bluuebunny/crossref_metadata_2025 huggingface dataset:
Breastfeeding for U.S. Women Living With HIV: A Medical and Ethical Policy Analysis [7M]
Authors: Gross Marielle , Tomori Cecelia , Anderson Jean , Coleman Jenell
Published: May 2017

INTRODUCTION:

US HIV guidelines recommend against breastfeeding (BF) by women living with HIV (WLHIV), regardless of viral load (VL) and combination antiretroviral therapy (cART), to eliminate risk of breast milk mother-to-child-transmission (MTCT). Cultural stigma may prompt intermittent, non-exclusive BF, further increasing risk. However, BF decreases morbidity and mortality for children and women, and is an important reproductive right. We sought to evaluate the medical and ethical bases of categorically prohibiting BF for WLHIV.

METHODS:

Our empirically informed ethical analysis: (1) reviews MTCT risk; (2) explores unique health risks of HIV-exposed infants and WLHIV; and (3) explores potential harms of universally prohibiting US WLHIV from BF.

RESULTS:

(1) MTCT from short-term exclusive BF is less than 1% with cART, even in low-resource settings. (2) Formula-fed HIV-exposed infants have increased risk of prematurity, low birth weight, sudden infant death syndrome, and necrotizing enterocolitis (all causes of US child mortality); and diabetes, asthma, and obesity. Without BF, WLHIV have increased risk of breast/ovarian cancer, hypertension, diabetes, heart disease, depression and unintended pregnancy. (3) Given low MTCT with cART and BF health outcome data, both groups may be disproportionately harmed by withholding BF. Further, non-exclusive BF without provider knowledge/support increases MTCT risk, and avoiding BF may impair bonding.

CONCLUSION:

There is extremely low MTCT from exclusive BF with cART and undetectable VL. Given potential benefits of BF for WLHIV and their infants, eliminating choice is ethically problematic. We propose a nationwide discussion to critically reevaluate the medical and ethical bases of prohibiting BF for select cART-adherent, virally suppressed WLHIV.
Providers Perspectives on Tdap Vaccination in Pregnancy Patients [8M]
Authors: Vidrine Samantha , DeCesare Julie , Roussos-Ross Dikea , Ashby Mary , Floyd Elizabeth , Peterson Hanna
Published: May 2017

INTRODUCTION:

The CDC recommends Tdap vaccination during pregnancy to increase infants' protection against pertussis. The best time to vaccinate is between 27 and 36 weeks gestation in order to maximize the maternal antibody response and transfer to the infant. This project looks at the providers prospective as to why women are not receiving the vaccine.

METHODS:

An 8 question survey was sent out to all members of the American College of Obstetricians and Gynecologists District XII. The questions were concerning Tdap vaccination in pregnancy. Responses were received from 139 providers.

RESULTS:

According to the survey, 83.4% of obstetricians universally offer Tdap vaccinations in the third trimester in their office. Of the patients who are offered the vaccine, 51-75% of patients accept the vaccine. Concern for vaccination safety was the most common response for why patients decline, followed by lack of understanding of importance. 55.9% of providers answered that they encounter barriers in trying to offer Tdap in their practice, and identified was lack of point of care availability (70.3%) as the most common barrier. Difference in vaccination rates between insure types were noted and 59% answered that Medicaid patients are less likely to receive Tdap in the third trimester due to lack of reimbursement.

CONCLUSION:

The most common reasons cited for patients to not receive Tdap vaccination in the third trimester is concern for safety and lack of understanding of importance. More than half of the providers answered that Medicaid patients are less likely to receive the vaccine due to reimbursement and point of care issues.
REPLENISH Trial: Combination Capsule of Estradiol/Progesterone (TX-001HR) for Treating Hot Flushes [5M]
Authors: Archer David F. , Graham Shelli , Gasper Gina , Constantine Ginger , Bernick Brian , Mirkin Sebastian
Published: May 2017

INTRODUCTION:

Many FDA-approved hormone therapies (HTs) combining estrogens and progestins are currently available in the US for treating menopausal symptoms. The use of FDA-approved HT has recently declined, while that of custom-compounded hormone therapy (CHT) with estradiol and progesterone has increased. Current reports suggest that up to 3 million women 40 years and older are using CHT (30 million prescriptions/year). Compounded BHT may be associated with endometrial cancer. No single product combining natural 17β-estradiol and progesterone has been approved yet by the FDA.

METHODS:

REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial (∼100 US sites) that evaluated the safety and efficacy of TX-001HR (a 17β-estradiol‒natural progesterone combination capsule) for treating moderate to severe hot flushes in postmenopausal women with an intact uterus. Of the total 1,847 women enrolled, 767 were randomly assigned to one of four TX-001HR daily doses (estradiol 1.0 mg/progesterone 100 mg, 0.5 mg/100 mg, 0.5 mg/50 mg, or 0.25 mg/50 mg) or placebo for 12 months (vasomotor symptom substudy); the remaining 1,080 women were randomly assigned between the active treatments. The four co-primary efficacy endpoints were the mean change from baseline to weeks 4 and 12 in frequency and severity of moderate to severe vasomotor symptoms for active treatments vs placebo. The primary safety endpoint was the incidence of endometrial hyperplasia at 12 months.

RESULTS:

TX-001HR 1.0 mg/100 mg or 0.5 mg/100 mg met all 4 co-primary endpoints, with significant improvements from baseline in frequency and severity of moderate to severe hot flushes at weeks 4 (all, P< 0.05) and 12 (all, P< 0.001) compared with placebo. Women treated with TX-001HR 0.5 mg/50 mg had significant improvements in hot flush frequency and severity at week 12 (both, P< 0.05) vs placebo, while those taking 0.25 mg/50 mg had significant improvements in frequency, but not in severity, at weeks 4 and 12 (both, P≤ 0.001). The incidence of endometrial hyperplasia or malignancy was 0% (by consensus read) with all four TX-001HR doses and placebo after 12 months of therapy. A high incidence of amenorrhea was achieved with all TX-001HR doses.

