bluuebunny/crossref_metadata_2025 huggingface dataset:
Chemotherapy and Optimal Timing of Delivery for Women with Human Epidermal Receptor-2 Positive Breast Cancer [33B]
Authors: Kuo Kelly , Senz Kayli , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Data are limited regarding the optimal management of breast cancer in pregnancy, particularly for human epidermal receptor-2 (HER2+) tumors and the potential fetotoxicity of subtype-specific chemotherapy. We sought to compare strategies for the management of HER2+ tumors and to determine the optimal gestational age for induction in regards to chemotherapy status and maternal-fetal outcomes.

METHODS:

A decision-analytic model was designed for women with HER2+ breast cancer at 20 weeks electing to continue their pregnancies, comparing 32 different strategies for scheduled delivery between 24-39 weeks gestation, with chemotherapy induction either at 24 weeks or delayed until after delivery. Baseline estimates of stage-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. Univariate and multivariate sensitivity analyses were performed to test the robustness of our model.

RESULTS:

For women assigned to antepartum chemotherapy, delivery at 39 weeks yielded the highest maternal and overall QALYs at all cancer stages. For women with HER2+ breast cancer deferring chemotherapy until after delivery, maternal quality-adjusted life years (QALYs) were maximized with induction at 37 weeks for stage I cancer, 32 weeks for stage II cancer, and 28 weeks for stage III cancer. Our model was heavily driven by the baseline probability of maternal death within 5 years, in addition to the expected progression of disease and decrease in survival rates with each week of non-treatment, and remained robust across reasonable ranges for all variables of interest.

CONCLUSION:

For women with HER2+ breast cancer diagnosed in early pregnancy, initiation of chemotherapy and delivery at term is recommended.
Can Initial Glycemic Control Predict Metformin Failure in Women with Gestational Diabetes? [38B]
Authors: Persad Malini D. , Ou Jennie , Bernasko James , Garry David , Garretto Diana , Herrera Kimberly
Published: April 2018

INTRODUCTION:

To determine if glycemic control prior to medication initiation predicts metformin failure in women with gestational diabetes (GDM).

METHODS:

A retrospective cohort study of women with GDM was conducted from 2013-2016. Included in the study were women with GDM started on metformin after a failed trial of diet therapy. Excluded from the study were women with pre-existing DM. Women were advised to take fasting and 1-hour postprandial finger sticks. Women were categorized as having adequate glycemic control on metformin (metformin success) or requiring the addition of or transition to an insulin regimen (metformin failure). Maternal demographics and average blood glucose (BG) values were collected. The sensitivity and the specificity of BG values as a screening test for metformin failure were analyzed and the corresponding ROC curves were plotted to assess the performance of the test. Parametric and nonparametric statistical analyses were performed with a p value of <0.05 as significant.

RESULTS:

A total of 118 gestational diabetics were identified, 19 (16.1%) women failed metformin therapy. There were no significant differences in maternal demographics in the groups. Compared to the metformin success group, those in the metformin failure group had significantly higher fasting BG values prior to medical management. Postprandial BG values were not different between groups. A ROC curve of the average fasting BGs revealed that a value of 90mg/dl was best predictive of metformin failure (AUC 0.74; p 0.002), with a sensitivity and specificity of 90% and 79% respectively.

CONCLUSION:

Elevated fasting BG values may predict metformin failure in women with GDM.
A Year of Mentored I-Pass Standardized Handoff Application: Observations of Local Versus National Trend [1C]
Authors: Gaspar-Oishi Maria , Saito-Tom Lynne , Hiraoka Mark
Published: April 2018

INTRODUCTION:

The I-PASS study group has created a nationally recognized standardized patient hand-off system that has been utilized by various residency programs. This study describes the impact of the I-PASS Mentored Implementation Project by comparing our local Ob-gyn residency I-PASS adoption with pooled data from residency programs that implemented I-PASS in the same period.

METHODS:

Patient hand-offs were evaluated on a weekly basis by attending physicians using a standardized observation tool. This data was submitted to the I-PASS study group and our site was provided with monthly run-charts that measured I-PASS core measures. Combined data from the other residency program sites were also provided.

RESULTS:

We compared three core measures: 1) Adherence to all elements of the I-PASS mnemonic: Locally, the average percent adherence was 33.3%, whereas nationally, the average was 50%. 2) Miscommunication: Locally, average occurrence of miscommunication was 23.3% whereas the national average was 8.2%. 3) Omission of important information: The average reported omission of important information was similar at both the local and national levels at 11.1% and 11.7%, respectively.

CONCLUSION:

In one year, the I-PASS Mentored Implementation Project has allowed our residency program to perform similarly to other programs around the country. Our local trend was not dissimilar to the national averages found in the pooled data. Both occurrence of miscommunication and omission of important information were below the core threshold of 25%. However, average adherence was lower than the national average and below the core goal of 75%. We will continue to look for innovative ways to improve handoff.
Multimedia Versus Traditional Informed Consent for Cesarean Delivery: A Randomized Controlled Trial [2C]
Authors: Ratan Rini B. , Rupley Devon M. , Palmerola Katherine , Smith Devin D. , Sealy Petra
Published: April 2018

INTRODUCTION:

Informed consent is an integral preamble to every surgery, traditionally consisting of a conversation between physician and patient reviewing risks, benefits, and alternatives to the proposed procedure. However, patients may absorb only a fraction of verbally communicated information. This study evaluated the use of a multimedia tool to improve pre-surgical consent for cesarean delivery.

