bluuebunny/crossref_metadata_2025 huggingface dataset:
Percent Absent End-Diastolic Velocity and Risk of Donor Twin Demise in Twin-Twin Transfusion Syndrome [19A]
Authors: Purnell Margaret E. , Chon Andrew H. , Korst Lisa M. , Llanes Arlyn , Grubbs Brendan H. , Chmait Ramen H.
Published: May 2019

INTRODUCTION:

We examined the association of percent absent end-diastolic velocity (%AEDV) in the umbilical artery with intrauterine fetal demise (IUFD) of the donor twin after laser surgery in patients with twin-twin transfusion syndrome (TTTS) Quintero stages III/IV. %AEDV was calculated as 100x the proportion of total cardiac cycle spent in AEDV.

METHODS:

Retrospective study of TTTS stage III/IV patients between 2006 and 2016. Donors were classified as having persistent AEDV (yes/no). In Part 1, we used multiple logistic regression analysis to test whether AEDV was associated with donor IUFD. We stratified these analyses by estimated fetal weight (EFW) discordance of ≥20% or <20%. In Part 2, we used similar models to test only those with AEDV to determine whether %AEDV was associated with IUFD. This was an IRB approved study.

RESULTS:

Of 344 stage III/IV TTTS cases, 153 (44.5%) donors had preoperative AEDV. In Part 1, we did not confirm an independent association between AEDV and donor IUFD. In Part 2, patients with AEDV who were discordant (N=129), had the following characteristics associated with donor IUFD: %AEDV (OR 1.04, 95% CI 1.01-1.08), %EFW discordance (OR 1.07, 95% CI 1.02-1.13), and presence of arterioarterial anastomoses (OR 5.15, 95% CI 2.06-12.89). In the non-discordant group (N=24), no association was found between %AEDV and donor IUFD.

CONCLUSION:

The presence of preoperative persistent AEDV was not an independent risk factor for donor IUFD in stage III/IV TTTS patients undergoing laser surgery. However, among donors with preoperative AEDV and EFW discordance ≥20%, %AEDV was positively associated with donor IUFD.
Insulin Requirements by Multiple Daily Injections Versus Pump in Women With Type 1 Diabetes Mellitus [22A]
Authors: Prior Alissa , Finneran Matthew M. , Smrz Stacy , Thung Stephen Francis. , Landon Mark B. , Gabbe Steven G.
Published: May 2019

INTRODUCTION:

This study aimed to describe insulin dose changes throughout pregnancy by insulin delivery method.

METHODS:

This was a retrospective cohort study of patients with T1DM in pregnancy who delivered at a large academic tertiary medical center from 2012 to 2016. Prescribed bolus and basal insulin doses were extracted from the medical record at three time points: early (<20 weeks), mid (28-32 weeks), and at delivery. The primary outcome compared dose changes by insulin delivery method (multiple daily injections [MDI] vs. continuous infusion [CSII]). Secondary outcomes were percent change in bolus, basal and total insulin units per day (U/d). Backward stepwise logistic regression was used to identify risk factors for >50% increase in insulin dose prescribed.

RESULTS:

There were 110 women who met inclusion criteria with 48 (43.6%) using MDI and 62 (56.4%) using CSII. MDI users' total insulin doses were higher at all time points (early: 36.0 vs 29.1 U/d; p=.016, mid: 51.5 vs. 38.8 U/d; P=.01, late: 121.9 vs 78.0 U/d; P<.001). The MDI users' basal dose percent of total insulin increased from early to late pregnancy (40% [25-60%] vs 30% [10-40%]; p<.01), but percent bolus was similar between groups (p=.991). Risk factors for a total daily insulin dose increase greater than 50% included increasing weight gain (OR 1.07; CI 1.03-1.1), increasing maternal age (OR 1.2; CI 1.02-1.2), and MDI use (OR 5.8; CI 2.0-17.2).

CONCLUSION:

Women with T1DM using MDI for insulin delivery required higher basal and bolus insulin doses at each time point when compared to CSII.
A Comparative Study of the Impact of Chronic Pelvic Pain on Quality of Life in Women With and Without Endometriosis [34A]
Authors: Bhide Sayuli , Flyckt Rebecca , Yao Meng , Falcone Tommaso
Published: May 2019

INTRODUCTION:

Few studies have examined the differing natural histories and quality of life in women with endometriosis-associated chronic pelvic pain (EACPP) versus other chronic pelvic pain (OCPP) in the years following surgery. In this study, we compared pain and quality of life scores in women with EACPP vs OCPP after surgery.

METHODS:

Women with CPP who had gynecologic surgery at the Cleveland Clinic between 2008 and 2010 with surgically confirmed endometriosis versus other CPP without endometriosis completed the EHP-30 and PROMIS validated quality of life questionnaires. Demographics and scores were compared between EACPP (N=84) versus OCPP (N=105) groups.

RESULTS:

Significant differences in racial demographics were seen between the two groups, with more African American patients in the OCPP group. The EACPP group had lower current disability than the OCPP group (3.6% vs 13.5%, P=.019). No significant difference was found in EHP-30 scores between groups. The PROMIS Global Health survey revealed no significant difference in Global Physical scores, however, the EACPP group had a lower mean Global Mental score compared to the OCPP group (12.5±3.4 vs 13.6±3.6, P=.057), a finding which approached significance. In exploratory regression models, higher age and higher Global Physical score were associated with lower EHP-30 scores (better health status) across all quality of life scales.