CONCLUSION:

TX-001HR 1.0 mg/100 mg or 0.5 mg/100 mg effectively treated menopause-related moderate to severe hot flushes and had a safe endometrial safety profile. If approved, TX-001HR – the first combination HT product containing naturally occurring 17β-estradiol and progesterone – may provide an alternative option for the estimated 3 million of women currently using unregulated, unapproved, compounded bio-identical in the US.
Zika Knowledge Among Pregnant Woman in an Inner-City Urban Hospital [10M]
Authors: Bhat Samhita , Gabbur Nagaraj
Published: May 2017

INTRODUCTION:

Zika virus has been shown to pass vertically during pregnancy. In the US, more than 800 pregnant women have tested positive and 26 infants have birth defects. Many organizations educate about Zika however, the effectiveness is not well known. A national poll of 1,275 individuals revealed that 23% were unaware of the birth defects; 20% believe there is a vaccine; 42% do not realize Zika virus can be sexually transmitted; and 25% think individuals with Zika will always have symptoms. In this study, pregnant women were surveyed to assess their Zika knowledge in an urban inner city setting.

METHODS:

A 14 question survey was administered to pregnant patients at SUNY Downstate Medical Center. 4 questions were demographic and 10 assessed knowledge regarding Zika.

RESULTS:

53 pregnant women were surveyed. 87% were unaware that Zika does not exhibit symptoms in most; 55% did not know there is no specific treatment; 28% were unaware of where Zika is found; and 28% were not aware Zika can be sexually transmitted. Kruskal-Wallis tests for one-way analysis of variance demonstrated greater knowledge regarding Zika in patients with more than one child compared to those with just one child (Mean: 7.90 vs 6.36, p=0.007).

CONCLUSION:

These results show that although the government has tried to educate about Zika, there are still areas of deficiency. Differences in Zika knowledge based on demographics was not noted except between women with one child and women with more than one child which should be investigated further.
Factors Associated With Zika Virus Information on County Health Department Websites in the State of Texas [11M]
Authors: Cuvillier James , Page-Ramsey Sarah M. , Rodriguez Emma , Ireland Kayla , Adesomo Adebayo , Ramsey Patrick S.
Published: May 2017

INTRODUCTION:

In the United States, Texas has the third highest reported Zika case incidence (218 cases, October 2016), including 13 pregnant women. Thus, prevention is a critical public health concern. Our objective was to evaluate factors associated with availability of Zika virus information on Texas county health department websites.

METHODS:

We reviewed Texas county health department websites for any Zika virus information, using internal searches for “Zika” when necessary. Factors potentially associated with availability of information on the county website (birth rates, “metropolitan” designation, reported Zika cases, and designation as a county bordering Mexico) were compared between groups using a Fisher's exact test and Student t-test where appropriate.

RESULTS:

Of 254 counties, 35 (13.8%) reported information about Zika virus on their county health websites. Mean birth rates in counties with information about Zika were higher than counties without Zika information (14.4/1000 vs 12.5/1000, p < 0.0001). These counties were also more likely to be “metropolitan” designation (77.1% vs 25.1%, p < 0.0001) and have Zika cases (45.7% vs 1.8%, p < 0.0001). Mexican border designation was not associated with increased likelihood of publishing Zika information (2.9% vs 6.4%, p=0.70).

CONCLUSION:

Very few Texas county health department websites contain any information about the Zika virus. Counties with higher birth rates, “metropolitan” designation, and Zika cases are more likely to have Zika information available. Disseminating county-specific resources and instruction on Zika surveillance, prevention, and monitoring of pregnancy and infant outcomes will be vital in preparing for potential future outbreaks or viral entry to local mosquito populations.
Zika Virus in a Non-Endemic Urban Population: Patient Characteristics and Ultrasound Findings [12M]
Authors: Eppes Catherine , Rac Martha , Dempster Carrie , Ballas Jerasimo , Davidson Christina , Aagaard Kjersti
Published: May 2017

INTRODUCTION:

The global Zika virus (ZIKV) outbreak has led to pregnant women seeking consultation, testing and ultrasound surveillance. We describe patient characteristics and ultrasound findings in a high-risk non-endemic Southern U.S. urban cohort.

METHODS:

This is a retrospective cohort study of women referred to our Obstetrics Infectious Disease Clinic for potential ZIKV exposure between February and September 2016 and tested accordance to Center for Disease Control (CDC) criteria. Patient characteristics, ultrasound findings and testing outcomes were recorded.

RESULTS:

A total of 105 gravidas were evaluated for ZIKV. Mean gestational age at last exposure and testing was 20+9.8 wks and 26.3 +8.9 wks, respectively. Geographic exposure was more common than sexual contact alone (90% vs 10%), though 61 (58%) reported partner co-travel. 95 (90%) were Hispanic and Mexico was the country most often traveled (50%). 21 (20%) women were symptomatic and 8 (11%) had positive test results (1 serum PCR and 7 with IgM and PRNT >10). There were 17 (18%) patients with ultrasound abnormalities; including microcephaly 12 (12%), intracranial abnormalities 3 (3%) and 11 (11%) with fetal growth restriction and/or oligohydramnios. There were 2 (2%) first trimester miscarriages and one stillbirth at 33 weeks. No congenital infection of ZIKV was confirmed either on amniocentesis or at delivery in the 48 (46%) of women delivered thus far.

