bluuebunny/crossref_metadata_2025 huggingface dataset:
Male Hormonal Contraceptive Safety: A Systematic Review of Adverse Events Across Investigational Methods [6A]
Authors: Franks Jennifer M. , Nguyen Brian T. , Dinalo Jen
Published: May 2019

INTRODUCTION:

Clinical trials of novel male hormonal contraceptives (MHCs) promise effective methods that may decrease global unmet needs for contraception. However, concerns about potential harms may influence uptake and impede development. No review has systematically documented the range and frequency of MHC-related adverse.

METHODS:

We searched OvidSP, Medline, Embase, Cochrane Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform for MHC clinical trials through 2017 (N=2,080). MHCs are defined by their expected action on steroid receptors to suppress spermatogenesis to contraceptive effect, while maintaining normal androgen levels. Trials were limited to those with >8 weeks of exposure and >30 participants. Considerations for the detection of adverse events and measurement of harms were identified; bias was independently evaluated and reported in accordance with PRISMA-harms guidelines.

RESULTS:

Twelve trials collectively enrolled more than three thousand participants, with median exposure of 52 weeks. Trials consistently noted significant decreases in HDL, increases in hemoglobin, increases in body weight, and decreases in testicular volume. 26 serious adverse events were reported; only 3 were considered possibly MHC-related (depression, suicide attempt, atrial fibrillation). Likely-related adverse events included acne, non-specific mood changes, and increased/decreased libido; screening and measurement of these outcomes was inconsistent across trials. Discontinuations for these events were uncommon.

CONCLUSION:

Long-term data are needed to determine the influence of MHCs on cardiovascular/metabolic risk. However, early MHC trials suggest the absence of serious harm for up to one year of use among healthy men. Future research should routinely incorporate standardized measures of mood and sexual function.
Effects of Protocol Changes on Postpartum Visit Attendance Rates and Patient Care at a Student-run Free Clinic [7A]
Authors: Rosenberger Marie , Fagan Taylor , Heil Cate , Calkins John William
Published: May 2019

INTRODUCTION:

The recommended 4-6 weeks postpartum visit is critical for mothers, however, 40% do not attend.1 Postpartum guidelines by American College of Obstetricians and Gynecologists (ACOG) are widely used, but based on observation and expert opinion.1 This study aims to determine effectiveness of new postpartum protocol using ACOG guidelines at a student-run free clinic. This study provides insight into effective strategies for this type of clinic.

METHODS:

Patients at JayDoc Free Clinic who delivered from 4/1/2014 to 10/31/2017 were included. IRB approval obtained. Patients managed prior to protocol implementation (Group 1; N=31), compared to patients managed using new JayDoc Free Clinic protocol (Group 2; N=44). The new protocol changes included scheduling postpartum appointments before delivery, appointing a postpartum liaison, and calling the patient after delivery and 1 day prior to appointment. Analysis performed using statistical package R and X2-statistics. Primary outcome was postpartum visit attendance rates, secondary outcomes included depression screening and contraception.

RESULTS:

Implementation of protocol led to an increase in scheduling postpartum appointments to 97.72% from 51.6% prior to implementation (X2 (1, N=75)=22.52, p<.01). Attendance was 69.38% of new protocol patients, compared to 61.5% in Group 1 (X2 (1, N=75)=5.4853, p<0.02). Group 2 increased LARC use to 51.16% from 23.08% (X2 (1, N=69)=4.20, p<0.05) and increased depression screening 79.07% from 52.17% when compared to Group 1 (X2 (1, N=66)=4.20, p<0.05).

CONCLUSION:

Implementation of new postpartum protocol demonstrated improved scheduling and attendance. The addition of an official protocol also helped ensure patients discussed contraception options and postpartum depression. Overall, the introduction of postpartum protocol modeled after ACOG guidelines enabled the student-run free clinic to improve processing and patient care, which resulted in attendance above the national average.
Team-Based Communication Increases Adherence to Suggested Decision-to-Incision Times in an Urban County Hospital [8A]
Authors: Cheeks Morgan , Habrylo Ireneusz , Brandon Kelly , Malekmadani Arienne , Yemane Hannah , Newmann Sara J.
Published: May 2019

INTRODUCTION:

Decision-to-Incision (DTI) research has investigated maternal and neonatal outcomes, while literature on decreasing DTI times remains sparse. Here we describe a quality improvement project, led by first-year medical students, aimed at reducing DTI times at a county hospital using a worksheet to guide communication during interdisciplinary huddles before each unplanned cesarean.

METHODS:

In 2017, medical students at Zuckerberg San Francisco General Hospital implemented a grading system to standardize the urgency of unplanned cesareans and interdisciplinary DTI huddles to assign target incision times for cesareans. Our initial intervention provided checklists for each team member. Following interviews with staff, we developed a printed communication tool to facilitate discussion around urgency, potential delays, and target incision time. Using worksheet and medical record data, we analyzed use of the DTI communication tool and DTI times pre-intervention (June-August 2016), post-checklist implementation (February-August 2017) and post-communication tool implementation (March-August 2018).

RESULTS:

Use of the DTI workflow in unplanned cesareans more than doubled from 20.2% to 47.7% after switching from checklists (n=74) to the communication tool (n=86). Mean DTI time decreased from 93 to 82 minutes during the same time period. Following implementation of the tool, 52.5% of unplanned cesareans occurred within five minutes of the suggested DTI times for each grade, and we observed a significant effect of urgency grade on DTI time [F(2,47)=11.3, P<.001].