CONCLUSION:

Reported pain and quality of life are similar between women with EACPP vs OCPP. However, racial representation and disability status are different between groups. Furthermore, multivariable regression models indicated that higher age and physical health ratings may be associated with better quality of life.
Maternal Morbidity and BMI in Placenta Previa [15B]
Authors: Arditi Brittany , Purisch Stephanie Erin , Friedman Alexander Michael , Gyamfi-Bannerman Cynthia
Published: May 2019

INTRODUCTION:

Placenta previa increases the risk of pregnancy complications, but how obesity modifies this risk is unknown. We sought to characterize how pre-pregnancy BMI is associated with maternal morbidity in the setting of placenta previa.

METHODS:

In this retrospective cohort study of women with placenta previa delivered by cesarean section, the primary exposure, BMI, was categorized as normal (18.5-25), overweight (25-30), or obese (>30). Women with BMI <18.5 or placenta accreta were excluded. The primary outcome, a composite including death, hysterectomy, blood transfusion, endometritis, surgical injury, arterial ligation, ileus, and ICU admission, among others, was compared by BMI.

RESULTS:

555 women were included. 306 (55%) were normal weight, 157 (28%) were overweight, and 92 (17%) were obese/morbidly obese. The primary outcome occurred in 21% of normal weight, 28% of overweight, and 30% of obese women (p=0.03). Increasing BMI was associated with blood transfusion (p=0.03), endometritis (p=0.04), uterine artery ligation (p=0.02), surgical injury (p=0.003), anesthetic complications (p=0.02), and increased length of hospitalization (p=0.02). In multivariable analysis adjusting for BMI, race, marital status, payor, diabetes, and number of cesarean sections, overweight women were more likely to require uterine artery ligation (adjusted OR 8.54, 95% CI 2.30-31.81).

CONCLUSION:

Increased pre-pregnancy BMI is associated with maternal morbidity among women with placenta previa. These findings can advise surgical planning and pre-delivery care for women with previa.
Creating Awareness of the Frequency of Cervical Exams in Patients With Term SROM [23B]
Authors: Lagon Elena , Pettit Kate Estelle , Dudley Donald J. , Chisholm Christian , Boyle Annelee
Published: May 2019

INTRODUCTION:

Studies have associated the number of cervical exams performed during labor with deleterious outcomes. The study objective was to compare the number of exams performed in term laboring patients with spontaneous rupture of membranes (SROM) before and after instituting a recording system.

METHODS:

We conducted a retrospective cohort study of 106 term singleton pregnancies admitted with SROM at our institution. A board was installed in the physician workroom tallying the number of exams per patient. Data were collected for 3 months before and after the intervention. Primary outcomes were total exams and exams per hour after SROM. Secondary outcomes included rates of intrauterine infection (IUI) and maternal and neonatal length of stay (LOS). Composite rates of adverse maternal outcomes (IUI, hemorrhage, ICU admission) and neonatal outcomes (code, ICU admission, sepsis) were studied. Data pre- and post-intervention were compared using chi-square and Student's t-tests. Subgroup analyses by care team compared total exams and exams per hour ruptured within the pre- and post-intervention groups.

RESULTS:

Mean exams per hour ruptured and mean exams in patients with IUIs were significantly lower post-intervention. Mean exams per hour ruptured was significantly lower for midwife-followed versus physician-followed patients in both periods. The post-partum, maternal, and neonatal LOS, mean total exams, and risk of adverse maternal and neonatal outcomes did not significantly differ.

CONCLUSION:

Installation of a recording system reduced the number of exams in patients with IUIs and exams per hour ruptured. Clinicians may consider instituting similar policies to create awareness of the number of cervical exams during labor.
Diabetes in Pregnancy: Does Counseling Help? [26B]
Authors: Hartey Sara , Sherbeny Fatimah , Abramovici Dorel , Abramovici Adi Rosa
Published: May 2019

INTRODUCTION:

Identify common themes of perceptions and fears relating to diabetes in pregnancy that may correlate with motivating factors or mental barriers to successful treatment. These factors are compared pre and post formalized education in order to assess the impact of individualized counseling among women with pregestational diabetes (PGDM) and gestational diabetes (GDM).

METHODS:

Subjects were diagnosed with PGD or GDM according to ACOG criteria. They were referred to our perinatal center for management. All gravidas received formal nutritional education focused on diet, lifestyle modification and treatment. After informed consent was obtained they were administered a IRB approved cross-sectional survey identifying measures of anxiety pre and post counseling. These responses were analyzed using Chi square test and JMP software.

RESULTS:

Population characteristics were comparable in the PGM and GDM groups, with the only difference being medical therapy in the beginning of the study. After counseling, GDM had a statistical decrease in anxiety of diagnosis (P<0.05), a decrease in anxiety regarding safety of medications (P<.05), and increased confidence in managing their diet (P<.05). Overall anxiety reduction was not seen in PDM however there was a trend towards significance when it came to reduction in anxiety of taking insulin (P=.07). The major motivating factor among both groups for adherence to their diet was preventing harm to the baby.

CONCLUSION:

Nutritional education can decrease anxiety and increase confidence in women diagnosed with GDM. Future studies may further show benefit of improved perinatal outcomes with formalized education.
Effect of Internal Iliac Arterial Balloon Occlusion on Estimated Blood Loss in Morbidly Adherent Placenta [29B]
Authors: Quist-Nelson Johanna Rachel , Crank Aislinn , Quist Arbor , Kim Christine , Richard Scott , Roman Amanda
Published: May 2019

INTRODUCTION:

The role of prophylactic placement of internal iliac arterial balloon occlusion prior to cesarean hysterectomy for anticipated morbidly adherent placenta (MAP) is a subject of debate. We aimed to compare estimated blood loss (EBL) in patients with suspected MAP and received internal iliac balloon occlusion to those who did not.

METHODS:

This is a retrospective cohort of patients at a single tertiary center with suspected MAP between January 2007 and June 2018. The intervention group received internal iliac arterial occlusion balloon occlusion prior to cesarean hysterectomy while the control group did not. The primary outcome was EBL.