CONCLUSION:

The prevalence of ultrasound abnormalities was higher than previously reported for as the baseline prevalence in the United States (3-5%). Further research is needed to determine if our findings are related to risk factors independent or dependent on ZIKV exposure or infection.
Home HPV Self-Collection in HIV-Infected Women: Assessing Acceptability and Prevalence [13M]
Authors: Lee Kristen , Ramroop Rosemary , Gaydos Charlotte , Barnes Perry , Anderson Jean , Coleman Jenell
Published: May 2017

INTRODUCTION:

Up to 55% of women living with HIV (WLHIV) are under-screened for cervical cancer, despite higher risk. Our objective was to examine HPV prevalence, compare home self-collected (SC) to clinician-collected (CC) HPV positivity, and measure acceptability of SC.

METHODS:

A prospective cohort study of WLHIV was conducted from February–September 2016 in Baltimore. IRB approval was obtained. Pregnant and hysterectomized women were excluded. HPV E6/E7 mRNA was detected from SC cervicovaginal and CC cervical cytobrushes using transcription mediated amplification. HPV DNA was detected from a 2nd CC cervical cytobrush using DNA nucleic acid hybridization. Descriptive and Cohen's kappa statistics were performed.

RESULTS:

There were 68 participants with mean age 48 (SD 9.6). The majority (89%) were Black with median CD4 count of 623 (IQR 379-811). Among the 81% of subjects who returned the home SC kits, HPV E6/E7 mRNA prevalence was 50.9% and 41.8% for SC and CC samples, respectively, while DNA prevalence was 34%. Concordance between SC and CC E6/E7 was 76.4% (ĸ=.53, p < .001), and 95.7% (ĸ=.91, p < .001) between CC E6/E7 and DNA. Pap tests were normal among 81.5% of negative home SC tests. The majority (83.3%) would use the swab again and recommend the swab to family/friends (88.2%).

CONCLUSION:

There was moderate agreement between home SC and CC HPV positivity. Home SC was acceptable. Most participants would use the swab again and recommend it to family/friends. Home SC could be used as an alternative method to screen WLHIV who do not regularly visit women's health clinics.
Tobacco Use and High Risk Genital HPV Infection Among United States Females [16M]
Authors: Han Jasmine , Tarney Christopher , Klaric John , Beltra Thomas
Published: May 2017

INTRODUCTION:

Human Papillomavirus (HPV) is a common sexually transmitted infection which causes cervical cancer that has association with tobacco use. We investigated the associations between objective biomarkers reflective of current tobacco exposures and high risk genital HPV prevalence among adult females in the United States.

METHODS:

The National Health and Nutrition Examination Survey (NHANES) sampled a representative cross-section of the non-institutionalized US population. During NHANES 2011-2012 cycle, 2838 adult females with valid HPV results were included in the analysis. DNA was extracted from self-collected vaginal swab specimens, and HPV genotyping was accomplished by PCR amplification. Nicotine metabolites were collected from serum and self-collected urine specimens.

RESULTS:

Nicotine exposure was a significant predictor of high risk (HR) genital HPV infection, p < 0.001. Compared to non-smokers, individuals with second hand nicotine exposure and infrequent smoker were more likely to be HR HPV positive; Odds Ratio (OR) 3.7, (95% Confidence Interval (CI), 1.6-8.5). Active smokers were more likely to test positive for at least one of the quadrivalent HPV vaccine type strains (HPV types 6,11,16,18); OR 2.2; (95% CI, 1.4-3.7) compared to the non-exposure group. The high risk HPV prevalence remained elevated in the nicotine exposure group, although analysis was adjusted for sexual behavior.

CONCLUSION:

In this large cross-sectional, population-based study, we demonstrated significant relationship between current tobacco exposure and high risk genital HPV infection, which causes cervical cancer. These findings highlight the need to examine the role of tobacco in the natural history of genital HPV infection and malignancy progression.
Obstetric Outcomes Complicated by Chlamydia Infection in All U.S. Deliveries Between 2011-2013 [18M]
Authors: Clennon Emily , Caughey Aaron B. , Bullard Kimberley
Published: May 2017

INTRODUCTION:

Despite recommended routine screening in pregnancy, infection with Chlamydia trachomatis affects thousands of pregnancies in the U.S. each year. This study analyzes recent, nationwide data on complications of pregnancy in the setting of chlamydia infection.

METHODS:

This retrospective cohort study examined 10,490,884 singleton deliveries in the U.S. between 2011-2013. Simple proportions of 14 obstetric complications were compared between pregnancies complicated by Chlamydia trachomatis and controls. Chi squared tests and multivariable regression were used for statistical analysis, with p < 0.05 as the cutoff for significance. Comparisons were controlled for co-infection, parity, congenital abnormality, and maternal race and ethnicity, age, education attainment, cigarette use, and weight.

RESULTS:

A total 194,045 pregnancies analyzed were complicated by maternal chlamydia. Infection was positively associated with gestational hypertension (adj. OR: 1.20), chorioamnionitis (1.24), neonatal ventilator requirement greater than 6 hours (1.18), neonatal antibiotic administration (1.32), and congenital abnormality (1.30). Infection was negatively associated with gestational diabetes (0.95), moderate (0.92) and severe (0.88) preterm delivery, macrosomia (0.87), and Apgar score at 5 minutes less than 4 (0.88). Caesarian section rates overall (0.79) and stratified by parity and previous CS were all lower among infected women. No significant association was found with overall preterm birth, maternal or neonatal ICU stay, or neonatal seizure.