METHODS:

English-speaking patients undergoing scheduled cesarean delivery at a single university hospital were eligible to participate. Patients were randomized to traditional verbal consent or to a multimedia tool for pre-surgical consent. Patients completed preoperative and postoperative surveys assessing subjective comprehension, satisfaction, and anxiety.

RESULTS:

Of 100 total study participants, 50 were randomized to receive verbal consent and 50 were randomized to multimedia consent. Demographic data including age, ethnicity, education, and prior surgery were similar in both cohorts. Pre- and post-surgical assessment of understanding, satisfaction and anxiety did not differ significantly between groups. However, 50% of patients who received multimedia consent said they would have preferred a video tool in prior surgeries versus 20% in the verbal cohort who wished they had viewed a video before undergoing previous surgeries (p=0.003). When analysis was limited to patients undergoing first cesarean delivery, patients receiving video consent reported lower anxiety for future cesarean sections (71.2 ± 31.1 on 100-point scale) versus verbal consent patients (85.8 ± 16.1), although this difference did not reach statistical significance (p=0.092).

CONCLUSION:

Our findings suggest that multimedia educational tools may be a valuable complement to traditional verbal conversations in the pre-surgical informed consent process.
Graduate Medical Education Salary Gap: Is Military Service an Equalizing Force? [4C]
Authors: Lutgendorf Monica , Thagard Andrew , Foglia Lisa M.
Published: April 2018

INTRODUCTION:

Disparities exist between resident salaries and other professionals. We compared salaries to determine if military pay equalizes financial disparities in civilian graduate medical education training.

METHODS:

Using aggregate salary data, we compared military versus civilian salaries for residents and staff physicians in OB/GYN. Military pay was from 2017 Defense Finance and Accounting Service (DFAS) tables, including: base pay, housing/subsistence allowances, incentive and board certification pay. Military residents were calculated for O-3, and staff salaries the average of O-4 and O-5. Civilian salaries were from Medscape 2016 Residents Salary & Debt Report, Medical Group Management Association (MGMA) 2017 Provider Compensation Report for private practice, and from 2015-2016 Association of American Medical Colleges (AAMC) Faculty Salary Report for academic providers, using the rank of Assistant Professor.

RESULTS:

The GME salary gap was positive, with mean civilian OB/GYN residents $55,000, compared to military residents $91,287, +66% difference. For staff, the salary gap is negative, with mean private practice $368,135 and mean academic $277,000 compared to military $163,099, -56% and -42% respectively. For subspecialists in OB/GYN, the military is $168,099 compared to private practice UROGYN $422,413 (-$60%); private practice REI $427,667 (-60%) academic REI $392,000 (-57%); private practice GYN/ONC $486,118 (-65%) academic GYN/ONC $323,600 (-50%); private practice MFM $536,279 (-69%) academic MFM $339,700 (-52%).

CONCLUSION:

A salary gap exists in the military, shifting from positive in residency to negative for staff. The gap is smaller for academic faculty compared to private practice. Actual salaries vary based on multi-year bonuses and scholarship programs that decrease debt.
One Way Video Interviewing As A Method to Augment the Residency Application [5C]
Authors: Breitkopf Daniel , Hopkins Matthew R. , Camp Christopher L. , Occhino John A. , Weaver Amy , Turner Norman S.
Published: April 2018

INTRODUCTION:

Despite the increase in residency applications, little change in the information available for review prior to a face-to-face interview has occurred. Asynchronous or one way video interviews (OWVI) may offer a way to collect additional data on applicants. Our objective was to assess the feasibility and acceptability of OWVI and to correlate OWVI performance with in-person interview scores.

METHODS:

Characteristics of successful residents were identified and OWVI questions were developed using medical student volunteers. Candidates who presented for in-person interviews during the 2016-17 season for OB/GYN (n= 45) and Orthopedic Surgery (n=98) were invited to participate in OWVI with 3 questions and a maximum of 3 minutes per question. Videos were reviewed and scored independently by 2 reviewers from the respective departments using a standardized 5-point scale.

RESULTS:

Forty-six (47%) Orthopedic and eleven (24%) OB/GYN applicants completed OWVI. The interviewer’s scores of OWVI were within one point of one another 84% of the time. High OWVI scores were correlated with higher in-person interview scores (r=0.26) and higher rank list placement (r=0.33). Sixty-two percent of the applicants were satisfied with the OWVI process. Most respondents wanted additional OWVI questions that would allow them to explain why they wanted to apply to a particular program.

CONCLUSION:

Asynchronous interviews enabled reviewers to differentiate applicants and their scores correlated with rank list placement and in person interview scores. The process was viewed by participants as a way to humanize their application and this may have potential to help screen applicants for residency.
Automated Residency Scheduling: Impacts on Resident Satisfaction and Wellness [6C]
Authors: Hollenbach Stefanie J. , Harrington Amy , Duecy Erin
Published: April 2018

INTRODUCTION:

Schedule generation for resident coverage is a complex undertaking. While most programs continue to use manual scheduling, large corporations have turned to operations research for algorithms that automate generation of significant portions of their employees' schedules. The goal of this study was to quantify the impact on residents of using algorithm-based schedule generation.

METHODS:

Prospective cohort study of current Ob-Gyn residents at University of Rochester before and after implementation of automated schedule generation with additional perspective data from the past decade of prior administrative chiefs via electronic survey sent by email. Descriptive statistics were performed on prior administrative chief perspectives; paired t-tests of unequal variance were performed for each resident questionnaire parameter of 5-point Likert scale responses.

