bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of Intrauterine Pressure Catheters (IUPC) Increases Risk of Post-Cesarean Surgical Site Infection [9B]
Authors: Rood Kara M. , Gee Stephen , Millen Katherine , Kellert Brian , Buhimschi Catalin , Klebanoff Mark
Published: May 2017

INTRODUCTION:

Surgical site infection (SSI) rates are increasingly being linked to payment incentives for hospitals and represent an important clinical quality indicator of care. Clinical interventions aimed to significantly reduce cost and morbidity can be designed through identification of key predisposing obstetrical risk factors for SSI. Studies conducted in a limited number of subjects suggest an association between IUPC and post-partum endomyometritis. Our objective was to examine the relationship between intra-partum use of IUPC and risk of post-cesarean SSI.

METHODS:

We performed a secondary analysis using data from Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry (1999-2002). Patients included in this analysis had a singleton viable pregnancy and a cesarean delivery following labor for recognized obstetrical indication from 24 to 42 weeks gestational age (GA). A multivariable logistic regression model was used to control for GA, race, BMI at delivery, smoking, limited prenatal care, length of labor, length of membrane rupture, PPROM, pre-gestational diabetes, hypertensive diseases, physical health status assessed using American Society of Anesthesiologists established categories, and maternal clinical chorioamnionitis.

RESULTS:

25,986 women were included in this analysis. The rate of SSI was 12.9% (1,542 of 11,941) in the patients with IUPC and 7.8% (1,099 of 14,045) in the patients without IUPC (P= < 0.001). The adjusted Odds Ratio for SSI among patients who had IUPC was 1.40, (95% CI=1.26-1.57, P= < 0.001).

CONCLUSION:

We present compelling data that in laboring women undergoing cesarean delivery, the use of IUPC is an independent risk factor for post-cesarean SSI.
Effect of Chronic Kidney Disease Stage on Pregnancy Outcomes [10B]
Authors: Scrivner Karen , Zwerling Blake , Caughey Aaron B.
Published: May 2017

INTRODUCTION:

This study aims to estimate the risk of adverse pregnancy outcomes in women with stages 1-5 chronic kidney disease (CKD).

METHODS:

This is a retrospective cohort study of 2,039,870 singleton, non-anomalous pregnancies recorded in the California Birth Registry from 2006 to 2010, of which 93 were complicated by CKD. 27 women were classified as stage 1 or 2, 21 as stage 3, 10 as stage 4 and 35 as stage 5 CKD. Outcomes included: preeclampsia, preterm delivery, intrauterine fetal demise (IUFD), small for gestational age neonates (SGA), and mode of delivery. Results were stratified by parity and analyzed with Pearson Chi-squared Tests and multivariable logistic regression analyses.

RESULTS:

Compared to the general population, all stages of CKD resulted in higher rates of adverse pregnancy outcomes. Women with stage 4 CKD experienced the highest rates of preeclampsia, preterm delivery, and IUFD (60.0%, 100.0%, and 10.0% respectively, all P.

CONCLUSION:

Although all stages of CKD are associated with worse pregnancy outcomes compared with the general population, there was a non-linear relationship between the severity of pregnancy outcomes and degree of kidney dysfunction. Those with more progressed disease on renal replacement therapy may account for the improved outcomes. Further research with a larger cohort is needed to better understand the impact of this chronic disease on pregnancy.
Hypertension Is Associated With Depressive Symptoms in Pregnant Women [23B]
Authors: Diaz Nicole M. , Mccarthy Alicia , Adams Marci , Elue Rita , Plunkett Beth
Published: May 2017

INTRODUCTION:

Hypertension and beta-blocker use have been associated with depression in the non-pregnant population. We evaluated the independent association of hypertension and beta-blocker use on antepartum depression risk.

METHODS:

We conducted a retrospective cohort study which included women who delivered within our health system between January 1, 2009, and March 31, 2015, who completed an Edinburgh Postnatal Depression Scale (EPDS) during pregnancy. Increased depression risk was defined as EPDS score >10, or an affirmative answer to endorsing self-harm. Hypertension was determined by blood pressure measurements and ICD-9 codes. We compared normotensive to hypertensive pregnancies, and hypertensive pregnancies requiring beta-blocker therapy to those without medication requirement. Multivariate logistic regression analyses were used to examine the influence of beta-blocker use and hypertension on antepartum depression risk.

RESULTS:

Of the 9192 deliveries, 95% were normotensive and 5% were hypertensive. Of the hypertensive group, 22% utilized a beta-blocker and 68% required no medication. Compared to normotensive pregnancies, antepartum hypertension was significantly associated with antepartum EPDS score ≥10 (adjusted OR 1.61, 95% CI 1.17, 2.21) and with endorsement of self-harm (adjusted OR 1.76, 95% CI 1.05, 2.95). In further analyses of hypertensive pregnancies, beta-blocker users demonstrated no difference in depression risk compared to women without medication use (EPDS score ≥10, adjusted OR 1.22, 95% CI 0.56, 2.63; endorsement of self-harm, adjusted OR 0.84, 95% CI 0.32, 2.21).

CONCLUSION:

Women with hypertension in pregnancy are at increased risk for depressive symptoms and thoughts of self-harm. Beta-blocker use does not appear to be associated with further increased risk.
Decisional Regret in Women Receiving High-Risk Results From Non-Invasive Prenatal Genetic Screening [24B]
Authors: Allyse Megan
Published: May 2017

INTRODUCTION:

Non-invasive prenatal testing (NIPT) panels have expanded rapidly from limited aneuploidy screening for trisomy 21 to expanded screening for aneuploidies and abnormalities, including sex chromosome aneuploidies and, recently, microdeletions. This study sought to understand the experiences of women receiving NIPT results and the effect of high-risk, false, or inconclusive results on maternal anxiety and pursuit of additional testing.