CONCLUSION:

Chlamydia infection is independently associated with increased odds of some of the obstetric complications we analyzed and decreased odds for others. Further investigation is required to determine if these differences are attributable to non-controlled socioeconomic factors, increased monitoring throughout pregnancy, or pathophysiologic mechanisms of infection.
Maternal Human Papillomavirus Infection Increases the Risk of Premature Rupture of Membranes [19M]
Authors: Cotton-Caballero Amaya , Dudley Donald , Ferguson James , Pettit Kate , Boyle Annelee
Published: May 2017

INTRODUCTION:

Our main objective was to assess the association between maternal human papillomavirus (HPV) infection and premature rupture of membranes (PROM).

METHODS:

We conducted a retrospective cohort study of singleton deliveries from 2010 to 2015. Women with HPV genotyping or cervical cytology results within 3 years were included. Maternal and fetal variables were abstracted from medical records. Chi-squared and logistic regression analyses were used.

RESULTS:

2,153 women were included. 38.5% were HPV positive. The prevalence of PROM (term and preterm) was 3.4%. HPV infection (p=0.01), history of PROM (p < 0.001), drug use or smoking (p=0.01), and ethnicity (p=0.05) were associated with PROM. HPV infection (OR=2.07, 95%CI: 1.21-3.55) remained associated with PROM when adjusting for history of PROM, cervical conization, drug use or smoking, ethnicity, and insurance. Adjusting for these covariates, HPV infection was associated with preterm PROM (OR=2.23, 95%CI: 1.12-4.43) but not term PROM (OR: 1.87, 95%CI: 0.81-4.34). PPROM was associated with preterm delivery (OR=129.01, 95%CI: 35.59-467.66) after adjusting for HPV infection, PIH, diabetes, placenta previa, placenta abruption, cervical conization, smoking or drug use, ethnicity, and history of PROM. HPV infection was associated with preterm delivery (p=0.04) in univariate analysis, but not in multivariable analysis (p=0.14). HPV infection had a univariate association with newborn septicemia (p=0.02), respiratory distress (p=0.01), NICU admission (p=0.001), and low birth weight (p=0.03).

CONCLUSION:

HPV infection is associated with an increased risk of preterm PROM. Preterm delivery resulting from PPROM is associated with an increased risk of adverse neonatal outcomes, but maternal HPV infection does not independently increase this risk.
The Effects of Zika in Pregnancy: The Miami Experience [20M]
Authors: Tse Colette , Picon Michelle , Rodriguez Patricia , Gonzalez Ivan , Starker Rebecca , Curry Christine
Published: May 2017

INTRODUCTION:

Zika virus infection in pregnancy is a global health concern. Obstetric providers in Miami care for a large numbers of pregnant women with suspected or confirmed infection from Zika-affected countries, as well as the first cases of local transmission in the United States. We are uniquely positioned to contribute data on the characteristics of Zika-infected pregnant women delivering in the US.

METHODS:

After receiving IRB approval a retrospective chart review was conducted. Using laboratory records of Zika testing (PCR and IgM) performed from January through September 2016 at multiple tertiary care centers in Miami, we extracted demographic data from all pregnant women with PCR and/or IgM tests positive for Zika virus. Testing was based on CDC guidelines at the time of testing, leading to heterogeneity in testing. Routine obstetrics parameters and presence of fetal or neonatal abnormalities were noted.

RESULTS:

A total of 997 pregnant women were tested for Zika. Of those screened, 32 had positive Zika IgM or PCR testing in serum or urine. At the time of writing, 23 had delivered. 2 had microcephaly based on CDC diagnostic criteria. 1 had abnormal intracranial findings and 6 had abnormal fetal ultrasounds prior to delivery. Of those who were still pregnant at the time of writing, 1 had fetal ultrasounds with abnormalities.

CONCLUSION:

In Miami we have a large population of women with Zika virus exposure in pregnancy. With a mix of local and remote infections, our group represents a diverse cohort from whom we can contribute a broad understanding of pregnancy implications.
Breast Feeding Rates in in Centering Pregnancy® Versus Traditional Certified Nurse Midwife Prenatal Care [27M]
Authors: Hahn Petra , Hoff Tara , Sharma Deepti , Huntly Jaimie , Hardy-Fairbanks Abbey , Stockdale Colleen
Published: May 2017

INTRODUCTION:

Centering Pregnancy® (CP) is a standardized interdisciplinary approach to prenatal care characterized by group visits of women with similar estimated delivery dates. Other forms of group prenatal care has been associated with increased rates of breastfeeding and decreased cesarean deliveries in adolescent and low-income women, however these outcomes have not been studied in a generalizable population.

METHODS:

IRB approved, retrospective chart analysis was conducted for women that participated in (1) CP care between March 2012 and May 2016 and (2) traditional individualized certified nurse midwifery (CNM) prenatal care during the same time period. Breastfeeding status was recorded on all discharging women and at a scheduled 6-8 week postpartum visit. Descriptive and comparative statistics were performed with P < 0.05 considered significant.

RESULTS:

126 women who participated in group CP care and 847 who were involved in individual CNM prenatal care were reviewed. Rates of vaginal delivery (including operative) were not statistically different between CP vs CNM groups (77.0% vs 83.2%, p=0.085). Breast feeding rates at discharge were higher among CP, but not significantly so (97.5% vs 93.1%, p=0.061). More women attended their postpartum visit in the CP group (94.4% vs 83.2%, p=0.001), and rates of breast feeding reported at the postpartum visit were higher in this group, though again, not significantly (89.1% vs 84.1% p=0.163).

