bluuebunny/crossref_metadata_2025 huggingface dataset:
Postpartum LARC Among the Privately Insured—Use After Preterm and Term Births [23J]
Authors: Goldthwaite Lisa , Maric Ivana , Shaw Kate A. , Stevenson David K. , Shaw Gary
Published: April 2020

INTRODUCTION:

Sub-optimal interpregnancy interval (IPI) and prior preterm delivery are risk factors for preterm birth. Provision of long acting reversible contraception (LARC) in the postpartum period may optimize IPI and thereby decrease the risk of a subsequent preterm birth. However, postpartum LARC uptake has not been investigated among those with a prior preterm delivery who are privately insured.

METHODS:

We used the national IBM MarketScan® Commercial Database to identify singleton deliveries from 2007-2016, spontaneous preterm birth, and follow up within 12 weeks postpartum. We compared LARC placement after preterm and term deliveries across years and by state.

RESULTS:

Among 3,132,107 singleton deliveries, 6.6% were preterm. Over the time period, postpartum LARC use more than doubled: 4.8% to 11.5% for intrauterine devices (IUDs), 0.1% to 2.3% for implants. In 2016, compared to term cohort, the preterm cohort was less likely to receive IUDs (10.1% vs 11.7%, P<.0001), as likely to receive implants (2.5% vs 2.3%, P=.15) and more likely to present for postpartum care (62% vs 56%, P<.0001). Placement of LARC prior to hospital discharge was exceedingly rare in both cohorts (preterm: 8 per 10,000 deliveries vs term: 7 per 10,000 deliveries, P=.05). State level analysis showed postpartum LARC use widely varied, by state (range 6%-32%).

CONCLUSION:

While postpartum LARC is increasing among the privately insured, exceedingly few receive LARC prior to hospital discharge. Postpartum follow-up is alarmingly low, highlighting the importance of inpatient LARC access. Variable state-level uptake and private reimbursement warrant ongoing surveillance and efforts to remove barriers to postpartum LARC for all.
Trends in Surgical Sterilization at an Academic Medical Center: Are We Being Opportunistic? [28J]
Authors: Barrows Emily , Truong Mireille , Johnson Molly , Siff Lauren
Published: April 2020

INTRODUCTION:

In the age of evidence-based medicine, physicians are expected to adapt quickly to changing recommendations. The Society of Gynecologic Oncology (SGO) released a practice statement in November 2013 recommending providers consider performing salpingectomy concurrently with other pelvic surgeries for prevention of epithelial ovarian cancers. This study evaluates practice changes from tubal ligation to salpingectomy for surgical sterilization at an academic center following these recommendations.

METHODS:

This IRB approved, retrospective cohort study evaluated interval surgical sterilization procedures performed in an academic medical center between 1/1/2012 and 12/31/2018. Descriptive statistics compared rates of salpingectomy with tubal ligation before and after 1/1/2014, as well as annually. A multivariable regression model was fit to the data to adjust for potential confounding differences between populations.

RESULTS:

243 surgical sterilization procedures were performed during the study time period. Salpingectomy accounted for 0/64 (0%) prior to the recommendation release and 86/168 (51.19%) after the release, (P<.0001). Rate of salpingectomies increased annually: 3/31 (9.7%) in 2014, 9/35 (20.5%) in 2015, 16/32 (50.0%) in 2016, 22/23 (95.7%) in 2017, 36/38 (94.7%) in 2018, (P<.0001). Adjusting for potentially clinically relevant differences in the populations, the only other variable associated with type of sterilization was insurance, (P=.0279). Mean surgical duration was 8.5 minutes longer after the recommendation release, (P=.0019). There were no differences in blood loss, intraoperative or postoperative complications.

CONCLUSION:

Significant practice change in sterilization method from tubal ligation to salpingectomy occurred immediately following the SGO recommendations, however complete adoption of these recommendations (defined as 95% of procedures) took 4 years to achieve.
Uptake of Postpartum Long-Acting Reversible Contraception: The Impact of Timing and Practice Patterns [29J]
Authors: Corbin Kaitlin , Miller Hayley , Bates Paige , Lerma Klaira , Noon Brigit , Shaw Kate A.
Published: April 2020

INTRODUCTION:

Uptake of long-acting reversible contraception (LARC) postpartum is impacted by differences in clinical practices, contraceptive counseling, postpartum follow-up and temporary Medicaid coverage. We sought to determine whether differences in inpatient provision influence uptake of preferred LARC by 8-weeks postpartum.

METHODS:

We performed an IRB approved, retrospective cohort study of all deliveries after 24 weeks gestation in two distinct practice groups at a single academic center in 2016: Practice A routinely offers initiation of intrauterine devices (IUDs) and contraceptive implants prior to hospital discharge; Practice B only routinely offers implants. We collected demographic information, documented postpartum contraception preference and LARC uptake by 8-weeks postpartum.

RESULTS:

We included all deliveries from Practice A (n=878) and Practice B (n=739). Patients from B were younger, Hispanic, publicly insured multiparas with a term, vaginal delivery. At discharge, more from B desired LARC (A: 27.2%, B: 39.2%; P<.001), but more from A desiring LARC initiated prior to discharge (A: 64.9%, B: 39.4%; P<.001). Postpartum follow-up was higher for B (A: 74.5%, B: 83.9%; P<.001), but by 8 weeks, uptake of desired IUD was higher for A (A: 72.9%, B: 51.6%, P<.001), with the majority placed inpatient for A (86.1% vs 10.6%; P<.001). Implant uptake by 8 weeks was similar (A: 86.3%, B: 90.4%; P=.41), with the majority placed inpatient (A: 72.5%, B: 69.2%; P<.001).

