bluuebunny/crossref_metadata_2025 huggingface dataset:
Toxicology Testing of Neonates: Do a Mother's Demographics Influence Decisions to Test? [35C]
Authors: Perlman Nicola C. , Smith Nicole A.
Published: April 2020

INTRODUCTION:

Toxicology testing of newborns carries substantial consequences to families, with implications for social service involvement, limitations on breast milk administration, and custody concerns. Clear guidelines for testing of neonates do not exist, and obstetric providers may have opportunities to influence practices of our pediatrician colleagues. We aimed to evaluate whether patterns concerning for implicit bias could be seen in toxicology testing of newborns.

METHODS:

We reviewed charts of all babies born at a single tertiary academic center between 1/1/18 and 12/31/18 on whom toxicology testing was sent. Demographic data was taken from mothers' charts as newborn demographics are not routinely recorded, and compared to sociodemographic data of all mothers with infants born in 2018, including age, race, marital status, ZIP code. Data was analyzed with Wilcoxon Rank Sum test, Chi Square test, or ANOVA where appropriate.

RESULTS:

Of 6438 births in 2018, Tox was sent on infants of 86 mothers (1.3%). Mothers of babies with toxicology testing sent were younger (P<.0001), less likely to be white (P<.0001), reported “single” as marital status (P<.0001), and lived in the lowest income ZIP code (P<.0001).

CONCLUSION:

Maternal age, race, marital and socioeconomic status appeared to significantly impact pediatricians' decisions to order toxicology testing on neonates. Evidence based guidelines may decrease implicit bias in neonatal toxicology testing, and better identify babies at risk of substance exposures.
Rural Women in the United States Burdened by High Maternal Transfer Rates [28C]
Authors: McDowell Laura , Hartenbach Ellen , Daphne Kuo Hsiang-Hui , Ehrenthal Deborah
Published: April 2020

INTRODUCTION:

To describe obstetrical transfer patterns concerning maternal characteristics and outcomes.

METHODS:

Using 2014–2016 birth records from the National Center for Health Statistics (NCHS) we examined antepartum transfer based on maternal resident county: large metropolitan center (LMC), large metropolitan fringe (LMF), medium metropolitan (M metro), small metropolitan (S metro), micropolitan (Micro) and non-core/rural (Non-core). We examined the association between transfer and sociodemographic, health, and peripartum characteristics.

RESULTS:

59,399 transfers occurred among 11,233,882 hospital births (0.53%). More were living in Micro (OR 3.68, CI 3.59–3.77) and Non-core counties (OR 5.05, CI 4.92–5.19), <18 (OR 1.40, CI 1.33–1.48), non-Hispanic American Indian/Alaskan Native (NH-AIAN) (OR 8.31, CI 8.06–8.56), without prenatal care (OR 4.29, CI 4.14–4.45) and Medicaid (OR 1.47, CI 1.44–1.49) or self-pay (OR 1.67, CI 1.60–1.74). Associated characteristics included smoking (OR 2.40, CI 2.35–2.46), BMI >40 (OR 1.77, CI 1.71–1.83), diabetes (OR 1.63, CI 1.59–1.67), hypertension (OR 3.67, CI 3.59–3.75), multiparity (OR 4.98, CI 4.87–5.10), breech (OR 3.84, CI 3.77–3.93), chorioamnionitis (OR 2.42, CI 2.32–2.53), cesarean (OR 2.04, CI 2.00–2.07) and preterm (OR 21.5, CI 21.1–21.9). Morbidity was high with increased blood transfusion (OR 5.21, CI 4.87–5.58), ICU admission (OR 9.64, CI 8.98–10.36), uterine rupture (OR 3.93, CI 3.07–5.02) and hysterectomy (OR 7.08, CI 4.87–5.57).

CONCLUSION:

Transport disproportionately affects rural women. These moms are more likely rural, younger, NH-AIAN, without prenatal care, and utilize Medicaid or self-pay. Numerous individual and health systems factors led to increased morbidity for mothers and infants suggesting areas for future quality initiatives.
Reducing Postpartum Oxycodone Usage at University Hospitals [33E]
Authors: Cossler Nancy , Liu James H. , Albertini Megan , Porter Steven , Niemi Marcie , Katz Tyler Jessica
Published: April 2020

INTRODUCTION:

Opioid analgesics are among the most common medications employed for postpartum pain management. However, opioid side effects such as nausea, vomiting, urinary retention, and sedation are problematic and can adversely impact postpartum recovery. In addition, the national opioid crisis has prompted enhanced vigilance around narcotic usage in healthcare settings. Non-steroidal anti-inflammatory medications and acetaminophen are an effective complement to opioid analgesia. We describe a systematic approach to reducing postpartum oral narcotic use at MacDonald Women's Hospital (MWH), a northeast Ohio-based hospital providing obstetric services and delivering approximately 4000 women/year.

METHODS:

Beginning on June 5, 2018, we implemented a postpartum care bundle comprised of the following interventions: 1) Providing scheduled PO acetaminophen and PO ibuprofen every six hours after vaginal delivery; and 2) Providing scheduled IV ketorolac every 6 hours for twenty four hours after cesarean delivery, followed by scheduled PO acetaminophen and PO ibuprofen until discharge.

RESULTS:

From May 2017—May 2018, oxycodone usage at MacDonald Women's Hospital averaged 181.6 doses per 100 patient days. From June 2018—May 2019, average rates of oxycodone usage decreased to 153.3 doses per 100 patient days. Following the rollout of the postpartum care bundle, there was no significant change in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) patient satisfaction scores related to pain communication (77.9% 6 months pre-bundle vs. 92.2% 6 months post-bundle).