CONCLUSION:

At our institution, incorporating CP group prenatal care improved the rates of women attending their postpartum visit but led to comparable rates of breastfeeding and vaginal delivery to individual CNM prenatal care.
Improving Compliance With Preeclampsia Guidelines Through an Electronic Medical Record Alert [29M]
Authors: Scott Dana M. , Rauk Phillip , Bangdiwala Ananta
Published: May 2017

INTRODUCTION:

Hypertensive disorders occur in 12-22% of all pregnancies, and account for 17% of maternal mortality in the US. In 2012 and 2013, the American College of Obstetricians and Gynecologists and the California Maternal Quality Care Collaborative released comprehensive guidelines for the diagnosis and treatment of preeclampsia. Electronic health records likely offer an opportunity to improve compliance with these guidelines via automated alerts.

METHODS:

A retrospective review of 289 patients admitted to the University of Minnesota Medical Center in 2015 with preeclampsia or similar disorder was completed. Compliance with the national guidelines for administration of rapid-acting antihypertensives, IV magnesium for seizure prophylaxis, oral antihypertensives, and appropriate timing of outpatient follow up was evaluated. A similar review will be performed six months after the implementation of an automated alert in the electronic health record notifying providers of severe-range blood pressures.

RESULTS:

Data collection for phase 1 is currently in process, and data collection for phase 2 will begin in January 2017. It is expected that 85% of patients with sustained severe-range blood pressures admitted to the antepartum and labor and delivery units will receive rapid-acting antihypertensives within 60 minutes, but only 65% of those patients located on the postpartum unit will receive appropriately timed antihypertensive therapy. Compliance with appropriately timed antihypertensives will improve in all locations following implementation of the automated alert.

CONCLUSION:

The electronic health record has the potential to improve patient care and compliance with American College of Obstetricians and Gynecologists and CMQCC preeclampsia guidelines. More work is needed to optimize the electronic health record's benefit.
The Efficacy of Antepartum Testing in Pregnancies Complicated by Fetal Gastroschisis [32M]
Authors: Bhagat Neha , Gimovsky Martin , Koscica Karen , Nazir Munir
Published: May 2017

INTRODUCTION:

Our objective was to determine if our approach to antepartum testing is effective at reducing perinatal mortality in fetuses with gastroschisis.

METHODS:

This retrospective case series analyzed fetuses with gastroschisis that underwent intensive fetal surveillance from 2008 to 2016. Data collected included maternal demographics, antenatal fetal testing, influence of testing on timing of delivery, gestational age at delivery, indication for delivery, and perinatal complications. The antenatal fetal surveillance was guided by the following testing protocol: monthly growth scan, twice weekly fetal testing with BPP/NST, consultation with a perinatologist, and strict maternal kick counting.

RESULTS:

This study had 11 patients, majority of which were young primiparous Hispanic women. IUGR complicated 59.5% of our pregnancies with gastroschisis. Bowel dilation greater than 18mm was noted in 31.8% of fetuses with gastroschisis; one was delivered due to bowel dilatation greater than 25 mm. Fourteen patients were sent to L&D from ATU, of which 9 were for nonreassuring fetal testing and 2 related to ultrasound findings. All patients sent from ATU for fetal compromise diagnosed on testing were delivered within 48 hours. Eleven patients were delivered for compromised fetal status as determined by abnormal fetal testing and/or decreased fetal movement. Prevalence of IUFD in fetal gastroschisis in our case series was 0%, as compared to 4.48% reported in the literature.

CONCLUSION:

Our protocol for antenatal fetal surveillance was effective in identifying the compromised fetus with gastroschisis leading to timely delivery. Increased awareness of IUFD and our comprehensive fetal testing protocol resulted in survival of all fetuses in this study.
Trends in Prenatal Care Among the Ngöbe Population of Panama [34M]
Authors: Matsuo Marie-Claire , Gottlieb Jillian , Goodrich Leigh , Ewald Ivy , Velasco Alyssa , Steller Jonathan
Published: May 2017

INTRODUCTION:

Maternal and infant mortality rates in Panama are reported as being within the best in Latin America, however there is a sharp contrast between rates reported in urban and rural populations. Maternal death rates among indigenous populations, such as the Ngöbe, reach as high as 658 per 100,000 live births. This study assesses the impact of poverty and geographic isolation on women's decisions to deliver at home versus a healthcare facility in this understudied population. Additionally, the use of prenatal vitamins and contraception are evaluated.

METHODS:

Given high rates of illiteracy, an oral questionnaire was administered, consisting of: 1. Preferences in delivery location 2. Use of prenatal vitamins 3. Experience with prenatal healthcare and family planning. Surveys were administered in Spanish to participants receiving services through the non-profit organization Floating Doctors.

RESULTS:

101 pregnant Ngöbe women participated. The majority of women preferred to deliver in a healthcare facility if possible (61%) and wished to use contraception (59%). Age was not a significant factor in the interest in using contraceptives (p=0.74), but the number of living children in the household was (p=0.02). The use of prenatal vitamins during pregnancy did not correlate with age (p=0.27) and was as low as 45%.

CONCLUSION:

This data further demonstrate the need for improved access to transportation to hospitals in order to reduce maternal and fetal morbidity and mortality among the Ngöbe population. Prenatal education and family planning could positively contribute to maternal and fetal health outcomes.
Analysis of a Multi-Disciplinary Program to Reduce Perineal Lacerations During Childbirth [36M]
Authors: Marko Emily , Fausett Merlin , Maxwell George , Stormes Stephanie , Deering Shad , Staat Barton
Published: May 2017

INTRODUCTION:

To analyze the effectiveness of a multidisciplinary simulation program aimed at reducing perineal lacerations during childbirth.