RESULTS:

There were 24 cases of suspected MAP. Balloon occlusion was placed in 17 (71%) cases, while 7 (29%) cases did not have balloon occlusion. Cases with balloon occlusion were more likely to have gynecology oncology (94.1% vs 42.9%, p=0.01) and more likely to receive cell saver (88.2% vs 42.9%, p=0.04). There was a non-significant trend towards lower EBL in women who received balloon occlusion (1200 [800, 2000] vs 3000 [1200, 3190], p=0.34). Transfusion outcomes did not differ between groups. Women who did have balloon occlusion were less likely to be admitted to the intensive care unit (ICU) after delivery (11.8% vs 57.1%, p=0.04). There were no complications observed from balloon occlusion. Neonatal outcomes did not differ between groups.

CONCLUSION:

There was a non-significant trend seen towards lower EBL in women with MAP and prophylactic internal iliac arterial balloon occlusion compared to those who did not.
Impact of a Student-Run Clinic in a Non-Profit Substance Abuse Rehabilitation Facility for Women [32B]
Authors: Tran Cassandra , Ngo Lisa , Crowley Michelle , Tran Stacey , Robinson William R.
Published: May 2019

INTRODUCTION:

Substance abuse is a growing problem among women, and is frequently accompanied by multiple gynecologic concerns. Residential substance abuse rehabilitation facilities offer an opportunity to address those concerns. The purpose of this report is to examine the impact of an all-volunteer, medical student-run clinic with faculty supervision within a non-profit, inner-city women's residential substance abuse rehabilitation facility.

METHODS:

625 clients were admitted, regardless of financial status, to a 70-bed residential substance abuse rehabilitation facility between 2016 and mid-2018. Data including Pap smears, Human Papillomavirus (HPV) infection, and sexually transmitted infection testing were analyzed.

RESULTS:

From January 2016 through August 2018, 175/625 (28.0%) clients accepted Pap testing. 52/175 (29.7%) had an abnormal result, defined as Trichomonas infection, HPV infection, or premalignant or malignant lesion. 240/625 (38.4%) clients accepted Gonorrhea/Chlamydia testing, and 6 were identified as having Gonorrhea or Chlamydia. In 2018 alone, Pap testing identified 7/44 (15.9%) clients as having premalignant or malignant lesions, including one case of squamous cell carcinoma. 9/24 (37.5%) had a high-risk HPV strain. 7/44 (15.9%) had Trichomonas. Clients also received counseling regarding personal health awareness and reduction of high-risk behaviors.

CONCLUSION:

The use of a student-run clinic to provide gynecologic services within a residential substance abuse rehabilitation facility has a major impact and is cost-efficient. Many clients have no other opportunity to obtain instruction on health awareness and high-risk behavior, as well as diagnosis and treatment of abnormal Pap smears and STIs. This model allows non-profit facilities to provide an otherwise unaffordable level of care.
Mapping the Cervical Cancer Care Cascade in Johannesburg, South Africa: Baseline Cohort Description [36B]
Authors: Oberlin Austin M. , Mulongo Masangu , Ramotshela Sibongile , Pasipamire Tafadzwa , Chibwesha Carla Joan
Published: May 2019

INTRODUCTION:

Despite universal access to antiretroviral therapy (ART) in South Africa, the burden of cervical cancer and its precursors among HIV-infected women remains substantial.

METHODS:

Using electronic medical record data from our cervical cancer prevention program in Johannesburg, we conducted a retrospective analysis (IRB approval obtained) of HIV-infected women undergoing screening, colposcopy, and loop electrosurgical excision procedures (LEEP) for cervical intra-epithelia neoplasia (CIN). We report baseline characteristics of this high-risk cohort.

RESULTS:

Between January 2011 and June 2018, 2,801 HIV-infected women were included in the cohort. The median age was 42 years (interquartile range [IQR] 35-49). 2,649 (95%) women were receiving ART and the median CD4 count was 520 cells/uL (IQR 359-700). Our analysis database included 3,613 Pap smears, 556 diagnostic biopsies, and 153 LEEPs. More than half of the cytology results (54%) were abnormal, requiring follow-up. The risk of biopsy-confirmed disease was also high: 243/556 (44%) cases of CIN1 and 198/556 (36%) of CIN2/3. Among 153 LEEPs, there were 35 (23%) cases of CIN1 and 106 (69%) of CIN2/3. Of these, residual disease was reported in 65/91 (71%) cases, with one margin positive in 32/91 (35%) and both margins positive in 33/91 (36%). LEEP margin status was not associated with grade of CIN (P=.07).

CONCLUSION:

In this cohort of HIV-infected women living in urban South Africa, attrition between screening, diagnosis, and treatment was considerable. Additionally, the LEEP margins were positive in more than two-thirds of women, raising concern for treatment failure and subsequent progression to invasive cervical cancer.
Examination of Provider Assessed Patient Pain During Colposcopy: Implications for Care Provision [11C]
Authors: Grotheer Annette , Lee Jared , Franklin Kelsey , Gillespie Kendra , Carugno Jose
Published: May 2019

INTRODUCTION:

The ubiquity of diagnostic cervical biopsy has resulted in subsequent reductions in morbidity and mortality secondary to cervical cancer. Minimizing psychological distress and procedural pain, known barriers to follow-up in patients with abnormal pap smears, remains an obstacle for optimization of care provision. However, few studies have quantified health care providers' (HCP) ability to anticipate patient pain.

METHODS:

Patients presenting to an academic gynecology practice for cervical biopsy with colposcopy completed surveys assessing demographics, anticipated biopsy pain, intra-biopsy pain, and other metrics. HCPs and their procedural assistants also estimated patient's perceived intra-procedural pain. Pain was quantified utilizing a visual-analog scale. Data analysis was performed using Spearman rank correlation, and coefficients were calculated. IRB committee approval was obtained.