CONCLUSION:

This intervention was associated with a decrease in postpartum in-hospital oxycodone usage without a negative impact on patient satisfaction scores.
Factor V Deficiency in Pregnancy: Could This Mean One and Done? [14N]
Authors: Varma Shruti , Christie Alexandra C. , Aikman Noelle Marie
Published: April 2020

INTRODUCTION:

Post-partum hemorrhage is the leading cause of maternal mortality worldwide. Our case outlines the importance of recognition of the risks of post-partum hemorrhage including the possibility of permanent sterility.

METHODS:

Case Presentation: A 32-year old G0 @ 39 2/7 weeks presented in labor with minimal prenatal care and congenital Factor V deficiency. Maternal Fetal Medicine and hematology consultants recommended fresh frozen plasma (FFP) to a goal INR of <1.5 mg/dL. Her level on admission was 3 mg/dL. Her Factor V assay was <1%; (nml>70%). She successfully delivered a female neonate and received tranexamic acid, FFP, Cytotec, packed red blood cells, and platelets secondary to heavy bleeding. After delivery, she was hemodynamically unstable and was transferred to SICU for monitoring. Her hemoglobin was 5.2 g/dL with continued bleeding. Ultrasound revealed a distended lower uterine segment with large blood within the cavity. She was unresponsive to blood products and was taken to the OR for exploratory-laparotomy with postpartum hysterectomy.

CONCLUSION:

Factor V deficiency is a rare coagulopathy which leads to a high hemorrhage risk in pregnancy. The incidence is one in one million. We identified multiple reports documenting successful management of Factor V deficiency in pregnancy with FFP given prior to delivery. These patients had deliveries without bleeding complications. However, as our case emphasizes, this coagulopathy can lead to detrimental outcomes in the intrapartum and post-partum period, even with FFP. It is crucial to identify and counsel patients extensively on the risks of hemorrhage during labor including the possibility of permanent sterilization.
Conservative Management of Placenta Accreta Using Helium Plasma Focused Radio Frequency Energy [11N]
Authors: Khamvongsa Peter , Rodriguez Anthony , Patel Naiya
Published: April 2020

INTRODUCTION:

Abnormal placentation, including placenta accreta, have been occurring at a higher incidence than before due to the increase in cesarean sections. The gold-standard treatment if uncontrolled bleeding occurs is peripartum hysterectomy, depriving woman of future fertility. The purpose of this case was to apply a conservative management by using a helium plasma device to fulgurate the placenta accreta at the uterine site.

METHODS:

Patient informed consent was obtained for submission of a case report. Cesarean delivery with low-vertical incision and manual extraction of the placenta was performed. The uterus was exteriorized and the helium plasma radio frequency (RF) device (J-Plasma system) was used to fulgurate the retained placental tissue, confirming hemostasis with a radius of 3 cm from the site. Hemabate was given to the site to maintain uterine contraction.

RESULTS:

The helium plasma device provided adequate hemostasis to the 12.76 cc of retained placenta accreta at 40% power 4 L/min gas flow, reducing lateral and depth damage of normal endometrial tissue. Quantitative blood loss was 560 cc. Obstetric hemorrhage and peripartum hysterectomy were avoided, allowing for future fertility.

CONCLUSION:

The helium plasma RF device provided a high-precision and efficient operative time in conservatively managing placenta accreta. This adds a safer alternative form of managing abnormal placentation and avoiding radical treatment. More research and trials should be done on larger placenta accreta and on other morbidly adherent placentas. It will be able to allow woman of high-risk to maintain their ability of reproducing in the future since a peripartum hysterectomy could be avoided.
Do Lipoid Metabolism Disorders Increase Risks of Maternal and Fetal Complications in Pregnancies? [12N]
Authors: Cai Emmy , Czuzoj-Shulman Nicholas , Abenhaim Haim A.
Published: April 2020

INTRODUCTION:

The effects of lipoid metabolism disorders (LMD) are not well understood in pregnancy; thus, this study aims at understanding the different maternal and fetal outcomes that can be associated with this condition in pregnancy.

METHODS:

Using the Healthcare Cost and Utilization Project – National Inpatient Sample from the United States, a retrospective cohort study was conducted to determine the risks of complications in pregnant women known to have LMDs. All pregnant patients diagnosed with LMDs between 1999 and 2015 were identified using the International Classification of Disease-9 coding. Maternal and neonatal outcomes in pregnant women with LMDs were analyzed using multivariate logistic regression.

RESULTS:

A total of 13,792,544 pregnant women were included in our study; 9,666 women were diagnosed with LMDs for an overall prevalence of 7.0 per 10,000 births. Births to women with LMDs were more likely to have pregnancies complicated by diabetes and hypertension. Women with LMDs were more likely to have premature births, OR 1.42 (95% CI 1.35–1.53), suffer from myocardial infarctions, 11.97 (6.07–23.58), venous thromboembolisms, 2.03 (1.64–2.51), postpartum hemorrhage, 1.34 (1.21–1.48), and maternal death, 3.52 (1.97–6.32). There was also an increased risk of congenital anomalies, 2.48 (2.09–2.93), intrauterine growth restriction, 1.41 (1.26–1.58), and intrauterine fetal demise, 1.79 (1.51–2.13).

CONCLUSION:

The effects of LMDs on pregnancies are not very well understood, but women with these disorders appear to be at significantly increased risks of poor maternal and fetal outcomes. Better understanding of these risks and complications can allow for better outcomes in pregnant women suffering from lipoid metabolism disorders.
Feasibility of Remote Monitoring to Confirm Exercise Adherence in High Risk Pregnant Women [15N]
Authors: Kogutt Benjamin K. , Sheffield Jeanne S.
Published: April 2020

INTRODUCTION:

Pregnancy is an ideal opportunity for women to focus on physical health; however, exercise recommendations are rarely met. At-home fitness is more accessible than ever due to technology-based interventions, and with the addition of wearable technology, real-time adherence and intensity feedback is possible. The objective of our study is to determine if contemporaneous, mobile technology can provide an innovative method to monitor exercise in a high-risk pregnant population remotely.

