bluuebunny/crossref_metadata_2025 huggingface dataset:
Culture Change and Decreased Cesarean Rate Through Implementing C.A.L.M. [35O]
Authors: Wahl Geneva , Gallagher Kristen , Lombard Emily , Takhsh Eden
Published: April 2018

INTRODUCTION:

In 2015, by putting the ACOG Consensus into practice, our institution was able to reduce our nulliparous, term, singleton, vertex (NTSV) cesarean rate by 5%. Our numbers then plateaued throughout 2016. In a continued effort to reduce the rate of cesarean sections amongst NTSV patients, we have instituted a multidisciplinary committee within our community hospital setting to help create a Consistent Approach to Labor Management (CALM). At the start of this project, our NTSV cesarean rate was 31.6%. Our benchmark goal was set at less than 24%.

METHODS:

The NTSV committee established four work groups with inspiration from the California Maternal Quality Care Collaborative (CMQCC) initiatives that included latent labor interventions, comfort measures for labor, second stage interventions, and ambulation in labor. Each work group focused on identifying variables that have an impact on the rates of cesarean section. An NTSV Fair was held to educate all staff and physicians. NTSV numbers were tracked and shared with all physicians in an unblinded, quarterly basis.

RESULTS:

Over an eight-month period we have been able to reduce our NTSV cesarean rate from 31.6% to 24.4%.

CONCLUSION:

The Consistent Approach to Labor Management (CALM) Project has helped us to nearly reach our benchmark goal for NTSV cesarean rates. Our NTSV committee will continue to educate our staff and physicians as we strive to change the overall culture towards supporting vaginal deliveries.
Nitrous Oxide in Labor: Predictors of Use and Conversion to Epidural Anesthesia [20P]
Authors: Brumley Jessica , Obican Sarah , Kendle Anthony , Louis Judette
Published: April 2018

INTRODUCTION:

We evaluated factors associated with conversion from nitrous oxide (NO2) to epidural anesthesia in laboring women.

METHODS:

We conducted a retrospective cohort study including women who delivered at an academic tertiary center during 1/1/2015-6/30/2017. Women with planned Cesarean delivery or with multiple gestations were excluded. At this center, self-administered NO2, intravenous opioids and epidural anesthesia are routinely offered. Electronic databases and medical charts were reviewed. Characteristics of women were compared using χ2, students T-test and Mann Whitney U test and logistic regression. P < 0.05 was considered significant.

RESULTS:

Among 13,615 women admitted for trial of labor, 16.9% (n=2, 265) used NO2 for labor analgesia. NO2 use increased annually 16.2%, 16.8% and 18%, p=.02 from 2015-2017. Women who used NO2 were more likely to be Caucasian, nulliparous, commercially insured, and have induced labor. The NO2 group was more likely to have maternal comorbid conditions or fetal indication for delivery, and these factors were predictive of conversion to epidural anesthesia. Women using NO2 were less likely to have a subsequent epidural placement, undergo a Cesarean delivery or have a NICU admission. Women were more likely to convert from NO2 to epidural anesthesia if they were Black, of Middle Eastern descent, Hispanic, obese, or nulliparous. Labor induction and augmentation were not predictive of conversion to neuraxial anesthesia.

CONCLUSION:

Use of NO2 in this ethnically diverse cohort was not associated with morbidity. These predictors of residual need for epidural anesthesia can assist in counseling patients prior to delivery.
Initial Body Weight Gain as a Screening Tool to Adverse Pregnancy Outcome [23P]
Authors: Lozovyy Violetta , Magruder Jordan , King Jade , Singh Shailini
Published: April 2018

INTRODUCTION:

Pregnancy weight gain is known to increase the risk of gestational diabetes and preeclampsia which can lead to preterm delivery. Inter-pregnancy weight retention worsens this risk. We have identified percent of initial body weight (IBW) gain that has relationship to maternal hyperglycemia and is lower than diagnostic of GDM criteria leading to adverse neonatal outcome.

METHODS:

227 mothers who had a delivery from June 2014 to July 2015 requiring entry into the neonatal hypoglycemia (NH) protocol for 24 hour monitoring after birth. Patients were excluded if collection of initial maternal weight was after 16 weeks GA as waiting any longer would be unreliable to approximate pre-gestational weight. Chi-square and t-tests were used to compare outcomes.

RESULTS:

Mothers with an initial BMI ≥25 who gained at least 15.3% ± 0.8% p=0.05 of their initial body weight throughout the pregnancy had normal GCT on initial screening. Additionally, there was a significant inverse correlation between weight gained during pregnancy and abnormal GCT.

CONCLUSION:

Early screening and intervention using 16±0.8% weight gain from initial maternal body weight could serve as a risk stratification tool along with glucose challenge (GCT) parameters. These women can be stratified early in the pregnancy course as having an increased risk for developing glucose intolerance and possibly neonatal hypoglycemia. Our findings suggest that overweight women are able to accommodate for greater changes in weight without affecting the GCT screening parameters, however not enough to prevent clinically significant neonatal hypoglycemia, therefore should be additionally subjected to glucose tolerance testing (GTT).
Fetal Gastric Area Ratio as a Predictor of Neonatal Abstinence Syndrome Treatment [26P]
Authors: Townsel Courtney , Stone Julie , DeBolt Chelsea , Ditommaso Nicole , Hussain Naveed , Campbell Winston
Published: April 2018

INTRODUCTION:

Opioid use in pregnancy doubled between 1998 and 2011. Neonatal abstinence syndrome (NAS) occurs in newborns exposed to opioids in-utero. Opioids delay gastric emptying and inhibit gastric motility in adults, however, it is unknown if opioids affect the fetal gastrointestinal system. We assessed whether gastric size in opioid-exposed fetuses predicts NAS treatment.

