bluuebunny/crossref_metadata_2025 huggingface dataset:
Induction of Labour in Low-Risk Pregnancies before 40 Weeks of Gestation: A Systematic Review and Meta-Analysis [11P]
Authors: Bapoo Shakira , Shukla Minakshi , Abbasi Nimrah , D'Souza Rohan
Published: April 2018

INTRODUCTION:

Retrospective data suggest that adverse outcomes in low-risk pregnancies are lowest at 39 weeks, and systematic reviews of randomized controlled trials (RCTs) suggests that induction of labour (IOL) after 37 weeks regardless of indication and cervical favourability is associated with lower rates of caesarean deliveries (CD) when compared with expectant management. Our objective was to determine whether IOL <40 weeks reduces CD rates and improves pregnancy outcomes.

METHODS:

We conducted a systematic review of RCTs comparing IOL to expectant management in low-risk women. We searched four databases until November 2016 using appropriate keywords and MeSH terms. Two authors independently completed title screening, data extraction and risk-of-bias (ROB) assessment using the Cochrane ROB tool. Meta-analysis was performed using RevMan 5.3 and results were reported as odds ratios and 95% confidence intervals (OR, 95%CI).

RESULTS:

We identified 2523 titles and included 14 eligible articles, most of which had low ROB. Outcomes for IOL (n=1268) vs. expectant management (n=1266) were as follows: CD 1.02 (0.81, 1.28), operative vaginal delivery 1.32 (1.06, 1.66), infective morbidity 1.26 (0.79, 1.99), perinatal mortality 0.72 (0.14, 3.71), postpartum 1.00 (0.73, 1.38), neonatal admissions 0.71 (0.33, 1.51), abnormal cord gases 0.69 (0.26, 1.87) and low 5-minute Apgar scores 0.94 (0.44, 2.03).

CONCLUSION:

There were no differences in rates of CD or other adverse pregnancy outcomes when IOL <40 weeks is compared with expectant management in low-risk pregnancies. A policy of IOL at 39 weeks to lower CD rates and improve pregnancy outcomes can only be recommended under the confines of RCTs.
Neonatal Hypoglycemia after Initiation of Late Preterm Antenatal Corticosteroids at a Single Center [13P]
Authors: Uquillas Kristen , Lee Richard , Chen Ellison , Ihenacho Ugonna , Cortessis Victoria , Barton Lorayne
Published: April 2018

INTRODUCTION:

After the publication of the Antenatal Late Preterm Steroids (ALPS) trial in 2016, LAC+USC Medical Center began to offer antenatal corticosteroids to patients at risk of late preterm birth. The ALPS trial found an association between late preterm corticosteroids and neonatal hypoglycemia, however this was not fully described.

METHODS:

We retrospectively examined data from all neonates born in the late preterm period between 2/1/15-7/31/17. Patients were excluded according to the ALPS study criteria. Hypoglycemia was defined as glucose <40 mg/dl within 72 hours of birth. Neonatal outcomes were compared between pregnancies treated with and without corticosteroids. Student’s T-test and Pearson’s chi-squared test were used as appropriate with a p-value <0.05 considered significant.

RESULTS:

During the study period, 67 (34.5%) received corticosteroids and 127 (65.5%) did not. There was no significant association between neonatal hypoglycemia and corticosteroids [OR 1.86 (95% CI 0.95-3.59), p = 0.05]. The mean glucose nadir (40.4±15.4 vs. 45.5±13.6, p = 0.02) and mean initial glucose (45.7±21.3 vs. 51.9±17.7, p = 0.03) were significantly lower in the neonates who received corticosteroids.

CONCLUSION:

Among a small population of late preterm neonates, there was no difference in the rate of hypoglycemia between those who did and did not receive corticosteroids. Although the hypoglycemia was more severe in the group who received corticosteroids, as evidenced by the significantly lower mean glucose nadir and mean initial glucose, there was no difference in the need for IV treatment or neonatal length of stay.
Characterization of Fetal Heart Rate Tracings During Eclamptic Seizures [15P]
Authors: Ambia Anne M. , Yule Casey S. , Wells C. Edward
Published: April 2018

INTRODUCTION:

The well-known association of fetal bradycardia following maternal eclampsia has not been described in detail. We sought to characterize fetal heart rate tracing at the time of an intrapartum maternal eclamptic seizure and the changes in obstetric management that may result.

METHODS:

This was a retrospective study of fetal heart rate tracings recorded during an eclamptic seizure and the resultant obstetrical management of our institution from August 2009 to December 2016. Eclampsia was diagnosed according to criteria of the ACOG Executive Summary. Tracings were reviewed independently by three physicians based on the National Institute of Child Health and Human Development Criteria. Maternal and fetal outcomes were then analyzed.

RESULTS:

A total of 70 women were diagnosed with eclampsia during this time period. Nineteen women experienced a confirmed intrapartum seizure while on fetal heart rate monitors. Of those who experienced an intrapartum seizure, 16 of the 19 patients (84%) developed fetal heart rate decelerations with a mean duration of 6±4 minutes. For all women, the mean duration from the eclamptic seizure to delivery was 244±263 minutes. As a result of the fetal heart rate tracings, two patients underwent a change in obstetric management with a resultant emergent cesarean delivery due to profound bradycardia to the 50s without recovery. There were no neonatal deaths and three neonatal intensive care admissions.

CONCLUSION:

Management of fetal bradycardia during eclamptic seizures remains challenging. Despite a period of prolonged fetal bradycardia associated with intrapartum eclampsia, close observation resulted in a favorable neonatal outcome in the majority of cases.
Fetal Laceration Injury at Cesarean Delivery: Comparison between Low-Risk and High-Risk Intrapartum Care [17P]
Authors: Vander Haar Emilie L. , Miller Russell , Simpson Lynn L.
Published: April 2018

INTRODUCTION:

Our objective was to determine the frequency, severity, and documentation of fetal laceration during cesarean delivery (CD) in patients receiving intrapartum low-risk (LRC) vs high-risk (HRC) care.