METHODS:

This is a prospective, randomized controlled pilot study with two arms: exercise vs. standard counseling. Exercise was logged and tracked remotely in both groups. Once an exercise session was recorded, participation was confirmed by cross-referencing participant's FitBit activity and heart rate monitor (San Francisco, CA), thus providing a method to confirm participation and monitor degree of exercise intensity.

RESULTS:

Sixteen total patients were enrolled, eight in each arm. 102 exercise sessions were logged: 80 (78%) in the intervention group vs. 22 (22%) in the non. Exercise was confirmed in 79 of the 102 exercise sessions (77%). Interestingly, only 18% of recorded sessions reached moderate intensity based on heart rate parameters, and none reached vigorous intensity.

CONCLUSION:

Connected health technologies can provide a reliable, cost effective, and efficient method to determine adherence to and degree of exercise intensity in a high-risk pregnant population. Providing feedback to patients about their actual vs. perceived exercise intensity may improve the efficacy of their regimens. Additional research is needed to determine which methods are most effective to motivate exercise in pregnancy.
Implementation of a Maternal Early Warning System Quality Improvement Initiative in Texas Hospitals [20N]
Authors: Patel Divya A. , Salahuddin Meliha , Wagner Amanda , Ramsey Patrick S. , Davidson Christina , Eppes Carey
Published: April 2020

INTRODUCTION:

Delayed response to abnormal maternal vital signs is a leading cause of preventable maternal death. Maternal early warning systems (MEWS) that alert providers to impending critical illness can improve maternal outcomes. Texas Department of State Health Services partnered with the Alliance for Innovation on Maternal Health (AIM) to launch the TexasAIM maternal safety initiative. The Texas perinatal quality collaborative (PQC) is implementing a quality improvement (QI) initiative to augment TexasAIM with a goal of integrating MEWS in a subset of Texas birthing hospitals by December 2019.

METHODS:

Reinforcement cohort (RC) hospitals were identified in January 2019 based on self-reported stage of MEWS implementation (n=15). The implementation framework uses the Institute for Healthcare Improvement Breakthrough Series modified to include the mentor model, and the AIM MEWS toolkit was adapted. Monthly data collection including process, structure and outcome measures began in June 2019.

RESULTS:

Most RC hospitals were urban (80%) and non-academic (53%), with at least 1,000 annual deliveries (73%). In 2017, the mean severe maternal morbidity rate in the RC hospitals and Texas overall was 196 and 170 per 10,000 deliveries, respectively. By August 2019, most providers (82%) and nurses (94%) were educated on the MEWS protocol. Three RC hospitals have fully integrated MEWS, with two serving as peer mentors to remaining RC hospitals.

CONCLUSION:

Implementation of MEWS, in conjunction with AIM bundles, may augment improvements in maternal health. Future work of the Texas PQC includes scaling the MEWS initiative to additional hospitals to support ongoing TexasAIM efforts to reduce maternal morbidity and mortality.
Oral Health Care in Pregnancy, ACOG Fellow Perspectives [27N]
Authors: Roussos-Ross Kay , LaPorte Amanda , Bright Melissa , Villanueva Kara Mia
Published: April 2020

INTRODUCTION:

The American College of Obstetrics and Gynecology recommends routine oral health care during pregnancy. Despite this recommendation, many pregnant women do not receive routine dental care. The reasons for discordance are complex. This study, conducted in conjunction with the ACOG District XII Committee on Healthcare of Underserved Women, surveyed ACOG District XII Fellows regarding their perceptions of factors that impact oral health care in pregnancy.

METHODS:

Between May and October 2019, ACOG District XII Fellows were asked to participate in an anonymous electronic survey on their practices regarding oral health in pregnancy. IRB approval was obtained. Descriptive statistics were estimated using SPSS (V25).

RESULTS:

107 ACOG Fellows completed this survey. Twenty-one percent of Fellows reported receiving education/training related to oral health in pregnancy. Less than half (48%) of Fellows reported asking oral health screening questions, 60% recommend that women undergo routine dental cleaning, and 65% reported counseling patients on the importance of oral health in pregnancy. Seventeen percent (17%) reported insufficient clinic time and 17% of Fellows reported lack of accepting dentists as reasons for not discussing oral health during prenatal care. However, 55% of Fellows reported patients would easily find an accepting dentist.

CONCLUSION:

District XII ACOG Fellows acknowledge the importance of routine oral health care in pregnancy. However, they perceive barriers to recommending care such as limited clinic time and patient access. Offering oral health education during provider training could improve screening rates and counseling. Additionally, increasing access to dental care could improve overall oral health in pregnant women.
Outcomes of Placenta Accreta Cases Managed via a Placenta Accreta Protocol Versus Without a Protocol [29N]
Authors: Juusela Alexander , Javadian Pouya , Gimovsky Martin Larry , Nazir Munir
Published: April 2020

INTRODUCTION:

Placenta accreta spectrum (PAS) is a collection of conditions of abnormal placentation that when undiagnosed at the time of delivery, can lead to massive hemorrhage, disseminated intravascular coagulopathy, hypovolemic shock, and maternal mortality. The purpose of our project was to evaluate outcomes before and after the creation and implementation of our institution's placenta accreta protocol.

