bluuebunny/crossref_metadata_2025 huggingface dataset:
Blood Pressure Trends in Pregnancy: Is There a New Normal? [29D]
Authors: Benham Joshua , Ganju Nihar , Sheth Sheetal , Marko Kathryn
Published: May 2017

INTRODUCTION:

Few studies have explored blood pressure (BP) trends in pregnancy and the postpartum period. The accepted belief is that BP in pregnancy stays close to non-pregnant values (120/80mmHg). Studies also suggest variance between clinic and home based BP measurements. In this report, we describe the use of digital health technology to gather weekly BP values and better track BP trends in pregnancy.

METHODS:

Retrospective analysis was conducted of pregnant patients enrolled in the first trimester from 12 university-affiliated clinics. Patients received a digital sphygmomanometer and were asked to check home-based blood pressure at least weekly. BP averages were categorized by pre-pregnancy body mass index (BMI).

RESULTS:

381 patient records had complete blood pressure data for the entire pregnancy totaling 8101 data points. Mean systolic BP was 101 mmHg (±11.3) for BMI < 18.5, 106 mmHg (±10.8) for BMI 18.5-24.9, 112 mmHg (±10.6) for BMI 25-29.9, 117 mmHg (±11) for BMI 30+. An ANOVA analysis demonstrated significant differences between weight classes (p < 2.8e-34). Mean systolic BP was higher in clinic vs at home except in the obese class.

CONCLUSION:

Mean systolic BP may be lower in pregnancy and increases significantly with increasing BMI. BP collected at home is frequently lower than clinic measurements and may be a more accurate reflection of “normal” BP. We plan to analyze this data to identify norms for each trimester. Further study of high frequency at-home BP monitoring is needed to improve our understanding of blood pressure trends in pregnancy.
Acceptability of Supplemental Progesterone to Prevent Preterm Labor and Low Birth Weight in Pregnant Zambian Women [32D]
Authors: Wong Jeffrey M.H. , Dogra Nupur , Kanga Neha , Ngoma Mary , Serghides Lena , Silverman Michael
Published: May 2017

INTRODUCTION:

Intramuscular and vaginal progesterone are recommended for the prevention of preterm labor (PTL) in women with risk factors. Studies are emerging to indicate that HIV-infected women on combination antiretroviral treatments (cART) are at risk of PTL and low birth weight (LBW) and may benefit from supplemental progesterone. This study aims to determine the perceived acceptability of various modes of progesterone supplementation to prevent PTL and LBW in HIV-infected and HIV-uninfected women.

METHODS:

HIV-infected and HIV-uninfected women were recruited in Lusaka, Zambia. The participants completed a questionnaire to assess their concern for PTL and LBW, and their willingness and preference for oral, vaginal, or intramuscular progesterone supplementation for preventing PTL and LBW.

RESULTS:

The study questionnaire was completed by 147 participants. 98.6% of participants would consider using a medication to help prevent PTL and LBW, of whom 97.9% would consider using an oral form of progesterone. In addition, 83.3% and 84.0% of women would consider intramuscular and vaginal (gel or tablet) administration of progesterone respectively. When choosing between intramuscular and vaginal modes of progesterone, 60.5% of participants (n=147) preferred intramuscular progesterone, while 39.5% preferred vaginal progesterone. There were no differences in preference between HIV-infected (n=70) and HIV-uninfected (n=77) women.

CONCLUSION:

Pregnant Zambian women demonstrated a high degree of acceptance for all modes of progesterone supplementation for the prevention of PTL and LBW. Women preferred intramuscular over vaginal supplementation. Progesterone supplementation can be considered a feasible intervention for preventing PTL and LBW in both HIV-infected and HIV-uninfected pregnant Zambian women.
Association Between Partner-Relationship Satisfaction During Pregnancy and Maternal Postpartum Depression [39D]
Authors: Mesina Anna M. , Kjerulff Kristen H. , Deimling Timothy , Phaeton Rebecca , Repke John T.
Published: May 2017

INTRODUCTION:

The purpose of this study was to investigate partner-relationship satisfaction during pregnancy and its association with postpartum depression. Several prenatal risk factors for postpartum depression have been identified, including history of depression, life stressors, and depression during pregnancy. However, little research exists on whether maternal-partner relationship dissatisfaction during pregnancy is associated with increased risk for postpartum depression.

METHODS:

This was a planned secondary analysis using data prospectively collected from interviews in the third trimester and at 1 month postpartum of women aged 18-35 who delivered their first singleton birth in Pennsylvania, 2009-2011 (N= 2,844). Relationship satisfaction was measured in the third trimester using items adapted from the Dyadic Adjustment Scale (DAS). Women scoring 12 or greater on the Edinburgh Postnatal Depression Scale (EPDS) at the 1-month interview were categorized as having postpartum depression. Multivariable logistic regression was used to evaluate the association between relationship satisfaction and postpartum depression, controlling for the confounders of marital status, poverty, race/ethnicity, age, history of anxiety/depression, and unintended pregnancy.

RESULTS:

Women in the lowest third on relationship satisfaction during pregnancy were significantly more likely to score as depressed on the EPDS (odds ratio, 2.14, 95% confidence interval, 1.29-3.55) in comparison to women in the highest third of the distribution, controlling for the confounders. Additional significant predictors were history of anxiety/depression, maternal age younger than 30, and non-white race/ethnicity.

