bluuebunny/crossref_metadata_2025 huggingface dataset:
Prenatal Genetic Diagnostic Testing in the Era of Cell Free Fetal DNA For Aneuploidy Screening [10D]
Authors: Enakpene Christopher A. , Tan C. Danielle , Morgan Tamandra , Sutherland Monique B. , DiGiovanni Laura M. , Della Torre Micaela
Published: May 2019

INTRODUCTION:

Prenatal screening for fetal aneuploidy has improved tremendously since the incorporation of cell-free DNA (cfDNA) in to the genetic screening armamentarium. Despite its improved detection rate of aneuploidy, this remains a screening tool and not designed to provide diagnostic information. This study aimed to assess whether initiation of cfDNA screening at the University of Illinois at Chicago (UIC) in January 2012 influenced the acceptance of prenatal diagnostic testing in at-risk women.

METHODS:

Retrospective study of two cohorts of women who received prenatal genetic counseling at UIC: pre-cfDNA era from January 2010 to December 2011 and cfDNA era from January 2012 to December 2016. Charts of eligible patients were reviewed; demographics, indications for genetic counseling and acceptance of diagnostic testing were analyzed. Statistical tests: Chi-square, Fisher exact test, Student t-test, bivariate and multivariate analysis were utilized.

RESULTS:

A total of 2371 women had genetic counseling at UIC from 2010 to 2016; 629 prior to cfDNA and 1741 after. There were 319 women who had diagnostic testing, 168 (26.7%) during pre-cfDNA era vs. 151 (8.7%) in the cfDNA era, RR 4.0 (95% CI 3.1-5.0), p<0.001. Multivariate analysis using Mantel-Haenszel test revealed that pregnant women prior to availability of cfDNA were more likely to pursue prenatal genetic diagnostic testing, and it remained statistically significant even after controlling for confounders, RR 1.20 (1.18-1.23), p<0.001.

CONCLUSION:

Advent of cfDNA as prenatal screening was associated with decreased utilization of diagnostic prenatal testing in women whose offspring were at risk of chromosomal abnormalities.
Rates of Neonatal Sepsis by Maternal Diabetes and Chronic Hypertension [12D]
Authors: Birch Mary Nienow , Frank Zoë , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

The purpose of this study is to characterize the rates of neonatal sepsis among infants born to mothers with diabetes mellitus, gestational diabetes, and chronic hypertension.

METHODS:

This is a retrospective cohort study of non-anomalous, singleton and twin deliveries in the US. We compared rates of sepsis among infants born to mothers with diabetes mellitus, gestational diabetes, and chronic hypertension to infants born to healthy mothers. Results were analyzed using Pearson Chi-Squared tests to control for maternal race, maternal age, insurance status, education level, diabetes, chronic hypertension, preeclampsia, chorioamnionitis, postpartum hemorrhage, cesarean section, nulliparity, and gestational age.

RESULTS:

Rates of neonatal sepsis were higher among infants born to mothers with diabetes mellitus and gestational diabetes than among infants born to mothers without diabetes (p<0.001). Diabetes mellitus yielded an odds ratio of 1.31 (95% CI 1.18-1.44) for neonatal sepsis. Gestational diabetes yielded an odds ratio of 1.17 (95% CI 1.12-1.22) for neonatal sepsis. Rates of neonatal sepsis were higher among infants born to mothers with chronic hypertension than among those born to healthy mothers (p<0.001). Chronic hypertension predicted neonatal sepsis with an odds ratio of 1.09 (95% CI 1.00-1.19).

CONCLUSION:

Infant rates of sepsis increase with maternal diabetes mellitus, gestational diabetes, and chronic hypertension. Maternal diabetes increases risk of neonatal sepsis independent of maternal race, maternal age, insurance status, education level, chronic hypertension, preeclampsia, chorioamnionitis, postpartum hemorrhage, cesarean section, nulliparity, and gestational age. Future research is needed to provide a causative explanation of the relationship between maternal diabetes, chronic hypertension, and neonatal sepsis.
Recumbent Versus Upright Positioning During Labor With an Epidural: A Cost-Effectiveness Analysis [13D]
Authors: Packer Claire , Hersh Alyssa R. , Greiner Karen S. , Gallagher Alexandra , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

A recent study, the BUMPES trial, found that recumbent positioning in labor for women with a low-dose epidural resulted in decreased time (minutes) of the second stage of labor and an increased number of spontaneous vaginal deliveries. We sought to examine the cost-effectiveness and outcomes associated with laboring upright versus recumbent position during the first delivery and its effect on the subsequent pregnancy.

METHODS:

We designed a cost-effectiveness model using TreeAge software comparing outcomes in women with a low-dose epidural who underwent labor in upright versus a recumbent position. We used a theoretical cohort of 1.1 million women. Outcomes included mode of delivery and maternal death in the index pregnancy, and mode of delivery, maternal death, uterine rupture and hysterectomy in the subsequent pregnancy. We measured cost and quality-adjusted life years (QALY) for both pregnancies. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY.

RESULTS:

We found that women using low-dose epidural anesthesia laboring in the recumbent position during her first labor resulted in fewer cesarean deliveries and reduced costs and improved QALYs for the first and subsequent deliveries. In our theoretical cohort, laboring in the recumbent position led to 38,190 fewer cesarean deliveries, 11 fewer maternal deaths, 66 fewer uterine ruptures, and 18 fewer hysterectomies, saving $165 million with 231,000 increased QALYs across both pregnancies (Table 1).

