bluuebunny/crossref_metadata_2025 huggingface dataset:
Ringed Placenta: Changes in Placental Perfusion Associated with Increased Mortality with Ventral Body Wall Defect [18E]
Authors: Tonismae Tiffany , Brown Brandon , Dungy-Poythress Lauren , Shanks Anthony
Published: April 2018

INTRODUCTION:

Purpose is to assess perinatal morbidity/mortality among infants with ventral wall defects (VWD) and abnormal placental perfusion patterns on prenatal MRI.

METHODS:

A retrospective case series of pregnancies complicated by VWD (omphalocele, OEIS sequence, and bladder exstrophy) performed over a 7-year period. Maternal and infant charts were reviewed for basic demographic data, placental pathology, and neonatal outcomes. MRI studies were reviewed by 2 experts with a specialized focus in fetal MRI.

RESULTS:

31 cases of VWD were noted, and 11 cases possessed a novel placental perfusion pattern of a “ringed placenta” (pattern of rings of hyperintense MR signal surrounding hypointense placental cotyledons) seen throughout the parenchyma. In cases with a ringed placenta, five of 11 (45%) survived until 6 months of age. For the control group of VWD without the ringed placenta fourteen of 20 (70%) survived until 6 months of age. The relative risk for stillbirth/neonatal demise vs stillbirth/demise within 24hrs was 1.32 vs. 2.3 in VWD with the ringed placenta.

Over 50% of infant demises with abnormal placental findings and 25% of normal placenta finding were found to be small for gestational age (SGA) at birth, while all of the surviving infants were within normal range birth weight for gestational age.

CONCLUSION:

Compared to those pregnancies without the “ringed placenta, cases of VWD with the ringed placenta had a higher rate of death and were more likely to be SGA at birth. We did not find an increased risk of extremely low birth weights. Further study is needed to characterize this finding.
Maternal Risk Factor Index and Primary Cesarean Delivery among Low-Risk Women in Texas in 2015 [19E]
Authors: Salahuddin Meliha , Mandell Dorothy , Lakey David , Patel Divya
Published: April 2018

INTRODUCTION:

Cesarean delivery (CD) accounts for over one-third of all Texas births (∼400,000 annually), with primary CD accounting for 20% of the overall CD. We examined associations of maternal risk with primary CD among nulliparous, term, singleton, vertex (NTSV) deliveries in Texas.

METHODS:

NTSV deliveries to women ages 15-49 years were identified using the 2015 Texas birth file (Center for Health Statistics, Texas Department of State Health Services). A risk factor index was constructed (score range: 0-6), including preexisting diabetes mellitus (DM)/gestational DM (GDM), preexisting hypertension (HTN)/gestational HTN, eclampsia, infertility treatment, smoking during pregnancy, and pre-pregnancy overweight/obesity, and categorized as 0, 1, 2, and 3+ based on the number of risk factors present. Multivariable logistic regression models were conducted to examine the associations between the categorized risk factor index and primary CD, overall and by maternal race/ethnicity.

RESULTS:

Among the 116,273 NTSV deliveries, 26.6% had primary CD. The most prevalent risks among those with primary CD were pre-pregnancy overweight/obesity (60.9%), gestational HTN (10.3%), and GDM (5.8%). The adjusted odds for primary CD for 1, 2, and 3+ risk factors were 1.66 (95% CI 1.60-1.71), 2.61 (95% CI 2.48-2.74), and 4.07 (95% CI 3.58-4.62), respectively. This dose-response relationship was observed for all race/ethnic groups.

CONCLUSION:

Over 50% of NTSV deliveries with primary CD had at least one maternal risk factor. Women with a higher risk index score had elevated odds for primary CD. Understanding patterns of maternal risk associated with primary CD among NTSV deliveries is vital to reducing the overall CD rate in Texas.
Early Versus Late Amniotomy in Nulliparous Women Undergoing Induction of Labor [20E]
Authors: Doulaveris Georgios , Powell Kristin , Fisher Nelli , Frieden Faith , Stone Joanne , Bernstein Peter
Published: April 2018

INTRODUCTION:

Our objective was to investigate the effect of early versus late amniotomy on obstetric and neonatal outcomes in nulliparous women undergoing induction of labor.

METHODS:

This was a retrospective cohort analysis of nulliparous patients undergoing induction of labor in seven academic New York hospitals over one year (2016) derived from a quality improvement database. Nulliparous women with a singleton gestation undergoing induction of labor requiring an amniotomy were included. Data selected for this analysis included timing of amniotomy, obstetric and neonatal outcomes. Early amniotomy was defined as artificially ruptured membranes prior to the active phase and late amniotomy after the onset of active phase of labor. Results were compared between early and late amniotomy groups. Standard univariate analyses were performed.

RESULTS:

7104 medical charts were reviewed. 411 (5.8%) patients were nulliparous, undergoing induction of labor that required artificial rupture of membranes. 249 (60.6%) patients had an early and 162 (39.4%) patients had a late amniotomy. There was no statistically significant difference in the two groups in the rates of cesarean delivery (17.8% vs. 16%), operative delivery (10.8% vs. 8%), chorioamnionitis (5% vs. 6.8%), admission to neonatal ICU (6.6% vs. 8.6%) or an Apgar score less than 7 at one minute (7% vs. 6.2%). Women that underwent an early amniotomy had shorter active phase of labor (277.1 ± 11.4 mins vs. 347.8 ± 19.8 mins, p= 0.0009).

