bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study [23OP]
Authors: Liu Brian , Ordon Michael , Bodley Janet , Liu Grace , Kroft Jamie
Published: May 2017

INTRODUCTION:

The Obstetrics program at the University of Toronto recently adopted a “night float” system, whereby residents work for a restricted number of hours overnight, but for four consecutive nights. The objective of this study was to determine if there has been a change in obstetrical patient outcomes following the introduction of restricted resident work hours.

METHODS:

We performed a population-based, retrospective cohort study using linked healthcare administrative databases in the province of Ontario, Canada. We included all obstetrical patients who underwent a delivery between July 2011 and June 2015 (two years prior to and after the implementation of resident duty hour restrictions), at three academic hospitals in Toronto, Canada. The primary outcome was a composite index of numerous maternal/fetal outcomes including maternal transfusion/postpartum hemorrhage, maternal infection, fetal mortality, NICU admissions and surgical/obstetrical complications. Secondary outcomes included assessment of each of the components of the primary outcome examined separately. A generalized estimating equation model, clustered by institution, was utilized to assess for a difference post-intervention.

RESULTS:

The pre-intervention cohort consisted of 6,763 deliveries, and the post-intervention cohort 5,548 deliveries. There were no differences in baseline patient demographics between groups. After the implementation of the restrictions, no significant difference was seen in the primary outcome. However, an increased incidence of composite maternal surgical/obstetrical outcomes (OR 1.2298, P=.0016) and transfusion/postpartum hemorrhage (OR 1.2629, P=.0006) was found.

CONCLUSION:

Since the implementation of resident duty hour restrictions with the addition of consecutive night shifts, there was an increased incidence of surgical/obstetrical complications and transfusion/postpartum hemorrhage.
Effect of Increased Abdominal Circumference on Outcomes in Ultrasounds With Estimated Fetal Weight Greater Than 90% [2P]
Authors: Nicasio Erica , Leung Katherine , Moore Simas Tiffany A. , Belady Petra , Leftwich Heidi
Published: May 2017

INTRODUCTION:

Macrosomia is associated with increased perinatal complications. Avoiding poor outcomes is an important goal of obstetric care, yet prenatal diagnosis of macrosomia remains a challenge. Third trimester ultrasound can predict large for gestational age (LGA), but the accuracy is unreliable. We sought to evaluate whether increased abdominal circumference (AC), predicts poor perinatal outcomes in pregnancies with estimate fetal weight (EFW) greater than 90%.

METHODS:

Retrospective cohort study of singleton pregnancies with EFW greater than 90% between 2006 and 2015. Exclusion criteria were lack of third trimester ultrasound, multiples and delivery outside of study institution. Primary outcome was cesarean delivery (CD). Secondary outcomes included 5 minute Apgar less than 7, NICU admission, LGA, shoulder dystocia, and composite of these 4. Demographics and outcomes were compared and adjusted for confounding factors.

RESULTS:

360 pregnancies met eligibility criteria. Pregnancies with fetal AC greater than 90% were more than twice as likely to be LGA and have a poor composite outcome in adjusted and unadjusted analysis. They were twice as likely to have a CD in unadjusted analysis only. However, those with AC greater than 95% had an almost 3 times increased risk of CD, which remained significant on adjusted analysis. They were also 3 to 4 fold more likely to have each of the poor obstetric outcomes and had a higher mean birth weight, all still significant in adjusted analysis.

CONCLUSION:

Our study shows that large AC, specifically AC greater than 95%, conveys the greatest risk for LGA, poor perinatal outcomes and CD in this cohort.
Effects of Ambient Light on the Biophysical Profile [6P]
Authors: Said Heather M. , Gupta Shweta , Wand Katy , Nguyen Thinh , Gross Gilad , Vricella Laura
Published: May 2017

INTRODUCTION:

The objective is to assess if ambient light serves as a fetal stimulus to decrease the time needed to complete a biophysical profile (BPP).

METHODS:

This is a randomized controlled trial in which 190 women with singletons were randomized to ambient overhead light or no ambient light during BPP. The hypothesis is that the ambient light group would require less total time to complete the BPP. Secondary outcomes include BPP total and subcomponent scores, delivery and neonatal outcomes. Sonographers not involved with the study performed the BPPs and documented end times. The investigators were blinded to allocation group when analyzing the data.

RESULTS:

89 women were randomized to no ambient light and 101 to ambient light. Demographics were similar among the two groups with the exception of race (81% African American with ambient light; 66% African American without ambient light; p = 0.006). No difference was noted among indication for testing, gestational age, fetal position, placenta location, BPP start time or performance of Doppler during the assessment. There was no difference in the time needed to complete the BPP (10.3 + 8.4 minutes with ambient light; 11.1 + 9.2 minutes without ambient light; p=0.518) or in total BPP ultrasound score (7.78 + 0.74 with light; 7.84 + 0.54 without light; p=0.527). Gestational age at delivery, mode of delivery, neonatal weight, Apgars, cord pH and NICU admissions were not different between groups.

CONCLUSION:

There is no evidence ambient light serves as a fetal stimulus to decrease the time needed to complete a BPP.
Litigation in Obstetrical Sonography: Lessons Learned From 100 Consecutive Cases in the Public Library of Law [7P]
Authors: Malik Yusria , Jackson David
Published: May 2017

INTRODUCTION:

Ultrasound is an essential technology in the practice of obstetrics and gynecology. Instruction in point-of-care obstetrical imaging is necessary for both resident and medical student curriculum. Few articles have examined case law in obstetrical sonography, with the last published case series reported in 2003.