CONCLUSION:

Laboring in a recumbent position with a low-dose epidural is a no-cost intervention that leads to improved outcomes, decreased costs and increased QALYs during the first and second delivery.
Fetal Pressure Injury After Labor Augmentation With Foley Bulb Catheter: A Case Report [15D]
Authors: Kennedy Amantia , Vallely Jaxon , Kicklighter Stephen , Petri Nicholas
Published: May 2019

INTRODUCTION:

Use of Foley bulb catheter is a common procedure for labor induction due to its efficacy and safety. In this report, we present the first case of fetal pressure injury as a result of labor augmentation with a Foley bulb catheter.

METHODS:

A 32-year-old primigravida at 35w0d gestation was admitted for induction of labor due to preterm premature rupture of membranes. Her pregnancy was significant for insulin controlled gestational diabetes. A Foley balloon was placed through the cervix, and inflated with 60cc of saline. 5 hours into the induction, the Foley balloon was noted to be behind the infant's neck, and was removed by deflating the balloon. The infant was delivered atraumatically via cesarean section hours later due to failure to progress. Initial exam was unremarkable aside from two dark macular areas at the base of the occiput and upper scapular area. At 32 hours of life there was significant subcutaneous swelling, central necrosis, and continued serous discharge. At this time, the lesion was determined to be an unstageable pressure injury.

CONCLUSION:

Intrauterine devices, including Foley bulb catheters, can provide external pressure to the fetus that can increase the risk of pressure injury development. In smaller fetuses, altered fetal descent and positioning can lead to this pressure being applied over surfaces that are more susceptible to pressure injury, such as the occiput. While this is the first reported case, the safety and standard practices of premature labor augmentation with a Foley bulb catheter should be further evaluated.
Risk Factors for the Development of Antepartum & Postpartum Depression in Patients Hospitalized During Pregnancy [16D]
Authors: Goodwin Alexandra I. , Welchman Caroline L. , Mead Julia , Hines Katherine Neuffer , Quinn Kristen H.
Published: May 2019

INTRODUCTION:

Postpartum depression is a recognized public health issue that affects 1 in 9 women nationally. However, less is known about antepartum depression in women, especially those hospitalized during their pregnancies.

METHODS:

This is a prospective cohort study that analyzes how certain characteristics influence the likelihood of pregnant women to develop anxiety and depression during their hospitalizations and in the postpartum period. Patients completed the Edinburgh Postnatal Depression Scale (EPDS) on admission and six week follow-up and an additional questionnaire.

RESULTS:

Of 93 women, 33% had a positive EPDS on admission. For the 49 women with six week follow-up data, 20% had a positive EPDS. High EPDS on admission was not correlated with high EPDS on follow-up. Number of living children, and maternal cause for this admission were correlated with higher EPDS scores on admission, and spirituality, greater gestational age, and fetal cause for this admission were correlated with lower EPDS scores. At six week follow-up visits, NICU admission during this pregnancy and previous hospitalization in pregnancy were associated with higher EPDS, and number of days in the NICU during this pregnancy was associated with lower EPDS scores.

CONCLUSION:

There are many unmet needs for women during pregnancy and in in the postpartum period. It is therefore imperative that we include depression screening as a routine part of admission for high risk pregnancies. Additionally, by identifying certain factors that may prevent or predispose women to depression, we can better screen patients who may benefit from increased psychosocial support surrounding their pregnancy.
The Compliance of a Patient Safety Bundle for Management of Morbidly Adherent Placenta [21D]
Authors: Quist-Nelson Johanna Rachel , Crank Aislinn , Quist Arbor , Kim Christine , Richard Scott , Roman Amanda
Published: May 2019

INTRODUCTION:

A recent expert review recommended the establishment of centers of excellence for care of patients with morbidly adherent placentas (MAP) as a primary method to improve outcomes. Our objective was to evaluate the compliance with a patient safety bundle for MAP by comparing pre and post-protocol time periods.

METHODS:

We performed a retrospective cohort study of singleton patients who had suspected or pathologically diagnosed MAP between January 2007 and June 2018. In June 2015 our tertiary center implemented a patient safety bundle for the management of MAP. This bundle involved a multidisciplinary approach, betamethasone administration, joint management by gynecologic oncology and maternal-fetal medicine intraoperatively after the placement of pre-operative internal iliac arterial occlusion balloon catheters by interventional radiology. The bundle also incorporated intraoperative blood salvage device. The primary outcome was incorporation of all 6 of the components of the bundle into a MAP cesarean hysterectomy: 1. Betamethasone 2. Gynecologic oncology 3. Preoperative balloon catheters 4. Blood salvage device in the operating room 5. Vertical skin incision 6. Fundal or high transverse hysterotomy.

RESULTS:

There were 41 cases of suspected and/or pathologically confirmed MAP during the study period. There were significantly more suspected MAP cases in the post protocol period (31.8% vs 89.5%, p<0.0001). Cesarean hysterectomy was performed for all patients. Compliance with of all components of the patient safety bundle was higher in the post-protocol group (4.5% vs 63.2%, p<0.0001).

CONCLUSION:

A patient safety bundle has improved compliance and standardized the execution of the multidisciplinary management of MAP.
Using the New Definition of Intraamniotic Infection: Is There Morbidity in the Women Left Out? [27D]
Authors: Smith Megan , Daifotis Helen , Denoble Anna Elisabeth , Dotters-Katz Sarah Kathleen
Published: May 2019

INTRODUCTION:

Recently, The American College of Obstetricians and Gynecologists updated definitions for intraamniotic infection (IAI): maternal fever (greater than/equal to 38.0C) and 1 or more symptom (fetal tachycardia, maternal white blood cell count >15,000/mm3, purulent discharge). Treatment is no longer recommended for women with fever <39.0 and maternal tachycardia or fundal tenderness (prior chorioamnionitis criteria). Our study compares postpartum infectious morbidity among women meeting chorioamnionitis criteria to women with IAI.