CONCLUSION:

The grading system adequately stratified the urgency of cesareans, while the communication tool streamlined discussion of potential delays. Guided interdisciplinary communication, not just checklists, facilitates team-based interactions critical to decreasing DTI times.
Vasa Previa: A New Paradigm in Patient Hospitalization, Timing of Delivery and Corticosteroid Use [11A]
Authors: Villani Linda A. , Al Torshi Rashida , Shah Prakesh S. , D'Souza Rohan D. , Kingdom John C. , Keunen Johannes
Published: May 2019

INTRODUCTION:

Vasa Previa occurs when fetally-derived umbilical cord vessels cross the internal os of the cervix. The aim of this study was to evaluate parameters that influence outpatient versus inpatient management in these cases.

METHODS:

Research Ethics Board approval was obtained for this study. Consecutive cases of vasa previa as diagnosed at Mount Sinai Hospital, Toronto from January 2008 to December 2017 were retrospectively reviewed. Cases were categorized into 3 arms for analysis: outpatients (OP), indicated hospitalized (IH) and non-indicated hospitalized (NIH). The NIH arm included asymptomatic patients admitted for surveillance, while the IH arm included symptomatic patients admitted for antepartum hemorrhage.

RESULTS:

84 cases of vasa previa were diagnosed during the study period. The IH group was admitted a median of 22.5 days longer vs the NIH group up to delivery. The IH group had the highest frequency of unplanned caesareans at 46.2%, vs 7.1% and 11.1% of cases in the NIH and OP groups, respectively. Despite having an equal number of unplanned caesareans, the NIH group delivered a median 1.7 weeks earlier vs the OP group (P=.0040). NIH patients were also more than twice as likely to receive corticosteroid therapy inappropriately vs the OP group (57.1% vs 27.8%, P=.0359). A median (IQR) of 5 (3.5-7.6) weeks between corticosteroid administration and delivery existed among patients who received this therapy inappropriately.

CONCLUSION:

Our evidence suggests that physicians have difficulty predicting imminent preterm delivery for proper corticosteroid use in this population, but may be able to offer asymptomatic patients the option of outpatient management.
Fetoscopic Laser Coagulation vs. Expectant Management for Stage I Twin-Twin Transfusion Syndrome [13A]
Authors: McWhirter Amanda , Speranza Rosa J. , Thompson Jennifer Ann , Shaffer Brian , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

While fetoscopic laser coagulation (FLC) has been shown to improve outcomes in twin-twin transfusion syndrome (TTTS) at higher stages, the management of stage I TTTS remains controversial. We sought to examine the cost-effectiveness and outcomes associated with FLC versus expectant management and the resultant effects on rates of single intrauterine fetal demise (IUFD), dual IUFD, delivery <32weeks, and neurocognitive disability.

METHODS:

A cost-effectiveness model using TreeAge software was designed to compare outcomes in monochorionic diamniotic (MCDA) pregnancies complicated by stage I TTTS in twins managed with FLC versus expectant management using a theoretical cohort of 100,000 women. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000 per QALY.

RESULTS:

When twin pregnancies complicated by stage I TTTS were treated with FLC there were higher rates of single and dual stillbirth, more deliveries <32 weeks, but fewer cases of neurocognitive disability. Additionally, there would be increased costs and lower QALYs making FLC a dominated strategy. In our theoretical cohort, expectant management led to 1811.8 fewer single IUFDs, 2569.9 fewer dual IUFDs, 1133.3 fewer deliveries <32 weeks, 6370.4 more neurodevelopmental disability, and saving $20,134.29 with 1.9 increased QALYs. Sensitivity analysis of probability of IUFD after FLC, demonstrated that below a probability of 29.5%, using FLC becomes the cost effective strategy.

CONCLUSION:

In MCDA twin pregnancies affected by stage I TTTS, expectant management resulted in improved outcomes, decreased costs, and increased QALYs. Of note, the rate of neurocognitive disability was increased in the expectant management group.
Impact of the Combined Diabetes Clinic on HbA1c Changes and Outcomes in Pre-existing Diabetics in Rural Saskatchewan [14A]
Authors: Adams-White Tanner , Udayasankar Vijayalakshmi
Published: May 2019

INTRODUCTION:

Pregnant women with pre-existing diabetes have increased risk for poor outcomes such as macrosomia, shoulder dystocia, still birth and intrapartum interventions. The Combined Diabetes Antenatal Clinic (CDAC) in Prince Albert (started in 2012) is a multidisciplinary clinic that serves rural northern Saskatchewan where the prevalence of diabetes in pregnancy is high. The goals of the CDAC are to improve euglycemia and pregnancy outcomes.

METHODS:

Retrospective cohort chart review to quantify the reduction in HbA1c after CDAC interventions and if the reduction in HbA1c improved pregnancy outcomes. Ethics approval was obtained from University of Saskatchewan.

RESULTS:

We identified 116 CDAC patients with pre-existing diabetes between 2012-2017. Majority of the population (52%) had to travel over 200 km to reach the CDAC clinic. There were high rates of obesity (71%) and high parity (28% Para 4 or more), majority were Type 2 diabetics and 87% of mothers were on insulin at the time of delivery. Women often (75%) presented to the CDAC after the first trimester. However, over 50% of patients who attended the CDAC reached the target of having an HbA1c below 6.5% prior to delivery. Mean change in HbA1c was -1.0% (SD 0.5-2.4) Mothers with HbA1c below 6.5% at the time of delivery had lower rates of shoulder dystocia (5.9% vs 2.3%) and still birth (11.8% vs 4.5%).

