bluuebunny/crossref_metadata_2025 huggingface dataset:
Pregnancy Outcomes in Women With Primary Systemic Vasculitis [13C]
Authors: Nguyen Vanessa , Wuebbolt Danielle , Pagnoux Christian , D'Souza Rohan
Published: April 2018

INTRODUCTION:

This study analyzes pregnancy outcomes in women with large, medium or small vessel vasculitis with the intent of aiding pre-conceptional counselling and informing antepartum and intrapartum care of these women.

METHODS:

We conducted a retrospective study of women with large-, medium- or small-vessel vasculitis and documented pregnancies between 2001 and 2016, identified from the Special Pregnancy Program Database at Mount Sinai Hospital, Toronto. We obtained information from hospital records and analyzed maternal, fetal/neonatal and obstetric outcomes between the different vasculitides.

RESULTS:

We identified 60 pregnancies in 50 women including 10 with large-vessel vasculitis (Takayasu’s arteritis), five with medium-sized vessel vasculitis, 30 with small-vessel vasculitis (16 ANCA-associated vasculitis, 14 with other such as IgA vasculitis), three with central nervous system vasculitis and two with retinal vasculitis. Vasculitis flares occurred in women with large-vessel (3/12), small-vessel (13/36) and retinal (2/3) vasculitis. Pregnancy complication rates were low, with one case each of first-trimester miscarriage, congenital anomaly, stillbirth and gestational diabetes. Although seven (26.4%) viable pregnancies resulted in preterm birth, the mean gestational age, regardless of the type of vasculitis, was over 35 weeks of gestation. Fetal growth restriction only occurred with small-vessel vasculitis (10 newborns, 28.6%). Of the 44 deliveries, 22 (50%) were spontaneous vaginal deliveries. All caesarean (18, 40.9%) and assisted vaginal (7, 15.9%) deliveries were for obstetric indications.

CONCLUSION:

With multidisciplinary management, women with vasculitis can anticipate excellent maternal and fetal outcomes, although they are at increased risk for late preterm birth.
Angiogenic Factors and Preeclampsia with Severe Features Among a Primarily African American Cohort [21C]
Authors: Perdigao Joana , Minhas Ruby , Chintala Sireesha , Mueller Ariel , Young Danielle , Rana Sarosh
Published: April 2018

INTRODUCTION:

Preeclampsia related morbidity and mortality is rising predominantly due to delayed identification of patients at risk for severe features (preE-SF). This study explored the association between angiogenic biomarkers (sFlt and PlGF) and preE-SF.

METHODS:

Women with hypertensive disorders of pregnancy (HDP) were enrolled upon admission. Blood samples were collected within 96 hours of delivery. Angiogenic markers were measured on an automated platform. Severe disease was defined by ACOG criteria as BP ≥160/110, thrombocytopenia, right upper quadrant pain/epigastric pain/transaminases, renal insufficiency, pulmonary edema, or cerebral/visual disturbances. Descriptive statistics were assessed with a Wilcoxon Rank Sum, chi-square or Fisher’s exact test, as appropriate. Univariate and multivariable logistic regression was used to assess for differences in outcomes and angiogenic markers were assessed in tertiles.

RESULTS:

Our study included 375 women with HDP, of which 127 (33.9%) had preE-SF, 115 (30.7%) had gestational hypertension, and 66 (17.6%) had chronic hypertension. Our cohort was predominantly African American (74.4%). Levels of sFlt1 (pg/ml) were significantly higher in women with severe features compared to those without (9372.5 vs. 3607.0; p<0.0001), while levels of PlGF (pg/ml) were lower (51.0 vs. 122.0; p<0.0001) and the ratio of sFlt1/PlGF was significantly higher (212.0 vs. 32.0, p<0.0001). The highest tertile of sFlt1/PlGF was strongly associated with preE-SF (OR 9.05, 95% CI: 4.25-19.24; p<0.0001) in multivariable analysis.

CONCLUSION:

This study demonstrates a significant association between an abnormal angiogenic profile and preE-SF in a primarily African American cohort. Additional evaluation of the role of angiogenic markers during assessment for HDP and disease severity is needed.
Addressing Decision Making in Progesterone Treatment for History of Preterm Delivery [27C]
Authors: Zuponcic Jacqueline , Lavin Justin , Cottrell Connie , Li Marissa
Published: April 2018

INTRODUCTION:

The United States infant mortality rate of 6.1 deaths per 1000 live births ranks 27th worldwide. The majority of perinatal morbidity and mortality is related to preterm birth, whose only FDA approved preventive treatment is intramuscular 17-hydroxyprogesterone (17-OH-P) from 16-36 weeks of gestation. Unfortunately, many patients refuse this treatment.

METHODS:

This 12 month prospective study utilized a short survey, in combination with focus groups, to identify social, cultural, and personal reasoning that influences patients’ decisions to accept or reject 17-OH-P treatment. We hypothesized that treatment refusal is multifactorial for any given patient.

RESULTS:

Acceptors (n=43) and refusals (n=7) were unable to generate sufficient power to identify statistically significant intragroup differences. However, utilizing these surveys and resultant focus groups, this study was able to identify trends within these populations which may guide future approaches to them. Patients refusing 17-OH-P often cited pain with injection, exhibited fatalistic beliefs regarding their care, and/or had personal concerns related to full term pregnancy. Acceptors were identified as candidates at the time of their previous preterm birth, coped better with treatment side effects, and/or had traumatic emotional reactions regarding their premature birth outcomes. Both groups cited barriers to their care–specifically including access and disparities within their care.

