bluuebunny/crossref_metadata_2025 huggingface dataset:
Oral Methergine: It’s Not Just for Postpartum Hemorrhage [30H]
Authors: Krychman Michael
Published: April 2018

INTRODUCTION:

Abnormal vaginal bleeding has a direct impact on a woman’s quality of life; anemia, fatigue, loss of time from work and the impact on marital relations, and social obligations are a few of the common adverse effects. Methergine® is widely accepted as a front-line medication treatment for primary and secondary post-partum hemorrhage (PPH) and for the treatment of bleeding after first trimester loss. Methergine is commonly used more broadly for bleeding not only associated with pregnancy, delivery, or pregnancy loss or fetal demise, but in a variety of other medical situations most likely to prevent excessive bleeding and the associated symptomatology associated with anemia.

METHODS:

A retrospective review of Humana Claims data base 1/1/2007- 9/30/2016 and ICD-9 codes cross referenced with Methergine® and diagnosis code was conducted.

RESULTS:

The Humana Claims data base consisted of 22.4 million claims (treatment, medical or laboratory). We found 10,952 claims which had used Methergine® as part of their treatment paradigm. 71% (7,796/10,952) were associated with primary or secondary PPH, and 29%(3,156/10,952) were non-Post-Partum Hemorrhage and non-first trimester loss use for hemorrhage prevention or excessive bleeding. The alternative ICD-9 diagnoses that were associated with Methergine® included menstruation, infection, and painful menses/dysmenorrhea.

CONCLUSION:

Methergine® is utilized in the obstetrical bleeding paradigm, given its mechanism of action, efficacy and safety profile. It is commonly prescribed in scenarios of hemorrhage or first trimester loss however up to one third of use may be for other indications. Future research is warranted to further confirm the efficacy and safety in non-obstetrical situations.
Does Time of Wound Complication Differ by Skin Closure after Cesarean Delivery? [34H]
Authors: Cooper Shontreal , Blanchard Christina , Szychowski Jeffrey , Tita Alan
Published: April 2018

INTRODUCTION:

A high proportion of post-cesarean wound complications occur after hospital discharge. We undertook this study to evaluate the association between skin closure methods following a cesarean delivery and wound complications occurring after hospital discharge.

METHODS:

This is a secondary analysis of data from a randomized trial in which women at 24 weeks’ gestation or greater undergoing cesarean were randomized to receive metallic staples or subcuticular suture for skin closure. Staples were removed at time of hospital discharge on post-op days 3-4 for Pfannenstiel incisions or days 7-10 for vertical. The primary outcome for the current analysis was any wound complication occurring after hospital discharge. Associations were examined with chi-square and Fisher exact tests.

RESULTS:

A total of 350 patients with follow-up through 4-6 weeks postpartum were included in the analysis: n=171 received suture closure and n = 179 received staples. Baseline characteristics including BMI and ethnicity were similar between closure groups. In the primary study wound complications occurred in 14.5% (n=26) of individuals with staples and 5.9% (n=10) with sutures, p=0.008. Approximately 50% of all wound complications occurred post-hospital discharge. The incidence of wound complications occurring post-hospital discharge was 6.7% (n=12) of patients receiving staples and 5.3% (n=9) of those receiving sutures; p=0.57. The RR (95% CI) of the wound complication after hospital discharge for sutures (relative to staples) was 1.3 (0.6-2.9).

CONCLUSION:

Although suture closure compared to staples is associated with fewer wound complications after cesarean delivery, we found no significant differences in the frequency of wound complications occurring after hospital discharge.
Standard vs Customized Post-Cesarean Opioid Prescription: A Randomized Controlled Trial to Reduce Unused Opioids [39H]
Authors: Osmundson Sarah , Lam LeAnn , Kook Bradley , Raymond Britany , Thompson Elizabeth , Richardson Michael
Published: April 2018

INTRODUCTION:

Most women have unused opioids after cesarean, a source of opioid misuse and diversion. This study examined whether customized prescribing can reduce unused opioids after cesarean.

METHODS:

Between 6/14/2017 and 8/25/2017, all English- and Spanish-speaking women >18 years undergoing a cesarean were considered for eligibility. Women with complicated cesarean or chronic opioid use were excluded. Eligible women were approached postoperative day 1 and informed consent was obtained. Enrolled women were randomized to standard post-discharge opioid prescription (30 tablets of 5mg oxycodone) or customized prescription (formula derived from a prior study, and based on inpatient opioid use). Subjects were contacted on postoperative day 14 to assess opioid tablets used and pain. The Tennessee Controlled Substance Monitoring Database was accessed to confirm dispensed opioids. The primary outcome was unused opioid tablets.

RESULTS:

Of 323 cesarean deliveries, 34 declined participation and 99 were excluded, leaving 190 (84%) for randomization. Of 172 in final analysis (18, 9.5% lost to follow-up), the proportions reporting unused opioids were 65/87 (74.7%) in customized group, 60/85 (70.6%) in standard group (p=0.74). The customized prescription group received half the opioid tablets (14 [IQR 12-16]) compared to standard group (30), used less opioids (8 [IQR 4-14] vs 15 [IQR 6-30], p<0.001), and had less unused (5 [IQR 1-8] vs 10 [IQR 0-22], p<0.001) tablets. Reported pain outcomes and analgesic satisfaction with analgesia were not statistically significant.