METHODS:

40 semi-structured telephone interviews were conducted with women who were currently or had recently been pregnant and received high risk (n=15), false positive/negative (n=19), or inconclusive (n=5) results from NIPT.

RESULTS:

Many women felt deceived by the advertised “99% accuracy” statistic of NIPT and asserted that much of their post-test anxiety could have been prevented by improved pre-test counseling. Several women felt pressured by providers to terminate, and most felt pressured to pursue invasive diagnostic testing. False results from NIPT had significant lasting effects the remainder of their pregnancies, their willingness to have more children, and their openness to doing NIPT again. Most women would not do NIPT in future pregnancies or would only do it if the panel was smaller.

CONCLUSION:

Findings suggest significant concerns about how clinical practices are integrating NIPT. Study participants indicate problems with the dialogue when NIPT is offered, the return of results, and the positive predictive value of expanded screenings. Given the confusion about NIPT accuracy, the prevalence of follow-up invasive tests, and the large number of women who regret doing NIPT, NIPT offering and the delivery of results need to be carefully approached.
Could Delayed Primary Closure Reduce Cesarean Wound Complications in Obese Women? A Case Study and Meta-analysis [29B]
Authors: Walton Robert , Peterson Logan , Harmon Tess , Napolitano Peter
Published: May 2017

INTRODUCTION:

Obesity increases the risk of post-cesarean wound complications. Delayed primary wound closure (DPC) is a technique that may prevent wound complications. Our goal was to discuss a case report of DPC in a parturient with extreme obesity (BMI greater than 60) having a cesarean delivery, and review the literature in the OB/GYN and general surgery literature to test our hypothesis.

METHODS:

We searched the MEDLINE and Cochrane Register of Controlled Trials through May 2016 with key words related to DPC and pregnancy. We also report the result of a patient with extreme obesity having DPC after cesarean delivery.

RESULTS:

There were two retrospective studies in the OB/GYN population, showing mixed results. Seven articles were identified in the general surgery literature, all RCTs. The wound complication rate was 32.8% vs. 17.5% (primary closure vs. DPC). A meta-analysis of these RCTs demonstrated a 0.50 relative risk reduction for DPC. In our case, a parturient with BMI of 61 had a cesarean delivery after failed induction of labor. A wound vacuum was placed in the subcutaneous space after fascia closure. On post-operative day two, skin was closed with staples. There were no significant complications.

CONCLUSION:

DPC is a potential technique for reducing wound complications after cesarean delivery. The OB/GYN literature is limited. A meta-analysis of the general surgery literature demonstrated a 0.50 relative risk reduction for DPC. The patient in our study had no significant complications. DPC is a technique that should be further studied to prevent wound complications in women with extreme obesity having cesarean delivery.
Use of a Standardized Algorithm to Decrease the Primary Cesarean Section Rate at a Major Tertiary Care Center [30B]
Authors: Reddy Aishwarya , Vick Tara , Miller Michael S. , Anderson William , Marshburn Paul , Kullstam Susan
Published: May 2017

INTRODUCTION:

At Carolinas Medical Center, a standardized algorithm was implemented in 2015. The study purpose is to determine if this algorithm decreased the primary C-section rate for PC-02 patients. Subanalysis will determine if primary C-section rate varied by OB practice. Secondary analyses will examine BMI, race/ethnicity and scheduled vs unscheduled admissions.

METHODS:

Retrospective chart review compared PC-02 deliveries during 2014 vs 2015. We hypothesize implementing the algorithm decreased the primary C-section rate. Chi-square was used for statistical analyses. P value less than 0.05 was statistically significant.

RESULTS:

PC-02 deliveries totaled 2,152 in 2014 compared to 2,109 in 2015. In 2014, 516 patients underwent primary C-section (24.0%) vs 455 patients who underwent primary C-section in 2015 (21.6%). There were no significant differences between the 2014 and 2015 populations while comparing race/ethnicity (P=0.47), BMI (P=0.83), or scheduled (P=.50) vs unscheduled admissions (P=.13). After combining 2014 and 2015 data, C-section rates significantly varied by race/ethnicity (P < 0.0001). BMI was significantly higher in patients who underwent primary C-section (P < 0.0001). Scheduled admissions had a significantly higher primary C-section rate (27.3%) vs unscheduled admissions (19.8%) (P < .0001).

CONCLUSION:

The decrease in primary C-section rate in the PC-02 population showed a trend toward statistical significance after implementation of a standardized algorithm (P=.06). Staff OB had the lowest primary C-section rate (19.3%, P < .0001). After combining the data from 2014 and 2015, we noted several significant differences. We propose the current PC-02 criteria be expanded to include additional factors which may significantly influence the primary C-section rate.
Unmasking Valvular Heart Disease in Pregnancy [31B]
Authors: Clevenger Nicole , Hutchison Justin , Hertz Amy
Published: May 2017

INTRODUCTION:

Hemodynamic changes of the heart during pregnancy including increased stroke volume, heart rate, and cardiac output can result as cardiac decompensation in women with valvular heart disease. These hemodyamic changes can unmask faulty valves in women putting them at an increased risk of acute respiratory distress and heart failure.