CONCLUSION:

The CDAC is effective in reducing the HbA1c and reductions below 6.5% is associated with improved pregnancy outcomes. We advocate pre-pregnancy counselling and booking early in pregnancy for pre-existing diabetes in this rural population
Association of Gastrointestinal Microbial Profiles and Estrogen Metabolism in Patients With Preterm Birth [21A]
Authors: Portugal Aileen , Le Nhung , Gong Yuan Yuan , Groesch Kathleen , Loret de Mola J. Ricardo , Braundmeier-Fleming Andrea
Published: May 2019

INTRODUCTION:

Researchers have explored various causes for preterm birth (PTB); yet, the effects of maternal gastrointestinal microbiome on estrogen metabolism and its influence on pregnancy remains unknown. The aim of this study is to analyze the effects of maternal gastrointestinal microbiome on estrogen metabolism during pregnancy by correlating the estrogen metabolite bioactivity with preterm birth.

METHODS:

Study participants (IRB#14-185) were recruited at Southern Illinois University School of Medicine, Department of Ob/Gyn. Twenty-four patients identified as being at risk for a repeat, PTB were recruited. Biological samples (urine and fecal samples) were collected during each trimester and a postpartum timepoint. Fecal samples were frozen and processed for DNA isolation. Microbial analyses were performed by miSeq amplicon sequencing using the V4 region of the bacterial 16S rRNA gene. Identification of 15 estrogen metabolites (2-, 4- and 16-hydroxylation pathways) in urine samples was performed using tandem mass spectrophotometry analysis. Data was evaluated using analysis of variance (ANOVA) and then by repeat measure design.

RESULTS:

Of the 24 patients, 18 delivered at term and 6 delivered preterm (25%). Gastrointestinal microbial profiles were altered in women with subsequent PTB. Additionally, decreased urinary levels of estrone, 17-epiestriol and 17-estradiol were found as early as the first trimester in subjects who delivered prematurely.

CONCLUSION:

This study highlights the interaction of the gastrointestinal microbiome on estrogen metabolism, possibly through hormone conjugation. Unbalanced levels of estrogen during pregnancy may predispose women to PTB. This investigation may elucidate novel screening tools to identify patients at risk for PTB and enable early clinical intervention.
Neighborhood Income and Caesarean Section Rates at a Tertiary Care Center in Canada [23A]
Authors: Hodge Meryl , Shen Minxue , Xie Ri-hua , Wen Shi-Wu , Walker Mark , Chen Innie
Published: May 2019

INTRODUCTION:

With rising rates of caesarean section (CS) in Canada and worldwide, non-clinical factors for CS warrant consideration. Our objective was to determine the association between a primigravid woman's neighborhood income and rates of CS.

METHODS:

A retrospective cohort study was conducted at an Ontario tertiary care center from January 2003 to December 2013. Rates of CS were determined using data collected from the Discharge Abstract Database. Women with singleton live births were included. The main exposure variable was neighborhood income quintile. A multivariable model was used to adjust for covariates and provide an estimate of the independent effect of neighborhood income on CS rate.

RESULTS:

The study cohort comprised 32,714 women. Compared with the lowest quintile, women in the highest quintile had increased rates of CS (Relative Risk (RR) 1.06, 95% Confidence Interval (CI) [1.02, 1.11]). Following adjustment for important confounders, there was no longer an association between neighborhood income and CS rate (adjusted RR 1.00, 95% CI [0.99-1.01]). Women in the highest quintile were more likely to have greater maternal age (P<0.001).

CONCLUSION:

Although differences in CS rates are seen by neighborhood income quintile, they appear to be related to maternal and infant clinical factors. Neighborhood income does not appear to be an independent predictor of CS.
Association Between Amphetamine Use and Pregnancy Outcomes in Women With a Hypertensive Disorder of Pregnancy [24A]
Authors: Speranza Rosa J. , Greiner Karen S. , Rincon Monica , Beeraka Sridivya S. , Burwick Richard M.
Published: May 2019

INTRODUCTION:

Amphetamine use in pregnancy is associated with adverse outcomes, but the association with hypertensive disorders is not well categorized. The purpose of this study was to demonstrate the relationship between amphetamine use and outcomes among women with hypertensive disorders in pregnancy.

METHODS:

Retrospective cohort study of subjects with hypertensive disorders of pregnancy that delivered at a single institution (Oct. '13-April '18). Utilizing discharge codes and individual chart review, subjects were stratified into two groups by amphetamine use: current vs. non-users. We assessed final hypertensive diagnosis, severe features of preeclampsia, and neonatal or maternal outcomes. Differences were analyzed by Fisher's exact, t-test, and logistic regression, with Î±=0.05.

RESULTS:

From 10,833 deliveries, 13.7% were classified with a hypertensive disorder of pregnancy of which 2.2% actively used amphetamines during pregnancy. Active users were more likely to be diagnosed with gestational hypertension and preeclampsia with severe features (p=0.009), and more often had severe range diastolic blood pressure (p=0.009). Adverse outcomes were increased for current amphetamine users when adjusting for maternal characteristics, and the odds of any severe feature of preeclampsia was 4.17 times greater compared to non-users in the fully adjusted model (95% CI: 1.11-15.71). However, when adjusting for other substance use, the association between amphetamines and composite maternal or neonatal outcomes was attenuated.