METHODS:

This is a retrospective cohort study of patients delivered at a single, academic medical center from January 2014 to December 2016. Medical records were reviewed for infants with a laceration after CD, and maternal, fetal, and obstetric variables were extracted. Lacerations were classified as mild, moderate, or severe. Patients assigned to LRC were compared to those assigned to HRC using appropriate bivariate analyses with an alpha of 0.05.

RESULTS:

Over the study period, there were 8,454 (62.7%) vaginal deliveries and 5,036 (37.3%) CDs. Of the CDs, 3,104 (61.6%) were performed on patients assigned to LRC and 1,932 (38.4%) to HRC. There were 14 total lacerations: 12 (85.7%) were classified as mild, 1 (7.1%) as moderate, and 1 (7.1%) as severe. There were more lacerations in patients assigned to HRC (71.4% vs 28.6%; p=0.01), with a fetal laceration rate of 1.3 per 1000 LRC CDs and 5.2 per 1000 HRC CDs. Of note, 42.9% of fetal injuries were associated with emergency CDs, and the risk of emergency delivery was higher in the HRC group, although this did not reach statistical significance (50.0% vs 25.0%, P=0.68). Documentation of fetal laceration was poor, recorded in only 42.8% of the maternal medical records.

CONCLUSION:

There was a four-fold increase in fetal injury associated with CD and HRC. Documentation of fetal injury at the time of CD needs improvement.
Postpartum Concerns after Discharge: Who has Them, and What are They? [19P]
Authors: Siegel Molly , Barrett Blair , Wheeler Margaret , Ustinov Alla , Li Ben , Rosenstein Melissa
Published: April 2018

INTRODUCTION:

To identify the prevalence of concerns among postpartum women and the factors associated with them

METHODS:

All postpartum women from March to June 2017 were contacted after discharge via an automated call. A call was successful if the woman engaged with the automated system, and those with concerns were contacted by a nurse. We compared call success and presence of concerns by mode of delivery, insurance type (public or private), parity, pregnancy complication (diabetes, hypertension, hemorrhage), and neonatal intensive care (ICN) admission using univariate analyses and multivariable logistic regression.

RESULTS:

881 women were called and 730 (83%) successfully contacted; 224 (29%) reported a concern. Women with operative vaginal delivery were more likely to report an issue than spontaneous vaginal and cesarean delivery (42% vs 28% p=0.04). Women with public insurance were less likely to be successfully contacted (68% vs 84% p=0.003), but the frequency of concerns were equivalent (28% vs 29%). Nulliparous women were more likely to answer the call (86% vs 79% p=0.004) and to report an issue (32% vs 25% p=0.05). Women with neonates in the ICN were less likely to be successfully contacted. When controlling for confounders, nulliparity (OR 1.5, 95% CI 1.1- 2.2) and private insurance (OR 1.9, 95% CI 1.1 - 3.8) were independently associated with successful contact.

CONCLUSION:

The majority of postpartum women responded to a call, and one third had concerns. The system was less effective in contacting women with public insurance. Nulliparous women and women with operative vaginal deliveries may benefit from additional discharge support.
Efficacy of Quantitative Blood Loss Compared to Estimated Blood Loss for Predicting Severe Obstetric Hemorrhage [21P]
Authors: Le Nicole K. , Briceno Maria , Brown Alyssa , Leavitt Karla , Louis Judette
Published: April 2018

INTRODUCTION:

Quantitative blood loss (QBL) has been proposed to be more accurate than estimated blood loss (EBL) for management of obstetric hemorrhage. We sought to evaluate the effectiveness of QBL in identifying women with severe obstetric hemorrhage.

METHODS:

We conducted a retrospective cohort study including all women who delivered at a tertiary center during 2/1/2013-1/31/2014. Medical charts were reviewed for relevant clinical data. Two methods were compared: quantitative blood loss and estimated blood loss. The data was analyzed using Spearman correlation and ROC curves where appropriate. P < 0.05 was considered significant.

RESULTS:

During the study period there were 9,890 deliveries and 2.9% were complicated by obstetric hemorrhage (N=287). Among women with postpartum hemorrhage, 47.5% had a cesarean delivery and 22.8% had a cesarean after labor. Overall, 26.8% of the women required a blood transfusion. Women who required a blood transfusion compared to those who did not need one, had a lower admission hemoglobin and took longer to stabilize. QBL (r= 0.33, p<.001) but not EBL (r= 0.2, p=.08) was correlated with a drop in hemoglobin. QBL estimation (sensitivity 87%, specificity 67%) showed a small improvement over estimated blood loss in the prediction (66% sensitivity, 85% specificity) of women who would require a blood transfusion [AUC=.84 (95%CI 0.810 to 0.908) vs. AUC=.77 (95% CI 0.698 to 0.882)], but no difference in blood transfusion (28 vs 22 %, p=.34).

CONCLUSION:

QBL has higher sensitivity in predicting severe obstetric hemorrhage but it was not associated with more frequent blood transfusions.
Isolated Echogenic Intracardiac Foci: A Comparison of Aneuploidy Screening Tests [28P]
Authors: Hacker Francis , Griffin Emily E. , Shaffer Brian L. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

The 2014 Fetal Imaging Workshop endorses obtaining a quad screen or cell-free fetal DNA (cfDNA) test in fetuses identified to have an isolated echogenic intracardiac foci (EIF) without prior aneuploidy screening. Our goal was to compare estimated outcomes and costs of the recommendation. We additionally hoped to gain information to assist providers in offering patient specific recommendations.