METHODS:

A retrospective analysis of quality metrics was performed for a mixed-modality simulation program that was adapted for a large multi-hospital system and disseminated to nurses, midwives and physicians. This inter-professional educational program included multiple teamwork strategies aimed at reducing perineal lacerations. Outcome measures included laceration rates and length of hospital stay for patients with lacerations. Linear regression was used for statistical analysis.

RESULTS:

Data was examined over a 3-year period including the year prior to and 2 years after the program was initiated. Reductions in laceration rates occurred for spontaneous vaginal deliveries (29.6/1000 to 6.7/1000, R2 = 0.68, p less than 0.001) and operative vaginal deliveries (135.1/1000 to 46/1000, R2 = 0.23, p=0.09). Average hospital length of stay for patients with lacerations was reduced from 1.12 to 0.94 days during the program implementation (R2 = 0.36, p=0.05).

CONCLUSION:

Modest reductions in perineal laceration rates and hospital length of stay were demonstrated through a multifactorial inter-professional educational program. Reducing severe perineal laceration rates benefits patients and hospital systems.
Effect of Obesity on Labor Inductions With Foley Plus Oxytocin Versus Oxytocin Alone [37M]
Authors: Mackeen A. Dhanya , Durie Danielle , Lin Monique , Huls C. , Packard Roger , Sciscione Anthony
Published: May 2017

INTRODUCTION:

To estimate the effect of body mass index (BMI) on labor and delivery outcomes for women induced with an intracervical Foley catheter plus oxytocin versus oxytocin alone after (near) term premature rupture of the membranes (PROM).

METHODS:

We performed a multicenter, randomized controlled trial of women with singleton gestations greater than or equal to 34 weeks with PROM and an unfavorable cervix (less than or equal to 2 cm dilated/80% effaced). Subjects were randomly allocated to a Foley catheter inflated to 30 mL with concurrent oxytocin infusion or oxytocin infusion alone. Block randomization was employed with stratification by parity, term/preterm and hospital site. Adjusted linear regression analysis revealed a non-significant shorter time to delivery (-55.4 mins, 95% CI -170.8-60.0, P=.349) in the Foley arm as compared to oxytocin arm. This secondary analysis was conducted to evaluate the effect of BMI on outcomes, within treatment groups.

RESULTS:

We enrolled 201 women and BMI was known for 198 patients. Twenty two had a BMI less than 25, 59 were overweight, 50 were class I obese, 40 were class II obese, and 27 were class III obese. Regardless of the treatment arm, the tests of trend across BMI categories were not significant for interval from induction to delivery, delivery within 24 hours, vaginal delivery within 24 hours, and cesarean delivery rate.

CONCLUSION:

Obesity did not appear to affect delivery outcomes for women induced after PROM with an intracervical Foley catheter plus oxytocin versus oxytocin alone.
Latinas' Agency and Their Construction of Birthing Knowledge: Implications for Patient Centered Care [1N]
Authors: Masghati Salome , Hayes-Bautista Teodocia Maria , Wohlmuth Cinna
Published: May 2017

INTRODUCTION:

To provide Patient-Centered Care to Latina women during labor and delivery, a physician must be aware of how she socially constructs the process of birth with reference to her stock of knowledge and sense of agency. Lay constructs of labor and birth provide a foundation for understanding ethnic motherhood in the 21st century. This study observes the properties and dimensions of the categories we term Latina ethnophysiology and ethnic agency related to pregnancy, labor and birth.

METHODS:

This is a qualitative study design. Data were from a subset of focus groups of 42 Latina women (both Spanish and English dominant) who had chosen to give birth at a community-based teaching hospital located in East Los Angeles. Data were analyzed using constructivist grounded theory.

RESULTS:

Latina women constructed mental models of the birthing process along with their ethnic identity and agency, with constructs often unknown to medical professionals. While the medical staff used formal models derived from a narrow, officially sanctioned range of knowledge sources, the patients' models were developed informally, utilizing a wide variety of unsanctioned knowledge sources including information from a relative's advice to stay indoors during a full moon to birthing via YouTube, Baby-R-Us, internet blogs and Jennifer Lopez movies.

CONCLUSION:

For Latina women, knowledge of the female anatomy and physiology related to birthing is socially constructed. Understanding and integrating the social construction of knowledge in specific segments of patient populations, such as low-income Latina women, informs Patient-centered care.
Cesarean Scar Pregnancy: A Three-Year Experience at Yale-New Haven Hospital [2N]
Authors: Deshmukh Uma , Grechukhina Olga , Ozan Bahtiyar Mert , Fan Linda , Sfakianaki Anna
Published: May 2017

INTRODUCTION:

The incidence of cesarean scar pregnancy (CSP) is rising along with the cesarean delivery rate. Data on the optimal management of the CSP are limited.

METHODS:

This is a series of all CSP cases diagnosed over the period 5/2013–8/2016 at Yale-New Haven Hospital. Data were collected retrospectively and prospectively from electronic medical records with approval from the Institutional Review Board.

RESULTS:

Sixteen cases of CSP were diagnosed in 14 patients, including 2 recurrences. Median number of prior cesarean deliveries was 3 (SD 0.98). Median gestational age at time of diagnosis was 45.5 days (6+3/7 weeks) (SD 11). Fetal cardiac activity was detected in 10 cases. Three patients had spontaneous demise of the CSP and were managed expectantly. Others opted for termination via systemic methotrexate alone (n=4); combined systemic/local methotrexate (n=5); systemic/local methotrexate with bilateral uterine artery embolization (n=1); systemic/local methotrexate with intra-sac KCl injection (n=2); and KCl injection with laparotomy and wedge resection (n=1). Three patients who underwent expectant management or methotrexate therapy had retained products of conception diagnosed 48, 61 and 82 days after initial diagnosis that required hysteroscopy and curettage. One patient opted for hysterectomy after curettage for definitive management. Three patients spontaneously conceived after resolution of CSP. Two patients had recurrences that were managed with methotrexate therapy. One patient has an ongoing viable intrauterine gestation.

