bluuebunny/crossref_metadata_2025 huggingface dataset:
Where Does the Time Go? Understanding What Delays Emergent Gynecologic Surgical Management from the ED to the OR [4F]
Authors: Gray Derwin , Mehta-Lee Shilpi S. , Echevarria Ghislaine , Schweizer William E.
Published: May 2019

INTRODUCTION:

Women who present to the emergency department (ED) for gynecologic issues at our institution undergo multiple evaluative steps. We sought to understand how these steps delay indicated operative management. Time spent at each stage of an ED visit for an acute surgical presentation was investigated as part of a quality improvement project for NYU Langone Health.

METHODS:

This retrospective, observational study quantifies time spent by patients at each evaluative stage from presentation to operating room incision time. We included females 18 years or older, presenting to the NYU Tisch Hospital ED with acute gynecologic complaints requiring surgery. Gynecology consult records from 9/1/16 to 8/29/17 were reviewed and surgical cases were identified. We defined five relevant time points for each patient: 1--initial presentation, 2--ED provider evaluation, 3--Gynecology consult, 4--time of imaging, and 5--surgical start time. We recorded time in hours, between the above evaluations.

RESULTS:

Of 1194 consults reviewed, 79 patients required urgent surgery for benign etiologies (eg, adnexal torsion, ruptured ectopic pregnancy or heavy vaginal bleeding). The median time spent from presentation to incision was 6.1 (IQR: 4.12-8.53) hours. The median time from presentation to finalization of imaging and from gynecology evaluation to incision were 0.78 (IQR: 0.35-1.4) and 3.3 (IQR: 1.6-5.4) hours, respectively.

CONCLUSION:

This information implies that throughout an evaluation for urgent gynecologic surgery, more than 50% of the time is spent after the decision has been made to operate. Further study of this time frame may ultimately improve bed utilization and reduce delays.
Does Resection of a Uterine Septum Improve Pregnancy Outcomes? [13F]
Authors: Connolly Courtney T. , Hill Melissa B. , Klahr Rebecca A. , Zafman Kelly B. , Rebarber Andrei , Fox Nathan S.
Published: May 2019

INTRODUCTION:

It is unknown if uterine septum resection improves pregnancy outcomes beyond early pregnancy loss. Our objective was to compare pregnancy outcomes between women with a septum and those who had septum resection prior to pregnancy.

METHODS:

Retrospective cohort study of women with a uterine septum cared for by a large maternal-fetal medicine practice from 2005 to 2018. We identified all women with singleton pregnancies and a septum or history of septum resection. Baseline characteristics and pregnancy outcomes were compared. Nonparametric testing was used for analysis, and regression analysis was performed to control for differences in baseline characteristics. IRB approval was obtained.

RESULTS:

148 women were included, 40 with an intact septum and 108 who had a septum resected. Women with a resected septum were older (33.5 vs. 30.4 years, p=0.006) and more likely to have undergone IVF (25.0% vs. 2.5%, p=0.002). Pregnancy outcomes did not differ between the groups. Although there was a higher rate of cesarean delivery in the resected septum group (42.6% vs. 20.0%, p=0.013), this was not true among women who attempted vaginal delivery. The difference in cesarean rates also likely explains the differences in estimated blood loss. There was no difference in the likelihood of retained or morbidly adherent placenta.

CONCLUSION:

Resection of a uterine septum prior to pregnancy is not associated with improved pregnancy outcomes compared to women with a septum. Septum resection should only be considered for the indication of early pregnancy losses. Further studies in larger cohorts could examine septum size as a potential confounding variable.
Adherence to New Definitions of Labor Arrest and Failed Induction Decreases Primary Cesareans [16F]
Authors: Greenberg Jessica , Cross Sarah Newbold , Pettker Christian Michael , Lee Illuzzi Jessica
Published: May 2019

INTRODUCTION:

To examine the use of cesarean delivery over time for labor arrest and failed induction and identify predictors of meeting criteria for these indications.

METHODS:

We analyzed rates of primary cesareans due to arrest of dilation, arrest of descent and failed induction among live births at Yale New Haven Hospital from 2010 through 2013. Criteria for labor arrest and failed induction were based on 2012 guidelines, and the proportions of deliveries meeting these criteria were calculated annually. Multiple logistic regression was used to assess cesarean delivery over time and identify predictors of meeting criteria. IRB approval was obtained.

RESULTS:

The total primary cesarean delivery rate decreased from 23.5% to 21.1% (<.03). The rate of primary cesarean delivery for arrest of dilation decreased from 5.1% to 3.4% (P<.0005), while the rate of meeting criteria for this indication increased from 18.8% to 34.9% (P<.003). Primary cesarean delivery for arrest of descent and failed induction remained stable; the percent of cases meeting criteria for arrest of descent increased from 57.8% to 71.0% (P<.007). Increased cervical dilation on admission increased the likelihood of meeting criteria for arrest of dilation and descent, and epidural use decreased the likelihood of meeting criteria for arrest of descent. As of 2013, 65.1% of primary cesareans for arrest of dilation, 29.0% for arrest of descent, and 50.0% for failed induction did not meet criteria.

CONCLUSION:

A decrease in the primary cesarean rate was associated with meeting new criteria for labor arrest. Increased adherence to these criteria could further reduce the cesarean rate.
Chronic Histiocytic Intervillositis: A Proposed Algorithm for Management of Subsequent Pregnancies [18F]
Authors: D'Souza Rohan D. , Zaffar Nusrat , Syeda Ambreen , Keating Sarah , Koby Lawrence , Malinowski Ann Kinga
Published: May 2019

INTRODUCTION:

Chronic histiocytic intervillositis (CHI) of the placenta is associated with serious adverse pregnancy outcomes not only in the index pregnancy but also in subsequent pregnancies. This study's aim was to propose an algorithm for the management of pregnancies following a histopathologic diagnosis of CHI.