METHODS:

We present two cases of previously undiagnosed valvular heart disease that was unmasked in late pregnancy and during labor. The first patient was a previously healthy 27-year-old female who presented at 38 weeks gestation with shortness of breath. She was diagnosed with pneumonia and developed pulmonary edema and acute respiratory failure. She was intubated and an emergency cesarean delivery was performed. Echocardiogram revealed severe mitral stenosis, tricuspid regurgitation, and congestive heart failure with valvular changes consistent with rheumatic heart disease. Patient was extubated on postpartum day 11 and later underwent a mitral valve replacement. Our second patient was a 29-year-old obese gravida 6 para 3 who presented at term in labor. Pregnancy was complicated by chronic hypertension. During labor, she developed acute pulmonary edema. After a spontaneous vaginal delivery, post-delivery echo showed severe mitral and tricuspid regurgitation with cardiomegaly. Patient was scheduled for valve replacement 6 months postpartum, but was non-complaint and eventually became pregnant again. She is scheduled for a mitral valve repair possible replacement 2 months postpartum.

RESULTS:

NA.

CONCLUSION:

The hemodynamic changes of late pregnancy and labor uncovered previously undiagnosed valvular disease in these two patients. Clinicians should have a heightened suspicion for valvular disease in women presenting with respiratory complaints.
A Performance Improvement Project for Jehovah's Witness Prenatal Patients [36B]
Authors: Buono Kristen , Bowen Andrea , Lee Jason D. , Lee Kimberly
Published: May 2017

INTRODUCTION:

Jehovah’s Witnesses (JW) may decline blood products based on religious beliefs. Previous studies have demonstrated that some JW patients may accept blood products during pregnancy. It is important to identify pregnant JW patients and clarify their acceptance of different blood products or alternatives in advance of delivery. This performance improvement project was designed to educate OBGyn providers and create a standardized process to identify JW patients who decline blood products and document their wishes regarding blood products and alternatives.

METHODS:

A department meeting was held to educate providers and a standard blood product preference form was created. A retrospective chart review of all self-identified JW patients who delivered was conducted to assess for identification in the problem list and standardized documentation of preferences regarding blood products.

RESULTS:

Between 2013-2014, 24 of 30 (80%) JW patients were identified in the problem list. Fourteen JW patients (46.6%) had further documentation of preferences, however often the information was incomplete. Between January 1, 2015 and June 30, 2016 after the project had been initiated, 9 of 10 JW patients (90%) who had a delivery were identified in the problem list and 7 of 10 patients (70%) had standardized documentation of preferences.

CONCLUSION:

Education of providers can lead to better identification of JW patients and more comprehensive documentation of their preferences regarding blood products. This workflow could be easily applied to other areas of care, including preoperative management.
Obstetric Outcomes and Interventions Between Low Normal Amniotic Fluid Index Compared to True Oligohydramnios [38B]
Authors: Holloman Conisha , Desai Neeraj , Paradise Courtney , Jodicke Cristiano
Published: May 2017

INTRODUCTION:

Our goal was to assess obstetric outcomes and interventions in patients with low normal amniotic fluid index versus oligohydramnios.

METHODS:

This was a retrospective study of deliveries between 2010 and 2014. Oligohydramnios was defined as Amniotic Fluid Index less than 5 cm (AF-5) and low normal amniotic fluid of 5 to 8 cm (AF-LN) on ultrasound performed greater than 24 hours before delivery. Outcomes included cesarean section, preterm delivery, Apgars at 1 and 5 minutes, umbilical artery pH, birth weight (BW), and admission to neonatal intensive care unit (NICU). Statistics included chi-square and student t-test.

RESULTS:

76 cases had AF-5 and 398 had AF-LN. Mean gestational age at delivery was 37.62 and 38.18 weeks (P=.005). Preterm birth rates were higher in AF-5 (P=.003), as well as both primary and all c-section delivery rates (P < .05). Our institution’s overall reported primary cesarean section rate for low risk pregnancies was 24%. Neonatal Apgars and BW were significantly lower in AF-5. There was no significant difference in NICU admissions. One fetal death was observed in each group.

CONCLUSION:

As expected, patients with true oligohydramnios have a higher rate of perinatal morbidity than those with low but normal amniotic fluid, with increased interventions in the true oligohydramnios patients. More investigation is warranted to assess whether earlier intervention in the oligohydramnios group may be the cause of the increased perinatal morbidity.
Risk Factors for Shoulder Dystocia at a Community-Based Hospital [4C]
Authors: Kim Tana , Vogel Rachel I. , Das Kamalini
Published: May 2017

INTRODUCTION:

Shoulder dystocia remains an unpredictable obstetrical emergency with potential for significant neonatal morbidity. Expert opinion recommends consideration of cesarean delivery for suspected fetal macrosomia of greater than 5000 g or 4500 g in diabetic patients, irrespective of other patient characteristics. The objective of this study was to identify risk factors for shoulder dystocia in our patient population.

METHODS:

This retrospective cohort study looked at singleton, term, vaginal deliveries from September 1, 2008 to December 31, 2014 at a single community hospital. Labor and delivery characteristics as well as maternal and fetal outcomes were compared between those with and without a shoulder dystocia. Risk factors were assessed using univariate and multivariate logistic regression models. A classification tree was utilized to identify independent risk factors associated with the highest incidence of shoulder dystocia.

RESULTS:

Our final sample included 8,930 deliveries with 299 (3.3%) shoulder dystocias. Independent risk factors included maternal Asian, African American, or Hispanic descent, diabetes, oxytocin augmentation, operative delivery, and increased fetal birth weight. Furthermore, the combinations associated with the highest incidence of shoulder dystocia were 1) nulliparous, birth weight 4000-5000 g [40.9%], 2) multiparous, diabetes, birth weight 4000-5000 g [30.8%], 3) nulliparous, birth weight 3500-4000 g [15.4%], 4) multiparous, birth weight 4000-5000 g [14.6%].