RESULTS:

Eighty patients were enrolled and 62 underwent cervical biopsy. Patients with higher anticipated pain perceived greater intra-procedural pain (P=.024). Women reporting more painful periods anticipated and perceived more pain (P<.001, P=.058). HCP's perception of pain correlated with patients' perceived pain (P=.066), however, only PGY3 and PGY4 OB/GYN residents predicted patient's perceived intra-procedural pain with statistical significance (P=.014). PGY1 residents, PGY2 residents (P=.039) and male assistants (P=.037) anticipated lower pain ratings than were reported by patients.

CONCLUSION:

Providers were able to accurately estimate a patient's pain, particularly upper level resident physicians. Patient age, baseline anxiety, and history of dysmenorrhea were reliable predictors of procedural pain levels. Utilizing said predictors of patient pain may serve to optimize patient satisfaction and patient follow-up.
Exercise Amongst Women With Psychiatric Disorders and Substance Misuse During Pregnancy [16C]
Authors: Ahuja Chaarushi , Lipkind Heather , Gilstad-Hayden Kathryn , Yonkers Kimberly
Published: May 2019

INTRODUCTION:

ACOG recommends 150 minutes/week of exercise to maintain fitness and reduce adverse outcomes. However, little is known about exercise habits of women with psychiatric disorders and substance misuse during pregnancy.

METHODS:

To examine associations of exercise with behavioral conditions and birth outcomes, we utilized data from a prospective pregnancy cohort study (n=2647). Participants may have had major depressive disorder (MDD) (n=220), anxiety disorders (n=375) and/or misused alcohol, marijuana, or illicit drugs (n=228), opioids (n=164), or nicotine (n=387). Self-reported, weekly exercise during the 1st trimester was categorized into 3 groups: none, 1-150 minutes, or ≥ 150 minutes. 1st trimester was a proxy because reported exercise is greatest during that time. The proportions of exercisers were compared between women with and without psychiatric disorders or substance misuse with chi-square tests. Logistic regression modeled the relationship between exercise, psychiatric disorders, substance use and birth outcomes (preterm labor, low birth weight).

RESULTS:

Overall, 44.7% of participants did not exercise and 24.2% met the weekly recommended goal (>150-minutes). Women with, compared to without MDD, were less likely to exercise (43.51% vs 58.64, p<0.01). This was similar for anxiety disorders (43.18% vs 54.40%, p<0.01), substance misuse (43.99% vs 53.07%, p=<0.01) and smoking (42.88% vs 55.81%, p<0.01) but not opioid use. Neither exercise nor its interaction with psychiatric conditions influenced the likelihood of adverse birth outcomes.

CONCLUSION:

Exercise, its relationship to psychiatric disorders, and impact on maternal health needs to be explored further. Focused efforts to encourage exercise may still prove beneficial for the mother.
Maternal Inflammation and Urogenital Microbial Profiling as Predictors of Preterm Birth [26C]
Authors: Idusuyi Brittany , Le Nhung , Gong Yuan Yuan , Ghareeb Allen , Loret de Mola J. Ricardo , Braundmeier-Fleming Andrea
Published: May 2019

INTRODUCTION:

Preterm birth (PTB) is defined as delivery prior to 37 weeks gestation. Maternal immune dysregulation is thought to play a major role in the development of PTB. We hypothesize that systemic maternal inflammation during pregnancy alters the urogenital microbiome and decreases immune suppression by reducing circulating and placental regulatory T cells (Tregs), the immune cells primarily responsible for maternal immune suppression.

METHODS:

Patients considered high risk for PTB were recruited from the Department of Ob/Gyn at SIU School of Medicine. Following exclusion for non-compliance and intrauterine fetal demise, 18 term and 6 preterm deliveries were assessed (25% preterm rate). Peripheral blood and urine were collected at various timepoints during gestation (8-12 weeks, 20-24 weeks and 32-36 weeks), delivery and 6 weeks postpartum. Lymphocyte buffy coats were extracted and flow cytometry analyses identified specific immune populations. Urinary microbial analyses were performed by miSeq amplicon sequencing using the V4 region of the bacterial 16S rRNA gene.

RESULTS:

Higher levels of peripheral Treg populations, corresponding with immune tolerance for the fetal alloantigen, were found in patients with term deliveries. Reduced levels of peripheral Tregs were found in patients with subsequent preterm deliveries. This group also had a higher ratio of Th17/Treg cells, corresponding with increased inflammation, and altered urinary microbial profiles at each gestational timepoint.

CONCLUSION:

We found atypical shifts in immune and urinary microbial profiles from women with another PTB as compared to women with term deliveries. Our results demonstrate a potential novel screening modality for PTB utilizing the mother's immunological and urinary microbial profiles.
Maternal Perioperative Morbidity and Race in Women with Placenta Accreta [28C]
Authors: Arditi Brittany , Purisch Stephanie Erin , Friedman Alexander Michael , Gyamfi-Bannerman Cynthia
Published: May 2019

INTRODUCTION:

Racial and ethnic disparities in obstetric outcomes are well documented in the literature, however the interaction between race and placenta accreta has not been investigated. We sought to determine whether race is associated with adverse maternal perioperative outcomes in this setting.

METHODS:

This retrospective cohort study was derived from an observational cohort of cesarean deliveries at US academic medical centers. Women with placenta accreta were included. Race and ethnicity were self-reported as African-American, Caucasian, and Hispanic. Other race and ethnicity groups were excluded. Outcomes including death, hysterectomy, uterine rupture, surgical injury, arterial ligation, and ICU admission were compared by race and ethnicity.