METHODS:

Retrospective cohort of women delivering vaginally at a single academic center. Demographics, antepartum, and intrapartum characteristics of women who met diagnostic criteria for chorioamnionitis were compared to those meeting IAI criteria using bivariate statistics. The primary outcome was postpartum infectious morbidity (PIM): endometritis, perineal infection, sepsis, urinary tract infection (UTI), and pyelonephritis. Backward-stepwise elimination was used to estimate odds of primary outcome. This study obtained IRB approval.

RESULTS:

Of the 229 women who previously met chorioamnionitis criteria, 51 (22.3%) did not meet new IAI criteria. Women meeting previous criteria were younger (median age 25 vs 27, P=0.02), more likely to have gestational hypertension (16.0% vs 3.4%, P<0.01), and were less likely to have 3rd or 4th degree lacerations (2.0% vs 13.4%, P=0.02). PIM occurred in 16/229 (7.0%) women overall; 5 (9.8%) in previously included group, and 11 (6.2%) with IAI. No difference in antibiotic receipt was observed. After adjusting for confounders, there was no difference in odds of PIM (aOR 1.65, 95% CI 0.55-4.99).

CONCLUSION:

Among women who met previous criteria for chorioamnionitis, but not for IAI, postpartum infectious morbidity is about 10%, and may be higher among those not given antibiotics.
Referral Patterns for Gynecologic Oncology Consultation [29D]
Authors: Madeka Isheeta , Burnett Brian A. , Shalowitz David I.
Published: May 2019

INTRODUCTION:

Women may experience worse outcomes from gynecologic cancers from delays in timely referral; however, care pathways for these patients are not well described. This study investigates the referral timeline of patients with suspected gynecologic cancers to identify opportunities for improved triage to subspecialist care.

METHODS:

50 consecutive patients seen at the Wake Forest Comprehensive Cancer Center for suspected malignancy or hyperplasia/dysplasia were identified. Clinical characteristics, demographics, number and sequence of providers seen for the patient's complaint, as well as time between evaluation, treatment, and referral were abstracted from the medical record. Descriptive statistics and logistic regression analyses were performed.

RESULTS:

Mean patient age was 58.5 years (SD=15.3). Mean distance traveled for care was 30 miles (SD=25). Disease sites included uterine corpus (n=27, 54%), ovary/fallopian tube/peritoneum (n=9, 18%), vulva (n=6, 12%), uterine cervix (n=5, 10%), and vagina (n=3, 6%). Referrals to gynecologic oncology were initiated by obstetrician-gynecologists (76%), family practitioners (12%), and emergency physicians (4%). 30% (N=15) of patients saw 2+ providers prior to gynecologic oncology referral. Mean interval between first evaluation and referral to gynecologic oncology was 39.3 days (SD=62.8). Mean interval between first evaluation and treatment was 75.9 days (SD=72.9).

CONCLUSION:

The >5 week interval between initial evaluation and referral to a gynecologic oncologist should be reduced through expeditious recognition of signs and symptoms concerning for malignancy. Additionally, education for non-obstetrician-gynecologists should target reducing the 30% of patients seen by multiple providers before gynecologic oncology evaluation. Factors associated with the highest risk for delays in care remain unclear.
Role of Cytochrome P450 Enzymes in the Maintenance of Breast Cancer Metastasized to the Bone [30D]
Authors: Chaudhari Sonal , Esteb Christopher , Chang Yu-Ting , Jones Richard
Published: May 2019

INTRODUCTION:

Metastasis of cancer cells causes most cancer-related deaths, prompting interest in its molecular mechanisms. Cancer homeostasis depends on the tumor microenvironment. Interactions between malignant cells and surrounding stroma contribute to cancer processes, including carcinogenesis and resistance to therapy. For example, multiple myeloma and leukemia cells can be protected from systemic chemotherapy by stromal cytochrome P450 enzymes (CYPs) that are found in the bone marrow (BM). We hypothesized that stromal CYPs protect solid tumors metastases to the BM.

METHODS:

We used a conditioned media model to mimic tumor microenvironment, asking whether a human BM mesenchymal stroma cell line can affect growth of a breast adenocarcinoma metastatic cell line (MCF7).

RESULTS:

We first established that the IC50 of Doxorubicin of MCF7 cells is 50nM, a concentration which also preserved growth of stromal cells. We found that concomitant treatment of Doxorubicin and Clarithromycin (a CYP3A4 inhibitor) sensitized MCF7 cells in stromal conditioned media more than treatment with only Doxorubicin, while it had no such effect in stroma-free conditions. Preliminary results also show that the concomitant treatment of Doxorubicin and Clarithromycin rescued the sensitivity of MCF7 cell line to Doxorubicin in stromal conditioned media, while it had no rescue effect in stroma-free cultures.

CONCLUSION:

Our results suggest that breast carcinoma cells are relatively resistant to Doxorubicin in the presence of BM stroma and that this resistance can be overcome by Clarithromycin. Our in vitro data suggest that like its role in hematological malignancies, stroma in the BM microenvironment creates biochemical niches that protect metastases from systemic chemotherapy.
Outcomes of Both Complex and Isolated Cases of Infants With Large Stomach on Fetal Ultrasound [33D]
Authors: McCormick Bridgette M. , Blakemore Karin J. , Johnson Clark , Bishop Juliet Chhay , Jelin Eric , Jelin Angie C.
Published: May 2019

INTRODUCTION:

A sonographically large fetal stomach has resulted in gastrointestinal obstruction, per case reports, and is often followed with serial ultrasounds. We hypothesize that a LS is predictive of neonatal bowel obstruction.