CONCLUSION:

This case series highlights the risk of complications associated with expectant management and methotrexate therapy, and demonstrates the potential for spontaneous conception following CSP.
Perinatal Morbidity Among Mothers of Medically Fragile Infants [3N]
Authors: Stuebe Alison , Tucker Christine , Ferrari Renee , Funk Michele Jonsson , Bryant Katherine , Verbiest Sarah
Published: May 2017

INTRODUCTION:

Mothers of medically fragile infants (MMFI) must recover from birth while attending to an infant in the neonatal intensive care unit (NICU). We hypothesized that, compared with mothers of well babies (MWB), MMFI would have more chronic medical problems and obstetric complications, increasing their need for postpartum follow-up.

METHODS:

Retrospective cohort study of mothers delivering at North Carolina Women's Hospital between 7/1/2014 and 6/30/2015. We defined MMFI as mothers of infants with a NICU length of stay of 3 or more days and MWB as mothers of infants not admitted to NICU. Outcomes were ascertained from the UNC Perinatal Database. We used chi square tests to compare health status and perinatal complications among MMFI, mothers of infants with NICU stays less than 3 days, and MWB. P values less than .05 were considered statistically significant.

RESULTS:

Among the 3,502 women who delivered a live-born infant, 10.5% were MMFI, 4.9% had an infant with a NICU stay less than 3 days, and 84.6% were MWB. MMFI were more likely than MWB to deliver by c-section (53.3 vs 24.4%, P < .01), be transfused with packed Red Blood Cells (5.7 vs 2.2%, P < .01) or Fresh Frozen Plasma (1.4 vs 0.37%, P=.04), and have chronic hypertension (16.0 vs 5.1%, P < .001), severe preeclampsia (24.7 vs 2.6%, P < .01) or HELLP syndrome (4.4 vs 0.3%, P < .01).

CONCLUSION:

MMFI have a greater burden of chronic disease and perinatal morbidity than MWB. Targeted approaches are needed to support the wellbeing of MMFI.
Perinatal Outcomes in Pregnancies With a Low Fetal Fraction on Non Invasive Prenatal Testing [4N]
Authors: Ali Marwan , Pryor Katherine , Chasen Stephen
Published: May 2017

INTRODUCTION:

Placental-origin cell-free maternal DNA is known as the fetal fraction (FF). Low FF is a risk factor for aneuploidy, and may be a risk factor for poor perinatal outcome. Our objective was to evaluate the relation between low FF, and perinatal outcome.

METHODS:

This is a retrospective review of singleton pregnancies who had NIPT. We compared the maternal BMI, gestational age of delivery (GA), birth weight (BW), and composite perinatal morbidity (CPM) between patients with a FF < 4% on NIPT (LFF), and those with a normal FF on their NIPT (NFF). The CPM was defined as the presence of any of the following complications: spontaneous abortion, hypertensive disorders of pregnancy, abruption, IUFD, preterm birth, low BW, NICU admission, or neonatal death.

RESULTS:

256 patients were included. 28 (10.9%) had LFF, while 228 (89.1%) had NFF. Median age was 35-years, and median GA was 39 weeks. The rate of CPM in the entire cohort was 26.5%. Median BMI was significantly higher in the LFF group (27.4 vs. 22.1 kg/m2; p< .001). There were no significant differences in CPM, gestational age at delivery or BW. Among the 28 patients in the LFF group, median FF in cases with CPM was significantly lower than in cases without CPM (2.0% vs. 3.2%; p=.04).

CONCLUSION:

There were no significant differences in obstetric outcomes between the two groups. Within the LFF group, lower FFs were associated with a higher rate of CPM. Larger studies are necessary to evaluate the association between uncommon outcomes and FF.
Postnatal Hospital Utilization Among U.S. Women With Intellectual and Developmental Disabilities [10N]
Authors: Mitra Monika , Parish Susan L. , Akobirshoev Ilhom , Moore Simas Tiffany A.
Published: May 2017

INTRODUCTION:

Women with intellectual and developmental disabilities (IDD) are at high risk for pregnancy and delivery related complications. However, there are no population-based studies about postnatal hospital utilization among U.S. women with IDD. We sought to examine the risk of postnatal hospital utilization and emergency department (ED) visits among women with and without IDD.

METHODS:

We conducted population-based retrospective cohort study using the 2002-09 Massachusetts Pregnancy to Early Life Longitudinal data and identified women with (N=541) and without IDD (N=1,623). The primary outcome measures were postnatal hospitalization and ED visits during the one-year postnatal period.

RESULTS:

Women with IDD have significantly higher risk of hospitalization and emergency department visit than the general obstetric population during the one-year postnatal period. Namely, women with IDD have 3.4 times higher odds (OR; 95% CI, 2.61–4.40; p < 0.001) of being hospitalized and 2.3 times higher odds (OR; 95% CI, 1.82–2.87; p < 0.001) of being admitted to emergency department during the one-year postnatal period compared to the general obstetric population.