METHODS:

A search was conducted in the US Public Library of Law for cases regarding obstetrical imaging. Of approximately 270 consecutive cases reviewed, one hundred were determined to be directly related to obstetrical imaging. These were extracted for location, year, causation, legal content, and resolution. Group comparisons for continuous variables were made using the Student's t test. Categorical variables were compared with Fisher's exact tests.

RESULTS:

Cases occurred from 1988 to 2016, with no measurable increase in frequency in the last decade. The most common states were New York, New Jersey and California. The most commonly represented ACOG districts were districts II, VI, IV, and VI. Four major categories of causation were elicited. Of missed diagnosis, 20% were due to inaccurate fetal biometry, 10% missed ectopic pregnancy, and the remainder were missed diagnoses of fetal abnormalities. Three out of six sonographer-related cases involved sexual assault. A subset of cases specifically related to wrongful life, wrongful birth, and wrongful death were brought in 20% of cases.

CONCLUSION:

Modern curriculum must stress meticulous fetal biometry, specific communication techniques, anatomic integrity, and diagnostic criteria to be met for ectopic gestations. The concepts of “wrongful life”, “wrongful birth” and “wrongful death” should be included in ongoing resident and student education.
Role of Genetic Sonogram After EIF Detection: A Cost-effectiveness Analysis [8P]
Authors: Hacker Francis , Griffin Emily , Shaffer Brian , Caughey Aaron B.
Published: May 2017

INTRODUCTION:

Echogenic Intracardiac Foci (EIF) have been associated with trisomy 21 (t21) but in isolation, the positive likelihood ratio is low or nonsignificant. The 2014 Fetal Imaging Workshop recommends a completed targeted ultrasound (US) to identify other findings associated with t21. In light of US's low sensitivity, difficulty achieving adequate visualization due to maternal factors, and barrier to specialized care for rural populations, our goal was to evaluate outcomes and costs of this recommendation.

METHODS:

A decision-analytic model was constructed using TreeAge software and probabilities derived from the literature. The model compared targeted US with no further studies in women with both a negative quad screen and fetal EIF identified on screening US. This was stratified by maternal age. T21 Sensitivities for US and quad screen for women below and above 35 were assumed at 69%, 68%, and 91% and were examined in sensitivity analysis. Strategies were compared to generate an incremental cost-effectiveness ratio, with a threshold set to $100,000 per QALY.

RESULTS:

Compared to no follow up, a targeted US in women less than 35 with an EIF and negative quad resulted in cost savings of $26,725,134 per 10,000 pregnancies, a dominant strategy in cost-effectiveness. In women 35 or older, the targeted US strategy resulted in 55 additional QALYs with cost savings of $19,692,030 per 10,000 pregnancies, also a dominant strategy. This remained cost effective to a risk for t21 of 0.0006 in fetuses with EIF.

CONCLUSION:

Our results indicate it is cost-effective to offer a targeted US when an EIF is visualized.
Does the Fetus With Klinefelter Syndrome Have a Disproportionately Long Femur Length at the Anatomy Ultrasound? [9P]
Authors: Navathe Reshama , Orzechowski Kelly , Brent Elyssa , Patel Shivani , Ross Judith , Weiner Stuart
Published: May 2017

INTRODUCTION:

To determine if children with a known diagnosis of Klinefelter Syndrome (KS) had a fetal anatomy ultrasound demonstrating long femur length (FL).

METHODS:

Case series of males with Klinefelter Syndrome (KS) receiving medical care in the pediatric endocrinology division at Thomas Jefferson University Hospital (TJUH) in 2014. We invited the mothers of these male children to participate in our study. Women who agreed to participate signed a medical records release form, which was sent to the delivering obstetrician requesting prenatal and delivery records. Records were reviewed for demographics, biometric measurements from the 18-22 week anatomy ultrasound, and delivery outcomes. Primary outcome was FL (calculated percentile based on Hadlock) from the anatomy ultrasound.

RESULTS:

In 2014, there were 100 males with KS being cared for at TJUH. 52 women agreed to participate in the study. We received medical records on 40 of these women (77%); of these, 30 records had the anatomy ultrasound report and delivery information. Mean gestational age at the time of the anatomy ultrasound 19.71 weeks (SD ± 1.29 weeks). 41% of women had an amniocentesis and a known prenatal diagnosis of KS. Femur length percentile was computed based on gestational age at the time of the ultrasound; mean FL percentile was 51.6% (SD ± 14.7%, range 8.7%-77.6%).

CONCLUSION:

The phenotype of males with Klinefelter Syndrome commonly results in tall stature, with a disproportionately long femur from early childhood. However, fetal femur length does not appear to predict an increased risk for Klinefelter Syndrome at the time of anatomy ultrasound.
Does Polyhydramnios Predict Adverse Perinatal Outcome in Congenital Diaphragmatic Hernia? [10P]
Authors: Berger Victoria , Sparks Teresa , Gosnell Kristin , Farrell Jody , Velez Juan Gonzalez , Norton Mary E.
Published: May 2017

INTRODUCTION:

To examine polyhydramnios as a predictor of adverse perinatal outcomes in prenatally diagnosed congenital diaphragmatic hernia (CDH).