CONCLUSION:

Customized opioid prescribing was associated with reduced opioid use and fewer unused opioids after cesarean, without affecting pain management.
Parental Views on Fetal Intervention in Down's Syndrome [1I]
Authors: Allyse Megan A.
Published: April 2018

INTRODUCTION:

Clinical trials for fetal surgery and gene therapy interventions in fetuses identified as having trisomy 21 (Down syndrome) have shown increasing success in human and animal models. These interventions vary from physical intercessions, such as cardiac repairs, to attempts at cognitive improvement, including retention and learning ability. However, these interventions have been controversial among family members and individuals living with Down syndrome. In particular, community members have argued that attempts to intervene in the natural progression of Down syndrome contravene efforts to encourage acceptance and support of individuals with Down syndrome.

METHODS:

We conducted a nation-wide, online survey of parents of individuals with Down syndrome about their opinions and willingness to accept prenatal interventions in pregnancies with Down syndrome.

RESULTS:

Parents were sharply divided on the acceptability of fetal interventions in pregnancies with Down syndrome. Parents expressed conflicts between the desire to give children every possible opportunity and the need and willingness to accept their children as they were and as complete individuals in their own right. A significant percentage reported that they would refuse prenatal gene therapy for potential cognitive intervention in pregnancies with Down syndrome.

CONCLUSION:

Significant investment is ongoing in the detection of and intervention in pregnancies affected by aneuploidies such as Down syndrome. This study emphasizes the need to include broader stakeholder populations, including families of existing individuals, in the development and translation of such therapies. Significant rejection from patient advocate populations may result from a lack of engagement.
Malpractice Risk and Vulnerabilities Ambulatory Obstetrics and Gynecology Practice [6I]
Authors: Pomerleau Mimi , Greenberg Penny , Baecher-Lind Laura
Published: April 2018

INTRODUCTION:

Malpractice claims may play an important role in the high cost of health care and may provide a lens through which patient’s perspectives of healthcare deficiencies are revealed. Learning from potential mistakes - or from the patient’s perception of harm - can help to identify areas for improvement in patient care.

METHODS:

This is a retrospective cohort study of claims from the CRICO Strategies National Comparative Benchmarking System (CBS) for malpractice cases asserted during the period 2006 and 2016. Cases selected for this analysis were open and closed malpractice claims and lawsuits from obstetric outpatient claims. Cases meeting selection criteria were qualitatively analyzed to determine contributing factors prompting harm and/or perceived harm.

RESULTS:

Of the 113,932 malpractice claims during this ten year period, 2,730 were obstetric-related, 548 originated within the outpatient setting, and 296 were associated with severe patient harm and/or death. Of these 296 claims, the top 5 contributing factors leading to the filing of the claim were perceived lapse of clinical judgment (45%), ineffective communication (25%), poor documentation (14%), clinician behavior related (11%), and clinical systems breakdown (11%).

CONCLUSION:

This review provides insight into vulnerabilities within the outpatient obstetrics setting and identifies areas for improvement. To provide safe and effective care, clinicians and administrators need to understand malpractice vulnerabilities and develop strategies to reduce risk. Our data suggests that the development of training or tools to support clinical decision making, communication strategies, and appropriate documentation are priority areas to reduce malpractice risk in the outpatient obstetrics setting.
Epidemiology of Hepatitis C in Pregnancy in North Central Florida: A Reassessment of Risks [10I]
Authors: McDilda Katelin , Egerman Robert , Gabrilovich Sofia , Lipori Gigi , Spiryda Lisa Beth
Published: April 2018

INTRODUCTION:

Hepatitis C virus (HCV) affects 1% - 2.5% of pregnancies. Universal screening is not recommended aside from those with risk factors including among others: intravenous or intranasal drug use, incarceration or those having a sexually transmitted infection. Our purpose was to assess the epidemiology of HCV in North Central Florida.

METHODS:

IRB approval was obtained for this retrospective descriptive study. Patients were identified through ICD-9 Diagnosis codes for HCV and pregnancy from 2009-2014. Data abstracted from medical records included demographic information, concomitant sexually transmitted infections, tobacco or substance abuse, transfusion history and tattoos.

RESULTS:

Of 17,081 patients, 275 patients were identified with HCV (prevalence 1.6%). Mean age of those infected was 27.3 years old (range 16 to 49) with 89.1% Caucasian and 7.3% African American. Concomitant infections with Hepatitis B, HIV, chlamydia and herpes simplex occurred in 9%, 0.7%, 16% and 12% of patients, respectively. Most HCV patients smoked tobacco (89%); one third smoked cannabis (34%). A history of intravenous drug use was present in 75% and cocaine use in 37.5%. Although not a classical risk factor for HCV, prescription narcotic use was reported among 2/3 patients whereas 44% took non-prescribed narcotics. A minority of women had exposure to either tattoos 28.5% or blood transfusion 15%.

CONCLUSION:

We identified prescribed and self-administered oral narcotic medication and tobacco use as additional risks for HCV. We suspect adhering to the current screening recommendations permits cases of HCV to be missed and that more widespread if not universal screening should be considered.
Outcomes Associated With Influenza-Like Illness in the Peripartum Period [14I]
Authors: Emeruwa Ukachi N. , Nour Nawal M. , Diouf Khady
Published: April 2018

INTRODUCTION:

Influenza-like illness (ILI) is defined as fever + cough +/- sore throat. Among women who present with these symptoms, influenza is in the differential diagnosis. This study spans 5 years following the 2009 H1N1 epidemic and aims to investigate characteristics of peripartum women with ILI, to identify risk factors for severe disease and to identify influenza-related maternal and neonatal complications.

METHODS:

Using microbiology data from Brigham and Women’s Hospital between 2012 and 2016, a retrospective analysis was done among peripartum women with influenza tests available.