CONCLUSION:

Early amniotomy in nulliparous women undergoing induction of labor may shorten the active phase of labor without increasing the risk of adverse obstetric or neonatal outcomes.
Provider Perceived Barriers to 17P Use to Prevent Recurrent Preterm Births [21E]
Authors: Danilack Valery A. , Hosmer Jennifer , Littman Lisa , Frost Jordana , Clyne Ailis , O'Brien James
Published: April 2018

INTRODUCTION:

Weekly prenatal injections of 17 Alpha-hydroxyprogesterone caproate (17P) reduce the risk of recurrent preterm birth, but are underutilized and new pricing structures have created additional barriers. We queried prenatal care providers about their use of 17P and aimed to identify barriers to patients obtaining the recommended regimen.

METHODS:

All twenty-six obstetric practices throughout Rhode Island were invited to complete a survey either on paper or online.

RESULTS:

Twenty-two practices completed the survey, including private practices and community- and hospital-based clinics. All practices reported prescribing 17P to patients for whom it was indicated. Overall, when practices were asked to what extent patients were prevented from getting the recommended regimen of 17P because of any access issues, 9% of practices answered “very much,” 18% answered “somewhat,” 36% answered “a little,” and 36% answered “not at all.” Barriers faced in prescribing 17P reported by more than half of practices included lack of insurance coverage and insurance restrictions. There were slightly more barriers reported for patients with private insurance than those with public insurance. Practices reported that at least some patients expressed concern or declined treatment with 17P for the following reasons: cost to patient (13/22 practices), schedule of weekly injections (12/22), dislike or fear of needles (10/22), fear of reaction or side effects of injection (10/22), transportation to clinic for injection (7/22).

CONCLUSION:

To ensure women are receiving a recommended regimen of 17P when indicated, it is important to improve patient education, streamline the insurance authorization process, and reduce barriers to obtaining 17P.
Biomarkers for Acute Brain Injury in Cord Blood [23E]
Authors: Little Sarah , Blennow Kaj , Zetterberg Henrik , Bibbo Carolina , Robinson Julian
Published: April 2018

INTRODUCTION:

We investigated whether the second stage of labor (mode and duration) is associated with differences in biomarkers of neuronal injury in cord blood.

METHODS:

Using a prospective, longitudinal biobank of cord blood specimens, all women who underwent a forceps or vacuum delivery were matched to 3 controls: (1) an unlabored cesarean, (2) the shortest second stage within 3 months and (3) the longest second stage within 3 months. Cord blood samples were analyzed for two established biomarkers of acute axonal injury: total TAU and neurofilament light polypeptide (NFL).

RESULTS:

Our cohort consisted of 56 women. Maternal comorbidities and labor complications were similar across groups. Median levels of NFL, but not TAU, were statistically different across the 4 groups (forceps/vacuum 19.8 vs. unlabored cesarean 11.0 vs. short second stage 15.4 vs. long second stage 21.1; p<0.01). The most marked differences were by second stage duration irrespective of mode. Those with a second stages >2 hours (N=19) had a median NFL level more than twice that of those with an unlabored cesarean (22.7 vs. 11.0; p<0.01).

CONCLUSION:

Neurofilament light polypeptide levels (NFL) are significantly greater in cord blood after a prolonged second stage. While there is no current data to suggest this is associated with long term neurologic morbidity, the robust association of NFL with neuroaxonal injury in adults may prompt further research. Using biomarkers of acute brain injury may help obstetricians further clarify safety of varying second stage durations and/or help neonatologists better predict which neonates may benefit from interventions, such as therapeutic hypothermia.
Opioid Withdrawal During Pregnancy May Reduce Rates of Neonatal Abstinence Syndrome (NAS) [27E]
Authors: Stephens Angela , Raley Susanna , Street Linda , Browne Paul
Published: April 2018

INTRODUCTION:

The incidence of Neonatal Abstinence Syndrome (NAS) has risen dramatically in the United States (U.S) during the past decade paralleling the increase in pregnant patients with opioid dependence. Current U.S. Drug Enforcement Agency (DEA) policy does not support opioid withdrawal during pregnancy. DEA policy and the paucity of Licensed Narcotic Treatment Programs in the U.S. that accept Medicaid payment has led to limited options for opioid-dependent patients who request voluntary withdrawal during pregnancy.

METHODS:

This pilot study was designed to assess safety and efficacy of voluntary withdrawal using methadone. The study is a prospective cohort comparing patients who enrolled in methadone withdrawal to a cohort of patients who chose to remain in methadone maintenance.

RESULTS:

31 pregnant patients were identified with opioid dependency at our institution from 2014 to present (ICDM 10). 15 patients were in the withdrawal program and 16 chose to remain in maintenance. 4 of those in the withdrawal program remain pregnant. One was lost to follow up. The rate of NAS in the methadone maintenance cohort was 33% (5/15). The rate of NAS in the successful withdrawal group was 0% (6/6). The rate of NAS in the failed withdrawal group was 100% (3/3). There was one pregnancy loss in each group. There was a spontaneous abortion in the maintenance group and one perinatal death at 26 weeks in the withdrawal group.