METHODS:

We performed retrospective cohort study of all prenatal sonographic cases with a large stomach visualized between 1/1/02-6/1/16. Inclusion criteria required a liveborn delivery within the Johns Hopkins health system. We excluded pregnancy loss/termination cases and cases delivered outside JHHS. We defined a large stomach as an increased measurement in 2 or greater dimensions based on a normogram. Cases were classified as isolated or complex based on additional US findings at initial presentation. We collected demographics, sonographic findings and postnatal outcomes. Approval was obtained by the Johns Hopkins IRB.

RESULTS:

We identified 340 fetuses with large stomach. Two hundred thirty three met inclusion criteria, including 160 isolated and 73 complex. Of the 160 isolated cases, none resulted in gastrointestinal obstruction. Those with isolated findings were significantly less likely to deliver preterm (n=24, 15.0% vs n=31, 42.5%, p<0.001). Isolated cases were less likely to be complicated by polyhydramnios (n=13, 8.1% vs. n=18, 24.7%, p<0.001), NICU admittance (n=30, 18.8% vs n=70, 95.9%, P<0.001) or neonatal procedure (n=1, 0.63% vs. n=60, 82.2, p<0.001).

CONCLUSION:

While a sonographically large fetal stomach has been reported to result in gastrointestinal obstruction, the rate may be lower than previously hypothesized. We found that <1% of large fetal stomachs resulted in obstruction. When isolated, a large stomach is not a sole indication for ultrasounds and postnatal imaging.
Changes in Fetal Doppler Parameters Following Ablation of Placental Anastomoses in Twin-Twin Transfusion Syndrome [34D]
Authors: Chepa-Lotrea Xenia , Belfort Michael A. , Shamshirsaz Alireza A. , Nassr Ahmed , Sanz-Cortes Magdalena , Dorado Jimmy Espinoza
Published: May 2019

INTRODUCTION:

Unequal placental sharing and unbalanced blood volume distribution contribute to TTTS in monochorionic pregnancies. This study describes changes in fetal Dopplers following laser photocoagulation of placental anastomoses.

METHODS:

230 women undergoing surgery for TTTS between 01/2012 and 05/2018 were included. Laser surgery was performed for Quintero stages II and greater, or stage I with symptomatic polyhydramnios, short cervix, or preterm labor. Pre and post-laser differences in impedance to blood flow in the umbilical artery (UA) and ductus venosus (DV) using pulsatility index (PI), as well as the middle cerebral artery peak systolic velocity [MCA PSV, as multiple of the median (MoM)] were calculated.

RESULTS:

TTTS Quintero stages I, II, III, and IV were present in 10%, 31.3%, 50.9% and 7.8% of cases. Median interval between scans before and after surgery was 2 days [interquartile range (IQR) 1-3 days]. Among donors, there was a significant reduction in UA PI [median prior: 1.313, IQR: 1.12-1.48 vs. median post PI: 1.186, IQR: 1.00-1.33, p<0.001). A similar trend among recipients did not reach significance. Among recipients, a significant elevation in MCA PSV was noted following surgery (median pre: 0.993 MoM, IQR: 0.82 to 1.12 vs. median post PSV: 1.077 MoM, IQR: 0.86-1.26; p=0.003. No significant differences were noted in DV PI changes in either donor or recipient twins.

CONCLUSION:

Reductions in the resistance to donor twin umbilical artery blood flow and improvements in recipient middle cerebral artery peak systolic velocity may represent early sonographic signs of TTTS resolution following laser surgery.
Current Experience With the Vaginal Breech Initiative at the George Washington University Hospital [1E]
Authors: Marko Kathryn I. , Gimovsky Alexis C. , Madkour Amr , Daines Dina , Abbasi Annam Hafeez , Soloff Michelle Aileen
Published: May 2019

INTRODUCTION:

We have established a Vaginal Breech Initiative (VBI) to increase access to, and training in, the process of vaginal breech delivery. The VBI is a collaborative care team composed of physicians and nurse-midwives that leads care of participating women. Components of the VBI are: thorough antenatal screening, strict inclusion and exclusion criteria, rigorous informed consent, established delivery guidelines, and frequent simulation training.

METHODS:

This is a retrospective analysis of the VBI from 8/2011 to 11/2017. Inclusion criteria were: gestational age 34-42 weeks, singleton pregnancy, estimated fetal weight 2000-3800g, frank or complete breech, flexed head, adequate clinical pelvimetry, head and abdominal circumference within normal range and concordant, spontaneous labor and presence of a Vaginal Breech Team member. The primary outcome was incidence of vaginal breech delivery. Maternal and neonatal outcomes were examined secondarily.

RESULTS:

In total, 47 patients underwent a vaginal breech trial of labor, of which 72.3% had a successful vaginal breech delivery (n=34/47). Piper forceps were utilized in 11.8% of deliveries (n=4/34). The incidence of postpartum hemorrhage was 2.1% (n=1/47). There was one 3rd degree laceration (2.1%; n=1/47). Neonatal outcomes included an 8.5% incidence of neonatal intensive care unit admission (n=4/47) and a 2.1% frequency of head entrapment (n=1/47).