CONCLUSION:

Here, we identified risk factor combinations with higher incidence for shoulder dystocia than the American College of Obstetricians and Gynecologists' threshold for recommending a cesarean section based on fetal macrosomia alone. Individualized risk assessment should be performed with emphasis on counseling and delivery options particularly in these high risk patients.
System, Provider, Patient, and Placental Factors Associated With Neonatal Hypoxia in a Single Hospital System [10C]
Authors: Friedman Perry , Shah Ishani , Ogunyemi Dotun
Published: May 2017

INTRODUCTION:

This is a systematic and collaborative review to determine multifactorial correlates of neonatal hypoxic conditions.

METHODS:

A systematic review was performed on all term neonates diagnosed with hypoxic conditions by a designated review team using a published morbidity form with at least 2 different reviewers extracting data from each case followed by a group discussion for consensus.

RESULTS:

Of 16,890 term singleton pregnancies from 2013-2014, 54 cases of neonatal hypoxia were identified, including hypoxic-ischemic encephalopathy (10, 18.5%), meconium aspiration syndrome (9, 16.7%), hypoxemia of the newborn (29, 53.7%), perinatal asphyxia (2, 3.7%), and other acidosis of the newborn (4, 7.4%). Obstetrical risk factors were present in 94.4%, including category 2 fetal heart rate patterns (20, 29%), repeat cesarean delivery (8, 11.6%), chorioamnionitis (5, 7.2%), birth defects (5, 7.2%), labor dystocia (4, 5.8%), IUGR (4, 5.8%), and abnormal biophysical profile (4, 5.8%). Placental pathology was present in 35 cases (64.8%) and absent in 9 cases (16.7%), with another 10 cases (18.5%) where the placenta was not submitted to pathology. The most common findings were thrombus (n = 14, 20.9%), inflammation (16, 23.9%), meconium staining (12, 17.9%), and infarcts (8, 11.9%). From a systems-based view, potential contributors to morbidity were problems with diagnosis (9, 16.7%), treatment (13, 24.1%), documentation (7, 13.5%) and team communication (3, 5.6%). Opportunities to improve care were felt to be present in 19 cases (35.2%).

CONCLUSION:

Neonatal hypoxic conditions are rare and are associated with significant prenatal morbidity. In a minority of cases, opportunities to alter care may be possible.
Rotational Thromboelastometry Use in Obstetric Hemorrhage: A Current Review [11C]
Authors: Kurata Nicole , Schlueter Ryan , Ueno Meryl , Burlingame Janet
Published: May 2017

INTRODUCTION:

Obstetric hemorrhage is the leading cause of maternal mortality in all countries. Novel technology that accurately and rapidly predicts hematologic status has considerable value in patient care and safety. Rotational thromboelastometry, or ROTEM, is a point of care viscoelastic test which provides results within minutes, making this modality highly useful in acute obstetric care settings.

METHODS:

We performed a database review of PubMed and MEDLINE for all articles regarding the use of ROTEM in obstetric hemorrhage. The search words employed were “ROTEM”, “rotational thromboelastometry”, “obstetric”, “hemorrhage”, “pregnancy”, “PPH” and “coagulation”. A total of 9 articles were identified with the primary outcome. Case studies were excluded. A review of the remaining 5 articles is summarized in Table 1 as collective results with supported conclusions.

RESULTS:

Rotational thromboelastometry has been used in critical care and trauma for many years. The articles report a considerable clinical utility of ROTEM in obstetric hemorrhage, but limited use in the United States. ROTEM is well correlated with conventional laboratory tests and is able to accurately and quickly assess coagulation disruption. The test is able to guide and modify transfusion choices in an acute obstetric setting. Because obstetric data is limited, further need for ROTEM protocols and procedure is necessary to guide physician practice.

CONCLUSION:

ROTEM use is limited in pregnancy and education is needed among obstetric care providers. As point of care test for rapid assessment of coagulation profile there is significant potential for more robust application in obstetric hemorrhage.
Does Prior LEEP and Genital Mycoplasma Co-Infection Increase Preterm Birth Risk? [12C]
Authors: Keller Rebecca , Al-Qaraghouli Mohammed , Kuo Chia-Ling , Townsel Courtney D. , Campbell Winston
Published: May 2017

INTRODUCTION:

Excisional cervical procedures and genital infections are independent risks for preterm birth (PTB). We evaluated if LEEP history and cervical Mycoplasma/Ureaplasma (Myco/Urea) co-infection increases risk of PTB.

METHODS:

Retrospective cohort study (1/2005 to 6/2016) of patients delivered under 37 weeks. Patients were selected by Myco/Urea admission cervical culture results. Medical record abstractions: demographics, cervical procedures history, pregnancy outcome. Exclusions: cerclage, knife cone, cryotherapy, multifetal gestations. CASES: LEEP history and positive Myco/Urea result, CONTROL GROUP A: LEEP history and negative Myco/Urea result, CONTROL GROUP B: without LEEP history and positive Myco/Urea result. Primary outcome: delivery gestational weeks (GW). Data analyzed by Fisher's exact, chi-square and Wilcoxon rank-sum tests. A linear regression model for comparison of CASES vs CONTROLS was adjusted for potential confounders. A p-value less than 0.05 (two-tailed) was significant.