CONCLUSION:

In this prospective cohort study, we found that low relationship satisfaction during pregnancy was a significant predictor of postpartum depression among first-time mothers.
A Comparison of Peripartum Scoring Systems of Anticoagulation for Venous Thromboembolic Prophylaxis [4K]
Authors: Orfanelli Theofano , Awomolo Adeola , Gomez Daniela , Doulaveris Georgios , Duzyi Christina
Published: May 2017

INTRODUCTION:

Postpartum VTE is rare (0.16%), however, its potential for mortality make it an important focus for intervention. The American College of Obstetricians and Gynecologists (the College) and the Royal College of Obstetricians & Gynaecologists (RCOG) have proposed scoring guidelines for antepartum (AP) and postpartum (PP) prophylaxis. Threshold scores for treatment have not been validated. Our study compared the potential impact of these scoring thresholds at a regional perinatal center.

METHODS:

We conducted a retrospective cohort study of patients admitted for maternity care over 4 months. Each patient was assigned an AP and PP risk score using both guidelines. Any VTE occurring up to 6 weeks postpartum was obtained by a review of the medical records. Fischer's exact test was used for categorical variables.

RESULTS:

311 women were included in our study. Using the RCOG scoring thresholds 29.2% of AP patients would require treatment compared to 10.9% of women when using the College guidelines (p < 0.001). Similarly for PP patients, 124 women (39.9%) would require treatment based on the RCOG guidelines compared to 63 women (20.3%) when using the College guidelines (p < 0.001). If prophylaxis were performed at a threshold score of 3 instead of 2 for PP patients by College criteria, 28 women (9%) would be treated.

CONCLUSION:

Significantly more patients would require prophylactic anticoagulation treatment based on the RCOG guidelines. Utilizing College guidelines and increasing the threshold for treatment would facilitate targeting patients at risk without an excessive burden of increased cost and complication rate to the global patient population.
Etiologies and Risk Factors of Placental Abruption and Neonatal Mortality: A Retrospective Study [6K]
Authors: Araji Sarah , Khoury Aldo , Elkafrawi Deena , Miller Jacob
Published: May 2017

INTRODUCTION:

Placental abruption is defined as bleeding at the decidual-placental border leading to placental separation prior to delivery of the fetus. Placental abruption is a significant cause of maternal and perinatal mortality. In this retrospective study, we aim to evaluate the correlation between various causes and risk factors of placental abruption and neonatal mortality.

METHODS:

A retrospective chart review of placental abruption patients at SJRMC between 1986-1996 was conducted. Preeclampsia, eclampsia, HELLP, CHTN, preterm labor and placenta previa were recorded. Smoking, alcohol and cocaine use were assessed. Perinatal morbidity was based on length of NICU stay; neonatal mortality was defined as stillbirth or death.

RESULTS:

Our sample size was 271 pregnant women with placental abruption. Sixteen of 271 had HELLP (5.90%), 76 of 271 had preeclampsia (28.0%), and 22 of 271 had CHTN (8.11%). Forty of 271 used cocaine (14.7%), 104 of 271 smoked (38.4%) and 45 of 271 used alcohol (16.6%). Nine of 271 pregnant women with placental abruption had placental previa (3.32%). 37 of 271 infants were stillborn (13.6%) and 44 of 271 were dead on discharge (16.2%). HELLP syndrome was directly proportional to infant death (P=0.026; 95% CI, 0.26 to 4.03). Preeclampsia was proportional to neonatal mortality (P=0.000); CHTN was statistically significant for neonatal mortality (P=0.0010). Cocaine and alcohol correlated with increased neonatal mortality (P=0.0057; P=0.0220).

CONCLUSION:

CHTN, HELLP, preeclampsia, and placenta previa as causes of placental abruptions were found to be statistically significant predictors of neonatal mortality. Smoking, cocaine and alcohol use were directly proportional to neonatal mortality.
Variation in Preferences of Pregnant Women for Outcomes Related to the Use of Anticoagulants in Pregnancy [16K]
Authors: Thomas Hannah , Wuebbolt Danielle , Nguyen Vanessa , Murphy Kellie , Sermer Mathew , D'Souza Rohan
Published: May 2017

INTRODUCTION:

Women requiring anticoagulants in pregnancy face increased maternal and fetal risks. The trade-offs women are willing to make to ensure optimal pregnancy outcomes are not known. This study was conducted to compare preferences of pregnant women with and without cardiac disease, for maternal and fetal outcomes resulting from anticoagulant use in pregnancy.

METHODS:

A cross-sectional study was conducted on pregnant women with cardiac or non-cardiac medical disorder. Study participants were presented with seven vignettes that described a combination of maternal and fetal outcomes related to the use of anticoagulants during pregnancy. Participants were asked to rank these vignettes and assign them with “utility values” (preferences) on a visual analogue scale (VAS), by the standard gamble (SG) and time trade-off (TTO) methods. These were presented on a scale of 0-100 where 0 represented maternal and fetal death, the worst outcome, and 100 represented perfect maternal-fetal health, the best.

RESULTS:

90 pregnant women (40 with and 50 without cardiac disease) completed the interviews. The median age was 32 [29-36] years and the median gestational age was 29.5 [22-34.3] weeks. The cardiac and non-cardiac groups had similar demographic characteristics. While no consistent trends were observed with VAS and TTO methods, with SG, women with cardiac disease consistently assigned higher utility values for the seven outcomes as compared with those without cardiac disease.

