bluuebunny/crossref_metadata_2025 huggingface dataset:
Racial Disparities in Maternal and Neonatal Outcomes Among Pregnant Women with Bipolar Disorder [29O]
Authors: Toffey David E. , Chatroux Louisa R. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

We sought to determine the differences in pregnancy outcomes among white, black, Hispanic, Asian/Pacific Islander, Native American women with bipolar disorder.

METHODS:

A retrospective cohort of 3,344 women with bipolar disorder and singleton, non-anomalous gestations was used to examine maternal and neonatal outcomes, assessed according to race. Maternal outcomes included gestational diabetes (GDM), chorioamnionitis, postpartum hemorrhage (PPH), and preeclampsia/eclampsia (abbreviated “Any PET”). Neonatal outcomes included preterm birth (divided into <37, <34 and <32 weeks gestational age), respiratory distress syndrome (RDS), and jaundice. Multivariate regression analyses and chi-square tests were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance.

RESULTS:

Compared to white women, and after controlling for confounders, Asian/Pacific Islander women were more likely to develop GDM, and chorioamnionitis, and trended towards higher rates of PPH. Additionally, black women trended towards higher rates of PET. Compared to neonates of white women, neonates of black women were more likely to be delivered preterm before 37, 34, and 32 weeks gestational age, and had higher rates of RDS. Additionally, Asian/Pacific Islander neonates trended towards higher rates of jaundice.

CONCLUSION:

Pregnancies of non-white women with bipolar disorder are associated with higher rates of obstetric and neonatal complications than pregnancies of white women, with specific complications and rates varying across races. This data may suggest disparities exist in management of pregnant women with bipolar disorder across different races.
Using a Cadaveric Model to Map the Epigastric Artery [39O]
Authors: Han Michelle , Yu Steve , Peacock Warwick , Chang Grace
Published: April 2018

INTRODUCTION:

Injury of the vessels of the anterior abdominal wall occurs in 0.2-2% of laparoscopic surgeries. The purpose of this study is to use surface landmarks on the abdominal wall of cadaver models to map out areas of safe trocar placement to avoid the inferior and superior epigastric arteries.

METHODS:

The inferior and superior epigastric arteries were dissected bilaterally in twenty formalin fixed cadavers. The rectus sheath was divided for adequate exposure of the entire length of the arteries from the pubic bone to the costal margin. Two reference points were defined. Point A was halfway between the umbilicus and the anterior superior iliac spine. Point B was 3cm below the costal margin on the midclavicular line (known as Palmer’s point on the left side). The distance from point A and point B to the inferior epigastric artery and superior epigastric artery, respectively, were measured bilaterally.

RESULTS:

Twenty formalin-fixed cadavers were dissected, for a total of forty epigastric arteries. Twelve female and eight male cadavers were included. The mean distance from point A to the inferior epigastric artery was 1.6 +/- 1.0 cm. The artery was always on or medial to point A. The mean distance from point B to the superior epigastric artery was 1.1 +/- 0.6 cm. The artery was always on or medial to point B.

CONCLUSION:

In trocar placement during laparoscopic surgery, staying lateral to a vertical line drawn from point A to point B is very likely to avoid the inferior and superior epigastric artery.
Management Strategies for Second Trimester Morbidly Adherent Placenta: An Academic-institution Study [4P]
Authors: Cui Ran , Bai Huimin , Zhang Zhenyu
Published: April 2018

INTRODUCTION:

To investigate and evaluate the clinical management strategies and outcomes of second trimester morbidly adherent placenta (MAP).

METHODS:

The medical records of patients with MAP who were diagnosed prenatally or after a terminated pregnancy in the second trimester in the past 10 years were retrospectively reviewed.