METHODS:

After IRB approval was obtained, a retrospective chart review of all deliveries at our institution from January 1st 2007 until December 31st 2015 was performed. Cases were grouped based on those managed following our institution's placenta accreta protocol and those not managed according to the protocol. The data was analyzed using a Student T-test and Chi-Squared (X2) analysis.

RESULTS:

There was a statistically significant difference in outcomes between cases managed with the protocol versus without the protocol for estimated blood loss (P=0.009), units of blood transfused (P=0.002), and intensive care unit admission (P=0.001).

CONCLUSION:

Establishing a suspected diagnosis of PAS before delivery allows for a scheduled delivery and pre-operative planning with a multidisciplinary team based on the severity of the PAS. No randomized controlled trials exist to guide management; therefore management varies between institutions and practitioners. Our retrospective study supports ACOG Committee Opinion No. 529's conclusion in that there was a statistically significant difference in outcomes between unplanned and planned cesarean hysterectomy. As this study demonstrated a clear decrease in adverse outcomes, since this study was performed, all patients with a high suspicion for PAS have been managed using our new protocol.
Acceptability of Using Newborns' Given Names at Birth: Survey in Postpartum and Antepartum Units [01O]
Authors: Besagar Sonya , Robles Patrick Louie , Rojas Chanel , Applebaum Jo R. , Adelman Jason S. , Goffman Dena
Published: April 2020

INTRODUCTION:

Wrong-patient orders present a significant patient safety risk to newborns during delivery hospitalization. Adopting a distinct newborn naming convention (Wendysboy vs Babyboy) significantly reduced the risk of wrong-patient orders in neonatal intensive care units. However, multiple-birth infants remain at high risk, attributable to errors between siblings with nearly identical names (Wendysboy 1, Wendysboy 2). Using newborns' given names at birth may reduce this risk, but acceptability to parents is unknown.

METHODS:

Research personnel surveyed a convenience sample of women in postpartum and antepartum units, in English or Spanish, at a large academic medical center. Data collected included: timing of newborn name selection, willingness to use given names for identification in the hospital at birth, demographics, and pregnancy-related information.

RESULTS:

A total of 253 women were surveyed postpartum (mean age 32.1±5.7 years; mean gestational age [GA] at delivery 38.5±1.7 weeks, 4.0% multiple gestation) and 25 antepartum (mean age 33.2±6.1 years; mean GA 30.3±3.2 weeks; 28.0% multiple gestation). Postpartum, 84.6% (214/253) of women had selected names and would have been willing to use them on the day of delivery; of those, 71.5% (153/214) had selected names before the 3rd trimester. Antepartum, 64% (16/25) had selected names that they would be willing to use at birth. The survey is ongoing; final results will be presented.

CONCLUSION:

The majority of parents have given names available for use at birth. Assigning given names rather than temporary names in the hospital is a feasible systems-level strategy to reduce wrong-patient errors among multiple-birth infants.
Characteristics of Patients Intending to Breastfeed in a Tertiary Obstetric Hospital in Louisiana [07O]
Authors: LeMoine Felicia , Chapple Andrew , Sutton Elizabeth , Pam Lakedra
Published: April 2020

INTRODUCTION:

Increasing the rates of breastfed infants has become a national health objective. Louisiana's breastfeeding initiation and continuance rates remain below the national average, ranking 49th of 50. Our goal is to identify demographic predictors of initial and continued intent to breastfeed.

METHODS:

We conducted a retrospective cohort study of electronic health records from deliveries at Woman's Hospital, a tertiary hospital in South-Central Louisiana, between July 2015 and June 2016 (n=6689; approved and monitored by Woman's IRB). Patients were asked upon admission for delivery if they intended to breastfeed. Their feeding plan (breast, formula, combination) was reassessed at discharge. Logistic regression was used to describe the populations most likely to intend to breastfeed prior to delivery and those that were breastfeeding successfully at the time of discharge.

RESULTS:

Between July 2015 and June 2016, 6,689 patients met criteria for analysis. Patients reporting intent to breastfeed prior to delivery were more likely Caucasian (P<.0001), married (P<.001), nulliparous (P<.01), privately-insured (P<.0001), educated (P<.0001), and older (P<.01) compared to patients not intending to breastfeed. These characteristics were similar in those with continued breastfeeding at discharge, however the strongest predictor of breastfeeding at discharge was intent to breastfeed prior to delivery (P<.0001). African American race was the strongest predictor of non-breastfeeding intent (P<.0001).

CONCLUSION:

Intent to breastfeed prior to delivery was the strongest predictor of breastfeeding at discharge; thus, prenatal breastfeeding education within the at-risk population is crucial to increasing breastfeeding rates. Future studies should assess factors influencing breastfeeding discontinuation and breastfeeding rates through six months postpartum.
Comparison of Doppler Indices in Patients With Umbilical Vein Varix (UVV) to Standard Doppler Indices [08O]
Authors: Rivera Patricia , Heslin Kayla , Forgie Marie M. , Stone Ryan , Kram Jessica J.
Published: April 2020

INTRODUCTION:

There is little consensus on antenatal management of umbilical vein varices (UVV). Our study reviewed biophysical profile (BPP) scores, Doppler indices, and maternal/neonatal demographics.

METHODS:

Following approval by our Institutional Review Board, we retrospectively reviewed singleton pregnancies with UVV from 1/1/2012 to 6/1/2019. Of those with Doppler studies, we compared middle cerebral artery (MCA), umbilical artery (UA), and ductus venosus (DV) values to the 50th percentile of standard indices. We reviewed BPP scores, fetal abnormalities, mode of delivery, maternal comorbidities, neonatal intensive care unit (NICU) admission, and APGARs. Basic descriptive statistics were conducted.