RESULTS:

One hundred and twenty nine women were tested. Fourteen percent (14.0%) had a positive influenza test, of whom 10 (55.6%) had received an influenza vaccine during pregnancy. Rates of antiviral treatment were higher in women with positive tests (88.9% vs 12.6%, P<.05).

Sixty five women (50.3%) were hospitalized for non-obstetric (pneumonia and asthma exacerbation) and obstetric complications. Nine (13.8%) were admitted to the ICU. The odds of an ICU admission were higher for women who were immunosuppressed (OR 2.3, 95% CI 1.1-4.8). Women with positive tests were more likely to have respiratory failure (11.1% vs 0.9%, P=.051).

CONCLUSION:

A small proportion of women presenting with ILI had laboratory-confirmed influenza. This may reflect the poor sensitivity of the test or another viral or bacterial illness. The low rate of influenza immunization during pregnancy highlights the need for further education of providers and patients. Maternal outcomes can be improved by having a high index of suspicion and promptly treating women with ILI.
Pregnant Women’s History of Vaccination and Acceptance of Hypothetical Zika Vaccine [15I]
Authors: Alholm Zachary , Zwick Ryan , Ault Kevin , Fitzgerald Sharon , Satterwhite Catherine
Published: April 2018

INTRODUCTION:

Promising Zika vaccines are currently in clinical trials. To prepare for public availability, the acceptability of a hypothetical Zika vaccine among pregnant women was assessed.

METHODS:

A short Likert-scale survey was administered to 100 pregnant women receiving routine prenatal care at the University of Kansas Medical Center from 07/07/2016 to 9/29/2016. Hypothetical vaccine acceptability was evaluated by calculating the proportion of respondents who strongly agreed with the statement “If a vaccine for Zika virus was available, I would get this vaccine while pregnant.”

RESULTS:

Of 100 patients surveyed, 48% expressed strong agreement to getting a hypothetical Zika vaccine while pregnant. Women indicating strong vaccine acceptance were more likely than women not indicating strong vaccine acceptance to feel strongly about the importance of a recommendation from their prenatal provider (98% vs 63%, p<0.01), the importance of children being up to date on all their vaccinations (97% vs. 83%, p=0.01) and the importance of getting recommended vaccinations during her pregnancy (97% v. 79%, p=0.03). Data suggested that women who had received vaccines during pregnancy were more likely to be strongly interested in a hypothetical Zika vaccine (Tdap vs no Tdap: 51% vs 22%, p=0.08; influenza vaccine vs. no influenza vaccine: 55% vs 36%, p=0.07).

CONCLUSION:

A Zika vaccine may be acceptable to pregnant women but would benefit from strong provider support and education about the risks and consequences of Zika infection and the benefits of vaccination.
Incidence of Syphilis Among Women Hospitalized for Delivery in the United States, 2005-2014 [16I]
Authors: Rowe Meghan E. , Admon Lindsay K. , Dalton Vanessa K.
Published: April 2018

INTRODUCTION:

Rising rates of congenital syphilis have captured national attention. Data on the incidence and distribution of syphilis among childbearing women are needed to inform prevention strategies. Our objective was to estimate trends in the incidence and regional distribution of syphilis among women hospitalized for obstetric delivery in the United States.

METHODS:

We performed a retrospective, serial cross-sectional analysis of all obstetric deliveries in the National Inpatient Sample between 2005 and 2014. National estimates were generated using multivariable logistic regression with predictive margins. Subgroup analyses were performed to estimate trends by rural vs. urban residence and hospital census region.

RESULTS:

8,193,707 hospital deliveries were identified. 2,386 deliveries were complicated by maternal syphilis, estimating 10,900 cases nationally. Compared to all other hospital births, higher proportions of women with syphilis were on Medicaid [74.3% (95% CI 71.4-77.0) vs. 43.6% (95% CI 42.5-44.7)], lived in urban counties [91.8% (95% CI 90.1-93.3) vs. 85.4% (95% CI 84.7-86.1)], and lived in the South [59.4% (95% CI 54.3-64.3) vs. 37.9% (95% CI 36.1-39.8)]. The incidence of syphilis diagnoses did not statistically increase over the study period when examining all deliveries: 2.6 (95% CI 2.1-3.2) per 10,000 in 2005-06 compared to 3.4 (05% CI 3.0-3.8) per 10,000 in 2013-14. Incidence did increase among urban women delivering in Midwest: 1.4 (95% CI 0.82-2.0) per 10,000 deliveries in 2005-06 to 3.5 (2.6-4.4) per 10,000 deliveries in 2013-14. No other time-trends were significant.

CONCLUSION:

The incidence of syphilis increased among urban women delivering in the Midwest between 2004-05 and 2013-14.
Individual Knowledge, Attitudes, and Practices Regarding Zika Virus During Pregnancy in Miami [19I]
Authors: Chandrasekaran Neeraja , Marotta Mabel , Taldone Sabrina , Singh Vivek , Koru-Sengul Tulay , Curry Christine
Published: April 2018

INTRODUCTION:

On July 2016, the first case of United States based Zika virus infection was identified in Miami, FL. Till date, there are no studies assessing knowledge and behaviors of Zika virus in Miami, FL. In this study, we aimed to assess knowledge, attitudes, and practices of Zika virus amongst pregnant women residing in Miami, FL.