RESULTS:

Of the 22 eligible residents, 21(95%) completed the pre-transition survey and 17(77%) completed the post-transition survey. Prior administrative chiefs (60% of prior decade) confirmed that schedule generation is time consuming (2-100 hours) with modifications required on a weekly to monthly basis. Following implementation of automated scheduling, there was an increase in resident satisfaction with initial (3.24 to 4.29, p=0.0017) and accommodation (2.67 to 3.65, p=0.01) schedule requests as well as improved satisfaction with transparency in schedule preparation (2.76 to 3.82, p=0.01) and perceived equitable accommodations (3.1 to 4.12, p=0.01). There was not a statistically significant impact on indicators of resident wellness.

CONCLUSION:

Implementation of automated scheduling software for this Ob-Gyn residency improved resident satisfaction. Regardless of scheduling approach, preparation of resident schedules is complex and provides ample opportunity for technology-based quality improvement.
Comparison of Thiel-Embalmed and Plastic Models for Teaching Female Pelvic Exam Technique [10C]
Authors: Chatman Alexandra I. , Shelton Kathryn M. , Becker Robert M. , Campbell Aaron D. , Gozmao Liane P. , Abercrombie Caroline
Published: April 2018

INTRODUCTION:

Medical students at ETSU Quillen College of Medicine currently receive pre-clerkship pelvic exam training through low fidelity simulation (LFS) pelvic models. These models do not allow students to gain familiarity with all aspects of the pelvic exam before clinical experiences. ETSU has adopted a soft embalming technique, the Thiel method, which allows for better soft tissue tactile preservation and joint mobility. This pilot study evaluated the utility of using the Thiel-embalmed donors compared to the current LFS models in teaching pelvic exam technique.

METHODS:

A randomized experimental study with fourteen first year medical students was conducted. Students were divided into the experimental group (Thiel-embalmed donor) and control group (LFS model). All students completed pre- and post-surveys assessing confidence, transference to clinical practice, and realism.

RESULTS:

The study suggests that students accepted both models as pelvic exam teaching platforms. Examining data from the groups’ post-surveys indicated that students using the Thiel-embalmed donor reported a high level of confidence with their skills, resolved the experience was transferrable to patient care, and determined that the Thiel donor was a realistic representation of the pelvic exam. The plastic model had less positive reviews on transference to patient care, being realistic, and instilling confidence in new skills.

CONCLUSION:

Due to the small sample size of this study, the data collected do not have the power to detect statistical significance in differences between student reception of both models. While more data need to be collected to determine statistical significance, this instruction method is a promising development in medical education.
Delivery of Nulliparous Women at Term with Vaginismus [15C]
Authors: Peleg David , Curelaru Shiri , Geva Gil , Warsof Steven L. , Ben Shachar Inbar
Published: April 2018

INTRODUCTION:

To compare the mode of delivery of nulliparous women with vaginismus at term to those without vaginismus.

METHODS:

This was a retrospective case-control study. Nulliparous women ≥37 weeks presenting in labor with a diagnosis of vaginismus, defined as chronic recurring difficulty for a woman to allow vaginal penetration, were included. The control group consisted of the next two nulliparous women delivering at term. Delivery data were compared between the groups.

RESULTS:

26 women with vaginismus were compared to 52 controls. Demographics were similar between the groups. The cesarean delivery rate was significantly higher in the vaginismus group (38% vs. 13%, p=0.019). Maternal request was the major contributing factor (19% vs. 0%, p=0.002). Four women in the vaginismus group required perineal suturing using IV sedation or general anesthesia compared to none in the control group.

CONCLUSION:

Nulliparous women with vaginismus have a significantly higher cesarean delivery rate. Maternal request is a major contributing factor rather than standard obstetrical indications. Perineal repair following vaginal delivery often requires iv sedation in the operating room.
Are CenteringPregnancy Patients More Likely Than Traditional Care Patients to Receive Influenza Vaccination? [17C]
Authors: Prieto Autumn , Roussos-Ross Dikea , Goodin Amie , Watson Amelia K.
Published: April 2018

INTRODUCTION:

CenteringPregnancy (CP) patients receive approximately 20 hours of prenatal care compared to 3 hours in Traditional Care (TC). Due to the social structure and additional time for discussion, we investigated whether CP patients were more likely to receive influenza vaccination compared to TC patients.

METHODS:

A retrospective chart review was conducted comparing all CP patients to a matched cohort of TC patients seen at UF Health between March 2015 and March 2017. Chi square analysis was performed, with a priori significance set at 0.05. Logistic regression models estimated the relationship between the outcome and CP versus TC participation, controlling for patient characteristics.

RESULTS:

A total of 153 CP patients and 259 TC patients were included in the study. CP patients received significantly greater influenza vaccinations (62.00% vs. 40.80%; p<0.001) than traditional care patients. After controlling for patient characteristics, CP patients were 1.84 times more likely to receive influenza vaccinations than TC patients (95% CI: 1.15-2.93).