METHODS:

A retrospective cohort study of CDH cases evaluated between 11/2008 and 6/2016. Perinatal outcomes including preterm birth and mode of delivery were compared between CDH cases with polyhydramnios (amniotic fluid index greater than 25 cm) and those with normal amniotic fluid index. Additional data compared between groups were fetal anatomic characteristics, intrauterine fetal demise (IUFD), gestational age at delivery, preterm birth, length of hospital stay, and neonatal death. Cases that resulted in termination were excluded. Chi square and Fischer's exact tests were used to compare proportions.

RESULTS:

192 cases were identified, and 56 of these (29.2%) had polyhydramnios. No significant associations were observed in fetal anatomic characteristics between the polyhydramnios and normal amniotic fluid groups. Similarly, there were no differences in gestational age at delivery, preterm birth, vaginal delivery, or neonatal or infant death between these groups. However, cases with polyhydramnios demonstrated a trend toward a higher risk of IUFD (33.3% vs. 66.7%, p = 0.06), and were more likely to have a prolonged neonatal length of hospital stay (37 days versus 22 days, p= 0.03) compared to cases with normal amniotic fluid.

CONCLUSION:

Comparing CDH cases with polyhydramnios to those with normal amniotic fluid, similar rates of fetal anatomic characteristics, preterm birth, vaginal delivery, and neonatal or infant death were observed. There was a trend toward a higher risk of IUFD in the polyhydramnios group, suggesting that these cases may merit closer antepartum surveillance.
Teleultrasound: A Validation Study [15P]
Authors: Rabie Nader , Sandlin Adam , Ounpraseuth Songthip , Nembhard Wendy , Lowery Curtis , Magann Everett
Published: May 2017

INTRODUCTION:

Ultrasound serves an important role in the prenatal diagnosis of fetal anomalies. There has been an increase in the use of teleultrasound protocols for fetal anatomical surveys. Despite the rising popularity of this modality, there are no large studies comparing the sensitivity and specificity of teleultrasound to on-site ultrasound.

METHODS:

This is a retrospective noninferiority study comparing teleultrasound to on-site ultrasound. We included all ultrasound studies performed for anatomical survey. We excluded those performed at < 17 weeks' gestation and on patients with multiple gestations. Every study was interpreted by a Maternal-Fetal Medicine specialist. Prenatal diagnoses were compared to postnatal diagnoses obtained from a mandatory statewide birth defects surveillance registry.

RESULTS:

During the study period, 5,430 ultrasounds met the inclusion criteria; there were 2,341 studies in the teleultrasound group and 3,089 studies in the on-site ultrasound group. The sensitivity, specificity and accuracy of teleultrasound were 53.96%, 98.14% and 95.51% respectively. The sensitivity, specificity and accuracy of on-site ultrasound were 68.29%, 92.95% and 90.16% respectively. We compared the two groups using the Farrington-Manning score test for noninferiority with a 0.15 noninferiority margin and 90% confidence interval. The proportion differences for sensitivity, specificity and accuracy were -0.1433 (CI -0.2240 – 0.0626), 0.0518 (CI 0.0369 – 0.0668) and 0.0535 (CI 0.0381 – 0.0689).

CONCLUSION:

The sensitivity of teleultrasound is inferior to that of on-site ultrasound. Teleultrasound is less likely to detect fetal anomalies, but is comparable to on-site ultrasound in identifying the specific anomaly. In addition, teleultrasound is comparable to on-site ultrasound in identifying non-anomalous fetuses.
Twin Anemia Polycythemia Sequence: A Complication of Monochorionic Diamniotic Twin Gestation [16P]
Authors: Savasan Zeynep Alpay , Zeb Amna , Scott Lauren
Published: May 2017

INTRODUCTION:

Twin anemia polycythemia sequence (TAPS) is an important prenatal complication of monochorionic twin gestations due to abnormal placental vascular anastomosis. Prenatal ultrasound is the only screening modality. Our objective was to evaluate the prediction potential of current prenatal ultrasound screening in diagnosing TAPS in monochorionic diamniotic twin gestations.

METHODS:

Maternal and neonatal medical records were reviewed for women with monochorionic diamniotic twins who delivered at Beaumont Hospital System (Royal Oak and Troy) from 2009-2014. Available prenatal ultrasound findings were compared with the neonatal outcomes. Postnatal TAPS diagnosis was confirmed with neonatal peripheral blood hemoglobin values.

RESULTS:

A total of 132 maternal charts were reviewed and 102 were used in data collection. The median maternal age was 31 years (19-45) with a median parity of 1 (0-3). Among these women 10% (n=10) had assisted reproductive technology. Median gestational age at time of delivery was 35.4 weeks (20.7-39). Median NICU stay for twin A and twin B were 9 (0-264) and 8.5 days, (0-103), respectively. Among 132 prenatal ultrasound screenings, 26% (n=32) were reported as abnormal. Thirty-three percent (n=34) of the neonates were diagnosed with anemia and polycythemia; of these neonates 29% (n=30) had anemia, 4% (n=4) had polycythemia. The sensitivity and specificity of prenatal ultrasound in the prediction of TAPS was 26% (95% CI: 13-44) and 77% (95% CI: 65-87), respectively.