METHODS:

We undertook a retrospective cohort study of maternal-neonatal dyads with chronic opioid use who delivered at our tertiary hospital January 2005 to April 2017. Primary outcome: treatment for NAS (3 consecutive Finnegan scores >8 or 3 scores >24 within 96 hours of life). Medical records were reviewed for maternal and neonatal demographics and fetal ultrasound images. Fetal gastric size was measured from abdominal circumference images using major and minor axis calculating an ellipse comparing this to the abdominal circumference to derive the gastric area ratio (GAR). Analysis was two-sided (alpha of 0.05) by t-test for continuous and chi square for categorical variables.

RESULTS:

We identified 49 maternal-neonatal dyads. NAS treatment occurred in 67% (n=33) of neonates. Neonatal length of stay was longer [26.9 (days) ± 13.7 vs 8.2 ± 7.7, p<0.001] and mean peak Finnegan scores were higher in infants treated for NAS (12 ± 3 vs 5 ± 3, p<0.001). GAR was not different between groups [2.91 ± 1.5 (treatment) vs 2.85 ± 1.6 (no treatment), p=0.90] and did not predict NAS treatment.

CONCLUSION:

Fetal GAR does not predict NAS treatment. More studies are needed to determine if an ultrasound marker predictive of NAS treatment exists.
The Utility of Transvaginal Cervical Length in Predicting Delivery Interval in Viable Outpatient Twin Pregnancies [27P]
Authors: Dubin Ariel , Lin Carol , Lyon Liisa
Published: April 2018

INTRODUCTION:

Predicting preterm delivery in twin gestations helps identify women who may benefit from interventions such as antenatal corticosteroids within 7 days of delivery. Our aim was to quantify the performance of short cervical length (CL) (<25mm) in outpatient twin gestations to predict delivery within 7 days.

METHODS:

Outpatient transvaginal ultrasound reports for diamniotic twin gestations of 23w 0d to 28w 6sd were reviewed between January 2010-July 2014. Index CL was defined as the first CL less than 25mm. Primary outcome was the positive predictive value (PPV) of spontaneous delivery within 7 days of index CL. Secondary outcomes included PPV of index CL of 15mm and 10mm.

RESULTS:

Of the 411 included charts, 52 patients (12.6%) had a short cervix. There were no significant differences in major risk factors for preterm birth. Four women (1% of the total study population) delivered within 7 days of index CL; three of these had a short cervix while one had a normal CL. PPV of 25mm CL was 5.8% (95% CI 1.2-16.0); NPV 99.7% (95% CI 98.5- >99.9). The PPV of 15mm and 10mm CL were 9.1% (95% CI 1.1-29.2) and 20.0% (95% CI 7.5-55.6).

CONCLUSION:

In this retrospective observational study, CL of less than 25mm had a poor positive predictive value for delivery within 7 days. 25mm CL cutoff may not be useful to time interventions such as betamethasone administration or hospitalization. PPV increases with decreasing CL. Other tools can be considered in addition to CL measurement for intervention.
Amniotic Fluid Index Curves in the Obese Gravida: One Size Fits All? [36P]
Authors: Chishom Taylor , Stephens Angela , Raley Susanna , Street Linda , Browne Paul
Published: April 2018

INTRODUCTION:

The purpose of this study was to evaluate whether amniotic fluid index (AFI) curves differed based on maternal body mass index (BMI) category.

METHODS:

This was a retrospective cohort study of 500 pregnant women receiving ultrasounds with AFI measurements. The study cohort was subdivided by maternal intake BMI into three groups: normal weight (18.5-24.9), overweight (25.0-29.9) and obese (>30). Demographic and outcome data were evaluated with chi square for dichotomous variables and ANOVA or Kruskal-Wallis on continuous variables as appropriate. Linear regression was used to evaluate AFI over gestation in each group and analysis of covariance was used to evaluate AFI over gestation between groups.

RESULTS:

There was no correlation between AFI and gestational age in each group (normal weight (R=.055), overweight (R=.161), obese (R=.018) or as an aggregate (R=.06)). However, there was a difference in AFI over gestation between groups (F (2,1740) = 9.96, P<.001). Both, pre-existing diabetes (P=.002) and chronic hypertension (P<.001), were more prevalent in obese gravida. Obese gravida were more likely to develop gestational diabetes (P<.001). Development of pregnancy hypertensive disorders did not vary between BMI groups (P=.145). Mean gestational age of delivery was similar between groups (P=.266); however, infant birth-weight increased with increasing maternal intake BMI (P=.040).

CONCLUSION:

In this cohort, there is a difference in AFI based on maternal BMI when accounting for gestational age. While the absolute difference in our cohort was small, this finding suggests we should evaluate this question on a larger scale and potentially re-visit a “one size fits all” approach to AFI.
CINE MRI During Spontaneous Cramps in Women with Menstrual Pain [7Q]
Authors: Kuhn Caroline , Hellman Kevin , Tu Frank
Published: April 2018

INTRODUCTION:

Prior research has suggested that changes in the MR signal occur in the myometrial layer in women with dysmenorrhea. Since the mechanisms of dysmenorrhea are poorly understood, characterization of the relationship between MR signal changes and spontaneous pain report would be useful for developing a diagnostic tool.