CONCLUSION:

Amphetamine users are more likely to be diagnosed with gestational hypertension and preeclampsia with severe features. Additionally, the concomitant use of other substances highlights the need to identify these patients at risk of adverse maternal and neonatal outcomes.
Predicting Neonatal Pathologic Disposition From Cardiotocography Using Machine Learning [25A]
Authors: Freedman Isaac G. , Agarwal Akshar , Doilicho Natnael , Cohen Eli , Pettker Christian Michael , Copel Joshua A.
Published: May 2019

INTRODUCTION:

Continuous cardiotocography (CTG) is widely used to monitor fetal heart rate and uterine contractions as a means of detecting intrapartum fetal distress. CTG use is associated with reductions in neonatal seizures and with increases in rates of cesarean sections (C-sections) and instrumental vaginal births. Given that unnecessary C-sections are associated with higher rates of morbidity and mortality, correct identification of C-section candidates is critical. However, agreement in CTG interpretation remains elusive, with high inter-and intra-observer variability in interpretation of tracings, which may lead to inappropriate interventions. Further, machine learning (ML) advances in other vital monitoring analytics have not been matched in CTG analysis. The objective of this study was to develop a cardiotocographic ML algorithm, a random forest (RF) model, which accurately predicts neonatal pathologic disposition to inform obstetric intervention.

METHODS:

We trained RF models to classify neonatal condition as healthy or pathologic on 13 summary statistics (features) from 1,831 continuous CTGs from the University of Porto SisPorto dataset. All measures of performance were calculated as out-of-bag (OOB), a statistical proxy for cross-validation, over 128 weak learner models.

RESULTS:

Our model identified healthy CTGs as not requiring obstetric intervention with an OOB sensitivity of 82.4%, a specificity of 99.4%, an accuracy of 97.9%, and a C-statistic of 0.908.

CONCLUSION:

Our model's OOB performance exceeds that of current methods and could dramatically reduce the rate of cesarean sections if widely implemented. The model is accurate, rapid, readily deployable, and extensible. Further research should test our algorithm on a larger population and in real-time.
Timing of Death and Rates of IVH, RDS, and NEC Among Infants With Neonatal Sepsis [27A]
Authors: Birch Mary Nienow , Frank Zoë , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

This study sought to evaluate infants with sepsis, stratified by preterm and term delivery, based on their rates of neonatal death (<28 days of life), infant death (28 days-one year), intraventricular hemorrhage (IVH), respiratory distress syndrome (RDS), and necrotizing enterocolitis (NEC).

METHODS:

This is a retrospective cohort study of non-anomalous, singleton and twin deliveries in the US. We compared preterm and term babies who died with sepsis. We also compared rates of IVH, RDS, and NEC among infants with sepsis. Results were analyzed using Pearson Chi-Squared tests to control for maternal race, maternal age, insurance status, education level, diabetes, chronic hypertension, preeclampsia, chorioamnionitis, postpartum hemorrhage, cesarean section, nulliparity, and gestational age.

RESULTS:

Rates of IVH, RDS, and NEC were significantly higher among infants with neonatal sepsis compared to non-septic infants. Rates of neonatal and infant death were increased in the sepsis group. These patterns are consistent among both preterm and term babies. Sepsis yielded an odds ratio of greater than 1 for all morbidities and mortalities examined. The one exception to this trend was neonatal death among preterm infants (OR: 0.52; 95% CI: 0.43-0.62%).

CONCLUSION:

Fetal AC <10th percentile identifies a cohort at higher risk for SGA who may have been overlooked with estimated fetal weight <10th percentile alone. This cohort can benefit from increased surveillance and additional pre- and post-natal counseling. Further, as a high portion of these patients delivered preterm, AC can guide timing of antenatal corticosteroids for fetal lung development and transfer to tertiary care centers when necessary.
The Impact of Limited Prenatal Care on Pregnancy Outcomes in Women With Depression [32A]
Authors: Howard Dagnie C. , Valent Amy , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

Depression is associated with a number of risks in pregnancy. This study aimed to examine how the number of prenatal care visits impacts pregnancy outcomes in women with depression.

METHODS:

This is a retrospective cohort study of singleton, non-anomalous births in California between 2007 and 2011 to compare outcomes of all women with depression who had 5 or more prenatal care visits compared with those with less than 5 visits. Outcomes included preterm delivery, intrauterine fetal demise, neonatal death, neonatal respiratory distress syndrome, placental abruption, maternal blood transfusion, and CDC severe maternal morbidity index score. To compare outcomes, we used chi-square and multivariate logistic regression controlling for socioeconomic status, age, parity, gestational age, ethnicity, diabetes, and hypertension.

RESULTS:

Of the 18,511 women with depression in our sample, those with limited prenatal care had higher risk of placental abruption, intrauterine fetal demise, preterm delivery, low birthweight (<2500 grams), neonatal respiratory distress syndrome, and severe maternal morbidity. Rates of neonatal death were significantly higher in the chi-square analysis (0.81% vs 0.15%, p = 0.002), however this difference did not persist in the multivariate analysis when controlling for potential confounding variables.

CONCLUSION:

In women with depression during pregnancy, limited prenatal care is associated with greater odds of adverse neonatal and maternal outcomes, including intrauterine fetal demise and severe maternal morbidity. These associations should be considered when providing care to pregnant women with depression. Additionally, further examination of the obstacles limiting access to regular prenatal care in this patient population should be pursued.
National Perinatal Outcomes Among Young Donor Oocyte Recipients [35A]
Authors: Schwartz Kaia , Boulet Sheree L. , Kawwass Jennifer F. , Kissin Dmitry
Published: May 2019

INTRODUCTION:

Previous studies demonstrated elevated risk of poor perinatal outcomes with donor versus autologous oocytes during assisted reproductive technology (ART), primarily among older women. We assessed perinatal outcomes among donor oocyte recipients <35 years old.