CONCLUSION:

Identifying these differences between women accepting and rejecting 17-OH-P may help to develop new approaches to improve patient acceptance of 17-OH-P therapy.
Addiction and Pregnancy, Addiction and Pregnancy: Analysis of an Intervention Protocol for Post-Cesarean Pain Control [38C]
Authors: Kunycky Christina , Callaghan Katherine , Lynch Kerry , Chase Gillian
Published: April 2018

INTRODUCTION:

As the scope of the opioid-addiction epidemic increases, so does the need for supportive providers and for comprehensive interventions to best manage a patient’s addiction. Treating pain following cesarean section necessitates such an intervention as hyperalgesia and increased tolerance have been well established in patients treated with methadone and buprenorphine.

METHODS:

A quality improvement project was conducted to guide postoperative pain control for patients on medication assisted treatment (MAT) through the University of Massachusetts Medical School’s Green Clinic for Addiction and Recovery. Providers were instructed to administer a regimen of increased post-operative opiate pain medication for an initial cohort of Green clinic patients scheduled to undergo a primary or repeat cesarean section. A retrospective chart review was then conducted, collecting pain scores and quantity of opiate pain medication given from the time of delivery to 72 hours post-operative. Adherence to the protocol was determined by type and quantity of pain medication received.

RESULTS:

Of 16 Green clinic patients to receive the protocol, only 41% of patients received the treatment protocol and the remaining 59% received standard post-operative orders. There was no significant difference in pain scores between groups receiving the treatment protocol vs. those receiving standard postoperative orders.

CONCLUSION:

Failure to follow the protocol for patients on MAT indicates the need for more effective systems-based implementation protocols but also the need for concurrent education of healthcare workers involved in the care of patients with addiction, as stigma and knowledge gaps cannot be excluded as factors contributing to failure to follow the protocol.
Distress and Productivity Loss Associated with Uterine Fibroids: Results From a U.S. Survey [5D]
Authors: Marsh Erica E. , Al-Hendy Ayman , Kappus Dale , Galitsky Alex , Kerolous Majid , Stewart Elizabeth A.
Published: April 2018

INTRODUCTION:

Uterine fibroids (UF) are highly prevalent among reproductive-age women with up to 50% of US women reporting symptoms that may be undiagnosed or untreated. The objective of this survey included understanding the impact of UF symptoms.

METHODS:

Female participants (≥18 years) were recruited via email from GfK KnowledgePanel®, a nationally representative panel of U.S. households, supplemented with opt-in consumer panels. The survey was 40-minutes long and used instruments such as the UFS-QoL and Aberdeen menorrhagia severity scale (AMSS).

RESULTS:

A total of 1,443 women were considered eligible and included in the study. Of the diagnosed women without hysterectomy (n=871), 68% passed blood clots, and 32% used ≥6 forms of protection/day based on the AMSS. Based on the UFS-QoL Symptom Severity Subscale, 44% and 43% of diagnosed women reported fatigue and heavy bleeding, respectively, as causing a 'great deal/very great deal' of distress. One-fifth of working women missed ≥8 work-hours monthly (21% full-time, 23% part-time workers). Of women who were undiagnosed but had UF-like symptoms ('at-risk'; n=300), only 49% were aware of UF. Approximately 84% passed blood clots, and 55% used ≥6 forms of protection/day. Of the at-risk women, 83% and 78% reported fatigue and heavy bleeding, respectively, as causing a 'great deal/very great deal' of distress. Overall, 22% full-time and 45% part-time workers missed ≥8 work-hours monthly.

CONCLUSION:

Women with UF experience distress and impaired work productivity. A substantial number of women may be undiagnosed with significant symptoms, underscoring the need for improved awareness and management of UF.
Occult Uterine Cancer in Presumed Benign Hysterectomies: A Population-Based Study [6D]
Authors: Xu Xiao , Wright Jason , Gross Cary , Lin Haiqun , Schwartz Peter E. , Desai Vrunda Bhavsar
Published: April 2018

INTRODUCTION:

To inform proper surgical planning and policy discussion regarding uterine power morcellation, this study estimated the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications.

METHODS:

Women who underwent a hysterectomy in 10/1/2003-12/31/2013 were identified from the New York Statewide Planning and Research Cooperative System database which includes all inpatient and outpatient hospital discharges in the state. We excluded women with a history or admitting diagnosis of gynecologic cancer or endometrial hyperplasia, or received hysterectomy for non-gynecologic indications. Diagnosis of uterine cancer within 28 days after the index hysterectomy was determined based on linked state cancer registry data.

RESULTS:

We identified 233,979 women who underwent a presumed benign hysterectomy. The prevalence of occult uterine cancer was 1.00% (95% confidence interval [CI] 0.96-1.04%), including 0.78% (95% CI 0.74-0.81%) for endometrial carcinoma and 0.22% (95% CI 0.20-0.24%) for uterine sarcoma. The prevalence for leiomyosarcoma was 0.15% (95% CI 0.13-0.17%). The rate of occult uterine cancer ranged from 0.27% in laparoscopic supracervical hysterectomy to 1.96% in total abdominal hysterectomy; and varied from 0.15% in women undergoing hysterectomy for endometriosis to 0.64% for uterine fibroids and 8.64% for postmenopausal bleeding. After adjusting for surgical indication, the risk of occult uterine cancer was significantly higher in older women (e.g., odds ratio=25.98 for age ≥60 years versus <40 years, P<.001).