METHODS:

We conducted a retrospective cohort study at a tertiary-level hospital that included CHI cases and controls matched by age, ethnicity, body mass index and pre-existing medical comorbidities, in a 1:2 ratio. We compared first- and second-trimester biomarkers for fetal aneuploidy, serum alkaline phosphatase (ALKP) and antenatal ultrasound findings, considering a p-value of <0.05 as statistically significant.

RESULTS:

We included 33 cases of CHI and 66 matched controls. The two groups were comparable except with regard to prior (92.6% vs. 43.3%, p<0.001) and current (87.9% vs. 42.2%, p<0.001) adverse obstetric outcomes. There were significant differences between groups in terms of abnormal first-trimester biomarkers in general (55.6% vs. 16.2%, p=0.003), and PAPP-A in particular (46.7% vs. 7.1%, p=0.005), second-trimester alpha-fetoprotein (25% vs. 0%, p=0.006), third-trimester ALKP levels (38.5% vs. 0%, p=0.045); second-trimester placental ultrasound findings (abnormal dimensions in 40% vs. 5.6%, p=0.02 and abnormal echotexture in 25% vs. 0%, p=0.047); third-trimester placental morphology (44% vs. 16.7%, p=0.009), umbilical artery Doppler studies (76% vs. 11.1%, p<0.001) and oligohydramnios (40% vs. 3.7%, p<0.001).

CONCLUSION:

The differences in biomarker and ultrasound findings between cases and controls was used to propose an algorithm for management of subsequent pregnancies, in terms of maternal and fetal surveillance, administration of antenatal corticosteroids and timing of delivery.
Emergency Department Usage Prior to Pregnancy is Associated With Use Postpartum [30F]
Authors: Williams Nayo Shepard , De La Guerra Justin , Borgida Adam F.
Published: May 2019

INTRODUCTION:

Improvement of care during the 90 days postpartum (“4th trimester”) is needed. Fifty percent of women return for their postpartum office visit; 10% use the emergency department (ED). We evaluated what factors might be associated with postpartum ED usage

METHODS:

This retrospective cohort study from an urban hospital-based clinic compared women who visited the ED within 90 days postpartum (Group 1) to women who did not visit the ED (Group 2). Variables assessed: age, marital status, race, delivery gestational age, parity, ED visits during the year prior to conception. We performed regression analysis to determine independent variables associated with ED usage 90 days postpartum. A P<.05 was significant. IRB approval was obtained for this study.

RESULTS:

Of 1297 women, there were 190 (14.8%) in Group 1. This group visited the ED 252 times (48.0% for non-emergent diagnoses). Three variables were significant. Group 1 women with cesareans (OR 1.77, 95% CI 1.29-2.42), women who visited the ED in the year prior to conception (OR 2.00, 95% CI 1.45-2.75) and frequent (≥3 visits/year) ED users (OR 2.94, 95% CI 1.84-4.62) were more likely to visit the ED in the 4th trimester versus Group 2.

CONCLUSION:

We found that women who visit the ED and were frequent users prior to pregnancy are more likely to continue that usage during the postpartum. Understanding risk factors for maternal ED usage is important as initiatives and care plans are developed during pregnancy for preemptive education and postpartum care.
Impact of an Integrated, Comprehensive Perinatal Substance Use Disorders Program for an At-Risk, Rural Population [34F]
Authors: Nathan Alyssa , Galvin Shelley , Coulson Carol Catherine , Ramage Melinda , Mullins Nathan Herman , Gannon Marie
Published: May 2019

INTRODUCTION:

The perinatal substance use disorders (PSUDS) program in Western North Carolina (WNC) began in 2014 and expanded into an integrated, comprehensive program utilizing the stages of change model. The program offers access to behavioral health, social services, and substance use treatment within enhanced obstetrical care visits. Our objective was to compare antenatal care utilization and obstetrical outcomes, through the fourth trimester, over time.

METHODS:

An IRB-approved, retrospective cohort study compared outcomes from 2014 and 2017. Primary outcomes included engagement in: antenatal care, behavioral health, and substance use treatment. Maternal socio-demographics, concurrent diagnoses, and birth outcomes were examined. Comparisons utilized Chi square or Fisher exact and Mann-Whitney or t-tests for categorical and continuous variables, respectively.

RESULTS:

The proportion of patients attending ACOG-based, expected number of prenatal visits increased 25.3% (P=.016). The 14.7% increase in postpartum attendance was not significant. Utilization of in-house substance misuse therapy increased 800% (P<.001); external referral uptake increased 1290% (P<.001). Utilization of pharmacotherapy increased 61% (P=.003) for psychological disorders and 34% (P=.005) for opioid use disorders. Prevalence of illicit drugs on maternal urine drug screen at delivery decreased from 67% to 43% (P<.001). Preterm delivery, cesareans and birthweight remained stable (P>.05).

