bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Attending Mentorship Program on Physician Confidence Performing Laparoscopic & Vaginal Hysterectomies [2I]
Authors: Heft Jessica , White Nicola C. , Panza Joseph Robert , Alvarez Ronald David , Zimmerman Carl
Published: May 2019

INTRODUCTION:

Hysterectomies for benign indications have become increasingly performed by fellowship-trained Subspecialists, possibly due to the lack of mentorship among surgeons. We sought to evaluate the change in confidence level of Specialist Attendings (Sas) with the enactment of an Attending Mentorship Program (AMP) for laparoscopic hysterectomies (LHs) and vaginal hysterectomies (VHs).

METHODS:

Sas were invited to participate in this IRB-approved study. Baseline and 6-month post-AMP confidence levels were obtained using a Visual Analog Scale (VAS). LH mentors were members of the MIGS Division. VH mentors were members of the FPMRS Division. Secondary outcomes of operative time, estimated blood loss (EBL), length of admission (LOA), and postoperative complication rates were recorded.

RESULTS:

Thirteen Sas met inclusion criteria for this study and agreed to participate. From July 1st, 2017 to December 31st, 2017, 12 of these surgeons participated in the AMP performing a total of 35 hysterectomies. Ten Sas performed 27 LHs; seven Sas performed eight VHs. VAS scores increased 1.05 cm (p = 0.002) for LHs and increased 0.34 cm (p = 0.33) for VHs. The differences in operative time and EBL were not statistically significant in the AMP groups compared to the non-AMP groups. LOA and postoperative complication rates were similar between all groups.

CONCLUSION:

Confidence levels of Sas in performing LHs increased when the AMP was implemented. Though an increase in VAS confidence scores for VH was seen, this was not statistically significant. Mentoring can be an important factor in SA hysterectomy confidence.
HIV Pre-exposure Prophylaxis (PrEP): Knowledge and Attitudes Among Healthcare Providers [8I]
Authors: Tiu Janeine , Robles Juan
Published: May 2019

INTRODUCTION:

HIV is a public health concern and studies have shown poor knowledge about pre-exposure prophylaxis (PrEP). Truvada is FDA-approved as PrEP. We explore the knowledge and attitudes towards PrEP among healthcare providers.

METHODS:

119 healthcare providers in Los Angeles completed an IRB-approved online survey. The survey assessed the participants' demographic information, level of training, specialty, practice setting, and their knowledge and attitudes about PrEP. We evaluated the relationship between the overall knowledge score vs. the overall attitude score before and after adjusting for the specified covariates using a linear regression model and a backwards procedure for final variable selection with p<0.1.

RESULTS:

Of the 119 respondents, 82% were female, 72% were 25-34 years old, 59% were Caucasian, 58% were in OB/GYN, and 91% were from an academic medical center. Our population showed good knowledge about PrEP where 66% of knowledge based questions were answered correctly by providers. Our participants had an increased attitude score, with a mean of 14 points (range 9-18). A higher overall knowledge score correlated to a higher overall attitude score (p=0.0021). Each one standard deviation increase in the knowledge score was associated with an approximately 2/3 of a point increase in the attitude score (mean change = 0.69, p<0.001). No demographic factors affected the knowledge score.

CONCLUSION:

In our population, provider knowledge is high and attitudes are positive towards HIV PrEP. Increased knowledge correlated to a more positive attitude towards PrEP. This can be used to guide future research to explore prescription patterns and identify barriers to implementation.
Informed Consents or Consent of Information? Assessing Quality of Informed Consents for Scheduled Cesarean Section [9I]
Authors: Jackman Janelle Mary , Martinez Carolina Cay , Byer Erroll , Balhotra Kimen
Published: May 2019

INTRODUCTION:

Informed consents of patients undergoing procedures are important not only for ethical and legal reasons but also for the quality of care. Patients' understanding allows for better cooperation, improves results and satisfaction and also helps prevent errors. Providers must ensure that the patient understands the nature of their condition, the risks and benefits of the procedure, the alternatives and agrees voluntarily. Although consents are a well-established practice, it often fails to meet its purpose. Providers must realize that signing a consent form is not equivalent to receiving informed consent.

METHODS:

A cross sectional survey of patients admitted for scheduled cesarean section. The anonymous questionnaires were administered within 30 minutes to 48 hours of having the consent explained. The questions focused on patient's recall of information about the explanation of the procedure, risks and alternatives, preferences about the decision process and overall satisfaction with the manner in which the consent was obtained.

RESULTS:

Only 9% of the patients didn't receive explanations about risks but 42% didn't have discussions of alternative options. Most patients (70%) weren't asked to repeat the explanation. Expectations about decision varied, with 65% favoring shared decision and nearly 26% preferring autonomous decision. Satisfaction was rated as good or very good by 94% of patients.

CONCLUSION:

In conclusion, most patients do not remember receiving explanations about alternatives for procedures nor are they asked to repeat explanations. We recommend that the quality of consents be regularly assessed, to ensure informed consent is being obtained.
Breastfeeding and Marijuana Use: Medical and Ethical Policy Analysis [10I]
Authors: Gross Marielle S. , Rosenblum Nadine , Bossano Carla M. , Milio Lorraine A.
Published: May 2019

INTRODUCTION:

U.S. guidelines recommend breastfeeding women avoid marijuana given concerns about infant neurodevelopment. Unfortunately, this has resulted in many physicians and hospitals prohibiting women who use marijuana from breastfeeding despite inconclusive evidence of harm and well-known benefits of breastfeeding. Meanwhile, marijuana use is increasing among reproductive-aged women, and complex personal/socioeconomic factors affect feeding choices. We assess evidence and ethical justification for current practice.

