bluuebunny/crossref_metadata_2025 huggingface dataset:
Indications for Primary Cesarean Deliveries and Their Association With Maternal Medical Comorbidities [17P]
Authors: Izewski Joanna , Morgan Jessica C. , Whelan Anna R , Wheatley Catherine , Buhimschi Catalin , Ford Catherine E.
Published: April 2020

INTRODUCTION:

Abnormal fetal heart tracing (FHT) remains one of the most common indications for primary cesarean delivery (PCD) in the United States. Literature suggests a possible association between maternal medical comorbidities and increased risk of cesarean delivery. This study aims to examine PCD for abnormal FHT stratified by various chronic and pregnancy-related medical comorbidities.

METHODS:

We used a retrospective cohort study design. Following IRB approval, electronic medical records were queried for all cesarean deliveries (n=666) performed at a single University hospital from January 1, to December 31, 2018. Data collected included maternal demographic, medical, and delivery information. Parametric and non-parametric tests were used for data analysis.

RESULTS:

Out of all cesarean deliveries, 357 surgeries were identified as PCDs. Most common maternal medical comorbidities included chronic hypertension (HTN) (11%, 39/357), pre-gestational diabetes mellitus (DM) (2.5%, 9/357), gestational HTN (9.5%, 34/357), preeclampsia without severe features (SF) (5%, 18/357), preeclampsia with SF (15%, 53/357), gestational DM (9.5%, 34/357). Subjects with chronic HTN (P=.003) and pre-gestational DM (P=.006) had a statistically significant higher rate of PCD for abnormal FHT. No difference was found for all other medical comorbidities.

CONCLUSION:

Our study suggests that patients with pre-existing medical comorbidities may have a statistically significant higher rate of PCD for abnormal FHT than other pregnancy-related medical comorbidities. Further prospective studies are needed to confirm this potential association and possibly aid in improving preventative measures for reducing PCD.
Agreement Between Providers When Determining Primary Cesarean Deliveries for Fetal Heart Tracings [03P]
Authors: Whelan Anna , Morgan Jessica C. , Izewski Joanna , Wheatley Catherine , Buhimschi Catalin , Ford Catherine E.
Published: April 2020

INTRODUCTION:

The most common indications for primary cesarean delivery (PCD) in the US are labor dystocia and abnormal fetal heart tracing (FHT). Category II tracings make up the majority of intrapartum tracings and management may differ among providers (Obstetricians [OB], midwives [CNM], and family medicine physicians [FM]). This study aims to determine the characteristics of FHT which resulted in PCD at UI Health (UIH) by provider type.

METHODS:

IRB approved, retrospective cohort study of primary CD at UIH during 2018. Data was abstracted from electronic medical records and analyzed in SPSS.

RESULTS:

357 PCD occurred during the study period. The most common indication for PCD was abnormal FHT (45.1%), malpresentation (18.2%), followed by labor dystocia (18.1%). When stratifying for provider type, FM had more CD for labor dystocia, while OB and CNM had more for FHT. However, when removing other objective indications, such as placenta previa and malpresentation, FHT was the most common regardless of which service managed antepartum and intrapartum care (45.1%, P=.12). The majority of tracings at the time of decision for CD were category II (84%). Minimal variability was present in (56%, P=.16). Late decelerations were most common at time of CD (46.6%, P=.17), followed by variable (41%, P=.55) and prolonged (15%, P=.14).

CONCLUSION:

Since standardization of categories of FHT by NICHD, there seems to be agreement among providers in terms of the management of category II tracings. More data is needed to confirm this trend, while continuing efforts to improve intrauterine resuscitation in order to decrease the PCD rate.
The Influence of Intrapartum Events on Patient Understanding in Labor [37O]
Authors: Varghese Elizabeth , Day Marilyn , Valdes Hannah , Garry David , Garretto Diana
Published: April 2020

INTRODUCTION:

There is a paucity of research about how much clinical and subjective variables influence a woman's understanding of the labor process. This study evaluates the correlation between intrapartum variables and patient understanding.

METHODS:

This is a cross-sectional observational study. Women completed surveys in the immediate postpartum period which assessed patient understanding of intrapartum events and patient satisfaction. Survey responses were compared to patient charts to determine patient understanding. Logistic regressions determined predictors of patient understanding.

RESULTS:

332 women completed surveys. 62% had vaginal deliveries, 57% were multiparous, 88% had regional anesthesia, and birth classes were attended by 84% of participants. 20% of women had postpartum hemorrhages. 74% of women self-reported maximum satisfaction, but 30% of women had 100% understanding of their intrapartum course. A significantly greater percentage of women who had 100% patient understanding reported maximum satisfaction (P=.006) with a correlation coefficient of 0.13 (R=0.13, 95% CI 0.03–0.24, P=.02). Patient satisfaction was higher in women with a vaginal delivery (P=.006), but vaginal deliveries, multiparity, advanced maternal age, regional anesthesia, feeling the doctor explained the labor course well, confidence in their doctor, support in labor, and having a birth plan/birth classes were not predictors of patient understanding. Women who felt they had high input into managing their labor increased patient understanding (OR 2.75, 95% CI 1.35–5.59, P=.005) and postpartum hemorrhage decreased it (OR 0.35, 95% CI 0.16–0.75, P=.008).

CONCLUSION:

Patient understanding in labor is decreased in postpartum hemorrhages but improved in women who felt they had input into their labor course.
Sex-Specific Differences in Neonatal Morbidity at Term [34O]
Authors: Bailey Erin , Raghuraman Nandini , Woolfolk Candice , Palanisamy Arvind , Macones George , Cahill Alison
Published: April 2020

INTRODUCTION:

Male sex is associated with worse outcomes among preterm neonates, but it is unclear if such sex discordant morbidity occurs in term infants. The aim of this study was to investigate the relationship between fetal sex and neonatal morbidity at term gestation.