CONCLUSION:

Current prenatal ultrasound screening guidelines have low sensitivity and specificity in predicting TAPS in monochorionic diamniotic twin gestations. New and updated prenatal screening methods may improve TAPS prediction.
Is Advance Maternal Age an Indication for Fetal Echocardiogram? [18P]
Authors: Patel Krunal , Parikh Bijal , Guirguis George , Williams Shauna , Apuzzio Joseph
Published: May 2017

INTRODUCTION:

Pregnancies in women of advanced maternal age (AMA) are at increased risk for aneuploidy and therefore could be at increased risk for congenital heart disease (CHD). Our objective was to assess whether AMA without another risk factor for CHD is associated with abnormal fetal echocardiogram.

METHODS:

This is a retrospective cohort study of all patients who were referred for specialized sonogram and fetal echocardiogram January 1, 2015 through December 31, 2015 at a single academic institution. Data was collected on demographics, indications for specialized sonogram and fetal echocardiogram, aneuploidy screening, amniocentesis results and obstetric outcomes. Patients were grouped by age (< 35 or > 35 at delivery) and rate of abnormal fetal echocardiograms were compared by Fisher's exact test.

RESULTS:

483 patients underwent specialized sonogram, 189 (39%) were AMA patients. Fetal echocardiogram was performed in 87 (46%) patients in the AMA group versus 134 (45.4%) patients in the non-AMA group. Abnormal fetal echocardiograms were found in 2 (2.2%) of the AMA group compared to 8 (6%) of the non-AMA group (p=0.32). Of the 65 AMA patients who did not have another indication for fetal echocardiogram, 2 (3%) had abnormal results (mild cardiomyopathy, VSD) whereas there were no abnormal echocardiograms in AMA patients with another indication (0/22). One of the two patients had an abnormal quad screen for increased risk for trisomy 21.

CONCLUSION:

In this cohort, AMA without another indication for fetal echocardiogram had a 3% rate of abnormal fetal echocardiogram. This suggests that a fetal echocardiogram should be considered in patients who are AMA.
Cost-effectiveness of Preimplantation Genetic Screening for Women Older than 37 Years Undergoing IVF [19P]
Authors: Collins Stephen C. , Xu Xiao , Mak Winifred
Published: May 2017

INTRODUCTION:

Adding preimplantation genetic screening (PGS) to in-vitro fertilization (IVF) has been shown to increase live birth rates (LBR) in women older than 37. However, PGS is an expensive procedure. It is important to evaluate the cost-effectiveness of IVF-PGS versus IVF alone in improving LBR.

METHODS:

We constructed a decision analytic model for a hypothetical fresh, autologous IVF cycle (with versus without PGS) for women older than age 37 who had a successful oocyte retrieval. The model incorporated probability and cost estimates of main clinical events including PGS, blastocyst transfer, clinical pregnancy, miscarriage, pregnancy termination, and live birth based on data from published literature.

RESULTS:

In base-case analysis, IVF-PGS offered a 4.2 percentage point increase in LBR for an additional cost of $4,287, yielding an incremental cost-effectiveness ratio (ICER) of $100,290 for one additional live birth. This ICER was less than the expected cost of $122,581 for achieving one live birth with IVF (assuming an average LBR of 15.3% and $18,707 per cycle for this patient population). Furthermore, sensitivity analysis suggested that ICER improved substantially with decreases in PGS cost and increases in PGS effectiveness. Monte Carlo simulation showed PGS to be cost-effective in 89.1% of iterations at an acceptability cutoff of $122,581.

CONCLUSION:

Considering the expected cost of achieving one live birth with IVF, PGS appears to be a cost-effective strategy for women older than 37 undergoing IVF. Additional research on patients' willingness-to-pay for an additional live birth would further inform our understanding regarding the cost-effectiveness of PGS.
Voicing Needs: The Experience of Fertility Care in the United States [21P]
Authors: Kudesia Rashmi , Bhasin Deepika , Lee Joseph A. , Daneyko Margaret , Collura Barb , Copperman Alan B.
Published: May 2017

INTRODUCTION:

To learn how reproductive medicine practices in the United States can improve patient care.

METHODS:

A 52-item survey that included six domains of structured and open-ended questions. Open-ended responses were evaluated by the grounded theory method.

RESULTS:

Patients stated a desire for personalized care, including being treated “like a person” and not “feeling like a number”. Many participants described feeling “herded” during morning hormone monitoring. Occasionally, they felt they might be receiving a “one-size-fits-all” treatment, and that diagnostic testing had been insufficient and could have led towards invasive treatment. Respondents voiced trust in their physician and that regular visitation helped their treatment experience. Twenty-eight respondents mentioned sensitivity as a center attribute. An absence in sensitive was perceived to be caused by provider burnout and the concept that “they know you don't really have a choice”. A desire to be treated with patience, educated and offered in-house ancillary care services were observed. Triggers viewed as unnecessary provocations during an already-stressful time included the presence of children in the waiting room, visibly pregnant patients or staff, particularly when there was a perception that someone “showed off her pregnant belly”, care costs, insurance coverage, inconvenient calls, center preference to email, and concern over a lack in regulation.

CONCLUSION:

While satisfied with overall care, some issues, such as lack of uniform insurance coverage, are out of our direct center control. Moreover, vigilance in office workflow, staff education, and forming partnerships with financial, emotional and complementary medical support services could improve the patient experience.
Cabergoline Preserves Implantation and Ongoing Pregnancy Rates in High Responders to Gonadotropin [22P]
Authors: Wilson Alexandra , Shu Yimin , Patel Bansari , Berga Sarah , Prokai David , Johnston-MacAnanny Erika
Published: May 2017

INTRODUCTION:

While infrequent, excessive response to gonadotropin occurs in spite of careful pre-cycle planning. We sought to determine the impact of cabergoline administration on implantation, clinical and ongoing pregnancy rates in patients with excessive response to gonadotropins without other features of ovarian hyperstimulation syndrome (OHSS) during fresh embryo transfer.