CONCLUSION:

Patients enrolled in CP are more likely to accept influenza vaccination compared to patients in TC. It is possible that the increased discussion within the group setting, and the knowledge that peers are accepting the vaccination, may motivate patients to receive the vaccination. Further investigation would be necessary to determine if these findings are reproducible.
A Clinical Evaluation of the 2014 ACOG/SMFM Obstetric Care Consensus Statement [24C]
Authors: White Andrew , Chambers Charis , Ertel Michelle , Gennaro Taylor , Friedman Alexander , Eichelberger Kacey
Published: April 2018

INTRODUCTION:

It is unknown whether primary cesarean deliveries (CDs) performed in compliance with the 2014 ACOG/SMFM Obstetric Care Consensus Statement (“guideline-compliant”) are associated with a modified risk of maternal and neonatal morbidity, when compared to primary CDs performed outside the new guidelines (“guideline-noncompliant”). Our primary objective was to determine if a guideline-compliant primary CD is associated with a modified risk for maternal or neonatal morbidity, when compared to guideline-noncompliant primary CD.

METHODS:

Retrospective cohort study of women undergoing primary CD at the state’s largest maternity hospital in 2015. Maternal, neonatal, and labor course variables were collected via review of electronic clinic records and labor notes. Univariate and logistic regression analyses were performed, where appropriate.

RESULTS:

827 women delivered via primary CDs during the study period, of which 288 (34.8%) were guideline-compliant, 215 (26.0%) guideline-noncompliant, and 324 (39.2%) guideline-not addressed. Women undergoing guideline-compliant primary CD were no more likely to experience an adverse maternal outcome compared to guideline-noncompliant and guideline-not addressed primary CDs, in adjusted analysis (AOR 1.10, 95% CI .58-2.07; AOR 1.20, 95% CI .67-2.14 respectively). However, guideline not-addressed primary CDs were associated with a significantly increased risk of any adverse maternal or neonatal outcomes, when compared to guideline-compliant primary CDs (AOR 4.16, 95% CI 2.78-6.23).

CONCLUSION:

Guideline-compliant primary CDs were not associated with increased risk of maternal or neonatal morbidity when compared to guideline-noncompliant primary CDs. Compliance with the 2014 Obstetric Care Consensus Statement may be associated with a decreased primary CD rate without an increased risk of adverse outcomes.
Adequacy of Prenatal Care in Young Pregnant Adolescents: A Retrospective Cohort Study [26C]
Authors: De Simone Avina P. , Arie Abenhaim Haim , Czuzoj-Shulman Nicholas , Spence Andrea
Published: April 2018

INTRODUCTION:

Adolescents often receive suboptimal prenatal care, which may account for increased adverse outcomes. We determined the distribution of inappropriate prenatal care by maternal age, examined the temporal trend of inappropriate care among adolescents ages 12-15 and their effects on neonatal outcomes.

METHODS:

Using the CDC Period Linked Birth/Infant Death File, we conducted a retrospective cohort study of adolescents ages 12-15 who delivered between 2011-2015. Adequacy of care was measured using the R-G INDEX. Linear regression analysis was used to measure adequacy of care and unconditional multivariate logistic regression was used to examine its effects on neonatal outcomes.

RESULTS:

We observed decreasing rates of inappropriate care with rising maternal age. Among 63,484 adolescents ages 12-15, 14,845 (23.38%) received inappropriate care with rates rising significantly during the study period. Inappropriate care was most common among mothers ages 12-15 who were of Black (31.74%) or Hispanic ethnicity (26.66%), those with more than one prior birth (two prior births 30.30%), those presenting to their first prenatal visit at >7 months gestation (97.51%), and those with higher BMIs (BMI 25-29.9 28.16%, BMI 35-39.9 29.69%, BMI 40+ 33.78%). Neonates born to adolescents ages 12-15 and who received inappropriate prenatal care were significantly more likely to involve IUGR (7.58%, OR1.40, 95% CI (1.30-1.51)), infant deaths (1.33%, OR 1.35, 95% CI (1.15-1.58)) and NICU admissions (9.84%, OR 1.27, 95% CI (1.19-1.35)).

CONCLUSION:

Inappropriate care decreased with rising maternal age. Adolescents ages 12-15 experienced increasing rates of inappropriate care from 2011-2015 and were associated with certain demographics and poorer neonatal outcomes.
Adequacy of Prenatal Care Between Hospital-Based, Prepaid, Bundled Program and Traditional Medicaid [28C]
Authors: Duncan Erin , Narvaez Jennifer , Topel Matthew , Haddad Lisa , Loucks Tammy , Ellis Jane
Published: April 2018

INTRODUCTION:

Access to adequate prenatal care (PNC) is a goal of HealthyPeople 2020. However, not all pregnancies in the U.S. are guaranteed this benefit, particularly in States that have not expanded Medicaid or have high concentrations of pregnancies in undocumented women. To address this gap, our institution created a prepaid, bundled PNC package (Grady Healthy Baby-GHB) for women who did not qualify for public insurance. Prenatal visits and two ultrasounds were included. Our goal was to determine whether GHB participants received adequate PNC relative to Medicaid.

METHODS:

Viable singleton deliveries from 2011-2014 were eligible. A randomly selected, retrospective cohort of 100 GHB and 100 Medicaid deliveries was created. Demographics, pregnancy information, number of prenatal visits and ultrasounds were abstracted and pregnancy risk status and adequacy of PNC determined. Descriptive statistics and logistic regression models were used to characterize groups and examine adequacy of PNC.

RESULTS:

GHB participants were older, more likely to be Hispanic and less likely to be Black compared to Medicaid participants (P<0.001 for all). Among women with a low risk pregnancy, GHB participants were more likely to have adequate PNC compared to Medicaid patients (P<0.001). Significance remained after adjustment (aOR 3.75, P=0.015). In high risk pregnancies, there was no difference in adequacy of PNC.