METHODS:

This was an IRB-approved HIPAA-compliant prospective feasibility study during 2015-2017 on 16 women with dysmenorrhea and 10 healthy controls both on and off their menses while not taking analgesic medication. Continuous MRI was acquired using single HASTE sequence along with simultaneous reporting of pain severity with a squeeze bulb. The temporal relationships of signal changes were evaluated with Pearson correlations, image averaging, and statistical comparison to a random temporal distribution.

RESULTS:

Spontaneous progressive decreases in myometrial signal intensity were more frequently observed in women on their menses than in the same women off their menses or participants without dysmenorrhea (p’s < 0.01). Women without reductions in myometrial signal intensity on their menses either had a history of endometriosis or were not in pain. Episodes of cramping occurred either immediately before or 32-70s after myometrial signal change onset (p’s <0.05).

CONCLUSION:

The combination of early and delayed subjective pain report - relative to a decrease in T2 weighted signal intensity – provides new evidence supportive of a contribution of myometrial activity and impaired hemodynamics to menstrual pain. The proposed approach will allow future studies to evaluate effects of interventions for uterine pain disorders and test mechanistic hypotheses about the etiology of visceral pain.
Patient Satisfaction with Single-Port vs Multi-Port Minimally Invasive Hysterectomies [16Q]
Authors: Perlin Lauren , Fisher Jay
Published: April 2018

INTRODUCTION:

Robotic surgery offers benefits such as shorter recovery time, shorter hospital stays, and decreased post-operative pain. Single-port robotic-assisted laparoscopy, which requires only a single incision, may offer further benefits.

METHODS:

Patient satisfaction was compared between those undergoing laparoscopic single-port vs multi-port hysterectomies. Patients received surveys on post-operative day 0 or 1, and at their two-week and six-week post-operative visits.

RESULTS:

Data analysis included survey responses from 29 patients of which 13 (44.8%) were in the single-port group and 16 (55.2%) were in the multi-port group. Patients who underwent single-port surgery had lower pain scores during their hospital stay (current pain 2/10 versus 5/10, P=.001, and maximum pain 5/10 versus 7/10, P=.008). They also had significantly lower estimated blood loss (65 mL versus 107 mL, P=.035) and shorter length of hospital stay (100% versus 87.5% discharged by POD#1, P=.01). Operative times did not differ between the two groups (176 minutes versus 171 minutes, P=.13). At two weeks and six weeks post-operatively, satisfaction scores were similar between the two groups with a trend towards improved satisfaction with incision appearance at six weeks (100% vs 61.5% completely satisfied, P=.13).

CONCLUSION:

Patients are more satisfied immediately after undergoing laparoscopic single-port hysterectomies as compared to multi-port hysterectomies. Patients experience significantly less pain while in the hospital. Additionally, estimated blood loss is decreased by 39% and patients are more likely to be discharged on the same day as their operation. The differences in satisfaction do not persist at patients’ two-week and six-week post-operative visits.
Is There a “July Effect” in Oncologic and Benign Gynecologic Surgery? [17Q]
Authors: Mastroyannis Spyridon A. , Buckingham Lindsey , Brensinger Colleen , Latif Nawar , Haggerty Ashley , Ko Emily
Published: April 2018

INTRODUCTION:

The “July Effect” is a phenomenon previously described as increased complication rates during times of trainee transition. This study aimed to evaluate the effect of academic quarter on perioperative outcomes for gynecologic surgery patients.

METHODS:

Patients who underwent gynecologic surgery with trainee involvement were identified in the National Surgery Quality Improvement Program (NSQIP) database between July 1, 2006 and June 30, 2012. Benign and oncologic cases were collected. Academic quarters of the year were defined as Q1: Jul-Sep, Q2: Oct-Dec, Q3: Jan-Mar and Q4: Apr-Jun. Major complications included surgical site infection (SSI), myocardial infarction, pulmonary embolism, stroke, deep vein thrombosis (DVT), and re-intubation. Kruskal-Wallis and Chi square tests were performed. Two-sided alpha with p<0.05 was designated as significant.

RESULTS:

Of 104,012 gynecologic surgeries, 25,290 (21,086 benign; 4204 oncologic) had confirmed resident involvement. In benign cases, re-operation rate was highest in Q1 vs Q2-4 (1.8% vs 1.1-1.6%; P=0.043); length of stay (LOS) in days was also increased in Q1 (2.0 vs 1.6-1.8, p=0.0149). In Q3, higher rates of organ space SSI and emergent cases were observed: (1.0% vs 0.5-0.6%, P=0.0197 and 4.3% vs 3.4-3.9%, p=0.0321 respectively). For oncology patients, only LOS was increased for Q1 (4.8 vs 3.8-4.1, p<0.0001).

CONCLUSION:

In this national sample, first academic quarter was associated with increased LOS and re-operation, but not overall severe complication rate in benign gynecologic surgeries. In oncology, LOS was increased, but overall complications, re-operation and readmissions were not. The “July Effect” did not hold true for gynecologic surgery with trainee involvement.
Association Between Uterine Fibroid Findings on Pelvic MRI, Bleeding Symptoms, and Quality of Life [19Q]
Authors: Shaffer Robyn K. , Fast Angela M. , Vu Kim-Nhiem , Dobberfuhl Amy D. , Ghanouni Pejman , Chen Bertha
Published: April 2018

INTRODUCTION:

Uterine fibroids are a common cause of abnormal uterine bleeding with diminished quality of life (QOL). Prior studies rely on sonography which can be inaccurate in evaluating fibroid size and location, especially in large fibroids. We sought to correlate uterine fibroid symptoms with fibroid characteristics using MRI imaging.