CONCLUSION:

Routine access to immediate postpartum IUD placement results in significantly increased uptake of desired IUD by 8-weeks postpartum, supporting provision of immediate postpartum LARC. Future efforts should focus on understanding if the option of immediate postpartum IUD placement influences contraceptive counseling, patient preferences and uptake.
Addressing Family and Genetic History in First Obstetric Visits [30J]
Authors: Walton Alexandra , Iyer Ankitha , Chang Judy
Published: April 2020

INTRODUCTION:

The American College of Obstetrics and Gynecology states asking pregnant patients about family history (FHx) of genetic disease plays an important role in identifying and managing pregnancies with higher risk of genetic conditions. Few studies have assessed these conversations between pregnant patients and their obstetric care providers (OBS).

METHODS:

IRB approval was obtained to collect audio recordings and to transcribe conversations between pregnant patients and OBS during the first obstetric visit. A formulated codebook identified conversation segments containing FHx and genetic disorders and labeled the content of conversations. An independent coder reviewed transcripts to insure intercoder reliability, validity and accuracy. We identified communication patterns, categories, and themes.

RESULTS:

Of 152 transcripts, FHx was discussed in 93% of conversations. Genetic disorders most commonly mentioned were Down Syndrome (89%), Cystic Fibrosis (78%) and Sickle Cell Disease (75%). These were often discussed in the context of genetic screening tests. OBS asked patients to identify their ethnicity in 40% of visits. The father of the baby was present for 32% of visits, father’s ethnicity assessed in 51%, and father’s FHx discussed 48% of the time. Father’s presence at the visit was not associated with likelihood of OBS asking about their FHx. In 10% of visits OBS conveyed assumptions that if the patient did not recognize a disease, this represented a negative FHx for that disorder.

CONCLUSION:

While OBS assessed FHx in most first obstetric visits, communication approaches used in these assessments may not elicit complete information given that specific disorders and father’s FHx were not consistently discussed.
Maternal Outcomes Associated With Induction of Labor at 39 Weeks Compared With Expectant Management [34J]
Authors: Rossi Jordan , Contag Stephen , Burn Sabrina , Diaz Maria , Yao Ruofan
Published: April 2020

INTRODUCTION:

To compare the risk of maternal complications associated with induction of labor (IOL) at 39 weeks gestation with that of expectant management (EM) beyond 39 weeks gestation.

METHODS:

This is a retrospective cohort analysis of singleton non-anomalous pregnancies in the United States between January 2015 and December 2017. Data was abstracted from the CDC National Center for Health Statistics from the Division of Vital Statistics. Analyses compared IOL at 39 weeks of gestation versus EM with delivery between 40 and 42 weeks of gestation. Maternal outcomes of interest included need for blood transfusion, development of chorioamnionitis, intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, and cesarean delivery (CD). Logistic-binomial regression analysis was performed to calculate the relative risk for the outcomes of interest, adjusting for confounding variables.

RESULTS:

There were 1,987,757 pregnancies included for analysis with 499,920 women in the IOL group. The risk of chorioamnionitis was 1.39% for IOL and 2.47% for EM (aRR: 0.58, 95% CI [0.56-0.59]). The risk of CD was 14.7% in the IOL group versus 14.8% in the EM group (aRR: 0.94, 95% CI [0.93-0.94]). Unplanned hysterectomy in the IOL group was 0.03% versus 0.02% in the EM group (aRR: 1.30, 95% CI [1.05-1.59]). There were no differences in risk of blood transfusion, ICU admission, and uterine rupture between the IOL and EM groups.

CONCLUSION:

Women who underwent IOL at 39 weeks had a lower risk of chorioamnionitis and CD compared to EM. However, there was a higher risk of unplanned hysterectomy with IOL at 39 weeks.
Modifiable Factors Influencing Postpartum IUD Expulsion and IUD String Visualization [35J]
Authors: Jagannathan Samantha , Yu Daohai , Lu Xiaoning , Finch Susan , Jeronis Stacey
Published: April 2020

INTRODUCTION:

The aim of this study is to identify factors that help prevent unintended and short interval pregnancy. Immediate postpartum IUD insertion should be offered routinely as a safe and effective option for postpartum contraception per ACOG. There is concern, however, that this results in a higher IUD expulsion rate than interval placement, as well increased failure in visualizing IUD strings at subsequent visits. In this study, we assess the effects of the four modifiable factors on both IUD expulsion and IUD string visualization when placed immediately postpartum: mode of delivery (SVD or CS), IUD type (Mirena/levonorgestrel or Paragard/copper), BMI (=35) and number of prior vaginal deliveries (<2 or >=2).

METHODS:

This retrospective study was performed between 7/1/2017 and 1/15/2019 at Temple University Hospital. 193 women ages 15-42 attended a postpartum visit after immediate IUD placement at this hospital. Demographic data, dilation at time of c-section, use of epidural and reasons for IUD removal were noted.

RESULTS:

Results indicate that none of the major factors when considered in isolation affect IUD expulsion. However, string visualization in postpartum visits is affected by two factors considered in this study: IUD type and mode of delivery.

CONCLUSION:

Better understanding of an individual patient’s risk factors for IUD expulsion will help providers to counsel patients appropriately as to when to receive IUD given higher expulsion associated with immediate postpartum IUD insertion. Given string non-visualization involves time and cost to the patient and provider, better counseling guidelines should be developed based on the results of this study.
Priority-Setting for Cochrane Review Updates With Clinicians and Consumers [36J]
Authors: Kumar Nimisha , Grant Sean , Haas David M.
Published: April 2020

INTRODUCTION:

The US Satellite of the Cochrane Pregnancy & Childbirth Group was launched in March 2019. One of the goals of the US-PCG was to engage both clinicians and consumers in a priority-setting exercise that aimed to (1) identify which systematic reviews to update and (2) reveal any gaps in current knowledge that require a new review.