METHODS:

We review: (1) Harm to infants from breastmilk marijuana exposure vs. avoiding breastfeeding, (2) Maternal health and psychosocial considerations, and (3) Current practices in light of principles of beneficence, justice, and autonomy.

RESULTS:

(1) Limited data suggests neurobehavioral changes among infants whose mothers use marijuana during breastfeeding, though socioeconomic confounders and difficulty of distinguishing in utero from breastmilk exposure hinder interpretation. Avoiding breastfeeding increases infants' risk of sudden infant death syndrome, sepsis, necrotizing enterocolitis, diabetes, asthma, and obesity. (2) Without breastfeeding, women have increased risk of cardiovascular disease, reproductive cancers, diabetes, depression and unintended pregnancy. Marijuana use is highest among underserved minority women who disproportionately suffer these health consequences and are especially vulnerable to punitive damages. (3) Benefits of breastfeeding for infants and women should be considered alongside risks of marijuana exposure through breastmilk. Lack of these considerations may exacerbate health disparities. Unbiased, culturally-informed counseling would promote open patient-provider communication and shared decision-making, and may improve long-term health.

CONCLUSION:

Restrictive breastfeeding policies for women who use marijuana which do not utilize an individualized, shared decision-making approach are not ethically justified, and may disproportionately undermine health of underserved women and infants.
Development of a Risk Assessment Tool for Surgical Site Infections (SSI) in an OBGYN Patient Population [18I]
Authors: Schweer David , Byun Sharon Y. , Davis John D. , Weber LeBrun Emily Elise
Published: May 2019

INTRODUCTION:

Surgical site infections (SSI), are defined as superficial, deep, or organ space infections that occur within 30 days of surgery. SSIs are known to greatly increase health care costs and hospital length of stay. In additional to using standard sterile surgical technique and antibiotic prophylaxis, additional strategies been proposed to reduce risk of SSI which include the use of negative pressure wound therapy devices.

METHODS:

We identified all post-cesarean delivery and post-hysterectomy SSI cases as per infection control criteria at the University of Florida between January 1 and December 31, 2017. We developed a SSI risk assessment tool based on based on review of these cases using a defect analysis tool, literature review of SSI risk factors and surgical risk calculators.

RESULTS:

There were 21 OBGYN surgical site infections in 2017. Of these infections, 14 occurred after cesarean delivery and 7 after hysterectomy for a rate of 1.56 and 2.46 respectively. The mean BMI was 41.3 and 39.27 for cesarean delivery and hysterectomy, respectively. Only, 33% of cases were scheduled surgery with the remaining classified as non-scheduled urgent or emergent cases.

CONCLUSION:

An EPIC “smartphrase” was created in our electronic medical record system to help identify patients at increased risk for SSI. Use of this smartphrase should prompt surgeons to consider additional wound infection prophylaxis such as the use of a negative pressure would therapy device. Future direction would include whether or not the use of such a smartphrase increases the use of additional wound infection protective strategies and reduced SSI risk.
Effect of Warmed Hysteroscopic Fluid Distention Medium on Postoperative Core Body Temperature: A Randomized Trial [8J]
Authors: Salazar Christina A. , Wong Marron C. , Miller Valencia E. , Morris Stephanie N. , Isaacson Keith B.
Published: May 2019

INTRODUCTION:

The purpose of this research study was to determine whether warming of the distention fluid during operative hysteroscopy will have an effect on perioperative core body temperature, and secondarily to assess postoperative self-rated pain scores.

METHODS:

Single-blind, 3-arm stratified randomized trial. Total of 96 patients were randomly allocated to 3 groups. Group 1 received normal saline fluid bags at room temperature 22°C (71.6°F), group 2 received fluid bags pulled from a warming cabinet set at 40°C (104°F), and group 3 received continuously warmed fluid at 40°C (104°F). Randomization was stratified by procedure type (myomectomy and non-myomectomy) to ensure 50% of the cases in each group included resections of submucous leiomyoma.

RESULTS:

There was no statistically significant difference between the 3 arms of the trial in near-core body temperature (P=.29) or in self-rated pain scores (P=.09). However, when compared to all other procedure types, the myomectomy procedures had statistically significant higher fluid deficits in group 1 (P=.01) and group 2 (P=.02), as well as significantly longer operative times in group 1 (P=.05) and group 2 (P=.03). Group 3 demonstrated no statistically significant difference in average fluid deficit between hysteroscopic myomectomy to all other procedure types (P=.16), despite there not being a statistically significant difference in total procedure time between myomectomy procedures and all other surgical procedure types (P=.42).

CONCLUSION:

Warming of hysteroscopic distention media did not impact near-core body temperature or post-operative pain scores. Use of continuously warmed hysteroscopic fluid in hysteroscopic myomectomy may decrease operative times as well as volume of fluid deficits.
Letrozole for the Treatment of Thoracic Endometriosis: A Case Report [15J]
Authors: Chadwick Tara Hardiman , Audlin Kevin
Published: May 2019

INTRODUCTION:

Thoracic endometriosis syndrome describes ectopic endometrial tissue within the thoracic cavity causing significant morbidity including cyclic chest pain, pneumothorax, hemothorax, and hemoptysis. Thoracic endometriosis is a rare condition usually requiring multiple interventions and hormonal suppression of the endometrial implants. Given the overexpression of aromatase P450 within endometrial tissue, off label use of aromatase inhibitors has been proposed as a mechanism for hormonal suppression with successful treatment of symptoms in cases of pelvic endometriosis.