METHODS:

All fresh IVF cycles undergoing embryo transfer from 2013-2016 in an academic center were reviewed to identify cycles with excessive response to gonadotropin. Patients were excluded if their embryos underwent preimplantation genetic screening or if early OHSS was diagnosed necessitating cryopreservation. All patients were triggered with urinary hCG and oocyte collection occurred 36 hours after trigger. Administration of cabergoline at the time of hCG trigger stratified the two groups. Choice to administer cabergoline was based on provider discretion. Differences between groups were obtained through chi-squared analysis.

RESULTS:

Sixteen patients (N=16) met inclusion criteria for study. Subjects were equally divided into cabergoline exposure (N=8) and absence of cabergoline exposure (N=8). The implantation rates were 28.5% (4/14) and 63.3% (7/11), in the non-exposure and exposure groups respectively. 50% (4/8) of the non-exposure group versus 75% (6/8) exposure group achieved clinical pregnancy. Ongoing pregnancy rates were identical with 75% rate (6/8) in both groups.

CONCLUSION:

In high responders, those who had co-administration of cabergoline maintain outstanding implantation rates and clinical and ongoing pregnancy rates. In patients exposed to cabergoline without other features of OHSS, embryo transfer may be carefully considered without compromise of implantation rates, particularly in those with high response.
New FIGO Guidelines on Gestational Diabetes [24P]
Authors: Dahiya Krishna
Published: May 2017

INTRODUCTION:

Gestational diabetes mellitus is one of the most common medical disorders found in pregnancy. Clinical recognition of GDM is important because timely intervention by dietary measures or insulin and fetal surveillance can reduce the well described associated maternal and fetal complications.

METHODS:

This observational study was done over a period of one year. Single step test using 75 gms oral glucose was used as screening and diagnostic test for GDM. A total of 500 pregnant women attending antenatal clinic were selected randomly for the study at less than 16 weeks POG. All the selected women were given a 75 gm anhydrous glucose powder dissolved in a glass of water, to be consumed over 5 minutes, irrespective to the time of last meal. A venous blood sample was collected at 2 hours for estimating plasma glucose by the glucose oxidase peroxidase (GOD-POD) method. GDM was diagnosed if 2 hrs plasma glucose is >140 mg/dl.

RESULTS:

Prevalence of GDM was found to be 7% in present study. Age ≥25 years, obesity, multigravidity and family history of diabetes mellitus were major risk factors for developing GDM. Maternal and fetal outcomes were poor in GDM group as compared to the control group. In GDM group common maternal complications were polyhydramnios and recurrent vaginal infections.

CONCLUSION:

Present study concurs with the WHO recommendation of 2-hr 75 gms OGTT as single step procedure for both screening as well as diagnosis of GDM. Hence we suggest the adaptation of 75 gms glucose single step test for screening and diagnosis of GDM.
Does Laterality of the Dominant Follicle Matter Under Ovulation Induction? [26P]
Authors: Gentry Adrienne , Theisen John G. , Norwick Holly , Pagidas Kelly
Published: May 2017

INTRODUCTION:

Evidence suggests that ovulation from the right ovary has a higher chance of pregnancy. Alternating ovulation from cycle to cycle also favors pregnancy, rather than when a woman ovulates from the same ovary cycle to cycle. There is minimal literature regarding laterality of dominant follicle with ovulation induction with clomiphene citrate and/or letrozole. The study objective was to evaluate laterality of dominant follicles and associated outcomes in ovulation induction or superovulation with letrozole or clomiphene citrate.

METHODS:

This retrospective chart review of patients who underwent ovulation induction with Letrozole or Clomiphene Citrate at the University of Louisville Fertility Center included women (age 18 or older) that had a monitored ovulation ultrasound. Exclusion criteria were any factors that excluded them from ovulation induction. Cycle differences analyzed via logistic regression to get odds ratio, CI, and p values.

RESULTS:

Overall, 171/188 cycles had a dominant follicle (91%). Pregnancy rate was 14.4% when a lead follicle was present. There was no difference in laterality of dominant follicle (left 53.2%, right 46.7%, P=0.44), no difference in pregnancy rate regarding laterality of dominant follicle (left 12.5%, right 14.1%, OR (R vs L) =1.15 (0.45-2.94), P= 0.94). Pregnancy rate was increased when more than one dominant follicle was noted (OR (2+ vs 1)=3.79 (1.31-10.95) P=0.01).

CONCLUSION:

The laterality of the dominant follicle does not seem to be influenced by ovulation induction with clomiphene citrate or letrozole and does not seem to influence a successful outcome. This study confirms that more than one dominant follicle increases your chance of pregnancy.
Rural, Resident Fertility Clinic Patients Have Little Insight Into Their BMI or Implications of Obesity on Fertility [27P]
Authors: Ulrich Nicole , Straney Jennifer , Luo Qingyang , Wells Lindsay
Published: May 2017

INTRODUCTION:

Abnormal weight and its effects on health and fertility are poorly understood by patients. We aimed to evaluate differences in knowledge of abnormal weight and its effect on fertility between patients seen for infertility and general gynecology (GYN) at a rural, resident-run clinic.