RESULTS:

We identified 1755 patients with Myco/Urea results: 37 CASES, 17 GROUP A , 47 GROUP B. Delivery GW: Cases 32±3.8, Control A 30.6 ±4.4, Control B 31.6±3.3 (p more than 0.05 Cases vs Controls). No significant difference in percentage of PPROM, smoking, antibiotic use between Cases vs Controls (p more than 0.05). A history of PTB was greater in Cases (32%) vs Control A (18%, p=0.34) or Control B (13%, p= 0.04). However, cases delivered earlier than controls. Antibiotic use was not different in CASES (51%) vs CONTROL B (48%); p=0.95.

CONCLUSION:

LEEP history and co-infection with genital Myco/Urea is not associated with increased risk for PTB compared to patients with LEEP history alone or Myco/Urea infection alone.
Safety and Efficacy of the Foley Balloon for Cervical Ripening During Induction of Labor in Women With Prior Cesarean [15C]
Authors: Ralph Jessika , Neuman Elizabeth , Zhang Liyun , Wenzlaff Miranda , Simpson Pippa , Hibbard Judith
Published: May 2017

INTRODUCTION:

Induction of labor in women with prior cesarean is a safe alternative to repeat cesarean. Current evidence has not determined the best method for women who require cervical ripening. We sought to determine whether the use of the Foley balloon is comparable in safety and efficacy to oxytocin.

METHODS:

We conducted a retrospective chart review of all women with prior cesarean undergoing induction between 1990 and 2015. We compared the vaginal delivery rate, maternal adverse event composite, and neonatal adverse event composite. The maternal composite included hemorrhage, infection, uterine rupture, and maternal death. The neonatal composite included 5m Apgar < 7, umbilical artery pH < 7, NICU admission, and neonatal death. Confounding variables, including Bishop score, previous vaginal delivery, gestational age, and presence of PROM, were identified by logistic regression.

RESULTS:

66 women were induced by Foley balloon and 405 by oxytocin. The vaginal delivery rate was significantly less in the Foley balloon group compared to the oxytocin group (55% vs 75%, p=0.001). The rates of maternal and neonatal adverse events were equivalent (24% vs 15%, p=0.070; 11% vs 10%, p=0.86). Logistic regression determined that women with 3 or more deliveries (odds ratio 0.22 (CI 0.01, 0.05)) and gestational age greater than 36 weeks (OR 0.30 (CI 0.11, 0.80)) were associated with decreased likelihood of maternal adverse events; premature rupture of membranes (OR 3.91 (CI 1.93, 7.92)) was associated with increased likelihood of neonatal adverse events.

CONCLUSION:

With careful patient selection, Foley balloon is an acceptable induction method in women with prior cesarean.
Agreement Between Postnatal Meconium Drug Screen and Maternal Urine Drug Screen for Drug Use During Pregnancy [16C]
Authors: Debbink Michelle , Smith Shannon , Langen Elizabeth
Published: May 2017

INTRODUCTION:

Postnatal meconium drug screen (MDS) is the test of choice for suspected fetal exposure to drugs, theoretically revealing exposures up to 3-6 months antenatally. The degree to which MDS correlates with maternal urine drug screens (UDS) is not well understood. Both test results have significant implications for families. We sought to assess agreement between antenatal UDS and postnatal MDS.

METHODS:

We included women with singleton pregnancies between 2009-2016 at a specialized clinic for substance use in pregnancy. Exclusions included delivery at another institution. Using MDS as an imperfect reference standard, the overall percent agreement (OPA), positive and negative percent agreement (PPA and NPA), and Cohen’s kappa for UDS were calculated for cannabinoids (THC) and cocaine. Tests positive for multiple drugs were descriptively compared.

RESULTS:

Among 108 pregnancies, most patients were white, with mean age of 28.6y. Approximately 50% had addictive disorders, while the remainder had chronic pain. For THC, the OPA was 83.3%, Cohen’s kappa was 0.58 (95%C.I. 0.40-0.77), PPA was 67.7%, and NPA was 89.6%. For cocaine, OPA was 91.7%, kappa, 0.59 (95%C.I. 0.40-0.78), PPA, 61.5%, and NPA, 61.5%. Thirty-four patients had multiple drugs on MDS or UDS. Of these, 7 (21%) had negative UDS with positive MDS; 2 (6%) had negative MDS with positive UDS. Concordant tests occurred in 11 cases (32.3%), and partially concordant tests in 11 cases (32.2%).

CONCLUSION:

The agreement between postnatal MDS and antenatal UDS is moderate. Disagreement between positive screens affects 30-40% of tests. These inconsistencies should be considered in patient care decisions and policies.
Symptomatology of Zika Virus Infection During Pregnancy [20C]
Authors: Canabal Jorge Acevedo , Cay Carolina , De La Vega Alberto
Published: May 2017

INTRODUCTION:

This study describes symptoms reported by patients with confirmed Zika virus (ZIKV) infection during pregnancy.

METHODS:

Data were obtained from patients attending our institution with a diagnosis confirmed either by positive real-time reverse transcription–polymerase chain reaction or immunoglobulin M enzyme-linked immunosorbent assay.

RESULTS:

A total of 273 patients with a diagnosis of Zika virus infection were identified with 222 (81.3%) reporting symptoms while 51 (18.7%) were asymptomatic. The average maternal age at diagnosis was 24 y/o (range 17-38) and average pre-pregnancy BMI was 26.48 kg/m2 (range 15.8–48.2) similar to our general low risk population. Reported symptoms included: maculopapular rash in 210 (94.6%), arthralgia 85 (38.3%), fever 46 (20.7%), general malaise 19 (8.6%), headache 29 (13.1%), conjunctivitis 36 (16.2%), hand and/or feet swelling 11 (5.0%), retro-orbital pain 12 (5.4%), itching 18 (8.1%) and vomiting 6 (2.7%). Less common symptoms were myalgia (7), back pain (6), bone pain (2), chills (1), cough (1), nausea (1), hand numbness (1), mild thrombocytopenia (1), ocular itching (1), dizziness (2), pancytopenia (1), and symptoms of upper respiratory tract infection (1). Eight two patients (36.9%) reported only one symptom. Rash was the most common isolated symptom in 79/82 patients (96%).

