bluuebunny/crossref_metadata_2025 huggingface dataset:
Reduction in Exposure to Opioids in Postoperative Obstetrical Patients [12T]
Authors: Arditti Lauren , Gallagher Kristen , Score Samantha Anne , Takhsh Eden
Published: May 2019

INTRODUCTION:

Post-operative pain management has been named a major contributing factor in the opioid crisis in America. With success of pain management in ERAS (Enhanced Recovery After Surgery) protocol for gynecologic and general surgery patients, similar ideology was introduced to post-operative obstetrical patients after cesarean section. Through education of the medical staff, we hoped to see an uptake of a modified ERAS protocol and fewer opioids for our postpartum obstetrical patients.

METHODS:

The intervention consisted of two elements: (1) the adoption of a modified ERAS protocol as a standard of practice for the unit through education of medical and nursing staff and (2) evaluation of the overall reduction of opioid medication use among post-operative patients with adequate pain control. Oral and PCA intravenous administration of morphine was the primary opioid included in the analysis.

RESULTS:

A total of 1,152 patients were included in the study between April 2017 and March 2018. The protocol was initiated in October of 2017. Morphine PCA use decreased by over 94%. Patients receiving PO morphine tablets (either 15 mg or 30 mg) decreased by 65%. We did not see a change in satisfaction scores following implementation of the new postoperative pain management protocol.

CONCLUSION:

In conclusion, adoption of a new standard of inpatient opioid prescribing in the postoperative obstetrical patient coupled with education of prescribers and nursing staff was associated with a reduction of inpatient exposure to opioids with similar pain control.
Risk Factors for Progression to Severe Features in the Outpatient Management of Preeclampsia [17T]
Authors: Treloar Mackenzie S. , Finneran Matthew M. , Smith Devin D. , Gonzalez-Brown Veronica M. , Rood Kara M.
Published: May 2019

INTRODUCTION:

Outpatient management is considered an acceptable surveillance method for women with preeclampsia (PE) without severe features (SF). While risk for disease progression has been studied in inpatient populations, outcome data for outpatient management is lacking. Our study aims to identify risk factors for disease progression in women with PE managed in the outpatient setting.

METHODS:

This was a retrospective cohort study of outpatients diagnosed with PE without SF at a large academic medical center from 2012-2017. The primary outcome was disease progression to SF. Demographic, diagnosis, and outcome data were compared between groups in univariate analysis. Backwards stepwise logistic regression was used to generate odds ratios (OR) adjusting for variables identified as risk factors for progression to SF.

RESULTS:

Of the 224 women who met inclusion criteria, 127 (56.7%) progressed to SF with a median latency from diagnosis of 7 days (IQR 1-12). Nulliparity was more common in the progression group (52% vs 35.1%; p=0.1), but no other demographic variables differed. Women with progression had an earlier gestational age (GA), greater rates of antihypertensive use, and higher systolic/diastolic blood pressure (BP), uric acid, and proteinuria at diagnosis. After stepwise regression, any systolic BP > 160 mmHg, uric acid > 4.65 mg/dL, GA < 32 weeks and nulliparity at diagnosis were independently associated with progression to SF (model AUC: 0.708; p<0.1).

CONCLUSION:

Over half of women with PE managed as outpatients progressed to SF. Nulliparity, GA, isolated severe-range systolic BP and uric acid levels were independently associated with progression to SF.
The NTSV Challenge; They Are Not All Created Equal [22T]
Authors: Mariona Federico G.
Published: May 2019

INTRODUCTION:

Obesity represents the prototypical example of a non-contagious endemic population health care concern. We explored the possible influences of extreme maternal obesity defined as a body mass index (BMI) of ≥50 k/mÂ2 on the primary cesarean rate of nulliparous patients, at term pregnancy, with a single live fetus and vertex presentation (NTSV), also classified as Robson TGCS group 2

METHODS:

A retrospective secondary analysis of prospectively collected administrative and clinical data in a limited cohort of extremely obese pregnant women care for in a single tertiary care hospital. Twins, non-vertex, preterm < 37 weeks gestation and multiparous were excluded.

RESULTS:

Between 2008 and 2018 442 extremely obese pregnant women were included. 120 patients were NTSV (27.1%). The unadjusted primary cesarean rate was 78.7%, adjusted 55.5%. (OR=2.4). 55.4% of the patients were induced, with a diagnosed failed induction of 41%. The expected number of cesarean deliveries was 26; the observed number was 60, a clinical an statistical significant difference.

CONCLUSION:

Maternal obesity continues to present a major health concern in the United States. Extreme obesity presents a clinical challenge during prenatal care and at delivery time. Efforts are in place to safely reduced the primary cesarean in the so called low risk pregnant women represented by the NTSV population. We have shown that extreme obesity in the NTSV population continues to militate against efforts at safely reducing the primary cesarean rate. We encourage a multiinstitutional effort to define the role of extreme obesity in safely reducing the primary cesarean rate.
The Role of Digital Cervical Examination in the Setting of a Sonographically Short Cervix [23T]
Authors: Shahawy Sarrah , Henricks Andrea , Chow Kimberly , Saladi Nikita , Saade George Robert , Miller Emily Stinnett
Published: May 2019

INTRODUCTION:

Many practices that have instituted universal cervical length (CL) screening have not included digital cervical examination in their process. Our objective was to investigate the incidence of cervical dilatation (CD) at various midtrimester CL thresholds as well as characteristics associated with CD that may inform who would benefit from digital examination in the setting of a short CL.