CONCLUSION:

The majority of patients undergoing breech vaginal delivery through our VBI had a successful vaginal breech delivery. Perinatal morbidity outcomes were rare. Through careful patient selection, counseling, and collaboration, breech vaginal deliveries performed in the context of a VBI are feasible in an academic medical center.
Delivery Outcomes in Women with Body Mass Index ≥40: A Systematic Review and Meta-analysis [2E]
Authors: D'Souza Rohan D. , Horyn Ivan , Jacob Claude-Emilie , Zaffar Nusrat , Maxwell Cynthia
Published: May 2019

INTRODUCTION:

To compare delivery outcomes in pregnant women with a body mass index (BMI) ≥40based on the planned and actual mode of delivery.

METHODS:

Five databases were searched until July 2017 to identify studies that reported on delivery outcomes in women with BMI ≥40. Outcomes were presented as proportions. Relative risks (RR) and 95% confidence intervals were calculated using random-effects meta-analysis.

RESULTS:

Eight observational studies with low risk-of-bias (Newcastle-Ottawa Scale) were included. Based on 1597 pregnancies, planned vaginal birth (VB) vs. planned caesarean delivery (CD) was associated with higher risk for postpartum hemorrhage (PPH) [7.27% vs. 3.44%, RR 2.116 (1.02-4.40)] and low five-minute Apgars [4.51% vs. 1.53%, RR 2.955 (1.01-8.63)]. Based on 4144 pregnancies, planned trial of scar after caesarean vs. repeat CD was associated with higher risk for endometritis [4.97% vs. 2.19%, RR 2.22 (1.60-3.09)], low five-minute Apgars [4.94% vs. 1.68%, RR 2.98 (2.03, 4.28)], birth trauma [1.06% vs. 0.21% RR 4.61 (1.77-12.03)] and prolonged hospitalization [30.3% vs. 26% RR 1.163 (1.05-1.29)]. Based on 3625 pregnancies, successful VB vs. intrapartum CD was associated with lower risk of PPH [15.06% vs 69.96%, RR 0.21 (0.19-0.23)], wound disruption [0% vs. 4.44%, RR 0.05 (0.003-0.88)], prolonged hospitalization [1.9% vs. 6.67%, RR 0.28 (0.08-0.98)] and low five-minute Apgars (0.95% vs. 5.56%, RR 0.17 (0.03-0.86)], but more birth trauma [5.91% vs. 0.56% RR 6.56 (1.26-34.10)]. Compared groups had dissimilar demographic characteristics.

CONCLUSION:

Given the clinical equipoise, a randomized trial is needed to determine the optimal mode of delivery in women with BMI ≥40.
Impact of Rural Hospital Closures on Patient Outcomes in a Perinatal Region of Georgia [4E]
Authors: Stephens Angela Jessica , Nezafat Kiana , Poch Alexandra , Ghosh Santu , Street Linda , Ray Chadburn
Published: May 2019

INTRODUCTION:

Rural hospital closures in the United States have left millions without access to healthcare. <50% of rural counties have hospital-based obstetrical services. Despite this, there are limited studies on the impact of obstetrical unit closures on patient outcomes. Augusta University Medical Center (AUMC) is the designated tertiary center for one of Georgia's six perinatal regions. We hypothesized that rural hospital closures directly impacted the outcomes of our patients.

METHODS:

The National Institute of Health's I2B2 software was used to identify charts of patients seen at AUMC for obstetrical services between January 1, 2010-December 31, 2011 and January 1, 2015-December 31, 2016. A retrospective chart review was performed to obtain and compare clinical outcomes between cohorts.

RESULTS:

6,096 charts were reviewed. 58.6% (3572/6096) of charts met inclusion criteria representing 74.6% (1501/2012) and 71.2% (2071/2910) of actual deliveries at AUMC for 2010-11 and 2015-16, respectively. Evaluated parameters included: obesity, birthweight, prematurity, APGARs, length of stay, insurance, psychiatric disease, hypertension, NICU admission, neonatal death, ICU admission, readmission, tobacco/substance use, cardiopulmonary disease, diabetes, VTE, transfusion/return to operating room. There we statistically significant increases in PTD and low APGARs/birth weight for those >76 miles away. Statistically significant decreases in normal birthweight infants for those >76 miles away. There were increased rates of substance abuse for all zip codes in 2015-16. There were no statistically significant differences in obesity, hypertension, neonatal death, ICU admissions, readmissions, VTE, or transfusions/return to the OR.

CONCLUSION:

Hospital closures within our perinatal region directly impacted aspects of patient outcomes at AUMC.
Development of a Venous Thromboembolism Prevention Tool in the Postpartum Period [5E]
Authors: Binstock Anna Berlyn , Larkin Jacob C.
Published: May 2019

INTRODUCTION:

Venous thromboembolism (VTE) is a leading cause of pregnancy-related morbidity. Consensus is limited regarding optimal postpartum thromboprophylaxis strategies, with individual practices guided by expert opinion and extrapolation from non-obstetric data. RCOG has developed treatment guidelines for post-partum thromboprophylaxis with limited specificity. We aimed to develop a more specific predictive model that could decrease the number needed to treat (NNT) to prevent VTE following Cesarean delivery.

METHODS:

We performed a secondary analysis of the MFMU sponsored Observational Study of Cesarean Section and Vaginal Birth after Cesarean Section. Studying 29,763 women that underwent Cesarean delivery, we performed logistic regression to develop a predictive model of VTE. This predictive algorithm was then applied to an independent dataset of 2875 women that underwent Cesarean delivery at Magee-Womens Hospital in 2011. We then compared the sensitivity/specificity of our developed algorithm with RCOG guidelines.

RESULTS:

There were 11 postpartum VTEs in our cohort (incidence 0.38%). The sensitivity of our model was 100%, specificity 8%. The sensitivity of the RCOG system was 100%, specificity 6%.