RESULTS:

182 women were included. 73 (40%) were Caucasian, 66 (36%) were African-American, and 43 (24%) were Hispanic. In regression analysis, the risk of severe morbidity (hysterectomy, uterine rupture, death) was significantly higher among Hispanic women as compared to their Caucasian counterparts (RR 2.8, 95%CI 1.1-6.9). African-American women were less likely to have a surgical injury than Caucasian or Hispanic women (4.6% vs 21.9% vs 16.3%, P=0.01). In adjusted analysis, African-American women remained at lower risk of surgical injury as compared to Caucasian women (adjusted OR 0.1, 95%CI 0.02-0.8). African-American women were also less likely to have hospital stays >4 days (adjusted OR 0.3, 95%CI 0.1-0.9).

CONCLUSION:

Hispanic women with placenta accreta have increased risk of severe perioperative morbidity. African-American women with placenta accreta are less likely to experience a surgical injury during cesarean delivery, and are less likely to have extended hospital stays.
Detection of Fetal Cardiac Anomalies Using Standard Sonography [32S]
Authors: Morgan Jamie L. , Byrne John J. , McIntire Donald D. , Twickler Diane M. , Dashe Jodi S.
Published: May 2019

INTRODUCTION:

To investigate fetal cardiac anomaly detection during initial and follow-up standard sonography, and evaluate the association between visualization of cardiac anatomy and anomaly detection.

METHODS:

This was an IRB-approved retrospective cohort study of singleton pregnancies that received care at our hospital and subsequently delivered a live-born infant with ≥1 major cardiac anomaly between October 2011 and March 2018. We reviewed cardiac anomaly detection during the initial standard ultrasound performed at 18 to 21 6/7 weeks, and among those with anomalies not detected initially, during indicated follow-up ultrasound. Detection was analyzed according to the number of follow-up exams and visualization of the 4-chamber view and left and right ventricular outflow tracts. Statistical analyses were performed using Chi-squared and Mantel-Haenszel test for trend.

RESULTS:

105 low-risk pregnancies had fetuses with major cardiac anomalies. 63 (60%) were detected during the 18 to 21 6/7-week standard ultrasound, and 17 (16%) were detected during follow-up standard ultrasound, yielding 76% overall detection. The 42 infants (40%) not detected initially were more likely to have suboptimal cardiac anatomy visualization (71% vs 29%, p<0.001). Number of visualized cardiac views also correlated with likelihood of detection (p<0.001). Of pregnancies with undetected fetal cardiac anomalies in which follow-up ultrasound was performed, 62% (17/26) were subsequently detected with a significant decrease in the proportion of suboptimal cardiac views compared to the initial scan (82% vs 17%, p=0.001).

CONCLUSION:

In a low-risk population, standard ultrasonography identified over half of major cardiac malformations during initial screening examination, with follow-up examination identifying 40% of those initially missed.
Multigene Panel Testing of Patients With Uterine Carcinoma Reveals Actionable Variants in Non-Canonical Genes [25O]
Authors: Dae-Hoon Im Dwight , Yorczyk Arielle , Yang Shan , Michalski Scott , Nussbaum Robert , Esplin Edward
Published: May 2019

INTRODUCTION:

Traditionally, targeted genetic testing for patients with carcinoma of the uterus (UC) has included the five Lynch syndrome (LS) genes and PTEN due to their association with UC. Now, other cancer genes actionable for treatment, prevention and early detection of malignancies can be included, at no additional cost. We report data on the diagnostic yield and clinical actionability in UC patients using a comprehensive genetic testing panel strategy.

METHODS:

With IRB approval, 6,582 consecutive patients with UC underwent hereditary cancer panel testing. Testing included up to 83 genes per the ordering clinicians' discretion. De-identified medical histories were obtained from requisition forms.

RESULTS:

A germline pathogenic or likely pathogenic (P/LP) variant was identified in 1,031 (15%) patients. Of these, 54% had a P/LP variant within a LS gene or PTEN while 39% had a P/LP variant in other cancer genes, including ATM, BRIP1, CHEK2, PALB2, and TP53 (excluding MUTYH heterozygotes). Of those with a P/LP variant 32% were eligible for clinical treatment trials, 52% qualified for FDA approved therapies, >90% had newfound NCCN guideline management recommendations, and cascade testing for at-risk family members.

CONCLUSION:

Hereditary multigene cancer panel testing identified many clinically actionable P/LP variants that would have been missed by traditional, targeted UC gene testing. Over 80% of patients with P/LP variants were potentially eligible for precision therapeutic intervention based in part on their germline test results. These data highlight the benefit of comprehensive panels for UC patients and the potential for cancer intervention, surveillance and family member cascade testing protocols.
Risk Factors for Stillbirth in an Inner-City Community Hospital [18C]
Authors: Posso Ramses G. , Gallo Danielle , Payero Elfy , Henderson Cassandra
Published: May 2019

INTRODUCTION:

The stillbirth rate at Lincoln Medical and Mental Health Center (LMMHC) in the Bronx is 1/130, which is higher than the national average. Our aim was to compare the reported risk factors for term stillbirth with the identified antenatal risk factors for all cases of fetal demise that occurred after 39 weeks of gestation.

METHODS:

For this IRB approved quality improvement project, we reviewed data from all of the term fetal demise that occurred at LMMHC from 2013-2017. We categorized women based on the following characteristics which have been reported as risk factors for stillbirth: Hypertension, Diabetes, Obesity (BMI>30), and Advanced Maternal Age (>35).

RESULTS:

For births at LMMHC from 2013-2015, the relative risk (RR) of having a Stillbirth for a woman with Obesity was 3.2 (CI 95% 1.8-5.3, p<0.0001), RR for Diabetes was 3.5 (CI 95% 1.9-6.2, p<0.0001), RR for Hypertension was 3.1 (CI 95% 1.7-5.5, p<0.0001). For births from 2016-2017, the RR of a woman with Diabetes to have a Stillbirth was 3.8 (CI 95%, 1.8-7.9, p<0.0004), the RR for Hypertension was 3.5 (CI 95% 1.6-7.3, p<0.0010). We did not have the BMI data for this time period. We did not see an increased risk of stillbirth in patients with AMA.