METHODS:

Using the Centers for Disease Control and Prevention's National ART Surveillance System, we analyzed all fresh embryo transfer cycles between 2010 and 2015 among women <35 years. Cycles using cryopreserved eggs, donated embryos, or a gestational carrier were excluded. We calculated predicted marginal proportions to estimate the unadjusted and adjusted risk ratios (aRR) and 95% confidence intervals (CI) for the association between donor versus autologous oocyte use and stillbirth, preterm delivery and low birth weight (LBW) among singleton pregnancies or births and stratified by number of embryos cryopreserved. Models were adjusted for patient and treatment characteristics.

RESULTS:

We included 71,720 singleton pregnancies occurring during 2010 to 2015. With zero embryos cryopreserved, donor versus autologous oocyte use was associated with increased risk for stillbirth (2.1% vs 0.6%), aRR 3.73 (CI 1.96-7.11); no association was found when ≥1 embryos were cryopreserved (0.54% vs 0.56%), aRR 1.15 (CI 0.59-2.25). Singletons resulting from donor oocytes were more likely to be preterm: 15.6% vs 11.0%, aRR 1.39 (CI 1.20-1.61) and LBW 11.8% vs 8.8%, aRR 1.34 (CI 1.16-1.55), no effect modification by number of embryos cryopreserved.

CONCLUSION:

Among women <35, donor oocyte use was associated with increased risk of stillbirth (with zero embryos cryopreserved), preterm delivery and LBW. Use of donor eggs, underlying reason for infertility, or both may drive this risk.
CenteringPregnancy® Increases the Likelihood of Postpartum Visit and Contraceptive Use [2B]
Authors: Yamada Rei , Wolf Abigail
Published: May 2019

INTRODUCTION:

The postpartum visit provides an important opportunity for women to discuss contraceptive options with their provider, but as many as 40% of women do not seek postpartum care. There are limited data on postpartum visit attendance and contraceptive use among women who receive group prenatal care. We studied the postpartum visit attendance and contraceptive use among women in our CenteringPregnancy® program.

METHODS:

We conducted a retrospective chart review of 90 CenteringPregnancy® participants who delivered their babies between June 2017 and June 2018 at an urban university hospital. We sent an online survey to the 58 participants who were between 3 and 6 months postpartum during the data collection period to ask about their current contraceptive use. This work was approved by Thomas Jefferson University's Institutional Review Board.

RESULTS:

Of the 90 participants, 88% (79) attended their individual postpartum visit in the first 90 days after delivery. Thirty-one surveys were completed between 3 and 6 months postpartum; 77% (24) reported using a contraceptive method. Of those, 54% (13) reported using a long-acting reversible contraceptive, and 88% (21) were happy with their contraceptive method. Of the 25 participants who reported being sexually active, 84% (21) reported contraceptive use.

CONCLUSION:

In our population, CenteringPregnancy® increased attendance at the postpartum visit. The additional contact time and structured educational content in CenteringPregnancy® create more opportunities for providers to counsel women about contraceptive options and may lead to increased uptake of long-acting reversible contraceptives compared to traditional prenatal care.
Perspectives on Pregnancy and Abortion Restrictions From Women Experiencing Intimate Partner Violence [5B]
Authors: O'Connor-Terry Carly , Gowda Tejasvi , Chang Judy
Published: May 2019

INTRODUCTION:

In recent years, legislation restricting abortion has become commonplace. Recent studies have identified that one third of women seeking abortion services have experienced intimate partner violence (IPV). The purpose of this study is to gather opinions and experiences of women who have experienced IPV on pregnancy and recent legislative trends restricting abortion.

METHODS:

Qualitative, semi-structured interviews were conducted with women seeking services for IPV at the Women's Center and Shelter in Pittsburgh. Interviews gathered information regarding feelings on pregnancy and specific abortion restrictions. After transcription, two independent reviewers identified themes from each interview.

RESULTS:

Nine interviews were conducted and coded. Participants described the occurrence of reproductive coercion in their relationships and influence of the partner in decision-making regarding pregnancy. The women voice concerns regarding policies requiring spousal notification of abortion and described such policies as a violation of the woman's privacy and autonomy. The 24-hour waiting period had mixed views: some participants viewed the waiting period as a time for reflection; others argued partners would have more control if women had to wait to get an abortion. While many argued that state-mandated counseling would be helpful, some participants felt that it would not change the person's mind and could add additional trauma to the situation.

CONCLUSION:

Women experiencing IPV are particularly vulnerable to recent policies and restrictions on abortion. Spousal notification requirements risk potential danger and further disempowerment. Varied perceptions of mandated waiting periods and counseling may be related to difference in the context or type of IPV experiences.
Medical School Curricular Development: Sex Trafficking, Adverse Childhood Experiences, and Trauma-Informed Care [7B]
Authors: Borham Kristina , Dawgert Francis , Triano Mary
Published: May 2019

INTRODUCTION:

The purpose of this study is to develop and assess second year medical students' ability to create a broad differential and think critically about the impact social factors may have on clinical presentation, specifically in sex trafficking victims. The lecture places emphasis on the relationship between adverse childhood experiences (ACEs) and trafficking as well the importance of trauma-informed screening techniques and care with these patients. There is a lack of training available to healthcare professions and therefore, a lack of awareness of the prevalence of human trafficking that results in a missed opportunity to better care for this unique patient population.