RESULTS:

A total of 50 patients were included in this analysis. A prenatal diagnosis was suggested in 29 patients, whereas the remaining 21 patients were diagnosed after termination in the second trimester. Expectant management (i.e., extending the gestational period as long as possible) was employed in 29 patients who were diagnosed prenatally. Eight patients failed to prolong their gestation and underwent pregnancy termination in the second trimester, and the remaining 21 (72.4%) women delivered in the third trimester. The neonatal mortality rate was 11%. For the 29 patients who underwent termination in the second trimester, subtotal hysterectomy was performed in 3 patients for life-threatening bleeding during the cesarean operation. Conservative management (i.e., leaving the placenta in situ) was applied in the remaining 26 patients. With the application of adjuvant treatments, including uterine artery embolization and medication, followed by curettage under ultrasound guidance, the implanted placenta passed out 76.6 (range: 19 to 192) days after termination. Uterus preservation was achieved in all 26 patients without severe

CONCLUSION:

Expectant management may be preferred for most patients with second trimester MAP under close monitoring throughout pregnancy. Conservative management may be a feasible therapeutic option for patients who underwent termination in the second trimester to preserve future fertility.
Detection of Non-trisomy Abnormalities in Chromosomes 13, 18, and 21 [6P]
Authors: Cacheris Phillip , Boomer Theresa , McCullough Ron , Caldwell Samantha , Donnenfeld Alan , Almasri Eyad
Published: April 2018

INTRODUCTION:

Non-invasive prenatal testing (NIPT) has become a mainstay of managing high-risk pregnancies, with the vast majority of testing targeting chromosomes 13, 18, 21, X, Y. NIPT traditionally reports trisomies of aforementioned autosomes; however, other abnormalities are encountered, including but not limited to, partial deletions, duplications, monosomies, many times producing non-reportable results. Presented are five cases showing non-trisomy abnormalities of chromosomes 13, 18, 21 which may have clinical impact.

METHODS:

Maternal blood samples submitted to Sequenom Laboratories® for MaterniT® 21 PLUS testing were subjected to DNA extraction, library preparation, and whole genome massively parallel sequencing.

RESULTS:

Case 1: NIPT demonstrated 13q21.1-q34 deletion. Amnioarray showed contiguous loss of heterozygosity/uniparental disomy: 13q21.1-q34. Case 2: NIPT demonstrated maternal 18p deletion. Maternal karyotype: mosaic deletion 18p11.32-11.21;previous child with 18p deletion. Case 3: NIPT demonstrated 18p duplication. Newborn blood karyotype: 47,XY,+18,i(18)(p10),r(18)(p11.2q23) [17]/46,sl, -r(18) [3]. Case 4: NIPT demonstrated 1 Mb duplication in Down syndrome critical region, likely of maternal origin. Maternal and fetal karyotype with microarray: 21q22.12-q22.13 duplication (900 kb). Case 5: NIPT demonstrated 21q11.2-q21.1 duplication. Amniotic fluid karyotype showed 47,XY,+mar with aCGH showing gain: 21q11.1-21.1.

CONCLUSION:

NIPT findings were communicated to the clinicians with specific recommendations for diagnostic follow-up, as many of these findings would (and did) elude standard karyotype analysis. Most NIPT is limited to whole trisomies of these chromosomes, resulting in non-reportable or misleading reports confounding clinical assessment. Six years into clinical NIPT, the ability to discern subchromosomal events, in addition to trisomy, is essential for providers looking to maximize NIPT clinical utility.
Tdap Vaccine Knowledge and Acceptance Rates during Pregnancy in a Los Angeles Public Teaching-Hospital Clinic [7P]
Authors: Kim Angela , Schiller Andrew , Mellon Michelle , Nelson Anita L. , Stohl Hindi E.
Published: April 2018

INTRODUCTION:

Though the prevalence of pertussis is on the rise, only 35% of pregnant women in California with public insurance reported receiving the tetanus, diphtheria and pertussis vaccine (Tdap). The Tdap vaccine has been shown to reduce the risk of neonatal pertussis by 78% if mothers received it in the third trimester. This study evaluates pregnant women’s knowledge about the Tdap and its acceptance rate during pregnancy.

METHODS:

After IRB approval was obtained, pregnant women receiving prenatal care at a public teaching-hospital clinic were individually interviewed from June to August 2017 about their knowledge of vaccines during pregnancy. Interviews were conducted in English or Spanish. Women who already received the Tdap were excluded. The clinic’s Tdap acceptance rate was obtained through chart review.

RESULTS:

Among 152 pregnant women who had not yet received the Tdap during the current pregnancy, 80(53%) had never heard of the vaccine. An additional 53(35%) had heard of the vaccine but could not identify why the vaccine was recommended in pregnancy. Forty-eight percent of these women were either undecided at the time of their interview or did not plan to get the Tdap. In contrast, the Tdap acceptance rate in the third trimester in this clinic was 84%.