CONCLUSION:

The implementation of a full spectrum PSUDS model of care improved maternal engagement across obstetrical care, behavioral health and substance misuse treatment; fewer babies were exposed in utero to harmful illicit drugs. Further research examining outcomes of WNC's PSUDS is ongoing; improvements in access and engagement in care by pregnant women with substance use disorders are encouraging.
From “Disappointing” to “Fantastic”: Patient Experiences With Labor Induction [02OP]
Authors: Danilack Valery A. , Siegel-Reamer Leah , Varela Natacha , Brousseau Erin Christine , Guthrie Kate M.
Published: May 2019

INTRODUCTION:

While over 20% of deliveries in the U.S. involve labor induction, there is a dearth of evidence regarding patient perceptions of their experiences and preferences about the process of care. We conducted postpartum qualitative interviews to elucidate women's expectations and experiences of the labor induction process.

METHODS:

We recruited women who underwent labor induction during their most recent delivery from our hospital's postpartum ward, aiming to enroll equal numbers with vaginal and cesarean deliveries. We conducted semi-structured qualitative interviews within two months of delivery. Research questions included expectations and lived experiences of the labor induction process, side effects and health outcomes of concern, reflections on personal tolerance of different interventions, and thoughts about an ideal process.

RESULTS:

From April-September 2018, we interviewed 36 women; 18 with a vaginal delivery and 18 with a cesarean delivery. The labor induction process involved a wide range of experiences, from unexpected, exhausting, stressful, overwhelming, and frustrating, to fast, smooth, and simple. Preliminary data show that women often perceived their induction to be longer than they expected. The medical intervention with the most adverse opinions was the Foley balloon catheter. Women's concerns regarding side effects and the need for intrapartum cesarean delivery largely centered on the health of their baby.

CONCLUSION:

Women's experiences with the overall process of labor induction, as well as specific medical interventions, influence their perceptions of quality of care during labor and delivery. Patient education, management of expectations, and shared decision-making throughout the process may improve patient experience and satisfaction.
Effects of Maternal Psychological Status Post Cancer Diagnosis in Pregnancy on Early Childhood Development [17OP]
Authors: Betchen Melanie , Gringlas Marcy , Grunberg Victoria , Cardonick Elyce
Published: May 2019

INTRODUCTION:

Approximately 1 in 1,000 women experience cancer during pregnancy. Evidence indicates that maternal psychological distress can negatively influence a child's language and cognitive development. This study looks at the relationship between child behavior and development and maternal psychological distress among women experiencing cancer during pregnancy.

METHODS:

Women (N=77) who experienced cancer during their pregnancies and enrolled in the IRB approved Cancer and Pregnancy Registry were invited to self-report psychological distress (Basic Symptoms Inventory) and trauma symptoms (Impact of Events Scale-Revised) when their child was at least 18 months of age. Women completed child behavioral functioning (Child Behavioral Checklist). Children underwent developmental testing (Bayley Scales of Infant and Toddler Development Third Edition). Bivariate correlations examined how maternal psychological distress and infant behavior and development were related at the time of assessment.

RESULTS:

When controlling for gestational age at birth, higher levels of maternal depression (r=0.771, P<0.05), anxiety (r=0.904, P<0.01), intrusive trauma symptoms (r=0.953, P<0.001), and avoidant trauma symptoms (r=0.953, P<0.001) was associated with a higher incidence of behavioral problems. This same relationship was not found for cognitive performance on standardized testing.

CONCLUSION:

Maternal psychological stress and depression after cancer during pregnancy can influence their children's development. When controlling for gestational age at birth, maternal distress only influences child behavioral, as opposed to cognitive development. These results highlight the importance of additional support required among women diagnosed with cancer during pregnancy even years after delivery.
Laterality of Single Umbilical Arteries and Associated Fetal Anomalies [05OP]
Authors: Uribe Katelyn A. , Eke Ahizechukwu C. , Witter Frank R.
Published: May 2019

INTRODUCTION:

Studies have suggested that single umbilical artery (SUA) is associated with adverse obstetric outcomes including growth abnormalities and congenital anomalies. The objective of this study was to determine if laterality of a single umbilical artery (SUA) is associated with specific sonographic findings or other abnormalities.

METHODS:

In this retrospective cohort study, medical records of patients who received an ultrasound at the Johns Hopkins Hospital with identified laterality of the SUA from 1990 to 2017 were reviewed after IRB approval. The primary outcome was the association of isolated left or right SUA with other congenital anomalies. Secondary outcomes included laterality association with intrauterine growth restriction (IUGR) and chromosomal abnormalities. Rates of sonographic abnormalities between fetuses with a right versus left SUA were compared. Multivariate marginal logistic and Poisson regression models were used to investigate the relationship between SUA and IUGR, adjusting for possible confounders. Further analyses were done using propensity score matching.

RESULTS:

Left SUA fetuses had a higher percentage of other fetal abnormalities (51.1% vs. 37.0%; P=0.04). In a multivariate marginal logistic regression analysis, a sonographic left SUA was significantly associated with cardiovascular (aOR 0.43, 95% CI 0.23-0.79; P=0.03) and gastrointestinal (aOR 0.43, 95% CI 0.23-0.79; P=0.03) abnormalities. No other ultrasonographic, doppler, or chromosomal abnormalities were significantly associated with a laterality of the umbilical artery.

CONCLUSION:

Our study identified a significant association between a left SUA and concomitant fetal cardiac and gastrointestinal abnormalities. Laterality of the SUA may be useful in identifying concomitant fetal anomalies, but requires further prospective validation.
FIRST PLACE Heparin Use is Associated With an Increased No-Call Rate of Cell-Free DNA Testing [22OP]
Authors: Lovell Daniel , Nitsche Joshua
Published: May 2019

INTRODUCTION:

To determine if the no-call rate for cell-free DNA testing is higher in pregnant women with hypertension, diabetes, or those taking aspirin and/or heparin.