METHODS:

A series of editorial team evaluations narrowed a list of over 600 relevant review titles down to 97, all of which were in 7 topic categories. A Qualtrics survey was used. Respondents self-identified as a clinician/researcher or consumer and then were asked to rank 10 titles into a “highest priority” area and could rank another 20 in a “medium priority” area. This survey was disseminated through various channels, including ACOG, March of Dimes, Cochrane, and social media networks.

RESULTS:

63 participated in our survey, with 45 clinicians and 18 consumers. Of the 7 categories, maternal medical problems and complications (MMPC) was the topic of most interest overall (79.4%). MMPC was chosen most by clinicians but was tied with psychosocial factors in postpartum care (PFPC) for consumers. Antiplatelet agents for preventing preeclampsia was the only title in the top 3 priority by both clinicians and consumers, but multiple titles overlapped in the top 10 priority.

CONCLUSION:

Clinicians and consumers were able to select priority titles for updating reviews with the groups often sharing some consensus. Stakeholder consensus on review topics will be further refined using Delphi methods to a final priority list by the end of 2019.
Activity Rest Prescription and Compliance in Women With Short Cervix [03K]
Authors: Bitar Ghamar , Sciscione Anthony , Fonge Yaneve
Published: April 2020

INTRODUCTION:

Despite lack of evidence to support efficacy, activity restriction is one of the most common prescribed interventions used for the prevention of preterm birth. With short cervix being one of the risk factors for preterm birth, the purpose of our study was to determine if women with short cervix are prescribed activity rest and if they are compliant.

METHODS:

This is a single-center retrospective cohort study of women identified with short cervix (<25 mm) prior to 28 weeks gestation of pregnancy who delivered between January 2018 and February 2019. The verified cohort was contacted by phone and administered a questionnaire to identify details regarding activity rest (work restrictions, pelvic rest, lifting restrictions or bed rest) during pregnancy. The primary outcome is rate of activity restriction in women and compliance of prescribed rest.

RESULTS:

Of women questioned, 37% of women with short cervix were placed on activity rest and 83% of these women were placed on rest by an obstetrician. 100% of women reported compliance with prescribed activity rest. 41% of women were prescribed pelvic rest separately from other forms of activity rest. Average gestational age at delivery was comparable for women on activity rest and those not on activity rest (31.2 vs 31.7 weeks gestation).

CONCLUSION:

Women with short cervix are being prescribed activity rest almost exclusively by obstetricians and are strictly compliant. Women consider activity rest and pelvic rest separate entities. Education to physicians may be needed to reduce unnecessary activity rest in pregnancy as it does not improve preterm birth rate.
Antenatal Steroids in Late Preterm Gestation: Efficacy of One vs Two Doses [05K]
Authors: Wajid Naji A. , Shanahan Lisa K. T. , Staudenmaier Emily K. , Vullo John , Gurram Padmalatha
Published: April 2020

INTRODUCTION:

Antenatal corticosteroid (ACS) administration in late preterm gestation has been shown to reduce neonatal morbidity and mortality. The objective of the study was to compare the efficacy of antenatal steroids among patients who received zero, one, or two betamethasone injections.

METHODS:

A retrospective review was performed of patients receiving ACS between 34 and 37 weeks gestation. Groups were defined as patients receiving zero doses (Group 0), one dose (Group 1), or two doses (Group 2). Antepartum complications and incidence of the following neonatal outcomes were studied: respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), neonatal hypoglycemia and neonatal ICU (NICU) admission. Exclusion criteria were administration of steroids before 34 weeks, and term deliveries. IRB approval was obtained.

RESULTS:

Groups 0, 1, and 2 consisted of 89 patients, 68 patients, and 57 patients, respectively. Maternal characteristics and antepartum complications were similar (P>.05). Gestational age at ACS administration and delivery was similar. Incidence of RDS was significantly higher in Group 1 (52.9%) compared to Group 2 (29.8%), while similar between Groups 0 and 1. Group 2 (31.6%) demonstrated a significantly higher rate of hypoglycemia compared to Group 1 (4.4%). Group 2 demonstrated higher NICU admission rate (86%) when compared to Group 0 (56.2%), while no significant difference was observed between Group 0 and Group 1.

CONCLUSION:

Incidence of RDS is significantly lowered only in patients receiving two doses of betamethasone. Further studies are needed to determine cost effectiveness of single dose administration when completion of two doses is unlikely.
Bringing Statistics to Life: Developing “Lived-Experience” Family Videos for a Periviable Decision-Support Tool [06K]
Authors: Edmonds Brownsyne Tucker , Hoffman Shelley , Laitano Tatiana , Coleman-Phox Kimberly , Castillo Esperanza , Kuppermann Miriam
Published: April 2020

INTRODUCTION:

To develop and incorporate ‘lived-experience’ videos of families describing their lives following periviable delivery into the Periviable GOALS (Getting Optimal Alignment around Life Support) decision-support tool.