METHODS:

This is a secondary analysis of a prospective cohort of women admitted for labor at term within a single institution from 2010 to 2015. The primary outcome was composite neonatal morbidity that included death, respiratory distress, mechanical ventilation, meconium aspiration syndrome, suspected sepsis, hypoxic-ischemic encephalopathy, therapeutic hypothermia, and seizure. Multivariable logistic regression was used to estimate the association between infant sex and neonatal morbidity.

RESULTS:

Of the 8578 participants, 51% delivered a male fetus. Birthweight was higher in male infants (3304 g vs 3177 g, P<.01), as were the rates of prostaglandin administration (19.0 vs 11%, P<.01), operative vaginal (4.0 vs 5.6%, P<.01), and cesarean delivery (15.4 vs 18.6%, P<.01). After adjusting for birthweight, male infants had a significantly higher risk of composite neonatal morbidity (aOR 1.21 [95% CI 1.04, 1.40]). This association was driven primarily by a higher rate of respiratory distress in male infants (1.34 [1.07, 1.68]).

CONCLUSION:

Term male infants appear to be at increased risk for neonatal morbidity compared to females even after adjustment for birthweight. This association was partly driven by a higher rate of respiratory morbidity in male infants. Our findings reinforce the current notion that neonatal outcomes can be sex-dependent, and call for further investigation into the physiologic mechanisms driving this association.
Quantitative MRI Measures of In Utero Feto-Placental Trajectories in Healthy Pregnancies [31O]
Authors: Amgalan Ariunzaya , Limperopoulos Catherine , Kapse Kushal , Quistorff Jessica , Bannantine Kathryn , Andescavage Nickie
Published: April 2020

INTRODUCTION:

The birth weight-placental weight ratio, a metric of placental efficiency in supporting fetal growth, is associated with fetal demise, neonatal and maternal morbidity. However, in vivo measures of placental health remain lacking. This study uses fetal body and placental volume metrics to (1) characterize in utero feto-placental growth patterns using in vivo three-dimensional MRI and (2) explore these associations with neonatal outcomes.

METHODS:

IRB approval was obtained. In a prospective observational study, healthy women with singleton pregnancies greater than 18 weeks gestation were recruited and underwent fetal MR imaging. The fetal body and placenta were manually outlined using ITK-SNAP software, volumes were calculated in mm3 and feto-placental ratio (FPR) was derived. Clinical data including gestational age (GA) at delivery, birthweight (BW) and corrected birthweight (BW z-score) were obtained.

RESULTS:

Thirty-five women underwent fetal MRI between 25 and 38 completed weeks gestation (mean=31.98±4.20). All pregnancies resulted in live births; 3 (8.5%) infants had birth weights less than 10% and 2 (5.7%) delivered before term. There was a positive association between GA and both fetal body volumes (FBV) and placental volumes (PV) (P<.001 for both) and between GA and FPR (P<.001). There was no association between in vivo FPR and GA at delivery or BW z-score, even with controlling for GA at MRI (P=.12–.88).

CONCLUSION:

We describe in utero trajectories for fetal-placental growth in healthy pregnancies using quantitative MRI tools. Understanding normal patterns of fetal-placental development are needed to be able to detect early in utero placental failure prior to the onset of fetal harm.
Predictors of Expedited Delivery in the Presence of Severe Fetal Acidemia (Umbilical Cord Arterial pH <7) [30O]
Authors: Brendel Katelyn , Gan Sarah , White Chase , Goldberg Jay
Published: April 2020

INTRODUCTION:

The purpose of this study was to determine which characteristics of EFM in babies with severe acidemia (umbilical cord arterial pH <7) affected whether delivery was expedited or not.

METHODS:

A retrospective cohort study was performed on babies with umbilical cord arterial pH <7. Two groups were identified: (1) expedited delivery (either operative vaginal delivery or urgent/emergent cesarean section) and (2) non-expedited delivery (spontaneous vaginal delivery, scheduled or non-urgent cesarean section). The last hour of EFM was reviewed. Maternal, labor, and neonatal characteristics between the groups were compared using Chi-squared test for independence and the Fisher's Exact Test. IRB approval obtained.

RESULTS:

Thirty neonates with umbilical cord pH <7.0 were identified. Of these, 47% were delivered in expedited fashion. There was no statistical difference between groups in average umbilical cord arterial pH or base excess, gestational age, if labor was induced, length of labor, Pitocin usage for labor augmentation, sentinel events, 5 minute Apgar score or neonatal length of stay. Recurrent late decelerations were more likely to be present in the expedited delivery group (31% vs. 0%), while moderate variability (100% vs. 69%), accelerations (77% vs. 31%), and category I tracing (46% vs. 8%) were more common in the non-expedited group.

CONCLUSION:

In babies born with umbilical arterial pH of <7, expedited delivery was more common in the presence of recurrent late decelerations during the last hour of fetal monitoring. A Category I fetal heart tracing, moderate variability, and accelerations were more common when the delivery was not expedited.
Impact of the Affordable Care Act on Cervical Cancer Trends in New Orleans [32H]
Authors: Masri Amal , Steinmetz Leah , Robinson William R.
Published: April 2020

INTRODUCTION:

To examine trends among women diagnosed with cervical carcinoma in New Orleans before and after the Affordable Care Act’s (ACA’s) Medicaid expansion was implemented in Louisiana in January 2016. Age at diagnosis, time since last doctor’s visit, progression free survival (PFS), and overall survival (OS) were analyzed between racial groups.