METHODS:

This retrospective IRB-approved cohort study included women with a singleton gestation with a midtrimester CL ≤ 2.5 cm who subsequently had a digital cervical examination within a week. The primary outcome was any CD on digital examination. Maternal sociodemographic, clinical, and sonographic characteristics were abstracted from the medical record. Bivariable and multivariable analyses were used to determine the relationship between these characteristics and CD. Receiver operating curves were developed to assess the predictive capacity of these characteristics to identify CD or CD ≥1 cm.

RESULTS:

Of the 256 women who met eligibility criteria, 103 (40.2%) were found to have any CD; 87 (34.0%) were at least 1 cm dilated and 8 (3.1%) were at least 2 cm dilated. While race/ethnicity, insurance status, nulliparity, a prior cervical excisional procedure, funneling on ultrasound, and the sonographic CL were each associated with CD, including all of these variables into a regression yielded a model with only fair predictive capacity to identify CD or CD ≥ 1 cm [AUC = 0.77 (95% CI 0.71-0.83) and 0.76 (0.70-0.82), respectively].

CONCLUSION:

As prediction of CD is limited, consideration should be given to performing a digital cervical exam in the setting of a sonographically short cervix.
What is the Optimal Cutoff for Maternal Serum Vitamin D Level to Predict Chorioamnionitis? [26T]
Authors: Persad Malini D. , Staszewski Cara , Khan Farzana , Perseleni Tatyana , Herrera Kimberly , Garretto Diana
Published: May 2019

INTRODUCTION:

To determine the optimal Vitamin D (25(OH)D) cutoff to predict of maternal intrapartum infection.

METHODS:

A cutoff for the optimal 25(OH)D level for the prediction of chorioamnionitis was derived from data collected from a trial on Vitamin D3 use from October 2016 and May 2018. Women not utilizing Vitamin D3 in the pregnancy were included in the analysis. Per the trial women with an intrauterine pregnancy, between 12-16 weeks gestation were included. Women taking Vitamin D3 supplements prior to enrollment, diagnosed with a malabsorption disorder, or carrying an anomalous fetus were excluded. Maternal demographics, baseline Vitamin D status, and the whether the participant development of intrapartum infection was collected from the electronic medical record. Clinical chorioamnionitis was defined as presence of an elevated temperature of 39C or greater or 38C, twice, 30 minutes apart with fetal tachycardia, maternal tachycardia, purulent vaginal discharge or uterine tenderness. Descriptive analyses were performed on baseline characteristics. The optimal Vitamin 25(OH)D cutoff was derived from a ROC curve.

RESULTS:

A total of 107 women were included in the analysis. Based on available data, the incidence of maternal infection was 3.8% (4/103) among participants. Women were approximately 30 years old, primarily Caucasian, parous, and overweight. The optimal cutoff for the maternal serum Vitamin D level in predicting chorioamnionitis was 20 ng/mL (sensitivity 70%, specificity of 100%; AUC 0.813; 95% CI 0.716-0.910).

CONCLUSION:

To predict chorioamnionitis, the optimal cutoff for maternal serum Vitamin 25(OH)D level is 20 ng/mL. Preconception optimization to this value should be considered to prevent intrapartum infection.
Urine Protein/Creatine Ratio at Term: Does It Change Management? [29T]
Authors: Zuber Matthew J. , Carlson Sandra Kathleen , Dudley Donald , Cortez Briana , Cotton-Caballero Amaya
Published: May 2019

INTRODUCTION:

We hypothesized that women with labor or rupture of membranes (ROM) commonly have proteinuria at term without preeclampsia as defined by urine protein/creatinine ratio (UPCR).

METHODS:

Women in this IRB-approved single-center, prospective cohort study were recruited at 35w0d-36w6d and provided a clean-catch urine for UPCR. With labor onset or ROM, a second urine specimen was collected. To detect a 10% difference in proteinuria between those with and without preeclampsia, we calculated a power of 82.3% and alpha of 0.05 for 84 patients.

RESULTS:

Baseline characteristics were similar between those with and without proteinuria. Race affected the risk of proteinuria, with 46.7% of Hispanic women, 27.3% African American, 7.1% Caucasian, and 0% of Asian patients having an elevated UPCR (>0.30) in labor or with ROM (P=.04). Only 3 patients in a cohort of 84 had UPCR > 0.30 between 35w0d and 36w6d. At admission, 13 of 84 patients (15.6%) had elevated UPCR. Five were diagnosed with preeclampsia without severe features (incidence 6%), and the diagnosis of preeclampsia did not correlate with the presence of proteinuria (P<.00). There was a trend toward elevated UPCR with ROM (26.7% vs 13.2%, P=.18). UPCR > 0.30 did not correlate with elevated blood pressure (>140/90) on admission (P=.48). Composite outcomes of maternal and neonatal morbidity were unchanged by proteinuria.

CONCLUSION:

Elevated UPCR is common independent of hypertension, with poor predictive value for preeclampsia at term. Proteinuria was more common in Hispanic and African American women. We question the clinical utility of UPCR in managing term hypertension.
Progesterone for Prior Late Preterm Birth: Is it Worth it? [34T]
Authors: Taliani Catherine A. , Hade Erinn , Finneran Matthew M. , Waickman Colleen , Frey Heather A.
Published: May 2019

INTRODUCTION:

To examine the use of any progesterone therapy versus none in the prevention of recurrent preterm birth (PTB) in women with only a history of late (340 - 366 weeks) prior spontaneous PTB.