CONCLUSION:

Successful, supervised opioid withdrawal during pregnancy may reduce rates of Neonatal Abstinence Syndrome as compared to opioid maintenance.
Optimal Timing of Delivery for Women with Hormone Receptor-Positive Breast Cancer [30E]
Authors: Kuo Kelly , Senz Kayli , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Data are limited regarding the optimal management of breast cancer in pregnancy. We aimed to compare strategies for the management of estrogen or progesterone hormone receptor-positive (HR+) tumors, and to determine the optimal gestational age for induction in regards to chemotherapy status and maternal-fetal outcomes.

METHODS:

A decision-analytic model was designed comparing 32 different strategies for scheduled delivery between 24-39 weeks gestation, with chemotherapy induction either at 24 weeks or delayed until after delivery. Baseline estimates of stage-specific mortality and the impact of delayed chemotherapy on survival rates were obtained from the literature. Our model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age.

RESULTS:

For women receiving antenatal chemotherapy, delivery at 39 weeks yielded the highest maternal and overall QALYs at all cancer stages. For women with stage I disease deferring chemotherapy until after delivery, no significant increase in 5-year mortality occurred until after 30-31 weeks gestation; induction at 37 and 38 weeks yielded the highest quality-adjusted life years (QALYs) from the maternal and societal perspectives, respectively. For women with stage II and III disease deferring chemotherapy, overall QALYs were maximized at 37 and 31 weeks, respectively. In univariate and multivariate sensitivity analyses, our model remained robust across reasonable ranges for all variables of interest.

CONCLUSION:

For women with operable HR+ breast cancer diagnosed in early pregnancy, antenatal chemotherapy and delivery at term are recommended; however, delaying chemotherapy until the postpartum period is reasonable for early stage disease.
Pregnancy Outcomes in Women with Gestational Diabetes Mellitus Diagnosed in the First Versus Second Trimester [31E]
Authors: Fahey Jacqueline , Wong Thalia , Afshar Yalda , Scibetta Emily , Janzen Carla , Rao Rashmi
Published: April 2018

INTRODUCTION:

First trimester screening is recommended for patients at higher risk for gestational diabetes mellitus (GDM). We sought to compare pregnancy outcomes in women diagnosed with GDM in the first versus second trimester.

METHODS:

This was a retrospective cohort study evaluating patients with GDM at a university clinic. The early diagnosis group had abnormal first trimester GDM testing. The late diagnosis group had normal first trimester testing, followed by abnormal second trimester testing. Mean differences in treatment interventions and maternal/neonatal outcomes were compared between groups.

RESULTS:

Of 115 total patients, 32 (28%) were diagnosed with GDM in the first trimester and 83 (72%) were diagnosed in the second trimester. There was no difference in number of antenatal testing visits, ultrasounds, or patients requiring medication for glycemic control (p = 0.78, p = 0.92, p = 0.92). Mean gestational age at medication initiation was earlier in the early diagnosis group (24.2 vs. 31.5 weeks; p < 0.001). There was no clinically meaningful difference in mean number of prenatal visits (11.7 vs. 10.4; p = 0.04) or nutrition consults (2.2 vs. 1.7; p = 0.005). Both groups had similar incidence of cesarean delivery and postpartum hemorrhage (p = 0.87, p = 0.57). There was no difference in minor or major adverse neonatal composite outcomes (p = 0.74, p = 0.48).

CONCLUSION:

Early GDM diagnosis and intervention in high-risk patients may positively impact their pregnancy by achieving similar maternal and neonatal outcomes without increasing the burden of clinic visits compared to those diagnosed in the second trimester.
Falling Third-Trimester Insulin Requirements and Adverse Pregnancy Outcomes: A Systematic Review [32E]
Authors: Sayyar Parastoo , Alavifard Sepand , D'Souza Rohan
Published: April 2018

INTRODUCTION:

There is conflicting evidence on whether falling insulin requirements in the third-trimester are associated with adverse pregnancy outcomes. Our objective was to systematically review the literature to determine the association between a ≥15 percent fall in insulin dose (PFID) and adverse pregnancy outcomes.

METHODS:

We searched Medline, Embase and PubMed from inception until October 2016 for English language articles describing falling insulin requirements and pregnancy outcomes. Article screening and data extraction was performed in duplicate. As significant clinical and methodological heterogeneity was anticipated, no formal meta-analysis was planned. Outcomes were described as proportions.

RESULTS:

We identified 1011 publications, of which three observational studies met eligibility criteria. Two studies that used ≥15 PFID were included in the quantitative analysis. Pregnancies with ≥15 PFID were associated with small-for-gestational-age (SGA) fetuses (6/40 vs. 7/153, p=0.04; risk ratio (RR) 2.95 [1.08, 8.07]). There were no differences in large-for- gestational-age fetuses (14/40 vs. 58/153; RR 1.07 [0.68, 1.70]), low 5-minute Apgar scores (6/40 vs. 16/153; RR 1.93 [0.52, 7.14]), caesarean deliveries (25/40 vs. 105/153; RR 0.90 [0.70, 1.17]), extreme preterm (3/35 vs. 2/104) birth, stillbirths (1/35 vs. 1/104) or hypertensive disorders (9/35 vs. 19/104, p=0.34).