METHODS:

This IRB approved, retrospective cohort study included 1395 patients with cell-free DNA testing performed between 2014-2018. Weight, gestational age at collection, cell-free DNA platform, parity, presence/absence of chronic hypertension, pre-gestational diabetes, or autoimmune disease, and use of heparin, aspirin, or immune modulating drugs, was gathered for each patient. Univariate and multivariate logistic regressions were performed to determine if chronic hypertension, pre-gestational diabetes, and use of heparin and/or aspirin affected the no-call rate.

RESULTS:

In the univariate analyses there was a significant increase in the odds of a no-call for chronic hypertension, pre-gestational diabetes, and heparin and/or aspirin use. The unadjusted odds ratios (OR) and 95% confidence intervals were 6.1 (3.3-11.1), 3.3 (1.5-7.3), and 13.9 (7.6-25.2), respectively. After adjustment for confounding factors including weight, gestational age at collection, cell-free DNA platform, autoimmune disease, and use of immune modulating drugs, only heparin and/or aspirin use remained a significant predictor of a no-call. The adjusted ORs were 1.5 (0.7-3.3), 0.7 (0.3-1.8), and 6.1 (3.0-12.6), for chronic hypertension, pre-gestational diabetes, and heparin and/or aspirin use, respectively.

CONCLUSION:

On multivariate analysis heparin and/or aspirin use increased the odds of a no-call following cell-free DNA testing. Based on this result, clinicians should consider other genetic testing options in patients taking heparin and/or aspirin, especially those with other conditions known to decrease cell-free DNA level.
Management of Postpartum Hemorrhage: Transfusion of Blood Products [24OP]
Authors: Menzies Anya V. , Poljak Dijana , Pearl Michael Loran , Gossner Gabrielle , Griffin Todd R. , Burke William M.
Published: May 2019

INTRODUCTION:

Postpartum hemorrhage causes significant maternal morbidity and mortality. Coordinated care and adherence to standard protocol in these events may improve patient outcomes. Few studies of the obstetric population focus on appropriate transfusion of blood products. Studies in the trauma and anesthesia literature recommend a 1:1:1 transfusion protocol. Adherence to these recommendations among labor and delivery units nationwide remains unclear.

METHODS:

After IRB approval was obtained, we conducted a retrospective analysis examining all pregnant patients greater than 23 weeks gestation who delivered between 2011-2017 and received transfusion of at least 4 units of packed red blood cells (PRBCs) at our institution. Patients were identified by blood bank transfusion records. Data was collected regarding patient demographics, labor course, hemorrhage event and management, postpartum course, and associated complications. Each case was analyzed for adherence to a transfusion protocol.

RESULTS:

There were 23,964 deliveries during the study period. 90 (0.38%) patients who received at least four units PRBCs were identified. The median total EBL was 2800 ml (450ml-9,000ml). The median units transfused were: PRBCs 4.0 (4-22), fresh frozen plasma 2.0 (0-17), platelets 0 (0-7). None of the patients received a transfusion of products in a 1:1:1 ratio. Of the 90 studied patients, 24 (26.7%) required admission to the intensive care unit.

CONCLUSION:

Obstetrical hemorrhage is a rare but serious event. From review of the data, adherence to standardized use of a transfusion protocol at this institution is rare. In order to diminish maternal mortality, utilization of a hemorrhage protocol with a transfusion ratio should be encouraged.
Maternal and Fetal Outcomes in Pregnancies with Long-term Corticosteroid Use: Retrospective Cohort Study [13OP]
Authors: Cai Emmy , Czuzoj-Shulman Nicholas , Abenhaim Haim Arie
Published: May 2019

INTRODUCTION:

Long-term corticosteroids is administered in pregnant patients with an array of autoimmune and inflammatory disorders. Our objective is to determine whether long-term corticosteroid use is associated with increased maternal and neonatal adverse outcomes.

METHODS:

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project - National Inpatient Sample from the United States. All pregnant patients on long-term corticosteroids were identified using International Statistical Classification of Disease-9 coding from 2003 to 2015. The effect of long-term corticosteroid use on maternal and neonatal outcomes was evaluated using logistic regression.

RESULTS:

Out of the 10,491,798 births included in our study, 3,999 were on chronic steroids, for an overall prevalence of 38 per 100,000 births. There was a steady increase in chronic steroid use from 2 to 81 per 100,000 births over the 12-year study period (P<.0001). Women on chronic steroids were more likely to have pregnancies complicated by gestational diabetes mellitus, 1.61 (1.46-1.79) and preeclampsia, 2.50 (2.26-2.77). They were also more likely to have caesarean sections, 1.73 (1.62-1.84), premature preterm rupture of membranes, 2.29 (2.06-2.54), sepsis, 1.77 (0.66-4.73), venous thromboembolisms, 5.25 (4.12-6.69) and uterine rupture, 3.39 (2.10-5.46). Neonates born from mothers on chronic steroids were more likely to suffer from prematurity, 3.02 (2.79-3.28) and congenital malformations, 2.42 (1.88-3.12).