METHODS:

A cross-sectional design was utilized for this study and a survey was distributed to the antenatal clinics at University of Miami to pregnant women. Completed surveys were entered onto Redcap and analyzed using SAS studio (SAS Institute Inc. Cary, NC, USA). Pearson's chi-square or Fisher's exact test were used to compare categorical variables and multivariate logistic regression was utilized to adjust for confounding variables.

RESULTS:

A total of 224 women were surveyed from January 2017-May 2017. Seventy-five percent of women answered questions about Zika virus transmission, prevention, and vulnerable population. On prevention, 61.4% of wore long-sleeved clothing, 87.8% used mosquito repellant, and 54.9% used condoms during intercourse. On multivariate regression, employment was associated with answering six knowledge questions correctly. First trimester was associated with wearing long-sleeved clothing [OR:2.538(1.260-5.114), p=0.0091] and perception of changed behavior due to Zika virus [2.458(1.128-5.356), p=0.0236].

CONCLUSION:

Knowledge, attitudes, and practices regarding Zika virus amongst pregnant women residing in Miami are adequate. The role of employment and workplace environment in promoting health education on Zika virus should be further evaluated.
Identifying Characteristics of Antenatal 3-Hour GTT as Markers for Abnormal Postpartum Glucose Tolerance [20I]
Authors: Mikell Chelsea J. , Pollack Rebecca , Zhao Jing , Andrews Mary
Published: April 2018

INTRODUCTION:

GDM is diagnosed on the basis of blood glucose levels that exceed specific glycemic thresholds. We sought to identify characteristics of antenatal glucose testing that may serve as markers for abnormal postpartum testing.

METHODS:

IRB approved retrospective cohort study. A database was created from all women who underwent a postpartum 2-hour oral glucose tolerance test at the Carolinas Medical Center Diabetes Clinic in Charlotte, NC between 2012-2015. Inclusion criteria: singleton pregnancy, diagnosis of GDM, postpartum GTT completed 4-12 weeks post-partum. GDM was diagnosed by at least 2 elevated values on a completed 3-hour glucose tolerance test (Carpenter-Coustan). Data was indexed using two methods: clinical groups and by number of abnormal values. Four groups were defined: Group A; abnormal fasting value. Group B; all values < 200mg/dl. Group C; Any value ≥200mg/dl. Group D; Both an elevated fasting AND any value ≥200mg/dl. Patients were also grouped according to the number of abnormal values on 3h GTT; either 2, 3 or 4 abnormal values. Chi-square or Mantel-Haenszel tests were used for categorical variables. T-tests and generalized linear models were used for continuous variables. Poisson regression models were used to calculate relative risks (RR) and 95% confidence intervals.

RESULTS:

407 patients met study criteria. 57% were diagnosed with abnormal 2-hour postpartum glucose tolerance (PGT). Groups A, C, and D had a greater RR of abnormal 2-hour PGT compared to Group B. Four abnormal values on 3-hour antenatal GTT compared with two abnormal values was associated with a higher risk of abnormal PGT. These results are not statistically significant.

CONCLUSION:

No statistically significant markers for abnormal PGT identified from the antenatal 3-hour GTT. The population in our study represents patients compliant with post-partum glucose tolerance testing. Our results may have been affected because patients with poor control of GDM are less likely to be compliant with postpartum glucose tolerance testing.
Hypertensive Disorders in Pregnancy and Gestational Diabetes: Does Weight Gained in Pregnancy Matter? [29I]
Authors: Reed Christina C. , Longo Monica , Chiossi Giuseppe , Landgren Rachel , Chauhan Suneet , Huff Cristina Wallace
Published: April 2018

INTRODUCTION:

The Institute of Medicine (IOM) released guidelines to optimize weight gain in pregnancy and prevent adverse outcomes. Our aim was to assess the role of pre-pregnancy BMI and maternal weight gain (MWG) as risk factors for hypertensive disorders (gestational hypertension or preeclampsia) and gestational diabetes (GDM).

METHODS:

A retrospective study reviewed weight gain during pregnancy including: women ages 18-45, singleton, prenatal care <20 weeks, no fetal anomalies, BMI ≥18.5, pre-pregnancy BMI and maternal weight at delivery. A multivariate logistic regression was used to determine the odds ratio (OR) of a composite maternal outcome (CMO) of hypertensive disorders and GDM, according to patient’s pre-pregnancy BMI (≥30 vs <30) and MWG (≥ vs < IOM recommendations per BMI category/trimester).

RESULTS:

Of the 494 women that met the inclusion criteria, 36% were obese and more than 50% had excessive weight gain in the 2nd and 3rd trimester. CMO was present in 22% of the study population. Obese women were more likely to develop the adverse CMO compared to normal/overweight women (p<0.01), and to deliver earlier (37.8±3 vs 38.3±2 weeks, p<0.02). Obese patients followed the IOM recommendations for MWG in the third trimester (100/176 vs 158/318, p=0.047). Multivariate logistic regression showed that obesity at entry to care, not trimester specific MWG, is associated with the composite outcome (aOR 2.0 with 95% CI 1.2-3.5; p<0.01).

CONCLUSION:

Pre-pregnancy BMI, more than MWG per trimester, significantly contributes to the onset of hypertensive disorders and GDM in pregnancy. Preconception counseling should focus on weight optimization before conception to improve maternal outcome.
Compliance with Timing Recommendations for Medically Indicated Deliveries and the Impact on Pregnancy Outcomes [32I]
Authors: Bicocca Matthew J. , Racusin Diana , England Joey , Ankumah Nana-Ama , Blackwell Sean C. , Refuerzo Jerrie S.
Published: April 2018

INTRODUCTION:

The objective of this study was to determine compliance with ACOG recommendations for timing of medically indicated deliveries (MID) and the impact on pregnancy outcomes for high risk pregnancies.