METHODS:

A decision-analytic model was constructed using TreeAge software and probabilities derived from the literature. The model compared use of quad testing to cfDNA in women with an isolated EIF identified on screening ultrasound, with T21 sensitivities assumed at 81% and 99% respectively. Baseline risk of T21 was assumed at 1/400. Positive likelihood ratio for T21 with an isolated EIF, was assumed to be 1.5. Outcomes of interest included T21 diagnosis, procedure related loss, termination, spontaneous abortion, and T21 live births. Strategies were compared to generate an incremental cost-effectiveness ratio, with a $100,000/QALY threshold, and applied to a theoretical cohort of 100,000.

RESULTS:

When compared to aneuploidy screening using quad testing, the strategy that utilized cfDNA after detection of an isolated EIF resulted in 47 fewer live T21 births and 85 additional QALYs with cost savings of $525,964 per 100,000 pregnancies; a dominant strategy in cost-effectiveness analysis.

CONCLUSION:

In a population with an isolated EIF identified on screening US without prior aneuploidy screening it is cost effective to offer cfDNA as compared to a quad screening test. Despite the higher cost of cfDNA, these results likely stem from the increased sensitivity and decreased false positive rate.
Perinatal Outcome of Fetal Umbilical Vein Varix: A Multicenter Cohort Study [29P]
Authors: Novoa Y Novoa Victoria Arruga , Tonni Gabriele , Prefumo Federico , Ruano Rodrigo
Published: April 2018

INTRODUCTION:

Umbilical vein varix (UVV) is a focal dilation of the fetal umbilical vein. Clinical significance is not clearly established but it has been associated with adverse outcomes. This study investigates the clinical outcomes of UVV diagnosed during pregnancy.

METHODS:

We performed a multicenter retrospective (USA, Chile, Italy and Brazil) study by reviewing 19 fetuses diagnosed with UVV between 2012 and 2017. We investigated gestational age at diagnosis and at delivery, UVV maximum diameter, fetal gender, associated anatomical anomalies, intrauterine growth restriction, fetal demise, type of delivery, birth weight, Apgar scores.

RESULTS:

UVV was diagnosed at 26.4+/- 4.4 weeks of gestation. Maximum diameter of the defect at diagnosis typically was 13.1+/- 5mm. The majority of fetuses were male (n=12, 63%). Growth restriction was diagnosed in 26% (n=5) of the fetuses. Seventeen (89%) infants survived. Fetal demise occurred in 2 (11%) patients; one was associated with structural anomalies, and the other fetus did not have any other associated anomaly. Vaginal delivery was performed in 10 (53%) patients; median weight at birth was 2870 g (270-4960 g). Median Apgar scores were 8 and 9 on 1st and 5th minutes consecutively (ranging from 0 to 10). Genetic and anatomical anomalies were present in 21% (n=4) of the fetuses and included: karyotype 47,XY+13, cleft lip and palate, cerebellar hypoplasia, aortic hypoplasia, cardiomegaly, Blake's pouch cyst, ambiguous genitalia, campomelic dysplasia with SOX9 mutation.

CONCLUSION:

UVV is a rare congenital condition that is usually associated with low frequency of other structural/genetic anomalies and with good prognosis.

ACKNOWLEDGEMENTS:

Waldo Sepulveda, Edward Araujo Junior, Mari Charisse Trinidad, and Heron Werner
Maternal Assessment With Sonography for Hemorrhage (MASH): A Prospective Cohort Study [33P]
Authors: Spiegel Tirtza , Yukhayev Anar , Fleischer Adiel , Meirowitz Natalie
Published: April 2018

INTRODUCTION:

Intra-abdominal hemorrhage must be diagnosed and managed expeditiously in women with hemodynamic instability after Cesarean delivery. Our objective was to determine the amount of free intra-abdominal fluid normally present on ultrasound after Cesarean delivery, and whether intra-operative blood loss influences this measurement.

METHODS:

Transabdominal ultrasound examinations were performed in the supine position 1 to 3 hours after Cesarean delivery. Free intra-abdominal fluid was measured using a 5-1 MHz phased array transducer. Vertical fluid pockets were combined for each subject using a 4-quadrant technique. Cases with intraoperative irrigation were excluded. Demographic and delivery data, including intra-operative blood loss, were collected and analyzed.

RESULTS:

None of the 85 participants had intra-abdominal bleeding within 12 hours after Cesarean delivery. One woman had an intra-abdominal hematoma and hemodynamic instability one day after delivery. Nineteen women (22.4%) had free fluid on ultrasound, with a median combined fluid pocket of 1.4 cm (range between 0.5 and 3.4 cm). Twenty women (23.5%) had intra-operative blood loss more than 1,000 ml. Intra-operative blood loss did not differ between women with and without free fluid on ultrasound (968 ml vs. 900 ml).

CONCLUSION:

Sonographic assessment for free fluid may be useful after cesarean delivery when intra-abdominal bleeding is suspected. Although a small amount of free fluid may be visualized in a minority of patients, a combined fluid pocket of more than 3 cm is uncommon, and requires further evaluation. This ongoing study will assess the inter-observer variability, and the diagnostic accuracy of this sonographic technique.
Timing the Second Trimester Fetal Ultrasound in the Obese Gravida [37P]
Authors: Weatherborn Megan , Leftwich Heidi , McGuinness Bailey , Ogamba Maureen , Leung Katherine
Published: April 2018

INTRODUCTION:

To identify the ideal time to perform the second trimester ultrasound for fetal assessment in the obese patient population we examined the relationship between scan completion rates and advancing gestational age.