CONCLUSION:

This systematic review of observational studies found no association between ≥15 PFID and adverse pregnancy outcomes, except for a higher number of SGA fetuses. This was not causal. Early delivery based on ≥15 PFID cannot be recommended. Instead, clinical management should involve continued maternal-fetal surveillance, exploring possible obstetric and metabolic reasons for this PFID, and treatment of the primary cause.
Pregnancy Outcomes in Patients with Neuromyelitis Optica: A Systematic Review [33E]
Authors: Wuebbolt Danielle , Andrejevic Katarina , Nguyen Vanessa , D'Souza Rohan , Wyne Ahraaz
Published: April 2018

INTRODUCTION:

Neuromyelitis Optica (NMO) is an antibody-mediated disorder characterized by recurrent myelitis and optic neuritis. Our objective was to systematically review pregnancy outcomes in women with NMO to aid counselling and management.

METHODS:

We searched MEDLINE, EMBASE, Web of Science, and PubMed from 1946 until August 2016 for relevant articles. Article selection, data extraction and quality assessment (QA), using the Joanna Briggs QA tool, were performed in duplicate. Outcomes were reported as proportions.

RESULTS:

We identified 2096 studies and included 22 studies describing 146 pregnancies in 112 women with NMO. QA scores for case reports and series were 7/8 and 5/10 respectively. The mean maternal age was 30±4 years and diagnosis-to-pregnancy interval was 6±4 years. De novo symptoms developed in 37%. Maternal outcomes included one postpartum death, one haemorrhagic stroke, one case of respiratory paralysis and 27 relapses, most of which involved myelitis (16) and optic neuritis (6). Relapses were treated with high-dose corticosteroids (20), plasmapheresis (15), immunosuppressants (11) and intravenous immunoglobulin (6), resulting in complete (12) or partial (10) recovery in most. In two cases symptoms worsened despite treatment, requiring emergency caesarean delivery. There were 121 (83%) livebirths, 115 (95%) of which were >37 weeks, 18 pregnancy terminations, five miscarriages, two stillbirths and no adverse outcomes on postnatal follow up (average 9 months).

CONCLUSION:

NMO is often diagnosed in pregnancy. Although women with NMO are at risk for relapses requiring aggressive management with high-dose corticosteroids, plasma exchange and immunosuppressants, retrospective data suggest that maternal and perinatal outcomes are comparable to the general population.
Use of Online Resources by OB/GYN Student Interest Group Officers and Advisors [2M]
Authors: Arnold Kate , Flint Caroline J.
Published: April 2018

INTRODUCTION:

OB/GYN medical student interest groups (SIGs) provide the first exposure for students to ACOG and APGO. Both organizations have resources for medical students on their websites, however, we hypothesize that many SIG leaders are unaware of these resources. The objective of our study is to assess SIG leader awareness of and perceived utility of online resources.

METHODS:

An IRB approved survey of 23 questions was sent to SIG leaders. One reminder was sent, then data collection was closed two weeks later.

RESULTS:

Online resources were underutilized with 30-40% of respondents being unaware of four out of five websites including the ACOG resident resource page, APGO residency directory, APGO clerkship guide, and the ACOG medical student Facebook page. All respondents had been to the ACOG website, however, only 31% had shared it with their SIG. Of note, 17% of SIG officers were not members of ACOG. Twenty-one percent of respondents were unaware that ACOG meetings often included medical student events.

CONCLUSION:

Our results show that there is much to be done in terms of disseminating information from our professional organizations to our future leaders. This would serve two purposes: First, it would engage leaders early and help foster their development; Second, it would help ACOG and APGO reach a larger audience. To increase awareness and utilization, we suggest sending SIG leaders, both medical student officers and faculty advisors, a welcome letter that includes a list of the resources in addition to the names of their ACOG fellow and junior fellow representatives for the state.
Quality As A Habit: Quality Improvement Training Curriculums In Obstetrics and Gynecology [6M]
Authors: Dhaliwal Amareen , Preet Mohan
Published: April 2018

INTRODUCTION:

With the advancement of To Err Is Human and Crossing the Quality Chasm, medical institutions have recognized the need to implement succinct Quality Improvement (QI) programs into the already packed Obstetrics and Gynecology (Ob/Gyn) residency curricula. While several residents conduct projects to teach quality improvement (QI), establishing QI methodology as a habit in Ob/Gyn requires several further integrated measures in the curricula.

METHODS:

This study aims to conduct a qualitative review of 84 articles in the last 30 years of literature through scientific databases on topics regarding Ob/Gyn QI training, outcomes, and education in order to propose a novel integrated framework for education in Ob/Gyn.

RESULTS:

Of 321 abstracts determined, 84 articles were analyzed. There are currently multiple training methods including simulations, audio and video seminars and webinars are in practice to improve QI. The review establishes methods to efficiently integrate such models into day-to-day teaching rather than single projects. The framework suggests for reducing gaps between determinants for improvements in QI training, the emerging characteristics of a system that enables trainees to learn hands on skills and broaden their horizon to predict upcoming challenges, and the measures of qualitative and quantitative efficiency in Ob/Gyn.