METHODS:

A retrospective cohort study was conducted including pregnant women greater than 32 weeks gestation in an academic-affiliated, Maternal Fetal Medicine private practice who were scheduled for a MID. Women were divided between those who delivered prior to their scheduled MID and those who made it to their scheduled time of delivery. Outcomes were compared between groups including maternal, delivery and neonatal outcomes using chi-square and Mann Whitney U test.

RESULTS:

Of 204 pregnancies scheduled for a MID, 94.6% (N=193) were compliant with ACOG recommendations. Non-MID occurred for primarily neurologic or malignancy indications. Seventy-seven (38%) delivered prior to their scheduled delivery date. The most frequent indications included labor (31.2%), preeclampsia (26.0%), gestational hypertension (24.7%) and multiple gestation (15.6%). These women had significantly earlier gestational age at delivery (35.4 vs 37.6 weeks; p = 0.0001), higher primary cesarean delivery rate (40.3 % vs. 20.5%; p =0.002), higher rate of NICU admission (53.2% vs 23.6%; p = 0.0001), and greater NICU days (11.4 vs. 1.9; p = 0.0001). No differences in maternal age, parity, race, or BMI were noted between groups.

CONCLUSION:

Compliance with ACOG guidelines for MID were achieved in 9 out of 10 high risk pregnancies. Deliveries prior to the scheduled date were due to labor, hypertensive disorders, and multiple gestation, and associated with late preterm birth, higher cesarean rate and NICU stay.
What Happens after a Failed External Cephalic Version? [36I]
Authors: Katukuri Vivek R. , Andrews Suzanne , Leeman Lawrence , Yonke Nicole
Published: April 2018

INTRODUCTION:

To compare perinatal outcomes following a failed external cephalic version (ECV) to a successful ECV and a planned cesarean delivery

METHODS:

This was a retrospective cohort study from January 2012 to June 2015. We included singleton, nonanamolous live births delivered after 36 weeks. We performed a comparison of perinatal outcomes between women who had an unsuccessful ECV, a successful ECV and a planned cesarean delivery. The primary outcome was a composite of neonatal outcomes, which included APGAR <7 at 5 minutes, NICU or intermediate care nursery admission, need for respiratory support and hypoglycemia. A secondary outcome was final mode of delivery among women attempting ECV.

RESULTS:

We identified 236 pregnancies meeting inclusion criteria, 126 (53.3%) of which attempted ECV with 110 (46.7%) undergoing planned cesarean delivery. The success rate of external cephalic version (ECV) was 50.7% (n=64). Among women who had successful ECV, the rate of cesarean section was 25% (n=16). Among women with failed ECV, the rate of the primary outcome was 6.8% (n=4), versus 12.9% (n=7) in the successful group and 10.9% (n=12) in the planned cesarean group (p=0.59). There was no difference in the rates of Apgar score <7 at 5 minutes, NICU or intermediate care nursery admission, need for respiratory support or hypoglycemia.

CONCLUSION:

ECV was not associated with an absolute risk increase in the primary composite outcome compared to planned cesarean for fetal malpresentation. This evidence provides support for ECV as a safe alternative for women with fetal malpresentation who desire a vaginal delivery regardless of outcome.
Coccidioidomycosis in Pregnancy: A Retrospective Review [7J]
Authors: Hermann Catherine , Lee Annie , Gray Kendra , Huls Christopher Kevin
Published: April 2018

INTRODUCTION:

Coccidioides is a fungus endemic to the southwestern United States. While uncommon during pregnancy, it is associated with disseminated disease and has historically carried an almost universal fatality rate in pregnant women. There has been little research to guide proper treatment during pregnancy. This retrospective review set out to assess cases of coccidioidomycosis at Banner University Medical Center-Phoenix to determine outcomes and success of managing these patients.

METHODS:

Charts were compiled for review based on inclusion criteria of coccidiomycosis diagnosed prior to or during pregnancy. 23 subjects met criteria and were enrolled. Primary outcome measure was maternal mortality. Secondary outcome measures included rates of maternal intensive care unit admission, maternal disseminated disease, neonatal intensive care unit admission, preterm delivery, disease transmission to neonates, birth defects, maternal drug toxicity secondary to treatment of coccidioidomycosis, evidence of placental or uterine pathology, and length of hospital stay.

RESULTS:

Descriptive statistics were used to analyze the data. None of the 23 subjects died as a result of coccidioidomycosis in pregnancy. The rate of maternal disseminated disease was 17.39%, and there was a 56.25% rate of maternal drug toxicity. Median and mean lengths of hospital stays were 7.5 days and 8.9 days, respectively.

CONCLUSION:

The results of this study suggest that coccidiomycosis in pregnancy continues to be rare and no longer carries the death sentence it once did despite high rates of maternal disseminated disease. However, maternal toxicity associated with treatment is high, and indicates a need for further study into prevention and management of these side effects.
The Effect of Planned Mode of Delivery in Morbidly Obese Women [29J]
Authors: Nicholls-Dempsey Laura , Czuzoj-Shulman Nicholas , Abenhaim Haim Arie
Published: April 2018

INTRODUCTION:

Morbidly obese women have a higher risk of experiencing adverse pregnancy outcomes. The aim of this study is to determine which planned mode of delivery, elective cesarean section versus vaginal delivery, presents better maternal outcomes in morbidly obese women.