CONCLUSION:

Long-term corticosteroids use in pregnancy is associated with maternal and fetal adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy to minimize complications.
Reducing Postpartum Opioid Use Following Cesarean Delivery: The Impact of an Opioid-Sparing Protocol [11T]
Authors: Peahl Alex Friedman , Harvey Steve , Bradley Andrew , Smith Roger
Published: May 2019

INTRODUCTION:

Opioid persistence following Cesarean Delivery (CD) is estimated at 1/300 women. Receipt of an opioid prescription and size of the prescription are risk factors for persistence. Opioid-sparing protocols for CD could reduce opioid use during and beyond the postoperative period. Interventions to date have targeted individual patient characteristics rather than hospital-wide protocols.

METHODS:

A single academic institution designed an opioid-sparing protocol for post-Cesarean patients, which was implemented in October 2017. Omnicell automated dispensing data was used to assess the protocol's impact on patterns of non-narcotic and narcotic pain medication use before and after implementation. Patient assessment of pain control was queried through the Press Ganey survey. Descriptive statistics and paired t-tests were used for analysis.

RESULTS:

Women undergoing Cesarean Section between July 2017 and September 2018 were included in the analysis. Patients received more scheduled non-narcotic medications after protocol implementation: acetaminophen (43.3%, 85.5% p=0.005), ketorolac (27.4%, 80.4% p=0.01), and ibuprofen (1.83%, 81.9% p=0.001). Unscheduled oxycodone was prescribed with the same frequency before and after implementation (85.4%, 86.1%, p=0.793). Administration of unscheduled oxycodone doses decreased from 60.45% to 13.28%, with a decrease in morphine milligram equivalents per patient from 25.5 to 10.0. Patient satisfaction remained unchanged over protocol implementation based on patient response to the Press Ganey question “my pain was well controlled during my hospitalization” (84 vs. 87, p=0.60).

CONCLUSION:

Opioid-sparing post-operative protocols for Cesarean Section can be easily implemented to reduce post-operative narcotic use, while maintaining patient satisfaction with pain control.
Using Raman Spectroscopy for Assessing Cervical Change During Labor: An Objective Approach to Labor Management [31T]
Authors: Masson Laura , Elsamadicy Emad A. , Mahadevan-Jansen Anita
Published: May 2019

INTRODUCTION:

Subjective assessment of digital examination can lead to different interpretations of cervical change and may affect labor management decisions. The aim of this study is to assess using Raman Spectroscopy to identify biochemical signatures associated with cervical change during labor.

METHODS:

At a major medical center, 10 adult pregnant patients were recruited and enrolled. The exclusion criteria were non-English speakers, prior preterm birth, prior LEEP, preterm labor or PROM. A portable Raman system with imaging-spectrograph, 785 nm diode laser, and fiber-optic probe were used. Measurements were taken at each prenatal visit starting at 37 weeks and during labor. The probe was placed at 3-6-9, and 12 o'clock positions and spectra were obtained. Both prenatal and labor peak ratios were compared and analyzed as function of cervical dilation.

RESULTS:

The average age and BMI were 25 years and 35.4 kg/m2 respectively. 40% underwent induction of labor with an average cervical dilation of 2.7 cm on admission. Raman peak amplitudes associated with extracellular matrix (ECM) proteins displayed significant differences between spectra measured at prenatal visits vs. labor. These included amide III band at 1253 cm-1 (P=.004), collagen and lipid-associated band at 1454 cm-1 (p=.001), and amide I band 1654 cm-1 (P=1.05x10-5). The 1454 cm-1band showed a distinct increase as a function of cervical dilation.

CONCLUSION:

Our study demonstrates that Raman spectroscopy is sensitive to biochemical changes in the cervix prior to the onset of labor as well as during labor progress. This may suggest reorganization of the ECM as the cervix remodels during labor.
Uterine Vascular Embolization Followed by Hysterectomy After Cesarean for MAP Without Extrauterine Involvement [32T]
Authors: Gatta Luke , Rodriguez Isabel Victoria , Gilner Jennifer Bushman , Grotegut Chad , Paula Lee S. , Secord Angeles
Published: May 2019

INTRODUCTION:

To review outcomes in women with morbidly adherent placenta (MAP) managed with selective uterine vasculature embolization (SUVE) at the time of cesarean hysterectomy (CHYS).

METHODS:

In 2005, our program implemented a multidisciplinary algorithm including interventional radiology (IR) and delayed hysterectomy for women with MAP. In 2012, the algorithm was revised for cases without extrauterine placental invasion to undergo SUVE after cesarean, followed by immediate hysterectomy. Subjects treated from 12/2012-8/2018 were reviewed. Primary outcomes included pRBCs transfused and EBL. Secondary outcomes included postoperative, immediate IR, and delayed IR complications. Data obtained via chart abstraction, and descriptive statistical analysis was performed.

RESULTS:

Identified 13 subjects: 12 scheduled, 1 emergent. All surgeries occurred in the hybrid OR, at mean 35w2d. For scheduled cases, mean EBL was 1292 mL (range 500-2000, std 468). 2/12 (16.7%) were transfused, mean 1.5u pRBC. All returned to postpartum floor, and discharged on average postoperative day 3.5. The emergent subject had EBL 4800cc, requiring 4u pRBC, 2u FFP, 1u cryoprecipitate, and ICU admission for one day. 9/13 (69.2%) used neuraxial analgesia only, and 4/13 (30.8%) converted to GETA. SUVE was performed using GelFoam (n=2), or particles (n=11) with no complications including pelvic infection, post-embolization syndrome, VTE, paresthesia, or ischemia. Postoperative complications included non-infectious wound opening (n=2) and wound infection (n=2). There were no reoperations or readmissions. On pathology, 2/13 (16.7%) had accreta, 9/13 (69.2%) had increta, 1/13 (7.7%) with percreta.