CONCLUSION:

The proposed integrated framework provides an evidence-based curriculum for improvement of QI training in the Ob/Gyn setting. In turn, this will assist in the training of Ob/Gyn residents to use QI measures as a habit, rather than a method of action.
An Educational Program to Address Maternal Health Disparities and High Infant Mortality in North Carolina [7M]
Authors: Patel Reena , Jones Rebecca , Sutton Jill
Published: April 2018

INTRODUCTION:

Infant mortality remains of significant concern in the United States. North Carolina infant mortality rates surpass national averages, while Pitt County exceeds the state average. Various factors have been shown to impact infant mortality, including prenatal care, breastfeeding, and socioeconomic status. Prenatal support and education can have an advantageous effect, particularly for vulnerable populations. This project seeks to demonstrate positive effects of prenatal support and education on anxiety, confidence, and lifestyle for mothers and partners in Pitt County, as analyzed through longitudinal prenatal education.

METHODS:

A curriculum was developed to cover topics including pregnancy health, breastfeeding, infant care, and safety. Participants completed pre- and post-class surveys, including the Spielberger State-Trait Anxiety Inventory, Lifestyle Indicator Questionnaire (Godwin), and skill confidence assessments. These items were scored and analyzed.

RESULTS:

The data indicated a decrease in mean anxiety from pre- to post-class (pre-class score: 33.8 vs. post-class score: 27.9; P<0.001). The data also showed increased mean confidence scores in multiple areas: breastfeeding from 1.9 to 2.9, infant CPR from 1.7 to 3.6, and infant choking rescue from 1.8 to 3.7 (P<0.001). Corresponding infant CPR and rescue assessment scores increased from a mean of 44.0 % to 98.0% (P<0.001). In qualitative analysis, 11 individuals reported specific healthy lifestyle changes throughout the series.

CONCLUSION:

This data suggests that prenatal support and education can decrease anxiety, increase confidence, and contribute to beneficial lifestyle changes, which can assist in decreasing infant mortality. Future research will further investigate longitudinal data to better understand program benefits and adapt strategies to improve effects.
Obstetric Residents’ and Nurses’ Critical Thinking Skills and Their Attitudes towards the Baby Friendly Initiative [9M]
Authors: Paul Rachel , Robbins Camaryn Chrisman
Published: April 2018

INTRODUCTION:

The Baby Friendly Hospital Initiative (BF) is shown to improve breastfeeding outcomes. Systems thinking (ST), a subset of critical thinking, helps individuals make inferences about behavior by developing a deeper understanding of underlying structure. The objectives of this project were to 1) explore characteristics of Ob/Gyn residents and nurses and their opinion of BF, 2) analyze the relationship between their ST skills and opinion of BF, adjusting for differences between residents and nurses.

METHODS:

Participants completed a survey assessing 1) opinions of BF 2) ST using the Systems Thinking Scale and 3) demographics. A linear regression examined the relationship between ST and BF scores, adjusting for factors significantly associated with the scores in univariate analysis.

RESULTS:

Thirty residents and 86 nurses participated. Residents had more males (p=.003), were less likely to have children of their own (p<.001), and were younger (p<.001). ST scores were not significantly different between residents and nurses (median=63 vs. 66, p=.93); however, residents had higher BF scale scores, indicating a more favorable opinion of the policy (median= 28 vs 24, p<.001). Higher ST scores were related to higher BF scores after adjusting for group (resident or nurse) and age (β=.218, p<.001).

CONCLUSION:

ST is significantly related to both residents’ and nurses’ opinions of BF; residents have a higher baseline for the relationship due to higher BF scores. Hospital administration can leverage this relationship by incorporating more ST into continuing education, resulting in more favorable opinions of new policies among their workforce and greater investment in the policy’s success.
Long-Acting Reversible Contraceptive Knowledge and Use in Medical Students [10M]
Authors: Fox Hannah , Zhao Songzhu , Hade Erinn , Isley Michelle
Published: April 2018

INTRODUCTION:

We assessed medical student use and knowledge of long acting reversible contraceptive (LARC) methods.

METHODS:

Medical students were surveyed electronically about their use and knowledge of LARC methods. A total LARC knowledge score was calculated by summing of the scores for all questions (range 0 to 8). LARC knowledge scores were compared between preclinical and clinical medical students, and further stratified by gender. The Cochran-Mantel-Haenszel (CMH) test was used to test the association between groups of total scores (0-3, 4-5, 6-8) and preclinical and clinical years among male and female students, controlling for age.

RESULTS:

Medical students use LARC methods more than the general population (30.1%, 95% CI: 24.7, 36.8 compared to 11.6% in the US population). LARC use increased from preclinical to clinical years (46% vs. 75% in the highest score group, CMH test p-value <0.0001, adjusting for age and gender). Knowledge scores were higher for preclinical years (mean score 5.25 vs 3.93, p-value=0.0016), but no significant difference for clinical years (mean score 6.54 vs 6.05, p-value=0.1621) when comparing female with male medical students. Both genders demonstrated increased LARC knowledge from pre-clinical to the clinical years, (p-value<0.0001 for both comparisons).

