to be unmarried (OR 4.49), use opioids (OR 2.81), have a history of drug use (OR 5.26), and have class II obesity (OR 2.21). They were less likely to be current smokers (OR 0.11) and to use psychiatric medications during pregnancy (OR 0.28). Babies born to African-American mothers were more likely to have meconium staining (OR 1.52), umbilical arterial pH less than 7.0 (OR 4.32), and length of stay greater than 5 days (OR 1.24). All other factors showed no statistically significant association.

CONCLUSION:

Despite key demographic and historical differences, African-Americans delivering in a suburban community setting had similar maternal and neonatal outcomes to the comparison population. The greatest adverse association was with umbilical arterial pH less than 7.0, although the absolute number of cases was small (n = 8).
Maternal Depression Scale: Does Access to Prenatal Care Influence Postpartum Depression Score? [35L]
Authors: Lua Lannah , Magliarditi Alexandra , Kelley Melissa , Jackson David
Published: May 2017

INTRODUCTION:

In 2016, the United States Preventative Task Force recommends screening for depression in adults, including postpartum women. Our purpose was to assess the prevalence of “screen-positive” postpartum women delivering within our system, and to determine if access to prenatal care (PNC) has a measurable influence on depression scale results.

METHODS:

The ten-question Edinburgh Postnatal Depression Scale was routinely administered to postpartum women in our hospital. A score of 10 or greater triggered physician notification and social services consultation. Multivariate analysis was performed to investigate correlations between positive postpartum depression scale in patients with no PNC (zero office visits), limited PNC (1 to 3 office visits) and adequate PNC (greater than 3 office visits).

RESULTS:

A total of 970 women from January 2015 to May 2015 were included. The sample distribution consisted of 81% with adequate PNC (n=786), 12.7% no PNC (n=123), and 6.3% limited PNC (n=61). Scores of 10 or greater occurred in 21.1% (n=26/123) with no PNC compared to 10.9% (n=86/786) with adequate PNC (P=.003). A greater percentage of patients with adequate PNC had private insurance compared to those without PNC (23.5% vs 8.1%, P=.0001). Furthermore, significantly more patients with no PNC were self-pay compared to those with adequate PNC (37.4% vs 4.3%, P=.0001).

CONCLUSION:

Few studies have confirmed inadequate PNC as a measurable variable for positive postpartum depression screen. Financial issues appear to be a confounding variable. Obstetrician surveillance for management of depression in this population is warranted. Further prospective, interventional studies can potentially use this cohort as a base.
Maternal Factors and Neonatal Morbidity Associated With Opioid Use in Pregnancy [36L]
Authors: Losso MerryJean , Friedman Perry , Whitten Amy
Published: May 2017

INTRODUCTION:

To identify the maternal factors and neonatal outcomes associated with opioid use in pregnancy.

METHODS:

This is a retrospective study of 16,980 term, singleton deliveries in a single hospital system from 2013-2014. Cases of opioid use during pregnancy (n = 1,648) were compared to unaffected pregnancies (n = 15,332) via logistic regression.

RESULTS:

In terms of maternal factors, opioid use was associated with black race (OR 2.78), gestational age greater than or equal to 41 weeks (OR 1.25), smoking (OR 1.66), history of drug use (OR 1.59), and history of any psychiatric disorder (OR 1.38). Multiparity was protective against opioid use (OR 0.48). For intrapartum factors, opioid use was associated with induction of labor (OR 2.42), use of antihypertensive medications (OR 1.79), severe perineal lacerations (OR 1.59), chorioamnionitis (OR 2.29), postpartum hemorrhage (OR 3.02), and operative or wound complications (OR 4.85). For neonatal outcomes, opioid use was associated with abstinence syndrome (OR 5.17), major birth defects (OR 2.65), and umbilical arterial pH less than 7.0 (OR 2.65).

CONCLUSION:

There are distinct demographic, social, medical, and obstetrical correlates of opioid use in pregnancy. Major maternal adverse associations include operative and wound complications and postpartum hemorrhage, while major neonatal adverse associations include abstinence syndrome and decreased umbilical arterial pH.
Association Between Skin Tags and Acanthosis nigricans With GDM and Hypertensive Disorders of Pregnancy [39L]
Authors: Park YeonJung , Patwardhan Sanjay , Chang Eugene
Published: May 2017

INTRODUCTION:

Acanthosis nigricans (AN) and skin tags (ST) are associated with metabolic syndrome and insulin resistance in nonpregnant women. Studies have shown similar risk factors for metabolic syndrome and preeclampsia. The purpose of this study was to determine whether the presence of AN/ST are associated with increased risk of GDM and preeclampsia.

METHODS:

This was a prospective cohort study at MUSC. Patients ages 18-45 were examined at their prenatal visit for AN/ST and offered enrollment prior to their glucose tolerance test. Patients with pregestational diabetes, known fetal anomalies, and late transfers were excluded. A validated scale was used to assess AN. ST was defined as the presence of skin tags in the neck or axillae. Rates of GDM and hypertensive disorders of pregnancy were compared using chi square analysis with significance set at p < 0.05.

RESULTS:

191 patients were enrolled but 24 dropped out. 81 of these patients had skin changes. 28.4% had AN and ST, 34.6% had just ST, and 37% had AN alone. No difference was found in GDM incidence between those with and without AN/ST (4.9% vs. 7%, p= 0.75). The presence of skin findings was significantly associated with an increased risk for hypertensive disorders of pregnancy (p < 0.001).

CONCLUSION:

The presence of AN/ST is not associated with an increased risk for GDM but associated with an increased risk for hypertensive disorders of pregnancy. Larger studies are warranted to explore this association. If valid, we may be able to identify women in whom low dose aspirin may be helpful.