CONCLUSION:

Women with cardiac disease value adverse pregnancy outcomes more favorably than non-cardiac patients. Whether this finding is related to risk-taking attitudes among cardiac patients, needs to be further explored.
Vaginal Progesterone – Cost and Health Care Utilization for Preventing Preterm Births in the United States [19K]
Authors: Eke Ahizechukwu C. , Onasanya Oluwadamilola , Johnson Clark T.
Published: May 2017

INTRODUCTION:

To examine the cost and healthcare utilization patterns of vaginal progesterone for the prevention of preterm-births in women with singleton gestations and a sonographic short cervix in the United States.

METHODS:

Using a nationwide database (MarketScan) of patients' de-identified healthcare and medication utilization, we assessed vaginal progesterone use and preterm-birth associated health care spending from January 2010 through December 2014. We compared the utilization rates across regions, states and age groups to estimate indirect benefits. We estimated national reductions in the number of preterm births, and preterm-birth associated costs.

RESULTS:

By December 31, 2014, the national utilization rate of vaginal progesterone was 62.5% in the Midwest, 63.6% in the Northeast, and 62.4% in the southwest. Relative reductions in preterm birth were 33% in 2012–2013 (95% CI, 29 to 37) and by 25% in 2013–2014 (95% CI, 23 to 27). Rates of hospitalization for preterm labor in 2010–2012, 2012–2013, and 2013–2014 were 24, 18, and 12 cases per 10,000 person-years with corresponding relative reductions of 52% in 2010-2012 (95% CI, 48 to 57) and 58% (95% CI, 47 to 59) in 2013–2014. Utilization rates was highest for Prometrium [78% (95% CI, 71 to 84)], Crinone [56% (95% CI, 51 to 63)] and Endometrin [28% (95% CI, 23 to 34)]. Nationally, for the 2010–2014 period, there was an estimated reduction of 65,250 hospitalizations for preterm births, saving approximately $113 million in treatment costs.

CONCLUSION:

Since the introduction of vaginal progesterone, preterm birth associated health care utilization and medical expenditures for U.S. hospitals have decreased substantially.
Does Intramuscular Progesterone Help Women With Prior Preterm Birth Screened for Ultrasound-Indicated Cerclage? [25K]
Authors: Wood S. Lindsay , Williams Bria N. , Tang Ying , Owen John
Published: May 2017

INTRODUCTION:

Weekly intramuscular 17α-hydroxyprogesterone caproate (17P) is endorsed by the American College of Obstetricians and Gynecologists for recurrent preterm birth (PTB) prevention. Cerclage is indicated in patients with prior PTB and a midtrimester cervical length (CL) less than 25 mm. We aimed to assess if these two preventive strategies, when combined, confer additive benefit in prolonging gestation.

METHODS:

Retrospective cohort of all singletons delivered at a single center that underwent CL screening from 2011 to 2016 for prior PTB. Exposure was any 17P use. Primary outcome was gestational age (GA) at delivery. Secondary outcomes included cerclage, preterm labor (PTL) admission, and preterm premature rupture of membranes (PPROM). ANCOVA was used to assess the relationship between 17P and delivery GA, controlling for cerclage, initial CL, number of prior PTB, and GA of earliest prior PTB.

RESULTS:

Of 409 patients who underwent CL screening, 293 received 17P (group 17P), and 116 did not. Groups did not differ by age, race, BMI, payer, number of prior PTB, or initial CL. GA of earliest prior PTB was lower in group 17P (27.4 vs 29.9 weeks; P < .001). Delivery GA occurred earlier in group 17P (35.7 vs 37.2 weeks; P=.002). Group 17P also had higher rates of PPROM (22.2% vs 11.2%; P=.011), PTL admission (42% vs 25%; P=.001), and cerclage (18.1% vs 5.2%; P < .001). After controlling for confounders, delivery GA remained significantly lower in group 17P (34.9 vs 35.9 weeks; P=.027).

CONCLUSION:

In a population with prior PTB followed with CL screening and ultrasound-indicated cerclage, 17P did not prolong gestation.
Factors Associated With Availability of Nurse-Family Partnership Programs in the State of Texas [27K]
Authors: Cuvillier James , Fisch Stanley
Published: May 2017

INTRODUCTION:

Current teen pregnancy rates generate significant social and economic costs, with highest rates in Hispanic, African American and socioeconomically disadvantaged youth. Their children are more likely to face health problems, incarcerations, unemployment, and to perpetuate teen pregnancies. Research-supported Nurse-Family Partnerships (NFPs) involving antepartum and postpartum nurse-home visits significantly improve teen pregnancy outcomes in Texas. Our objective was to evaluate socioeconomic, obstetrical, and perinatal outcomes of Texas counties currently served by NFPs.

METHODS:

We analyzed Texas and national population statistics, birth rates, socioeconomic factors, and obstetrical and neonatal outcomes extracted from federal and state databases.

RESULTS:

Currently, 21 Texas NFPs serve eligible women in 34 out of 254 Texas counties. These counties have higher average teen birth rates (44 per 1000) and higher average maternal poverty rates (33%) than the state of Texas (34 per 1000; 30%) and the United States (21 per 1000; 27%). They also have a higher proportion of absent prenatal care (4.5%), and infants with very low birth weights (1.7%). Across Texas, access to prenatal care decreases with decreasing maternal age, and teens have the highest rate of absent prenatal care (6.6-8.5%) and lowest rate of care starting the first trimester (6.6-8.5%). Absent prenatal care was also correlated with higher representation of birth defects.