METHODS:

Subjects with Medicaid coverage diagnosed with cervical cancer at an urban medical center between 2005-2019 were identified via hospital databases. Data were reviewed retrospectively and analyzed using SPSS.

RESULTS:

451 subjects (310 black, 103 Caucasian, 38 Hispanic) were identified: 375 pre-ACA (2005-2016) and 76 post-ACA (2016-2019). All comparisons pre- vs post-ACA and results not statistically significant unless specified. Cumulative analysis: age 49.9 vs 53.0 years (P<.001), doctor’s visit 18.7 vs 16.4 months (P<.001), PFS 52.5 vs 71.2 months (P<.001), and OS 57.6 vs 72.9 months (P<.001). Black: age 49.8 vs 49.0 years; doctor’s visit 19.2 vs 15.3 months; PFS 45.2 vs 36.9 months; OS 49.8 vs 39.5 months. White: age 51.9 vs 53.8 years; doctor’s visit 14.9 vs 11.0 months; PFS 50.4 vs 75.7 months (P<.006); OS 56.6 vs 77.3 months (P<.01). Hispanic: age 50.2 vs 42.4 years (P<.001), doctor’s visit 23.0 vs 19.5 months; PFS 54.5 vs 72.4 months; OS 59.0 vs 75 months.

CONCLUSION:

The ACA’s Medicaid expansion was associated with decreased time since last doctor’s visit and increased PFS and OS, notably in Hispanics and Caucasians. Hispanic women were diagnosed at earlier ages post-ACA which likely influenced early treatment and favorable prognoses. Conversely black women had decreased PFS and OS post-ACA which approached statistical significance, and they had the lowest PFS and OS pre-and post-ACA of all groups. This suggests access to care is not the only factor influencing cervical cancer outcomes in this disproportionately affected group.
Analyzing Patient Experiences From Crowd-Sourced Reviews of Crisis Pregnancy Centers in California [05I]
Authors: Chan Elaine , Korotkaya Yelena , Sridhar Aparna
Published: April 2020

INTRODUCTION:

Crisis Pregnancy Centers (CPCs) are non-profit organizations that claim provision of pregnancy counseling resources. As more patients utilize online reviews to select healthcare providers, we evaluated patient experiences of CPCs through analysis of crowd-sourced review forum, specifically Yelp.

METHODS:

Active CPCs were identified using the Crisis Pregnancy Center Map, derived from directories maintained by CPC national organizations. Yelp listings were identified using business name or address. Reviews were collected from every CPC in California with a Yelp listing. Repeated ideas and concepts were tagged with codes extracted from data.

RESULTS:

We identified 145 active California CPCs. 122 had Yelp listings. 619 total Yelp reviews were extracted by October 1st, 2019. There were 503 5-star reviews, 14 4-star, 3 3-star, 16 2-star, and 83 1-star in total. Among negative reviews (n=102), 6 themes emerged: inadequacy of medical care, lack of transparency, paternalistic approach, poor customer service, psychological harm. Among a positive review set (n=100), patient satisfaction resulted from faith-based care, accessibility of CPCs for uninsured individuals, free services, patient treatment, crisis counseling. 12.5% of reviews voiced financial stress or lack of insurance.

CONCLUSION:

Crowd-sourced review forums may provide data into the quality of care perceived by patients in CPCs. 84% of CPCs in California use Yelp. Patients ambivalent on pregnancy outcome felt their care was inappropriate, whereas patients continuing pregnancy felt supported. Positive reviews were not related to quality of medical care. The results of this study may help explain the wide disparity commonly observed between conventional quality metrics and crowd-sourced online reviews.
Availability of Ulipristal Acetate and the Impact of a Brief Educational Intervention at Retail Pharmacies [07I]
Authors: Stamm Carol A. , Borgelt Laura M. , Ball Nina , Rupp Leanne , Weber Rachel , Arbet Jaron
Published: April 2020

INTRODUCTION:

A Colorado study in 2014 determined levonorgestrel (LNG) emergency contraception (EC) to be completely accessible in 23% of pharmacies. No study has evaluated the availability of ulipristal acetate (UPA), which is a more effective form of EC, available by prescription in Denver. The goal was to assess availability of UPA EC, ability of pharmacy staff to answer questions about it, and determine if the American Society of Emergency Contraception (ASEC) educational tool was perceived as useful.

METHODS:

134 retail pharmacies within 10-mile radius of the state capitol were included: one-half were randomized to receive the ASEC handout. Three pharmacies subsequently merged. (N=131) All pharmacies received a standard mystery call two weeks after the intervention mailing. The pharmacies receiving the handout received additional calls one and 9 weeks after the original call, to assess handout usefulness and were asked about the intervention tool.

RESULTS:

UPA EC was reportedly available in only 24, or 18.3%, of pharmacies. 36.4% of pharmacy staff members counseled that there was no difference between UPA and LNG EC. Only 18.6% of pharmacy staff seemed aware of the higher efficacy of UPA. Few pharmacy staff recalled seeing the ASEC handout: 13/65 (20%) at one week and 3/65 (4.6%) at nine weeks. One site reported that the handout was posted.

CONCLUSION:

Although UPA is available by prescription (therefore covered under the Affordable Care Act) and has a higher efficacy than LNG EC, it is not readily available. A single educational intervention did not have lasting value to pharmacists.
Knowledge and Attitudes Towards LARCs Among Medicaid Recipients Desiring Surgical Sterilization [24I]
Authors: Leung Andrea , Loh Andrew , Ahmady Malalay , Haque Sidra , Pentlicky Sara , Gurney Elizabeth
Published: April 2020

INTRODUCTION:

We sought to compare knowledge and attitudes about long-acting reversible contraceptives (LARC) among reproductive-age Medicaid recipients with satisfied parity who were not currently using LARC.