METHODS:

This is a retrospective study at a single tertiary care center. Inclusion criteria were pregnant women with BMI ≥30 who had second trimester fetal ultrasound and delivery at our institution. Exclusion criteria were pregnancies without documented BMI, ultrasound not performed between 18 0/6 and 21 6/7 weeks, multiple gestations, or ultrasound performed for indication other than fetal anatomic assessment. Ultrasound reports were incomplete if they indicated suboptimal or non-visualization of any of 30 fetal anatomic structures. Chi square analysis was used to compare rates of completed surveys.

RESULTS:

2,138 records met study criteria. Using 18 weeks as a reference group, the odds of having a complete survey at each gestational age were calculated. At 19 weeks the OR was 1.35 [1.1-1.7, p = 0.001] and at 20 weeks OR 1.37 [1.05-1.8, p = 0.01]. At 21 weeks the difference was no longer statistically significant, OR 1.3 [0.95-1.9]. We found no difference in rates of completed surveys when comparing 19 to 20 weeks, OR 1.015 [0.76-1.34, p = 0.46].

CONCLUSION:

In obese gravidas, the odds of having a complete scan were greatest at 19 and 20 weeks gestational age. Therefore in this population it appears useful to wait until 19 weeks to perform the second trimester fetal ultrasound, but delaying the scan did not further increase the chance of a complete scan.
Factors Associated With Contraceptive Method Choice Among HIV+ Women: A Cross Sectional Study [38P]
Authors: Tote Katherine , Raziano Valerie , Haddad Lisa , Wall Kristin
Published: April 2018

INTRODUCTION:

Effective contraceptive use is crucial for HIV-positive women to prevent unintended pregnancy. We aim to explore the factors influencing contraceptive method choice among HIV-positive women in the US.

METHODS:

HIV-positive women age 18-45 completed a cross-sectional survey and were eligible if they reported recent sexual activity and had not been sterilized. Chi-square tests and multivariable logistic regression were used to assess factors associated with Tier 1/2 efficacy methods (IUDs, implant, ring, pill, and Depo) within the past month compared to Tier 3 (condom, withdrawal) or no method use.

RESULTS:

Of 105 eligible participants, 31(26%) reported usage of efficacy Tier 1/2 methods. Significant factors associated with higher efficacy method use were younger age (unadjusted prevalence odds ratio per year, cPOR .86 95% CI .80-.91), age over 19 at time of HIV diagnosis (cPOR .28 95% CI .08-.57), higher recent CD4 count (>200 cells/µL, cPOR 2.5, 95% CI 1.1-6.0), HIV+ status during prior pregnancy (cPOR 6.3 95% CI 1.4-29.4), and belief that ‘it’s okay to take birth control that stops your period from coming’ (cPOR 2.8 95% CI 1.1-7.1). While knowledge did not differ significantly across efficacy tiers, the study population revealed a general lack of knowledge regarding contraceptive methods and a notable lack of self-efficacy regarding these choices.

CONCLUSION:

The women in this study who chose higher efficacy methods were clinically healthier. This may reflect more attention to care, patient compliance, or more time during HIV visits to address contraception. Improved knowledge about contraceptive methods is needed among HIV+ women.
Incidence and Characteristics of Cervical Cancer in Elderly Women [3Q]
Authors: Lababidi Suzanne , McQuerry Kristen J. , Duan Ran , Johnson Marian Symmes , Fredericks Tricia , Baldwin Lauren
Published: April 2018

INTRODUCTION:

Cervical cancer screening guidelines currently recommend cessation of screening after the age of 65 in the absence of previous dysplasia. Patients over the age of 65 are still susceptible to the disease however. This project aims to describe the incidence of cervical cancer in elderly patients as well as characteristics of their disease.

METHODS:

The American College of Surgeons’ National Cancer Database was queried for cervical cancer patients aged 18-99. Variables collected included age, grade, stage, and histology of the disease. Multivariate regression and Cox proportional hazard models were performed to analyze association between the variables as well as survival data.

RESULTS:

A total of 18,015 patients were included in the analysis. Of the patients included, 21% were over the age of 65. Older age was associated with higher grade and stage of disease at time of diagnosis (P<.0001). Older patients were also noted to do more poorly, with an increased risk of death of 1.3% for every year older a patient was at time of diagnosis (95% CI 1.0%-1.64%).

CONCLUSION:

Cervical cancer is as much a disease of the elderly as it is a disease of the young. It is important for clinicians to remain vigilant when screening for the disease and to obtain a proper history, including previous history of dysplasia, when treating these patients. Older patients diagnosed with the disease have typically more advanced and more aggressive disease than their younger counterparts.
Salmonella Tuboovarian Abscess [4Q]
Authors: Chow Stephanie
Published: April 2018

INTRODUCTION:

Salmonella is an extremely rare cause of tuboovarian abscesses.

METHODS:

Here we report a case of a 33 year old female found to have a ruptured tuboovarian abscess caused by Salmonella.

RESULTS:

After recent travel to South East Asia, our patient presented in septic shock after 1 week of fevers, diarrhea, and abdominal pain. Imaging showed an 11 x 8 cm bilobed cystic, thick-walled lesion in the right adnexa, concerning for a tuboovarian abscess. She underwent computed tomography (CT) guided drain placement resulting in 200 ml of viscous, chocolate-colored fluid aspirated. Despite antibiotics and a drain, she continued to have fevers to 103 F and developed an acute abdomen. Repeat CT revealed interval development of three new abdominal and pelvic abscesses measuring up to 13 cm in greatest dimension. She then underwent a diagnostic laparoscopy, pelvic washout, and ovarian cyst drainage. Both abscess drainage and intraabominal fluid collected from surgery grew out pan-sensitive Salmonella.