METHODS:

Participation in this 12-question survey-based analysis of weight/fertility knowledge was offered to patients seen in our rural, resident-run clinic. Survey assessed knowledge of abnormal weight and its effect on fertility, yielding a “Fertility Knowledge Score” and “Physician Education Score.” Visit number, age, visit type, and body mass index (BMI) were collected via chart review. The mean correct scores of both groups of patients (infertility and GYN) were compared using 2 sample T-test and Chi-squared test.

RESULTS:

Surveys for 44 infertility patients and 51 GYN patients were included. Infertility patients had higher mean BMI (37.5) than gynecology patients (32.9), (p=0.0263); 91% of fertility patients and 80% of GYN patients were overweight/obese. Infertility patients (p=0.0239) and patients with higher BMI (p=0.0112) reported discussing weight/BMI with a physician more often. There was no difference in survey scores between new and established patients overall or when these scores were analyzed by patient weight.

CONCLUSION:

Both infertility and GYN patients have little insight into their own BMI, with no change over visits. BMI is higher among infertility patients. Though, infertility patients have high general knowledge of effects of abnormal weight on fertility. This suggests we are not effectively discussing individual implications of weight/BMI despite large numbers of overweight/obese patients under our care.
Reproductive Uterine Transplantation: Ethical Considerations [30P]
Authors: Allyse Megan
Published: May 2017

INTRODUCTION:

The recent live births of five babies after elective uterine transplantation from a live donor has demonstrated one possible mechanism to address absolute uterine factor infertility. However, national and cultural factors contributed to the ethical and medical permissibility of uterine transplant in the Swedish context. These factors may be different in other socio-national contexts. We sought to understand the potential permissibility of the procedure in the US context.

METHODS:

We conducted an ethical analysis of the potential practice of elective reproductive uterine transplantation in the US from a perspective of women's health and rights.

RESULTS:

Relevant vectors of analysis include alternative paths to parenthood, considerations of baseline status versus enhancement, reproductive rights, feminist critiques, allocation of healthcare resources, and the balance of risk and benefit. Compelling arguments are made on both sides of the deliberation under all vectors.

CONCLUSION:

On balance, arguments for or against elective uterine transplant in the US context appeared to balance. However, the most compelling factors that must be addressed in order to justify the procedure include the absence of alternatives, the risk to donors and recipients, and the healthcare opportunity costs.
Hysterosalpingogram (HSG) vs Mid-Cycle Ultrasound (MCUS) in Anatomic Assessment of Infertile Women [32P]
Authors: Durowade Taiwo , Ayers Jonathan
Published: May 2017

INTRODUCTION:

Utero-tubal anatomic abnormalities represent a very important etiology for primary infertility, and proper evaluation is critical for directed therapy. The most common methods used for evaluation of patients presenting with infertility are: transcervical injection of contrast media with radiography; Hysterosalpingogram (HSG) or transcervical injection of saline with ultrasound; Saline infusion sonography (SIS). However, these methods are painful, costly and can be “non-diagnostic.” Studies show that there is a ten-fold increase in estradiol levels during the mid-cycle. This increases fallopian tube fluid production and endometrial gland thickness, thereby providing a “natural contrast” vs iodinated contrast of HSG. This study proposes that a mid-cycle 2D ultrasound (MCUS) can provide the same accuracy of information as HSG without the pain, cost and potential false findings.

METHODS:

In the year prior to this study, 153 women with primary infertility underwent both HSG and MCUS during their evaluation at IVF Michigan. The HSG and the dynamic MCUS were performed by a reproductive endocrinologist. The findings of tubal and uterine abnormalities identified with HSG were compared with those identified with MCUS.

RESULTS:

MCUS identified all distal tubal occlusions with sensitivity and specificity of 100% compared to HSG, and it identified uterine abnormalities with 76% sensitivity and 96% specificity.

CONCLUSION:

Physician performed dynamic MCUS provides an excellent screening alternative for anatomic assessment of women with infertility and may eliminate the need for invasive testing in this population.
Management of Ectopic Ovary in the Setting of Mullerian Agenesis [35P]
Authors: Kanter Jessica , Jarrard Merry , Gavrilova-Jordan Larisa
Published: May 2017

INTRODUCTION:

Mullerian agenesis can be associated with a complex array of other congenital anomalies, including ectopic ovaries. As a rare finding, clinical recommendations are not clear cut, therefore we present a case report and literature review to develop recommendations for clinical management of an ectopic ovary in the setting of complete Mullerian agenesis.

METHODS:

An adolescent female with primary amenorrhea underwent complete evaluation at an academic reproductive endocrinology clinic. Clinical management recommendations were developed based on literature review.

RESULTS:

Physical examination of the 16-year-old amenorrheic female revealed a short blind vagina, fullness of the left inguinal canal, normal sexual hair distribution and breast development. Further evaluation with pelvic MRI demonstrated absence of the uterus, normal right ovary, and ectopic ovarian gonad located in the left inguinal canal. She was additionally found to have absence of the left kidney and a hypertrophic right kidney with a single ureter. We performed extensive literature review to develop clinical recommendation on ectopic ovary in patients with complete Mullerian agenesis, also known as Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. The considerations of gonadal conservation, risk of malignancy, and indications of ovarian transposition were evaluated in preparation of management recommendations.