METHODS:

Through patient-engaged research methodology, patient-partners advocated ‘bringing statistics to life’ by including videos into the tool (IRB-approved). Five videos were created; each contained two families’ stories reflecting: death following comfort care, non-survival following resuscitation, or survival with mild, moderate, or severe neurodevelopmental impairment (NDI). Diverse families represented the spectrum of NDI, using different scripts for bereavement versus survival. Professional videographers filmed and edited the segments (3-5 minutes), which were embedded into the GOALS tool. Focus groups were conducted with pregnant women (20-26 weeks) and women who have delivered periviably to assess the videos’ acceptability.

RESULTS:

Ten families participated in the ‘lived-experience’ videos. Half were African American and half were white; children were age 16 months to 4 years. Bereaved parents were asked about end-of-life experiences and support after loss, while survivor segments described typical days, on-going medical care, and family adjustment. The videos were rated “excellent” (41.7%) or “good” (25%) by focus group participants (n=12). Most (91.7%) thought the tool provided sufficient information and would be useful in helping families make treatment decisions.

CONCLUSION:

Videos provide context for families to make meaning of complex prognostic information on long-term outcomes. They must be developed with caution due to their potential to introduce anchoring, conformity, or optimistic biases. Stakeholder engagement and diverse representation across the spectrum of outcomes and decisions may help to mitigate potential biases.
Cost and Reimbursement for Low Risk Prenatal Care in the United States [10K]
Authors: Baker Mary V. , Butler-Tobah Yvonne , Theiler Regan
Published: April 2020

INTRODUCTION:

This study calculates the financial margins for delivery of routine antenatal care as reimbursed by Medicaid. Prenatal care cost varies with overhead, provider type, and number of office visits. Antenatal care is only one component of the global obstetric bundle, which also includes intrapartum and postpartum care.

METHODS:

Revenue was based on 2015 Medicaid reimbursement for the pregnancy global package (CPT 59400). All fifty states were represented. Provider time cost was estimated using mean wages for obstetricians and midwives, or using national mean wage data when state-specific data was unavailable. Staff time for provision of low risk prenatal care was determined prospectively from a study of 133 low risk patients. Sensitivity analysis was performed by varying overhead as a percentage of total revenue. Routine prenatal labs, ultrasounds, intrapartum care, and postpartum care were not included in our analysis.

RESULTS:

Patients received an average of 215 minutes of direct provider time per pregnancy. At the 50th percentile for physician payment and assuming overhead is 40% of revenue, practice margins varied by state from -$1,061 to +$785, with a median of -$161. This does not include the cost of intrapartum or postpartum care. The median margin for antenatal care was negative if overhead exceeded 18% of revenue.

CONCLUSION:

In a majority of states, reimbursement for the global obstetric package reimbursed by Medicaid is less than the actual cost of prenatal care alone. Improving reimbursement or decreasing costs is necessary to make maternity care cost-effective for obstetrics practices.
Early-Onset and Preterm Preeclampsia After Bariatric Surgery [12K]
Authors: Livergood Mary Christine , Harrison Rachel , Allen Katherine , Lak Kathleen , Cruz Meredith
Published: April 2020

INTRODUCTION:

We sought to determine the rates of early-onset and preterm preeclampsia in women with a history of bariatric surgery compared to controls.

METHODS:

We performed a retrospective cohort study of 189 singleton pregnancies in women who had undergone a bariatric procedure prior to pregnancy and compared them to early pregnancy body mass index (BMI) and delivery date matched controls at a single center between 2005 and 2019. Early-onset and preterm preeclampsia were defined as preeclampsia requiring delivery prior to 34 weeks and 37 weeks, respectively. Pregnancy outcomes were compared using univariate and multivariate analysis.

RESULTS:

Of the 189 pregnant women with history of bariatric surgery, 5 (2.7%) had early-onset preeclampsia and 10 (5.3%) had preterm preeclampsia. Compared to early pregnancy BMI-matched controls, there was no difference between groups in the rates of early-onset preeclampsia (aOR 1.98, 95% CI 0.15-26.85). A subgroup analysis was performed on the rates of these disorders stratified by different types of bariatric surgery. Using gastric sleeve as the reference group, there were lower rates of early-onset preeclampsia and preterm preeclampsia in patients with a Roux-en-Y gastric bypass procedure (aOR 0.02 95% CI 0.00-0.95 and aOR 0.17 95% CI 0.03-0.99, respectively).

CONCLUSION:

Bariatric surgery was not associated with decreased rates of early-onset and preterm preeclampsia. In the subset of patients with a Roux-en-Y gastric bypass procedure, there were lower rates of preeclampsia prior to 34 and 37 weeks of gestation.
Fetal Growth Restriction and Cesarean Delivery for Nonreassuring Fetal Heart Rate Tracing in the Late Preterm Period [15K]
Authors: Bitar Ghamar , Jain Vanita , Ruhstaller Kelly , Mapp Alexandra , Sciscione Anthony
Published: April 2020

INTRODUCTION:

Women with fetal growth restriction (FGR) are often counseled about the fetus being unable to tolerate induction of labor and the risk for cesarean delivery (CD) for non-reassuring fetal heart tracing (NRFHT), especially in the late preterm period (between 34.0 and 36.6 weeks, LPP). The purpose of our study was to determine the association between FGR and CD for NRFHT in the LPP.

METHODS:

We performed a single-center case control study of women undergoing induction of labor (IOL) in the LPP between January 2010 and January 2017. Women were included if they underwent IOL between 34.0 and 36.6 weeks gestation of pregnancy with a non-anomalous, vertex, singleton gestation. Women with a previous CD and contraindications to IOL were excluded. Rates of FGR in women undergoing CD for NRFHT were compared to those undergoing CD for other indication or vaginal delivery.