CONCLUSION:

The majority of pregnant women in a low-income clinic have limited understanding of the importance of the Tdap during pregnancy. Interestingly, most pregnant women in this population nonetheless received the vaccine. Educational initiatives about the Tdap may improve patients' knowledge and help them become more informed in their pregnancy-related decisions.
Does a History of IUD Contraceptive Usage Affect Placental Location in Future Pregnancies? [9P]
Authors: Bergh Eric P. , Duncan Sarah , Pan Stephanie , Overbey Jessica , Stone Joanne , Ferrara Lauren
Published: April 2018

INTRODUCTION:

It is unknown how a history of prior IUD usage affects future pregnancy implantation outcomes. Our objective is to determine the impact of prior IUD usage on placentation and obstetric outcomes in subsequent pregnancies.

METHODS:

Retrospective matched cohort study, where one group of patients had placement of an IUD at Mount Sinai in the last 7 years (2010-2016) prior to a pregnancy and one group with no history of IUD usage. Patients are matched 2:1, two no IUD placements for each IUD patient. They are matched by parity, unit in which they received care, and delivery time (±3 days). Outcomes were obtained via chart review.

RESULTS:

1736 patients underwent IUD placement during the study period, of which 71 subsequently had their device removed, became pregnant and delivered. Four patients were removed from the analysis: 2 delivered at outside institutions, a patient with a 14 week loss and a patient with a twin pregnancy. In all, 67 patients had a subsequent singleton pregnancy outcome beyond 20 weeks. There were no significant differences in placental location nor in the incidence of low lying placenta or placenta previa. Secondary outcomes of EBL, fetal weight, and mode of delivery did not differ. Finally among 43 patients for whom the duration of IUD usage was known, there was no evidence of an association between either duration of IUD usage nor duration of time from removal to delivery on placental outcomes.

CONCLUSION:

History of IUD usage does not appear to affect the location of placentation in future pregnancies.
Late Preterm Steroids and Peripartum Maternal Infection at a Single Center [14P]
Authors: Chen Ellison , Uquillas Kristen , Lee Richard , Ihenacho Ugonna , Cortessis Victoria , Barton Lorayne
Published: April 2018

INTRODUCTION:

Antenatal corticosteroids (ACS) are commonly administered to pregnant women at risk of delivery before 34 weeks to enhance fetal lung development. Following the Antenatal Late Preterm Steroids (ALPS) trial in 2016, this practice was extended to mothers at risk of delivering in the late preterm period (34 0/7 to 36 6/7 weeks). However, corticosteroid use is known to predispose patients to infection. This study aims to investigate whether women given late preterm ACS at our center were at increased risk of chorioamnionitis or endometritis, or had prolonged postpartum hospitalizations.

METHODS:

A retrospective chart review identified all LAC+USC patients who based on the ALPS trial were eligible for late preterm ACS between February 2015 and July 2017. Maternal outcomes were compared using Student’s t-test for continuous data and Pearson’s chi-squared test for categorical data. Significance was defined as a P-value <0.05.

RESULTS:

Of 194 mothers found to eligible, 67 (34.5%) received ACS. The incidence of chorioamnionitis or endometritis was not significantly different between those who did and did not receive ACS, respectively (1.5% vs. 6.3%, p = 0.13). ACS recipients did not have significantly different postpartum length of stays compared to those who did not receive ACS (3.7 ± 1.1 vs. 3.7 ± 1.1 days, p = 0.88).

CONCLUSION:

At LAC+USC, mothers who received late preterm ACS did not appear to experience greater risk of peripartum maternal infections, and ACS administration in the late preterm period did not appear to alter postpartum recovery time.
Periviable Preterm Birth: A Descriptive Study of Deliveries from 2011-2017 [16P]
Authors: Lynch Tara , Drennan Kathryn
Published: April 2018

INTRODUCTION:

The rate of preterm birth in 2015 was 9.63% in the United States, which includes a smaller subset of periviable pregnancies. These neonates have a wide range of morbidity and mortality resulting from severe prematurity.