CONCLUSION:

Our results suggest that medical school curricula impart accurate knowledge of LARC methods, translating into increased use compared to the general population as well as increased use and knowledge across their medical education. The gender discrepancy in LARC knowledge suggests that curricula need to be improved to ensure that both male and female medical students take away similar knowledge.
Cervical Cancer Screening in Underserved Populations: Reflex versus Co-Testing for Cervical Cancer [16M]
Authors: Heller Michaela , Cottrell Connie , Fish Barry , Powell Angela
Published: April 2018

INTRODUCTION:

Cervical cancer is the second most common cause of cancer mortality among women worldwide. Several studies concluded that cervical cancer screening and intervention programs should target communities with lower socioeconomic status due to lower rates of screening and knowledge. The Women's Health Center (WHC) at Akron General Cleveland Clinic hosts free bi-annual cervical cancer screenings. All patients are screened with simultaneous cytology and HPV testing as opposed to specific age and HPV reflex guidelines. The primary objective of this study is to determine the rate of positive HPV results in underserved women with normal cervical cytology to evaluate the benefit of initial co-testing.

METHODS:

Patients’ charts were reviewed from inception of the program in October of 2006 to October 2014 to review cytology and HPV DNA results. Analysis was completed using descriptive statistics, which included prevalence rates of normal cytology with positive HPV testing.

RESULTS:

512 women participated in the free screening program. Of the 512 women participating, 94% did not have insurance and 63.7% of them never had a previous pap smear. Of those, 70 had positive HPV results. The prevalence of negative cytology among women with positive HPV was 47% (n=33). Of these 72% (n=24) tested positive for high risk HPV strains and 22% (n=9) were positive for low risk HPV.

CONCLUSION:

Findings from this study have important implications in developing free and effective cervical cancer screening programs for lower socioeconomic women and the potential benefit for initial co-testing.
Impact of Mental Health Services on Prenatal Care Adherence [19M]
Authors: Valji Farida , Nguyen Diem-Tran , Prescott Jessica E. , Ihenacho Ugonna , Sobrinho Giovanna , Dossett Emily C.
Published: April 2018

INTRODUCTION:

Pregnancy is an opportunity to identify and begin treatment for mental illness, yet obstetric clinics aren’t always equipped to diagnose and treat mental illness. The Obstetrics Mental Health (OBMH) clinic provides integrated mental health services in an academic, safety-net medical center’s prenatal care clinic. We evaluated whether adherence to OB Mental Health appointments increased adherence to prenatal medical care.

METHODS:

Data was retrospectively abstracted from the electronic medical record from July 2014 to October 2016. Included in the study were non-incarcerated pregnant women over 18 years of age who had attended an OBMH intake appointment. Engagement with OBMH care was defined as attending at least one OBMH appointment after the initial intake appointment. Adherence to prenatal care was defined per the ACOG recommended visit schedule.

RESULTS:

Of the 138 women that met the inclusion criteria, 50.7% were prenatal care adherent, 55.1% were OBMH adherent, and 35.8% were adherent to both. Fisher’s exact test demonstrates an association between OBMH adherence and increased prenatal care adherence with a two-tailed p value of 0.0396.

CONCLUSION:

Our results show a significant association between women who were OBMH adherent and increased prenatal care adherence compared to women that were not OBMH adherent (p<0.05). This suggests that addressing women’s mental health needs in a prenatal care setting encourages them to comply with prenatal medical care. Women receiving mental health care may be more emotionally and cognitively able to comply, more trusting of providers, or motivated by the convenience. Further research of collaborative care models can explore postpartum outcomes.
Patient Views on the USPSTF Statement Regarding the Annual Screening Pelvic Exam [23M]
Authors: Shelton Justin A. , Style Alyssa , Horn Philip , Goldberg Jay
Published: April 2018

INTRODUCTION:

The screening pelvic exam has been an integral part of the gynecologic annual well-woman visit. A recent US Preventative Services Task Force (USPSTF) statement states that there is insufficient evidence to support or refute the performance of annual screening pelvic exams in asymptomatic, non-pregnant adult women.

METHODS:

Patients in an outpatient gynecologic resident continuity clinic were asked to complete a 14-question survey inquiring about their views on annual screening pelvic exams, as well as demographic information. Statistical analysis was performed using the Student’s t-test.

RESULTS:

100 female patients, ranging from 15 to 64 years of age, completed the survey. 81% identified as African American or Hispanic/Latino. 63% were insured by either Medicaid or Medicare. 94% reported an annual household income < $50,000. 69% were unaware of the recent statement regarding annual screening pelvic exams made by the USPSTF. 66% believed that the annual screening pelvic exam was necessary, even in asymptomatic women. 33% were concerned that something would be overlooked or missed if they did not receive a pelvic exam. Of the patients with an annual household income < $50,000, 67% believed that the annual screening pelvic exam was necessary versus 100% with an annual household income > $50,000 (p < 0.05).

CONCLUSION:

The majority of women disagreed with the recent USPSTF statement that the annual screening pelvic exam may be unnecessary.
The Benefits of Cancer Genetic Panel Testing in At-Risk Women: A Single Institution Experience [24M]
Authors: Frost Anja S. H. , Toaff Miriam C. , Biagi Tara , Stark Elizabeth , McHenry Allison , Kaltman Rebecca
Published: April 2018

INTRODUCTION:

The scope of panel testing for hereditary cancer syndromes is expanding rapidly. We sought to evaluate the role of panel testing in identifying actionable genetic mutations in high-risk or affected women, beyond BRCA-limited testing.

METHODS:

A retrospective chart review was conducted of all patients presenting to a multi-disciplinary cancer program at George Washington University for genetic counseling from 1/2015 and 12/2016. The results of testing and management implications, based on NCCN guidelines, were recorded.