RESULTS:

The odds of FGR were statistically significant for women who underwent a CD for NRFHT as compared to those having a vaginal delivery or CD for other indication (AOR 4.0; 95% CI 1.97-8.08) and (AOR 3.08; 95% CI 1.13-8.43). African American women had higher odds of IUGR than their white counterparts (AOR 2.65; 95% CI 1.46-4.82).

CONCLUSION:

Women with a diagnosis of FGR are significantly more likely to have a CD for NRFHT than a CD for other indication or VD in the LPP. This information should be included in counseling women who are undergoing an IOL and have a diagnosis of FGR in the LPP regardless of their indication for induction.
Is In-Utero Marijuana Exposure Associated With Childhood Developmental Delay? [20K]
Authors: Roussos-Ross Kay , Dukharan Victoria , Goodin Amie
Published: April 2020

INTRODUCTION:

Women are at the highest risk for developing a substance use disorder during their reproductive years. The prevalence of marijuana use in the US during pregnancy is 7%. Data is unclear regarding long-term effects of in-utero marijuana exposure. Given that the endocannabinoid system is present at around day 16 of gestation, it is plausible that maternal marijuana use could affect fetal brain development. This purpose of this study was to determine correlations between in-utero marijuana exposure and childhood developmental delay.

METHODS:

After IRB approval, a retrospective chart review of infants with a history of marijuana exposure in utero was conducted. A total of 230 study subjects met inclusion criteria and were analyzed.

RESULTS:

The majority of subjects, 84 (59.6%) were noted to have feeding problems in infancy. Forty one subjects, 17.8% showed abnormal muscle tone, 39 subjects, 17%, were noted to be small for gestational age (SGA). Speech delay was present with a frequency of 10.0%, 23 subjects. Fine motor delay was seen in 25 subjects, 10.9% and global development delay with noted in 21 subjects, 9.1%.

CONCLUSION:

Results from this retrospective chart review indicate possible risks of short-term (feeding problems, abnormal muscle tone, SGA) and longer-term developmental delays. Further research is necessary to determine whether these effects are due to marijuana alone, or if confounding factors are involved. In order to educate and advise the public about the effects of marijuana use in pregnancy, this relationship must first be understood.
Isolated Leukocytosis to Predict Chorioamnionitis in Preterm Prelabor Rupture of Membranes Between 24 and 33 Weeks [21K]
Authors: Cardenas Carlos , Khoury Aldo
Published: April 2020

INTRODUCTION:

During Prelabor Premature Rupture of Membranes (PPROM), Chorioamnionitis is an indication for delivery; hence prompt diagnosis is of major relevance for maternal and neonatal outcome. Chorioamnionitis can affect about 40-70% of preterm births with premature rupture of membranes. The objective of this study is to assess the relevance of isolated leukocytosis in predicting Chorioamnionitis during PPROM between 24 and 33 weeks.

METHODS:

In this retrospective study performed at our institution from 2014 to 2017, 161 pregnancies with PPROM where selected. The last white blood cell count (WBC) obtained before delivery was used as an indicator for Chorioamnionitis, which was diagnosed by placental histologic findings. Patients were classified as PPROM without Chorioamnionitis and with Chorioamnionitis with and without Leukocytosis (>15,000 cells/ml). Time of when Celestone was given in relation to the last WBC obtained, indication for delivery and presence of other signs of infection including fever were documented.

RESULTS:

81 patients had PPROM without Chorioamnionitis; only 9 (11%) had leukocytosis. From the patients with Chorioamnionitis, 50 (62.2%) had leukocytosis (Average WBC 17,500) and 30 (37.8%) did not (Average WBC 9,900). 85% of the patients with leukocytosis had Chorioamnionitis. Only 2.5% of patients with Chorioamnionitis had fever and 20% of the patients with Chorioamnionitis were delivered due to suspected infection. Sensitivity for Leukocytosis was 62.5% with specificity of 88.8%. Receiver operating characteristic AUC was 0.723 (p value<0.001, 95% confidence interval 0.6396 to 0.8066).

CONCLUSION:

Isolated leukocytosis can become a strong predictor for Chorioamnionitis if repeated periodically during PPROM between 24 and 33 weeks.
Marijuana Use and Perinatal Outcomes Among Obstetric Patients in a Southern California Safety Net Hospital [22K]
Authors: Sasso Elizabeth , Komatsu Emi J. , Johnson Brittney , Bolshakova Maria , Cortessis Victoria , Mullin Patrick
Published: April 2020

INTRODUCTION:

Recreational marijuana use is increasing and poses a risk to both mother and the fetus. We aimed to assess marijuana use and perinatal outcomes in the local obstetric population at our hospital.

METHODS:

An IRB approved retrospective chart review identified a cohort of women with singleton gestations who delivered at LAC/USC hospital between 2015 and 2018. Women with self-reported marijuana use were compared with a control group. Demographic characteristics, maternal and perinatal outcomes were evaluated. Associations between these factors and marijuana use were assessed with univariate and multivariate regression.

RESULTS:

Of 2792 women who delivered during the study period, 151 (5.4%) had documented marijuana use. Compared to 192 non-users, marijuana users were more likely to be younger, non-Hispanic, undomiciled, unemployed and use other illicit substances. Marijuana users entered prenatal care later (14.2 vs. 22.1 weeks, P<.001), were more likely to have preeclampsia (P=.046) and cesarean delivery (P=.01) and had infants with average birth weight 106 grams less (P=.02) than controls. After adjusting for confounders, marijuana use was not significantly associated with preterm birth or composite perinatal morbidity, but remained associated with 4.1-fold greater likelihood of delivering a small for gestational age (SGA) infant (95% CI 1.95-8.74).