METHODS:

A case report of a 48 year old with recurrent thoracic endometriosis following hysterectomy with bilateral salpingo-oophorectomy. Her disease was significant, resulting in pneumothorax requiring bleb resection and pleurodesis, as well as subsequent hemothorax requiring chest tube placement. She was maintained on Lupron therapy after surgical sterilization with recurrent hemothorax again requiring thoracentesis. She was subsequently switched to Letrozole with resolution of symptoms and no further episodes of hemothorax. The patient consented to publication of a case report.

RESULTS:

After 21 months of Letrozole treatment, the patient has remained asymptomatic without recurrence of hemothorax. Following surgical sterilization, the main source of estrogen is peripheral conversion of androgens to estrogen through the aromatization process. Thus, aromatase inhibitors can be used to eliminate this pathway for estrogen synthesis that can stimulate endometriosis.

CONCLUSION:

While aromatase inhibitors have been demonstrated to reduce the pain associated with pelvic endometriosis, this case report demonstrates its potential efficacy in treating thoracic endometriosis as well. Additional research is needed to determine the potential for aromatase inhibitors to become a mainstay in the treatment of thoracic endometriosis.
Cervical Length Screening: Barriers to, and Patient Perception of, Cervical Length Measurement [31J]
Authors: Bradley Danielle , Cobb Christina , Landau Erin , Wolfberg Adam
Published: May 2019

INTRODUCTION:

Universal cervical length screening is not yet the standard of care in the United States, but meta-analyses suggest that such a practice could reduce the incidence of preterm delivery and is cost-effective. The objectives of this study were to 1) determine the prevalence of cervical length screenings among users of the mobile app, Ovia Pregnancy, and 2) identify barriers to receiving a cervical length measurement.

METHODS:

A survey about experience with cervical length measurement and barriers to receiving a measurement was sent to users of a pregnancy mobile app. Respondents were age 18 or older, United States residents, and pregnant (n=2,145).

RESULTS:

A total of 796 (37%) of respondents indicated that their healthcare provider measured the length of their cervix. Among 1,349 (63%) women who have not had a cervical length measurement, 349 (26%) reported that they would be unlikely to ask their healthcare provider to measure their cervical length, 727 (54%) reported that they would be likely to ask, and the remaining 273 (20%) were neutral on the topic. The most frequently reported barriers to a cervical length measurement were that their healthcare provider had not suggested it (44%), they had never heard of a cervical length measurement prior to taking the survey (21%), and concerns that the screening would not be covered by insurance (15%).

CONCLUSION:

Survey results indicate that more can be done to educate patients about the importance of cervical insufficiency during pregnancy, as well as to encourage providers to regularly measure their patients' cervical length.
May-Thurner Syndrome in Pregnancy [7K]
Authors: Mama Saifuddin Taiyeb , Pistilli Stephanie
Published: May 2019

INTRODUCTION:

Thromboembolic disease is responsible for approximately 11% of maternal deaths in the United States. May-Thurner syndrome occurs when compression by the right common iliac artery against the fifth lumbar vertebra causes left common iliac vein obstruction and thrombosis. The incidence is 22-24%. It increases the risk for deep vein thrombosis. Pregnancy and oral contraceptives are risk factors. Diagnosis is by CT, MRI and venography. If anticoagulation therapy is not effective, angioplasty and endovascular stenting are needed. If undiagnosed and untreated, the patient can develop post-thrombotic syndrome with chronic edema, pain, hyperpigmentation, varicosities and skin ulcerations.

METHODS:

A 34 year old female G3 P0020 at 27 weeks gestation presented with left thigh, groin and gluteal region swelling and pain. Doppler studies were negative. Symptoms persisted and MRI/MRV diagnosed thrombosis of the left common and external iliac veins. The only antecedent precipitating event was a 2.5 hour plane flight 10 days prior. Screening for hypercoagulable disorders was negative. The patient was placed on Lovenox antepartum, anti Xa levels followed and continued postpartum for 6 weeks. MRV 2 months postdelivery revealed partial recanalization of vessels. In her second uneventful pregnancy, the patient initiated early care, was started on Lovenox, and delivered vaginally.

CONCLUSION:

May-Thurner syndrome is a rare condition with significant morbidity and mortality. Apart from pregnancy, this patient had no risk factors. The continuing symptoms prompted an appropriate diagnosis by MRV. Immediate anticoagulant treatment helped to prevent post-thrombotic syndrome. A high index of suspicion is needed to avoid misdiagnosis.
Impact of Sleep Habit on the Contraceptive Effectiveness of a Fertility Awareness-Based App [1O]
Authors: Rowland Simon , Kallner Helena Kopp , Gemzell-Danielsson Kristina , Trussell James , Scherwitzl Elina Berglund , Scherwitzl Raoul
Published: May 2019

INTRODUCTION:

The Natural Cycles digital fertility awareness-based method of contraception computes a daily fertility status based on dates of menstruation and basal body temperature (BBT) measurements. Every morning, the user measures her BBT upon waking, before getting out of bed. This study aims to further understand the impact of sleeping habits on the effectiveness of the app for pregnancy prevention.