CONCLUSION:

Texas NFPs serve counties with relatively high rates of teen pregnancies, maternal poverty, and absent prenatal care. This baseline data allows for advocacy, funding, and expansion of NFPs in Texas counties with comparably high levels of low-income, first-time mothers, including critically underserved Texas-Mexico border counties.
Focal Placenta Accreta: Risk Factors, Adverse Obstetrical Outcomes, and Recurrence in Subsequent Pregnancies [10L]
Authors: Mullen Clodagh R. , Battarbee Ashley N. , Ernst Linda M. , Peaceman Alan M.
Published: May 2017

INTRODUCTION:

To assess the risk factors for and obstetrical outcomes associated with manually extracted placentas with pathologic diagnosis of focal accreta.

METHODS:

This was a retrospective case control study of patients with adherent placentas requiring manual extraction from January, 2009 to December, 2014 which underwent pathologic examination. Women with diagnosis of focal accreta on placental pathology were compared to those without focal accreta. All women with an antepartum diagnosis of placenta accreta were excluded. No cases of placenta increta were found. Chi-squared, t-test, and multivariable regression were performed to identify risk factors for and adverse obstetric outcomes associated with focal accreta.

RESULTS:

Four-hundred and ninety-one women met inclusion criteria. Those with focal accreta (n=100) were more likely to have a previous cesarean (19.0% vs 10.7%, p=0.03), prior uterine surgery (35.0% vs 19.7%, p=0.001), and in vitro fertilization (35.0% vs 19.7%, p=0.001). Adverse obstetrical outcomes were more common in women with a focal accreta including hemorrhage, transfusion, and peripartum hysterectomy. There were no differences in neonatal outcomes. In multivariable analysis, focal accreta remained associated with all maternal hemorrhagic morbidities. In the 130 observed subsequent pregnancies, there was an increased risk of adherent placenta requiring manual extraction (42.9% vs 19.0%, p=0.04) and recurrence of pathologic finding of focal accreta (29.6% vs 6.8%, p=0.05) in those women who had a focal accreta in the index pregnancy.

CONCLUSION:

For patients with adherent placentas requiring manual extraction, the pathologic finding of focal accreta is associated with an increased risk of hemorrhagic morbidity and retained placenta in subsequent pregnancies.
Do Differences Exist Between Groups With Varying Numbers of Abnormal Values on the Glucose Tolerance Test? [15L]
Authors: Shaia Kathryn , Connolly Katherine , Soffer Marti , Amorosa Jennifer , Wagner Brian , Stone Joanne
Published: May 2017

INTRODUCTION:

To determine whether patients with one abnormal value on the glucose tolerance test (GTT) have different outcomes compared to patients with varying numbers of abnormal values.

METHODS:

We conducted a retrospective chart review of women undergoing a glucose challenge test (GCT) followed by a GTT from July 2010-July 2015. Patients with pre-gestational diabetes were excluded. Primary outcomes were infant birth weight and mode of delivery. Secondary outcomes included shoulder dystocia, NICU admission, and development of preeclampsia. Data was analyzed via multivariable regression models.

RESULTS:

5,913 charts were reviewed. 5,124 patients had a normal GCT. 499 had an abnormal GCT and zero abnormal values on the GTT (Group 0). 147 had one abnormal value on the GTT (Group 1), and 143 had two or more abnormal values on the GTT (Group 2). After controlling for maternal age, infant sex, and gestational age, group 0 had a significant increase in rate of cesarean delivery, birth weight, NICU admission, shoulder dystocia and preeclampsia compared to patients with a normal GCT. Group 1 had a significant increase in rate of cesarean delivery, birth weight, NICU admission and preeclampsia when compared to group 0. No significant differences in outcomes existed between group 1 and group 2, the treated gestational diabetics.

CONCLUSION:

Glucose intolerance is a spectrum with an increasing number of abnormal GTT values leading to an increased likelihood of poor outcomes. Patients with an abnormal GCT should be counseled on potential maternal and neonatal morbidities and the potential to modify outcomes with treatment.
Differences in Social Support in Perinatal Depression [19L]
Authors: Scibetta Emily , Dossett Emily C. , Hom Patricia , Gutierrez Griselda , Moini Moraya , Reina Astrid
Published: May 2017

INTRODUCTION:

Depression during pregnancy is a known risk factor for low birth weight (LBW) and preterm birth (PTB). Identifying social risk factors for depression in pregnancy can impact directed perinatal services aimed at reducing PTB and LBW. This study describes associations between partner status and depression in pregnant women in high prevalence areas for PTB and LBW in Los Angeles.

METHODS:

From December 2013 through August 2016, community health workers conducted a novel prenatal risk assessment with evidence-based screening tools for psychosocial risk factors in women enrolling into a Los Angeles County prenatal care program. Depression was measured using Center for Epidemiological Studies-Depression scale. Chi-square tests were performed.

RESULTS:

Analyses included data from 3,214 women. This cohort exhibited high rates of depression (23%). Women scoring high for depression were significantly less likely to report being married (chi-square=53, p less than 0001) or living with the father of their babies (chi-square= 71, p less than 0001). Unmarried women (35%) scored higher for depression than married women (21%). Women who did not live with the father of their babies (40%) scored higher for depression than those who did (26%).