METHODS:

We performed a descriptive study of neonates delivered at an academic hospital with a level IV NICU from 2011 to 2017. All neonates delivered at 22-25 6/7 weeks gestation were included. Subjects were identified using NICU and birth certificate databases.

RESULTS:

A total of 212 neonates were included. 21.7% did not have active resuscitation and 2.4% of neonates did not require intubation in the delivery room. Survival was 0% at 22 weeks, 47.5% at 23 weeks, 76.4% at 24 weeks and 88.1% at 25 weeks. (p<0.0001). When stratified based on exact gestational age of delivery there was a linear trend that was observed with survival increasing and neonatal death decreasing with increasing gestational age but this did not reach statistical significance (p=0.31). Finally, there was a decreasing rate of vaginal delivery (100.0% at 22 weeks, 60.0% at 23 weeks, 32.8% at 24 weeks and 29.8% at 25 weeks) and increasing rate of cesarean delivery (0.0% at 22 weeks, 40.0% at 23 weeks, 67.2% at 24 weeks and 70.3% at 25 weeks) with increasing gestational age (p<0.0001).

CONCLUSION:

We observed a high rate of survival with periviable preterm birth. As the survival rate of periviable neonates continues to increase, further information on the prediction of survival and risks associated with mode of delivery are needed.
Management of Perinatal Iron Deficiency Anemia: A Retrospective Review of a Community Based Intervention [18P]
Authors: Fernandes Samantha , Darbinian Jeanne , Postlethwaite Debbie , Shirazi Aida , Mandel Sarah
Published: April 2018

INTRODUCTION:

Unresolved iron-deficiency anemia in pregnancy contributes to maternal and neonatal morbidity, which may be preventable by iron administration. Kaiser Permanente San Francisco (KPSF) Perinatal Anemia Management Program (PAMP) developed a comprehensive algorithmic approach to identify and treat iron-deficiency anemia. A retrospective observational study was conducted to assess the impact of PAMP on peripartum anemia prior (1/2012-6/2013), during (9/2013-2/2015) and after (3/2015-8/2016) its implementation.

METHODS:

Iron-deficient anemic pregnant women delivering at KPSF were identified during the above time periods and divided into cohorts who received prenatal care at KPSF, exposed to PAMP versus KPSF satellites, not exposed to PAMP. Data for 2nd, 3rd trimester and delivery hemoglobin values, parenteral iron administrations and blood transfusions were electronically extracted and analyzed using Chi-square statistics, t-tests, ANOVA, and non-parametric tests to compare differences among groups.

RESULTS:

The mean % change in hemoglobin was significantly higher during-PAMP and post-PAMP among women receiving prenatal care at KPSF compared to women who received prenatal care at satellites (PAMP: 14.6 vs. 12.7, p<0.01; post-PAMP: 15.2 vs. 13.1, p<0.01). The number of KPSF women receiving parenteral iron was highest during PAMP (n=63) and remained constant for satellite women for the three time periods (n=4). Finally, the number of blood transfusions sequentially decreased by period regardless of place of prenatal care (pre-PAMP: n=25, PAMP: n=13, post-PAMP: n=11).

CONCLUSION:

The PAMP comprehensive approach was associated with improvements in peripartum iron-deficiency anemia, increased parenteral iron administration and a decrease in blood transfusions. Implementation of similar programs may in turn lower maternal and neonatal morbidity.
Does Mode of Delivery Impact Cervical Dysplasia Progression? [25P]
Authors: Baur Anna R. , Isaacs Christine
Published: April 2018

INTRODUCTION:

For many women, prenatal care represents the most likely opportunity to access health care and thus, is an ideal time to screen for cervical dysplasia and counsel appropriately. Prior studies show that delivery can increase the rates of regression of cervical dysplasia, however, few studies have looked into whether the mode of delivery (vaginal vs. cesarean) impacts the course of cervical intraepithelial neoplasia (CIN).

METHODS:

A retrospective chart review at an urban academic hospital was preformed from 2009-2014 searching by ICD-9 codes for pregnancy, delivery, and cervical dysplasia. We compared antepartum and postpartum cervical cytology and pathology of 149 patients following cesarean versus vaginal delivery.