CONCLUSION:

Women with low risk pregnancies enrolled in a prepaid, bundled PNC package were more likely to receive adequate care than women with Medicaid. This study has implications for all pregnancies that begin as uninsured, especially in the current political climate.
Acceptance of Vaccination in Centering Pregnancy in an Inner-City Community Teaching Hospital [29C]
Authors: Jaramillo Helen , Casquero-Leon Jorge , Abduallah Amirah , Inglis Steven , Magloire Tamara , Khalil Susan
Published: April 2018

INTRODUCTION:

Centeringpregnancy® models, or group pregnancy can help increase compliance with visits, and improve key quality metrics. Vaccination with Tdap, is an important component in preventative care during pregnancy. The goal of this study is to assess this in centerpregnancy® groups, in an inner city community teaching hospital.

METHODS:

A retrospective chart review was performed in a prospectively maintained database of centeringpregnancy® patients, that received care in an inner-city community teaching hospital’s outpatient setting. Charts were reviewed for vaccination compliance with Tdap.

RESULTS:

A total of 146 participants were included. Most were compliant with their prenatal care sessions, 2.7% missed 3 or more visits. The acceptance rate during pregnancy, when asked if they would agree to receive Tdap vaccination was 95%. However, at the time of administration, 4 declined. The administration of the vaccine to the group was 87%, with most receiving it in the third trimester (92.3%). The remainder agreed to receive the vaccination in the postpartum unit.

CONCLUSION:

Further studies are needed to investigate reasons for non-acceptance of vaccination during pregnancy in diverse patient settings. The utility of group pregnancy models confers an opportunity for health education and peer-modeling.
A Survey of Women and Their Providers Regarding Gestational Weight Gain Across the United States [31C]
Authors: Power Michael L. , Gaspar-Oishi Maria , Gibson Kelly S. , Rhoades Courtney , Turrentine Mark , Yamamura Yasuko , Mackeen A. Dhanya
Published: April 2018

INTRODUCTION:

Assess patient and provider knowledge and opinions about gestational weight gain (GWG) particularly in relation to the Institute of Medicine (IOM) guidance with respect to maternal body mass index (BMI).

METHODS:

Questionnaires were distributed by medical centers across the United States to patients (8 sites) and providers (7 sites). Data on maternal BMI and GWG was collected at all sites.

RESULTS:

1,157 women returned questionnaires (1,820 maximum possible). A majority at all sites reported a provider discussed their expected GWG with them. Close to half reported that a provider had discussed potential harms from inappropriate GWG. Most of the women (71.2%) considered their obstetrician to be a helpful resource for GWG advice. Most providers (87.5%) reported they were aware of the IOM guidelines. As many providers disagreed (18.8%) as agreed (20.8%) that they were successful at helping their patients gain an appropriate amount of weight during pregnancy (58.3% were neutral). Physician self-reported confidence was associated with their opinions on whether they could help their patients avoid excessive GWG. The most common outcome at all sites was GWG above the IOM recommendations. Overweight and obese women were more likely to gain above recommendations. Providers underestimated the proportion of their patients that gained below recommendations (8.5% versus 18.9%).

CONCLUSION:

Providers are aware of the dangers of excessive GWG and are counseling patients. Providers appear more cognizant of excessive GWG and underestimate the proportion that may have inadequate GWG. Most women are not achieving an appropriate GWG, especially overweight and obese women.
Are Postpartum Hemorrhage Kits Enough? Evaluating Their Impact on Maternal Blood Loss [39C]
Authors: Stark Sydney , Gibson Kelly S.
Published: April 2018

INTRODUCTION:

Postpartum hemorrhage (PPH) is a common complication and preventable maternal mortality. We hypothesized our units PPH medication and supply kits would lead to lowered and sustained blood loss in PPH cases.

METHODS:

Retrospective cohort study of PPH cases 18 months prior to kits (PRE), 12 months after (POST-1), 12-24 months after(POST-2). Cases include women ≥18 years with PPH in perinatal database or uterotonics noted in pharmacy database. PPH defined as >500ml estimated blood loss (EBL) at vaginal, >1000ml EBL at cesarean delivery. Primary outcome was median blood loss measured qualitatively through EBL and quantitatively through hemoglobin change (Hgb). Time to medication administration was assessed. ANOVA, chi-squared, and Fisher’s exact analyses used as appropriate.

RESULTS:

195 women included (86 PRE, 42 POST-1, 67 POST-2). Groups had similar maternal age, BMI, parity, gestational age, rates of induction, and cesarean delivery. Total mean EBL vaginal deliveries (PRE 983 ±497ml, POST-1 1,035 ± 447ml, POST-2 1,075 ± 565ml, P=0.64) and cesareans (1,630 ± 755ml, 1,480 ± 780ml, 2,025 ± 1,419ml, P=0.36) were not significantly different between groups. Change in Hgb from delivery to postpartum day 1 was not significantly different (P=0.19). Times to administration and rates of medication use were similar between groups for Methergine, Carboprost, oxytocin, misoprostol, and blood transfusion.

CONCLUSION:

Introduction of PPH kits alone not associated with lower EBL or improved time to uterotonic administration. This work highlights importance of evaluating the impact of quality improvement projects after implementation. Using only portion of bundle may not lead to improved patient outcomes.
Risk of Occult Uterine Cancer in Myomectomy: A Population-Based Study [2D]
Authors: Desai Vrunda Bhavsar , Wright Jason , Gross Cary , Lin Haiqun , Schwartz Peter E. , Xu Xiao
Published: April 2018

INTRODUCTION:

Prior research on occult uterine cancer has centered on hysterectomies. This study aimed to extend current literature by examining the prevalence of occult uterine cancer in women undergoing myomectomy in a population-based sample and identify its associated risk factors.