METHODS:

A retrospective chart review was conducted for patients seen at the Stanford Fibroid Clinic. Patient demographics, medical history and pelvic MRI data were collected on 60 patients with completed Uterine Fibroid Symptom (UFS) and Health Related-Quality of Life (HR-QOL) surveys. Primary outcomes included UFS and HR-QOL scaled scores and sub-scores.

RESULTS:

Patients with anemia had significantly worse UFS (mean 73.0 vs 43.4, P=.006) and HR-QOL scores (mean 34.6 vs 61.1, P=.006). Post-menopausal patients had significantly better HR-QOL scores (mean 74.5 vs 49.9, P=.034). The dominant fibroid volume was significantly smaller in women with worse UFS symptoms (UFS>75) (mean 99.5 vs 247.1 mL, P=.015) compared to women with few UFS symptoms (UFS<25). Worse symptoms tended to be seen when fibroids were located in the fundus vs body (mean UFS 58.5 vs 37.7, P=.059) or if fibroids were submucosal or intracavitary compared to intramural or subserosal (mean UFS 78.1 vs 46.9, P=.076).

CONCLUSION:

Abnormal uterine bleeding in conjunction with anemia contributed more significantly to symptom severity and QOL than fibroid size. UFS was inversely related to fibroid volume, suggesting fibroids that cause bleeding have a disproportionate impact on symptom severity independent of size.
Gynecologic Surgeons’ Perspectives on Risk Factors and Prophylaxis of Trocar Site Hernias: A National Survey [22Q]
Authors: Wells Ali , Germanos George , Salemi Jason , Mikhail Emad
Published: April 2018

INTRODUCTION:

Although trocar site hernias (TSH) occur in only 1.5-1.8% of all laparoscopic procedures, TSHs can represent serious postoperative complications. The purpose of this study was to survey gynecologic surgeons who are active members of the Society of Laparoendoscopic Surgeons (SLS) in order to elicit their experiences with TSHs, including fascial closure preferences.

METHODS:

After reviewing the clinical and epidemiological literature to compile relevant questions, an anonymous survey was designed using Qualtrics web-based survey software. The survey link was sent to all members of SLS via email. Descriptive analyses included frequencies, percentages, and chi-square tests or Fisher’s exact tests for measures of association.

RESULTS:

Respondents included 242 gynecologic surgeons, 54.2 % of whom reported at least one patient developing a TSH within the past 10 years. The likelihood of having ≥1 patient with TSH increased with higher monthly surgical volume; 39.5% for low-volume surgeons (≤10 procedures/month) compared to 71.4% of high-volume surgeons (≥20 procedures/month) (p<0.01). Current use of fascial closure devices was more common among surgeons in an academic practice (60.3%) compared to those in private practice (39.6%, p <0.01). Among all respondents, 87.6%, 16.1%, and 2.5% close 10-12mm, 8mm, and 5mm ports, respectively, without differences according to surgical volume or practice setting. Approximately 6% reported closing more than one port size.

CONCLUSION:

Increased surgical volume is directly proportional to TSH development. Port size remains one of the main risk factors for TSH development, with most respondents closing only 10-12 mm ports irrespective of surgical volume or practice setting.
Does Cost Influence the Choice of Disposable vs Reusable Instruments? Survey of Obstetrician/Gynecologists [24Q]
Authors: Yang Helen , Ross Sue , Capstick Valerie
Published: April 2018

INTRODUCTION:

A “cost awareness” campaign was undertaken at the Lois Hole Hospital for Women from 2015 to 2016 to raise awareness about costs of disposable versus reusable instruments for laparoscopic procedures. We undertook a survey of obstetrician/gynecologists (Ob/Gyns) to find out if the campaign had affected their attitudes about choosing disposable versus cheaper reusable instruments.

METHODS:

In 2015 and 2017, all full-time university-associated Ob/Gyns were mailed a cover letter, questionnaire and coffee card ($5) with postage-paid return envelope. Responses (with unique ID) from Ob/Gyns who perform laparoscopic procedures were entered into a password-protected REDCap database on a secure server. Data analysis used REDCap summary descriptive statistics.

RESULTS:

34/47 eligible Ob/Gyns (72%) completed questionnaires before and after the intervention, with median 11.5 years in practice. The majority had undertaken MIS training, mainly during residency (78.4%) and conferences (73.0%). Before the intervention, the three most important qualities influencing their decision to use a particular instrument were safety (64.9%), effectiveness (54.1%) and personal experience (48.6%), and after the intervention were effectiveness (63.0%), safety (47.8%) and ease of use (47.8%). Device cost was ranked sixth (29.7%) before and fourth after (26.1%).

CONCLUSION:

Given the current economy, operative costs are constantly under review. Knowledge about Ob/Gyns’ attitudes provides information to design more effective awareness campaigns to encourage use of less costly instruments. To change practice, a campaign increasing Ob/Gyns’ exposure to cheaper but safe and effective instruments may help to increase uptake and potentially lead to cost reduction. Cost awareness alone is unlikely to change practice.
Can We Talk About Sex? Patient and Providers’ Comfort with the Sexual History [26Q]
Authors: Hart Casuarina , Ganz Eric , Brustman Lois
Published: April 2018

INTRODUCTION:

Sexual histories are essential in evaluating and counseling patients. The evolution in sexual practices has not been incorporated into the modern sexual history. The aim of this study was to determine the types of sexual behaviors patients engage in, provider counseling, and patient comfort discussing sexual behaviors.