CONCLUSION:

At a safety net hospital, antepartum marijuana use is significantly associated with SGA at birth. Marijuana users have higher maternal morbidity including preeclampsia and cesarean delivery, and are more likely to enter prenatal care later and report poly-substance use. Healthcare disparities associated with marijuana use make this a population of critical interest.
Maternal Early Warning Signs in Pregnant Women With Trauma [23K]
Authors: Yaghi Alia , Ireland Kayla
Published: April 2020

INTRODUCTION:

Traumatic events during pregnant are relatively common and remain a leading cause of non-obstetric maternal morbidity. Maternal physiologic changes generate alterations in maternal vital signs (VS). Utilizing maternal early warning criteria of VS (MEWS) may aid in identification and recognition of women with at risk of morbidity from traumatic injury.

METHODS:

Retrospective cohort of pregnant women in Level I trauma center who presented with trauma from 2006-2017 by Emergency Medical Services (EMS). We compared Injury Severity Score (ISS) and TRISS in women with abnormal MEWS and normal MEWS VS from EMS records. Statistical tests included Fischer’s exact test for categorical variables and t test for comparisons of continuous variables. Linear regression models were used to evaluate predicting covariates correlation with ISS and TRISS.

RESULTS:

Of the 460 pregnant women treated for trauma, 240 (52%) arrived by EMS and 56 (12%) women had at least one abnormal MEWs criteria on the scene and only 3 patients had more than 1 abnormal VS. Most common injury mechanism was MVC (75%), Assaults (9%) and falls (7%). ISS (8.3 vs 8.79, P=.45) and TRISS (0.993 vs 0.925, P=.14) were not significantly different between women with normal and abnormal MEWS. However, with multivariate linear regression, scene heart rate (P=.02, 95% CI 0.108 to 0.009) and respiratory rate (P=.013, 95% CI 0.3 to 0.03) significantly correlated with ISS. No scene maternal VS were associated with TRISS.

CONCLUSION:

Although maternal vital signs correlate with injury severity, women with abnormal vitals utilizing MEWS criteria are not associated with more severe injury.
Maternal Morbidity Associated With Cesarean Deliveries Due to Arrest of Dilation [24K]
Authors: Mokhtari Neggin , Kawakita Tetsuya , Nachman Einav , Haddad Andrew , Iqbal Sara Naeem
Published: April 2020

INTRODUCTION:

It has been suggested that cesarean delivery during labor is associated with increased maternal morbidity compared with cesarean delivery without labor. We sought to examine the morbidity associated with cesarean deliveries due to arrest of dilation.

METHODS:

We conducted a retrospective cohort study of all women undergoing cesarean delivery from January 2016 to June 2018 at a single hospital. Each chart was reviewed to examine the primary indication for cesarean delivery. We examined maternal morbidity including chorioamnionitis, blood transfusion, superficial and deep incisional surgical site infections (SSI), and endometritis. We compared outcomes between women who had cesarean delivery due to arrest of dilation and those for other indications. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). IRB approval: STUDY00000045.

RESULTS:

Of 2957 women who underwent cesarean delivery, 214 (7.2%) had a cesarean delivery due to arrest of dilation. The rate of chorioamnionitis rates was significantly higher with arrest of dilation compared to other indications for cesarean delivery (13.6% vs. 3.6%, P<.01). Women that had cesarean delivery due to arrest of dilation compared to those who had other indications had similar rates of blood transfusion (7.5% vs. 7.6%; aOR 1.31 [95% CI 0.77–2.25]), SSI (4.7% vs. 3.1%; aOR 1.84 (95% CI 0.93–3.67]), and endometritis (2.8% vs. 1.6%; aOR 1.78 [95% CI 0.74–4.30], respectively).

CONCLUSION:

In contrast to theoretical concern, we found that postpartum complications (blood transfusion and postpartum infections) are similar between cesarean delivery due to arrest of dilation and cesarean delivery for other indications.
Risks Associated With Arrest of Descent Cesarean Deliveries [28K]
Authors: Mokhtari Neggin , Kawakita Tetsuya , Haddad Andrew , Gold Stacey , Iqbal Sara Naeem
Published: April 2020

INTRODUCTION:

Cesarean deliveries in laboring women are considered to have higher rates of complications compared to cesarean deliveries for other indications. We sought to evaluate if cesarean delivery for arrest of descent poses more maternal morbidity than other cesarean section indications.

METHODS:

We conducted a retrospective cohort study of women undergoing cesarean delivery from January 2016 to June 2018 at a single hospital. Chart review was performed to evaluate the primary indication for cesarean delivery. Maternal morbidity outcomes analyzed were blood transfusions, deep and superficial incisional surgical site infection (SSI) and postpartum endometritis. Multivariable logistic regression was performed to calculate adjusted odds ratios with 95% confidence intervals. IRB approval: STUDY00000045.

RESULTS:

A total of 2,957 women underwent a cesarean section, of which 165 (5.6%) had a cesarean section for arrest of descent. Women who had arrest of descent cesarean deliveries were more likely to experience SSI (8.5 vs. 2.9%, (aOR 4.48 [95% CI 2.41-8.31]) and postpartum endometritis (6.1% vs. 1.4%, (aOR 5.28 [95% CI 2.50-11.15]) compared to women who had cesarean deliveries due to other indications. There was not an increased risk of blood transfusion between the two groups (7.9% vs. 7. 6%, (aOR 1.34 [95% CI 0.74-2.43]).