CONCLUSION:

While both our prediction models identified all postpartum VTEs, use of either predictive model would result in thromboprophylaxis of >90% of patients undergoing Cesarean section. The inability to distinguish between patients that will and will not develop VTE indicates a limited utility to predictive models. Universal thromboprophylaxis may be a more effective strategy.
Does 1st Trimester Hemoglobin A1c Predict Adverse Pregnancy Outcomes? [9E]
Authors: Davis Jay , Heiselman Cassandra , Hoffmann Eva , Dinglas Cheryl , Vintzileos Anthony M. , Heo Hye Jung
Published: May 2019

INTRODUCTION:

Recent prospective study demonstrates a correlation between 1st trimester HgA1c with development of gestational diabetes (GDM) in low risk populations. We sought to determine if 1st trimester HbA1c is predictive of GDM, abnormal ultrasound (U/S) parameters, and adverse pregnancy outcomes (APO) in high-risk pregnant populations and define the optimal HbA1c cut-off value.

METHODS:

IRB-committee approved retrospective cohort study performed on 156 singleton, non-pregestational diabetic pregnancies (HbA1c<6.5%), screened with 1st trimester HbA1c for increased risk of GDM, in an academic center between August 2016 to June 2018. HbA1c was correlated to the development of GDM, U/S parameters (femur length/abdominal circumference, head circumference/abdominal circumference, and observed/expected weight ratios, and amniotic fluid indices) at ∼20weeks, ∼30weeks, and ∼36weeks, birth weight parameters, and other APO using Receiver Operating Characteristic curves (ROC) and corresponding areas under the curves (AUC). Spearman correlation coefficients assessed the relationship between 1st trimester HbA1c values and observed/expected EFW, birth weight, and ponderal index.

RESULTS:

Among these 156 patients, prevalence of GDM was 16.0%. There was statistically significant correlation between 1st trimester HbA1c values and development of GDM (AUC=.728, P<.0003) at an optimal HbA1c cutoff value of 5.4%. There was no correlation between 1st trimester HbA1c and U/S parameters, birth weight parameters, or other APO.

CONCLUSION:

1st trimester HbA1c is predictive of GDM development in high-risk populations at values above 5.4%, a value much lower than the current AGOG guideline (HgA1c<5.7) for early GDM screening. In women without pregestational diabetes (HgA1c<6.5), HbA1c does not predict abnormal fetal U/S parameters or APO.
Outcomes of Water Immersion During The Second Stage of Labor [11E]
Authors: Valarezo Vanessa , Powel Jennifer E. , Benito Carlos , Yates Joann
Published: May 2019

INTRODUCTION:

Water immersion during labor and delivery has become popularized, resulting in questions regarding outcomes, safety, and efficacy. Our study analyzed neonatal and maternal outcomes of water immersion during the first and second stage of labor and delivery, and compared outcomes to land births as controls.

METHODS:

Retrospective cohort study of singleton, cephalic presentation term pregnancies between January 2013-March 2017. This study was IRB approved. Comparison groups included: labor and land birth, water immersion exposure, and all deliveries in the study period. Obstetrical and neonatal outcomes were reviewed and analyzed. Student t-test, Mann Whitney test, Test of Proportion and Chi square tests were utilized for analysis. Significance was set at P=<0.05.

RESULTS:

Vaginal delivery (P<.001) and vaginal birth after cesarean section (VBAC) (P<.001) rates were higher in the water immersion exposure group compared to land births. The cesarean (P<.001) and operative delivery (P<.001) rates were lower. The uterine rupture rate was not significant (P=.94) between water immersion exposure and land birth groups. NICU admission rates were not significantly different between the immersion exposure and land birth groups (P=.99).

CONCLUSION:

Water immersion has positive outcomes in terms of increased rates of vaginal delivery and successful VBAC, and decreased rates of cesarean section. Water immersion for the second stage of labor and delivery is similar, if not better, than land birth in terms of maternal outcomes. Neonatal outcomes after water immersion exposure were similar to land births.
Patients With Diabetes Mellitus Managed With Insulin Detemir: Hospital Outcomes [18E]
Authors: Christman Lauren , Piszczek Jaclyn , Magee Maxwell , Ferris Letisha , Duong Jennifer , Farley Darren
Published: May 2019

INTRODUCTION:

Approximately 7% of pregnancies are complicated by diabetes mellitus. Due to a greater prevalence of obesity and sedentary lifestyle, the prevalence of diabetes is increasing globally. The aim of this study is to evaluate hospital outcomes of patients with diabetes mellitus managed with insulin detemir during pregnancy.

METHODS:

We retrospectively reviewed all patients managed with insulin detemir at a single maternal fetal medicine clinic. Patients included in the study delivered between January 1, 2007 and August 31, 2016 at a single institution. Patients were excluded if pregnant with a neonate not expected to survive, or if hospital stay was beyond 21 days. IRB committee approval was obtained for this study.

RESULTS:

Of 161 patients, 154 were included in the final analysis. The majority of patients had gestational diabetes (75.3%, n=116) and were white (73.4%, 113/150). Average maternal age at delivery was 31.0±5.4 years old (range: 19-43). Sixty-six were obese at the initial appointment (42.9%). Average hospital stay was 2.6±1.2 days (range: 1-8). Half of patients delivered via cesarean (51.3%, n=79). Average neonatal weight was 3.3±0.6 kilograms (range: 1.3-5.0). APGAR scores were 8 at 1 minute (54.4%, 74/136), and 9 at 5 minutes (78.5%, 117/136). Average neonatal glucose was 62.3±14.0 mg/dL (range: 37-107). Average maternal glucose during the hospital stay was 109.2±22.6 mg/dL (range: 67.3-184). Six (3.9%) patients received regular insulin treatment during their hospital stay.