METHODS:

We conducted a cross-sectional survey using 18 true/false and Likert-items compiled from previously validated surveys assessing perceptions about LARC. We compared two groups: people seeking surgical sterilization and those who were not. Our primary outcome was the proportion of correct responses. Secondary outcomes were the proportion with negative LARC perceptions, and the proportion who would consider using LARC. 67 subjects were needed to detect a small-medium estimated effect size of Cohens f2=0.20, with 95% power and alpha=0.05.

RESULTS:

67 people participated: 43 desiring sterilization and 24 not. Subjects desiring sterilization were older (mean age 31.9 versus 28.4, P=.01), had higher gravidity (6 versus 3, P=.01) and parity (3 versus 2, P=.01). Subjects desiring sterilization had lower overall knowledge about LARC (62% correct responses versus 70%, P=.042) and more negative perceptions about LARC (54% versus 38%, P=.048). Fewer subjects desiring sterilization correctly identified LARC efficacy as equal to sterilization (32% versus 83%, P<.01), and fewer would consider using LARC (IUD: 23% versus 58%, P<.01; implant: 16% versus 46%, P<.01). A higher proportion of subjects desiring sterilization agreed with “I do not like the idea of putting an object in my body” (60% versus 29%, P=.014).

CONCLUSION:

Lower knowledge about LARC, particularly regarding efficacy, among people desiring sterilization underscores the need for comprehensive counseling. The higher proportion of negative perceptions towards LARC among people desiring sterilization warrant further study.
Sexual Satisfaction With the Vaginal pH Regulator: Results From the AMPOWER Clinical Trial [32I]
Authors: Thomas Michael A. , Culwell Kelly , Dart Clint , Howard Brandon
Published: April 2020

INTRODUCTION:

The Vaginal pH Regulator (VPR™) is an investigational, non-hormonal, woman-controlled gel for prevention of pregnancy. Given the lubricating properties of VPR, the objective of the current analysis is to report on sexual satisfaction/function from AMPOWER.

METHODS:

AMPOWER was a phase 3, single-arm, open-label, IRB-approved trial in women aged 18-35 years and conducted at 112 U.S. sites (NCT03243305). Women were instructed to administer VPR intravaginally immediately before or up to 1 hour before each episode of vaginal intercourse. The primary endpoint was 7-cycle cumulative pregnancy rate. Sexual satisfaction/function was an exploratory endpoint and assessed via questionnaires administered at baseline (Study Visit 2, Cycle 0) and Study Visits 3 (Cycle 2), 4, and 5.

RESULTS:

Compared to their previous contraceptive method (N=1,330), more women reported positive impacts to their sex life with VPR (a little/a lot of improvement: with previous contraceptive in the 4 weeks prior to enrollment=16.9%; with VPR at Visit 3=44.5%) and in their ability to maintain lubrication during intercourse (no difficulty in maintaining lubrication: baseline=73.9%, Visit 3=82.5%). Women also reported improvements in sexual function measures, with the percentage reporting “none” at baseline vs Visit 3, respectively, as follows: vaginal dryness (59.8% vs 79.9%); lack of sexual desire/interest (61.9% vs 71.2%); vaginal tightness (58.5% vs 70.5%); pain during intercourse (70.5% vs 80.8%); anxiety about sexual performance (80.3% vs 85.4%); and inability to orgasm (60.8% vs 69.9%).

CONCLUSION:

In AMPOWER, women reported improvement in measures of sexual satisfaction/function after just 1 cycle of use with VPR compared to baseline.
The Maryland Contraceptive Equity Act (MCEA): Provider Awareness and Impact on Contraception Provision [35I]
Authors: Cheedalla Aneesha , Lee Jessica , Burke Anne E.
Published: April 2020

INTRODUCTION:

The Maryland Contraceptive Equity Act (MCEA) took effect in January 2018, with the goal of reducing barriers to contraception among insured individuals. Key provisions allow 12-month supplies/prescriptions of short-acting contraception and remove prior-authorization requirements for long-acting reversible contraception (LARC). We sought to assess MCEA impact on contraceptive provision in Maryland.

METHODS:

From March-June 2019, we emailed an Institutional Review Board-approved survey to Obstetrics/Gynecology (OBG), Internal Medicine (IM), Pediatrics, and Family Medicine (FM) providers throughout Maryland. The 24-item survey queried provider’s prior awareness of the MCEA, changes to counseling, prescribing, and administrative practices based on the MCEA prior to the survey, likelihood of changes after MCEA awareness, changes in prior-authorization requirements for LARC, and MCEA impact on contraception access. Responses utilized a 5-point Likert scale (1: Very unlikely – 5: Very likely).

RESULTS:

The survey was sent to 1256 providers with 164 responses (13%): 67 OBG, 53 IM, 22 Pediatrics, 22 FM. One-hundred fourteen (70%) providers were unaware of the MCEA. The mean score of likelihood that the MCEA would change contraceptive counseling was 3.4/5 (SD 1.30), prescribing practices 3.5/5 (SD 1.29), and administrative practices 3.2/5 (SD 1.27). Of providers offering LARC, 22/42 (52%) reported fewer prior-authorization requirements since MCEA enactment. Fifty-eight percent of providers thought the MCEA very likely to increase access to LARC and 40% rated it very likely to increase access to short-acting contraceptives.