METHODS:

Women with a singleton gestation and a history of late spontaneous PTB who received prenatal care at a single tertiary medical center between 2011-2016 were included in this IRB approved retrospective cohort study. Pregnancies were considered exposed to progesterone if it was initiated prior to 24 weeks; those with a fetus with a major congenital anomaly were excluded. The primary outcome was PTB <37 weeks. In order to control for treatment selection bias, adjusted risk differences (aRD) in PTB proportions and 95% two-sided confidence intervals were estimated via inverse probability weighted (IPW) regression with adjustment for multiple pregnancies per patient through robust sandwich standard errors. Secondary outcomes included: PTB <34 weeks, spontaneous PTB, neonatal intensive care unit admission, and gestational age at delivery.

RESULTS:

Of the 478 pregnancies included, 56% (n=270) received progesterone. After adjustment for treatment selection bias, pregnancies which received progesterone therapy had an increased risk of late PTB (<37 weeks: aRD: 11.5% (2.9, 20.0)). Similarly a significant increase in late spontaneous PTB (<37 weeks: 9.6% (3.2, 16.1)) and NICU admission (11.7% (5.2, 18.2)) was identified. No substantial difference in PTB <34 weeks was identified between exposure groups.

CONCLUSION:

This study suggests that progesterone supplementation may not be effective at preventing recurrent PTB in women with a prior spontaneous PTB between 340 - 366 weeks gestation.
Timing of Pregnancy After Ovarian Hyperstimulation Syndrome and Pregnancy-Related Outcomes [35T]
Authors: Sangtani Ajleeta , Ismail Maryama , Khan Zaraq
Published: May 2019

INTRODUCTION:

The incidence of ovarian hyperstimulation syndrome (OHSS) after assisted reproduction is approximately 3%. The outcomes of pregnancy in immediate versus delayed pregnancy has not been previously studied.

METHODS:

A retrospective cohort study was conducted using the Rochester Epidemiology Project Database. Residents of Olmsted County and the surrounding 9 counties with OHSS were identified between 1995 and 2017. Patients were included if they had a pregnancy lasting ≥20 weeks gestation after the diagnosis of OHSS. Background data and pregnancy outcomes were collected. Data were then analyzed using a combination of t-test and Chi squared test. Women with OHSS and same cycle pregnancy were compared to those with subsequent cycle pregnancy.

RESULTS:

85 women with OHSS were analyzed, 47 with same-cycle pregnancies and 38 with subsequent cycle pregnancies. Background data did not differ between the two groups for infertility cause, body mass index, gestational age, parity, or number of embryos transferred. OHSS treatment modalities (paracentesis, thoracentesis, hospitalization and medical treatment) did not differ between groups. Patients with same-cycle pregnancies had neonates delivered at 35.6 weeks compared to 38.3 weeks with delayed pregnancies (p=0.0006). Patients with same cycle pregnancies also had lower birth weights compared to patients with delayed pregnancies (3201 g v 2628 g, p=0.003). Incidence of hypertensive disorders, diabetes, placental abruption, thromboembolism, intrauterine fetal death, intrauterine growth restriction, and 1 and 5 minute Apgar scores did not differ between the two groups.

CONCLUSION:

The data gives new insight into the risk of same-cycle pregnancies in patients with OHSS. Larger studies are needed to confirm the data.
The Use of Minimal Ovarian Stimulation to Achieve Autologous Pregnancy in Extremely Poor Prognosis Patients [36T]
Authors: Prokai David , Li-Jon Wu John , Babayev Samir , Carr Bruce R. , Bukulmez Orhan
Published: May 2019

INTRODUCTION:

Patients with extreme advanced reproductive age and/or markedly diminished ovarian reserve are often recommended to undergo oocyte donation following failure to obtain embryos or achieve pregnancy with conventional high dose ovarian stimulation protocols. We present a cohort of patients who were recommended to use oocyte donation who underwent minimal stimulation for the purposes of embryo banking subsequently achieving ongoing pregnancy.

METHODS:

Retrospective cohort.

RESULTS:

A total of 20 self-referred patients after only being offered donor oocyte at an outside fertility clinic. Characteristics of this cohort included mean age 40.1 ± 0.74 years, Anti-Müllerian hormone 0.89 ng/mL ± 0.19, and the average number of conventional high dose cycles prior to referral was 2.2 ± 0.3 cycles. Of the patients undergoing minimal ovarian stimulation protocols, 90% (18/20) were able to have embryos frozen after undergoing 3.8 (+/- 0.41) cycles. Of these patients, 61.1% (11/18) progressed to embryo transfer (ET). For those who underwent ET, a total of 5 ongoing pregnancies (45% pregnancy rate) were achieved with an average time to pregnancy of 1.3 ± 0.24 years. Two spontaneous pregnancies (1 ongoing and 1 miscarriage) occurred during the course of treatment.

CONCLUSION:

Repetitive minimal simulation protocols with embryo banking allow the opportunity for autologous pregnancy in patients who previously failed conventional stimulation protocols and were recommended donor oocytes.
Should Penicillin Allergy Be Confirmed During Pre-operative Testing? [38T]
Authors: Lozo Svjetlana , Wagner Daniel , Goldberg Roger , Shah Nirav , Silver Richard Karl , Solomonides Toni
Published: May 2019

INTRODUCTION:

Documentation of a penicillin allergy often results in use of broad-spectrum antibiotics for surgical site infection prophylaxis which can contribute to antibiotic resistance and higher medical cost. The primary aim of our study is to prospectively determine the true prevalence of penicillin allergy in patients undergoing urogynecological surgeries so that the use of alternative antibiotics could be curtailed when appropriate.