CONCLUSION:

Symptoms of ZIKV infection are varied. The characteristic rash is not present in 5% of symptomatic patients and conjunctivitis is much less frequent than previously reported. Physician bias may lead to testing patients with certain classic symptoms. Since clinical symptoms may be absent, vague, or varied, physicians must be alert at any sign that could suggest infection.
AFI, SDP and Transvaginal Cervical Length: Parameter of Predictive Delivery Latency in PPROM [21C]
Authors: Lee Young Joo , Kim Yoon Hwa , Jo Hyun Nyung , Kim Seung Chul
Published: May 2017

INTRODUCTION:

Prediction of delivery latency complicated with preterm premature rupture of membrane (PPROM) is important for reducing maternal and neonatal complications. However, no studies have correlated parameters including amniotic fluid index, single deepest pocket, transvaginal cervical length, and C-reactive protein as predictive of the latency interval to delivery. We investigated the latency period from PPROM to delivery according to above parameters and predicted delivery latency using cutoff values of these parameters.

METHODS:

The retrospective study was performed on 121 PPROM patients enrolled between March 2010 and July 2015. Measurements including amniotic fluid index, single deepest pocket, transvaginal cervical length, and C-reactive protein were made in 99 singleton pregnancies with PPROM. Latency was defined as the period from sonographic measurements to delivery day.

RESULTS:

Gestational age at delivery, body mass index, amniotic fluid index, single deepest pocket, and transvaginal cervical length had significant differences according to delivery latency at 3 days. The median gestational age at delivery, amniotic fluid index, and single deepest pocket were lower, and transvaginal cervical length was significantly shorter in delivery latency within 3 days. Amniotic fluid index and single deepest pocket had the highest sensitivity (82.2%) and single deepest pocket combined with transvaginal cervical length showed the highest specificity (75.9%) and area under curve value. A predicted median latency period was less than 2 days within the cutoff value of parameter.

CONCLUSION:

Amniotic fluid index and single deepest pocket combined with or without transvaginal cervical length could be useful predictive parameters of the latency period from PPROM to delivery.
Standardizing the Usage of Oxytocin During Induction of Labor With a Checklist: A Cost-effectiveness Analysis [29C]
Authors: Chatroux Louisa R. , Caughey Aaron B. , Savitsky Leah , Sargent James , Zwerling Blake
Published: May 2017

INTRODUCTION:

Oxytocin is generally considered to be safe and effective for induction and augmentation of labor, but has been implicated in uterine hyperstimulation and adverse fetal outcomes. The management of labor with oxytocin in response to changes in fetal status is in need of additional consensus guidelines. This study sought to assess the cost-effectiveness of implementing an oxytocin in-use checklist.

METHODS:

A decision-analytic model was built using TreeAge with probabilities, costs and utilities derived from the literature. Primary outcomes included: Cerebral Palsy, neonatal mortality, and mode of delivery. Secondary outcomes included: cost per quality-adjusted life year (cost-effectiveness threshold set at $100,000/quality-adjusted life year, NICU admission, and low 5 minute Apgar score (< 7). Sensitivity analyses were performed to determine the robustness of our baseline assumptions.

RESULTS:

In a theoretical cohort of 900,000 women, representing the estimated number of women undergoing induction at term in U.S., implementing the in-use checklist for women undergoing induction with oxytocin at term was a cost-effective strategy. Use of the checklist prevented 13,140 NICU admissions, 1,080 low Apgar scores, 50 neonatal deaths, 27,000 cesarean deliveries, and 30 cases of cerebral palsy. Sensitivity analysis revealed that the strategy is also cost-saving if the checklist costs less than #304 per delivery. Estimated cost of the checklist was $35 per delivery.

CONCLUSION:

Standardizing oxytocin administration with an in-use checklist is both cost-effective and cost-saving. Most importantly, it reduces neonatal and maternal morbidity and mortality. Examination of both how to translate the use of such checklists and improve their impact deserves further attention.
Survival, Resuscitation and Morbidities in Extremely Preterm Infant – A Retrospective Cohort Study [23C]
Authors: Hussaini Sofia , Czuzoj-Shulman Nicholas , Spence Andrea , Abenhaim Haim Arie
Published: May 2017

INTRODUCTION:

This study aims to evaluate survival to discharge, resuscitation, predictors of survival and short-term morbidities of preterm babies born at less than 24 weeks.

METHODS:

We conducted a retrospective cohort study using the Nationwide Inpatient Sample-Healthcare Cost and Utilization Project database. We evaluated the neonatal outcomes of all live birth admissions of less than 24 weeks from 2003-2011, excluding newborns with known congenital malformation. We used multivariate logistic regression to estimate the predictors of survival and intact survival in (1) all resuscitated newborn less than 24 weeks and in (2) resuscitated and survived infants.

RESULTS:

There were 9,644 live births that met study criteria, of which 76% were not resuscitated and 24% were resuscitated. The survival rate among resuscitated infants was 42.86%, while the overall survival rate to discharge among non-resuscitated infants was 10.27%. Mortality was highest in the first 2 days of life. The incidence of intraventricular hemorrhage was 13.62%, respiratory distress syndrome was 65.79%, and necrotizing enterocolitis was 0.91%. The rate of intact survival was 31.89 % in resuscitated newborn less than 24 weeks of gestation. Birth weight greater than 500g and urban non-teaching hospitals were positive predictors of survival, with an adjusted OR of 1.46 (95% CI 1.12-1.90) and OR of 1.71(95% CI 1.43-2.06), respectively.