CONCLUSION:

Most contraceptive providers were not aware of MCEA provisions, but report that with increased awareness, their contraceptive counseling and prescribing practices are likely to change.
Intention Versus Uptake: LARC Among Postpartum Women in a Federally Qualified Health Clinic [17J]
Authors: Freeman Emily , Heiselman Cassandra , Bacak Stephen , Knebusch Madeleine , Cottrell Connie
Published: April 2020

INTRODUCTION:

Access to full spectrum contraceptive methods, including long-acting reversible contraception (LARC), is critical for preventing unintended and short-interval pregnancy. Despite serving a population at high risk for unintended pregnancy, federal qualified heath centers (FQHC) often have limited access to LARC on-site and at associated hospitals that may impact contraceptive utilization. The goal of the study was to examine access and barriers to LARC uptake among women at a FQHC.

METHODS:

We conducted a retrospective chart review of all women seen for antenatal care at a single resident run FQHC from 2014 to 2017. Women age 18-40 and who delivered at the associated hospital were included. The FQHC offered intrauterine device (IUD) but did not offer contraceptive implant placement. The associated hospital did not provide immediate postpartum LARC during the study period.

RESULTS:

In our study, 560 women were identified. There was a 60.5% postpartum follow-up over the study period. 65% (n=364) had documentation of a confirmed postpartum contraception plan prior to delivery. Of women with a plan, 27% (n=100) expressed desire for postpartum LARC. Only 21% (n=21) of women who desired LARC actually received LARC within the first 6 months after delivery. All IUDs were received at the FQHC. No women received a contraceptive implant at an outside facility.

CONCLUSION:

Our data suggests that when LARC options are not readily available, postpartum uptake is poor regardless of intention. Therefore, strategies need to be developed to improve access to all LARC methods, including expanding immediate postpartum services and improving antepartum contraception counseling.
Maternal Fetal Medicine Physician Understanding, Attitudes, and Practice in Regards to New Abortion Legislation [18J]
Authors: Morgan Elizabeth A. , Miller Jill , Thompson Rachel , Jones Cresta W.
Published: April 2020

INTRODUCTION:

Second trimester diagnosis of congenital anomalies and genetic disorders is often performed by Maternal Fetal Medicine (MFM) Physicians, who counsel on available options including termination of pregnancy (TOP). Recent abortion legislation, including implementation of gestational age limits, waiting periods, and mandatory counseling, can directly influence these conversations with patients. The Guttmacher Institute reports 58 such restrictions in the first half of 2019 alone. The purpose of this study was to understand how MFM Physicians perceive these legislative changes and whether they modify clinical practice in response.

METHODS:

We mailed an anonymous survey to all physician members of the Society of Maternal Fetal Medicine in January 2018 and again in April 2019. The survey included questions on physician demographics, knowledge of abortion legislative changes in the past five years, and impact on clinical practice.

RESULTS:

Of 2217 surveys mailed, 686 (30.3%) physicians responded. 33.2% of respondents reported changes to abortion provision legislation, 53.4% denied changes and 13.4% were unsure. In 30 of the 47 states represented, MFMs disagreed whether there were changes to legislation in their state. Of the 359 physicians reporting new legislation, 243 (67.7%) stated they changed clinical practice in response. Physicians also reported concerns with increasingly necessary out of state referrals, as well as rushed decision making and increasing financial burdens to low-income patients.

CONCLUSION:

There was significant variation in MFM Physician response regarding changes to abortion legislation. Many MFMs reported changes to legislation resulting in alterations of clinical practice and voiced concerns in regards to increasing patient burdens.
17-P for Women With Congenital Uterine Anomalies: Does it Impact Preterm Birth Risk? [01K]
Authors: Dotters-Katz Sarah K. , Schwartz Amanda R.
Published: April 2020

INTRODUCTION:

The effectiveness of 17P in the prevention recurrent of preterm birth (PTB) among women with congenital uterine anomalies (CUA) is unknown. This study evaluate association between 17P and delivery gestational age among women with CUA and a previous spontaneous PTB.

METHODS:

This study is a retrospective cohort of women with CUA who delivered at 2 health systems from 2013-2019. Women with ≥1 prior spontaneous PTB carrying non-anomalous, singleton gestations were included. The primary outcome was delivery gestational age. Secondary outcomes included delivery <37 and <34 weeks. Women receiving 17P were compared to those who did not receive 17P using Wilcoxon rank sum, Fisher’s exact, and chi-square.

RESULTS:

Of the 48 women with prior PTB, 11 (22.9%) received 17P. Demographic, medical, and obstetric characteristics were similar between women who did and did not get 17P. The subtype of CUA was also similar by 17P status. The initial cervical length was more than 35mm in both groups and did not differ, nor did rates of PPROM (25% vs 12.5%, 0.63). The median delivery gestational age was similar between groups [37.7 (IQR 30.7-38.3) vs. 37.1 (IQR 31-38.4) weeks] for those who did and did not receive 17P, respectively. Rates of recurrent PTB 0.99) and 0.99) were also similar in those who did and did not receive 17P.

CONCLUSION:

In this cohort of women with prior PTB and CUA, recurrent PTB was common, and though 17P was used in fewer than 1 in 4 women, use of 17P did not appear to impact this risk.
Addressing the Epidemic: Screening for Substance Use in Pregnancy [04K]
Authors: Campbell Jolene L. , Cheese Callie , Muller Corinna
Published: April 2020

INTRODUCTION:

The purpose of this project was to implement the use of an evidence-based model and validated screening tool for high-risk substance use in pregnancy. Substance use among pregnant women has quadrupled. Unidentified and untreated substance use can lead to poor maternal/ fetal outcomes and is currently the leading cause of maternal death in the U.S.