METHODS:

This study was undertaken as the practicum project in an institutional Patient Safety and Quality Fellowship. In phase I, retrospective chart review of patients' allergies and surgical site infection prophylaxis medication was performed (2017). Subsequently (Phase II; 1/18-9/18), penicillin allergy testing was offered as part of pre-operative evaluation to at-risk patients and results were used to modify care as appropriate.

RESULTS:

In 2017, 51% of patients with penicillin allergies received broad-spectrum antibiotics for surgical site infection prophylaxis. In 2018, 44 patients had a history of penicillin allergy (28 reported rash, 6 had hives and 10 could not recall their reaction); all were offered testing; 28 accepted, and 26 (93%) had negative results. These 26 women (60%) were able to receive recommended prophylaxis via cefazolin without complication.

CONCLUSION:

Our findings support penicillin allergy testing for at-risk urogynecology patients as part of pre-operative assessment. This strategy has the potential to promote antibiotic stewardship, improve care, and reduce cost. We cannot extrapolate to other surgical cohorts without considering patient age, gender differences and other factors, but confirming penicillin allergy in other surgical groups seems warranted.
Use of Hormonal Contraception in Women Suffering From Migraine [6S]
Authors: Johnson Amy , Tilden Elizabeth , Newmark Alexis , Grosberg Brian , O'Sullivan David
Published: May 2019

INTRODUCTION:

Migraine is a common condition in reproductive age women, with menses as a frequent trigger. The use of continuous combined hormonal contraception (CHC) has been shown to reduce the frequency of estrogen-associated migraine by as much as 80%. With newer low-dose estrogen formulas, the Centers for Disease Control and Prevention (CDC) re-categorized CHC as acceptable for women with migraine without aura. The International Headache Society Task Force concluded that low-risk patients may benefit from CHC regardless of the presence of aura. We hypothesized that CHC is underutilized in appropriate candidates despite recent guidelines.

METHODS:

An IRB-approved retrospective chart review was performed to assess the use of hormonal suppression in women with migraine. Electronic medical records were reviewed over two years for women age 18-50 suffering from migraine. Patient data extracted included demographics, medical history, and medications.

RESULTS:

A total of 7,451 female migraine suffers were identified, the majority (n=6,404, 85.9%) without aura. 18.9% of all patients were identified as having at least one risk factor for CHC use, primarily smoking or hypertension. There was no statistically significant difference in hormone utilization based on headache type; 22% of patients without aura (20.4% pills, 1.4% ring, 0.2% patch) and 19.8% of those with aura (18.1% pills, 1.6% ring and 0.1% patch). There also was no difference among those identified specifically as menstrual migraine (27.3% pill, 1% ring).

CONCLUSION:

The majority of patients with migraine are low risk for CHC and potential candidates for hormonal suppression.
Trends in Abortions Performed in Georgia Following Partial Enactment of a 22-Week Ban [4S]
Authors: Redd Sara , Berry-Bibee Erin , Hartwig Sophie , Lathrop Eva , Haddad Lisa , Cwiak Carrie
Published: May 2019

INTRODUCTION:

We investigated trends in abortions performed in Georgia before and after partial enactment of House Bill 954 (HB954) in January 2013, which bans abortions at 22 weeks from last menstrual period.

METHODS:

Using publicly available data from Georgia Department of Public Health's state-mandated Induced Termination of Pregnancy forms, we estimated changes in the numbers of abortions provided before (2009-2012) and after (2013-2016) the law went into partial effect, stratified by gestational age, state of residence, and year.

RESULTS:

From 2009 to 2016, 257,161 abortions were performed in Georgia, including 131,655 pre- and 125,506 post-law; 88% were among Georgia residents and 4% occurred ≥20 weeks gestation. Following HB954, the number of ≥20-week abortions among in-state residents declined 22% (9% for 20-23 weeks, 74% for ≥24 weeks). Among out-of-state residents, abortions occurring ≥20 weeks declined 41% (14% for 20-23 weeks, 92% for ≥24 weeks). By year, abortions occurring 20-23 weeks declined steadily among in-state residents (549 in 2013 to 409 in 2016), but among out-of-state residents temporarily increased in 2013 (443) and 2014 (497), then sharply declined in 2015 (321) and 2016 (248). Trends in ≥24-week abortions were similar for in- and out-of-state residents, spiking from ∼0 in 2013 and 2014 to 138 in 2015.

CONCLUSION:

Following HB954, abortions occurring ≥20 weeks gestation declined in Georgia, though differential trends were found across study years and residence. We are continuing to evaluate the impact of the 22-week ban, which went into full effect in October 2015, on reproductive health access, outcomes, and systems across the Southeast.
Trends in Utilization of Brachytherapy in Cervical Cancer in a Single Military Medical Center [37R]
Authors: Kucera Calen W. , Miller Caela
Published: May 2019

INTRODUCTION:

Standard of care (SOC) treatment for locally advanced cervical cancer consists of chemotherapy, external beam radiation and brachytherapy. Despite significant survival benefits, there is a national decline in utilization of brachytherapy in recent years. Currently only 44% of US patients with locally advanced cervical cancer receive brachytherapy. We believe military medicine and our military medical center has avoided this trend and correctly administers SOC treatment for locally advanced non-operable cervical cancer.