CONCLUSION:

No statistical difference in blood transfusion was seen between the arrest of descent group and the control group. The rates of SSI and postpartum endometritis were higher in those with arrest of descent cesarean deliveries compared to other indications for cesarean delivery. Higher vigilance in the postpartum period for infection would be prudent in this population.
The First Prenatal Visit: An Opportunity for Improved Shared Decision-Making for New Prenatal Genetic Tests [31K]
Authors: Farrell Ruth M. , Collart Christina , Pierce Madelyn , Edmonds Brownsyne Tucker , Rose Susannah
Published: April 2020

INTRODUCTION:

Discussions about prenatal genetic screening and diagnostic testing (PGT) in early pregnancy are challenging, given the complexity of available options and time constraints of the initial prenatal visit (PNV). We examined the impact of a point-of-care shared decision-making (SDM) tool on PGT discussions during PNVs.

METHODS:

We conducted a cluster randomized control trials to assess PGT discussions. We analyzed transcripts from 131 PNV audio recordings. Transcriptions were coded by two independent, blinded coders who measured SDM using the OPTION scale and completed a content checklist. Variables were compared using Chi-square and Fisher exact tests.

RESULTS:

Discussions placed greater emphasis on Trisomy (T) 21 (85.5%) than T18 (60.3%) and T13 (54.2%) and, when addressing diagnostic testing, greater emphasis on amniocentesis than CVS (53.4% vs. 24.4%). Only 21.4% of visits addressed the chance of a false positive, which providers were more likely to discuss with primiparas (P=.03). Providers with ≤10 years in practice were more likely to assess patients’ preferred approach to education (P=.026) and level of involvement in decision making (P=.011). Statistically significant higher OPTION scores were noted among NEST users compared to control for 3 of the 12 SDM items. NEST users were more likely to discuss advantages of all screening options compared to control (P=.025).

CONCLUSION:

Data from this study demonstrates existing challenges in addressing the decision-making needs of pregnant patients engaging with prenatal genomic-based tests. Future educational efforts should focus not just on PGT implementation, but also on efforts to enhance SDM by educating healthcare providers.
Threatened Preterm Labor Admissions: A Population Based Study to Assess Trends and Financial Effect [35K]
Authors: Lavie Anat , Czuzoj-Shulman Nicholas , Spence Andrea , Abenhaim Haim Arie
Published: April 2020

INTRODUCTION:

Threatened preterm labor (TPTL) is a common hospitalization indication among pregnant women, often for unnecessarily prolonged periods of time. The accurate identification of women not actually in preterm labor avoids unnecessary and costly interventions. The purpose of our study is to describe admissions for TPTL and assess their financial burden.

METHODS:

We carried out a cohort study on all pregnancy admissions using the United States’ Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database between 1999-2015. We identified all TPTL admissions and a comparison was done between length of hospital admission for patients who delivered during that same admission ("Delivery" group) versus those who were discharged without delivering ("Observation" group).

RESULTS:

There were a total of 15,337,934 pregnancy admissions during our study period, of which 1,307,934 were for TPTL. The rate of total TPTL admissions decreased over the 16-year period, with a mutual increase in rate of "delivery" and decrease in rate of "observation" admissions over time. Of the total TPTL admissions, 70.5% and 29.5% were in the "delivery" and "observation" groups, respectively. Within 48 hours of admission, 82% of the "delivery" group delivered, whereas 60.8% of the "observation" group were discharged. Of the remaining total- 52.2% delivered eventually, with more than half of them after more than 6 days of admission. In subset analyses, total cost for the "observation" admissions group was 4,059,004,590$ with mean cost of 10,782$ per patient per admission.

CONCLUSION:

Despite improvement in rate of total TPTL admissions throughout the years, and more specifically decline in rates of unnecessary admissions, given their high cost, consideration should be taken for discharging more patients no later than 48 hours, after which our clinical ability to discriminate those who will deliver is sparse.
Type 2B Von Willebrand Disease in Pregnancy: A Systematic Literature Review [36K]
Authors: Pierce-Williams Rebecca , Karl Taylor , Delgado Natalie , Lackritz Katherine , Al-Kouatly Huda B.
Published: April 2020

INTRODUCTION:

Type 2B Von Willebrand Disease (VWD) is a rare hereditary bleeding disorder that is associated with thrombocytopenia. Our objective was to review obstetric complications in women with Type 2B VWD.

METHODS:

A systematic literature search was conducted using PubMed, Scopus, and Cochrane Central Register of Controlled Trials to include all publications that address Type 2B VWD in pregnancy. Our primary and secondary outcomes were incidence of postpartum hemorrhage (PPH) and incidence of thrombocytopenia in pregnancy, respectively.

RESULTS:

20 studies met inclusion criteria. There were 32 pregnancies with Type 2B VWD in 27 women. Primary PPH was reported in 9/20 (45%) and secondary PPH was reported in 6/13 (46%) and occurred between 5-32 days. Factor concentrate treatment was administered before delivery and postpartum in 16 and 18 pregnancies, respectively. 17 pregnancies required blood products postpartum. Platelet transfusion was given in 13/17 (76%) pregnancies. Red blood cell transfusion was performed in 6/17 (35%) pregnancies. Thrombocytopenia in pregnancy was reported in 27/28 (96%). 23/27 (85%) were severe thrombocytopenia with mean platelet count of 33.7±22.7 × 103/ul and 4/27 (15%) were mild thrombocytopenia (range, 126-150 × 103/ul). No maternal mortality was reported.