CONCLUSION:

Married and cohabitating pregnant women were significantly less likely to score high for depression. These findings suggest that social supports are critical pregnant women's mental health, which we know impacts PTB and LBW. Women with limited partner support could benefit from increased mood surveillance and psychological interventions during prenatal care.
Differences in Patients With a Positive Drug Screen for Opiates Versus Other Substances in Pregnancy [20L]
Authors: Stephens Amanda J. , Holcomb Garret , Ouyang David W.
Published: May 2017

INTRODUCTION:

Opioid abuse has reached epidemic levels in the past decade drastically changing the landscape of drug abuse in the US. Current guidelines for drug screening in pregnancy may not reflect contemporary patterns of use and over sample women of color and low socioeconomic status.

METHODS:

This is a retrospective cohort study of obstetric patients who had urine drug screens (UDS) ordered between 2013 and 2015 in a suburban tertiary care hospital. Of those with a positive UDS, we compared the characteristics of those with positive opiate screens to those who screened positive for other substances excluding opiates.

RESULTS:

112 UDS were positive during the study period, 45 (40.2%) for opiates and 67 (59.8%) for other substances, most commonly marijuana (n=60), benzodiazepine (n=10), and cocaine (n=8). Subjects with positive opiate screens were more likely to have private insurance compared to other insurances (P < .05). Publicly insured were more likely to test positive for nonopiates than opiates. African Americans were significantly less likely to test positive for opiates compared to subjects of other races (P < .05). Caucasians' use was similar between the two groups (42% opiate, 43% other). A history of substance abuse was more common in those who screened positive for non-opiates whereas subjects whose infants required NICU admissions were more likely to test positive for opiates. Current or former tobacco use was similar between these two groups.

CONCLUSION:

Women who screen positive for opiates compared to other substances during pregnancy are different. A separate validated screening method for opiate use in pregnancy is needed.
Comparison of Characteristics and Outcomes of Morbidly Adherent Placenta in Twin Versus Singleton Pregnancies [24L]
Authors: Bateni Zhoobin , Erfani Hadi , Belfort Michael , Shamshirsaz Alireza A.
Published: May 2017

INTRODUCTION:

To compare the characteristics and outcomes of patients with morbidly adherent placenta (MAP) in twin pregnancies versus singleton pregnancies.

METHODS:

All patients with pathology confirmed MAP (placenta accreta, increta or percreta) from January 2000 to June 2016, were included in this retrospective study. Data were reported using descriptive statistics and appropriate statistical methods were used based on the normality of the data.

RESULTS:

Total of 189 cases of pathologically confirmed MAP were identified over the study period, 13 of which were twin gestations. Median gestational age at delivery, gravidity and parity were lower in twin patients (P < 0.05). Regarding the severity of the adherence, 76.9% of the twins versus 51.5% of the singletons were placenta accreta and the remainder were either placenta increta or percreta (P = 0.04). Although not statistically significant, median blood loss during the surgery was 1000 cc higher in twin pregnancies which is clinically significant. Also the median hospital stay after surgery was 2 days longer in twin gestations (P = 0.03). Moreover, the rate of unsuspected subjects in twins was higher than the singletons; 69.2% versus 27.3% (P < 0.01).

CONCLUSION:

As the first report comparing MAP in twin versus singleton pregnancies, our study showed higher rate of MAP in Assisted Reproductive technology and lower rate of deep invasion (i.e. placenta increta or percreta) in twins, similar to findings by others in case reports resulting from IVF. Estimated blood loss was not significantly higher, however clinically may be important.
Longitudinal Patterns of Anti-Mullerian Hormone Across Normal Gestation [37L]
Authors: Roy Amrita , Whitcomb Brian , Healy Andrew
Published: May 2017

INTRODUCTION:

Anti-Mullerian hormone (AMH) is a protein produced by granulosa cells of developing follicles and has demonstrated utility as an age-independent marker of ovarian reserve. Recent studies have suggested that AMH levels in pregnancy may serve as predictors of adverse pregnancy outcomes such as hypertensive disorders of pregnancy or preterm birth. These studies highlight the importance of characterizing AMH longitudinally throughout uncomplicated pregnancy. This study assessed the longitudinal pattern and associated variability of AMH throughout normal pregnancies.

METHODS:

We performed a prospective cohort study of 30 low risk pregnancies at our institution. Plasma levels of AMH were determined by sensitive ELISA in samples collected at five prenatal visits, at mean gestational ages of 11, 17, 25, 31 and 36 weeks. The longitudinal patterns of AMH were analyzed by repeated measures ANOVA using linear mixed models. Smoothed plots of AMH over gestation in PING were generated with cubic spline models using PROC LOESS. The interclass correlation coefficients (ICC) were estimated comparing variation among women (between subject) and during pregnancy (within subject).

RESULTS:

Mean AMH varied significantly by gestational age at sample collection, decreasing substantially in the first trimester and continuing throughout pregnancy. Though AMH varied substantially between women, variation over gestation was high and an ICC of 0.67 (95% confidence interval: 0.52, 0.79) observed.

CONCLUSION:

This pilot study demonstrates new information to establish normal AMH levels in uncomplicated pregnancies. Further studies are needed to assess the significance of longitudinal patterns of AMH in pregnancies complicated by adverse pregnancy outcomes compared to levels in uncomplicated pregnancies.
Then and Now: Experts Insights on Understanding the Women's Health Initiative Hormone Therapy Trials [4M]
Authors: Pinkerton JoAnn V. , Kaunitz Andrew , Lalonde Andre
Published: May 2017

INTRODUCTION:

More than a decade following publication of the Women's Health Initiative (WHI) clinical trials for hormone therapy (HT), perception in the medical community remains that HT is unsafe for postmenopausal women. The evidence suggests otherwise for the majority of symptomatic menopausal women under 60 years and within 10 years of menopause.