METHODS:

A questionnaire addressing sleeping habits was sent out to users through an in-app message. The response rate was 45.2%, resulting in 39,244 women being included in the analysis. The sample was divided into cohorts based on the selected questionnaire answer. For each cohort, the contraceptive effectiveness was calculated as a one year typical-use Pearl Index (PI). (EPN, Stockholm, diary number 2017/563-31).

RESULTS:

Most users reported that they wake up at the same time during work days (52%). Other answers were; wake up several times during the night (16%), wake same time every day (14%), shift work (12%), and sleep in or snooze (6%). The PI of all respondents was 4.9 (SD±0.1), sensitivity analysis showed that if those who did not respond were included, the PI was significantly higher (PI 6.6±0.1). Sub-cohort analysis showed that those reporting “sleep late/snooze” had the lowest PI (3.7±0.4).

CONCLUSION:

In this study, the fertility awareness-based method app had a typical-use PI between 3.7 and 6.1, depending on self-reported sleeping habits. Respondents had a lower PI than those who did not respond, suggesting that other factors such as behavior and compliance influence the effectiveness outcome.
Impact of Cesarean Delivery Rate Calculation Method on Hospital Ranking [6O]
Authors: Langen Elizabeth Suzanne , Low Lisa Kane , Dasmunshi Sudipta , Kamdar Neil , Moniz Michelle , Morgan Dan
Published: May 2019

INTRODUCTION:

How to best quantify a hospital's cesarean delivery (CD) rate remains controversial. We compared hospitals' ranked performance using two common methods of calculating the CD rate.

METHODS:

We included 64 hospitals in the Blue Cross Blue Shield (BCBS) Michigan Value Collaborative. We calculated the nulliparous, term, singleton, vertex (NTSV) CD rate based on birth certificate data and the low risk CD rate defined by the Society of Maternal Fetal Medicine using BCBS claims data. Hospitals were ranked according to each CD rate, changes in quartile rank were identified, and hospitals that did and did not shift quartile rank were compared. We compared changes in NTSV and SMFM CD rates for each hospital in the five-year period using Generalized Linear Models of their slope.

RESULTS:

The median NTSV CD rate was 27.9% (range: 17.7% to 39.5%); the median SMFM CD rate was 15.6% % (range: 9.5% to 26.5%). 30 (48%) hospitals shifted quartile rank when using NTSV vs SMFM methodology. Hospitals were more likely to shift quartile rank if their CD rate ranking placed them in a middle quartile or if they had a smaller share of BCBS patients. When comparing the change in hospital specific CD rates over the five year study period, there was concordance between the NTSV and SMFM methodology for only 69.2% (31 hospitals).

CONCLUSION:

As hospitals' primary CD rate comes under increasing scrutiny, payers, patients and quality improvement efforts should recognize the variability in rank that can be driven by measurement approach.
Spinal Muscular Atrophy: Ordering Trends Pre- and Post-ACOG Committee Opinion 691 [17O]
Authors: Dyr Brittany , Fanelli Kimberly , Weinblatt Vivian , Heim Ruth , Donnenfeld Alan E.
Published: May 2019

INTRODUCTION:

Spinal muscular atrophy (SMA) is a leading inherited cause of infant death and is second to cystic fibrosis (CF) as a common, life-limiting autosomal recessive disorder. In March 2017, the American College of Obstetrics and Gynecology (ACOG) released a committee opinion (691) stating that screening for SMA should be offered to all patients considering pregnancy or currently pregnant.

METHODS:

To assess the uptake of SMA screening following the ACOG recommendations, a retrospective analysis of tests ordered from healthcare practices for single gene carrier screening of SMA and CF was performed. Data were analyzed over two equal time periods pre- and post-March 2017.

RESULTS:

Data were collected from nearly 4,000 healthcare providers who ordered at least one SMA test in the study period. The average number of monthly tests ordered per practice was six pre-ACOG opinion, and 16.7 post-ACOG opinion. Over 50% of practices did not order SMA testing prior to the ACOG opinion. Among practices regularly ordering testing for CF there was an increase in testing for SMA post-opinion, however, the number of CF tests received was 27% higher than SMA tests received.

CONCLUSION:

Carrier screening for SMA increased more than two and half times post ACOG opinion, likely due to the new recommendations. Despite the increase in SMA carrier tests, the number of SMA tests post-opinion did not match the number of CF tests from healthcare practices sending both tests to our laboratory. These findings suggest increased adoption of SMA screening guidelines but still not at the level observed for CF.
Women's Perspectives on Preferences for Care During Labor and Delivery [23O]
Authors: Plough Avery , Rucker Amber , Short Trisha , Filosa Shannon , Loveless Donald E. , Shah Neel T.
Published: May 2019

INTRODUCTION:

Research across healthcare has shown variation in patient's preferences for the information and decision-making authority they would like to have during their care. Patients' voices can be particularly important in obstetrics where women's preferences combined with clinician's expert judgment are critical to making the best possible decisions in complex and uncertain situations.

METHODS:

All women >15 years old who delivered at a large hospital in Tulsa, Oklahoma and did not have a scheduled cesarean or fetal demise were invited to complete a survey about their labor and delivery care experience prior to the implementation of a team-based quality improvement project. Participating women completed the multiple choice survey on paper during their postpartum stay. The Harvard and hospital IRBs approved the study.