METHODS:

IRB approval was obtained via expedited review. Second year medical students at GCSOM completed an identical online pre- and post-survey online that evaluates attitudes and knowledge on sex trafficking. Students will be administered a second post-survey 6 months later, following a case based learning exercise.

RESULTS:

Students showed greater than 75% improvement in knowledge regarding specific care and treatment of sex trafficking victims immediately following the lecture, most notably comfort with identification and resources. Students will be evaluated to assess long term retention and application at six months post.

CONCLUSION:

Current medical school curricula does an excellent job at teaching aspects of psychosocial care at baseline. However, trafficking is not included in these discussions. Utilization of peer driven didactics help to improve student engagement and retention of knowledge regarding sex trafficking. Future curricula could be student driven or proposed as elective journal clubs/discussions to facilitate learning.
Does Your Boss Do Your Pap?: Opinions on OB/GYN Residents Obtaining Personal Health Care From Program Faculty [9B]
Authors: Frost Andrea Nicole , Cook Ian , Hoffman Mark Richard
Published: May 2019

INTRODUCTION:

Obstetrics & Gynecology residents and their partners often require care during residency. Many obtain care from program faculty, but little is known about opinions on this topic. The purpose of this study is to determine if Obstetrics & Gynecology residents' opinions differ from those of their program directors regarding whether a conflict of interest exists when residents obtain personal care from program faculty.

METHODS:

An anonymous survey with questions using a modified Likert scale from previously validated surveys was administered to program directors and residents from United States Obstetrics & Gynecology residency programs. SAS (9. 4) was used to analyze the data via chi-squared test. Significance was defined as p<0.05.

RESULTS:

Data was collected on 72 surveys from 57 residents and 15 program directors. Questions regarding conflict of interest showed no significant difference between groups with one exception: program directors were more concerned that care would cause embarrassment for residents (p=0.0401). Results also trended toward significance for multiple questions. Residents felt more concerned about the cost of outside care (p=0.0878) and about care not being fully documented in their records (p=0.0668). Program directors felt more concerned about information from residents' records being seen by others (p=0.0717) and residents feeling uncomfortable about disagreeing with advice from faculty (p=0.0913).

CONCLUSION:

While the majority of responses between groups were not found to be significantly different, the survey did show concern for conflicts of interest among both program directors and residents. Given the concern that conflicts of interest could exist, further investigation is warranted.
Actual vs Perceived Macronutrient Intake During Pregnancy: A Pilot Study [13B]
Authors: Marty Makenna , Heinig Meredith Jane
Published: May 2019

INTRODUCTION:

Macronutrient intake during pregnancy has significant effects on maternal and infant health, yet pregnant women's ability to estimate adequacy of their intake is unknown. This study sought to gauge pregnant women's awareness of pregnancy macronutrient guidelines, and investigate if women's perception of adequate intake was a reliable marker for adherence to guidelines.

METHODS:

Pregnant women were recruited to participate in a survey and 24-hour recall. Surveys collected self-reported knowledge of guidelines and perception of guideline adherence. 24-hour recalls were analyzed to systematically assess dietary intake. Subjective opinions were compared to analyzed diets to determine if perception of adequately meeting guidelines equated to sufficient intake. This project was deemed Exempt by the UC Davis Institutional Review Board.

RESULTS:

Of the twenty-nine participants included in analysis, 51.7% reported being somewhat or more familiar with pregnancy macronutrient recommendations. Women were most likely to accurately estimate adherence to carbohydrate guidelines (65.5%), least likely to estimate adherence to water guidelines (51.7%), and equally likely to accurately estimate adherence to protein and fat guidelines (58.6% for each). The most common resources from which participants obtained pregnancy nutrition information were obstetrician/physician (75%), and the Internet (60%). Bivariate linear regression investigating relationships between accuracy of estimation and other variables (age, gravidity, education level, number of nutrition resources used) showed no significant associations.

CONCLUSION:

These results indicate that education for pregnant women of macronutrient intake guidelines can be improved, and a more reliable means for pregnant women to assess their own adherence to guidelines is needed.
Acute Decompensated Heart Failure Following Cesarean Delivery: A Case of Undiagnosed Rheumatic Heart Disease [14B]
Authors: Hmaidan Sarah , Benson Meagan , Hadley Emily , Gilmore Wyman
Published: May 2019

INTRODUCTION:

Heart failure is a leading cause of maternal morbidity and mortality in the United States. It commonly occurs in the peripartum period—the last trimester and five months following delivery. It stems from multiple etiologies, most commonly peripartum cardiomyopathy and preexisting cardiac disease. The diagnosis of heart failure in the peripartum period is often delayed or misdiagnosed because its symptoms closely resemble those seen during normal pregnancy, pulmonary embolism, preeclampsia, and HELLP syndrome - including fatigue, shortness of breath and edema.

METHODS:

A 25-year-old G2P2 Burmese patient with no prior medical history presented five-days post cesarean delivery with chief complaint of shortness of breath, chest pressure, and palpitations. She was found to have tachypnea, tachycardia to the 140's, and hypoxemia with an oxygen saturation of 85%. Her EKG demonstrated atrial fibrillation with rapid ventricular response. Echocardiogram revealed findings consistent with undiagnosed Rheumatic Heart Disease (RHD) including bi-atrial enlargement, moderate mitral valve regurgitation, moderate tricuspid valve regurgitation, severe aortic valve regurgitation, moderate pulmonic valve regurgitation, and an LVEF of 55-60%.