METHODS:

IRB-approved, voluntary, anonymous surveys were distributed at the Mt Sinai associated Obstetrics and Gynecology outpatient offices. These surveys used a Likert scale to evaluate sexual behaviors, if providers discussed certain behaviors, and patients’ comfort discussing their behaviors with providers.

RESULTS:

207 surveys were completed and analyzed. 90% of our patients participated in vaginal sex, 47% of patients participated in anal sex, 89% of patients received oral sex, and 85% performed oral sex. 39% of patients reported never using a condom. Patients are infrequently asked about sexual habits by providers. Only 50.7% of patients reported being asked about condom use. Over 80% of patients felt comfortable discussing sexual behaviors. The sexual behaviors that had a statistically significant age distribution were the use of sex toys and hook up apps.

CONCLUSION:

Our patients are sexually active in a variety of ways at or above the national average. More of our patient population is engaging in anal sex than the national average by 11%. Our patients are not being asked the basic sexual history. In general patients feel comfortable discussing sexual habits with providers. Age is not relevant when screening most sexual behaviors. This survey showcases a missed opportunity in screening and counseling patients.
Viable Umbilical Tissue Use in Laparoscopic Myomectomy: Study Design and Short-Term Post-Operative Outcomes [29Q]
Authors: Karon Magdalene
Published: April 2018

INTRODUCTION:

Despite alternative methods such as embolization or leuprolide injections, myomectomy remains the “gold standard” for removing uterine fibroids, especially in younger women desiring pregnancy. Laparoscopic myomectomy offers a minimally invasive approach with the best chances for conception. However, post-operative adhesions and defects within the endometrial lining are still a risk. Thus, an ideal adjunct would promote endogenous regeneration of the tissue defect created by the surgery, minimize adhesions, and improve blood flow for future embryo implantation. We present for the first time use of viable, cryopreserved umbilical tissue (vCUT*, Stravix, Osiris Therapeutics, Inc.) in myomectomy. vCUT is ideal for prevention of adhesions and strengthening of the incised uterus due to its pro-regenerative, anti-fibrotic, angiogenic, and anti-inflammatory properties. vCUT contains all endogenous neonatal extracellular matrix proteins, growth factors, and tissue viable cells, including mesenchymal stem cells, in their native state.

METHODS:

Ten women underwent laparoscopic myomectomy. After fibroid removal the endometrium was closed with a monofilament suture, and vCUT was incorporated into the closure layer. Patients will be assessed at 3mo and 6mo post-op by 3D Doppler sonography for endometrial thickness and followed until time of conception and mandatory Cesarean delivery. At delivery, uterine anatomy and scarring will be assessed and, when possible, biopsies taken.

RESULTS:

Preliminary data show all patients are healing well with minimal pain, no complaints, and no abnormal bleeding. Data collection is on-going for 3mo (n=5) and 6mo (n=5) outcomes.

CONCLUSION:

Viable, cryopreserved umbilical tissue shows promise as a novel adjunct to support endometrial regeneration following laparoscopic myomectomy.
Ultrasound Prediction of Small-for-Gestational Age at Birth: The More, the Merrier? [39Q]
Authors: Beddow Meghan E. , Blue Nathan R. , Savabi Mariam , Katukuri Vivek R. , Fritts Cody , Chao Conrad R.
Published: April 2018

INTRODUCTION:

Compare the ability of serial ultrasound (US) exams to predict small-for-gestational age (SGA) at birth compared to a single US exam at various gestational ages.

METHODS:

We reviewed deliveries at our institution from January 1, 2013 to March 31, 2017. We included well-dated, non-anomalous, singleton pregnancies with multiple estimated fetal weight (EFW) measurements before delivery. EFWs and percentiles were calculated using the Hadlock formulas. Fetal growth restriction (FGR) was defined as EFW <10th percentile, and SGA was defined as birth weight <10th percentile. We calculated the sensitivity, specificity, positive and negative predictive values for serial US exams to predict SGA at birth, as well as for a single US performed at either 24-276, 28-316, 32-356, or ≥36 weeks gestation.

RESULTS:

We included 1926 pregnancies (5609 total US exams, mean: 2.93 per patient). The rate of SGA at birth was 11.8% (n=228), and 14.2% (n= 274) had FGR on one or more US exams. The sensitivity of serial exams (48.2%, 95% confidence interval [CI] 41.6-54.9) to predict SGA was comparable to a single US performed at 32-356 weeks (50.3%, 95% CI 42.8-57.7) or ≥36 weeks (49.4%, 95% CI 38.5-60.4), whereas a single US at 24-276 or 28-316 weeks performed less well.

CONCLUSION:

To predict SGA at birth, the best sensitivity is achieved using either serial US exams or a single US performed beyond 32 weeks. If a single additional US is indicated to screen for FGR, it may be reasonable to delay this US until 32 weeks gestation.
Use of Enhanced Recovery after Surgery (ERAS) in Major Gynecologic Surgery [1R]
Authors: Owens Kristin , Stovall Dale W.
Published: April 2018

INTRODUCTION:

The enhanced recovery after surgery protocol (ERAS) is a postoperative protocol which emphasizes quality of recovery over speed. Our study compared postoperative antiemetic and opioid use before and after implementation of the ERAS program at MDMC.

METHODS:

In this single-center, cohort study, we identified two groups of patients for comparison. The first group was women who underwent a major gynecologic surgical procedure 6 months prior to ERAS implementation and the second group were women who underwent their procedure in the six months after implementation. Major gynecologic procedures included TAH, TVH, myomectomy, and open staging procedures. Primary outcomes were post-op anti-emetic and opioid therapy. Secondary outcomes included intraoperative i.v. fluids and length of stay (LOS).