METHODS:

We utilized the Brooke Army Medical Center Tumor Registry to identify women with locally advanced cervical cancer between January 1997 and March 2018. We reviewed medical records to determine if they received SOC treatment as well as potential associated demographic factors. Data was then analyzed using logistic regression models. (IRB approval was obtained).

RESULTS:

We found that of the 147 patients with cervical cancer, 36 had locally advanced cervical cancer, 28 (77.8%) met SOC treatment. We found no statistically significant associated factors to include race, rank, duty status, or stage. Reasons for not completing SOC treatment included vesico-vaginal and recto-vaginal fistulas, declining treatment, and rare histologies.

CONCLUSION:

Our military institution has nearly double the rate of SOC brachytherapy compared to national use. Although we have a small sample size we expect that these trends would be consistent across military medical centers. The contribution of economic and social factors that decrease use of brachytherapy nationwide may be mitigated by the equal access to care provided by military medicine, and the decrease in out of pocket expenses by military beneficiaries at military facilities.
Risk of Cancer and Performance of Ultrasound in Postmenopausal Women Who Failed Endometrial Biopsy [36R]
Authors: Doulaveris Georgios , Chen Alice , Orfanelli Theofano , Escobar Pamela , Dar Pe'er , Rotenberg Ohad
Published: May 2019

INTRODUCTION:

To assess the risk of endometrial cancer or hyperplasia (EmCH) and the performance of transvaginal ultrasound (TVS) in postmenopausal women who had a failed endometrial biopsy (EMB).

METHODS:

Retrospective study of all women, aged 55 and older, who underwent EMB between 1997 and 2008. Failed EMB was defined as “absent” or “insufficient” endometrial tissue. Patients' data was collected until 2015 for long term surveillance. We assessed TVS utilization, the ability of TVS to provide adequate measurement of the endometrial echo (EE) and performance of TVS for detection of EmCH. For the performance of TVS we used EE cutoff of ≥5 mm.

RESULTS:

1808 postmenopausal women underwent EMB during the study period. In 269 (14.9%), endometrial sampling failed to obtain tissue. Of these cases, 16/269 (5.9%) had a final diagnosis of EmCH. 125/269 (46.5%) of women had concurrent TVS to assess their endometrium. EE could be adequately visualized in 111/125 (88.8%). Mean EE was significantly thicker in women eventually diagnosed with EmCH compared to those with benign diagnosis (17.4 mm vs 10.2 mm, p= 0.01). In women who had insufficient EMB and had accessible EE measurements via TVS, endometrial thickening had a sensitivity of 100%, specificity of 46.1%, NPV of 100% and PPV of 11.1% in diagnosis of EmCH.

CONCLUSION:

EMB failed to obtain tissue in 14.9% of postmenopausal women of which 5.9% had EmCH. TVS provided adequate EE measurement in 88.8% of these cases. Thick endometrium had 100% sensitivity and 100% NPV in the diagnosis of EmCH but with low specificity and PPV.
Protocol Management of Cholestasis of Pregnancy [32R]
Authors: Shepard Sarah Therese , Brost Brian , Stark Craig , Alkis Mallory
Published: May 2019

INTRODUCTION:

Intrahepatic Cholestasis of Pregnancy (ICP) is associated with intrauterine fetal demise (IUFD) and severity of disease is associated with higher rates of IUFD. Antepartum management of (ICP) is highly variable. Consensus in clinical practice is to encourage delivery at 37 weeks regardless of severity. We evaluated if standardizing the management of ICP based on bile acid level would affect maternal and neonatal outcomes.

METHODS:

Women diagnosed with ICP and delivered at our hospital were prospectively followed from 01/02/2012-01/01/2018. Maternal and neonatal outcomes were evaluated before and after institution of a standardized management protocol. A 6 month wash-out period was utilized. Statistical methods performed included the Chi Square test, Fischer exact probability test and the two sample t-test. IRB approval was obtained and standards upheld.

RESULTS:

Ninety-two patients were included in the analysis. The bile acid level was higher in the post guideline group 69 umol/L vs the pre guideline group 30 umol/L (p =0.002). No difference was noted in the cesarean rate (p=0.56), NICU admissions (p=0.075), or 5 minute APGAR (p=0.609). The rate of composite neonatal respiratory morbidity was higher in the post guideline group (p=0.0023). There was one IUFD in the post-guideline group that occurred at 28 weeks in the setting of a twin pregnancy and bile acids of 264.

CONCLUSION:

Induction at 39 weeks for pregnancies with bile acids 20 or less did increase composite neonatal respiratory morbidity. Guidelines and standardization of care for cholestasis of pregnancy would help reduce variability between providers and deliveries prior to 39 weeks.
Prelabor Rupture of Membranes at Term: When Should We Recommend Induction? [31R]
Authors: Teal Elizabeth Nicole , Lewkowitz Adam , Tran Carol , Koser Sarah , Gaw Stephanie
Published: May 2019

INTRODUCTION:

Prelabor rupture of membranes (PROM) affects approximately 8% of pregnancies. The TermPROM Study demonstrated that immediate induction of labor (IOL) versus expectant management for up to four days result in similar rates of cesarean and neonatal infection but increased maternal infection. ACOG endorses IOL for PROM but states expectant management may be considered. However, guidelines on the safest duration of expectant management are lacking. This study aims to determine whether there is an optimal time from PROM to IOL initiation.

METHODS:

This retrospective cohort study included nulliparous women with non-anomalous, singleton, cephalic pregnancies who underwent IOL for PROM at a tertiary-care academic hospital from January 2015 to April 2017. Primary outcome was vaginal delivery (VD) rate. Secondary outcomes were IOL duration, infection, hemorrhage, and NICU admission. The data were analyzed using the Kruskal-Wallis test and logistic regression.