RESULTS:

Overall, 84 women were identified with UVV at an average gestational age of 32 weeks. Notably, 40.5% had used tobacco. Of the fetuses, 13.1% had intrauterine growth restriction, 6% tricuspid regurgitation, 31% anatomic abnormalities. No abnormal BPPs and fetal demises were identified. Sixty-two percent had an abnormal doppler value, with the MCA Doppler differing most from standard indices. Average gestational age at time of delivery was 37 weeks and the cesarean section rate was 26% with a minority due to non-reassuring fetal status (27%). There were three indicated preterm deliveries secondary to umbilical vein thrombus. For the neonates, 31% were admitted to the NICU. Only one had a 5-minute APGAR score <5.

CONCLUSION:

Doppler abnormalities are common in pregnancies affected by UVV with MCA being the most commonly abnormal. None had abnormal BPPs and few required interventions such as indicated cesarean section due to fetal status. This raises the question: is antenatal testing and Doppler testing of any utility?
Cost Analysis and Diagnostic Yield of Histopathology Versus Genetic Testing for Evaluation of Pregnancy Loss [10O]
Authors: Maisenbacher Melissa , Merrion Katerina , Kutteh William
Published: April 2020

INTRODUCTION:

Miscarriage evaluations, including histopathology studies and genetic testing, are performed to determine the cause of the loss and provide maternal medical management guidance. This study examined the cost and diagnostic effectiveness of histopathology and single nucleotide polymorphism (SNP) array-based genetic testing to identify molar pregnancies, defined as conceptions with excess paternal genetic contribution, or another cause of the loss.

METHODS:

Products of conception cases from a single institution (Recurrent Pregnancy Loss Center, Fertility Associates of Memphis, Memphis, TN), are routinely sent for histopathological examination and genetic testing. Retrospective analysis of the results and cost of both evaluations were compared. (IRB E&I 15148-03).

RESULTS:

Fifty-nine cases were examined. SNP array-based testing showed 27 normal (46%) and 32 abnormal cases (54%), including 3 molar (diandric triploidy). Histopathology identified three molar cases; only one was confirmed by SNP microarray. In this cohort, the self-pay cost for histopathology was $241 and for SNP array was $349. The rate of correctly identifying molar pregnancy by histopathology was 1/59 or $14,219/case identified, and by SNP array was 3/59 or $6,864/case identified. Similarly, the rate of identifying a cause of the loss by histopathology was 1/59 or $14,219/case identified and by SNP array was 32/59 or $643/case identified.

CONCLUSION:

Comparison of the cost of SNP array analysis with histopathology evaluation results in a similar expense to the patient. SNP array is an alternative to identifying patients with a molar pregnancy and provides additional clinical information to providers at a significantly lower cost per case for cause of loss identified.
Does Food Access Impact Neonatal Birth Weight? [11O]
Authors: Sawangkum Peeraya , Tanner Jean , Campos Adriana , Fryer Kimberly , Wilson Ronee , Louis-Jacques Adetola
Published: April 2020

INTRODUCTION:

Food deserts are typically found in low-income, low-resource areas that can impact health outcomes. A population-based study in Florida was conducted to determine if living in a food desert was associated with a higher prevalence of low birth weight (LBW, <2500 grams).

METHODS:

Birthweight and demographic information were obtained from the Florida Community Health Assessment Research Tool Set. These data were linked to census tract-level food access information obtained from the US Department of Agriculture Food Access Research Atlas. A low-income, low-access tract (LILA) is a census tract with 20% of the population having income less than 80% of the statewide median family income and with at least 500 people, or 33% of the population, living more than 1 mile (urban areas) or more than 10 miles (rural areas) from the nearest supermarket. Prevalence ratios and 95% confidence intervals were calculated using Poisson regression models.

RESULTS:

From 2008 to 2018, there were 2,368,114 live births with nonmissing birthweight and food access designation in Florida. Approximately 8.6% were LBW, and 18.9% of all LBW occurred in LILA tracts. After adjusting for maternal race/ethnicity, the prevalence ratio (PR) for the association between living in a LILA tract and LBW was 1.06 (95% CI 1.05–1.07). Stratifying by race/ethnicity, the PR were as follows: white non-Hispanic 1.13 (95% CI 1.11–1.15), black non-Hispanic 1.05 (95% CI 1.03–1.06), and Hispanic 1.00 (95% CI 0.98–1.02).

CONCLUSION:

Maternal food access is associated with a higher prevalence of LBW infants in Florida, particularly in white non-Hispanic populations.
Effects of Breastfeeding on NAS Symptom Severity, Infant Pharmacologic Use, and Length of Hospital Stay [12O]
Authors: Turkheimer Lena , Valea Fidel A. , Simcox Kimberly , Hays Jacinda
Published: April 2020

INTRODUCTION:

Prenatal opioid maintenance therapy (OMT) exposure is associated with neonatal abstinence syndrome (NAS) (Finnegan, Connaughton et al., 1975). Our study examines the effects of breastfeeding on NAS symptom severity, pharmacologic use, and length of treatment.

METHODS:

Data was extracted retrospectively from the medical charts of 74 infants born to mothers on OMT at Carilion Roanoke Memorial Hospital (CRMH) and analyzed using propensity score matching, which examines group differences in outcome while controlling for pre-existing differences in background variables (Rosenbaum & Rubin, 1985). IRB approval was obtained.