RESULTS:

A total of sixty subjects were included in the study, 29 in the pre-ERAS group and 31 in the post-ERAS group. The mean age of the study population was 49.5. There were no differences between groups in regards to post-operative anti-emetic use. A significantly greater proportion of subjects in the post-ERAS group, none of whom received PCA administration, received i.v. opioids on the ward, 25.8% (8/31) versus 6.9% (2/29), respectively (P < 0.05). The post-ERAS group also received significantly less intraoperative i.v. fluids, 1595.9 mL versus 1909.5 mL, respectively (P < 0.05). The LOS was less for the post-ERAS group, 2.0 days versus 2.5 days, but the difference was not significant.

CONCLUSION:

Implementation of ERAS for major gynecologic procedures at Methodist significantly reduced i.v. fluid use, but did not reduce the need for anti-emetic or opioid therapy.
Ilioinguinal/iliohypogastric Nerve Blocks as a Treatment for Pelvic Pain in a Gynecologic Population [4R]
Authors: Cooke Carly M. , Flaxman Teresa , Chen Innie , Singh Sukhbir S.
Published: April 2018

INTRODUCTION:

Ilioinguinal/iliohypogastric nerve blocks (IINBs) are a simple, minimally invasive option for managing pain associated with ilioinguinal/iliohypogastric neuropathy (IIN). This study assessed the safety and efficacy of IINBs in women with IIN associated pelvic pain.

METHODS:

A retrospective chart review of patients who received IINBs at The Ottawa Hospital between January 1st, 2012 and July 13th, 2017 by a single physician was performed. Patient demographics, history, examination findings, and block data were extracted. Chi-square and Mann-Whitney U tests explored differences in patient characteristics between women with and without effective response to IINBs.

RESULTS:

Amongst 106 meeting inclusion criteria, 381 IINBs were performed. Most women had a history of chronic pain (n=97,90%), endometriosis (n=69,65%), and/or lower abdominal surgery (n=95,90%). On examination, 56 women (53%) had tenderness within the IIN distribution, 59(56%) had point tenderness, 20(19%) had a positive Carnett’s sign, 21(20%) had allodynia, and/or 7(7%) had hyperalgesia. Data regarding effectiveness was available for 301/381 blocks. Of these, the majority (n=227,75%) greatly improved pain, 11%(n=33) somewhat improved pain, 10%(n=31) had no effect, and 3%(n=10) worsened pain. Sixty women (57%) had at least one block which greatly improved pain. Five women (5%) reported complications which could be directly related to blocks. No significant differences in patient characteristics were observed between women with and without effective response to IINBs.

CONCLUSION:

Ilioinguinal/iliohypogastric nerve blocks may provide pain relief for women with complex pelvic pain and features of central sensitization with a low rate of adverse events. Future prospective studies on IINB safety and efficacy are warranted.
Awareness, Attitudes, Practices and Continuation of HPV Vaccines in Lebanon [7R]
Authors: Seoud Muhieddine , Jaafar Iman , Ghanem Rayan , Adra Abdallah
Published: April 2018

INTRODUCTION:

HPV is a major cause of anogenital, oropharyngeal and penile cancers. Currently, there are three safe and effective HPV vaccines, however introducing them in the Middle East is slow for various social, cultural and religious reasons.

METHODS:

At the women health center of the AUBMC, HPV vaccination was offered to women and their daughters since 2007. We will present a retrospective review of a prospectively collected database on 563 Lebanese females who received these vaccines.

RESULTS:

From 2007 to 2017, a total of 563 females were HPV vaccinated. (379 (67%) had Gardasil and 183 (33%) had Cervarix; P=0.00). Their average age was 25.64±5.86(12.16-51.12). hundred 449 (87%) completed 3 doses and 67 (13%) took only 2 doses. The 3 doses completion was highest between 2007-2013 [329/449 (72%)] while the 2 doses completion was more common from 2013-2017 [47/57 (70%)]. 2/175 (1.13%) of those who received Gardasil had subsequent abnormal Pap smears (mostly LSIL) after an average of 33 months, while 5/91 (5.5%) of those who received Cervarix had abnormal Pap smears [ASCUS: 3/91 (3.3%); HSIL: 2/91 (2.2%,) after an average of 5 months and 1 month respectively]. The average abnormal cytology rates at AUBMC is 1.9-2.2% during that period of time.

CONCLUSION:

We report successful introduction and continuation of HPV vaccine into our private patient Middle-Eastern population. Longer follow-up is needed to assess the proper impact on genital warts, pre-cancerous genital lesions and genital and other cancers.
Physicians’ Perspective on Reproductive Health Education [9R]
Authors: Do Linh , Reddy Sireesha
Published: April 2018

INTRODUCTION:

Reproductive health education (RHE) to adolescents is essential to decreasing teen pregnancy rates, increasing contraceptive use and overall knowledge of reproductive health. We are interested in learning physicians’ perspective on RH topics, what age is appropriate for the discussions and on parental presence during RHE discussions.

METHODS:

A 20-question survey with inclusion criteria, demographics, and subjective norm concerning 9 RHE topics such as puberty, period, STI, pregnancy, contraception, sex, HIV/AIDS, abortion, and gender identity and sexual orientation were inputted on RED CAP. An individualized link was emailed to 123 pediatric, Obstetrician & Gynecologist, and family physicians at Texas Tech University Health Center. 42 surveys completed.