RESULTS:

The 246 patients were divided into groups by time from PROM to IOL initiation: <12 h (n=116, 47.2%), 12-24 h, (n=96, 39.0%), and >24 h (n=34, 13.8%). There was no difference in VD rate, IOL duration, infection, or NICU admission amongst groups. There was an increased odds of hemorrhage with IOL greater than 24 hours after PROM (aOR 2.74, CI 1.18 - 6.33). There were no differences in NICU admission.

CONCLUSION:

In this cohort, expectant management up to 24 hours was not associated with increased maternal or fetal risks. Expectant management beyond 24 hours was associated with increased risk of hemorrhage. This suggests that patients with PROM can be safely offered expectant management for up to 24 hours.
Pregnancy Related Emergency Department Visits in a Clinic Population: A Quality Improvement Review [28R]
Authors: Gilroy Laura Claire , Tomczyk Setul Ram
Published: May 2019

INTRODUCTION:

For many women in the United States, their local emergency department (ED) is the only option for medical care. As the number of uninsured and underinsured patients increases, there is a mounting burden on emergency departments to care for patients with both urgent and non-urgent complaints. We looked to assess patients initiating care at a resident-run clinic who already presented to our local emergency department with pregnancy-related complaints.

METHODS:

A retrospective chart review was performed of patients who received prenatal care in the resident-run clinic over 6 months. This was cross referenced with hospital records to identify those patients who presented to the emergency department prior their initial prenatal visit.

RESULTS:

Two hundred and twenty three patients were seen at the clinic over 6 months. 59 (26.5%) presented to the ED prior to initiating prenatal care. The patients presenting to the ED were significantly younger (mean age 28.6 versus 30.6 years (p=0.034). The mean gestational age at first ED presentation was 9 weeks and 1 day. The majority of patients had pain (37%) or bleeding (27%) as their presenting complaint. There was no significant difference in wait time for an initial OB appointment between those consulted by the Gynecology service in the ED versus those seen by an ED physician (3.65 versus 4.65 weeks, p=0.152).

CONCLUSION:

Our data suggest visiting the ED does not significantly improve early pregnancy care for clinic patients. There is potential for improving this system in a way that will benefit patients and lower institutional costs.
Postpartum Severe Maternal Morbidity Among Mothers of Neonatal Intensive Care Unit Infants [20R]
Authors: Stuebe Alison M. , Tucker Christine , Ferrari Renee , Verbiest Sarah , Pate Virginia , Jonsson-Funk Michele
Published: May 2019

INTRODUCTION:

To reduce maternal mortality, it is critical to identify women at increased risk of postpartum complications.

METHODS:

We conducted a retrospective cohort study of mothers delivering liveborn infants at North Carolina Women's Hospital between 7/1/2014 and 6/30/2016. NICU mothers were defined as women with ≥1 infant admitted to the Neonatal Critical Care Unit. We used data from the UNC Health System Epic Electronic Medical Record to ascertain hospital visits between discharge and 12 weeks postpartum. We used Alliance for Innovation on Maternal Health (AIM) criteria to define postpartum severe maternal morbidity (PSMM). We used Fisher's exact tests to compare rates of PSMM among mothers of well babies (MWB), compared with NICU mothers.

RESULTS:

Among 6849 women in our cohort, there were 488 emergency department visits, 239 OB triage visits, 62 hospitalizations for observation, and 171 inpatient admissions at the North Carolina Women's Hospital within the first 12 weeks postpartum. There were no postpartum maternal deaths. NICU mothers were more likely to have at least one hospital visit than MWB (173/1081, 15.6% vs. 517/5768, 9.0%, p<.0001). PSMM by AIM criteria was experienced by 33/6849 women (0.48%). NICU mothers were more likely to experience SMM than MWB (1.2% vs. 0.38%, Fisher's Exact p = 0.01, OR 2.69, 95% CI 1.30-5.56).

CONCLUSION:

About 0.5% of mothers were readmitted with PSMM. Actual rates of PSMM are likely higher, as we only ascertained encounters within the UNC Health System. The risk of PSMM was higher among NICU mothers than among mothers of well babies.
Peripartum Intensive Care: Experience in an Urban Hospital Setting [17R]
Authors: Upadhyay Ruchi , Elkafrawi Deena , Sultana Carmen , Gaither Kecia
Published: May 2019

INTRODUCTION:

As women with co-morbid conditions become pregnant, it is not surprising that the rate of peripartum ICU admissions reflect this occurrence. Critically ill peripartum patients present a unique population, as the presence of a fetus, in conjunction with altered maternal physiology and a co-existing disease entity makes their care challenging. The purpose of this study is to describe the clinical characteristics of peripartum patients requiring intensive care in an urban hospital center.

METHODS:

IRB approved retrospective chart review of women admitted to the ICU between the first trimester of pregnancy through six weeks postpartum, from January 2014 through January 2017. Data collected on age, ethnicity, BMI, presence/absence of prenatal care, substance abuse and attendant co-morbidities for antepartum and postpartum patients.

RESULTS:

Seventy three patients were admitted to the ICU. The majority of the antepartum patients admitted lacked prenatal care, were noted to be tobacco/substance abusers; sepsis, DKA and respiratory dysfunction were the predominant morbidities. Conversely, the majority of the postpartum patients had prenatal care, and were morbidly obese; preeclampsia, cardiomyopathy and postpartum hemorrhage were the predominant morbidities.