CONCLUSION:

Considering the known risk factors of stillbirth and the potential benefits of delivery at 39 weeks gestation, induction can be considered to potentially decrease the risk of stillbirth. Physicians should utilize shared decision making with their patients who exhibit these risk factors.
Excision of Incidentally Discovered Bladder Leiomyoma During Repeat Cesarean Section: A Case Report [12K]
Authors: Eucalitto Patrick , Djordjevic Miroslav , Bryant Gwyneth
Published: May 2019

INTRODUCTION:

Leiomyoma account for <0.5% of all bladder tumors. In women, the majority are identified during diagnostic work-up for symptoms such as urinary retention or frequency, recurrent UTI, dysuria or dyspareunia. Per our literature review, the surgical management of bladder leiomyoma has never been reported during cesarean section. Our case report describes the surgical management of an incidentally discovered 4 centimeter vesicoperitoneal leiomyoma during scheduled repeat cesarean section.

METHODS:

A 33-year-old G2P1001 at 39 weeks gestational age presented for scheduled repeat cesarean section. She had a known history of uterine fibroids with no symptoms suggestive of bladder involvement. After closing the hysterotomy, the pelvic anatomy was inspected. A firm 4 centimeter mass was discovered within the vesicoperitoneum along the right superior aspect of the bladder. Its appearance was consistent with other small leiomyoma noted on the uterus. The findings were discussed intraoperatively with the patient and informed consent was obtained to remove the bladder mass. The bladder was retrofilled with normal saline to rule out intramural involvement and to identify a safe plane for resection. Excision was achieved with 5 milliliters of additional blood loss.

CONCLUSION:

Our report highlights the surgical technique used to remove the mass. We include preoperative ultrasound images (inconclusive for the surgical diagnosis), intraoperative photographs, and postoperative histopathology. Our discussion emphasizes the importance of thorough pelvic anatomy inspection during cesarean section, particularly since the patient was 18 months status post primary cesarean section. Finally, we review the pathophysiology of leiomyoma and discusses management of leiomyoma in atypical locations.
First Trimester Uterine Incarceration Resolved With Conservative Management in a Multifetal Gestation [19K]
Authors: Carney Alexandra C. , Tobler Kyle James
Published: May 2019

INTRODUCTION:

Gravid uterine incarceration has an incidence of 1 in 3,000 to 10,000 pregnancies. Presentation typically occurs between 14 and 16 weeks gestation. There has been only one previously reported case of uterine incarceration in a multifetal gestation. In symptomatic patients, treatment has included ultrasound-assisted manual reduction, colonoscopy-assisted insufflation, laparoscopy and laparotomy. We present a case of uterine incarceration of a twin gestation successfully resolved with bowel preparation and suppository pain control overnight followed by pessary placement requiring minimal ultrasound-assistance.

METHODS:

32 year old Gravida 5 Para 3 at 9 weeks gestation with a twin pregnancy by in vitro fertilization, presented with severe, intractable pelvic pain. Transvaginal ultrasound revealed a significantly retroverted incarcerated uterus. She was admitted for close observation and scheduled for manual reduction in the OR the next morning. Overnight, she received a bowel preparation and a Belladonna suppository for pain management. The following morning, the patient's pain had significantly improved. Ultrasound revealed substantial improvement and mobility of the uterus. Manual reduction required minimal force. A ring pessary was placed in the posterior cul-de-sac to maintain appropriate uterine position. The patient reported complete immediate resolution of pain following the procedure.

CONCLUSION:

Standard management for uterine incarceration has yet to be established; therefore, case reports are used when this rare complication occurs. Our case highlights that thorough bowel evacuation followed by pessary placement may be an effective first line treatment in symptomatic patients, thus avoiding surgical management. Additionally, anticholinergic effects of suppository pain control may contribute to uterine relaxation and self-reduction.
Joint Impact of Maternal Body Mass Index and Race on Macrosomia [31K]
Authors: Zhao Sifang Kathy , Velez Edwards Digna R. , Jones Sarah H. , Torstenson Eric , Hartmann Katherine Eubanks
Published: May 2019

INTRODUCTION:

Macrosomia (birthweight > 4,000g) increases risk of birth complications and metabolic syndrome for the infant. Motivated by racial differences in prevalence of obesity and macrosomia, we examined the joint influence of maternal body mass index (BMI) and race on risk of macrosomia.

METHODS:

Right from the Start is a prospective pregnancy cohort that enrolled women from southeastern US (2000-2012). Maternal height and weight were measured around six weeks gestation. Race was self-reported during a first-trimester telephone interview. Infant birthweight was obtained from medical or vital records. The joint effect of maternal BMI and race was assessed using stratified logistic regression, adjusting for maternal age, income, and gestational age.

RESULTS:

Among 3,986 women, 506 (13%) gave birth to a macrosomic infant. Non-Hispanic blacks had lower risk of having a macrosomic infant compared to non-Hispanic whites (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.34, 0.71). This observation holds for non-Hispanic blacks regardless of BMI status (normal [18.5-24.9 kg/m2] OR 0.34, 95% CI 0.14-0.79; overweight [25.0-29.9 kg/m2] OR 0.34, 95% CI 0.16-0.70; obese [≥-30.0 kg/m2] OR 0.53, 95% CI 0.30-0.94). For non-Hispanic whites (OR 1.52, 95% CI 1.11-2.08) and Hispanics (OR 2.71, 95% CI 1.01-7.30), being obese is associated with higher risk of macrosomia compared to normal weight non-Hispanic whites.