CONCLUSION:

The risk of occult uterine cancer in presumed benign hysterectomy was 1%. Older women and those who underwent total abdominal hysterectomy or with postmenopausal bleeding were at higher risk.
Laparoscopic Myomectomy vs Laparoscopically Assisted Myomectomy by Minilaparotomy: A Retrospective Study [8D]
Authors: Di Francesco Lucia , Javadian Pouya , Nezhat Farr , Nezhat Camran
Published: April 2018

INTRODUCTION:

In this study we compared the short-term outcomes of laparoscopically assisted myomectomy by minilaparotomy (LAM) vs laparoscopic myomectomy (LM) for symptomatic leiomyomas.

METHODS:

hundred and eleven women with symptomatic leiomyomas of the uterus were included in the study. Retrospectively 51 patients with history of LM and 60 patients with history of LAM were evaluated. Patients record and history, patients characteristics, surgical course, intra and postoperative data etc. were documented and studied. Data was analyzed using SPSS. P value less than 0.05 was considered significant.

RESULTS:

There were no significant differences between groups regarding age, parity and BMI. Median diameter of largest myoma was significantly higher in LAM group (7.3±2.7 vs. 6.1±2.2, P value: 0.01). The median excised tissue weight in the LAM group (200 gr, range: 30-1400) vs LM group (78.5 gr, range: 20-990) was found statistically significant (P<0.005). The proportion of women with intramural fibroids and both intramural and subserosal fibroids was similar among the two groups. There was no statistically significant dependence between operation time (158.2±42.8 vs 153.1±48.4, P=0.55), median post-op hospital stay (380 min vs 398 min, P=0.37) and median estimated blood loss (600 cc vs 600 cc, P=0.64). No patients needed an admission to intensive care nor rehospitalization. Indeed, no patients in both group had post-op major complications.

CONCLUSION:

LAM is an acceptable alternative to LM and could have all the benefits of LM. By performing LAM, especially for larger myomas, morcellation of tissue and repair of the uterus is much easier.
Case Series of Laparoscopic Retroperitoneal Hysterectomy: Outcomes, Cost and Patient Satisfaction [11D]
Authors: Baxi Rupen , MacKoul Paul , Danilyants Natalya , van der Does Louise , Haworth Leah
Published: April 2018

INTRODUCTION:

Laparoscopic Retroperitoneal Hysterectomy (LRH) is a minimally invasive hysterectomy approach incorporating retroperitoneal dissection to ligate the uterine arteries at the origin, lateralization of ureters, vaginal specimen extraction and transvaginal cuff closure. Our study evaluates LRH in terms of outcomes, cost, and patient satisfaction.

METHODS:

Retrospective chart review of 756 consecutive cases undergoing LRH for benign indications at a suburban hospital from 2011-2013. Data collected: patient characteristics and surgical outcomes. Direct hospital costs were estimated using a combination of micro- and gross-costing. Satisfaction surveys were mailed to the same patient population with a 12% response rate.

RESULTS:

Mean uterine size: 328.9g (SD 343.1), ranging from 20g to 9,314g. Mean operating time (OT): 61.8 min (SD 31.0). Average length of stay (LOS) 0.2 (SD 0.5) days with 88% discharged same day. Intraoperative and postoperative complication rates: 2.2% and 3.2%, respectively. Conversion to mini-laparotomy (<5cm) = 1.2% (9 cases). Conversion to laparotomy (>5cm) = 0.0%. Zero use of power morcellation. Average cost per case $4,061. Postoperative survey indicated 87.2% overall patient satisfaction rate.

CONCLUSION:

A distinguishing aspect of the LRH procedure is a standard retroperitoneal dissection with delineation of the ureter and control of the blood supply by uterine artery ligation at its origin. This technique is key to low complication rates, which minimizes OT, LOS, and costs, and contributes to patient satisfaction, and costs, and contributes to patient satisfaction. Further studies comparing LRH to the most widely performed minimally invasive hysterectomy approaches are warranted for this effective and cost-efficient procedure.
Contribution of Previable Births to Racial Disparity in Infant Mortality Rates the United States [22D]
Authors: Lee MacKenzie , Hall Eric , DeFranco Emily
Published: April 2018

INTRODUCTION:

All live births that occur <20weeks contribute to Infant Mortality Rates (IMRs) as all result in death. We aim to describe racial variation in US IMRs attributed to infant deaths among previable (<20week) live born infants.

METHODS:

Population-based retrospective cohort study of all US live births from 2007-2014, using CDC WONDER database’s Linked Birth/Infant Death Records. Data were stratified by maternal race and gestational age (GA) at birth. We compared the proportion of infant deaths within previable and periviable/viable (≥20weeksGA) categories. The US reported IMR (births at all GAs including <20weeks) was compared to an adjusted IMR (≥20weeks), and the difference (≥IMR) was calculated for each race/ethnicity.

RESULTS:

Previable infant deaths represented 4.12%, 7.69%, and 4.99% of total deaths for non-Hispanic White, non-Hispanic Black, and Hispanic groups, respectively. The contribution of previable deaths to the total IMR of these racial/ethnic groups are .21, .89, and .26 per 1000 live births, respectively, P<.0001. Adjusted IMRs of the groups are 4.98, 10.85, and 4.69 deaths per 1000 live births.