CONCLUSION:

Type 2B VWD in pregnancy has significant morbidity, with high incidence of primary and secondary PPH. The majority of patients required the use of factor concentrate before and after delivery in addition to postpartum blood products. The incidence of severe thrombocytopenia was also high, indicating that Type 2B VWD should be considered in the differential diagnosis of severe thrombocytopenia in pregnancy.
Use of a Kinyarwanda-Based Edinburgh Postpartum Depression Screen in a Maternity Ward of a Major Referral Hospital [37K]
Authors: Mushi Juliet , Uwayo Francine , Irakoze Magnifique , Nathan Lisa , Rulisa Stephen
Published: April 2020

INTRODUCTION:

Maternal mental health has often been relegated to the margins of global women's health discourse despite mounting evidence of the disproportionate burden of common mental health problems among pregnant women in low-and middle-income countries. The Edinburgh Postnatal Depression Scale (EPDS) is a validated tool used to screen for perinatal depression. We developed a version of this screening tool in Kinyarwanda and administered it to 105 women receiving prenatal and postnatal care at the University Teaching Hospital of Kigali (CHUK).

METHODS:

IRB approval was obtained for this prospective study was obtained at Albert Einstein College of Medicine and CHUK from 2016 to 2017. An English version of the EPDS tool was translated to Kinyarwanda and administered to 105 women who consented to participate in this survey project. Descriptive and comparative analysis was performed using STATA 16.

RESULTS:

The majority of women completing our survey were young, multiparous, with at least a primary school education (59%). Most of the women completed the EPDS while postpartum and 85% had an EPDS score less than 10. Higher levels of educational attainment were significantly associated with an EPDS score less than 10 (P<.05). 55% of women surveyed felt that postpartum depression is an issue affecting their communities, with over 60% of women agreeing that stigma prevents pregnant women from seeking help for mental wellness.

CONCLUSION:

We identified level of educational attainment as a factor associated with a low EPDS score among women admitted at a maternity ward in a large referral hospital in Rwanda.
Characteristics of Women Diagnosed With Preeclampsia With Severe Features Based on Hypertension Alone [05L]
Authors: Romagano Matthew P. , Flint Matthew , Sachdev Devika , Apuzzio Joseph , Williams Shauna F. , Gittens-Williams Lisa
Published: April 2020

INTRODUCTION:

The objective of this study was to compare pregnancy and postpartum characteristics amongst women diagnosed with preeclampsia with severe features (PE-SF) based on hypertension alone versus those with additional criteria for PE-SF.

METHODS:

This is an IRB-approved retrospective cohort study of women with a diagnosis of PE-SF, identified by hospital discharge records over a 1-year period. Electronic medical records were reviewed. Women diagnosed with PE-SF based on severe hypertension alone (HTN-A) in the absence of other criteria for preeclampsia were compared to those with PE-SF that had additional criteria for preeclampsia (e.g. proteinuria or clinical/laboratory signs or symptoms).

RESULTS:

105 women had PE-SF or chronic hypertension with superimposed PE-SF over the study period. 22 (21%) of these women were diagnosed based on HTN-A. Maternal demographics, intrapartum/postpartum characteristics, laboratory values, delivery outcomes, and postpartum follow-up rates were similar. Those diagnosed with PE-SF based on HTN-A had a lower mean protein-to-creatinine ratio (0.2 vs 1.5, P=.003). For women who attended a 1-week postpartum blood pressure check, the rate of those with severe hypertension were similar between the HTN-A and other criteria groups (2/12 vs 3/49, P=.233) but the HTN-A group was more likely to have severe hypertension at the 3-4 week postpartum visit (4/13, 31% vs 2/57, 3.5%, P=.009).

CONCLUSION:

Women who receive a diagnosis of PE-SF based on severe hypertension alone in the absence of other abnormal findings still have a significant rate of persistent hypertension postpartum. These women should be followed and managed for persistent hypertensive disease in the postpartum period and beyond.
Contraindications to Magnesium Sulfate and Alternative Seizure Prophylaxis for Severe Preeclampsia [09L]
Authors: Prasannan Lakha , Blitz Matthew J. , Rochelson Burton L. , Gerber Rachel P.
Published: April 2020

INTRODUCTION:

Intravenous magnesium sulfate is considered first-line seizure prophylaxis for preeclampsia, reducing the risk of eclampsia by half. Absolute or relative contraindications to this medication include myasthenia gravis, severe renal failure, cardiac ischemia, heart block and pulmonary edema. Levetiracetam, an alternative antiepileptic drug considered safe in pregnancy, has been suggested in such cases though its efficacy remains uncertain. Our objective was to determine how frequently alternative anticonvulsant medications are administered for seizure prophylaxis in severe preeclampsia and to identify the documented indications in such cases.

METHODS:

IRB approved, retrospective cohort study of women with a diagnosis of preeclampsia at 34 weeks of gestation or greater who received seizure prophylaxis at a tertiary university hospital from 2014-2017. Demographics, clinical characteristics and contraindications to magnesium sulfate, if present, were evaluated. Patients were excluded if they had a pre-existing seizure disorders or incomplete medical records.

RESULTS:

A total of 1,370 patients were included; 3.2% (n=44) received levetiracetam for seizure prophylaxis. Most of the levetiracetam group (79.5%) initially received magnesium. The most commonly documented contraindication was pulmonary edema (n=14) which was confirmed by imaging (either ultrasound or chest x-ray) in less than half of cases; other reasons included changes in laboratory data (n=11; increasing serum creatinine, serum magnesium >7 mg/dL), development of additional signs/symptoms (n=11; hypotension, headache, vision changes, decreased urine output) and patient refusal (n=3). Five cases did not document any contraindication.

CONCLUSION:

The use of alternative anticonvulsant medications in preeclampsia, which may be less efficacious, must be reserved for true contraindications to magnesium sulfate.