RESULTS:

186 women completed the baseline postpartum survey from July-September, 2018. Among these women, 97% of women at least wanted to be informed about their care, and 80% also wanted to be engaged in shared-decision making about their care. 86% of women had the role they wanted in their care. 90% felt comfortable sharing their preferences with their full care team, but only 78% felt that these preferences made a difference in their care.

CONCLUSION:

The vast majority of women want to both be informed about their care in labor and delivery and play an active role in shared decision-making. The gap between women reporting having the role they wanted in care and feeling that their preferences made a difference in their care highlights opportunities for improvement in labor and delivery care.
Patient Preference of Gynecologist Attire in the Office Setting [13P]
Authors: Echeverri Natalia , Salazar Alejandra , Timmons Douglas , Willis Markie , Palin Hannah , Carugno Jose
Published: May 2019

INTRODUCTION:

Patient's perception of their physician can affect physician-patient relationship. Does gynecologist attire in the office setting influence patient's perception of physician quality, level of trust, return for follow up visits or likelihood to recommend the physician to a friend or family member?

METHODS:

A cross sectional anonymous survey was given to 200 patients who were seen in the office gynecology setting in a mayor academic urban center. Subjects were shown a series of 4 pictures of a hypothetical physician in 4 different set of clinical attire, business (suit), professional (white coat), surgical (surgical scrubs) and casual (jeans and t-shirt) and were asked which physician they prefer for different hypothetical scenarios (office visit, major surgery, gynecologic emergency). Descriptive statistic was used to analyze the data.

RESULTS:

Mean age 32.9 year, most patient were Caucasian (59%) and self-identified as Hispanic (58.8%) Most patients preferred physicians wearing white coats (62%) followed by surgical scrubs (20%) (p<0.034). Although when presented the hypothetical scenario of counseling for mayor surgery patients preferred physician wearing scrubs. (p<0.007) In case of a gynecologic emergency surgical scrubs and white coat were equally preferred. (p<0.01) Attire did not have significant effect on patient's perception of gynecologist knowledge, ability to care as well as level of authority.

CONCLUSION:

Patients prefer gynecologist wearing white coats or surgical scrubs when in the office setting. The use of suit as well as casual attire is not well perceived by patients and should be avoided if possible.
Surgical Equipment and Medication Price Awareness Amongst Obstetrician Gynecologists [16P]
Authors: Nguyen Michelle , Gray Kendra , Steck-Bayat Kayvahn , Mahnert Nichole
Published: May 2019

INTRODUCTION:

Milestones established in 2013 by the Accreditation Council for Graduate Medical Education (ACGME) supports the addition of a systems-based practice milestone to assess residents' incorporation of cost awareness into clinical judgment and decision making. Minimal formal education is provided to residents regarding costs related to medications and devices. The primary aim of this study was to evaluate teaching faculty and obstetrical learners accuracy at estimating the costs of common obstetrical devices and medications.

METHODS:

After an IRB was approved, an anonymous survey was distributed to OB/GYN residents and attendings with teaching privileges at University affiliated Banner Health hospitals in Arizona. Participants were asked to provide demographic data and rate statements related to cost awareness pertaining to patient care in addition to estimates of cost of commonly used of surgical equipment and medications based on images. Statistical analyses was then performed on the data.

RESULTS:

The subjective survey showed that the majority of respondents felt that cost was important in the selection of surgical devices/items, that surgical device pricing should be transparent, and that their personal knowledge on prices of surgical devices/medications at the institution was below average or poor. The statistical analysis was consistent with this assessment as the majority of respondents were not able to accurately estimate the pricing of items within a 10% range.

CONCLUSION:

At academic institutions, where cost awareness is expected to be a part of residency training, better methods to educate teaching attendings and residents should be considered to make ACGME milestone assessments more accurate and meaningful.
The Readability of Online Patient Education Materials from Major Obstetrics and Gynecology Societies [17P]
Authors: Fahimuddin Fatimah Z. , Sidhu Sanam , Agrawal Anubhav
Published: May 2019

INTRODUCTION:

Poor health literacy, or the diminished ability to obtain, process, and understand medical information to make an appropriate health-related decision, may be a factor in rising medical expenses. With more emergency department visits and worse health outcomes, the estimated cost of avoidable medical expenses ranges from $106 to $238 billion annually. In an attempt to correct this, the American Medical Association, National Institute of Health, and United States Department of Health and Human Services recommend all patient education materials be written at or below a sixth-grade reading level. Access to appropriate online educational information may be a limiting factor in overcoming poor health literacy and its associated outcomes.

METHODS:

An analysis of the 410 online patient education materials from eight recognized obstetrics and gynecology societies was completed, and Flesch-Kincaid Grade Level (FKGL), Flesch Reading Ease (FRE), Gunning Fog Scale (GFS), and SMOG Grade (SMOG) readability scores were calculated to assess the readability of these resources.

RESULTS:

Across all eight obstetrics and gynecology societies, the readability scores exceeded the recommended sixth grade reading level. The average FKGL, FRE, GFS, SMOG for the 69 obstetrics-related articles were 8.9, 55.8, 12.1, 11.5, respectively. The mean FKGL, FRE, GFS, SMOG for the 341 gynecology articles were 8.7, 53.5, 11.9, 10.6, respectively.