METHODS:

With IRB approval, 65 pregnant women were screened for substance use with a validated screening tool and provided brief intervention and/or referral to treatment as indicated. Data was collected over an 8-week period and analyzed using SPSS.

RESULTS:

Screening revealed that 61.4% of the women reported substance use (alcohol use, tobacco use, non-medical prescription drug use, or illicit drug use) in the past year. Continued substance use after knowledge of pregnancy was reported by 0% for alcohol use, 18.5% for tobacco use, 1.5% for non-medical prescription drug use, and 10.7% for illicit drug use. Screening indicated that 7.7% of the women had moderate to high-risk illicit drug use and all these women received a brief intervention and were referred for treatment. The project results were compared to the average substance use in pregnancy reported by local and recent literature data which included: 5.5-8.5% with alcohol use, 13.2-15.9% with tobacco use, and 6-7.7% with illicit drug/non-medical prescription drug use.

CONCLUSION:

This project confirms that substance use in pregnancy is an ongoing health issue and supports recommendations from the leaders in obstetrics and addiction medicine for universal substance use screening in all women of reproductive age.
The Impact of Mode of Delivery on Early Preterm Morbidity and Mortality [32K]
Authors: Zahedi-Spung Leilah D. , Raghuraman Nandini , Woolfolk Candice , Macones George , Cahill Alison
Published: April 2020

INTRODUCTION:

Whether the mode of delivery for early preterm infants influences the risk of adverse outcomes is an ongoing topic of debate. This study aims to determine whether cesarean delivery is independently associated with improved early preterm neonatal morbidity or mortality.

METHODS:

This is a retrospective cohort study of preterm deliveries at 22.0–29.0 weeks gestation between 2010 and 2015, excluding multiple gestations, intrauterine fetal demise, and induction terminations. The primary outcome was a neonatal morbidity composite (apgar <5 at 5 min, prolonged ventilation >28 days, IVH, NEC, coagulopathy, discharged on home ventilator support, or discharged with enteric feeding tube). The secondary outcome was neonatal death. Outcomes were compared between patients who underwent cesarean vs vaginal delivery. Patients were first matched for ethnicity (black v. other). Propensity scores were estimated utilizing logistic regression models adjusting for small for gestational age, gestational at delivery, and nulliparity. IRB approval was granted through Washington University.

RESULTS:

Of the 273 (56.9%) early preterm deliveries, 125 (45.8%) were cesarean deliveries and 148 (54.2%) were vaginal deliveries. After matching, there were 115 patients in each group. In vertex fetuses, there was no significant difference in neonatal mortality within 24 hours (aOR 1.48 CI 0.56, 3.90) or within 28 days of delivery (aOR 0.71 CI 0.27, 1.90) by mode of delivery. There was no difference in composite neonatal morbidity.

CONCLUSION:

In this propensity score analysis, the risk of neonatal death or neonatal morbidity was not significantly improved among early preterm neonates delivered by cesarean versus vaginal delivery.
Use of Placental Growth Factor (PLGF) for Aneuploidy Screening in Pregnancy: A Systematic Review [38K]
Authors: Badeghiesh Ahmad , Volodarsky-Perel Alexander , Hemmings Robert , Gil Yaron , Balayla Jacques
Published: April 2020

INTRODUCTION:

Placental growth factor (PLGF) is a protein of trophoblastic origin. Whether addition of PLGF to combined serum aneuploidy screening tests improves detection rates for trisomy 21 is controversial.

METHODS:

We performed a systematic review of the literature until August 2019. We performed a goodness of fit test and retrieved the coefficient of determinations (R2) before and after the introduction of PGLF, as a function of false positive rates. Receiver-operating characteristic curves are provided in order to illustrate findings.

RESULTS:

We identified a total of 51 studies, of which 8 met inclusion criteria. Three prospective and five case-control studies included a total of 834 aneuploidy cases and 105,904 euploid control pregnancies. Detection rates (DR) were proportional to false-positive rates (FPR) across all studies, and ranged from 59.0% to 95.3% without the use of PLGF and 61.0% to 96.3% with PLGF (FPR 1% to 5%). Goodness of fit regression analysis revealed a logarithmic distribution of DR with R2=0.109 in the no PLGF group and R2=0.06 in the PLGF group. These indicate a large variation between DR for a given FPR across studies. Our analysis demonstrates average improvements in DR of 3.3% for a 1% FPR, 1.7% for a 3% FPR, and 1.4% for a 5% FPR.

CONCLUSION:

Addition of PLGF to prenatal screening using serum analytes mildly improves trisomy 21 detection rates between 1.4 and 3.3% for FPR’s between 5% and 1%, respectively. Future studies should address the cost-benefit analysis of introducing PLGF for prenatal screening.
Bladder Rupture Following Both Successful and Failed Trial of Labor After Cesarean [02L]
Authors: Bennett Carrie , Newton Kathryn , Wilkins Catherine , Schleicher Maria
Published: April 2020

INTRODUCTION:

The incidence of bladder injury during cesarean section is estimated to be 0.08 to 0.94%. In patients with previous cesarean delivery, rate of bladder injury after successful VBAC is 0.2% while unsuccessful TOLAC confers 1.1% risk. The average length of bladder injury is 4.2 cm.

METHODS:

Case presentation.