CONCLUSION:

Our patient likely had Salmonella enteritis with bacterial translocation to a right ovarian endometrioma, complicated by purulent peritonitis after cyst rupture following drain placement. Women with symptoms of pelvic inflammatory disease and gastroenteritis should be screened for enteric pathogens including Salmonella.
Incidence and Knowledge of Hypoactive Sexual Desire Disorder and Its Treatment: A Survey [6Q]
Authors: Phillips Nancy , Bachmann Gloria A. , Yeung Percy , Lu Chi-Wei
Published: April 2018

INTRODUCTION:

HSDD has been recognized as a sexual disorder since 1950. Low sexual desire is self-reported by approximately 40% of women, with the true disorder present in about 14%. Despite this, studies consistently show women being hesitant to discuss sexual issues with their physicians. Women may feel low desire is a normal result of aging, or are unaware of possible treatment. Treatments for HSDD include identification and treatment of secondary causes, counseling or sex therapy, or most recently, flibanserin, FDA approved in 2015.

METHODS:

An IRB approved survey on HSDD was distributed to women aged 18 and over presenting to a general gynecology practice. The aim of the survey was to gather information on the incidence of decreased sexual desire, knowledge that HSDD was considered a medical diagnosis and assess if women were aware of treatment options.

RESULTS:

One hundred and thirty-three women participated in the survey. 29% reported decreased desire and 50% of these women reported distress, for a 14.5% incidence of HSDD. However, only 22% of respondents were aware that HSDD was a medical condition and only 12% were aware of an FDA approved medication for it.

CONCLUSION:

HSDD, by definition, causes marked personal or interpersonal distress. Yet women are not aware that this is a recognized medical condition. As even less women are aware that treatment options exist, even those who would consider discussing this with their physician may be hesitant to do so. Better education of both patients and physicians will help to better serve this unmet need.
Baseline Burden of Endometriosis-Associated Pain among Women in Two Phase 3 Elagolix Studies [10Q]
Authors: Leyland Nicholas , Surrey Eric , Soliman Ahmed M. , Eichner Samantha , Chen Kun , Snabes Michael
Published: April 2018

INTRODUCTION:

Few data exist on the extent of symptoms in women with endometriosis. This analysis examined baseline pain burden among women with moderate to severe endometriosis pain in two phase 3 studies of elagolix (an oral, non-peptide GnRH antagonist) for the management of endometriosis-associated pain.

METHODS:

Elaris EM-I and Elaris EM-II were two double-blind, randomized, 6-month, placebo-controlled phase 3 studies evaluating two elagolix doses (150 mg once daily and 200 mg twice daily) in women with endometriosis-associated pain. This analysis included randomized women pooled across studies and treatment groups. Dysmenorrhea (DYS) and non-menstrual pelvic pain (NMPP) scores were recorded in a daily electronic-diary and characterized as ‘none’, ‘mild’, ‘moderate’, and ‘severe’, with definitions that incorporated daily functioning. Days with DYS or NMPP and severity of pain are summarized. Baseline was defined as the average of the last 35 days during the screening period.

RESULTS:

At baseline, the mean [SD] number of days women reported DYS and NMPP was 8.0 [3.0] days (97.6% of menstruating days) and 20.5 days [5.4] (90.3% of non-menstruating days), respectively (N=1686 for the combined studies). Enrolled women reported moderate/severe DYS and NMPP most days during the baseline phase (mean [SD]: DYS, 80.5% [21.2] of menstruating days; NMPP, 57% [29.0] of non-menstruating days).

CONCLUSION:

On average in these two phase 3 studies, women with endometriosis-associated pain experienced DYS or NMPP > 90% of days during the baseline phase and moderate/severe pain was reported for a majority of the days when pain was reported.
Obstetric and Gynecological Outcomes in Patients with STAT3-deficient Hyper IgE Syndrome [13Q]
Authors: Chepa-Lotrea Xenia , Urban Amanda , Bergerson Jenna , Weisman Hannah , Stratton Pamela , Freeman Alexandra
Published: April 2018

INTRODUCTION:

Autosomal dominant Hyper IgE syndrome (AD-HIES) is a primary immunodeficiency due to STAT3 mutations, resulting in eczema, recurrent skin and pulmonary infections, and mucocutaneous candidiasis. Little is known of gynecologic-obstetric complications but with improved therapies, women are living longer making reproductive health more pertinent.

METHODS:

We prospectively interviewed and retrospectively reviewed medical records of adult women with AD-HIES evaluated at NIH between 2000-2017.

RESULTS:

Of 60 patients aged 19-66 years (mean 35), 45 women were interviewed, and chart reviews were performed on 15, of whom eight were deceased. 21/60 (35%) reported having regular cervical cytology testing with seven (33%) having abnormal squamous cells of unknown significance (ASCUS). Five women reported vulvar cysts/abscesses requiring drainage. Nine women had IUDs placed, in some to suppress menses-associated vulvar eczema/abscess flares; no infectious complications were reported. Over 30% of women chose not to conceive given underlying disease. Of 16 women with pregnancies, 15 women had 26 live births, 6/16 (38%) had miscarriages, and 3/16 (19%) experienced recurrent pregnancy loss. . Three women whose pulmonary symptoms worsened during pregnancy were diagnosed with progression of parenchymal lung disease post-partum. One woman experienced worsening of skin manifestations. Other reported postpartum complications included one incisional infection (after Caesarean) and one hemorrhage leading to hysterectomy.