CONCLUSION:

Diagnosis of RHD is rare in developed countries due to near eradication from improved efforts to administer antibiotic treatment. We hope our presentation sheds light on the burden of RHD that persists in developing nations and encourages providers to assess the possibility of this diagnosis in a subset of patients. Prompt diagnosis requires heightened awareness among multidisciplinary teams, a high degree of suspicion, and confirmation via echocardiographic studies. Treatment with targeted therapies can recover ventricular function in the majority of cases.
Antenatal Predictors of NICU Admission at a High-Risk Perinatal Center [16B]
Authors: Lane Monet , Dudley Donald J. , Cortez Briana , Boyle Annelee C. , Ferguson James E.
Published: May 2019

INTRODUCTION:

The purpose of this study was to identify antenatal predictors of NICU admission at 34 weeks gestation and beyond at a high-risk perinatal center.

METHODS:

An IRB approved, quality improvement database was created containing clinical and sociodemographic data from 8,858 deliveries at 34+ weeks from January 2011 to May 2018. All data was obtained from the University of Virginia Clinical Data Repository. Relationships between NICU admission and potential antenatal predictors were stratified by gestational age (GA) and assessed using Pearson chi-square or logistic regression.

RESULTS:

Out of 8,858 births, 1,313 infants (14.8%) were admitted to the NICU with a mean length of stay of 13.2 days. Mean length of stay was longest for 35 week deliveries (15.5 days, 95% CI 12.48-16.3) and was shortest for 42 week deliveries (3.4 days, 95% CI 1.27-4.30). Most term NICU admissions occurred at 39 weeks (20.7%, P<.001). Of NICU admissions, 764 (58.2%) were male and 549 (41.2%) were female, yet gender was only associated with NICU admission at 39 weeks (P=.01). Cesarean delivery (P=0.00-0.02) and neonatal abstinence syndrome (P=.00-.01) were significantly correlated with NICU admission in all GA groups except 34 and 42 weeks. Risk factors associated with NICU admission varied by GA at delivery.

CONCLUSION:

NICU admission average length of stay exceeds usual maternal stays. Common obstetric complications were associated with NICU admission. Analysis of local data can guide quality improvement efforts to address risk factors for NICU admission. This could have future implications for development of programs that decrease identified risks and NICU admissions.
Arcuate Uterus as an Independent Risk Factor for Adverse Pregnancy Outcomes [17B]
Authors: Connolly Courtney T. , Hill Melissa B. , Klahr Rebecca A. , Zafman Kelly B. , Rebarber Andrei , Fox Nathan S.
Published: May 2019

INTRODUCTION:

Mullerian anomalies are associated with adverse pregnancy outcomes. However, it is unclear if arcuate uterus, a milder abnormality, is also associated with adverse outcomes. The objective of our study is to estimate the association between arcuate uterus and adverse pregnancy outcomes using a similarly high risk control cohort.

METHODS:

Retrospective cohort study of women with an arcuate uterus cared for by a single maternal-fetal medicine practice from 2005 to 2018. We included all women with a singleton pregnancy and an arcuate uterus and randomly selected (3:1) patients with singleton pregnancies and no uterine anomalies from the same practice as controls. Baseline characteristics and pregnancy outcomes were compared. Chi-square test, Fisher's exact test, and Student's t-test were used, as appropriate. IRB approval was obtained.

RESULTS:

A total of 32 women with an arcuate uterus and 96 controls were included. There were no differences in baseline characteristics between the groups. Women with arcuate uterus had lower birthweights (2992+/-600 vs. 3238+/-560 g, p=0.037) and a higher likelihood of IUGR (25.0% vs. 9.4%, p=0.024), despite similar starting BMI and weight gain in pregnancy. There was a higher rate of malpresentation (21.9% vs. 5.2%, p=0.005), but not an overall increased risk of cesarean delivery.

CONCLUSION:

Having an arcuate uterus is significantly associated with lower birthweight and IUGR, as compared to high-risk controls. This suggests that arcuate uterus is itself a risk factor for poor fetal growth, as opposed to simply being a marker for a higher risk pregnancy.
Barriers to Completing Second-trimester Antenatal Screening: A Retrospective Cohort Study [19B]
Authors: Beshar Isabel , Henkel Andrea , Cahill Erica , Blumenfeld Yair Josh. , Shaw Kate
Published: May 2019

INTRODUCTION:

This study identified barriers to completing the second-trimester antenatal screening ultrasound.

METHODS:

All women completing a Level II anatomy scan between Jan 1 2017 and Dec 31 2017 at one of the seven Lucile Packard Perinatal Diagnostic Center across Northern California were identified by an electronic query of the ClickView Ultrasound database. Maternal age, parity, insurance, distance traveled to clinic, gestational age (GA) at first scan, GA at follow-up scans, and type of anomaly were abstracted from the medical record.

RESULTS:

Our sample included 2000 women with screening ultrasounds between 16 and 24 weeks GA. The median GA at presentation for first ultrasound was 141 days (range 111-168 days) with 64.1% (n=1282) presenting after 20 0/7 weeks. 32.7% (n=654) of women were asked to return for an additional ultrasound as there were incomplete views. Of these 654 women, 17% (n=113) were lost to follow-up. Increased risk of being lost to follow-up was observed among women with public insurance when compared to those with private insurance (OR 1.44, CI 0.96, 2.17). There were also trends for women who were very close (<24 miles) or very far (>100 miles) having increased risk of being lost to follow-up.