RESULTS:

Physicians believe parents should be in the room during RHE discussions with a P<.05% with a 32% response rate. Significantly more Obstetrician & Gynecologist prefer to discuss contraceptive use with parental presence out of the 9 RHE topics for both male and female adolescents compared to pediatricians. Physician parental status does not affect their opinion on parental attendance during this conversation.

CONCLUSION:

OBGYN, pediatricians and family medicine doctors desire parent presence when discussing RHE topics. This may be for fear of what parents may think about certain topics. However, confidentiality is also a concern. Physicians need more counselling that parents and their adolescents desire confidentiality. Our previous survey showed that dependent on topic and age, confidentiality and sole discussions can be appropriate.
Necessity of Routine Post-Operative Day One Hemoglobin after Cesarean Section [17R]
Authors: Potocnik Elizabeth A. , Alford Catherine , Plante Brianne , Elliott John
Published: April 2018

INTRODUCTION:

Cesarean section represents the most common surgery in the United States. The national cesarean section rate has increased in recent years and most recently was found to be 32.2%. Given the increased blood loss from a cesarean section compared to a vaginal delivery, it is routine practice at our institution to obtain a post-operative complete blood count (CBC) on the first day following all cesarean sections to evaluate for post-operative anemia. Despite this, studies have shown that the rate of blood transfusion following cesarean section is low.

METHODS:

A retrospective chart review of all patients who underwent a term, uncomplicated cesarean section in 2016 was undertaken.

RESULTS:

The cesarean section rate at Riverside Methodist Hospital for the year of 2016 was found to be comparable to the national average at 31%. The charts of 2,041 patients were reviewed, 587 did not meet inclusion criteria. Of the 1,439 patients included, 15 (1.0%, 95% CI 0.6-1.7) required blood transfusion. Eight of these patients experienced symptoms of anemia, four were asymptomatic but showed clinical signs of anemia, and three were asymptomatic without clinical signs. The average estimated blood loss recorded at the time of surgery was found to be 1017.9cc (468.1) for those who were transfused compared to 641.1cc (152.7) for those who did not undergo transfusion (P =.01).

CONCLUSION:

Given the low rate of blood transfusion following a routine, uncomplicated cesarean section, a routine post-operative CBC may not be necessary and the accrued cost of continuing this practice is significant.
Timing of Uterine Tamponade and Associated Morbidity in Patients with Stage 3 Postpartum Hemorrhage [20R]
Authors: Ernst Amanda , Vogel Rachel Isaksson , Bojan Katelyn , Erickson Alexandra , Das Kamalini
Published: April 2018

INTRODUCTION:

Mortality from postpartum hemorrhage (PPH) is decreasing in the United States, however the incidence of PPH is actually increasing. Stage 3 PPH, or estimated blood loss greater than 1500 mL as defined by the California Maternal Quality Care Collaborative, often requires second-line intervention including uterine tamponade with Bakri balloon, dilation and curettage, uterine artery embolization, hemostatic sutures, compression sutures, or ultimately hysterectomy. Although guidelines exist for management of PPH, the timing and use of second-line therapies is less standardized and varies based on provider experience. We sought to determine whether timing of uterine tamponade, generally the first line treatment of ongoing PPH, is associated with morbidity among patients who experienced stage 3 blood loss.

METHODS:

This is a retrospective chart review of women with stage 3 PPH at a single academic institution. Patient demographics, delivery information, timing of second-line interventions and transfusion, and morbidity were abstracted from the electronic medical record. Morbidity included ICU admission, hemorrhagic shock, disseminated intravascular coagulopathy, renal failure, and endometritis.

RESULTS:

Between 2007 and 2015, 267 patients experienced a stage 3 PPH. Second-line therapies were used in 116 patients, with Bakri balloon being the most commonly used intervention. 28 patients had Bakri balloon placement within 30 minutes of PPH, compared to 19 patients who had placement after 30 minutes. Women who received a Bakri within 30 minutes of onset of PPH experienced lower composite morbidity.

CONCLUSION:

Placement of a Bakri balloon within 30 minutes of the onset of PPH may decrease morbidity in patients with stage 3 PPH.
Improving Obstetric Hemorrhage Morbidity and Mortality by a Checklist-based Management Protocol [26R]
Authors: Smith Rachael , Foley Michael , Hermann Catherine , Erickson Laurie , Mercer Laura
Published: April 2018

INTRODUCTION:

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the US. Many obstetrical teams rely on clinical judgment when managing PPH, however critical care research has demonstrated that specific and uniform protocols result in better outcomes. This study analyzed the effect of implementation of a checklist-based management protocol for PPH.

METHODS:

A checklist was developed by a multidisciplinary team for the management of PPH that focused on timely diagnosis and systematic administration of uterotonics, invasive interventions, transfusions, and lab draws. A training video was used to introduce the protocol to nursing and physician staff. Following formal implementation, pre and post-protocol analyses were performed using nine matched months from 2015 and 2016. Outcome measures were surrogates for maternal morbidity.

RESULTS:

147 subjects met criteria in the pre-protocol group and 150 met criteria in the post-protocol group. Within the analysis of the first three matched months, there was a significant decrease in surgical interventions for PPH (p value 0.039) and a decreased length of stay for PPH following cesarean sections (p value 0.039). In the 9 month analysis, there was a significant decrease in severe PPH as defined by an EBL of >2L (p value 0.035).