METHODS:

A 30-minute expert interview CME program discussed the accurate interpretation of data from the WHI trials. Correct answers were compared between immediate pre- and post-tests, including case-based scenarios.

RESULTS:

15,236 participants have engaged with the program to date (July 1–August 31, 2016) with 355 completions. Participants included physicians, 50%, and nurses, 21%, with 31% in women's health, 30% in primary care and the rest distributed among other specialties. Correct responses improved from pre- to post-test for all questions, including outcomes from the WHI trials (22%-52% to 49%-88%), attributes of new menopausal medications (43% to 67%) and appropriate application of clinical guidelines (64% to 90%). For most case-based questions, responses improved from 58%-83% in the pre-test to 78%-96% in the post-test, with one question in older postmenopausal women (aged 62) only improving from 42% to 48%.

CONCLUSION:

Results demonstrate the negative impact of inappropriate data interpretation, its effect on clinical care and guideline application. Continued uncertainty remains regarding HT risks, interpretation of follow-up studies, and the benefits/risks of newer medications. Future educational efforts must reinforce the need to treat symptomatic menopausal women according to the best available evidence, and how benefits exceed risks for many women with existing/new HT medications.
Universal Chlamydia Screening for Women With Threatened Preterm Labor: A Cost-Effectiveness Analysis [14M]
Authors: Gimovsky Alexis , Berghella Vincenzo , Werner Erika
Published: May 2017

INTRODUCTION:

To estimate the cost and effect of universal chlamydia (CT) screening compared to no CT screening for women presenting with threatened preterm labor in the United States.

METHODS:

We created a decision model comparing universal screening for CT versus no CT screening for women presenting with threatened preterm labor. Assumed probabilities included incidence of CT in women with preterm labor of 12% and a conditional probability of congenital CT of 60%. Primary outcome was the cost to prevent one case of neonatal chlamydia. A strategy was considered cost-effective if cost was < $100,000 to prevent one case of congenital chlamydia. One way sensitivity analyses and Monte-Carlo simulations assessed the robustness of the model.

RESULTS:

Screening for CT at the time of threatened preterm labor was cost saving, saving $17,202,570 and preventing 6,624 cases of neonatal chlamydia and 1,268 cases of preterm birth/100,000 women screened. One way sensitivity analysis revealed that the model was sensitive to incidence of maternal CT and cost of CT screening and treatment. CT screening remained cost saving when the incidence of maternal CT was >1%. Monte Carlo analyses revealed that screening was cost-saving in 87.3% of simulations, cost effective, but not cost-saving in an additional 3.5% of simulations, and not cost-effective 9.1% of the time.

CONCLUSION:

Screening for CT at time of presentation for threatened preterm labor in the United States is cost saving in the majority of conditions. Only in populations at extremely low risk for Chlamydia does it decrease health care costs to defer CT testing.
Zika Screening Beyond Brazil: Zika Madness and Cost of Reassurance? [15M]
Authors: Al-Ibraheemi Zainab , Ashmead Graham , Porat Natalie , Taylor Dyese , Sinha Anila
Published: May 2017

INTRODUCTION:

Zika infection during pregnancy can cause severe birth defects. We investigated patients concerns evaluated for Zika exposure in a perinatal center.

METHODS:

Following outbreak of Zika, patients presented to our fetal evaluation unit were prompted to provide information regarding exposure to the Zika Feb-July 2016. Information recorded included: travel to Zika areas, symptoms, mosquito bites, tests, ultrasound findings, partner exposure and use of barrier protection. Zika related visits and results were reviewed.

RESULTS:

A total of 13,769 ultrasounds were performed. Seventy two patients expressed concern regarding Zika exposure. One third of patients came solely for Zika screening for a total of 77 visits. Fifty four percent reported a mosquito bite, 10 % had Zika related symptom. Two patients had a fetal head circumference (HC) < 3%: one had craniosynostosis on MRI and the other was normal at birth. Fifty two patients had lab testing were negative. Two thirds of the patients' partners reported travel history only 1 had Zika testing. Thirty eight percent patients reported sexual activity after suspected exposure to Zika only 10% used a barrier method.

CONCLUSION:

Patient concerns regarding Zika exposure declined precipitously after peaking early in 2016 likely due to avoiding travel to Zika affected areas. Less than 1% of visits were solely for Zika concerns, none of which had a positive sonographic evidence of infection. The minimal cost of Zika screening appeared to provide reassurance with negligible impact on the flow of care. As Zika spreads to Florida and other states, the clinical burden of screening may increase.
Compliance With Guidelines on Group B Streptococcal Sepsis Prophylaxis During Unscheduled Cesareans [22M]
Authors: Schwenk Evan E. , Campbell Blaine , Duong Jennifer , Harkins Kristin
Published: May 2017

INTRODUCTION:

In 2013, compliance with the American College of Obstetrics and Gynecology (the College) guidelines for Group B streptococcus (GBS) prophylaxis was 69.6% at our institution. In non-compliant cases, 80% were due to lack of antibiotics. Afterward, improving GBS prophylaxis was emphasized during an Obstetrics and Gynecology Section meeting, but no formal education was provided. The objective of this project was to assess whether there has been an improvement in compliance with prophylaxis for GBS.

METHODS:

Retrospective review of GBS positive women confirmed at term gestation, who delivered via unscheduled cesarean from October 2014 to March 2015 was performed. Women were included if gestational age at delivery was 37-39 weeks, and spontaneous rupture of membranes or active labor was documented prior to delivery. Compliance was determined based on evidence of appropriate antibiotics for GBS according to the College guidelines.