CONCLUSION:

Nearly a third of women presenting for an anatomy scan were asked to return due to incomplete views on initial scan, with 17% of these women lost to follow-up. Should laws propose limits on abortion after 20-weeks, this study suggests a percentage of California women would not have important screening information from the anatomy scan.
Delivery Method of Neonates at 22 Weeks' Gestation: A Decision Analysis [25B]
Authors: Zhou Clarice G. , Sargent James Andrew , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

In women who desire resuscitation of a periviable neonate, a cesarean delivery is commonly used for the usual indications. The objective of this study was to examine the impact of mode of delivery of a 22-week neonate on current and future pregnancies.

METHODS:

Decision-analytic model was constructed using TreeAge software to compare outcomes of the delivery method at 22 gestational age in a theoretical cohort of 5,200 pregnant women. The interventions compared are cesarean delivery with a classical incision versus vaginal delivery in pregnancies where neonatal resuscitation efforts have been requested by the patient. The neonatal outcomes of the periviable birth and the clinical outcomes of the subsequent pregnancy were assessed along with the healthcare costs and quality-adjusted life years (QALYs). All probabilities, utilities, and costs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY.

RESULTS:

Out of the 5,200 pregnancies, a classical cesarean would lead to 936 fewer neonatal mortalities. However, there would be 525 more children with neurodevelopmental disabilities. In subsequent pregnancies there would be 29 more previas, 15 more accretas, and 16 more hysterectomies. Overall, a vaginal delivery led to lower costs and higher QALYs when compared to a classical cesarean.

CONCLUSION:

For a 22 week periviable fetus, a vaginal delivery will lead to decreased clinical complications of placenta previa, placenta accreta, and hysterectomy in the subsequent pregnancy when compared with classical cesarean. This suggests that the risks of maternal complications of subsequent pregnancies should be addressed when discussing delivery plans of 22 gestational age pregnancies.
Does Daily Self-Weighing (DSW) Compared to Routine Care Impact Postpartum Weight Loss? [27B]
Authors: Lohr Ali , Hoppe Kara Kjersten. , Mei Chaoqun , Antony Kathleen M.
Published: May 2019

INTRODUCTION:

Gestational weight gain not lost during the postpartum period contributes to obesity. eHealth technologies have demonstrated promise in promoting postpartum weight loss. In non-obstetric populations, DSW also demonstrates efficacy. This study examined the impact of remote patient monitoring (telehealth (TH)), inclusive of DSW on postpartum weight loss.

METHODS:

This was a secondary analysis of 428 postpartum women diagnosed with hypertensive-related disorders in pregnancy (HTN). In the parent non-randomized controlled trial, participants were allocated in a 1:1 concurrent manner to TH versus routine care. Participants in the TH arm received a tablet, a Bluetooth-enabled scale, and BP equipment to use daily. The amount of postpartum weight lost was compared, and the trend of postpartum weight loss was assessed among women completing DSW.

RESULTS:

Demographic variables were similar between groups except TH participants had more severe HTN disorders and were more likely to have undergone Cesarean. The mean weight loss from delivery to the 6-week postpartum visit for TH participants utilizing DSW was 22.72 (SD 10.5) pounds, while the control group lost an average of 22.83 (SD 11.4) pounds (p 0.92).

CONCLUSION:

In this study, weight loss among women with HTN discharged with TH utilizing DSW was not statistically different than women with HTN discharged with routine care. Prior studies examining DSW included healthy weight-related messages. This study suggests that DSW alone may be insufficient to promote postpartum weight loss in the immediate 6-week postpartum period.
Do Patients Undergoing Surgery on a Gynecologic Oncology Service Really Need a Routine Type and Screen? [38B]
Authors: Kirschen Gregory , Dayton Samantha , Pearl Michael Loran , Kirschen Gregory
Published: May 2019

INTRODUCTION:

Preoperative bloodwork for patients undergoing gynecologic oncology surgery routinely includes a type and screen (T&S) due to potential need for blood products. However, it remains unclear whether a routine T&S is necessary.

METHODS:

We performed an IRB-approved retrospective chart review of 800 women who underwent surgery on the Gynecologic Oncology Service at Stony Brook University Hospital from 2009-2016. Data included patient demographics, pre-operative test results, surgical indication and procedure(s), and need for transfusion.

RESULTS:

88.9% of women had a T&S performed. Of these, 76.8% had just T&S performed, 15.3% were converted to T&C without transfusion, and 7.9% required transfusion. All those who underwent T&C or transfusion had an initial T&S. Those requiring transfusion were significantly older (59.1 vs. 55.2 years; p=0.048), more likely to undergo hysterectomy (64.9% vs. 41.0%; p=0.0004), undergo major (defined as entering the peritoneal cavity) vs. minor surgery (10.6% vs. 2.2%; p<0.0001), and had cancer or possible cancer indications vs. benign indications (8.84% vs. 4.92%; p=0.0367). After controlling for these significant factors, surgery type remained significantly associated with transfusion (p=0.0002).

CONCLUSION:

Our results indicate that routine type and screen for younger women undergoing minor surgery for benign indications is unwarranted. In our sample, only 1.72% of this targeted population (below median age women having minor surgery with benign indications) required a transfusion. With T&S and T&C costing roughly $100 and $400, respectively, per test, there is a potential for substantial cost savings with elimination of unnecessary routine preoperative type and screen.