CONCLUSION:

The implementation of a checklist based management protocol for PPH has shown a promising trend in improving maternal outcomes and healthcare delivery for obstetric hemorrhage. Specifically, significant improvement in severe PPH rates was demonstrated. Further multi-center research is needed to demonstrate consistent beneficial effects of such protocols.
The Discovery of Unbalanced Translocations through Genome-Wide cfDNA Testing [32R]
Authors: Dyr Brittany , Boomer Theresa , Caldwell Samantha , Almasri Eyad , Wardrop Jenna , Donnenfeld Alan
Published: April 2018

INTRODUCTION:

The MaterniT® GENOME test reports on genome-wide copy number variations >7Mb, making it uniquely positioned to identify deletions and duplications, such as those in unbalanced translocations. Since late 2015, more than 28,000 MaterniT® GENOME samples have been ordered. Here we describe cases where unbalanced translocations have been discovered.

METHODS:

Maternal blood samples submitted for genome-wide cfDNA testing were subjected to DNA extraction, library preparation, and whole-genome massively parallel sequencing as described by Jensen et al. Sequencing data were analyzed using a novel algorithm as described by Lefkowitz et al.

RESULTS:

A total of 28,760 samples were submitted to the clinical laboratory and 1,392 (4.8%) of these resulted positive. Among all positives, 49 were interpreted as possible translocation events between two chromosomes. Fetal confirmation was reported in 59% with an additional 37% likely concordant given family or clinical history, there were two cases (4%) lost to follow up and zero reported discordant cases. Prior knowledge of parental translocation existed for 29%, while 16% were identified as follow up to cfDNA testing. A minority of cases (6%) were de novo, with the remaining subset pending full parental assessment (51%). Totals will be updated prior to final publication.

CONCLUSION:

Familial translocations not previously amenable to cfDNA screening may now benefit from early identification or added reassurance. New discovery of families at risk of carrying a translocation often helps explain past pregnancy complications, as well as clarify future reproductive risk. MaterniT® GENOME is a relevant screening tool for families with a known translocation or suggestive family history.
Perinatal Outcomes in Twin Pregnancies Complicated with Short Cervix Treated with Cervical Cerclage [35R]
Authors: Idler Jay , Maldonado Maria , Hase Naomasa , Nunez Aldo , Paridon Alexander , Patwardhan Manasi
Published: April 2018

INTRODUCTION:

Multifetal pregnancies are associated with poor outcomes. The goal of this study was to compare perinatal outcomes, in twin pregnancies complicated by short cervix managed with cerclage placement, to those managed expectantly.

METHODS:

We performed a retrospective cohort study of twin pregnancies complicated with short cervix (defined as <2.5cm) diagnosed before 24 weeks of gestation, at our institution between 2010 and 2015. Neonatal and pregnancy outcomes of patients who had cerclage placed were compared to those who did not. Independent t-test and Pearson’s chi-square test was used for the data analysis.

RESULTS:

835 twin pregnancies were reviewed. 33 patients (3.9%) had short cervix before 24 weeks of gestation. Fourteen (42.4%) of these patients had a cerclage placed. Of those whose pregnancies reached viability (75%), 15 (62.5%) did not have a cerclage in place, while nine (37.5%) did. Mean gestational age at delivery was significantly earlier in those who had a cerclage placed as compared to those who did not (27 versus 32 weeks; p = 0.03). Admission to the neonatal intensive care unit (NICU) was significantly higher in those who had a cerclage placed (9 vs. 12; p= 0.03). Birth weight was significantly lower, with a mean of 1010 grams in the cerclage group as compared to 1748 grams for those without a cerclage (p = 0.01).

CONCLUSION:

Consistent with other meta-analyses, our study demonstrates that cerclage placement in twin pregnancies complicated by short cervix is associated with poorer outcomes. Cerclage placement should be used with caution, after performing a detailed risk-benefit analysis.
BRCA Mutation Testing for First-Degree Relatives of Women With High-Grade Serous Ovarian Cancer [4OP]
Authors: Kwon Janice S. , Tinker Anna , Hanley Gillian , Pansegrau Gary , Carey Mark S. , Schrader Kasmintan
Published: April 2018

INTRODUCTION:

Women with high-grade serous ovarian cancer (HGSC) have a 20% chance of carrying a BRCA1 or BRCA2 mutation and are eligible for BRCA testing. Many are untested, therefore their female first-degree relatives (FDR) may not qualify for testing unless they have specific ethnicity or other personal/family cancer history. We conducted a cost-effectiveness analysis to evaluate BRCA mutation testing for these FDR who are otherwise ineligible for testing.

METHODS:

A Markov Monte Carlo simulation model estimated the costs and benefits of 3 strategies for female FDR of HGSC patients whose BRCA status is unknown: 1) no BRCA testing; 2) universal BRCA testing, followed by risk-reducing bilateral salpingo-oophorectomy (RRBSO) for mutation carriers (“BRCA testing”); 3) universal RRBSO, without BRCA testing (“RRBSO”). Effectiveness was estimated in quality-adjusted life year (QALY) gains. Sensitivity analyses accounted for uncertainty around various parameters. The time horizon was 50 years.

RESULTS:

BRCA testing for female FDR of HGSC patients yielded a higher average QALY gain at acceptable cost compared to no BRCA testing, with an ICER of $7,729 per QALY. BRCA testing was more effective and less costly than RRBSO (19.20 QALYs vs 18.48 QALYs, and $10,108.35 vs $13,959.20, respectively), therefore BRCA testing is the dominant strategy. Results were stable over a wide range of plausible costs and estimates. Compliance with hormone replacement therapy had to exceed 84% for RRBSO to be the preferred strategy.

CONCLUSION:

BRCA mutation testing should be offered to all female first-degree relatives of women with high-grade serous ovarian cancer when their BRCA mutation status is unknown.