RESULTS:

The first patient is a 26 year-old gravida 3 para 2 presenting at 39w3d in spontaneous labor with history of 31 week emergent cesarean for breech presentation at complete dilation. Labor augmented with oxytocin and patient progressed to complete. Successful vacuum-assisted delivery performed for fetal bradycardia. Approximately 90 minutes after delivery, patient was noted to have copious amounts of fluid from the vagina upon retrograde bladder fill. Exploratory laparotomy demonstrated posterior bladder rupture from dome to neck and anterior cervicovaginal rupture causing cervical avulsion. The second patient is a 34 year-old gravida 2 para 1 presenting at 38w6d in spontaneous labor with history of cesarean for failed vacuum delivery. Patient progressed to complete by own mechanism but opted for cesarean after 1 hour of pushing. After an atraumatic delivery of infant, entirety of Foley catheter was noted within surgical field. Large cystotomy present from posterior aspect of dome distally through trigone and bladder neck concurrent with uterine rupture demonstrating vaginal extension.

CONCLUSION:

Successful VBAC does not preclude urologic injury. TOLAC counseling should be individualized based upon prior operative reports, with high indices of suspicion when hysterotomy may have been performed lower than anticipated. With early recognition of injury, favorable prognosis can be achieved.
Comparing Internal and External Severe Maternal Morbidity (SMM) Review in Illinois [06L]
Authors: Geller Stacie , Garland Caitlin , Horne Ashley , Locher Stephen
Published: April 2020

INTRODUCTION:

A majority of states have implemented maternal mortality review committees, but Illinois is the only state to also implement facility-level, multidisciplinary review of SMM at all obstetric hospitals as recommended by the Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists.

METHODS:

Facility-level multidisciplinary SMM review was implemented in all perinatal networks in 2017 using a modified 2-factor scoring system recommended by CDC/ACOG (ICU admission and >4 units of packed red blood cells). A standing external, multidisciplinary SMM review committee was also established to review a subset of reviewed cases to improve the hospital review process and to compare external committee decisions to the internal review.

RESULTS:

The external committee found 34% of SMMs were potentially preventable compared to 16% across internal review. In external review, the most common factors contributing to SMM was medical decision making, however internal review found pre-existing conditions and pregnancy complications as leading preventable factors. The external committee found more provider (63% vs 16%) and system (41% vs 16%) opportunities to alter SMM than the internal committees (patient factors).

CONCLUSION:

This study is the first to present findings on statewide implementation of SMM review both within hospital and by external committee and compare parallel facility-level and state-level review. External review shows more preventability and more provider and system opportunities to prevent SMM compared to internal review. External review by a multidisciplinary committee provided more opportunities to identify strategies to alter outcomes, however both offer opportunities for quality improvement and population-based findings.
Conservative Management of Preeclampsia (CMOP): A North Carolina Quality Improvement Project [08L]
Authors: Ollendorff Arthur , Cochran Keith , DeJoseph Jodi , Greenberg Rachel , Gutierrez Susan , McCaffrey Marty
Published: April 2020

INTRODUCTION:

According to birth certificate data, hypertension in pregnancy is a leading cause of premature births in North Carolina. A quality improvement project was developed using the 2014 Hypertension in Pregnancy guidelines to properly diagnose hypertensive disorders of pregnancy and see which diagnoses led to premature birth.

METHODS:

Birthing hospitals in North Carolina participated in a quality improvement project sponsored by the Perinatal Quality Collaborative of North Carolina. In phase one of the project, hospitals attended a series of monthly webinars, semiannual face-to-face meetings and received periodic support from the PQCNC core team to review best practices to correctly diagnose each of the hypertensive disorders. Hospitals submitted monthly data about their delivered mothers with any hypertension in pregnancy diagnosis through a secure web portal.

RESULTS:

Twenty-two birthing hospitals participated in phase one of the project between March 2015 and March 2016 accounting for 56,743 deliveries (48% of the deliveries in the state). There were 7,550 women (13.3%) with any hypertension in pregnancy diagnosis. 661 of these women delivered prior to 34 weeks and 1254 delivered prior to 37 weeks. The cost common hypertension diagnosis related to prematurity was preeclampsia with severe features (48%).

CONCLUSION:

More than half of the premature infants born to mothers with hypertension in North Carolina were delivered with a diagnosis other than preeclampsia with severe features. With a more complete picture of the severity of hypertension in pregnancy and the role it plays in prematurity in North Carolina, women's health leaders in the state can define potential interventions.
Maternal Near Miss at a Tertiary Teaching Hospital in Mekelle, Ethiopia [21L]
Authors: Yeman Awol , Teka Hale , Zelelow Yibrah Berhe , Mohammednur Sumeya , Goba Gelila , George Jessica
Published: April 2020

INTRODUCTION:

A peripartum near-miss event occurs when a woman nearly dies, but survives a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy. As maternal deaths are rare occurrences, near-miss cases can be used instead to elucidate the events leading to complications and the obstacles that must be overcome to treat complications, hence providing valuable information on obstetric care. This study aimed to assess maternal near miss at Ayder Referral Hospital (ARH).

METHODS:

Our study was a retrospective chart review of near miss cases seen at ARH between July 1, 2016 and June 30, 2017. WHO near miss criteria was used to select cases.

RESULTS:

Over the study period, there were 3,899 deliveries, 236 near miss, and 13 maternal deaths at ARH. The leading causes of near miss were hemorrhage (41.9%), hypertensive disorders of pregnancy (41.1%), sepsis (9.3%), labor abnormality (4.6%), and medical disorders of pregnancy (3.6%). In terms of timing of near miss diagnosis, 37.7% occurred antenatally, 25% intrapartum, 32% postpartum, and 5.1% post abortion. 86% of cases were referred from other health facilities. Majority of the patients (80%) arrived to our hospital in critical condition. Ninety percent of the near miss cases had antenatal care (ANC) at health center.