CONCLUSION:

There are significant racial/ethnic differences in the relative contribution of previable births to each group’s IMR in the US. Non-Hispanic Black mothers had the largest number of previable births and the largest IMR if a lower GA cutoff of 20 weeks is considered. One potential method of standardizing IMR on the regional, national, and international levels is to impose a minimum gestational age for infant mortality calculations. However, this approach may obscure the disproportionate contribution of previable births to IMRs among the non-Hispanic black population.
Electronic Fetal Monitoring Predicts Severe Fetal Acidemia (Umbilical Cord Arterial pH [25D]
Authors: Gan Sarah , Goldberg Jay
Published: April 2018

INTRODUCTION:

The purpose of this study was to determine how frequently intrapartum electronic fetal monitoring (EFM) was interpreted as concerning, with delivery expedited, in babies with severe acidemia (umbilical cord arterial pH < 7).

METHODS:

A retrospective cohort study was performed on babies with umbilical cord arterial pH < 7. Two groups were identified: (1) expedited delivery (either operative vaginal delivery or urgent/emergent cesarean section) and (2) non-expedited delivery (spontaneous vaginal delivery, scheduled or non-urgent cesarean section). Maternal, labor, and neonatal characteristics between the groups were compared using Chi-squared test for independence and the Fisher’s Exact Test.

RESULTS:

30 babies were identified with umbilical cord arterial pH < 7. 47% were delivered in expedited fashion. 53% were delivered in non-expedited fashion. Of the expedited delivery group, 79% were delivered by cesarean section and 21% by operative vaginal delivery. Of the non-expedited delivery group, 56% were delivered by cesarean section (scheduled or non-urgent). There was no statistical difference between groups in average umbilical cord arterial pH or base excess, gestational age, if labor was induced, length of labor, Pitocin usage for labor augmentation, sentinel events, 5 minute Apgar score or neonatal length of stay.

CONCLUSION:

Only 47% of babies with umbilical cord arterial pH of < 7 delivered in expedited fashion. There was no statistical difference in maternal, labor or neonatal characteristics between the expedited and non-expedited delivery groups. Poor sensitivity of EFM in predicting intrapartum hypoxia and acidemia limits the ability to expedite delivery in the presence of fetal acidemia.
Discharge Analgesics after Vaginal or Cesarean Section Delivery [32D]
Authors: Molero Bravo Ricardo
Published: April 2018

INTRODUCTION:

The first exposure to opioids for many women is after delivery. We seek to evaluate the rates of opioid prescriptions written at the time of discharge after delivery at Kapi’olani Medical Center for Women and Children (KMCWC) for the year 2016, and how these rates changed after new opioid prescribing guidelines were distributed by the CDC in March 2016

METHODS:

We conducted a review of all deliveries at KMCWC during the months of January and September for the year 2016. Deliveries in which the baby was admitted to the NICU were excluded. Both cesarean and vaginal deliveries were assessed and the quantity of prescribed opioids at the time of discharge.

RESULTS:

There were a total of 907 deliveries that met inclusion criteria, 456 during January and 451 during September. There were 104 (22.8%) cesarean sections during the month of January and 352 (77.2%) vaginal deliveries. In September, there were 90 (20.0%) cesarean sections and 361 (80%) vaginal deliveries. The percentage of vaginal deliveries which received opioids at the time of discharge decreased from January to September (29% vs. 22%, p=<0.05). The mean number of prescribed pills was significantly lower for cesarean sections (30.5 vs. 28.6, p=0.0049) and a decrease for vaginal deliveries (26.5 vs. 25.5, p=0.35).

CONCLUSION:

The numbers of opioids prescribed decreased from January compared to September 2016, showing that behavioral change can occur in the teaching hospital setting. Even though this data is reassuring, more work needs to be done to help alleviate the opioid epidemic.
Sleep Apnea Screening: An Overlooked Aspect of Routine Prenatal Care [33D]
Authors: Saeed Haleema , Chauhan Gaurav , Daklallah Youssef , Attali Ami , Swain Monique , Sangha Roopina
Published: April 2018

INTRODUCTION:

Obstructive sleep apnea (OSA) in pregnancy can lead to adverse maternal and neonatal outcomes such as pre-eclampsia, intrauterine growth restriction (IUGR), gestational diabetes (GDMA) and preterm birth. Polysomnography screening is “gold standard” for OSA but can be logistically challenging and not cost-effective. In this study, we will investigate simple screening tools such as the Berlin (BQ) and STOP-BANG questionnaires (SBQ) for OSA in pregnancy.

METHODS:

We screened 169 pregnant women using the BQ and SBQ in the third trimester. A chart review was performed for primary outcomes: pre-eclampsia, IUGR and GDMA. Secondary outcomes were gestational age at time of delivery, Apgars, and birth weight. Demographics such as age, race, BMI, gravidity and smoking history were also reviewed.

RESULTS:

Of the 169 women who participated in the study, 58 women(34.3%) were screened as high risk on the SBQ. Of these, 34.5% were subsequently diagnosed with pre-eclampsia(p=<0.01), 22.4% with GDMA(p=0.098), and 8.6% with IUGR(p=0.743). Of the 80 women(47.3%) who screened high risk on the BQ, 30% were diagnosed with pre-eclampsia(p=<0.01), 21.3% with GDMA(p=<0.01) and 7.5% with IUGR(p=0.929). Rate of preterm births were significantly higher in both BSQ and BQ high risk group at 29.3% and 26.3%, respectively(p=<0.01). No significant difference was noted in demographics.

CONCLUSION:

Obstructive sleep apnea is a modifiable risk factor that can be screened at time of first prenatal care visit, using the STOPBANG and Berlin questionnaires. Identifying and treating those with OSA early in pregnancy may lead to a decreased risk of pre-eclampsia, gestational diabetes and subsequent preterm deliveries.
Does Pregnancy Weight Gain Increase the Risk of Metformin Failure in the Treatment of Gestational Diabetes? [35D]
Authors: Persad Malini D. , Ou Jennie , Bernasko James , Garry David , Garretto Diana , Herrera Kimberly
Published: April 2018

INTRODUCTION:

To determine if maternal weight gain is associated with a higher risk of metformin failure in women with gestational diabetes (GDM).