CONCLUSION:

We observed increased risk for macrosomia among obese non-Hispanic whites and Hispanics, but not non-Hispanic blacks. Understanding the interplay between maternal BMI and race could guide personalized strategies for assessing maternal weight and risk of macrosomia to inform use of ultrasound to identify macrosomia.
Incidence of Monozygotic Multiple Pregnancies After Single Embryo Transfer (SET): Review of SART Reported Outcomes [37K]
Authors: Peyser Alexandra , Blitz Matthew J. , Vohra Nidhi , Leung Tung Ming , Lesser Martin , Hershlag Avner
Published: May 2019

INTRODUCTION:

To calculate the incidence and risk factors of monozygotic multiple pregnancies after SET.

METHODS:

A review of all SET cycles from 2005-2015 that resulted in more than one fetal heartbeat on ultrasound was conducted. Descriptive statistics were used to determine factors associated with an increased risk of multiple pregnancies after SET.

RESULTS:

67,884 SET cycles met inclusion criteria, resulting in 1,307 (1.9%) twin gestations and 36 (0.06%) triplet or higher-order multiples. Mean age and BMI of subjects was 35.7±5.4 years and 24.6±14.9 kg/m2, respectively. Majority of subjects were from the Northeast or from the southern U.S. Autologous oocytes accounted for 84.2% of the twin cases and 91.6% of the triplets or more. 63% of the twins and 72% of the triplets or more underwent a fresh cycle. Sperm source was from the partner in 96% of both twin and triplet cohorts.

CONCLUSION:

Risk of monozygotic twinning (MZT) in IVF is 1.9% which is 5 times the rate of MZT in natural conception. While the risk of identical triplets is low (0.06%), it is not negligible. The mechanism underlying this increased risk in IVF embryos is unclear and probably includes culture conditions as well as micromanipulation. It is unclear how a single embryo splits into three: Is it the result of two sequential monozygotic splitting? Prospective IVF patients should be informed of the risk of identical multiples even with SET. Patients who desire the transfer of two blastocyst should be warned of at least one embryo splitting, ending up with a triplet pregnancy.
Pregnancy Rates in In Vitro Fertilization Are Superior When Trophectoderm Biopsy Is Done Only on Hatching Embryos [40K]
Authors: Singh Sonali , Hobeika Elie , Traub Michael Lawrence
Published: May 2019

INTRODUCTION:

In-vitro fertilization (IVF) with trophectoderm embryo biopsy and pre-implantation genetic screening (PGS) for aneuploidy, followed by elective single frozen embryo transfer (eSET) is becoming increasingly popular. However, embryos can be biopsied at various stages of blastocyst development. No studies to date have specifically investigated differences in pregnancy outcomes by timing of embryo biopsy.

METHODS:

Retrospective study of patients (n=363) at a single IVF center between January 1, 2013 and December 31, 2016 undergoing eSET with PGS. Embryo grading assessed at the time of biopsy and transfer. Pregnancy rates analyzed by embryo expansion, inner cell mass and trophectoderm grading. Statistical analyses performed by t-test, chi squared, Mann Whitney and Fischer exact tests. Interactions between embryo expansion, inner cell mass and trophectoderm grading were analyzed by 2-way ANOVA. IRB approval obtained.

RESULTS:

Implantation, clinical pregnancy and live birth rates improved significantly (P=.0001) and pregnancy loss decreased substantially (P<.001) with increased embryo expansion and if embryos were hatching at the time of embryo biopsy. For non-expanded or expanded embryos at biopsy, that later hatched at the time of eSET, pregnancy outcomes remained poor (live births 0% and 5.9%). Pregnancy rates from eSET with PGS where embryos were allowed to hatch, were far better than eSET of embryos without PGS.

CONCLUSION:

Embryos biopsied before they are hatching have extremely poor pregnancy outcomes regardless of how much they expand by the time of eSET. The embryo biopsy on a non-hatching embryo seems to significantly damage the embryo. IVF labs should wait until embryos hatch before performing trophectoderm biopsy.
Neutrophil/Lymphocyte Ratio: Predictive Biomarker for Outcomes of Early Pregnancy of Unknown Location [7L]
Authors: Arora Anubha , Menon Sharifa , Sanusi Ayodeji , Akinnawonu Kolawale Felix , Kumar Abhishek , Fuks Aleksandr
Published: May 2019

INTRODUCTION:

Pregnancy of unknown location (PUL) (positive pregnancy test with no evidence of intrauterine or extrauterine pregnancy on Transvaginal sonogram) requires serial hCG levels and imaging till final location of pregnancy is ascertained. Inflammation plays part in pathogenesis of abnormal pregnancies. Neutrophil/lymphocyte ratio (NL) is a marker of inflammation and prognosis. We conducted the first study to investigate the role of NL as predictor of outcomes of PUL.

METHODS:

Retrospectively, 145 patients presenting to ER at tertiary care hospital from Jan 2011-Jan 2016 were included, with exclusion criteria of hemodynamic instability, intraperitoneal hemorrhage, underlying cancer or hematological disorder, infection, smoker. Study was IRB exempted. Demographics, parity, presenting symptoms, b-hCG levels and NL ratio at presentation were noted. Patients followed up in time and final outcomes classified as: Definite intrauterine pregnancy, Nonviable pregnancy, definite ectopic pregnancy, probable ectopic, spontaneously resolving PUL, treated persistent PUL. SPSS software was used for statistical analysis.

RESULTS:

NL for normal versus abnormal pregnancy (all other categories) was 1.868±0.12 vs 3.08±1.81 (P=.001). NL for intrauterine versus extrauterine pregnancies were compared = 2.077±1.11 vs 2.74±0.83 (P=.0058). For hCG levels less than 3500, NL for normal versus abnormal pregnancies were 1.93±0.25 vs 2.92±0.34 (P<.001). NLR > 1.83 had AUC =0.793, sensitivity 86.9%, specificity 62.3% (ROC). Binary regression analysis revealed NLR was statistically significant (beta= 2.83, P=.002).