RESULTS:

Of 673 patients that underwent single site, BRCA-limited, or panel testing, 17% (n=116) were found to have at least one deleterious mutation, of which 96% (n=111) had changes in clinical management. Over one half (65%, n=65) of patients who tested positive for a mutation had undergone panel testing and three-quarters (n=49) of those individuals were diagnosed with non-BRCA mutations. The latter group represents patient’s whose mutations would have been missed without a broader panel test. Ninety-six percent of those testing positive for a mutation (n=111) had significant increase in clinical surveillance and/or management. All of the true negative individuals (n=45) were able to decrease their surveillance and/or management.

CONCLUSION:

Despite concern that the results of panel testing do not translate into clinically impactful management of high-risk individuals, our data indicates that guideline-based management is frequently altered by such testing. Obstetrician-gynecologists should incorporate detailed family histories into their routine visits, and counsel patients on the availability and utility of genetic panel testing when appropriate.
Evaluation of Physician Communication Skills During Simulated Vacuum-Assisted Deliveries [29M]
Authors: Mella Maria Teresa , Lee Yuo-yu , Bernstein Peter , Atallah Fouad , O'Neill Loraine , Friedman Frederick
Published: April 2018

INTRODUCTION:

The objective of this study was to determine if a targeted education program using a mannequin-simulated vacuum-assisted delivery could improve the communication skills of obstetricians.

METHODS:

This study involved a concurrent assessment of the performance of obstetricians during vacuum-assisted vaginal deliveries using synthetic models. All obstetricians within an existing Obstetric Quality Improvement Collaborative with operative vaginal delivery privileges were enrolled in the study. All evaluators underwent a rigorous training program to ensure uniformity. Demographic information including years in practice and simulation experience were recorded. Eight communication skills and an overall assessment were scored using a standardized checklist. Performance on all variables was evaluated before and after a targeted training session.

RESULTS:

288 obstetricians participated across the 5 study hospitals. The majority (69%) of subjects was female, and most (70%) had greater than 10 years of training. For all 8 communication skills measured and for the overall performance, there were statistically significant improvements following the simulation and targeted education session. Communication skills did not vary by sex of the participant. Obstetricians with an intermediate level of experience (6-10 years) appeared to perform best across all parameters.

CONCLUSION:

Our data show that a simulation training program including a targeted education session in vacuum assisted-deliveries improves obstetrician communication skills.
Prep for Residency: Can Students and Interns Benefit from the Same Simulation-based Curriculum in Obstetrics? [30M]
Authors: Garrison Etoi , Ware Jamie , Dewey Charlene M.
Published: April 2018

INTRODUCTION:

Residency programs struggle to provide trainees with opportunities for formative assessments of their knowledge and skill. The purpose of this study is to determine if a simulation based training in obstetrics can be used to teach and assess APGO/CREOG knowledge/procedural skill competencies to medical students and interns with varying experience.

METHODS:

A pilot curriculum to assess basic obstetric knowledge and skill was developed by medical school/residency faculty. Trainees were asked to manage a term labor patient in three simulated scenarios: (1) membrane rupture, (2) preeclampsia and third trimester bleeding and (3) SVD with basic neonatal evaluation. Checklists and global rating scales were used for performance assessments. Pre- and post surveys assessed trainee knowledge/confidence. Statistical analysis was performed using paired t- tests and chi square analysis.

RESULTS:

Eight graduating medical students, 6 advanced interns, and 9 day 1 interns from two medical schools participated in a Preparation for Residency workshop April-July 2017. Knowledge/procedural deficiencies were identified for students and day 1 interns. Advanced interns struggled with neonatal resuscitation despite proficiency with vaginal delivery, preeclampsia, and membrane rupture. Confidence improved in all areas tested for junior trainees (p<0.05). Two scenarios were expanded to assess advanced interns in basic ultrasound skills and the management of postpartum hemorrhage. Significant improvements in advanced intern confidence were noted (p<0.05).

CONCLUSION:

Simulation provides opportunities for formative assessment of learners as they begin residency training. Faculty feedback was used to identify optimal targets for deliberate practice-based improvement for each trainee regardless of skill level and experience.
Forceps Assisted Vaginal Delivery Simulation Training: Changes in Resident Confidence, Knowledge and Skill [31M]
Authors: Rose Kelsey , Afshar Yalda , Jensen Kirsten
Published: April 2018

INTRODUCTION:

Simulation is a powerful learning tool for low frequency events. In 2015, 3.1% of all deliveries were operative vaginal deliveries and only 0.56% were forceps assisted vaginal deliveries (FAVD). The aim of this study is to create a simulation-based curriculum on FAVD and evaluate resident knowledge, confidence, and performance before and after training.

METHODS:

An IRB-approved prospective cohort study was conducted. Obstetrics and gynecology residents participated in three hours of a three-part simulation training including a video, didactic teaching, and hands-on simulation practice during the 2016-2017 academic year. A 26 item pre- and post-survey and skills assessments was conducted to assess confidence, knowledge, and ability to perform a forceps delivery. Our primary outcome was improvement in resident confidence and skill.