METHODS:

A retrospective cohort study of women with GDM was conducted from 2013-2016. Included in the study were women with GDM started on metformin after a failed trial of diet therapy. Excluded from the study were women with pre-existing diabetes mellitus. Women were categorized as having adequate glycemic control on metformin (metformin success) or requiring the addition of or transition to an insulin regimen (metformin failure). Metformin failure was defined as the inability to obtain glycemic control despite utilization of the maximum metformin dosage, or provider discretion. Maternal demographics and weight parameters were collected from the medical records and compared between the 2 groups. Parametric and nonparametric statistical analyses were performed with a p value of < 0.05 as statistically significant.

RESULTS:

A total of 146 women with GDM were identified, of which 21 women (14%) failed metformin therapy. There were no differences in maternal demographics. Although the overall weight gain in pregnancy was not statistically significant between the 2 groups, mothers who failed metformin therapy had significantly less weight gain from pre-pregnancy to GDM diagnosis and higher weight gain from GDM diagnosis to delivery compared to those who did not fail metformin therapy.

CONCLUSION:

Women who were successfully treated with metformin, gained less weight after GDM diagnosis. Providers should consider weight gain in pregnancy in counseling women regarding their risk of metformin failure in the treatment of GDM.
Effectiveness of a Patient Decision Aid in Postpartum Contraceptive Counseling [1E]
Authors: Cha Sandolsam , Levi Erika , Findley Molly , Leung Wendy , Tarrash Miriam , Benfield Nerys
Published: April 2018

INTRODUCTION:

Effective postpartum contraceptive counseling helps patients meet their reproductive life goals. Patient decision aids (PtDA) can facilitate counseling but the optimal structure and medium for a PtDA is unknown.

METHODS:

On postpartum day 1, women who had not received a postplacental LARC were randomized to: 1) a paper-based PtDA that featured contraceptive options for side-by-side comparison, 2) standard contraception brochure, or 3) website with comparison of contraceptive options. All patients received counseling utilizing their assigned tool. The concordance between a patient’s decision and their values (“decision quality”) and the extent to which she is clear about her values and feels informed (“decision-making process quality”), were evaluated using validated surveys.

RESULTS:

126 patients were enrolled. The average age of participants was 28.9, half were Latina, 69% had public insurance, 42% were primiparous, and 60% had a vaginal delivery. There were no statistical differences among the groups except for counseling time (6.4 min for PtDA, 6.6 min for the website, and 4.9 min for the standard brochure, p=0.0152). The primary outcomes of “decision quality” and “decision-making process quality” were not statistically different. Regardless of the material, women found them helpful and would recommend to a friend. Although none of the materials highlighted LARC methods, half of all participants chose a LARC method.

CONCLUSION:

Women were satisfied with all approaches to postpartum contraception counseling in this study, which on average took only seven minutes. Our PtDA offer a low-tech solution that women find helpful. Further research is needed to determine its impact in the long-term.
Post-Partum LARC Utilization Among Group Prenatal Care Participants in Atlanta, Georgia [4E]
Authors: Patberg Elizabeth , Young Marisa , Haddad Lisa
Published: April 2018

INTRODUCTION:

CenteringPregnancy (CP) is a model of group prenatal care (PNC) that reduces preterm birth and increases patient satisfaction. Less is known about post-partum outcomes. This study was conducted to determine whether CP participants have increased utilization of long-acting reversible contraception (LARC) post-partum in comparison to those in traditional PNC.

METHODS:

We conducted a retrospective cohort study of 422 women who received PNC and delivered at Grady Memorial Hospital in Atlanta, Georgia between 2011 and 2015. Participants were eligible if enrolled in Medicaid and received at least three PNC visits with a Certified Nurse Midwife in either CP (n=248) or traditional PNC (n=174). Demographic and clinical data were abstracted from the electronic medical record. Unadjusted relative risk (RR) and adjusted incidence rate ratios (aIRR) with 95% confidence intervals (CI) were generated to compare CP with traditional PNC.

RESULTS:

One quarter of women (26%) chose LARC for post-partum contraception. CP participants were more likely to use LARC by 12 weeks post-partum in comparison to those who received traditional PNC (aIRR 1.89; p=0.01), adjusting for age, mode of delivery, number of prenatal visits and primiparity. Short inter-pregnancy interval was similar between the CP and traditional PNC groups (RR 0.95, p=0.57).

CONCLUSION:

Women in CP groups may be more likely to choose LARC post-partum contraception but were no less likely to have a short inter-pregnancy interval.
Long Acting Reversible Contraceptive Uptake in a Student Health Center Following the 2016 Presidential Election [9E]
Authors: Sridhar Aparna , Baker Zoe , Elias Sam
Published: April 2018

INTRODUCTION:

In the context of recent political changes and concerns regarding the potential repeal of mandated contraception coverage in the United States (U.S.), the media reported a sudden increased interest in long acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs) and etonogestrel implants (Nexplanon). Data compiled from 2500 Aetna Health physicians similarly revealed an abrupt increase in IUD-related appointments from October-December 2016.

METHODS:

This is a retrospective review of medical records, comparing the number of women presenting for LARC insertions at the UCLA Arthur Ashe Student Health Center in Los Angeles in the 8 weeks preceding and following the 2016 U.S. presidential election. The volume of LARC insertions during this timeframe was also compared to the volume of LARC insertions during the same 16-week period in the previous year.