METHODS:

We conducted a population-based, retrospective cohort study using the United States' Health Care Cost and Utilization Project's Nationwide Inpatient Sample to evaluate maternal outcomes in morbidly obese women without comorbidities delivering between 2000 and 2014. Multivariate logistic regression was used to compare outcomes in morbidly obese women according to mode of delivery.

RESULTS:

We identified a total of 77,666 deliveries in otherwise healthy morbidly obese women. The planned cesarean group comprised 13.4% of the cohort. When compared to women in the planned vaginal group, the planned cesarean group was at higher risk for transfusion (OR 1.48 [95% CI 1.23–1.77]), chorioamnionitis (OR 1.61 [1.44–1.81]) and major puerperal infection (OR 1.28 [1.05–1.56]). Women in the planned cesarean group had a lower risk of postpartum cardiomyopathy (OR 0.07 [0.02–0.22]), amniotic fluid embolism (OR 0.08 [0.02–0.31]), deep vein thromboembolism (OR 0.25 [0.08–0.79]), sepsis (OR 0.18 [0.07–0.44]) and wound dehiscence (OR 0.36 [0.23–0.59]). These reduced risks in the latter are partly due to the high rate of cesarean among planned vaginal deliveries in which morbidities appeared highest.

CONCLUSION:

Emergency cesarean section presents higher risks compared to planned cesarean section. Given that many planning a vaginal delivery will undergo emergency cesarean section, morbidly obese women should be informed of the high rate of failed vaginal delivery and subsequent risks.
Comparison of Management Options for Twin Pregnancies Affected by Midtrimester Incidental Cervical Shortening [30J]
Authors: Qureshey Emma , Quinones Joanne , Sarno Albert , Rust Orion
Published: April 2018

INTRODUCTION:

Prematurity is the leading cause of neonatal death and twin gestations account for 25% of preterm deliveries. Cervical shortening is a risk factor for preterm delivery. The purpose of our study is to evaluate strategies to prevent spontaneous preterm birth in twins with a short cervix by transvaginal sonogram.

METHODS:

Retrospective cohort study comparing expectant management, vaginal progesterone and cerclage in the management of cervical shortening (<2.5 cm) in twins. Information regarding baseline characteristics and pregnancy outcomes were obtained. Comparisons were made using Student t-test for continuous variables and χ2 analysis or Fisher exact test for categorical variables.

RESULTS:

Between January 2006 and July 2016, 93 pairs of twin gestations with cervical shortening were identified. Strategies included expectant management (n=41, 44.1%), cerclage (n=30, 32.3%) and vaginal progesterone (n=22, 23.7%). Demographic characteristics were similar between groups. A trend was observed towards a shorter cervical length in cerclage group (1.67 cm expectant management, 1.31 cm cerclage and 1.77 cm vaginal progesterone, P=.06). Delivery information was available for 73 patients. Gestational age at delivery was similar between groups (31.7 weeks +- 4.6 in expectant management, 30.6 weeks +- 4.9 in cerclage and 32.5 weeks +- 3.9 in vaginal progesterone, P=.39). Rate of chorioamnionitis was also similar.

CONCLUSION:

Our data suggest that the gestational age at delivery of twin gestations with cervical shortening is not impacted by management strategy. There was no benefit to cerclage placement in preventing preterm birth. Large randomized studies comparing expectant management, vaginal progesterone and cervical cerclage are essential before altering clinical practice.
Evaluation of Fetal Movement Tracking Mobile Applications Using an Adapted APPLICATIONS Scoring System [31J]
Authors: Cowles Steven , Weise Fleckenstein Maria Daniela , Quiner Trevor E.
Published: April 2018

INTRODUCTION:

Fetal movement tracking is commonly encouraged by clinicians as a means of antenatal surveillance. We sought to identify the most comprehensive and top-rated mobile applications for fetal movement tracking that are available for patient and research use.

METHODS:

Application distribution platforms were searched systematically and a list of fetal movement tracking applications was created. Comprehensiveness was by inclusion of: guidelines from professional societies, real-time tracking functions, mechanisms for manual entry of data, and the ability to monitor trends, the ability to export data. We used a modified APPLICATIONS scoring system to evaluate the comprehensiveness, accessibility, and functionality of qualifying applications.

RESULTS:

A total of 104 individual fetal movement tracking applications were identified on the Google Play Store and the Apple App Store. Of these, twenty-six were identified as being available on both operating systems. Seven applications were eliminated for not being free or for being associated with a specific healthcare center. Of the remaining applications, no application received a perfect score on the APPLICATIONS scale and there was significant heterogeneity in the completeness of each application. Comprehensive pregnancy tracker applications were more likely to be complete than stand-alone fetal movement tracking applications.

CONCLUSION:

Identification of the most comprehensive and user-friendly mobile applications for tracking fetal movement could allow for greater patient compliance and the ability to perform more comprehensive research in the potential benefits of fetal movement monitoring.
Prenatal DHA Supplementation and Pregnancy Outcomes in Women With Diabetes [39J]
Authors: Fowose Mobolaji , Hamilton Owen J. C. , Colditz Graham , Tuuli Methodius G. , Carter Ebony B.
Published: April 2018

INTRODUCTION:

Docosahexaenoic acid (DHA) supplementation may improve pregnancy outcomes, but its role in patients with diabetes is unclear. The object of this study was to determine the association between DHA and pregnancy outcomes in women with diabetes.