CONCLUSION:

Among patients treated with insulin detemir during pregnancy, few patients required supplemental insulin treatment during the hospital stay for delivery. Neonatal outcomes were satisfactory.
Peripartum Chest Pain Should Prompt Cardiac Evaluation [23E]
Authors: Hasan Abida , Hill Michael , Massad Malek , Shroff Adhir , DiGiovanni Laura M. , Briller Joan
Published: May 2019

INTRODUCTION:

Cardiovascular disease is a leading cause of maternal morbidity and mortality. Women are at 3 to 4 fold higher risk acute myocardial infarction (AMI) during pregnancy and post-partum (PP). Spontaneous coronary artery dissection (SCAD) is the most common cause of AMI typically presenting within 6 weeks PP. Diagnosis can be missed given low suspicion for ischemic etiologies in young women with chest discomfort.

METHODS:

A 29-year-old G2P2002 without cardiac risk factors, who provided consent for presentation, underwent uncomplicated vaginal birth after cesarean at 39 weeks. Delivery and immediate PP course were uncomplicated. She was discharged PP day 2. On PP day 22, she self-presented to ED with substernal chest pain (CP) reporting that she had called EMS with prior CP episodes days 5 and 15 PP and was told CP was due to anxiety. EKG suggested ischemia and troponins were elevated. She received sublingual nitroglycerin, aspirin, beta-blocker, and heparin. Coronary angiography demonstrated 60-70% left main coronary artery stenosis, 90% distal left anterior descending artery stenosis, and 100% occlusion of left circumflex artery raising concern for underlying SCAD. While SCAD can often be managed conservatively, she continued to have symptoms with rising biomarkers despite medical therapy, and underwent coronary bypass surgery on PP day 25. Diagnosis of SCAD was confirmed intraoperatively.

CONCLUSION:

Peripartum women with SCAD may be missed because of young age and few risk factors for atherosclerosis. This case illustrates the imperative of maintaining a high index of suspicion for ischemic disease when women present with CP during pregnancy or PP.
Placenta Accreta: Does Antenatal Diagnosis Improve Maternal and Neonatal Outcomes? [25E]
Authors: Kim Angela , Stohl Hindi E.
Published: May 2019

INTRODUCTION:

The incidence of placenta accreta has been increasing in the US. Accretas can be diagnosed antenatally (via prenatal imaging) or at time of delivery. The primary benefit of antenatal diagnosis is multidisciplinary delivery planning. However, data is limited on whether antenatal diagnosis of accreta improves pregnancy outcomes. The objective of this study is to compare maternal and neonatal outcomes in patients with versus without an antenatal diagnosis of accreta.

METHODS:

This is an IRB-approved, retrospective chart review of patients delivering at Harbor UCLA from January 2005 to January 2016 with a pathology-confirmed diagnosis of accreta. Statistical analysis was performed using Chi-square and T-test with SPSS software.

RESULTS:

Of the 16 patients with pathology-confirmed accreta, 10 patients had antepartum diagnosis and 6 patients were diagnosed at delivery. Compared to unsuspected cases, suspected cases had a non-significantly lower mean gestational age at delivery (35+6 vs. 36+6 weeks, p=0.488), maternal length of stay (5.6 vs. 8 days, p=0.117) and estimated blood loss (3200 vs. 3666 ml, p=0.645) and a non-significantly higher number of NICU admissions (60% vs. 30%, p=0.696). Significantly more midline incisions were performed in suspected accreta group versus unsuspected accreta groups (70% vs. 12.5%, respectively, p=0.001). All 16 cases of accreta resulted in peripartum hysterectomy.

CONCLUSION:

We found few differences in maternal and neonatal outcomes between suspected and unsuspected accreta cases. Our findings may be limited by sample size or may highlight the overall importance of delivery of accreta at a tertiary center, where complications are relatively low.
A Systematic Review of Telehealth on Clinical Outcomes in Obstetrics & Gynecology [27E]
Authors: DeNicola Nathaniel G. , Lowery Curtis L. , Marko Kathryn I. , Grossman Daniel Aaron
Published: May 2019

INTRODUCTION:

Telehealth is an emerging trend that has applications for obstetrics, gynecology, and Ob/Gyn specialties. These novel developments warrant robust scientific evaluation and clinical guidance.

METHODS:

A literature search was conducted by a team of medical librarians. Telehealth interventions included virtual visits with audio/visual, mobile health, wearable devices, and SMS; interventions were excluded if it only involved telephone calls or websites. Outcomes were organized by Low-Risk Obstetrics, High-Risk Obstetrics, Family Planning, and Specialty. The PRISMA method was followed, an evidence distilling system was used which included dual review of studies for quality rating and risk of bias assessment. To quality rate the studies we used the Cochrane Collaboration's tool for assessing the risk of bias for RCTs and the ROBINS-I tool for assessing risk of bias in non-randomized studies.

RESULTS:

Low-Risk Obstetrics yielded 1781 references, 19 met inclusion. An effect of telehealth intervention was found on smoking cessation, pregnancy wellness, influenza vaccination, and breastfeeding. High-Risk Obstetrics yielded 1271 references, 14 met inclusion. An effect was found on diabetic management, preterm labor, prenatal visit reduction, and asthma control. Family Planning yielded 527 references, 13 met inclusion. An effect was found on contraceptive continuation and on access to medical abortion. Specialty yielded 1387 references, 8 met inclusion. An effect was found on sexually transmitted illness, menopause management, stress urinary incontinence, weight loss, and gynecology post-operative management.