RESULTS:

The total number of LARCs inserted increased from 53 in the eight weeks prior to the 2016 presidential election, to 118 in the eight weeks after the election, representing a 123% increase in LARC uptake (p-value=0.02). Over the same 16-week period in the previous year, there was no statistically significant change in number of LARC procedures. No other major changes occurred in the clinic over the 8-week period after the election to account for an increased volume of LARC insertions.

CONCLUSION:

LARC intake increased significantly in our patient population following the 2016 presidential election. We will continue to monitor LARC uptake patterns to determine whether an increased volume of LARC insertions is sustained over a larger timeframe.
Pregnancy Success via Intrauterine Insemination and Effect of Sperm Morphology: Systematic Review & Meta-Analysis [10E]
Authors: Kohn Jaden R. , Kohn Taylor , Ramasamy Ranjith
Published: April 2018

INTRODUCTION:

Couples in which the man has abnormal sperm morphology are often counseled that natural conception and intrauterine insemination are ineffective and that in vitro fertilization is the only option. Our objective is to determine the effect of sperm morphology on pregnancy success using intrauterine insemination (IUI).

METHODS:

We systematically searched for studies published prior to January 2017 that 1) reported ultrasound-verified clinical pregnancies per IUI cycle; 2) assessed sperm morphology using the Kruger Strict Criteria; and 3) reported morphology at the >4% and ≤4% and/or ≥1% and <1% thresholds. For all studies, mean female age was between 25 and 40 years and mean total motile sperm count (TMC) was greater than 10 million. Estimates were pooled using random effects meta-analysis.

RESULTS:

Data were extracted from 20 observational studies involving 41,018 cycles of IUI. Comparing men with >4% and ≤4%, the rate of ultrasound-verified pregnancy per cycle of IUI was not statistically or clinically different (14.2% vs. 12.1%, p=0.06) and the risk difference was 3.0% (95% CI 1.4–4.6%), indicating three additional pregnancies per 100 IUI cycles. Comparing men with ≥1% and <1%, there were no statistical or clinical differences in the rate of ultrasound-verified pregnancy per cycle of IUI (14.0% vs. 13.9%, p=0.97) or in the risk difference (1.6%, 95% CI -4.5–7.6%).

CONCLUSION:

There appears to be no clinical difference in IUI pregnancy success among those with normal and abnormal sperm morphology, when accounting for total motile sperm count and female age. Abnormal sperm morphology alone should not exclude couples from attempting IUI.
Randomized Trial Comparing Three Methods of Perineal Skin Closure at the Time of Second Degree Repair [12E]
Authors: Swenson Carolyn W. , Low Lisa K. , Kowalk Katie , Seiler Kristian , Fenner Dee
Published: April 2018

INTRODUCTION:

We aimed to test the null hypothesis that there is no difference in patient pain among three different methods of perineal skin closure during second-degree repair: 1) suture, 2) no suture, and 3) surgical glue.

METHODS:

A single-blind randomized controlled trial of women post vaginal birth with a second-degree perineal laceration was conducted at a tertiary care teaching hospital August 2014-April 2017.Following repair of the deep tissues per standard fashion, women were randomized to perineal skin closure with suture, no suture or surgical glue using a 1:1:1 allocation. Pain was assessed using the McGill, 100-mm VAS and Present Pain Index at 1 day, 2 weeks and 6 weeks postpartum.

RESULTS:

35 women were randomized: 14 received suture, 11 no suture and 10 had surgical glue. Demographics were similar between groups. At 2 weeks, women with suture had higher pain scores than those with surgical glue or no suture (McGill: suture vs glue vs no suture, 16.2 ± 9.9 vs 6.4 ± 8.4 vs 4.7 ± 5.8, ANOVA p = .021; VAS: 50.6 ± 31.7 vs 17.7 ± 25.7 vs 10.9 ± 12.2, ANOVA p=.009). At 6 weeks, pain scores remained higher with suture versus glue (McGill, p = .045) and no suture (VAS, p = .047). No difference in pain was seen between women with glue vs no suture.

CONCLUSION:

Compared to no suture and surgical glue, suturing the perineal skin was associated with the highest pain scores 6 postpartum weeks. Pain with surgical glue and no suture was similar.
Can the 2-hour Glucose Tolerance Test (GTT) Values Predict Metformin Failure in Women with Gestational Diabetes? [14E]
Authors: Persad Malini D. , Ou Jennie , Bernasko James , Garry David , Garretto Diana , Herrera Kimberly
Published: April 2018

INTRODUCTION:

To determine if the GTT values have utility in predicting metformin failure in women with gestational diabetes (GDM).

METHODS:

A retrospective cohort study of women with GDM was conducted from 2013-2016. Included in the study were women with GDM started on metformin after a failed trial of diet therapy. Excluded from the study were women with pre-existing DM, or were started on glyburide or insulin therapy initially. Women were categorized as having adequate glycemic control on metformin (metformin success) or requiring the addition of or transition to an insulin regimen (metformin failure). Maternal demographics and GTT values were collected. The sensitivity and the specificity of the GTT values as a screening test for metformin failure were analyzed and the corresponding ROC curves were plotted to assess the performance of the test. Parametric and nonparametric statistical analyses were performed with a p value of <0.05 as significant.