CONCLUSION:

NL could triage patients with PUL. Larger studies are needed to confirm the utility of this test which could save multiple labs and imaging, and avoid catastrophes like administration of methotrexate to normal Intrauterine pregnancy.
Pulmonary Leiomyomatosis: A Case Report [10L]
Authors: Kailasam Aparna , Dubinskaya Alexandra , Roland Phillip Y.
Published: May 2019

INTRODUCTION:

Benign metastasizing leiomyomatosis (BML) is a rare disorder, first characterized by Steiner in 1939, which manifests with extrauterine leiomyomata affecting areas such as the lung and bone. The clinical course is generally indolent, but patients can present with pulmonary symptoms.

METHODS:

CD is a 54 yo G4P2022 who presented to the emergency department with a 7 day complaint of moderate to severe chest pain radiating to her shoulder, exacerbated with movements. Surgical history included total hysterectomy at age 34 for uterine leiomyomata. Initial cardiac work up was negative. CT scan revealed fifteen pulmonary nodules and an ovarian mass. Transvaginal ultrasound showed two unilocular ovarian cysts. Laboratory results included CA-125 = 20.4 and FSH/LH = 14.5/11.3. CT guided biopsy of a pulmonary nodule demonstrated features of leiomyoma. Following this biopsy, the patient underwent VATS resection of the largest pleural nodule. The case was reviewed at the multidisciplinary tumor board. The final diagnosis was pulmonary benign metastasizing leiomyomatosis (BML). The left ovarian mass was felt to represent a benign ovarian neoplasm unrelated to BML. The patient was encouraged to undergo bilateral oophorectomy to limit the growth of her pulmonary leiomyomata. She elected for observation of her condition.

CONCLUSION:

The diagnosis of BML is rare and typically affects patients with a history of uterine leiomyomata s/p hysterectomy. Differentiating BML from malignant metastasis is important to avoid unnecessary procedures or delayed treatment. BML patients generally remain asymptomatic, though some patients may present with pulmonary symptoms. Anti-estrogenic, anti-hormonal therapies and surgical management have been suggested as treatment.
Implementation of Nitrous Oxide as an Analgesic Option on Our Labor and Delivery Unit [17L]
Authors: Canestraro Anthony John , Tussey Christina , Erickson Laurie Paullette
Published: May 2019

INTRODUCTION:

Our institution initiated a pilot program to introduce nitrous oxide as an analgesic option during labor and delivery. Nitrous oxide has previously been proven to be safe and effective, but its use is limited by the need for technical equipment and trained staff to safely provide it. It proves useful in labor and delivery as it has quick onset to effective pain relief and is less invasive than neuraxial anesthesia.

METHODS:

Anesthesia and obstetric staff were trained on the nitrous oxide delivery system. We then assessed users' demographics, labor characteristics, pain scores, and outcomes through retrospective electronic medical record review from May 2017 to September 2017. Patient satisfaction surveys were also administered and evaluated.

RESULTS:

During rollout, 113 patients used nitrous oxide. Exclusive use was seen in 54 women (47.8%) with conversion to epidural in 58 women (51.8%). Indications varied with 109 (95.6%) citing pain management, 9 (7.9%) using during procedures, and 2 (1.9%) using due to epidural contraindication. Side effects reported included dizziness in 16 (14.4%) and nausea in 5 (4.5%). Timeliness of pain management and overall satisfaction with the birth experience were rated as 5 out of 5 points in 85% and 87% of patients, respectively.

CONCLUSION:

Nitrous oxide proved to be a useful analgesic option with promising patient satisfaction scores. Its ease of implementation, low side effect profile, versatility, and effectiveness support its adoption as a supplement to our analgesia options in labor and delivery.
Improving Compliance With Preeclampsia Guidelines Through an Electronic Health Record Alert [19L]
Authors: Spencer Nicole Marie , Gabra Martina , Bedell Sabrina M. , Scott Dana , Ananta Bangdiwala , Rauk Phillip N.
Published: May 2019

INTRODUCTION:

Hypertensive disorders of pregnancy occur in 12-22% of all pregnancies and account for 17% of maternal mortality in the US. National guidelines for management of hypertensive disorders were developed by the American College of Obstetrics and Gynecology (ACOG) and the California Maternal Quality Care Collaborative (CMQCC). An electronic health record automated alert offers an opportunity to improve compliance with these guidelines.

METHODS:

A Blood Pressure Alert (BPA) was incorporated into an existing electronic health record to notify providers when a patient had a documented severe range blood pressure, defined as systolic blood pressure ≥-160 or diastolic blood pressure ≥110. Pre- and post-intervention data was collected via retrospective chart review. Compliance with national guidelines for administration of rapid-acting antihypertensive medication, IV magnesium for seizure prophylaxis, and initiation of oral antihypertensive medication postpartum was evaluated.

RESULTS:

Appropriate treatment of sustained severe-range blood pressure episodes with a rapid-acting antihypertensive medication within 1 hour of diagnosis improved after the implementation of the BPA (35% vs 54%, p<0.01), which was statistically significant. There was no significant change in the administration of IV magnesium sulfate (89% vs 80%, p=0.06) or prescription of oral antihypertensive medications at discharge (89% vs 93%, p=0.31).

CONCLUSION:

An automated electronic health record alert improved timely administration of rapid-acting anti-hypertensive medications for severe range blood pressures on an academic Labor and Delivery Unit and has the potential to improve overall compliance with ACOG and CMQCC preeclampsia guidelines. Increased adherence to these guidelines may improve maternal morbidity and mortality rates in the US.