RESULTS:

Of the sixty infants included, at five days old thirty were being fed formula only, thirteen were breastfed only, and seventeen were fed both breastmilk and formula. Propensity score matching was used to match the thirteen breastmilk only infants to thirteen of the formula-only infants. Mean peak NAS Finnegan scores in the formula and breastmilk groups were 11.54 and 6.54, respectively (P=.03). Mean length of infant pharmacologic treatment was 1.46 months for formula fed infants and .33 months for breastfed infants (P=.02). Among matched pairs with one infant receiving pharmacologic treatment and one not receiving treatment, the formula fed infant was more likely to have received pharmacologic treatment (P=.04).

CONCLUSION:

This study shows that breastfeeding decreases symptom severity, infant pharmacologic use and length of pharmacologic treatment. The use of propensity matching accounts for confounding variables more appropriately than previous studies, likely increasing the reliability of the findings.
Effects of Delayed Cord Clamping on Neonatal Outcomes in Pregestational Diabetes at Term [13O]
Authors: Bennett Carrie , Munoz Jessian Louis , Yao Meng , Singh Katherine
Published: April 2020

INTRODUCTION:

Placental blood transfusion via delayed cord clamping can increase infant blood volume 10–20%. Hyperbilirubinemia is a well-known sequelae of infants born to diabetic mothers. Our study sought to evaluate the effects of delayed cord clamping on neonatal hyperbilirubinemia in a population prone to this phenomenon.

METHODS:

In January 2016, our institution implemented a thirty-second delayed cord clamping policy for provider-deemed eligible patients. This retrospective cohort study represents infants of pre-gestational diabetics who delivered before and after implementation. 72 patients were selected for each arm to achieve 80% power to detect a 15% difference between groups. Term singleton gestations were included. Study period was October 2014 to August 2017. Primary outcome was neonatal transcutaneous bilirubin. Secondary outcomes included serum bilirubin, jaundice requiring phototherapy, hypoglycemia, polycythemia, neonatal respiratory distress, and NICU admission. Subgroup analysis for outcomes in Type I diabetes and Type II diabetes was also performed.

RESULTS:

145 patients were included in the final analysis. Transcutaneous bilirubin was 10.1 ± 3.4 for immediate cord clamping and 9.5 ± 3.4 for delayed cord clamping (P=.25). There were no statistically significant differences between groups in jaundice requiring phototherapy, hypoglycemia, polycythemia, neonatal respiratory distress, or NICU admission. No differences were observed in neonatal outcome by subgroup analysis of Type I versus Type II pre-gestational diabetes.

CONCLUSION:

In our study, there was no statistically significant increase in transcutaneous bilirubin in term infants of mothers with pre-gestational diabetes after undergoing 30 seconds of delayed cord clamping. Further research is needed to ascertain long-term neonatal effects.
Incidence of Jaundice by Maternal Body Mass Index and Diabetes Status [19O]
Authors: Thayer Sydney Marie , Owens Sarah N. , Garg Bharti , Caughey Aaron B.
Published: April 2020

INTRODUCTION:

To examine the association between body mass index (BMI) and neonatal jaundice in women with pre-existing diabetes, gestational diabetes, and without diabetes.

METHODS:

This is a retrospective cohort study of women with singleton, non-anomalous, term pregnancies between 2007 and 2011 using linked vital statistics and discharge data. Chi-square tests were used to compare rates of neonatal jaundice in diabetic and non-diabetic women categorized by BMI class. Pre-pregnancy BMI was categorized into underweight, normal weight, overweight, obesity, and morbid obesity. Multivariable logistic regression was used to examine the association of BMI with jaundice by diabetes classification, controlling for maternal race/ethnicity, age, parity, education, and insurance status.

RESULTS:

The cohort of 1,859,198 consisted of 364,392 (19.6%) obese pregnant women. Overall, a higher BMI class was found to be associated with increased odds of neonatal jaundice, independent of diabetes status. Underweight pre-pregnancy BMI was associated with decreased odds of jaundice when compared to normal-weight women. When compared to women without diabetes, those with gestational and pre-existing diabetes have significantly increased odds of neonatal jaundice (aOR 1.15, 95% CI 1.14–1.17 and aOR 1.63, 95% CI 1.57–1.69, respectively). A significant association was demonstrated between BMI category and jaundice for women with gestational diabetes and no diabetes. In contrast, we did not find a statistically significant relationship between BMI class and neonatal jaundice among women with pre-existing diabetes.

CONCLUSION:

Diabetes status and higher BMI category are associated with increasing incidence of neonatal jaundice. Obstetrical education for women in these categories should emphasize the increased potential of this neonatal complication.
Low 5-Minute Apgar Score and Severe Neonatal Outcomes in Preterm Prelabor Rupture of Membranes [21O]
Authors: Hoover Elizabeth A. , Sawangkum Peeraya , Duncan Jose R.
Published: April 2020

INTRODUCTION:

The Apgar score has limited prediction accuracy of adverse outcomes. We studied the association of a low 5-minute Apgar score with severe neonatal outcomes (SNO) in pregnancies complicated by preterm prelabor rupture of membranes (PPROM).

METHODS:

We conducted a secondary analysis of a prospective cohort study of singleton pregnancies with PPROM at an academic institution from October 2015 to May 2018. Fetal demise and complex anomalies were excluded. The primary exposure was Apgar <7; the primary outcome was SNO. The rate of SNO was compared in neonates with a 5-minute Apgar score <7 to those ≥7. SNO was defined as one or more of the following: RDS; necrotizing enterocolitis; grade III-IV IVH; neonatal sepsis; or neonatal death. Fischer exact test was utilized for statistical analysis.

RESULTS:

Of 105 pregnancies included, 89 were African American and 83 delivered ≥28 weeks gestation. SNO occurred in 42 neonates (41%). 20 newborns received a 5-minute Apgar score <7 (19%); the median gestational age at delivery was significantly less in this group (26 vs. 32 weeks, P<.001). Therefore we compared the association of 5-minute Apgar <7 and SNO after 28 weeks gestation; neonates with Apgars <7 were more likely to develop SNO than those with scores ≥7 (6 (100%) vs. 15 (18%); RR 5.1; 95% CI 3.3–8.0; P<.001).