CONCLUSION:

A multidisciplinary approach including use of SUVE at the time of CHYS is a safe and feasible strategy for women with MAP.
PPROM Prior to 33 0/7 Weeks: When Should Rescue Course Corticosteroids Be Given? [23R]
Authors: Zalles Laura X. , Ryan Lindsay N. , Fischer Richard L.
Published: May 2019

INTRODUCTION:

Timely administration of corticosteroids reduces RDS of the newborn, IVH, necrotizing enterocolitis, and perinatal mortality. Corticosteroids are optimally effective 1-7 days after the first dose. A single rescue course of steroids may be given at least 1-2 weeks after the initial course. We sought to determine the optimal timing for administration of rescue course corticosteroids in women with PPROM prior to 33 weeks.

METHODS:

This was an IRB-approved retrospective cohort from 2013-2017 of 66 singleton gravidas with PPROM at 23 0/7-32 6/7 weeks. Observing when these women spontaneously labored or underwent indicated delivery, we compared hypothetical strategies for timing of rescue corticosteroids. This included administration of corticosteroids at 1, 2, 3, or 4 weeks after PPROM, versus withholding until spontaneous labor or indicated delivery. A Chi-squared test was used to compare the likelihood of delivery within the optimal window of the first dose of either the initial or rescue corticosteroids.

RESULTS:

The median interval from PPROM to delivery was 6.6 (3.3-16.4) days. Giving rescue corticosteroids 1 week after PPROM had the greatest number of deliveries occurring in the optimal window compared to 2, 3, or 4 weeks. Withholding rescue corticosteroids until spontaneous labor or indicated delivery was statistically less likely to result in deliveries during the optimal window compared to routinely giving corticosteroids 1 week after PPROM (45.5% vs 63.6%, p=0.04).

CONCLUSION:

In women with PPROM prior to 33 weeks, routinely administering rescue course corticosteroids 1 week after PPROM improves the likelihood of delivery within the optimal window for corticosteroid benefit.
Postpartum Opioid Use Among Military Health System Beneficiaries: Lessons for the Nation [19R]
Authors: Watters Julie , Banaag Amanda , Massengill Jason C. , Petersen Scott M. , Koehlmoos Tracey , Staat Barton C.
Published: May 2019

INTRODUCTION:

The opioid epidemic in the US has been given much attention in recent years. The most common source of prescription opioids, among people who misuse them, is through family or friends, implicating that healthcare providers are likely overprescribing.

METHODS:

We evaluated postpartum opioid prescriptions at discharge among patients insured by TRICARE using the Military Health System Data Repository. The primary outcome compared the prevalence of opioid prescription at discharge for postpartum patients within civilian purchased care and direct military treatment facilities. Secondary outcomes investigated mode of delivery and demographics for those receiving opioid prescriptions. We included women age 15-49 years old insured by TRICARE between 2010-2015 with a pregnancy-related postpartum discharge diagnosis. We excluded abortive pregnancy outcomes and incomplete data sets. We extracted data using ICD-9 and CPT codes, and performed logistic regression using SAS 9.4.

RESULTS:

Postpartum patients receiving civilian purchased care were more likely to be discharged with an opioid prescription compared to direct care (OR 3.9, 95% CI 3.8-3.99). Asian race was least likely to receive an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Age 15-19 had a lower odds of opioid prescription at discharge.

CONCLUSION:

Our data indicates that women who are cared for in civilian facilities were more likely to be prescribed an opioid at time of discharge when compared to military facilities. Factors such as race and age were also associated with opioid prescribing practices. OB/GYNs may be overprescribing opioids postpartum, and this study highlights areas for improvement.
Increasing Prevalence of Chronic HCV Infection in an Academic Obstetric Clinic: Evidence for Universal Screening [12R]
Authors: Lazenby Gweneth B. , Orr Cody , Guille Constance , Meissner Eric
Published: May 2019

INTRODUCTION:

U.S. rates of hepatitis C virus (HCV) are rising in reproductive age women, and approximately 1-2.5% of pregnant women are infected. We sought to determine the prevalence of opiate abuse and/or HCV infection among pregnant women presenting for prenatal care. Our second objective was to determine how often pregnant women with HCV are referred and receive treatment for HCV. Lastly, we sought to determine how likely HCV-exposed infants were referred and received appropriate screening for perinatal HCV infection.

METHODS:

We performed a retrospective chart review from 2007-2016. Eligible subjects were pregnant women with ICD-9/10 diagnosis codes for HCV infection and/or opiate abuse. Variables related to patient characteristics and pregnancy outcomes were obtained from an institutional perinatal information system. Referral and treatment practices for women and HCV-exposed infants were obtained from the electronic health record.

RESULTS:

Mirroring the diagnosis of opiate abuse, chronic HCV infection increased significantly in 10 years (P=0.03). Patients with chronic HCV infection had a median age of 27 (IQR 24-33) and were primarily Caucasian (95%). Only 0.7% of women presenting for delivery were screened for HCV, with over 78% of women with chronic HCV going undiagnosed. Only one-third of identified HCV-exposed infants were referred for HCV testing and only 9% received HCV testing.

CONCLUSION:

Increasing HCV infection is a consequence of the U.S. opiate epidemic. Risk-based screening results in missed opportunities for diagnosis and treatment referral. Implementation of universal screening in pregnancy will likely identify additional cases and is an important strategy for addressing the HCV epidemic.
Adverse Outcomes of Nuchal Translucency Measurement ≥3 mm and <3.5 mm [13G]
Authors: Taylor Dyese , Nelson Zoe , Hussain Farrah , Lam Melissa Chu , Dawnette Lewis Lois Brustman
Published: May 2019

INTRODUCTION:

There is a lack of data in the literature about outcomes of pregnancies with NT measurement ≥3mm and <3.5 mm. The objective of this study was to look at outcomes of these pregnancies.