METHODS:

Using the New York Statewide Planning and Research Cooperative System database, women who underwent an inpatient or outpatient myomectomy in New York State in 10/1/2003-12/31/2013 were identified based on ICD-9 and CPT codes. We excluded patients with an admitting diagnosis or history of gynecologic cancer or endometrial hyperplasia, as well as those with non-gynecologic indications. Diagnosis of uterine cancer within 28 days after the index myomectomy was determined based on linked state cancer registry data.

RESULTS:

38,804 women underwent a myomectomy for presumed benign indications in our sample. The prevalence of occult uterine cancer was 0.12% (95% confidence interval [CI] 0.08-0.15%). When examined by cancer subtypes, 0.04% (95% CI 0.02-0.06%) had endometrial carcinoma, 0.08% (95% CI 0.05-0.10%) had uterine sarcoma, and 0.04% (95% CI 0.02-0.06%) had leiomyosarcoma. The risk of occult uterine cancer varied by surgical indication (0.10% in women with fibroids versus 0.05% for menstrual disorders and 8.00% for postmenopausal bleeding). Older women (e.g., 2.70% for age ≥60 years versus 0.06% for age <40 years, adjusted odds ratio [aOR]=28.08, P<.001) and Asians (0.27% in Asians versus 0.12% in non-Hispanic whites, aOR=4.04, P=.02) were at higher risk.

CONCLUSION:

The prevalence of occult uterine cancer in women undergoing myomectomy was low. However, risk of occult malignancy varied by patient age, race and surgical indication.
Intuitive Surgical Inc. Payments to Ob/Gyns Compared to Other Specialties: Analysis from 2014 Open Payments Database [4D]
Authors: Guha Paulami , Espinal Mariana , Dinh Tri , DeStephano Christopher
Published: April 2018

INTRODUCTION:

Study Objective: To determine the payments made to Obstetricians and Gynecologists (OBGYNs) compared to other surgical specialties by the makers of the Da Vinci robot-Intuitive Surgical, Inc. in 2014.

METHODS:

Design: Retrospective cross-sectional study (Canadian Task force classification- II-3).

Setting:

Payments to OBGYNs in the United States compared to the total Intuitive Surgical payment amount in each state as analyzed from Centers for Medicare & Medicaid Services (CMS)’ Open Payments website.

Subjects:

General OBGYNs, OBGYN subspecialists (Gynecologic Oncology, Reproductive Endocrinology, Female Pelvic Medicine and Reconstructive Surgery, Gynecology), and providers in other specialties nationwide.

Interventions:

Compare Intuitive Surgical Inc. payments to OBGYNs versus other surgical specialties as analyzed from publicly available CMS Open Payments database.

RESULTS:

A total of 50 states received money from Intuitive Surgical Inc. in 2014. Payments to general OBGYNs totaled $5,061,439, OBGYN subspecialties received $1,591,556, and other surgical specialties that use the Da Vinci platform received $33,011,657. Total payments per state can be represented in a map diagram. The state of Texas got the highest amount. Payments to OBGYNs divided by total payments in each state can be depicted in a similar fashion, Wyoming state had the highest value.

CONCLUSION:

OBGYNs received a significant proportion of funding from Intuitive Surgical Inc. as compared to other surgical specialties in 2014. We recommend that OBGYNs update or declare any conflicts when required.
Magnesium for Fetal Neuroprotection: Should it be Started When Delivery is Not Imminent in PPROM? [12D]
Authors: Hom Katherine , Brar Bobby , Kennel Patricia , Jackson David
Published: April 2018

INTRODUCTION:

Magnesium sulfate may decrease moderate to severe cerebral palsy or death when administered to women at risk for imminent delivery < 32 weeks. Research guidelines included restarting magnesium for fetal neuroprotection up to 34 weeks. Our purpose was to determine whether a magnesium bolus should be given to stable patients admitted with preterm premature ruptured membranes (PPROM) <34 weeks, or whether it can be delayed until delivery appears imminent.

METHODS:

Recent PPROM patients at a single, University hospital were retrospectively evaluated. Maternal demographics, delivery outcomes, and neonatal outcomes were analyzed.

RESULTS:

From January 2013 to May 2016, a total of 10,565 deliveries occurred. The incidence of PPROM <34 weeks was 0.5% (n=52). The mean gestational age of those who received magnesium was 28 6/7 weeks compared to 31 2/7 weeks in those with no magnesium (P<0.004). Precipitous deliveries for labor or fetal compromise prevented re-administration of magnesium in 83%. An unexpected trend for decreased intraventricular hemorrhage was seen in patients with PPROM receiving magnesium (1/26 = 3.8%) versus those not receiving magnesium (4/26 = 15.4%) P = .35.

CONCLUSION:

Few recent studies have investigated the timing of magnesium sulfate for fetal neuroprotection in patients with PPROM. Our data supports immediate administration of magnesium to all patients admitted with PPROM <34 weeks, including those deemed stable on admission. Further prospective studies are indicated to assess the neuroprotective benefits of magnesium for neuroprotection at 32-34 weeks in PPROM.
Management of Labor and Delivery after Fetoscopic Repair of Open Neural Tube Defect [15D]
Authors: Kohn Jaden R. , Rao Vibha , Sellner Allison A. , Sharhan Dina , Belfort Michael A. , Sanz Cortes Magdalena
Published: April 2018

INTRODUCTION:

Fetal repair of open neural tube defect (NTD) improves motor/cognitive outcomes and decreases need for postnatal shunting. Cesarean delivery is mandated when this is done via hysterotomy. The fetoscopic approach has comparable neonatal benefits to the open hysterotomy approach, but allows for vaginal delivery. This study describes the outcomes for labor and delivery following fetoscopic repair.