CONCLUSION:

As women with AD-HIES are living longer, they elect to have children or prevent pregnancy; knowledge of their reproductive choices and complications can improve their care. While these women may choose to attempt pregnancy, the risk of recurrent pregnancy loss and worsening disease warrants discussion.
The Potential Cost-Effectiveness of Extended Genotyping in US Cervical Cancer Screening Paradigms [14Q]
Authors: Asjes Caitlin , Andrews Jeff
Published: April 2018

INTRODUCTION:

A multitude of factors determine a women’s risk of cervical cancer and also determine the most cost-effective patient management. HPV extended genotyping (XGT) can support patient triage and management via individual risk stratification. It’s important to understand the potential clinical and economic impact of adding XGT into existing screening paradigms.

METHODS:

An Excel-based budget impact model was calibrated for the US population. Disease and genotype-specific prevalence was derived from the BD Onclarity Clinical Trial and published literature. The model compares: Cytology-based screening with ASCUS triage by HPV DNA testing and Co-testing. Each scenario compared a pooled HPV assay and one reporting high-risk genotypes individually. The model follows patients through one screening cycle and compares disease outcomes (CIN2+) and costs.

RESULTS:

The initial results demonstrate the use of XGT has the potential to increase cervical cancer and CIN2+ disease detection. While under certain scenarios there may be a minor increase in colposcopies performed, this analysis shows that by utilizing XGT up to 50% more high-risk genotypes would be referred to colposcopy, with more lower-risk genotypes being deferred to a 1 year follow-up. By this mechanism the model suggests that XGT will increase the colposcopy yield and decrease costs.

CONCLUSION:

Incorporating XGT into the existing screening paradigms could lead to improved patient outcomes and lower costs in the US. While this model only looked at the impact of the first screen, further research is recommended into the impact of XGT on persistence tracking and individualized patient management over time.
Enhanced Recovery Pathway for Minimally Invasive Hysterectomy: Outcomes of a Quality Improvement Initiative [15Q]
Authors: Bozzuto Laura , Mastroyannis Spyridon A. , Salva Catherine , Haggerty Ashley
Published: April 2018

INTRODUCTION:

Enhanced recovery after surgery (ERAS) pathways have decreased postoperative pain and shortened hospital stays. This quality improvement project at a tertiary care academic medical center sought to implement an ERAS pathway for patients undergoing minimally invasive hysterectomy (MIH) for benign indications and evaluate perioperative outcomes.

METHODS:

Consecutive patients managed under an ERAS protocol (implemented June 1, 2016) undergoing MIH for benign indications from August 1-October 31, 2016 were compared to consecutive historical controls (August-October 2015). Demographic, operative, and clinical information was abstracted. Descriptive statistics and bivariate analyses were performed.

RESULTS:

There were 41 procedures performed by 15 surgeons pre-ERAS intervention and 47 performed by 18 surgeons post-ERAS implementation. There was no statistical difference between the groups by age, race, insurance status, ASA class, or BMI. After ERAS implementation, the percentage of patients discharged by noon increased (14.6 to 36.2%, P= .022) with a significant difference in length of stay (P=.029). The use of patient controlled analgesia (PCA) decreased from 51.2 to 10.6% (P<.001). Postoperative narcotic use decreased significantly with a reduction in intravenous oral morphine equivalents (OME) from a median of 5mg (SD 0-25mg) to 0mg (SD 0-4 mg) [P<.001] and in median total OME from 45mg (SD 25-128.5mg) to 24mg (SD 5-48mg) [P<.001]. There was no significant change in postoperative complications or readmissions.

CONCLUSION:

An ERAS pathway quality improvement initiative for benign MIH can be effectively implemented at a large academic center. Our quality improvement program resulted in improved postoperative recovery outcomes and a significant reduction in post-operative narcotic usage.
Congenital Cervical and Vaginal Malformations: Lessons from 42 cases Managed Clinically by a Common Protocol [28Q]
Authors: Pan Hongxin , Luo Guangnan
Published: April 2018

INTRODUCTION:

To outline the anatomic variations and the clinical management of congenital cervical and vaginal malformations in a cohort of 42 patients in China.

METHODS:

From January 2008 to January 2017, a total of 42 patients with congenital cervical and vaginal malformations were treated in the department of Gynecology at the 3rd affiliated hospital of Shenzhen University (China). Clinical examinations, magnetic resonance imaging, hormonal profile and laparoscopy were collected. All surgical findings were carefully reviewed to determine the anatomic characteristics of the cervical and vaginal malformations.

RESULTS:

The mean age at the time of symptom onset was 12.8±1.9 years (range 9-17). The mean time from symptom onset to surgery was 3.4±0.9 years (range 0.1-14). Among the 38 patients, (90.5%) had pelvic endometriosis. Among the 38 patients with pelvic endometriosis, 20 patients had ovarian endometrial cysts. Endometriosis was staged as minimal-mild in 21 and as moderate-severe in 17. Of the 42 patients, 5 underwent hysterectomy during their first surgery and 37 received cervical reconstruction surgery. Among these 37 patients, 25 underwent Luohu III procedure (peritoneal vaginoplasty, trachelectomy and uterus-neovagina anastomosis), 12 underwent Luohu IV procedure (laparoscopic vaginal section and peritoneal vaginoplasty). Of the 37 patients with a preserved uterus, 2 attempted pregnancy up to day, and one woman achieved a successful pregnancy but experienced premature delivery.

CONCLUSION:

Our study found that cervical and vaginal malformations might be successfully treated by uterovaginal anastomosis under laparoscopy. With appropriate evaluation and individualized management, we believe that a successful treatment and pregnancy outcome might be achieved.
Postoperative Opioid Utilization Following Benign Gynecological Surgery [31Q]
Authors: Movilla Peter , Kokroko Jolene , Kotlyar Amalia , Rowen Tami
Published: April 2018

INTRODUCTION:

There is increasing concern for opioid over-prescribing patterns, with nearly quadrupling of the number of opioid prescriptions in the United States since 1999. There are no guidelines for directing the opioid prescription patterns following benign gynecological surgery.