RESULTS:

Twenty residents consented to participate and 14 surveys were completed (70%). There was a 28.5% increase in self-perceived confidence before and after training for all residents (P<.001). Significant differences in perceived confidence between resident classes were seen pre-simulation (P<.001). Junior residents demonstrated an increase in perceived confidence (P<.001), while senior residents did not (P=.13). There was an overall improvement in the percentage of residents who performed the required skills for an accurate forceps delivery post-simulation (P=.001).

CONCLUSION:

Our developed forceps simulation curriculum improves resident perceived confidence and skill. Additional simulation training will involve consenting training sessions. Future analysis will look at the number of forceps deliveries at our institution since the initiation of the simulation-based training curriculum.
Evaluation of Physician Technical Skills During Simulated Vacuum-Assisted Deliveries [33M]
Authors: Friedman Frederick , Teresa Mella Maria , Bernstein Peter , Atallah Fouad , Lee Yuo-yu , Sandler Raymond
Published: April 2018

INTRODUCTION:

The objective of this study was to determine if a targeted education program using a mannequin-simulated vacuum-assisted vaginal delivery could improve the technical skills of obstetricians.

METHODS:

This study involved a concurrent assessment of the technique obstetricians employed while performing vacuum-assisted vaginal deliveries using synthetic models. Study enrollees consisted of all obstetricians within an existing Obstetric Quality Improvement Collaborative who maintain operative vaginal delivery privileges. All evaluators underwent a rigorous training program to ensure uniformity. Technical skills and an overall assessment were scored using a standardized checklist of 14 tasks. Data points were collected while assessing the subjects’ technique both before and after a targeted training session.

RESULTS:

Complete assessment was available for 288 obstetricians across the 5 participating hospitals. The majority (69%) of subjects was female, and most (70%) had greater than 10 years of training. For 8 of the technical skills, as well as for the overall assessment, there was statistically significant improvement following the simulation and the targeted education session. When comparing overall technical skills based on sex of the obstetrician and years in practice, there were no differences in degree of improvement following the educational session.

CONCLUSION:

Our data show that a simulation training program including a targeted education session in vacuum assisted-deliveries improves obstetrician technical skills.
Simulation-Based Curriculum is Effective in Teaching Principles of Vaginal Breech Delivery [35M]
Authors: Higgins Erin , Becker Les , Auguste Tamika
Published: April 2018

INTRODUCTION:

Simulation has yet to be fully implemented into the curriculum in many obstetrics and gynecology residencies across the U.S. Reasons for resistance to implementation include cost, time requirements both of instructors and learners, and a paucity of data demonstrating the benefit of simulation with regards to skills training. Advocates of simulation in residency training note its value in teaching high-acuity, low-frequency events such as vaginal breech delivery.

METHODS:

We implemented a one year simulation curriculum incorporating obstetric and gynecologic skills training, standardized patient encounters, and teamwork training. Residents at all levels participated in the training sessions, which were a mandatory part of the educational curriculum. End-of-the-year evaluation was accomplished through the use of a two-hour practical exam in which residents performed skills at 13 different stations. Faculty evaluations of residents were collected for each station using an objective skills card that scored both clinical knowledge and procedural skills.

RESULTS:

We found that residents’ performance at the vaginal breech station improved consistently over 3 years of data collection. The junior cohort improved from 70.0% to 83.3% proficiency from PGY-1 to PGY-3, while a more senior cohort improved from 78.6% to 84.6% from PGY-2 to PGY-4. An third cohort that began the curriculum in the PGY-3 year improved from 90.4% to 91.6%.

CONCLUSION:

This pilot study demonstrates that a simulation-based educational curriculum is an effective method of teaching residents procedural skills and knowledge to improve competency in the area of vaginal breech deliveries.
Development of a Simulated Intra-Abdominal Model and Visual Analog Scale to Assess Visual Clarity of Laparoscopes [37M]
Authors: Palvia Vijay , Gonzalez Aaron Herrera , Richard Vigh , Anasti James
Published: April 2018

INTRODUCTION:

Visual clarity (VC) is vital in performing laparoscopic surgery. However, few studies provide a direct assessment of laparoscopic VC or techniques to improve VC.

METHODS:

A box was constructed of ¼ inch acrylic glass with opaque insulation. An attached humidified source was heated to give a constant 81% humidity at 36 degrees Celsius. A 10 mm laparoscope was inserted and positioned 8 cm distal to a laminated white card containing black 12 pitch font. Four standard still images of varying visual clarity were captured and designated VC1, VC2, VC3, and VC4. A 10 cm visual analog scale (VAS) was used to rate VC scores. The 0 cm mark indicated total visual obstruction and the 10 cm mark indicated perfect visual clarity. The performance of the VAS was determined by having observers rate the still images. The observers were blinded to the VC rating and number of standard images used. Intra-observer and inter-observer differences were calculated.

RESULTS:

Standard images were assessed in random fashion 4 times by each of the 4 independent observers (64 total readings). Observed means were calculated (VC1, 9.2 ± 0.57 cm; VC2, 7.4 ± 0.65 cm; VC3, 4.4 ± 0.65 cm; VC4, 1.4 ± 0.52 cm). All values differed from each other (p < .001). Inter-observer differences were < 0.54 ± 0.37 cm and intra-observer differences were < 0.35 ± 0.13 cm.

CONCLUSION:

Our novel simulation model applied a visual analog scale that can serve as a tool to compare various techniques utilized for improving laparoscopic visual clarity.