CONCLUSION:

In pregnancies complicated by PPROM, a low 5-minute Apgar score may be associated with severe neonatal outcomes. We recommend our findings be corroborated in diverse populations.
Use of Ropivacaine Wound Infusion Device for Cesarean Deliveries: Effect on Narcotic Use and Length of Stay [38P]
Authors: Khangura Raminder , Nkemeh Christine , Cooper Shontreal , Campbell Winston , Hammer Erica
Published: April 2020

INTRODUCTION:

Women who use peripartum opioids for cesarean delivery have a 2.2% rate of new persistent opioid use. Opioids have consequences for breastfeeding women, and may contribute to CNS depression in the mother and her breastfed infant. Suboptimal perioperative pain management is associated with chronic pain, delayed functional recovery, impaired maternal-fetal bonding greater opioid use and postpartum depression. Women undergoing cesarean delivery may benefit from local anesthetics delivered by wound infiltration or transversus abdominis plane block. The ropivacaine continuous wound infusion device used in non-obstetrical surgery has shown clinically meaningful reductions in opioid use yet still good pain control. We hypothesize that mothers who use a continuous wound infiltration device for postpartum pain management use less narcotic pain medication compared to mothers who do not use the device.

METHODS:

This is a retrospective case-control study of 18 patients who received a wound infiltration device matched to 18 controls. Charts were abstracted for patient characteristics, length of stay (LOS) and morphine milligram milliequivalents (MME) of opioids used postpartum.

RESULTS:

The primary outcome of total MME and other demographic and clinical variables were not statistically associated with the use of the infiltration device (P>.05). The Spearman correlation coefficient between total MME and LOS (in days) was 0.38, which was not statistically different from zero (no association) with the p-value of 0.12.

CONCLUSION:

While non opioid adjuncts may be useful in reducing narcotic use postpartum, the wound infusion device did not appear to be more beneficial.
Validity of the Emergency Severity Index (Version 4) in Postpartum Women After Cesarean Delivery [40P]
Authors: Kawakita Tetsuya , Thomas Alexandra , Landy Helain J.
Published: April 2020

INTRODUCTION:

To examine the validity of the Emergency Severity Index version 4 (ESI v.4) in women who presented to an Emergency Department within 6 weeks after cesarean delivery.

METHODS:

This was a retrospective cohort study of all women who presented to MedStar Washington Hospital Center Emergency Department from July 2013 to June 2018 within 6 weeks after cesarean delivery. Acuity level was assigned by triage nurses using the ESI v.4 algorithm (1 being the highest acuity and 5 being the lowest acuity). To analyze the validity of ESI v.4, women were divided into 3 groups: high-acuity (ESI levels 1 and 2), medium-acuity (ESI level 3), and low-acuity (ESI levels 4 and 5). We examined the rates of readmission, specialty consultations such as gynecologists, and high resource use (2 or more).

RESULTS:

Of 439 women who presented to the Emergency Department, the distribution of acuity levels was as follows: low-acuity 20.1%; medium-acuity 56.0%; and high-acuity 23.9%. High-acuity and medium-acuity groups had higher rates of hospital admission compared to low-acuity group (2.3% vs. 19.1% vs. 47.6%; P<.001). High-acuity and medium-acuity groups had higher rates of specialty consultation compared to low-acuity group (12.5% vs. 47.2% vs. 69.5%; P<.001). High-acuity and medium-acuity groups had higher rates of high resource use compared to low-acuity group (15.5% vs. 70.8% vs. 86.0%; P<.001).

CONCLUSION:

The ESI v.4 was predictive of readmission, specialty consultation, and high resource use in women who presented to the Emergency Department within 6 weeks after cesarean delivery.
Validation of a Cesarean Delivery Risk Calculator in Women Undergoing Induction of Labor [39P]
Authors: Gammon Betsy L , Melanson Nicole , Chronister Briana , Urban Amanda , Dudley Donald
Published: April 2020

INTRODUCTION:

Prior studies of risk factors for unsuccessful inductions are largely limited to nulliparous women with favorable cervices. Our objective is to validate a recent risk model for cesarean delivery (CD) after induction with an unfavorable cervix (Levine et al., AJOG 2018;218:254).

METHODS:

We performed an IRB-approved retrospective chart review of deliveries between March 2011–2019. Of 2,392 inductions, we analyzed a convenience sample of 1,050, identifying 582 full-term, singleton pregnancies with unfavorable cervices (modified Bishop score ≤6; ≤2 cm dilation). Using the Labor Induction Calculator, participants were grouped by predicted CD probability (Group 1: 0–19.9%; Group 2: 20–39.9%; Group 3: 40–59.9%; Group 4: ≥60%). Grouped analysis was performed to determine whether actual CD rates within risk groups matched the expected probability. Logistic regression was performed to determine whether higher predicted CD probability was associated with increased CD rates (STATA16.0, College Station, Texas).

RESULTS:

The rate of actual CD was less than predicted for our population overall (actual 19.1% v. predicted 28.3%) and for each group. In higher predicted risk groups, actual CD rates were less than predicted (Group 3: actual 36.7% vs. predicted 49.3%*; Group 4: actual 41.2% vs. predicted 66.6%*; *P<.001). Logistic regression using CD probability as an independent risk factor for CD identified an Odds Ratio of 1.05 (95% CI 1.03–1.06, P<.001).