CONCLUSION:

Telehealth has interventions with effect on clinical outcomes in obstetrics, gynecology, and specialty fields. Women's health providers can gain guidance on these new opportunities through continued research.
Early Detection and Intervention of Postpartum Preeclampsia With the Use of Mobile and Digital Tools [29E]
Authors: Sheth Sheetal , Morin Caitlin
Published: May 2019

INTRODUCTION:

Hypertensive disorders in pregnancy are a leading cause of morbidity and mortality. This case series examines the ability of an integrated technology platform to augment surveillance with remote blood pressure (BP) readings in low-risk pregnant women and allow for real time intervention by providers of care.

METHODS:

Pregnant women presented at the clinic of an urban academic medical center. Patients were placed on an optimized prenatal care plan that consisted of an alternative in-clinic visit schedule and an integrated technology platform, provided by a mobile/digital health firm. Patients used the mobile app as well as collected weight and BP data weekly. The platform includes advanced remote monitoring technology to identify aberrant data points. A “trigger alert” mechanism alerts clinicians when aberrant data points are identified and enable the early detection of certain high-risk conditions, such as preeclampsia. Case 1: Patient 1, G3P1010 recorded 26 BPs antenatally; all BPs were less than 140/90. Postpartum, BPs were elevated and led to hospital readmission for magnesium sulfate. Case 2: Patient 2, G3P0020 recorded 21 BPs antenatally; all BPs were less than 140/90. Postpartum, BPs were elevated and led to hospital readmission for magnesium sulfate. 15 BPs were recorded after discharged and antihypertensives were titrated according to these data points.

CONCLUSION:

Remote monitoring of BP in low-risk pregnant women resulted in frequent recordings during the antepartum and postpartum periods. Remote monitoring of BP could offer more robust monitoring in low-risk pregnancies and allow for real time identification and intervention of high blood pressure.
Is it Time to Move the Hysteroscopy Out of the Operating Room? [30E]
Authors: Echeverri Natalia , Timmons Douglas B. , Palin Hannah , Florez Laura , Ring Sarah , Carugno Jose
Published: May 2019

INTRODUCTION:

Traditionally, hysteroscopy has been a hospital-based procedure under general anesthesia however the emergence of small diameter hysteroscopes and the vaginoscopy approach has allowed it to be transitioned to the office setting. This study compares office versus OR operative hysteroscopy with respect to success rate and operative time.

METHODS:

Retrospective chart review of 66 hysteroscopies performed in the OR under general anesthesia compared to 22 in office hysteroscopies performed without anesthesia using the vaginoscopy "no touch' technique.

RESULTS:

Patients' characteristics were similar in both groups. The procedure was successfully completed in 80% (18/22) of the in-office group and 100% (66/66) of the OR group. Hysteroscopic office procedures indications were: 2 (9.1%) postmenopausal bleeding, 5 (22.7%) retained IUD, 7 (31.8%) for suspected polyp, 8 (36.4%) for abnormal uterine bleeding. Hysteroscopic OR indications were: 2 (3.0%) abnormal uterine bleeding, 3 (4.5%) retained IUD, 11 (16.7%) postmenopausal bleeding, 50 (75.8%) suspected polyp. Mean operative time for in office hysteroscopy was 28.3 SD ±3.3 minutes versus 88.4 SD ±23.2 minutes (p<0.001). There was no complication in either group.

CONCLUSION:

In office hysteroscopy without anesthesia, using the vaginoscopy “no touch” technique, had a significantly less operative time when compared to those performed in the OR. Encouraging practitioners to adopt in office hysteroscopy would allow to eliminate anesthesia risks and optimize utilization of OR time which could represent increased patient's satisfaction and decreased cost.
Age Related Outcomes in Patients Undergoing Cytoreductive Surgery for Advanced Stage Adnexal and Uterine Cancers [36E]
Authors: Valant Roseanna Jo , Fazzari Melissa , Laitman Lauren Elisabeth , Griffiths Courtney Sarah , Jimenez Edward A. , Chalas Eva
Published: May 2019

INTRODUCTION:

To evaluate impact of aging on extent of surgical procedure in advanced gynecologic cancers.

METHODS:

Retrospective analysis of the ACS National Surgical Quality Improvement Program targeted gynecologic data was conducted to assess frequency of cytoreductive surgery (CRS) performed in patients with stage III and IV gynecologic cancers between 2014 and 2016 using ICD-9 and CPT codes. Complication rates examined across age groups: <65, 65-74 and 75+ years old. Frequencies of complications and procedures were compared between groups via chi-square tests, age-associated trends in rates were evaluated via Cochran-Armitage tests.

RESULTS:

Of 2858 patients, 1336 had adnexal/peritoneal cancers and 1258 had uterine cancer. CRS was performed in 76% and 21% of each diagnosis, respectively. No statistical difference in the rate of CRS by age group. Patients undergoing CRS vs. non CRS for uterine cancer had increased risk of wound complication (p=0.001), venous thrombosis (p=0.02), transfusions (p<0.001), death (p=0.01), return to OR (p<0.001), and readmission (p<0.001). Those undergoing CRS for adnexal/peritoneal cancers had increased rates of transfusions (p=0.01) and any overall complication (p=0.01). When comparing across age groups, no statistically significant difference in the rate of the following post-operative complications: wound, venous thromboembolism, urinary tract infection, transfusion, death, return to the OR, or readmission. However, patients >75 with uterine cancer who had CRS were at increased risk for sepsis (p=0.05).

CONCLUSION:

In appropriately selected patients, age does not appear to impact rate of CRS or majority of perioperative complications. Older patients with advanced stage gynecologic cancers should be offered surgery based on sound clinical judgement.