CONCLUSION:

Near miss is substantial problem in North Ethiopia. Most referred patients arrived in critical condition, suggesting support and transportation from referring institutions should be improved. Additional research is need to assess the quality ANC given that 90% of the near miss cases had ANC.
Betamethasone-Induced Atrial Fibrillation With Rapid Ventricular Response in Pregnancy: Case Report [05M]
Authors: Verkh Dave , Chalifour Stephanie , Giannina Gregg , Yassin Haidar , Scibetta Craig , Greenspan David L.
Published: April 2020

INTRODUCTION:

Atrial fibrillation (AF) is a common cardiac arrhythmia but a rare occurrence in obstetrical patients.

METHODS:

A 24-year-old G6P2032 without significant medical history presented at 32 3/7 weeks gestation for routine obstetrical care. The fetus was suspected to have a hypoplastic right heart via fetal echocardiography at 24 5/7 weeks of gestation. She reported decreased fetal movement and audible fetal decelerations were noted during her exam. The patient was referred to the hospital and was noted to have category II fetal heart rate tracing (FHR). Considering the possibility of delivery before 37 weeks, she was given 12 mg betamethasone intramuscular injection at 32 3/7 weeks, which was repeated in 24 hours. The FHR improved to category I throughout prolonged monitoring. The following day, the patient returned complaining of severe palpitations, shortness of breath and was noted to have a pulse of 159 BPM while in AF with rapid ventricular response. She was started on an esmolol drip for rate control and failed to spontaneously convert to normal sinus rhythm (NSR). A transesophageal echocardiogram was performed, followed by direct current cardioversion (DCCV) with 150 J. The patient remained symptom-free in NSR after the DCCV and was discharged on 40 mg enoxaparin. Patient informed consent was obtained for submission of this case report.

CONCLUSION:

This case illustrates the uncommon, yet acknowledged risk of corticosteroid-induced AF. There have been reported cases of AF in pregnant patients receiving both betamethasone and beta-mimetics; however, these case reports attribute the AF to the beta-mimetics. This is believed to be the first reported case of betamethasone-induced AF in pregnancy.
Differences in Post-Delivery Blood Pressures Between Women Who Will Develop Postpartum Preeclampsia and Controls [12M]
Authors: Brubaker Laura H. , Brawley Amalia M. , Williamson Mary H. , Stetter Christy M. , Kunselmanl Allen R. , Pauli Jaimey M.
Published: April 2020

INTRODUCTION:

Postpartum preeclampsia (with first clinical manifestation after delivery) is poorly understood but has the potential for catastrophic consequences for patients. Predictive variables in the postpartum period may improve outcomes. The purpose of this study was to determine if there is a difference in blood pressure in the immediate postpartum period (delivery to discharge) in women readmitted with postpartum preeclampsia and controls.

METHODS:

Deliveries in a 5-year interval (2014-2019) at a university hospital were included in this retrospective cohort study (n=3,621 unique patients). IRB committee waiver was obtained for the study. Exclusion criteria were diagnosis of preeclampsia, eclampsia, or Hemolysis Elevated Liver Enzymes Low Platelets (HELLP) prior to delivery. Cases included readmissions for preeclampsia, eclampsia, or HELLP diagnosed after delivery (n=26). Controls were randomized from remaining patients (3:1 controls to cases, inflated by 10% to account for prevalence of exclusion criteria) (n=78). Each subject’s highest systolic (SBP) and diastolic blood pressure (DBP) from delivery until discharge was recorded. Two sample t-tests were used, significance set at 0.05.

RESULTS:

The mean peak SBP for cases was significantly higher than controls at 147.4 mmHg (SD 13.4 mmHg) compared to 133.3 mmHg (SD 12.0 mmHg) (P<.001). Mean peak DBP for cases was also higher than controls at 91.6 mmHg (SD 8.7 mmHg) compared to 82.9 mmHg (SD 8.0) (P<.001).

CONCLUSION:

Blood pressure in the immediate postpartum period was higher in women readmitted for postpartum preeclampsia compared to controls. This information may be a first step in developing a predictive model to better understand and predict postpartum preeclampsia.
Effectiveness of Maternal Safety Bundle for Obstetric Hemorrhage at a Large U.S. Military Hospital [15M]
Authors: Joseph Katherine , Wilson Karen L.
Published: April 2020

INTRODUCTION:

Postpartum hemorrhage is one of the leading causes of maternal deaths worldwide. Attempts to remedy this problem have led to the implementation of multiple maternal safety bundles, of which one was recently implemented at Womack Army Medical Center at Fort Bragg, NC. The goal of our study is to determine the effectiveness of this bundle in predicting postpartum hemorrhage in a military population.

METHODS:

Our study included patients that delivered from March through December 2017, who were deemed either moderate or high risk for postpartum hemorrhage. We looked at blood transfusion rates and risk factors for receiving transfusions. Numerical variables were compared using Student’s t or Wilcoxon Rank Sum as appropriate. Categorical variables were compared with the χ2 Test of Independence or Fisher’s Exact.

RESULTS:

There were 423 patients who were considered ‘moderate’ risk (78.7%) or ‘high’ risk (21.3%) for postpartum hemorrhage. Of patients considered high risk, 11.1% required a blood transfusion, whereas significantly fewer patients classified as moderate risk required a transfusion (3.9%, P=.0150). The only significant risk factors for blood transfusion in this sample were patients with history of a prior postpartum hemorrhage (P=.0027, assessed antepartum) and less than 70,000 platelets assessed intrapartum (P=.0082).

CONCLUSION:

Our study shows that this bundle for obstetric hemorrhage was able to predict a higher rate of transfusion for those deemed high risk. Interestingly, our analysis showed only 2 risk factors of 26 were found to be statistically significant for blood transfusion.