CONCLUSION:

Our CD rates were lower than predicted by the model in all groups, with a particularly pronounced difference among higher risk groups. Prior to adopting risk prediction calculators, validation studies should be performed in specific populations where they will be employed.
The Use of Silver in Cesarean Wound Bandages: A New Way to Decrease Infection and Healthcare Costs [36P]
Authors: Grossman Tracy , Fields Jessica , Chan-Akeley Rosalyn , Dayal Ashlesha
Published: April 2020

INTRODUCTION:

Post-cesarean surgical site infection (SSI) occurs after 3.7–9.8% of cesarean deliveries and is associated with significant morbidity and healthcare costs. Silver has antimicrobial properties and bandages impregnated with it are associated with decreased rates of SSI in non-obstetric surgery. Our objective was to compare the rates of deep and superficial cesarean SSI before and after the institution of silver-impregnated bandages and to analyze related healthcare costs.

METHODS:

This was a retrospective cohort study comparing the rates of cesarean-related SSI five months before and after the institution of silver-impregnated bandages and associated healthcare costs. Data was analyzed using chi-square and Fisher's exact test.

RESULTS:

There were 1,044 cesarean deliveries and 33 wound-related emergency department (ED) presentations during the study period. The demographics of the standard-of-care (n=538) and silver-bandage (n=506) groups were similar. The overall rates of deep and superficial SSI were 0.8% (n=8) and 0.6% (n=6) respectively. The use of silver-bandages was associated with a decrease in the rate of deep SSI (0.6% (n=3) vs 0.9% (n=5), P=.2) and superficial SSI (0.4% (n=2) vs 0.7% (n=4), P=.3). There were 24% fewer ED presentations in the silver-bandage group (13 vs 17) and one wound dehiscence requiring re-operation and negative-pressure wound-therapy, which was in the standard-of-care group. Healthcare costs related to SSI, ED presentations and long-term wound care were 29% less in the silver-bandage group.

CONCLUSION:

The use of silver-impregnated bandages was associated with a decreased rate of cesarean SSI and decreased healthcare costs. Longer-term studies will likely yield statistically significant decreases in SSI and healthcare costs, as post-cesarean SSI is a rare outcome.
The Effect of an Oxytocin Rest Period on Cesarean Delivery Blood Loss [35P]
Authors: Cochrane Elizabeth , Huber Ashley , Jou Christopher , Chappelle Joseph
Published: April 2020

INTRODUCTION:

Studies have demonstrated that two hours of oxytocin exposure can desensitize uterine oxytocin receptors; which may increase blood loss during delivery. Oxytocin's half-life is 10–15 minutes, previous work suggests that it takes approximately 60 minutes to be eliminated. Our objective was to determine if a greater than 60-minute oxytocin rest period prior to cesarean delivery had an impact on blood loss.

METHODS:

An IRB-approved retrospective cohort study of 272 women who underwent primary cesarean delivery after oxytocin augmentation between January 2013 and December 2017 at Stony Brook University Hospital was conducted. Women with a prior cesarean delivery, a cesarean hysterectomy, multiple gestation, and a greater than 240 minute oxytocin rest period were excluded. The primary outcome was percentage change between pre- and post-operative hematocrit (Hct) in women with less than 60-minute oxytocin rest period (60 min).

RESULTS:

There was no difference in demographic or obstetric characteristics between the groups. Women in the >60 min group had a higher cumulative dose (5112+4765 mU vs. 77017325 mU, P=.003), longer duration of oxytocin administration (671±458 min vs. 892±558 min, P=.001), and were more likely to receive uterotonics (6.7% vs. 15.2%, P=.047). No significant difference in percent change in HCT (-17.3±8.6 vs. -17.8±8.7, P=.635) was identified. Linear regression demonstrated a weak relationship between cervical dilation and percent change in Hct. (R2=0.048, P<.001).

CONCLUSION:

No significant correlation between duration of oxytocin rest period and blood loss was found. Women receiving oxytocin augmentation do not appear to benefit from oxytocin rest periods before proceeding to cesarean delivery.
Simultaneous Use of Oxytocin With Foley Balloon in Nulliparous Women Undergoing Induction of Labor [33P]
Authors: Eid Joe , Moutos Christopher , Jacobs Sara , Saade George R. , Saad Antonio
Published: April 2020

INTRODUCTION:

Simultaneous use of oxytocin with Foley Balloon (FB) in induction of labor (IOL) is thought to shorten the interval to delivery. Our objective was to evaluate the effect of such approach on time to delivery and mode of delivery in nulliparous women.

METHODS:

This secondary analysis included nulliparous women who participated in a randomized controlled trial comparing methods of FB placement for cervical ripening. These patients received either oxytocin after FB removal (FB group) or oxytocin simultaneously with FB (FB-Pit group). Our primary outcome was time from FB placement to delivery in hours. Secondary outcomes included mode of delivery, and total time FB was in place. Wilcoxon rank sum test, Student's t-test and Chi Square test were used as appropriate. P<.05 was considered significant.

RESULTS:

The original trial involved 372 patients, 172 were nulliparous and were included in this study. Patients' characteristics were similar in both groups. No difference was noted between FB and FB-Pit groups respectively in terms of time from FB placement to delivery (23.1 vs 21.3 hours; P=.2) or total time FB was in place (8.5 vs 9.1 hours; P=.3). Rate of vaginal delivery was also not significantly different between the two groups (63% in FB group vs 67% in FB-Pit group, P=.5).

CONCLUSION:

Simultaneous use of oxytocin with FB in nulliparous women undergoing IOL did not significantly shorten the time to delivery or improve rate of vaginal delivery. These findings suggest the use of oxytocin in early stages of cervical ripening in such population may have no benefit.