CONCLUSION:

There exists a paucity of studies relating to peripartum intensive care--and of those, most focus on the postpartum aspect. The findings of this study are interesting in that both antepartum and postpartum patients were analyzed. Obesity confers a number of associated outcomes inclusive of hypertensive disorders and cardiac dysfunction. Our findings suggest that outreach programs directed to encouraging early prenatal care with screening for evidence of cardiac dysfunction/preeclampsia risk would be of benefit.
The Search for Vaginal Candida Resistant Infections, A Descriptive Study [15R]
Authors: Tiran-Saucedo Jose , Garza Humberto , Leon Yvette , Godinez-Burgos Jesus Alfonso
Published: May 2019

INTRODUCTION:

An increase in the prevalence of drug-resistant candida species has been observed due to the free sale of antifungal agents, which has also led to changes in vaginal colonization by other species with greater resistance such as C. krusei or C. glabrata. The purpose of the study was to identify candida species isolated in vaginal cultures and to determine their sensitivity and resistance to antifungals.

METHODS:

The research was conducted at the Mexican Institute of Infectious Diseases Gynecology and Obstetrics (IMIGO). The culture and microbial susceptibility were performed using VITEK®2 AST-YST system and then classified as sensitive, intermediate or resistant to the use of Flucytosine, Fluconazole, Voriconazole, Amphotericin, Caspofungin and Micafungin. We included women with symptoms of vaginal candidiasis regardless of their age and previous treatments.

RESULTS:

A total of 90 positive cultures were obtained. The isolated microorganisms were C. albicans 68%, C. glabrata 19%, and C. krusei, C. tropicalis and C. parapsilosis 1%. C. albicans was classified as 15% resistant and 9% intermediate resistant with Fluconazole, in addition 6% resistant and 12% intermediate resistant to Voriconazole. C. glabrata was classified as 42% intermediate resistant to Fluconazole, and 5% intermediate resistant to Voriconazole, Amphotericin B and Micafungin.

CONCLUSION:

There is an important increase in the diagnosis of C. glabrata compared to that reported in the literature where the predominance by species is C. albicans. In addition, higher resistance was found in the C. albicans and C. glabrata species to anti-fungal of the triazole family, specifically Fluconazole and Voriconazole.
Streptococcal Non-Menstrual Toxic Shock Syndrome [14R]
Authors: Zimmer Zoe Clark , Schexnayder Brian , O'Neill Shea
Published: May 2019

INTRODUCTION:

Case report.

METHODS:

Case Study: We describe the case of a 21-year old gravida 0 with history of substance abuse and genital herpes who presented to the hospital with fever and malaise of several days duration. On examination she exhibited cervical motion tenderness concerning for pelvic inflammatory disease and severe maculopapular rash accompanied by an episode of hypotension. The patient was transferred to the intensive care unit, where her clinic picture met the CDC case definition for probable toxic shock syndrome. Streptococcal disease was suspected due to elevated anti-DNAse B titers. She underwent treatment with antibiotics and intravenous immunoglobulin and discharged home after one week of hospitalization. At discharge she exhibited characteristic desquamation of the palms and soles. The incidence of non-menstrual toxic shock syndrome has remained stable despite the decline in menstrual toxic shock associated with high-absorbency tampon use. While the CDC's case definition is useful in defining a case, a patient is often resuscitated and treated-to their benefit--before criteria can be met to confirm diagnosis. In discussion of this case we review the epidemiology, pathophysiology, and management of this life threatening illness, and reaffirm the importance of maintaining a high index of suspicion for patients with a similar presentation. Informed consent was granted by the patient. She understands that no personally identifying information would be included in the report and that every effort for anonymity would be made, but could not be guaranteed. The patient was offered the opportunity to read the manuscript and associated materials.

CONCLUSION:

Case report.
Partial Molar Gestation Presenting as Hypertensive Emergency [33Q]
Authors: Montanez Kathleen R. , DeSouza Nelson , Talise Paul C.
Published: May 2019

INTRODUCTION:

The reported incidence of partial hydatidiform is 23 to 1,299 per 100,000 pregnancies. Women present with early pregnancy complications such as bleeding, pelvic discomfort, or hyperemesis. The diagnosis is often made on pathologic evaluation after treatment for a presumed missed abortion. If the pregnancy continues past the first trimester, intrauterine growth restriction and oligohydramnios are common. Partial molar gestations continuing into the second trimester may present with hypertensive emergency or thyrotoxicosis.

METHODS:

A 29-year-old G3P1 at 18 weeks and 3 days gestational age presented to the emergency room for acute onset headache. Severe range blood pressures up to 231/125, serum beta-hCG of 638,645 and an abnormal appearing placenta on bedside ultrasound were concerning for partial molar gestation. She was admitted to the intensive care unit for a nicardipine drip due to refractory hypertension. The patient refused uterine evacuation at this time due to presence of a fetal heart rate. On hospital day four, she had severe range blood pressures despite two oral agents and consented to delivery. Prior to placement of laminaria, she started hemorrhaging after rupture of membranes prompting an emergent dilation and evacuation. She refused packed red cells due to religious concerns but consented to other blood products. She received three units of fresh frozen plasma and one pack of platelets. She was discharged home on postoperative day three. Her human chorionic gonadotropin was followed appropriately.