CONCLUSION:

Ovarian conservation without ovarian transposition is an optimal clinical management in the case of unilateral ectopic ovary in patients with Mullerian agenesis. Absence of significant increase of malignant transformation should be discussed with these patients. A review of possible oocyte recovery from an ectopic ovary and role of assisted reproductive technology is highly recommended to diminish patient anxiety about future fertility.
Reproductive Options for Transgender Patients [36P]
Authors: Luikenaar Rixt
Published: May 2017

INTRODUCTION:

The Affordable Health care Act 1557 in May 2016 forbids discrimination on the basis of gender by physicians. Obstetricians and gynecologists continue to see an increase in the number of transgender patients desiring to reproduce and have children. They have questions about surrogacy, egg freezing and are looking for nonjudging obstetricians to deliver their babies. There are few to none data showing effect of cross hormone therapy on fertility. Barriers to access of care have been lack of education of physicians and the lack of insurance companies offering transgender inclusive health plans.

METHODS:

Since 2011 I have treated over 2,000 transgender and gender nonconforming patients. Besides hormone therapy, pre- and postoperative care, primary and preventive care I also heard many reproductive questions, either about sperm and egg banking, surrogacy or pregnancies. I performed a literature review study which revealed very few articles. From my own patient histories I continue to hear about being mis-gendered or doctors not paying attention to preferred pronouns or assuming they want their reproductive organs removed.

RESULTS:

There are no evidence based studies that tell us how to counsel our transgender patients about future fertility, however many transgender men and women desire pregnancy.

CONCLUSION:

This is pioneer work. There are few data and still many physicians have issues with trans men and trans women's reproductive rights. We need to support and advocate for this minority that needs us to help them make healthy decisions for themselves and their families, however different they may be from yours.
Inpatient Prenatal Yoga for Hospitalized High-Risk Antepartum Patients: A Feasibility Study [1Q]
Authors: Demtchouk Veronica , Kelly Jeannie , Prigo Corinne , Dangel Alissa
Published: May 2017

INTRODUCTION:

Prenatal yoga has been shown to be a safe and effective treatment for depression and pain, while improving high-risk pregnancy outcomes. This study investigated the feasibility of establishing a prenatal yoga program for hospitalized high-risk antepartum patients.

METHODS:

Patients admitted for at least 72 hours to the antepartum service at a tertiary care center were screened for eligibility and consented. Additional medical clearance was obtained from their primary obstetrician. A 30-minute prenatal yoga session was held once a week by a certified prenatal yoga instructor. Physical activity level was adapted to accommodate patients on modified bed rest. Participants completed a questionnaire following the conclusion of each session addressing class timing, length, and frequency. Antepartum nurses were also surveyed to evaluate their perspective.

RESULTS:

The majority of antepartum patients hospitalized for pregnancy-related complications were offered participation. Of these, 34 women consented and were eligible to participate; 13 attended at least one session during their hospitalization. Others did not participate due to scheduling conflicts with fetal testing, change in clinical status, lack of interest the day of, and delivery or discharge. Post session patient surveys revealed that all patients enjoyed class length and frequency and viewed them as beneficial for managing stress, musculoskeletal discomfort, and sleep quality. Nursing surveys revealed the class did not affect their ability to provide medical care for the patients.

CONCLUSION:

Inpatient prenatal yoga is a feasible and acceptable intervention for high risk women admitted for antepartum management. Future study of the effect on maternal and fetal outcomes should be strongly considered.
When Is Illicit Drug Screening Indicated in Pregnant Women on Labor and Delivery in Colorado? [3Q]
Authors: Son Shannon L. , Heyborne Kent , Sheeder Jeanelle , Guiahi Maryam
Published: May 2017

INTRODUCTION:

Women on labor and delivery undergo illicit drug screening for various indications many of which may not be appropriate indicators of use. We investigated which indications are associated with positive testing.

METHODS:

We performed a historical cohort study of all pregnant women with positive drug screens on labor and delivery at a safety-net hospital in Denver, Colorado between 2010-2014. Testing was performed at provider discretion based on concern for substance use and patients were consented. Illicit drugs are included; tetrahydrocannabinol is not. Chart abstraction included testing indications, demographic, reproductive, social, and substance use characteristics. Descriptive statistics were computed.

RESULTS:

Between 2010-2014, there were 121 positive urine toxicology screens. Most women in our cohort were ≤30 years old (70.2%), white (81%), not Hispanic (55.4%), single (54.5%), and unemployed (90.9%). Obstetrical indications for testing: preterm labor (24.0%), placental abruption (14.0%), abnormal maternal behavior (11.6%), intrauterine fetal demise (6.6%), abnormal maternal vital signs (5.8%), outborn delivery (6.6%), precipitous delivery (3.3%), trauma (5.0%), pain (3.3%), and abnormal fetal monitoring (0%). Social indications for testing and frequencies of a positive test were: self-reported illicit drug use (61.2%), documented historical use (9.1%), no prenatal care (21.5%), and scant prenatal care (5.0%). 77% of positive tests had at least one social indication for testing.