METHODS:

This was an IRB approved study, from 1/2013-12/2017, of patients who presented for genetic counseling after an NT measurement of ≥3 mm and <3.5 mm. The primary outcome was the rate of abnormal prenatal testing results defined as termination of pregnancy, genetic abnormality or abnormality on fetal echocardiogram. In addition, the multiple of the median (MoM) for the gestational age was calculated and correlation with the primary outcome was tested.

RESULTS:

9 patients were studied who had NT measurements ≥3 mm and <3.5 mm. In respect to the primary outcome, 27% of patients had abnormal pregnancy outcomes. 69% of patients chose to have NIPS testing while 45% of patients decided to have invasive testing. Of the patients that had NIPS, 6% had abnormal results. 27% of the patients who had invasive testing had an abnormal karyotype or microarray. All patients that had Noonan testing were negative. 76% of patients in our cohort opted to get a fetal echocardiogram. Of these patients, 19% had an abnormal echocardiogram result with the majority of abnormalities being VSDs. There was not a meaningful correlation between the nuchal translucency measurement MoM and abnormal results.

CONCLUSION:

1 in 4 pregnancies with NT ≥3mm and <3.5mm had an abnormal prenatal outcome. Patients with this NT measurement should be offered further testing, especially fetal echocardiogram, given the rate of abnormalities.
The Levonorgestrel 52 mg Intrauterine System Is Effective and Safe for Six Years [13M]
Authors: Westhoff Carolyn L. , Keder Lisa M. , Gangestad Angelina K. , Teal Stephanie Beth , Olariu Andrea I. , Creinin Mitchell D.
Published: May 2019

INTRODUCTION:

Liletta®, a levonorgestrel (LNG) 52mg contraceptive intrauterine system (IUS), is under investigation in an ongoing multicenter trial for up to ten years of use. Here we evaluate six-year efficacy and safety data.

METHODS:

We enrolled women aged 16-45 years with participants aged 36-45 years undergoing safety evaluation only in this IRB-approved trial. After IUS placement, we followed 1,568 women aged 16-35 years and 146 women aged 36-45 years, assessing pregnancy rates through six years and safety outcomes in all women regardless of duration of use.

RESULTS:

The 16–35 year-old subjects included 986 (57.5%) nulliparous and 433 (25.3%) obese women. To date, more than 375 women have completed 6 years of use; more than 125 have completed 8 years. Nine pregnancies occurred over 6 years including two in year 1, four in year 2, one each in years 3-5, and none in year 6. Six (67%) pregnancies were ectopic. The cumulative life-table pregnancy rate through year 6 was .87 (95% CI .44-1.70). Two perforations following IUS placement were diagnosed within the first year and none since. Expulsion occurred in 68 (4.0%) participants, most (50 [73.5%]) during the first year with 2 per year in years 6 and 7. Pelvic infection was diagnosed in 15 (.9%) women, most (11 [73.3%]) occurring after 6 or more months of use. Only 40 (2.3%) women discontinued due to bleeding complaints, primarily (n=30 [75.0%]) in the first 2 years.

CONCLUSION:

The LNG 52 mg IUS is highly effective over six years of use and has an excellent extended safety profile.
Googling Abortion Pills: The Ease of Buying Misoprostol and Mifepristone Online for Home Use [1N]
Authors: Kerestes Courtney , Freese Mikayla , Stockdale Colleen K. , Hardy-Fairbanks Abbey J.
Published: May 2019

INTRODUCTION:

In an era of increasing abortion restrictions at the state level, as well as ease of access to information online, misoprostol and mifepristone bought online has become an option for some women seeking to end their pregnancy. This study seeks to elucidate the type of information available online as well as the credibility of websites selling these medications.

METHODS:

Eight search terms were identified using top keywords related to medical abortion and self-managed abortion. IRB approval was waived. Depersonalized, delocalized searches for each of these eight terms were done using Google, Yahoo!, and Bing, and the top 50 results were recorded. Unique websites with health information about abortion were further analyzed for medical information and sales of mifepristone and/or misoprostol.

RESULTS:

Out of the 1200 search results located, there were 327 unique websites and 109 websites that met our inclusion criteria. Of these, there were 25.7% non-profits, 23.9% general information sites, 20.2% primarily selling medications, 10.1% affiliated with clinics/hospitals, 13.8% affiliated with crisis pregnancy centers, and 6.4% of other types. Over one third (34.9%) were clearly pro-abortion and 23.9% were anti-abortion. 34.9% advised taking the medications without a provider involved and 22.6% of the websites sold medications, with an average price of $214 for a pack with 200 mg mifepristone and 800 mcg misoprostol.

CONCLUSION:

There are a large number of websites selling mifepristone and misoprostol for home use without a physician. This is important for physicians to be aware of since women may seek care after use of these medications.
Prevalence and Screening Perinatal Intimate Partner Violence Pregnancy Risk Assessment Monitoring System 2012-15 [12N]
Authors: Minns Annie , Peahl Alex Friedman , Kusunoki Yasamin , Terplan Mishka , Dalton Vanessa , Admon Lindsay Kennedy
Published: May 2019

INTRODUCTION:

Current guidelines recommend screening women of reproductive age for intimate partner violence (IPV), and pregnancy is a high-risk period for IPV. Yet, in the perinatal period, little is known about prevalence of IPV, rates of screening for IPV, or healthcare utilization among affected women.