CONCLUSION:

Second trimester partial molar gestations are rare and may present with severe sequalae requiring emergent evacuation of the uterus.
Effect of Chronic Hypertension on Treatment of Urgent Hypertension in Patients With Severe Pre-Eclampsia [10F]
Authors: Litman Ethan , Cui Yiwen , Feustel Paul , Bringley Johanna , Rijhsinghani Asha
Published: May 2019

INTRODUCTION:

We studied the impact of pre-existing hypertension on the management of severe hypertension in patients diagnosed with preeclampsia.

METHODS:

We analyzed 227 antepartum patients who developed severe blood pressures (systolic >=160 mmHg and/or diastolic >=110 mmHg) requiring IV labetalol over a 2-year period. Patients were grouped by diagnosis of chronic hypertension with superimposed preeclampsia with severe features (CHTN, n=82) versus preeclampsia with severe features (preE, n=142). Electronic records were reviewed for anthropomorphic data. Blood pressure was extracted every 15 minutes starting after the first dose of labetalol. We performed a repeated-measures analysis of variance for statistical modeling, controlling for patient-patient variance.

RESULTS:

The baseline systolic (SBP) and mean arterial pressure (MAP) did not differ significantly between CHTN and preE groups (SBP of 164 vs. 167 mmHg, p=0.2; MAP of 119 vs. 121 mmHg, p=0.2). ANOVA revealed a significant effect of time and demonstrated a consistently significant greater SBP decrease per unit of time in preE group compared to CHTN (p<0.002, Model R2=70%). Differences in MAP between the two groups remained constant post-treatment and approached significance (p=0.052, Model R2=67%). The greatest difference in SBP between the two groups was observed 30 and 60 min post-treatment (8 and 9 mmHg, respectively, p<0.002).

CONCLUSION:

Patients with pre-existing hypertension achieved a smaller reduction in SBP and MAP compared to those without, when given the same treatment for acutely severe blood pressure. This suggests that the former group of patients may benefit from alternative drug regimens to achieve adequate blood pressure control.
Reasons for Unplanned 30-Day Readmission After Total Laparoscopic Hysterectomy: A Single Institution Study [3D]
Authors: Le Chi , Elsamadicy Emad A. , Lee Jaclyn , Brown Kelsei
Published: May 2019

INTRODUCTION:

There is a scarcity of literature regarding surgical outcomes after total laparoscopic hysterectomy (TLH). We investigated patient risk and reasons associated with readmission within 30 days after TLH.

METHODS:

Medical records of 168 consecutive patients who underwent TLH at a major academic center between 2010 and 2012 were reviewed. Robotic hysterectomies were excluded. Patient's age, BMI, and co-morbidities before surgery were collected. Timing, reasons, and management of readmitted patients were evaluated.

RESULTS:

Among 168 patients reviewed, 8.9% of patients were readmitted within 30 days (95% CI: 5.5-14.2%). Intraoperative variables revealed the average length of operation (151 ± 52 minutes), average estimated blood loss (90±107 ml), and urine output (350±245 ml). No intraoperative transfusions were performed. Over half (60%) of patients were obese (BMI>30), and associated co-morbidities included anemia (33.3%), depression (26.7%), anxiety (26.7%), hypertension (20.0%), and diabetes (13.3%). The average time until return were 9.0 ± 6.0 days with the main location of readmission through the emergency department (93.3%). Primary chief complaints were pain (86.7%), nausea (33.3%), and vomiting (26.7%). Shortness of breath (13.3%), UTI (13.3%), Fever (13.3%), and bleeding (13.3%) were reported. At readmission, 33% of patients were only observed, while 6.7% received antibiotics, and 73.3% receiving additional pain control.

CONCLUSION:

Our study showed that readmission after TLH tend to occur after soon after discharge. Obesity and pain were the most frequent co-morbidity and complaint respectively, requiring readmission within 30 days. Future studies are necessary to identify patients who are at greater risk of readmission to improve surgical outcomes.
Improving Preoperative Administration of Azithromycin in Indicated Cesarean Sections [22L]
Authors: Handley Katelyn Foster , Nakahara Angela , Gillispie Veronica
Published: May 2019

INTRODUCTION:

To use quality improvement tools to improve preoperative administration of azithromycin in unscheduled cesarean sections (C/S).

METHODS:

We determined baseline adherence to the guideline by chart review from 11/01/2017 to 02/11/2018. Unscheduled C/S was defined as a C/S after rupture or the onset of labor. This quality improvement initiative involved three plan-do-study-act (PDSA) cycles over a 2.5 month period including: PDSA#1: modified the timeout prior to cesarean section to include indication for and administration of azithromycin; PDSA#2: updated the L&D admission order set to include a PRN order for azithromycin; PDSA#3: added azithromycin to the Pyxis. We evaluated each intervention by comparing the percentage of patients receiving azithromycin in indicated C/S before and after implementation to determine if the change idea for that PDSA cycle was effective. We also gathered data on prospectively determined data points including emergent status, indication for azithromycin, indication for C/S, and practice type.

RESULTS:

Administration rate increased from 74% to 90% after all interventions (p=0.12). The rate increased after PDSA#1 to 75%, decreased after PDSA#2 to 71%, then finally increased to 90% after PDSA#3. In the subset of nonemergent cesarean sections, the administration rate increased from 75% to 94% (p=0.08). According to indication for azithromycin administration, 82.2% of ruptured patients received azithromycin while only 43.8% of laboring only patients received azithromycin. Administration also differed by indication for cesarean section.

CONCLUSION:

We were successful in increasing the administration of azithromycin in indicated cesarean sections to our goal of 90% compliance.