RESULTS:

A total of 118 gestational diabetics were identified, 19 (16.1%) women failed metformin therapy. There were no significant differences in maternal demographics between groups. A ROC curve of the fasting GTT value revealed that a value of 103mg/dL was best predictive of metformin failure (AUC 0.653; p 0.04, with a sensitivity and specificity of 42% and 90% respectively. The ROC curves of the 1 hour value and 2 hour value on the GTT were not statistically significant (AUC 0.578, p 0.28; and AUC 0.579, p0.28 respectively).

CONCLUSION:

An elevated fasting GTT value may help predict metformin failure in women with GDM.
Progesterone Effects on Vaginal Cytokines in Women with a History of Preterm Birth [15E]
Authors: Demishev Michael , Persad Malini D. , Peresleni Tatyana , Baker David , Hilsenroth Jessica , Garry David
Published: April 2018

INTRODUCTION:

To evaluate the vaginal immune response of intramuscular progesterone supplementation in pregnant women at risk for preterm birth compared to normal healthy pregnant controls.

METHODS:

A prospective, cohort study from June 2016 to August 2017 included women at a gestational age 11-16 weeks, >18 years of age, and a singleton pregnancy after IRB approval. Women in the progesterone arm had a history of preterm birth and received intramuscular 17-hydroxyprogesterone caproate. Controls were comprised of healthy, uncomplicated pregnancies. Exclusion criteria were vaginitis, diabetes mellitus, hypertension, and other chronic diseases affecting the immune response. A vaginal wash was performed on entry to the study, at 26 to 28 weeks, and at 35-36 weeks. Samples underwent semi-quantitative detection of human inflammatory markers. Immunofluorescence pixel density data was analyzed and P value <0.05 was considered significant.

RESULTS:

There were 39 women included, 10 with a prior preterm birth and 29 controls. The baseline demographics and pregnancy outcomes for both groups were similar in age, parity, race, BMI, gestational age at delivery, mode of delivery, and birth weight. Enrollment cytokines in women with a prior preterm birth, including IL-1 alpha (39.2+25.1% versus 26.1+13.2%; P=0.04), IL-1 beta (47.9+26.4% versus 24.9+17%; P<0.01), IL-2 (16.7+9.3% versus 11.3+6.3%; P=0.03), and IL-13 (16.9+12.4% versus 8.2+7.4%; P=0.01), were significantly elevated compared with controls. In the third trimester the cytokine densities for IL-1 alpha (26.0+18.2% versus 22.3+12.0%; P=0.49), IL-1 beta (31.8+15.9% versus 33.1+16.8%; P=0.84), IL-2 (10.0+8.4% versus 10.9+5.9%; P=0.71), and IL-13 (9.1+5.9% versus 10.0+6.5%; P=0.71) were all statistically similar between the prior preterm birth group and the healthy controls, respectively.

CONCLUSION:

There is an increased cytokine presence in vaginal washings of women at risk for preterm birth which appears to be modified following administration of 17- hydroxyprogesterone caproate compared with healthy controls.
Qualitative Analysis of Challenges Managing Staff and Bed Availability on Labor and Delivery Units [34E]
Authors: Plough Avery , Henrich Natalie , Galvin Grace , Shah Neel T.
Published: April 2018

INTRODUCTION:

Mangers of labor and delivery units need to ensure that their limited supply of beds and nursing staff are adequately available, despite uncertainty regarding future patient needs. The ability to address this management challenge has been associated with patient outcomes, however best practices for managing labor and delivery unit resources have not been defined.

METHODS:

We conducted a secondary analysis of 96 interviews with nurse and physician managers from 48 labor and delivery units across the United States. Based on emerging themes, we identified common challenges in managing bed and staff availability. For each management challenge, we assessed specific management practices based on proactiveness (ability to mitigate challenges before they occur) and systematicness (ability to address challenges in a consistent and reliable manner).

RESULTS:

We identified four key challenges common to all labor and delivery units: 1) scheduling planned cases, 2) tracking patient flow, 3) monitoring bed and staff availability in the moment, and 4) adjusting bed and staff availability in the moment. We observed that proactiveness and systematicness represented distinct characteristics of management practices with some units exhibiting proactiveness but not systematicness and vice versa. Units with both proactive and systematic practices appeared best positioned to reliably address resource challenges effectively.

CONCLUSION:

Labor and delivery unit managers should assess both the proactiveness and systematicness of their existing resource management practices and consider how their practices could be modified to improve operations and quality of care.
Obstetrical and Neonatal Outcomes in Pregnancies Affected by Cannabis Abuse or Dependence [36E]
Authors: Petrangelo Adriano , Czuzoj-Shulman Nicholas , Abenhaim Haim Arie A.
Published: April 2018

INTRODUCTION:

Cannabis is one of the most commonly used illicit drugs during pregnancy in the United States and this prevalence may rise with a growing number of states legalizing its use. We aimed to describe the rate of its use during pregnancy and evaluate its adjusted effect on obstetric and neonatal outcomes.

METHODS:

We performed a retrospective population-based cohort study composed of 12 million births in the United States between 1999 and 2013, extracted from the National Inpatient Sample, compiled by the Healthcare Cost and Utilization Project. Births to mothers abusing or dependent on cannabis were identified using ICD-9 codes and were compared to unexposed women. The adjusted effect of cannabis exposure during pregnancy on various obstetrical and neonatal outcomes was assessed with the use of unconditional logistic regression.

RESULTS:

There were 66,925 births to mothers using cannabis with an incidence rising from 0.28% in 1999 to 0.95% in 2013, p<.05. Compared with the reference population, women reporting cannabis use were at a significantly higher risk of having a preterm premature rupture of membranes (OR 1.46, 95%CI 1.35-1.58) and miscarriage (OR 1.46 95% CI 1.34-1.58). Neonates born to exposed mothers were at a higher risk of being born prematurely (OR 1.40 95% CI 1.36-1.43) and growth restricted (OR 1.35 95%CI 1.30-1.41).