METHODS:

Using 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, we examined the prevalence of IPV in the perinatal period, rates of screening during prenatal care, and receipt of prenatal care among affected women. Adjusted logistic regression models and predictive margins were used to generate estimates and examine time-trends.

RESULTS:

2.4% (95% CI 2.3-2.6) of women reported IPV. 51.0% (95% CI 50.6-51.5) of women reported screening for IPV during prenatal care, including 47.0% (95% CI 42.3-51.6) of affected women. 98.6% (95% CI 98.0-99.2) of affected women reported some prenatal care, and 80.2% (95% CI 77.7-82.7) reported prenatal care in the first trimester.

CONCLUSION:

Only half of women reported screening for IPV during prenatal care, including less than half of affected women. High proportions of affected women engaged in prenatal care, suggesting missed opportunities to reach this vulnerable population.
Is Teaching Residents How to Code a Valuable Intervention? [16N]
Authors: Kuhlmann-Capek Maggie J. , Olson-Koutrouvelis Gayle , Munn Mary B.
Published: May 2019

INTRODUCTION:

Appropriate documentation is an important component of quality health care. In academic medical centers, most documentation is done by residents. Given the scope of topics for resident education, a formal curriculum for documentation is often non-existent. Poor documentation has important consequences, including financial loss and compromise of quality indices. We sought to determine if instructing residents in basic coding principles improved the rate of appropriate documentation for early-term deliveries.

METHODS:

Residents were given a one-hour lecture focused on inpatient documentation, with a section on documenting appropriate justification for early-term deliveries. Subsequent documentation over a one-week period by each of the second- and third-year residents in attendance (n=7) was reviewed, and the rate of appropriate documentation for early-term deliveries was compared to similar documentation prior to the intervention for the same residents. This was compared to documentation by second- and third-year residents who did not attend the lecture (n=9).

RESULTS:

There were 153 total encounters analyzed. 29 were for patients who underwent early-term delivery. Of the pre-intervention early-term deliveries, the reasons for delivery in 8/13 (61.5%) were incorrectly documented. Of the post-intervention early-term deliveries, the reasons for delivery in 6/16 (37.5%) were incorrectly documented. 5/6 (83.3%) of the post-intervention early-term deliveries which were incorrectly documented were by residents who had not attended the lecture.

CONCLUSION:

Teaching residents coding and formal documentation is a valuable intervention. These simple interventions stand to make a significant impact on both financial and quality indices. These interventions will also serve to better prepare trainees for their transition into practice.
Maternal Near Miss Determinants at a High-Risk Maternity Hospital in Northeastern Brazil: A Prospective Study [26N]
Authors: Lima Telmo , Katz Leila , Kassar Samir , Amorim Melania
Published: May 2019

INTRODUCTION:

To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators.

METHODS:

A prospective cohort study approved by the Ethics Committee (CAAE n. 37977014.0.0000.5011) was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016, including all pregnant women, after informed consent, and excluded those not discharged at the end of the study or those unable to contact after the 42nd postpartum day. We used the MNM criteria recommended by WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed, p values were two-tailed, and significance level was 5%.

RESULTS:

1,094 pregnant women were studied, 682 (62.4%) without adverse maternal outcomes and 412 (37.6%) with those outcomes, 352 potentially life-threatening conditions (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1,002 live births were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1,000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy.

CONCLUSION:

These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.
Morbidly Adherent Placentation: Predictive Value of Ultrasound and MRI Using a Scoring System [36N]
Authors: Winfrey Olivia K. , Brekke Emily , Lee James T. , Hendrix Nancy W. , Chavan Niraj R.
Published: May 2019

INTRODUCTION:

Ultrasound and MRI are useful modalities to diagnose morbidly adherent placentation (MAP). This study aimed to integrate imaging features and maternal risk factors into a model to predict MAP.

METHODS:

We conducted an IRB-approved retrospective cohort study between January 2015 and June 2018 of patients with suspicion of MAP. Demographics, obstetric history, and clinical/histopathologic outcomes were obtained. A blinded maternal-fetal medicine physician reviewed 69 ultrasounds from 25 patients to catalog MAP-associated features. Of these 25, 16 had an MRI reviewed by an abdominal radiologist. Chi-square test of independence and Fisher exact test determined associations between maternal variables, imaging features, and diagnosis. Using logistic regression modeling, a scoring system was created based on statistically significant predictors.

RESULTS:

Of 361 patients with clinical or sonographic concern for MAP, 25 had high index of suspicion. Of these, 20 (80%) had clinical diagnosis of MAP at delivery. Twelve (60%) required cesarean hysterectomy; ultrasound alone identified MAP in 8 (66%). Of those having MRI, it was diagnostic in 6/10 (60%), with histopathologic confirmation. Placenta previa (P=.001), loss of retroplacental clear zone (P=.05), placental lacunae (P=.005), and bladder invasion (P=.001), as well as color Doppler (P=.03) and transvaginal imaging (P=.018) were significantly associated with histopathologic MAP. No MRI features were significant. Using a threshold score of ≥3, the scoring system predicted 9/12 (75%) MAP cases requiring cesarean hysterectomy.

CONCLUSION:

Several sonographic features were significantly associated with histopathologic MAP. Further research is warranted to assess the added value of MRI to improve the predictive accuracy of the scoring system.