CONCLUSION:

The findings of the study add to the emerging body of research on postnatal hospitalizations among women with IDD. Development, testing and implementation of evidence-based interventions that effectively support women with IDD during their postnatal period are critical. Furthermore, there is critical need for future research to develop postnatal care guidelines for women with IDD, understand the underlying mechanisms driving the increased postnatal hospitalizations, and educate health care professionals about the postnatal needs of women with IDD.
Cesarean Sections for Abnormal Fetal Heart Tracings: Setting Appropriateness Indicators Based on Neonatal Outcome [11N]
Authors: Ahken Stephanie , Peprah Mary Kwakye , Chen Innie , Wen Shi Wu , Black Amanda
Published: May 2017

INTRODUCTION:

Fetal distress is often suspected solely on atypical/abnormal cardiotocography which is subject to inter-individual variability. We identified C-sections performed for atypical/abnormal cardiotocography and compared neonatal outcomes to C-sections performed for labor dystocia. Indicators of C-section appropriateness were developed and applied.

METHODS:

A retrospective cohort study was conducted using data from Ontario's Perinatal database. Primary outcomes were C-section rates for fetal distress and neonatal outcomes (arterial pH, Apgars, neonatal resuscitation, NICU admission). A C-section for abnormal/atypical cardiotocography was “appropriate” if one or more of these outcomes occurred: 1-minute Apgar < 3, 5-minute Apgar < 7, arterial pH < 7.20, resuscitation required, or NICU admission.

RESULTS:

Between 2006-2014, 146,676 primary C-sections were performed; 20% were performed for atypical/abnormal cardiotocography. Compared with C-sections for labor dystocia, there were significant differences in maternal age, parity, induction of labor, and level of care (p < 0.001). Odds of newborn resuscitation (ORadj 1.48, CI 1.41-1.54) and NICU admission (ORadj 2.21, CI 2.08-2.34) were higher when indication was atypical/abnormal cardiotocography. Less than half (42.3%) of these neonates had at least one of the criteria used to determine C-section “appropriateness.” Rate of “appropriate” C-sections differed by size of center (p < 0.001), induction of labor (p=0.0027), oxytocin use (p < 0.001), level of care (p < 0.0001), and fetal surveillance method (p=0.004).

CONCLUSION:

In the absence of objective measures of intrauterine fetal well-being, C-sections may be performed for fetal distress when they are not required. Developing indicators for C-section appropriateness may guide strategies to reduce C-section rates.
Pre-Delivery Hemoglobin Is a Modifiable Prenatal Target in Reducing Postpartum Transfusion [12N]
Authors: Hamm Rebecca F. , Srinivas Sindhu K. , Bastek Jamie A. , Wang Eileen Y.
Published: May 2017

INTRODUCTION:

Postpartum hemorrhage (PPH) is a major cause of morbidity and mortality. One modifiable factor is pre-existing anemia. Our objective was to identify a threshold admission hemoglobin (aHgb) below which the risk of postpartum transfusion would be significantly increased.

METHODS:

This is a retrospective study of all women who delivered at the Hospital of the University of Pennsylvania between October 15, 2013 and December 15, 2013. Deliveries were included if both admission and 12 hour postpartum blood count (12hCBC) were available. Medians and distributions were calculated. Chi-Square, Mann-Whitney, and logistic regression were used.

RESULTS:

592 of 626 (95%) women were analyzed. Twenty (3.4%) women were transfused. The overall group 5th percentile and median aHbg were 9.3 g/dL and 11.7 g/dL respectively. The 5th percentile (7.7 vs. 9.5 g/dL, p < 0.001) and median aHgb (9.7 vs. 11.7 g/dL, p < 0.001) were both significantly lower among those who were vs. were not transfused. Admission Hgb cut points are associated with different test characteristics in predicting transfusion. Progressively lower aHgb led to incrementally improved specificity with only minimally decreased NPV.

CONCLUSION:

Our data suggests that, despite poor sensitivity, an aHgb of 9.5 was associated with a 98% NPV and a < 5% false positive rate, making it an excellent antenatal tool to screen women at risk for receiving postpartum transfusion. Achieving this aHgb may serve as an antepartum target in anemic patients to potentially decrease transfusion risk and improve maternal outcomes.
Predicting Perinatal Outcomes With an Obstructive Sleep Apnea Screening Tool [13N]
Authors: Bracero Luis A. , Chaffin Samantha , Calhoun Byron , Seybold Dara , Power Peter , Bush Stephen
Published: May 2017

INTRODUCTION:

The objective was to determine if a screening tool for obstructive sleep apnea (OSA) can be used to predict adverse perinatal outcomes.

METHODS:

Prospective observational study of patients receiving prenatal care (June 1 2013-May 31 2014) at a tertiary care center clinic. Patients were universally screened for OSA with the STOP questionnaire, a concise tool with four questions related to snoring, tiredness during daytime, observed apnea, and high blood pressure. It has been validated in surgery patients. Positive and negative screens and several confounding variables were included in a backwards logistic regression model to predict the following adverse perinatal outcomes: cesarean delivery, preeclampsia, preterm delivery (PTD) (<37 weeks), low birth weight (LBW) (<2500 g), Intra Uterine Growth Restriction, and Neonatal Intensive Care Unit (NICU) admission.

RESULTS:

Of the 680 patients who received prenatal care, 442 (65%) had singleton births and were included in analysis. Patient body mass indexes ranged from 12.8-61.4 with mean of 29.7. This study population had high tobacco (241; 54.5%) and illicit drug use (155; 35.1%). Positive STOP screens (64;14.5%) were associated with two outcomes: PTD and NICU admission. For PTD, history of pre-term labor was the strongest predictor, followed by STOP and nulliparity with odds ratios (OR) of 4.2 (95% CI 2.0-8.8; p < 0.001), 2.8 (95% CI 1.4-5.8; p=0.004), and 2.3 (95% CI 1.2-4.4; p=0.013). For NICU admission, a positive STOP was the only significant predictor with 2.5 OR (95% CI 1.1-5.7; p=0.036).

CONCLUSION:

The STOP screening questionnaire may be useful in predicting PTD and NICU admission.