METHODS:

We performed a retrospective cohort study of pregnant women with type 1, type 2 and gestational diabetes who delivered at Barnes-Jewish Hospital from 2012 to 2016. Women prescribed prenatal vitamins (PNV) with DHA were compared to those prescribed PNV without DHA. The primary outcome was hypertensive disorders of pregnancy. Secondary outcomes included preterm birth (PTB), neonatal hyperbilirubinemia and postpartum depression. Outcomes were compared between women who used PNV with and without DHA. Logistic regression was used to control for potential confounders.

RESULTS:

Of 298 women in the cohort, 30 (10.1%) took a PNV with DHA. DHA use was significantly lower among women who were obese, African American, Latina, and had medical co-morbidities and was higher in those with a history of PTB. Women taking a PNV with DHA were less likely to develop hypertensive disorders of pregnancy after adjusting for obesity, race, medical comorbidities, and history of PTB (20.0% versus 50.0%, aOR 0.29; 95% CI 0.10–0.84). There was no significant difference in neonatal hyperbilirubinemia, PTB and postpartum depression.

CONCLUSION:

PNV supplementation with DHA is associated with a reduced risk of hypertensive disorders of pregnancy in a high-risk cohort of women with diabetes. Larger prospective studies are needed to determine the impact of DHA on maternal and neonatal outcomes in women with diabetes.
Patterns and Correlates of Cervical Cancer Screening Initiation in a Large Integrated Healthcare System [1K]
Authors: Becerra-Culqui Tracy A. , Lonky Neal M. , Chen Qiaoling , Chao Chun R.
Published: April 2018

INTRODUCTION:

The cervical cancer incidence rate has not declined among 24–25 year-olds between 2000 (2.79 per 100,000) and 2013 (2.93 per 100,000). We studied cervical cancer screening initiation in young women and how woman and provider factors affect the timing of screening initiation to effect prevention. We examined patterns and correlates of cervical cancer screening initiation among women turning age 21 in a large community-based practice.

METHODS:

Female members who turned age 21 (baseline) during 2013–2015 and had not previously received Papanicolaou (Pap) test were evaluated during 2016 using electronic health records. Incidence rate and cumulative incidence of screening initiation was calculated. Associations between patient and provider characteristics and screening initiation were evaluated using multivariable Cox models.

RESULTS:

Of 38,257 women studied, the Pap screening initiation rate was 44 per 100 person-year(s). Approximately 40% initiated screening within 1 year after turning age 21. I Asian/Pacific Islanders, Medicaid enrollees, those whose primary language is not English, those with a recent inpatient visit, those with a primary care physician (PCP) in specialties other than family practice, and those cared for by a male rather than female PCP less often initiated screening. History of Human Papilloma virus and flu vaccination, a history of pregnancy, contraception use, and sexually transmitted infections had more timely screening initiation.

CONCLUSION:

Less than half of the women insured for preventative services initiated screening at age 21. Strategies to improve adherence to screening initiation guidelines should consider a tailored approach for at risk subgroups and addressing initiation challenges associated with male physicians.
Impact of Physician Gender Selection on Patient's Perceptions of Experience With Women's Health [9K]
Authors: Turrentine Mark , Ramirez Mildred , Stark L. M. , Snead Carrie , Schulkin Jay
Published: April 2018

INTRODUCTION:

To evaluate women's attitudes about the role of obstetrician-gynecologists (ob-gyn) gender selection and their perceptions of knowledge, experience, and understanding with women's health.

METHODS:

Two large private practice ob-gyn groups anonymously surveyed patients at scheduled office visits to explore the role of gender in the selection of their ob-gyn and their perceptions of the physician's knowledge, experience, and understanding with women's health. The Mann-Whitney U test was utilized for comparisons.

RESULTS:

In 2017, 996 patients were surveyed with 803 returned (81% response rate). Women who saw a female physician were more likely to be younger (36 versus 39 years) and married (88% versus 82%) than women seen by a male. Women who saw female ob-gyns (compared to those that saw a male) reported that the gender of their physician was important to them (62% versus 20%, P<.01). Women who saw a female ob-gyn perceived their physicians have a greater knowledge (27% versus 3%, P<.01), experience (51% versus 14%, P<.01), and understanding (54% versus 8%, P<.01) with women's health in comparison to women who choose a male. The top three rank-order reasons women choose a female ob-gyn were physician ratings, gender, and office location. In contrast, the reason women choose a male ob-gyn were physician ratings, availability, and office location.

CONCLUSION:

Women who seek a female ob-gyn feel strongly about the gender and have perceptions their physicians are more knowledgeable, experienced, and understanding about women's health compared to a male ob-gyn.
The Risk of Cesarean Delivery as Related to Maternal Height and Race [16K]
Authors: Skeith Ashley E. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

We sought to determine differences in the rate of cesarean delivery associated with maternal height as related to race.

METHODS:

We conducted a retrospective cohort study of 9,208,030 women with singleton, non-anomalous, vertex, term gestations from 2012 to 2014 and examined rates of cesarean delivery based on maternal height and race. Maternal height was divided into 2-inch increments and race was classified as Asian, Hispanic, White, or Black. Results were stratified by parity and history of previous cesarean delivery. Chi-square tests were employed for statistical comparisons and a P-value of less than 0.05 was used to indicate statistical significance.

RESULTS:

Overall, we found that maternal height is inversely related to risk of cesarean delivery, regardless of race. The overall odds ratio of cesarean delivery as related to increasing maternal height is 0.93 (95% confidence interval [CI], 0.9309–0.9321). When stratified by race, our results showed that height is most protective for Asians (OR 0.91, 95% CI 0.909–0.918) and least protective for Hispanics (OR 0.95, 95% CI 0.946–0.949), indicating that for every 2-inch increase in maternal height, there is a 9% reduction in risk of cesarean delivery in Asian women, but only a 5% reduction in risk for Hispanic women.