CONCLUSION:

Mortality and morbidity of extremely preterm infants born at less than 24 weeks of gestation is high. However, selected extremely preterm newborns can be viable without major short-term morbidity. Providing patient counseling requires up-to-date estimates of the health outcomes in extremely preterm births.
Epidemiology of Trauma-Associated Threatened Abortions Presenting to U.S. Emergency Departments From 2013 to 2015 [30C]
Authors: Bandzar Sean , Gupta Shabnam , Atallah Hany
Published: May 2017

INTRODUCTION:

Threatened abortions are one of the most psychologically distressing and frequently occurring complications in the first trimester of pregnancy. Approximately 30% of threatened abortions result in spontaneous abortions. The objective of this study was to investigate the epidemiology of trauma-associated threatened abortions presenting to United States emergency departments (EDs) using nationally representative data.

METHODS:

A retrospective analysis of the National Electronic Injury Surveillance System (NEISS) database was conducted. The NEISS database is a national probability sample of over 60 US EDs. Inclusion criteria were pregnant women with vaginal bleeding from trauma seen in US EDs from calendar year 2013 to 2015. All injuries were stratified by age, gender, race and disposition.

RESULTS:

From calendar year 2013 to 2015, there were 1358 trauma-associated threatened abortions that presented to US EDs. The mean age was 27 years old. There were a higher percentage of threatened abortions in whites (43%) than in blacks (27%) and Hispanics (13%). Approximately 18% of races were not recorded. The majority of threatened abortions occurred after slipping down a set of stairs (48%). A high percentage of threatened abortions also occurred after slipping in restrooms at home (19%). The majority of patients were discharged home after being evaluated in the emergency department (76%). Approximately 12% of patients were admitted or observed at the hospital.

CONCLUSION:

Falls down stairs were the primary mechanism of injury for threatened abortions in this cohort. Further efforts are warranted to explore safety measures to prevent injuries and decrease the frequency of trauma-related threatened abortions.
Adverse Maternal and Perinatal Outcomes: A Comparison of United States- and Foreign-Born Women [32C]
Authors: Adegoke Tejumola , Pinder Leeya , Ndiwane Ndindam , Vragovic Olivera
Published: May 2017

INTRODUCTION:

Despite significant socio-economic disadvantages, improved perinatal outcomes have been observed among foreign-born women relative to the native population in multiple countries. The current study aims to assess perinatal outcomes of United States (U.S.)- and foreign-born women in Boston, Massachusetts; and investigate how these differences are impacted by socio-demographic risk factors.

METHODS:

We analyzed singleton, index pregnancies (n=11,124) among women delivering at Boston Medical Center between January 2010 and December 2015. Outcomes included preterm birth, cesarean delivery, hypertensive disorders, abnormal glucose tolerance, premature rupture of membranes (PROM), fetal growth restriction, low birth weight at term (LBW, less than 2500g), neonatal intensive care unit (NICU) admission and intrauterine fetal demise (IUFD). Multivariate regression was used to control for maternal age, race, ethnicity, insurance coverage and tobacco use.

RESULTS:

Preterm birth, hypertensive disorders, PROM, LBW, NICU admission and fetal growth restriction were more common among U.S.-born women and their neonates (P less than .000). Foreign-born women were more likely to have abnormal glucose tolerance (P equals .008). Controlling for maternal characteristics eliminated the effect of maternal birthplace on fetal growth restriction (adjusted OR 0.98) and abnormal glucose tolerance (adjusted OR 1.06), but did not modify the effect on other study outcomes.

CONCLUSION:

U.S.-born women are at higher risk of adverse perinatal outcomes than foreign-born women. This increased risk persists for many outcomes even after controlling for confounders. As the immigrant population in the U.S. grows, understanding the social and physiologic determinants of these differences may guide targeted interventions critical for improving overall maternal and child health.
Antepartum Venous Thromboembolism Prophylaxis Dosing With Low Molecular Weight Heparin in Obese Population [34C]
Authors: Parrott Jessica , McCall Caitlyn , Udovich Mason , Holland Marium
Published: May 2017

INTRODUCTION:

To determine adequacy of venous thromboembolism prophylaxis dosing with low-molecular-weight heparin (LMWH) in pregnant women based on anti-Xa concentrations, with focus on the obese population.

METHODS:

A retrospective cohort identified 50 subjects treated with prophylactic LMWH during pregnancy at the University of Kansas Medical Center between January 2012 and May 2016 were identified from the electronic medical record. Subjects were excluded if they did not deliver at our medical center, were not monitored with anti-Xa levels, or were receiving prophylaxis for proteinuria. The data abstracted from the chart included subject demographics, BMI, indication for pharmacologic thromboprophylaxis, LMWH dosing, anti-Xa levels, weight gain, and potential complications. Fischer exact test and ANOVA were used for statistical analysis.

RESULTS:

31 subjects were identified who were treated with an initial starting LMWH dose of 40mg daily. Of these, only 32.26% (10/31) had a prophylactic anti-Xa level (0.2-0.4). When stratified by BMI at treatment start, 58.82% (10/17) with BMI < 30.0 compared to 0% (0/14) subjects with BMI >30.0 reached a prophylactic anti-Xa level (p=0.0008). When stratified by gestational age at treatment start, 45% (9/20) in the first trimester, 33.33% (3/9) in the second trimester, and 0% (0/2) of subjects in the third trimester were at a prophylactic anti-Xa level on daily 40mg LMWH (p=0.24).