CONCLUSION:

Cannabis use during pregnancy has steadily increased over the study period and is associated with important adverse newborn outcomes. With legalization of cannabis use for recreational purposes, pregnancy may become an important public health concern and should be monitored.
Patterns of Gestational Weight Gain in Relation to Maternal Body Mass Index in Rural Pennsylvania [37E]
Authors: Power Michael L. , Lott Melisa , Mackeen A. Dhanya , DiBari Jessica , Schulkin Jay
Published: April 2018

INTRODUCTION:

To assess whether the patterns of gestational weight gain (GWG) in a rural population changed after the release of the 2009 Institute of Medicine (IOM) guidance on GWG modified by maternal pre-pregnancy body mass index (BMI).

METHODS:

We examined GWG in 18,217 term singleton births between 2006 and 2015 in which maternal pre-pregnancy BMI and GWG could be calculated from electronic medical records at Geisinger in PA.

RESULTS:

The proportion of births with recorded maternal pre-pregnancy BMI and data to calculate GWG increased after 2010, suggesting greater effort in tracking maternal weight. However, the pattern of GWG did not change between 2006 and 2015, with the proportion of women who gained outside of recommendations remaining constant. Only 26% of women in this population gained within recommendations. More than 50% of overweight and obese women gained above IOM recommendations in all years. Underweight women were the most likely to gain below recommendations (33%). GWG above recommendations was associated with higher birthweight, low Apgars and a greater increase in maternal blood pressure throughout pregnancy. Underweight women who gained below recommendations had the highest proportion of low birth weight babies (10.4%).

CONCLUSION:

Despite the publication of IOM recommendations in 2009 and an apparent increase in tracking maternal weight after 2010, GWG in this population did not change between 2006 and 2015. A majority of overweight and obese women gained above recommendations and one third of underweight women gained below recommendations. GWG outside of IOM’s recommendations was associated with poorer outcomes.
The Treatment of Hypothyroidism Among Pregnant Women: A Retrospective Analysis [13M]
Authors: Lage Maureen , Espaillat Ramon , Vora Jamie , Hepp Zsolt
Published: April 2018

INTRODUCTION:

This study examined treatment patterns of hypothyroidism among pregnant women.

METHODS:

The Optum ClinformaticsTM DataMart retrospective claims database was used to identify women in 2014 who were age 18 to 49, were identified as having hypothyroidism, and had at least one recorded thyroid-stimulating hormone (TSH) laboratory value during their pregnancy (N=3,448). The study examines differences in characteristics between pregnant patients treated with levothyroxine (N=2,340) and untreated pregnant patients (N=1,108) as well as treatment target achievement based upon American Thyroid Association guidelines (2011).

RESULTS:

The average age was 32.76 years old (SD=4.80) with a median TSH value of 1.97 mIU/L (interquartile range 1.27 to 3.53). Compared to untreated pregnant women, treatment with levothyroxine was associated with significantly younger age (32.57 versus 33.14 years; P=0.0011), a lower Charlson Comorbidity Index (0.16 v 0.21; P=0.0086), and lower rates of comorbid type 2 diabetes (4.79% versus 6.77%; P=0.0164) and migraines (2.74% versus 4.06%; P=0.0376). Among women treated with levothyroxine, 52.61% had a last recorded TSH value consistent with ATA guidelines, 23.85% were under-treated, 1.03% were over-treated, and 22.52% did not have TSH monitored during their pregnancy.

CONCLUSION:

This study found significant differences in general health and comorbidities between pregnant women treated with levothyroxine and those untreated. These results suggest that a relatively large percentage of pregnant women are not being appropriately managed for their hypothyroidism.
Delivering Health Care to Refugee and Immigrant Women in Clarkston, GA: Opening a Women’s Clinic [28M]
Authors: Kaplan Jessica , DeSimone Mia , Phan Le Thien-Linh , Newman Sarah , Goedken Jennifer
Published: April 2018

INTRODUCTION:

Refugee women are a vulnerable population who experience barriers accessing healthcare and disparities in health outcomes. Eighty-five women from the Clarkston Community Health Center (CCHC), a primary care clinic serving an uninsured refugee and immigrant population, were surveyed using a women’s health needs assessment. Eighty-four percent of reproductive aged women experienced unmet family planning needs, 46% of women over 40 years had never had a mammogram, and 29% of women over 21 years had never had a pap smear. While the survey didn’t specifically address sexually transmitted infections (STIs), 38/82 (46%) requested access to STI screening. Lack of knowledge and access to care were cited as common barriers.

METHODS:

Using the CCHC infrastructure, funding from Emory School of Medicine, and volunteer community providers, we opened a women’s clinic in January 2017. We have collected data on number of patients, presenting complaints, services provided, and referrals.

RESULTS:

As of September 2017, the clinic has served 230 women. Out of the 185 women offering reasons for attending clinic, 24% presented for contraception, 14% for STI testing or treatment, 10% for Pap smears, 3% for breast complaints, and the other 49% for specific gynecologic complaints. We have performed 80 pap smears, tested or treated 63 women for STI’s, and provided 33 women with contraception. We have referred 46 women for mammograms or other evaluation.

CONCLUSION:

The needs assessment was critical to the development of the clinic. However, it underestimated the STI related needs of the population. This may be important to others considering a similar undertaking.