METHODS:

Retrospective cohort study at a single institution from 2014-2017.

RESULTS:

32 patients had fetoscopic repair followed by either vaginal delivery (n = 16) or cesarean (n = 16) at 38.1 (26-40.2) and 36.3 (25.5-40.5) weeks, respectively.

There were three elective cesareans (one breech with severe IUGR, one prior cesarean, one macrocephaly) at 39.0 (37.1-39.0) weeks. Thirteen cases were delivered by non-elective cesarean at 35.2 (25.5-40.5) weeks: five had urgent pre-labor indications (four abnormal FHTs, one breech with PPROM), and eight were indicated during labor (four abnormal FHTs, three suspected abruptions, one breech after labor onset).

Of sixteen vaginal deliveries, three required instrumentation and one was a VBAC. Eight had a second-degree laceration.

In total, 24 patients labored. Seven patients were induced at 39.0 (35.5-39.5) weeks; one required cervical ripening with dinoprostone while six were induced with oxytocin only. Two patients received labor augmentation with oxytocin. The most common oxytocin protocol started with 2 mU/min and increased 1-2 mU/min q45min; most cases received a maximum of 20 mU/min or less. The mean oxytocin exposure was 18.3+/-10.6 hours. No inductions failed.

CONCLUSION:

Induction of labor and vaginal delivery after fetoscopic NTD repair is safe with reduced maternal morbidity.
Cost-Effectiveness of Planned Hospital vs Out-of-Hospital Vaginal Births after Cesarean in Term Pregnancies [18D]
Authors: Shields Michelanne , Chatroux Louisa R. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Given the upward trend of cesarean deliveries in the last decade, more women face the decision to pursue either a trial of labor after cesarean (TOLAC) or a repeat elective cesarean delivery. Women choose to pursue TOLAC both in the hospital setting and out of the hospital. Our study sought to evaluate the cost-effectiveness of planned hospital vs out-of-hospital vaginal birth after cesarean (VBAC) in term pregnancies.

METHODS:

A decision-analytic model was built using TreeAge software with probabilities, costs, and utilities derived from the literature. The primary outcomes included: cesarean sections, hypoxic ischemic encephalopathy (HIE), cerebral palsy (CP), and neonatal mortality. Secondary outcomes included: cost per quality-adjusted life year (QALY), and maternal mortality. Sensitivity analyses were employed to determine the robustness of the results.

RESULTS:

In a theoretical cohort of 750,000 women representing yearly otherwise low-risk term attempted-VBAC in the US, planned VBAC in the hospital resulted in 282 fewer cases of neonatal HIE, 63 fewer cases of CP, and 1,419 fewer neonatal deaths when compared to intended delivery out-of-hospital. Our model suggests that planned hospital birth is cost-effective, with an incremental cost-effectiveness ratio (ICER) of $25,782/QALY. Planned hospital births also resulted in 77,550 more cesarean sections, but there was no observed difference in rates of maternal mortality.

CONCLUSION:

Planned VBAC in the hospital are more expensive than home deliveries for term pregnancies, but are cost-effective. Planned hospital births reduce neonatal morbidity and mortality, and on balance increases overall QALYs, but at the cost of an increased cesarean section rate.
Transcervical Balloon Catheter for Cervical Ripening: Weighted Traction or Tension [23D]
Authors: DeCesare Ana , Decesare Julie , Manek Kimberly
Published: April 2018

INTRODUCTION:

The goal of induction or augmentation of labor is to achieve vaginal delivery, while balancing both maternal and fetal safety. The rate of induction of labor has more than doubled since 1990, with more than 22% of all gravid women undergoing induction of labor. Several randomized controlled trials have investigated labor outcomes when comparing transcervical balloon catheters to use of prostaglandins or oxytocin. Few studies have investigated methods of transcervical bulb set up. At our institution, mechanical cervical dilation is accomplished with the use of transcervical balloon catheters, which are inflated with 60mL of saline. It is up to provider discretion to place the balloon catheters on traction or tension.

METHODS:

The objective of this study is to compare pre- and post- transcervical balloon catheter cervical dilations and time from placement to expulsion. Patients were randomized to either the leg or bag group and Bishop score was required to be less than 6. We hypothesized that the use of transcervical balloon catheter on weighted traction would result in a larger cervical dilation and a shorter balloon catheter placement to expulsion time.

RESULTS:

A total of 73 patients were randomized, with 43 in the bag group and 30 patients in the leg group. Results showed that the intervention of the bag saved 74 minutes of time and was statistically significant, with a p value <.05. Bishop score change between the two groups was not statistically significant, with a p value = .74. At our hospital average cost for labor and delivery is $326 per hour. Average cost savings per patient using bag over leg is $400.98.