CONCLUSION:

Pregnant women with initial BMI >30.0 treated with daily 40mg LMWH are not likely to achieve a prophylactic anti-Xa level. BMI or weight-based dosing should be considered and patients should be monitored with anti-Xa levels during pregnancy.
Empathetic Yet Resistant: Accommodating Immigrant Women’s Preferences for Female Providers [36C]
Authors: Aubrey Christa L. , Mumtaz Zubia , Chari Radha , Mitchell Peter (BF)
Published: May 2017

INTRODUCTION:

For women migrating from different religio-cultural environments, having a female obstetrical provider may be particularly important. While accommodating these requests can be seen as providing patient-centered care, the feasibility and ethical questions of gender discrimination and educational implications make it a contentious issue. The objective of this study was to gain obstetricians’ understanding of the importance, effect, and challenges to providing care when immigrant women prefer a female obstetrician.

METHODS:

A focused ethnography was conducted using purposive sampling of 20 obstetrical providers in Edmonton, Alberta, Canada. Data collection comprised of a single semi-structured interview with participants. Interviews were audio-recorded and transcribed verbatim. Data was managed by a qualitative data analysis software, and analyzed using thematic analysis.

RESULTS:

A total of 13 female and seven male physicians were interviewed. In line with patient-centered care, physicians recognized the validity, and empathized with immigrant women’s preference for female providers. However, they were resistant to accommodating these requests, stemming from concerns about the extent to which host communities should accommodate immigrant cultural requests, based on the ability of the health system to respond, discerning coercion-free patient decision-making, implications for training and quality of care, and fear of perpetuating and exacerbating gender inequalities in medicine.

CONCLUSION:

Physicians faced a dilemma trying to balance patient preferences with their own autonomy as a physician and a person. Identifying physician’s values and perspective will enhance understanding of the patient-physician relationship, ultimately progressing towards addressing this issue both philosophically and practically.
Barriers for Tdap Vaccination in Pregnancy [38C]
Authors: Ashby Mary , Roussos-Ross Dikea , Julie DeCesare Hanna Peterson , Vidrine Samantha , Floy Elizabeth
Published: May 2017

INTRODUCTION:

The American College of Obstetricians and Gynecologists (the College) and the Centers for Disease Control and Prevention recommend the Tdap vaccination in the 3rd trimester of pregnancy in order to protect newborns from neonatal pertussis. The purpose of this study was to identify barriers to Tdap vaccination in pregnancy.

METHODS:

A multisite study was conducted at UF Health and Sacred Heart Hospitals in Florida. This study was performed in conjunction with the College's District XII Committee for Healthcare of Underserved Women. Admitted postpartum patients were offered a survey to complete on day of discharge.

RESULTS:

A total of 162 patients completed the survey. Forty-eight patients had private or government-sponsored insurance (TriCare, Medicare, VA) and 114 patients had Medicaid. Of private/gov-insured patients, 62.5% (30) received Tdap in the 3rd trimester compared to 21.9% (25) of patients with Medicaid. Of those who did not receive Tdap in the third trimester, 50% (6) of private/gov-insured patients cited education while 34% (21) of patients with Medicaid cited lack of access. Of patients who did not receive Tdap in the third trimester, 46.5% (53) of the Medicaid patients received it postpartum compared to 37.5% (18) of private/gov-insured patients.

CONCLUSION:

Patients with Medicaid insurance are less likely to receive the Tdap vaccine in the 3rd trimester than those with private or other government-sponsored insurances. In patients who did not receive Tdap, those with Medicaid cited lack of access as the primary reason they did not receive the vaccine while those with private/gov-insurance cited education-related reasons. Tdap vaccination rates in pregnancy could be increased by improving both education and access to patients.
Long-Term Skills Retention After Obstetric Simulation Training for Skilled-Birth Attendants in Rural Rwanda [9D]
Authors: Pimentel Veronica Maria , Rwab Denis , Gahima John , Rulisa Stephen , Bernstein Peter S. , Nathan Lisa
Published: May 2017

INTRODUCTION:

The World Health Organization advocates for the presence of attendants at every birth skilled at managing normal pregnancies and obstetrical complications. We aimed to evaluate the long-term skills retention gained by skilled birth attendants (SBAs) who completed a spontaneous vaginal delivery (SVD) and postpartum hemorrhage (PPH) simulation-training program.

METHODS:

A pre-post intervention study was conducted with a convenience sample of SBAs in rural Rwanda. Two separate groups of SBAs underwent initial simulation training with pre- and immediate post-testing. Group A had training in February 2013. Group B had training in February 2014. Simulation drills to assess skill retention were conducted in September 2015 for both groups. Participants were scored on communication, evaluation, and management skills. Median scores were calculated and the Wilcoxon signed-rank sum test compared the pre-training, post-training, and retention scores.

RESULTS:

68% (13/19) of SBAs in Group A and 53% (8/15) SBAs in Group B were available for the skill-retention evaluation. There were no demographic, experiential, or educational differences between groups. After training, both groups showed immediate improvement in almost all the areas evaluated. At 2 years, Group A showed significant falls in their scores in three of the areas evaluated while group B at 1 year demonstrated a decline in only one of the areas evaluated.

CONCLUSION:

Simulation training is an effective method for acquisition of SVD and PPH skills in low resource settings. Most skills were retained 1 year after the initial training, but lost after 2 years, which suggests that training should be conducted on a yearly basis.