CONCLUSION:

Online patient education materials provided by major obstetrics and gynecology societies do not currently adhere to recommended readability guidelines. Continued efforts to provide accessible and informative patient education materials is needed to help improve health literacy for women.
Successful Management of Severe Idiopathic Fetal Hydrops With Thoracoamniotic Shunts [34P]
Authors: Rondon Leah , Martinuzzi Kurt , Woodham Padmashree , Hannah Dawn , Krishna Iris
Published: May 2019

INTRODUCTION:

This case report describes successful management of severe idiopathic fetal hydrops with thoracoamniotic shunts.

METHODS:

Patient is a 38 y/o G2P0010 who initiated care at 6 weeks. She was evaluated by perinatology for AMA and a fibroid uterus. First trimester and anatomy ultrasounds were unremarkable. She had low-risk genetic screening and normal MSAFP. A growth ultrasound at 23 weeks demonstrated bilateral pleural effusions. Evaluation included: normal fetal echocardiogram, Rh positive with no antibodies, negative serum TORCH titers, normal microarray, and negative amniotic fluid TORCH PCR. Due to worsening bilateral pleural effusions and development of fetal hydrops, patient underwent left-sided thoracoamniotic shunt placement at 25 and 26 weeks after receiving antenatal corticosteroids with resolution of left-sided pleural effusion and hydrops. She was admitted at 31 weeks for re-accumulation of left-sided pleural effusion and administration of rescue corticosteroids. At 32 weeks the fetus was again noted to have fetal hydrops and delivery was recommended. A primary LTCS was performed due to nonreassuring fetal heart tones. Patient delivered a female fetus weighing 1845 gram with APGARS of 2/7. The neonate spent 25 days in NICU with no evidence of pulmonary hypoplasia and was discharged home in stable condition. There was no identified etiology for hydrops and neonate was thriving at 6 week postpartum visit.

CONCLUSION:

Fetal intervention in a severe case of fetal hydrops can lead to an excellent neonatal outcome. Placement of thoracoamniotic shunts allowed for fetal lung development in setting of severe pleural effusions and allowed an additional 6 weeks of intrauterine growth.
Secondary Traumatic Stress in Obstetrics & Gynecology: Provider Experience and Programmatic Needs [3Q]
Authors: Kruper Abbey , Kaljo Kristina , Parthum Kristina , Treat Robert , Domeyer-Klenske Amy Elizabeth
Published: May 2019

INTRODUCTION:

Secondary traumatic stress (STS) is the resulting effects from exposure to adverse medical events and may include symptoms of depression, fear, or work avoidance. Â1 This study aims to understand STS in Ob-Gyn physicians and assess needs for interventions to promote wellness.

METHODS:

An explanatory mixed-methods analysis used an anonymous survey distributed to an Ob-Gyn department at a Midwest academic institution followed by focus groups and individual interviews. IBM® SPSS® 24.0 generated descriptive statistics, point-biserial correlations, and reliability analysis. Constant comparative analysis identified themes. Institutional IRB approval was obtained.

RESULTS:

Twenty-seven individuals (52% residents/40% faculty) completed the reliable (alpha=0.71) survey. Ten faculty participated in interviews/focus groups. Anxiety (81%), guilt (62%), disruptive sleep (58%) were most frequently reported STS symptoms (mean number of symptoms=(3.4±2.1)). Individuals reporting anxiety were more likely to seek support from colleagues (rpb=0.5, p<.006); those reporting guilt would go to friends (rpb=0.5, p<.007). Disrupted sleep more commonly led to seeking mental health services (rpb=0.5, p<.007). Provider description of STS included: responsibility, guilt/shame, self-doubt, anxiety/rumination and sleep disturbance. Effects varied from task avoidance to hypervigilance. Protective factors included support from colleagues and ability to compartmentalize work/home. Mental health treatment and faith-based, introspective beliefs facilitated coping. Desires for support varied: those reporting anxiety were more interested in peer-to-peer responders (rpb=0.6, p<.001), those reporting guilt would use debriefing sessions (rpb=0.4, p<.023).

CONCLUSION:

STS wellness programs including peer support and group processing can promote collegiality, shared learning, and emotional support. A breadth of resources is imperative to address individual provider needs.
The Impact of ICD-10 on Obstetric Coding [5Q]
Authors: Gomez Daniela , Jayakumaran Jenani , Schuster Meike
Published: May 2019

INTRODUCTION:

We aimed to review the accuracy of current International Classification of Diseases and Related Health Problems (ICD) coding practices at our institution which affect the delivery complication rate.

METHODS:

A retrospective review of vaginal and cesarean delivery complications with respective ICD-10 codes was performed (September 2017 to June 2018) at Robert Wood Johnson Barnabas Health. After review of 3 months of data, codes used erroneously were identified. Re-education of both coders and providers was performed. Subsequent coding rates were tracked for the remainder of the study period.

RESULTS:

Based on the Joint Commissions list of reportable complications, 67 cesarean and 177 vaginal delivery complications were identified over a 10-month period. Ten cesarean and 26 vaginal delivery complications were found to be coded erroneously; recoding decreased complications by 14% for both. Between September and January, recoding rates for cesarean and vaginal delivery complications were 26% and 15% respectively. After re-education in January, rates dropped to 3% (cesarean) and 14% (vaginal). Interim review in April identified codes persistently being used inappropriately with respect to vaginal delivery complications, despite re-education. Restrictions requiring supervisory review and physician query were placed on codes in question, further decreasing vaginal delivery complications. We decreased our complication recoding percentage from 26% to 3% and 15% to 11% for cesarean and vaginal deliveries respectively.