RESULTS:

Of 43 patients reviewed, 31 met inclusion criteria. The majority of women 38 weeks gestation (45.2%, n=14). Rectovaginal swab confirmed GBS positive status in 24 (77.4%) cases. The majority of women delivered via primary cesarean (54.8%, n=17). Out of 31 cases, 26 (83.9%) were compliant with the College guidelines on GBS prophylaxis. Of the non-compliant cases, 4 of the 5 (80%) were due to no evidence of antibiotics being administered for GBS. There were 3 (9.7%) cases in which antibiotics were not given for surgical prophylaxis.

CONCLUSION:

Adherence to GBS prophylaxis guidelines improved since 2013, but failing to administer any antibiotics continues to be the primary reason for non-compliance.
Improving Physician Behavior With an Obstetric Dashboard [30M]
Authors: Xiong Katherine , Boehrer Robyn Horsager
Published: May 2017

INTRODUCTION:

The American College of Obstetricians and Gynecologists no longer recommends routine use of episiotomy. However, high variation in provider practice continues to exist. The objective of this study was to determine if a physician dashboard reporting individual and group episiotomy rates could reduce usage to below the national benchmark of 5.5%.

METHODS:

Baseline data extracted from records of patients delivering between 1/1/2015 and 7/15/2015 were entered into a dashboard that listed all obstetricians at our hospital. Identities were blinded and physicians were provided individual and group rates. Data were then collected prospectively following dashboard implementation.

RESULTS:

The institutional baseline rate for episiotomy performance was 9.9%, with individual rates ranging from 0.0% to 55.6%. Following dashboard implementation, there was a significant reduction in the institutional rate (9.9% pre-intervention vs 2.7% post-intervention, P value less than .001). Our analysis also validated the increased risk of severe, third and fourth degree perineal lacerations with the performance of episiotomy [OR 4.1 (1.2, 14.0)]. Despite the reduction in episiotomy utilization, we were unable to demonstrate a reduction in the frequency of severe perineal lacerations (2.42% pre- vs 1.31% post-intervention, P value equal to 0.1), suggesting that multiple factors contribute to these events.

CONCLUSION:

When variation in physician performance exists, utilizing a physician dashboard comparing providers' behaviors can result in significant improvements in provider and institutional performance on specific metrics. We plan to evaluate whether this intervention can significantly reduce our rates of cesarean delivery in nulliparous, term, singleton, vertex gestations.
Perinatal Depression and Anxiety — Implementing Screening and Response Protocols [6N]
Authors: Keats John , Kendig Sue , Simas Tiffany Moore , Byatt Nancy , Hoffman Camille , Kay Lisa
Published: May 2017

INTRODUCTION:

Perinatal mood and anxiety disorders are the most common pregnancy complications, and are associated with adverse maternal, infant and child outcomes. Recognizing this, the Council on Patient Safety in Women's Healthcare developed an evidence-based safety bundle to establish a standard of care for these disorders that is relevant to every woman in every clinical setting. Its objective was to outline how to implement current recommendations at the practice level.

METHODS:

To promote safety bundle dissemination, the American College of Obstetricians and Gynecologists invited 20 nationally representative obstetric and behavioral health providers to engage in a journey mapping process. The journey map followed the safety bundle format and addressed implementation steps needed to screen for and respond to perinatal mood and anxiety disorders. Opportunities to ease implementation were also assessed.

RESULTS:

The journey map focused on the process of addressing these disorders and identified multiple potential barriers. Each step of implementation must consider an ever changing obstetric practice environment, and the absence of related direct reimbursement. It is critical to focus on implementation until consensus is reached regarding outcomes measures to assess screening and treatment.

CONCLUSION:

As the implications of untreated perinatal mood and anxiety disorders are better understood, it is critical to develop and disseminate implementation processes to help obstetric practices screen for and address this issue. Implementation protocols need to be customized to each unique care setting. Further efforts are required to establish meaningful outcome measures.
Placenta Accreta: Descriptive Study of Risk Factors and Maternal Outcomes in a Tertiary Hospital in Puerto Rico [7N]
Authors: Gonzalez Cristina , Mendez Kemari , Rivera Nelly
Published: May 2017

INTRODUCTION:

Cesarean section is one of the most important risk factors for abnormal placentation and in 2012 the CDC reported a C-section rate of 48.5% in Puerto Rico, one of the highest in the world. Placenta Accreta has been implicated to increase morbidity/mortality with detrimental outcomes to the patient as well as to the fetus. The objective of the current study is to describe the population and outcomes of Puerto Rican women diagnosed with abnormal placentation in a tertiary hospital.

METHODS:

We performed a retrospective descriptive study of medical records identified with a diagnosis of abnormal placentation from 2009-2015 from the University District Hospital in PR. Data regarding patient demographics, risk factors, maternal and fetal outcomes were obtained and recorded in an electronic database using EPI INFO.

RESULTS:

20 medical records were analyzed. Mean maternal age was 31 years, BMI:28 and mean gestational age at delivery was 28 weeks. All but one had previous cesarean sections. Mean neonatal weight was 2417 g. 11 patients had an EBL of more than 2 L and 10 received post op blood transfusions. 2 patients had to be admitted to the ICU, 1 received ACLS and died. 11 bladder injuries were reported. 17 cesarean hysterectomies performed to control hemorrhage.