METHODS:

We are conducting a prospective study assessing postoperative pain prescriptions and medication usage via telephone survey.

RESULTS:

Our preliminary results show that 54 patients underwent a benign gynecological surgery at the University of California San Francisco from August to September 2017. 45 (83.3%) patient's received an opioid prescription. 15 (27.8%) were hysteroscopy procedures, 31 (57.4%) laparoscopy, 5 (9.3%) laparotomy, and 3 (5.6%) categorized as others. On average 41.7 morphine milligram equivalents (MME) of opioids were prescribed following hysteroscopy, 176.0 MME following laparoscopy, 260.0 MME following laparotomy, and 83.3 MME following others. 33 (61.1%) patients completed the telephone survey. On average 25.6 MME of opioids were not utilized by postoperative day seven following hysteroscopy, 116.6 MME following laparoscopy, 298.1 MME following laparotomy, and 29.1 MME following others. 26 patients completed the telephone survey and utilized opioids. 46.2% would keep excess opioids for future use. 23.1% would dispose of excess opioids.

CONCLUSION:

Opioid analgesics are a major component of current gynecological postoperative pain management. On average patients receive in excess an equivalent of 15.5 tablets of 5mg oxycodone following laparoscopic surgery not utilized by postoperative day seven. A majority of patients are keeping excess opioids for utilization outside of their intended purpose. Data collection is ongoing and estimate an additional 100 patients for the completed study.
Impact of BMI on Pelvic Inflammatory Disease [32Q]
Authors: Ashrafian Sogol , Uyar Denise
Published: April 2018

INTRODUCTION:

Tubo-ovarian abscess (TOA) is a serious complication of pelvic inflammatory disease (PID) reported in 34% of patients. Obesity is a concern among women of all ages and has been shown to adversely affect healthcare outcomes. We compared PID infections in women with BMI > 30 and < 30 admitted for the treatment of PID to determine how obesity impacts PID.

METHODS:

A retrospective study was performed on patients admitted with PID (ages 18-40) between January 2010 and July 2017. Patients were stratified into BMI ≥30 vs. BMI <30. Data reviewed included diagnosis, past medical history, length of stay, readmissions and procedural interventions.

RESULTS:

72 patients met inclusion criteria. Thirty-eight patients had BMI > 30 and 34 patients had a BMI < 30. Women with a BMI > 30 had a higher incidence of TOA (65.8% v. 38.2%); greater number of procedures (50% v. 14.7%) and a greater length of hospital stay (6.9 ± 5.1 v. 4.0 ± 1.9). Patients with BMI > 30 were less likely to use tobacco (28.9% v. 41.2%), less likely to be readmitted (15% vs 50%) and more likely to be diabetic (26.3% v. 2.9%).

CONCLUSION:

BMI > 30 was associated with greater morbidity demonstrated by more severe PID infections with a greater incidence of TOAs, need for more invasive interventions and longer length of hospital stay. In women with BMI > 30, TOA was diagnosed twice as often than reported in the literature. Elevated BMI may be an additional risk factor to consider when treating women with PID.
Clarity for Improving Standardized Obstetrician-Neonatologist Neonatal Handoffs [33Q]
Authors: Dunnington Helen , Lake Natasha , Iniguez Suzanne , Baruah Isa
Published: April 2018

INTRODUCTION:

There are currently no standardized methods of handoff between Labor & Delivery (L&D) and Neonatology teams for neonatology-attended deliveries. Communication breakdown occurs in approximately 70% of sentinel events resulting in perinatal mortality or permanent disability. Barriers to effective patient handoffs include confusion over role clarity, transferring unnecessary information, time constraints, and room volume. Standard communication in the delivery room could reduce communication variability and promote safer care. Our goal was to evaluate if standardized handoffs between the L&D and Neonatology teams in unplanned neonatology-attended cesarean deliveries would result in more complete and efficient transfer of critical patient information.

METHODS:

Members of the L&D and Neonatology teams were surveyed to determine critical areas of patient handoff in neonatology attended cesarean deliveries. Survey results were utilized to determine areas that required change for subsequent Plan-Do-Study-Act worksheets. Reliability of the process was assessed by Neonatology response respiratory therapists who submitted a separate observational survey.

RESULTS:

Over a 3 month period, 38 deliveries were assessed. The following transfer of critical information was identified: Obstetrician to Neonatologist - gestational age, single versus multiple gestation, presence of meconium, fetal heart rate abnormalities, fetal anomalies, and reason for the call. Whereas Neonatologist to Obstetrician - APGAR score, gender, birth weight, resuscitative measures, and disposition of infant. Both the L&D and Neonatology teams reported that a streamlined handoff process improved workflow and team satisfaction (15 and 16% positive increase, respectively).

CONCLUSION:

Standardization of handoffs and role identification improve communication of critical information between L&D and Neonatology teams.
Outcomes in Trial of Labor after Cesarean Section in Twin Pregnancies [36Q]
Authors: Walker Allison R. , Skeith Ashley E. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

We sought to compare delivery and neonatal outcomes in twin pregnancies undergoing a trial of labor after cesarean section (TOLAC).

METHODS:

This retrospective cohort included 2,013 pregnancies undergoing a TOLAC and compared outcomes of cesarean section (CS) versus vaginal birth after cesarean section (VBAC). Delivery outcomes included unplanned hysterectomy, Apgar score <7 at 5 minutes, NICU admission, transfusion, and assisted ventilation >6 hours. Multivariate regression analyses and chi-squared test were used for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance. Age, race, BMI, education, and insurance status were controlled for.