CONCLUSION:

In conclusion, out study demonstrated statistically significant shorter time to delivery in the bag group. This resulted in a shorter induction process, as well as a cost saving to the labor and delivery unit and will be utilized to add evidence to the most efficient method of cervical ripening. Additional research points will analyze time to active phase of labor and time to delivery of the infant
Delivery of the Posterior Arm as Initial Maneuver to Relieve Shoulder Dystocia Increased Neonatal Humeral Fractures [24D]
Authors: Gold Stacey , Hirsch Daniel , Schutzman David , Cohen Arnold , Jaspan David , Goldberg Jay
Published: April 2018

INTRODUCTION:

Delivery of the posterior arm as the initial maneuver to relieve shoulder dystocia increased neonatal humeral fractures. To evaluate if institutionally adopting delivery of the baby’s posterior arm as the initial maneuver during shoulder dystocia has increased the rate of neonatal humeral fractures.

METHODS:

In the beginning of 2011, Einstein Medical Center Philadelphia initiated a policy of attempting to deliver the posterior arm as the initial maneuver to resolve shoulder dystocia with the aim of decreasing brachial plexus injuries. Hospital databases were searched to identify deliveries complicated by neonatal humeral fractures, as well as other delivery information. Statistical analysis was performed.

RESULTS:

Between 2004 and 2010, 3 neonatal humeral fractures were identified from 13,536 vaginal deliveries. Following initiation of the posterior arm policy, from 2011 through August of 2017, 31 humeral fractures were identified from 13,750 vaginal deliveries. Almost all humeral fractures were associated with a shoulder dystocia. The rate of neonatal humeral fractures following the intervention increased by a factor of 10.8. The rate of humeral fracture pre- and post-intervention were compared with both Chi-squared test for independence and the Fisher’s Exact Test with both p values < 0.000001.

CONCLUSION:

Initially attempting delivery of the posterior arm to resolve shoulder dystocia was associated with a significant increase in the rate of neonatal humeral fractures. Further study is warranted to determine if there was a decrease in the rate of brachial plexus injury to justify continuation of our current institutional management of shoulder dystocia.
Pregnancy Outcomes Following Liver Transplantation: A Two-Centre Retrospective Study [36D]
Authors: Zaffar Nusrat , Soete Elisabeth , Van Mieghem Tim , D'Souza Rohan
Published: April 2018

INTRODUCTION:

This study reports pregnancy outcomes in women following liver transplantation to aid counselling and management of these women.

METHODS:

We conducted a retrospective study including women with pregnancies following liver transplantation followed at Mount Sinai Hospital, Toronto, Canada and University Hospital Leuven, Belgium between 1989 -2016. Pregnancy outcomes were reported as proportions.

RESULTS:

We identified 28 women that had 41 pregnancies following liver transplantation. The mean maternal age was 30 (±7) years and transplant-to-pregnancy interval was 8.5 (±5.1) years. Six women had received two liver transplants prior to conception, but had normal liver functions at the start of pregnancy. Immunosuppressants included tacrolimus ± azathioprine (26), cyclosporine (4) and prednisone with immunosuppressants (11). Maternal complications included hypertension (10), renal insufficiency (6), gestational diabetes (4), graft deterioration (2), infection (2) and anemia requiring blood transfusion (1). Fetal/neonatal adverse outcomes included two miscarriages, three stillbirths, one neonatal death, five small-for-gestational-age infants and one minor congenital anomaly. There were 22 term and 14 preterm infants with a mean gestational age of 36+5±4.23 weeks. Although the cesarean delivery rate was high (61%), all were performed for obstetric indications.

CONCLUSION:

With appropriate multidisciplinary care and with stable graft function at the onset of pregnancy, women with liver transplants can have successful pregnancies with low rates of graft complications, if they adhere to their immunosuppressive regimens. Graft deterioration responds well to increase in the dose of immunosuppressants and high-dose glucocorticoids. The use of these in pregnancy is not associated with adverse fetal/neonatal outcomes.
Risk Scoring Index for Development of Preeclampsia among Women: A Retrospective Cohort Study [39D]
Authors: Lim Vanessa Marie T. , Zamora Brenda Bernadette B.
Published: April 2018

INTRODUCTION:

Worldwide, there is an increasing thrust to develop better screening methods for preeclampsia. But in the Philippines, there is limited research regarding approach to screening for development of preeclampsia. This retrospective study aimed to identify significant clinical risk factors associated with preeclampsia and develop a risk scoring index.

METHODS:

A retrospective cohort study of women with live births at a tertiary hospital, St. Luke’s Medical Center from January 2015 to April 2016 was conducted. Several variables associated with Preeclampsia were considered. Outcome measure was development of preeclampsia. A risk scoring index was developed from the results of the logistic regression analysis. Computed scores were plotted in a receiver operating characteristic curve and cut-off values were determined.

RESULTS:

The overall prevalence of preeclampsia was 4.5%. Among the variables evaluated, presence of chronic hypertension (OR 4.179, 95% CI 7.572-563.181) and respiratory tract infection (OR 3.128, 95% CI 4.196-124.263) showed the strongest significant association with development of Preeclampsia. The odds of developing preeclampsia were also increased in patients who had gestational diabetes mellitus (OR 1.222, 95% CI 1.559-7.389), urinary tract infection (OR 2.455, 95% CI 5.723-23.678), and vaginal infection (OR 1.577, 95% CI 2.126-11.020). The formulated preeclampsia risk scoring index was 5.75, specificity of 91.8%, sensitivity of 74.5%, positive likelihood ratio of 9.2.

CONCLUSION:

Maternal age, and presence of chronic hypertension, gestational diabetes mellitus, and maternal infection significantly affect development of preeclampsia among women studied. Women are more likely to develop preeclampsia 9 times more with a risk score of greater than or equal to 5.75.