CONCLUSION:

Maternal height modifies the risk of cesarean delivery, which varies based on race. Though stature as related to race has not typically been included in prenatal counseling for women, it may be reasonable to alter counseling based on these patient characteristics.
The Decision to Admit for Threatened Preterm Birth [25K]
Authors: Fisher Lytia , Lewis Dawnette , Waldron Carolyn , Pan Stephanie
Published: April 2018

INTRODUCTION:

Preterm labor (PTL) is the most common reason for antepartum hospital admission, yet only 10% of those presenting will deliver within 7 days, while 30% resolve spontaneously. The American College of Obstetricians and Gynecologists (ACOG) defines PTL as regular uterine contractions with change in cervical dilation and/or effacement, or regular contractions with cervical dilation of at least 2 cm. We hypothesized that the majority of patients admitted for PTL do not meet ACOG criteria and have lower prevalence of preterm birth.

METHODS:

This IRB-approved, retrospective chart review included all PTL admissions of singleton pregnancies less than 37 weeks gestation at Mount Sinai West from October 1, 2012 to October 1, 2016, excluding those with membrane rupture, pre-eclampsia, or abruption. Statistics included χ2, Student t-test, and multivariable logistic regression.

RESULTS:

PTL admissions (n=179) were divided into those that met ACOG criteria on first admission (n=73) and those that did not (n=106). Patients who did not meet ACOG criteria had a much lower prevalence of preterm birth than those who did (40/92 [41.2%] versus 55/67 [82.1%]; P<.001), and the ACOG group was more likely to deliver on first admission (53/71 [74.7%] versus 19/104 [18.3%]; P<.001). Demographics were comparable between groups, except median gestational age at admission was higher for the ACOG group (35.1 [33.1–36.3] versus 30.77 [28.7–33.6]; P<.001). Adjusting for gestational age at admission, the association between meeting ACOG criteria and delivering on initial admission was OR 9.96 (95% CI 4.62–21.29; P<.001).

CONCLUSION:

ACOG criteria for PTL are frequently ignored when admitting patients. Stricter adherence could reduce unnecessary admissions and costs.
Impact of Provider Gender on Patient Engagement With Prenatal Mental Health Care [31K]
Authors: Prescott Jessica E. , Valji Farida , Nguyen Diem-Tran , Sobrinho Giovanna , Ihenacho Ugonna , Dossett Emily C.
Published: April 2018

INTRODUCTION:

Perinatal psychiatric disorders affect up to 20% of pregnant women, and are especially prevalent among women of lower socioeconomic status and women who have experienced intimate partner violence (IPV). Here we evaluate the association between provider gender and engagement with mental health care during pregnancy in a group of women seeking care at a safety net hospital.

METHODS:

This analysis includes retrospectively abstracted clinical data from patients referred to the Obstetrics Mental Health Clinic (OBMH) at a large urban county hospital between July 1, 2014 and September 1, 2016. The OBMH Clinic receives referrals from prenatal care providers and social workers for pregnant women with comorbid psychiatric symptoms. Included in the study were pregnant women, ages 18 and older, who had attended an OBMH intake interview. OBMH adherence was defined as attending at least one follow-up appointment during pregnancy after initial intake.

RESULTS:

One hundred thirty-seven patients met study criteria and were included in this analysis. There was no significant difference in OBMH adherence for women seeing a male versus a female psychiatric provider for their intake interview (χ2=2.39, df=1, P=.122). Among women with a diagnosis of posttraumatic stress disorder secondary to IPV, there was no significant association between OBMH adherence and provider gender (χ2=.084, df=1, P=.77).

CONCLUSION:

Provider gender is not a statistically significant predictor of adherence to OB mental health care. Findings suggest that women could benefit from longitudinal prenatal mental healthcare regardless of the gender of their mental health care provider.
Implementation of the ALPs Trial Into the Clinical Setting [36K]
Authors: Lauder Jhenette , Ruhstaller Kelly , Jain Vanita , Sciscione Anthony
Published: April 2018

INTRODUCTION:

With the advent of the antenatal late preterm steroids trial (ALPS), clinical practice patterns have changed. We sought to determine our hospital's rate of adherence to the ALPS protocol in the first year since its implementation.

METHODS:

This is a retrospective cohort study of all late preterm, singleton deliveries in our academic, tertiary care facility from March 1, 2016 to February 28, 2017. Exclusions included aneuploidy and major fetal anomalies. The primary outcome was the appropriate implementation of ALPS, including the identification of ineligible patients. Patients were divided based on delivery in the first or second half of the year. Secondary outcomes included maternal and neonatal outcomes. Data was analyzed as intention-to-treat. Student's t-test, χ2, and univariable logistic regression were utilized for analysis.

RESULTS:

Four hundred seven women with singleton pregnancies delivered in the late preterm period, and 393 were eligible for analysis. No significant differences were noted in demographic or clinical characteristics, including race, parity, admitting service, delivery indication, delivery mode, or birth weight between women who delivered in the first or second half of the year (all P>.05). In the year following adoption of ALPs, there was a significant improvement in the identification and implementation of the protocol (61.8% versus 79.2%, P<.01). There was a trend towards improved neonatal outcomes. However, likely due to the small sample size, it did not reach statistical significance.

CONCLUSION:

Implementation of ALPS improved over the first year following its adoption in our institution. However, 1 in 5 women were inappropriately managed. A strategy for increasing adherence to the ALPS protocol is needed.