RESULTS:

VBACs were associated with Apgar scores <7 at 5 minutes (OR 3.21; 95% CI 2.31-4.47) and lower NICU admission rate (OR 0.75; 95% CI 0.62-0.90). Unplanned hysterectomy, transfusion, and assisted ventilation >6 hours were not statically significant.

CONCLUSION:

VBACs were associated with a lower Apgar scores and fewer NICU admissions than CS in twin pregnancies undergoing TOLAC.
Office versus Operating Room Hysteroscopy: A Comparison of Outcomes and Resource Utilization [3R]
Authors: Dilday Elizabeth A. , Shields Jessica K. , Kho Kimberly A.
Published: April 2018

INTRODUCTION:

Parkland Hospital Gynecology Clinic initiated office hysteroscopy while continuing hysteroscopy in the operating room (OR). This study compares utilization of resources between office and OR cases.

METHODS:

Retrospective chart review of hysteroscopies from April 1, 2016 to March 31, 2017 in the OR, Ambulatory Surgery Center (ASC) and Gynecology Clinic. Data regarding preoperative evaluation, operative details and time spent the day of the procedure was collected.

RESULTS:-

Patients undergoing procedures in the office and OR were similar with median age 44 SD ±11.0 vs 46 SD ±11.1 years (p=0.92) and BMI of 30.7 SD ±7.6 vs BMI of 34.4 SD ±9.0 kg/m2 (p=0.82). -75 (24.6%) office and 230 (75.4%) OR hysteroscopies were performed -Indications for office procedures were: 33 (44%) suspected polyp, 23 (30.7%) IUD related, 7 (9.3%) postmenopausal bleeding, and 6 (8%) intracavitary mass. Indications for OR were: 65 (28.4%) suspected polyp, 36 (15.7%) hyperplasia, 29 (12.7%) abnormal uterine bleeding and 24 (10.5%) IUD related -34.6% of office procedures required OR hysteroscopy for: 9 (40.9%) large polyp, 5 (22.7%) pain, 9 (22.7%) cervical stenosis, and 3 (13.6%) fibroid found. There were 3 (1.11%) complications in the OR and 0 (0%) in the office (p=0.32). Patients undergoing office procedures spent 153 minutes (SD ±57 minutes) in clinic compared to 337 minutes (SD ±168 minutes) for OR (p=0.02). Prior to hysteroscopy, patients undergoing office hysteroscopy required 1.01±1.17 studies vs 3.12±6.12 studies (p=0.003).

CONCLUSION:

When comparing hysteroscopies in the office versus the OR, demographics and indications were similar. In-office cases involved significantly less time from patients and superior utilization of resources.
Case Report: Management in a 25-year-old with Severe Erosive Vulvovaginal Lichen Planus [6R]
Authors: Syed Fatima , Vyas Anuja
Published: April 2018

INTRODUCTION:

Erosive lichen planus (ELP) is a rare inflammatory dermatologic condition characterized by scarring and adhesions. ELP can involve female genitalia causing vulvar anatomic distortion and vaginal stenosis. Topical corticosteroids or calcineurin inhibitors are the mainstay of medical therapy. Vaginal adhesions and scarring can be managed with intravaginal steroids, dilators and surgical release.

METHODS:

Chart review; Literature review

RESULTS:

We present a 25-year-old Caucasian G0 with oral-vulvo-vaginal ELP. At time of presentation she had severe vaginal adhesive disease and was unable to have intercourse. The patient underwent surgical genital lysis of adhesions after which she was able to conceive and deliver a term neonate. Patient maintained vaginal patency in the puerperal period with topical corticosteroids, intravaginal corticosteroids and dilators.

CONCLUSION:

With aggressive surgical and medical management and continued close surveillance, patients with ELP affecting the vulva and vagina can have significantly improved quality of life and successfully deliver term pregnancies.
Demographic Factors Associated with Opioid Use Following Laparoscopic or Robotic Hysterectomy [8R]
Authors: Cohen Michael , Weston Erica , Raker Christina , Huang David , Mathews Cara
Published: April 2018

INTRODUCTION:

The number of opioid-related deaths has quadrupled in the United States since 1999, and the opioid crisis is well-defined. The purpose of this study is to identify demographic predictors of increased inpatient and post-discharge opioid use in order to tailor postoperative opioid dispensation.

METHODS:

This study is a secondary analysis of a prospective cohort designed to correlate mindfulness with post-operative pain in patients undergoing laparoscopic or robotic hysterectomy by a gynecologic oncologist at a single institution. Inpatient opioid use was measured via chart review and outpatient use via surveys at 1-2 week and 4-6 week post-operative visits and via pharmacy records. Demographic information was measured via chart review and pre-operative surveys. Descriptive statistics and correlation were used to determine associations.

RESULTS:

Mean age (n=126) was 60.4 (SD 11.66) and mean BMI was 33.6 (SD 9.35). Additionally, 54% of subjects had private insurance, 20% had Medicaid products, and 25.6% had Medicare. 85% of subjects were referred from a private OBGYN office. Younger patients used significantly more opioids inpatient and outpatient based on total milligram morphine equivalents (MME) (p=0.0003 inpatient, p=0.045 outpatient) and total number of doses (p=0.001 inpatient; p=0.048 outpatient). Insurance source trended with post-discharge MMEs used, with Medicaid patients using more, but this correlation was not statistically significant (p=0.13). BMI, race, insurance status, referral source, and comorbidities did not predict post-operative opioid use.

CONCLUSION:

Older patient use fewer opioids and this population may be a target for smaller postoperative prescriptions to reduce unused opioids. This warrants further study in other populations.