CONCLUSION:

Our findings suggest detailed chart review by medical providers in addition to re-education of coding staff and providers can improve accuracy rates for obstetrics coding.
Uterine Arterio-Venous Malformations: An Unrecognized Cause of Abnormal Uterine Bleeding [13Q]
Authors: Allen Ashley , DeLeon Frank D. , Kremer Timothy , Flood-Shaffer Kellie F.
Published: May 2019

INTRODUCTION:

Uterine arteriovenous malformations (AVM) have been considered a rare, but life-threatening cause of uterine bleeding. Not including this condition in the differential diagnosis of abnormal uterine bleeding can lead to misdiagnosis with erroneous treatment, or can delay diagnosis with potential complications associated with severe blood loss.

METHODS:

A 20-year-old woman with a recent history of a spontaneous abortion presented to the emergency room for a syncopal episode and very heavy vaginal bleeding (hgb 4.9). After transfusion, patient was treated with oral contraceptives. Two months later, she presented again with a near syncopal episode and further heavy uterine bleeding. Further evaluation with doppler imaging revealed an area of increased vascularity in the myometrium. Angiography revealed a hypertrophic arterial mass with early venous drainage. A unilateral uterine artery embolization was performed which was successful in stopping further abnormal heavy uterine bleeding.

CONCLUSION:

Uterine AVMs should be considered in reproductive age women with a recent history of pregnancy presenting with continuous vaginal bleeding. Bleeding may present on a spectrum from mild to severe depending on size of the defect. Doppler imaging is a useful screening tool. Angiography confirms the diagnosis, provides a method of definitive treatment, and should be considered in patients when Doppler imaging cannot exclude the presence of an AVM.
Over 50% of Nulliparous Women ≥40 Years of Age Will Have a Cesarean Delivery [31Q]
Authors: Fay Emily E. , Sienas Laura , Napolitano Peter , Sitcov Kristin , Souter Vivienne L.
Published: May 2019

INTRODUCTION:

Women ≥40 years old at delivery are increasing and older women are at higher risk for adverse pregnancy outcomes. We sought to evaluate delivery outcomes in these women.

METHODS:

We conducted an IRB exempt, retrospective cohort study using data from a multi-center quality initiative. Nulliparous singleton births between 1/2012-12/2017 at participating hospitals were included. Patients with intrapartum transfers, missing birth data, or missing/implausible data for maternal age were excluded. Age was stratified into 4 groups: 12-19 years, 20-29 years, 30-39 years, and 40-55 years. Rates of delivery outcomes were compared between women aged 20-29 years and 40-55 years using a Ï‡2 test. Adjusted relative risks were calculated after controlling for obesity (body mass index ≥30), race-ethnicity, and chronic hypertension.

RESULTS:

There were 48,093 nulliparous singleton births at 20+0 to 42+6 weeks' gestation. After exclusions (n=1891) were removed, the cohort included 46,202 births: 36,146 (78.2%) in 20-29 years and 1155 (2.5%) in 40-55 years groups. Only 33% of older women achieved a spontaneous vaginal birth, compared to 62% of women age 20-29 (p<0.001). This difference is primarily due to high cesarean delivery (CD) rate (57.7%) in older women, with 25.8% of older women never attempting vaginal birth. Older women are at significantly higher risk of having a CD for all major indications with only a minority (2.8%) of older women having a non-medically indicated CD.

CONCLUSION:

Older women have an over 50% risk of CD with lower rate of attempting and achieving vaginal birth. This can be useful in counseling about delivery expectations.
Oxytocin Versus Misoprostol for Augmentation After Prelabor Rupture of Membranes [32Q]
Authors: Freret Taylor S. , Chacon Kelly M. , Bryant Mantha Allison S. , Kaimal Anjali J. , Clapp Mark A.
Published: May 2019

INTRODUCTION:

Data are limited regarding the use of misoprostol vs oxytocin for augmentation after prelabor rupture of membranes (PROM). As nulliparas with unfavorable cervices benefit from cervical ripening for induction, our objective was to determine if admission-to-delivery times varied between nulliparas with PROM who initially received oxytocin vs misoprostol for labor augmentation.

METHODS:

This retrospective cohort comprised all term, nulliparous women with PROM from July 2016 to December 2017 at a single institution. Women were excluded if they presented in labor, had cervical dilation >2 cm, or were expectantly managed. The primary exposure was oxytocin vs misoprostol as the initial augmentation medication. The primary outcome was time from admission to delivery. Secondary outcomes included: full dilation reached, cesarean delivery, chorioamnionitis, and neonatal intensive care unit admission. Linear regressions with log transformation were used to estimate the effect of misoprostol vs oxytocin on time to delivery, controlling for patient factors. IRB approval was obtained.

RESULTS:

130 patients were included. Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (median 16.9 vs 19.9 hours, P=.013). There were no significant differences in the secondary outcomes between the misoprostol and oxytocin groups. In the adjusted model, women who received misoprostol for their initial augmentation agent had a 20.9% longer time from admission to delivery (95% CI 5.8%-36.0%) compared to women receiving oxytocin.