CONCLUSION:

The most prevalent risk factor was previous cesarean sections. Increased blood loss, prematurity and bladder injuries were the most common complications. Our results demonstrate the importance of identifying risk factors and managing suspected cases in a setting where immediate access to blood transfusions and subspecialist are available.
Placental Pathology Findings Associated With Adverse Outcomes Among Women With Sickle Cell Hemoglobinopathies [8N]
Authors: Brown Jewel , Sinkey Rachel , Steffensen Thora , Louis-Jacques Adetola , Louis Judette
Published: May 2017

INTRODUCTION:

The objective of this study is to investigate the relationship between placental pathology findings among women with sickle cell hemoglobinopathies (SCH) and adverse perinatal outcomes (APO).

METHODS:

This is a retrospective cohort study of non-anomalous, singleton infants born to mothers with laboratory confirmed SCH and placental pathology results. Medical charts were reviewed for maternal and neonatal outcomes as we sought to identify histologic findings associated with APOs. APOs included fetal death, small for gestational age neonates, umbilical cord pH < 7.2, 5 minute Apgar < 7, and neonatal death.

RESULTS:

One hundred thirty-five patients met inclusion criteria. Eighty-six percent had sickle cell trait, 12% had sickle cell disease, and 2% had hemoglobin SC disease. Twenty-seven pregnancies (20%) were complicated by APOs. There was no difference in presence of the following placental findings among the APO group as compared to the group without APOs: delayed villous maturation (p=0.59), perivillous fibrin deposition (p=0.58), placental infarction (p=0.62), chorioamnionitis (p=0.63), funisitis (p=0.24), villous congestion (p=0.39), and increased syncytial knots (p=0.10). When placental pathology findings among patients with sickle cell anemia were compared to patients with other types of SCH, there was a difference among groups with respect to increased syncytial knots (p < 0.01).

CONCLUSION:

There was no difference in placental pathology findings among patients with SCH with and without APOs. Severity of maternal disease was associated with a higher rate of increased syncytial knots; which are associated with reduced uteroplacental perfusion and may be induced by exposure of the placenta to hypoxia or oxidative stress as seen in SCH.
Predicting Term Induction to Delivery Intervals Utilizing Machine Learning [14N]
Authors: Clifford Corey , Namaky Devin , Holbert Michael
Published: May 2017

INTRODUCTION:

Machine learning methodologies, such as artificial neural networks, are increasingly being used to improve clinical decision making. They can be used to discover complex relationships in clinical data. The goal of this study was to evaluate their ability to predict term induction to delivery intervals.

METHODS:

A retrospective cohort of 439 term inductions that resulted in an unassisted vaginal delivery was used to develop a predictive artificial neural network. This model utilized factors known at the time of induction, such as maternal demographics, pregnancy history, cervical examination, and current pregnancy complications. A separate cohort of 233 patients was then used to evaluate the efficiency of the model.

RESULTS:

On the cohort of 233 patients, the model exhibited a predictive odds ratio for delivery within 12 hours of 5.76 (95% CI 3.17-10.43, P < .001). Furthermore, it exhibited a sensitivity, specificity, positive predictive value, and negative predictive value of 78%, 62%, 80%, and 59% respectively. The five elements that contributed the greatest were Bishop score-position, maternal race, parity, presence of diabetes in the current pregnancy, and presence of hypertensive disease in the current pregnancy. Of the remaining factors; gestational age, cervical dilation, gravidity, and maternal BMI demonstrated moderate weighting. The remainder were less important.

CONCLUSION:

A machine learning approach is moderately successful in predicting induction to delivery intervals in term patients. This technique could be used to guide the timing of the initiation of induction in these patients to maximize staffing availability and improve outcomes.
Predictors of a Positive Illicit Drugs Screens for Pregnant Women in Colorado [15N]
Authors: Son Shannon L. , Heyborne Kent , Sheeder Jeanelle , Guiahi Maryam
Published: May 2017

INTRODUCTION:

There are no clear guidelines to determine when illicit drug screening in pregnant women is warranted. We investigated which testing indications reliably predict a positive screen.

METHODS:

We performed a historical cohort study of all pregnant women who underwent drug screening on labor and delivery in 2014 at a safety-net hospital in Denver, Colorado. Testing was performed at provider discretion and with patient consent. Illicit drugs were included in the urine toxicology screen; tetrahydrocannabinol was not. Chart abstraction included testing indications, demographic, reproductive, social, and substance use characteristics. We performed descriptive frequencies and used Fisher's exact tests to compare testing results.

RESULTS:

In 2014, 166 urine toxicology tests were performed; 14 (8.4%) were positive. Women with positive tests were more likely to have had a prior STI (83.3% vs 39.7%, p>0.01), previous child protective services case (35.7% vs 8.6% p=0.009), child removed from custody (60.0% vs 7.3%, p < 0.001), prior drug use (92.9% vs 34.2%, p < 0.001) or treatment (64.3% vs 11.2%, p < 0.001), self-reported current drug use (71.4% vs. 27.6%, p < 0.01), current tobacco use (71.4% vs 19.7%, p < 0.001), less than 5 prenatal visits (58.3% vs 28.0%, p=0.05), or outborn delivery (28.6% vs. 0.7%, p < 001). No obstetrical indications were associated. A composite variable including history of child protective services case, child removed from custody, history of drug use or treatment, and/or self-reported drug use had a PPV=100% and NPV=65%.

CONCLUSION:

Using a composite variable based on historical factors to determine performance of drug screening may be a strong predictor of positive tests and reduce over-testing.