CONCLUSION:

Over three-fourths of positive tests were performed based on social factors elicited from patient histories. While obstetric indications did provide some positive tests, emphasizing excellent history taking may optimize illicit drug testing strategies.
The Use of Omega-3 Fatty Acids to Improve Insulin Sensitivity in Pregnancy: A Pilot Study of Safety and Tolerability [6Q]
Authors: VanWinden Kristi R. , Montoro Martin , Silverstein Emily , Ovalle Blanca , Shulman Ira , Ouzounian Joseph G.
Published: May 2017

INTRODUCTION:

Omega-3 fatty acid (n3 FA) consumption is associated with improved insulin sensitivity in some diabetic populations, but can cause adverse effects at high doses. The objective was to evaluate the tolerability of high-dose n3 FA supplementation in obstetric patients with diet-controlled gestational diabetes (GDM).

METHODS:

Women with diet-controlled GDM between 24 and 30 weeks of gestation were randomized in a prospective, double-blind fashion to receive either 2200 mg daily of commercial fish oil (1300 mg eicosapentaenoic acid (EPA) + 900 mg docosahexaenoic acid (DHA)) or an identical placebo for a minimum of 6 weeks. Pre-and post-treatment evaluations were calculated using the homeostatic model assessment of insulin resistance (HOMA-IR) and measures of safety and tolerability.

RESULTS:

In this pilot study, 14 GDM patients were randomized to treatment with fish oil (N=7) or placebo (N=7). Of these, 35.7% (3 in the treatment group, 2 in the placebo group) did not complete the treatment course due to intolerance. No clinically significant adverse effects, obstetric or neonatal complications were noted. Two patients in each group required initiation of medical therapy for glucose control subsequent to enrollment. While the pilot study was not adequately powered to detect a difference in objective measures of glucose control between the groups, no significant differences in fasting glucose, fasting insulin, or HOMA-IR levels were noted.

CONCLUSION:

High dose omega-3 fatty acid supplementation appears to be safe in pregnancy, but some patients have bothersome side effects that may limit compliance. The use of omega-3 fatty acids to mitigate insulin resistance in gestational diabetes warrants further investigation.
Recurrent Preterm Delivery in Women Receiving 17-P is Not Influenced by Prior Spontaneous Preterm Delivery Etiology [8Q]
Authors: Barton John , Rhea Debbie , Sibai Baha
Published: May 2017

INTRODUCTION:

To compare rates of recurrent preterm delivery (PTD) in women receiving 17-P therapy for prior spontaneous PTD (sPTD) due to either Preterm Premature Rupture of Membranes (PPROM) or preterm labor (PTL).

METHODS:

Study sample derived from a national database of women receiving 17-P therapy as part of a PTD prevention program. Inclusion criteria: women meeting SMFM criteria recommendations for 17-P administration, documented history of prior sPTD, singleton gestation and receiving at least 4 weekly 17-P injections. Demographic and clinical risk factors for PTD as well as pregnancy outcomes were compared between those with prior history of sPTD with PTL vs PPROM. Rank and chi-square tests were used to compare study groups, with P-values < .05 considered statistically significant.

RESULTS:

2,084 women with prior sPTD were studied: 450 with prior PPROM, 1,634 with prior PTL. There were no significant differences between prior PPROM vs prior PTL study groups for race, ethnicity and pre-pregnancy BMI < 20 or >30. The number of previous PTDs (1.3 ± 0.6 vs 1.3 ± 0.6), gestational age of the most recent PTD (31.8 ± 4.6 vs 31.5 ± 4.5 weeks) and the total number of 17-P injections (18.7 ± 2.4 versus 18.9 ± 2.3) were also similar. Overall, with 17-P therapy, there were no significant differences between study groups for PTD at < 37.0, < 35.0 and < 32.0 weeks or sPTD < 37.0 weeks.

CONCLUSION:

In women receiving 17-P therapy, recurrent PTD and sPTD rates are not affected by the etiology of the prior sPTD.
The Rate of Elevated Antenatal Edinburgh Depression Score in Pregnancies Complicated by Gestational Diabetes [12Q]
Authors: Herrero Tiffany , Fratto Victoria M. , Nelson Evelyn , Hamlin Alyssa , Laurent Louise , Ramos Gladys A.
Published: May 2017

INTRODUCTION:

The US Preventative Task Force recommends depression screening in pregnancy. The Edinburgh Depression Scale (EDS) is a self-administered screening tool for the diagnosis of depression. An EDS of greater than or equal to 10 is considered elevated and correlated with depression. Despite correlation with depression, maternal and neonatal outcome in high risk populations is unclear.

METHODS:

This is a retrospective study of singleton pregnancies with gestational diabetes at UC San Diego between 2010-2014 with an antepartum EDS. The primary outcome was the rate of elevated EDS and referral for treatment. The secondary outcomes included maternal characteristics, perinatal outcome, and postpartum follow-up.

RESULTS:

210 women met inclusion criteria. 53.2% (107/210) had an elevated EDS score and 71% (76/107) were referred for counseling. Of these, 24.5% (26/76) attended their counseling appointments. 18.7% (20/107) received pharmacologic treatment. Patients with a positive EDS score had a higher rate of PTD (19.6% vs 9.7% (p=0.05)), higher rate of obesity, and less weight gain. No statistical differences were noted in SGA, however, a trend toward a higher rate of these outcomes were noted in the group with elevated EDS (SGA 9.4% vs 2.9% (p=0.08). There were no differences in delivery method, rates of macrosomia, and diabetic control.

CONCLUSION:

53% of women with gestational diabetes had an elevated antenatal EDS and approximately 44.9% received treatment. Despite these interventions, a higher rate of PTD and lower weight gain was noted in those with an elevated EDS. Further studies are needed to determine the best intervention and its effect on perinatal outcomes.