CONCLUSION:

In term, nulliparous women with PROM and an unfavorable cervix, those who received oxytocin had a shorter admission-to-delivery interval than women who received misoprostol as their initial augmentation agent.
Spiking in the Second Stage: What are the Neonatal Implications? [19D]
Authors: Daifotis Helen , Smith Megan , Denoble Anna Elisabeth , Dotters-Katz Sarah Kathleen
Published: May 2019

INTRODUCTION:

Recent ACOG guidelines don't specify management of isolated maternal fever (IMF). Infectious signs and symptoms may be challenging to interpret in the 2nd stage of labor, with some patients less likely to receive treatment. We compared rates of severe neonatal morbidity between women treated with antibiotics and those untreated for IMF in the 2nd stage.

METHODS:

Retrospective cohort of term singleton vaginal deliveries with new-onset, isolated maternal fever (38.0 to 38.9C) during 2nd stage of labor. Primary outcome was severe neonatal morbidity (necrotizing enterocolitis, sepsis, intubation/respiratory distress and death). NICU admission and length of stay (LOS) also assessed. Neonates whose mothers received antibiotics were compared to untreated women. Bivariate statistics were used to analyze data. This study obtained IRB approval.

RESULTS:

IMF was seen in 116 women, with 75 (64.7%) receiving antibiotics. Demographics, antepartum complications, and delivery characteristics did not differ between groups. Maternal treatment affected neonatal antibiotics receipt (98.7% vs 48.8%, P<0.01). A total of 10 neonates (8.6%) had a severe morbidity 6 (8.0%) among treated women and 4 (9.8%) among untreated women (P=0.71). Invasive respiratory support was required more frequently in untreated group (9.8% vs 5.3%, P=0.45). No differences observed in NICU admission (15.1% vs 7.5%, P=0.37) or median NICU LOS. Among infants who received post-natal antibiotics, severe morbidity occurred in 20% of those untreated in-utero and 8.1% of treated (P=0.21).

CONCLUSION:

Severe neonatal morbidity occurred in approximately 1/12 infants born after IMF in the 2nd stage. Neonates of treated mothers were more likely to receive postnatal antibiotics, but not more likely to experience severe neonatal morbidity.
The Utility of the ACOG Mobile Application's Indicated Delivery Calculator for Obstetrics Resident Physicians [25D]
Authors: Sridhar Aparna , Morikawa Erika , Nguyen Tina , Sridhar Aparna
Published: May 2019

INTRODUCTION:

The ACOG mobile application includes an IDC to provide evidence-based decision-making support when considering conditions that may necessitate early delivery.

METHODS:

After IRB exemption, obstetric residents at our tertiary academic center (n=28) were asked to determine delivery timing for fifteen obstetric scenarios, with and without use of the IDC. A mixed effects logistic regression model assessed the change in proportion of test items correct. We conducted semi-structured interviews of the residents' experience utilizing the calculator.

RESULTS:

Residents' ability to identify the correct gestational age at delivery for the obstetric scenarios significantly improved after use of IDC (47% pre to 86% post; p<0.01). Differences in the amount of change by year of residency were assessed using a time-by-group interaction term and no significant difference was noted. Positive feedback included the calculator being “user-friendly,” “convenient,” and “well-organized.” The ability to enter multiple co-morbidities was thought to be the best feature of the application. Residents expressed desire to incorporate this tool into their practice. Criticism about the calculator included desire for more robust yet streamlined complication list, more evidence-based references and elimination of prompt for estimated due date/gestational age.

CONCLUSION:

ACOG's IDC was effective in improving accuracy of residents' clinical decisions regarding delivery timelines for complex obstetric scenarios. Users quickly adapted to the tool and successfully navigated the features. Streamlining the input prompts and complication choice list may improve efficiency and increase use. Future studies can focus on identifying the effect of IDC on a national sample of residents as well as providers in practice.
Demographics and Outcomes Associated With End Stage Renal Disease After Pregnancy Related Acute Kidney Injury [3E]
Authors: Angarita Africano Ana Milena , Segev Dorry L , Johnson Clark , Kucirka Lauren Marie
Published: May 2019

INTRODUCTION:

Pregnancy related acute kidney injury (AKI) remains an important cause of maternal and fetal morbidity and mortality, which can result in end-stage renal disease (ESRD) requiring life-long renal replacement. Little is known about the characteristics of those who develop ESRD after pregnancy related AKI.

METHODS:

The United States Renal Data System (USRDS) national registry between 1990 and 2015 was used to analyze the frequency of postpartum renal failure and associated risk factors. We used Cox proportional hazards models to evaluate risk factors for mortality and access to transplant among those with post-partum ESRD.

RESULTS:

There were 224 cases of ESRD due to post-partum renal failure vs 151,974 reproductive age women who developed ESRD secondary to other causes. Minorities were disproportionately affected: African-American women comprised 28.6% of those with post-partum renal failure but only represented 15.7% of births over the same time period. Similarly, Hispanic women represented 28.0% of those with post-partum renal failure but only 20% of live births. African-Americans with ESRD due to post-partum renal failure had a 2.15-fold higher hazard of mortality. Women with post-partum renal failure had better overall survival compared other causes of renal failure (HR=0.38, p<0.001). Despite this, women with post-partum renal failure had 0.45 lower hazards of receiving a kidney transplant, even after adjusting for demographic characteristics (P<.001).

CONCLUSION:

There are racial disparities in development of post-partum ESRD, with African-American and Hispanic women disproportionately affected. Women with post-partum ESRD are significantly less likely to receive a transplant despite having better overall survival.