RESULTS:

Two statistical analyses were performed. In the first analysis, we used the colposcopy result when available and the pap result only when no colposcopy report existed. Normal and LSIL/CIN 1 was classified as low grade dysplasia while HSIL/CIN 2/CIN 3 was classified as high grade dysplasia. We compared outcomes of pre- and post-delivery pathology with respect to vaginal delivery vs. cesarean delivery. Our results showed no statistical significance with dysplasia changes (regression or progression) based on mode of delivery. Our secondary analysis used mathematical extrapolation of the data when a pap screening or colposcopy result was missing either antepartum or postpartum. Overall, progression of dysplasia was more common than regression, regardless of mode of delivery (p=0.095 for CD, p=0.022 for VD).

CONCLUSION:

Vaginal versus cesarean route of delivery does not impart a statistically significant influence or advantage on overall cervical dysplasia regression rates.
Does an Upward Trend in Fetal Weight Predict Large-for-Gestational Age in Pregnancies Complicated by Diabetes? [30P]
Authors: Beddow Meghan E. , Blue Nathan R. , Savabi Mariam , Katukuri Vivek R. , Chao Conrad R.
Published: April 2018

INTRODUCTION:

Determine whether an upward trend in estimated fetal weight (EFW) percentile predicts large-for-gestational age (LGA) at birth in women with diabetes.

METHODS:

We reviewed deliveries at our institution from January 1, 2013 to March 31, 2017. We included well-dated, non-anomalous, singleton pregnancies with gestational or pre-gestational diabetes mellitus with ≥2 measured EFWs who delivered at term. EFWs and percentiles were calculated using the Hadlock formulas. The differences in EFW percentiles between two consecutive exams were calculated and receiver-operator characteristics plotted to identify the optimal threshold to predict LGA. LGA was defined as birth weight >90th percentile. We compared the rates of LGA in pregnancies with an upward-trending EFW percentile to those without using Chi square.

RESULTS:

We analyzed 235 pregnancies, with an LGA rate of 12.8% (n=30). Using the receiver-operator characteristics, we defined an “up-trending EFW” as an increase of ≥15 percentile points. To predict LGA, this cutoff had a sensitivity of 70% (95% confidence interval [CI] 50.6-85.3), specificity 51.7% (95% CI 44.6-58.7), positive predictive value 17.5% (95% CI 13.9-21.8), and negative predictive value 92.2% (95% CI 87.0-95.4), with a positive likelihood ratio of 1.45 (95% CI 1.1-1.9). The rate of LGA at birth among fetuses with an up-trending EFW was 17.5%, versus 9% for those without (p= 0.03).

CONCLUSION:

In pregnancies complicated by diabetes, an up-trending EFW percentile indicates an increased risk for LGA at birth.
Late Third Trimester Ultrasound Improves Accuracy of Predicted Birthweight in Women with Class III Obesity [32P]
Authors: Reforma Liberty , Teefey Christina Paidas , Durnwald Celeste P. , Srinivas Sindhu , Sammel Mary , Wang Eileen
Published: April 2018

INTRODUCTION:

Optimal timing of third trimester (3rd tri) ultrasound in the obese population is unclear. Later scans are technically difficult while earlier scans may not reflect clinical changes closer to term. We compared the accuracy of early versus late 3rd tri ultrasounds in predicting actual birthweight (BW) in women with class III obesity.

METHODS:

A retrospective chart review of women with a pre-pregnancy BMI>40kg/m2 who underwent both an early (28w0d-34w6d) and late 3rd tri scan (35w or greater) was performed. Subjects delivered at two urban tertiary centers. The gestation-adjusted projection method calculated a predicted BW (pBW) using the ultrasound EFW to allow for comparison with actual BW. Paired t-tests compared absolute BW error and percent error. McNemar’s test compared the proportion within 15% of actual BW between scans.

RESULTS:

189 women were included. The difference between pBW and actual BW was similar with 75g (SD 367g) for the late scans versus 83g (SD 446g) for the early scans (p=0.765). However, 82.5% of women had a pBW within 15% of actual BW at the late scan compared to only 73% at the early scan (p-value=0.024). There were 22 cases of fetal growth restriction (FGR) (<10th percentile) at delivery. The late scan detected 9 cases of FGR (41%, p<0.003) not detected at the early scan.

CONCLUSION:

In obese women, the late 3rd tri scan predicted BW more accurately than the early scan and identified additional cases of FGR not previously detected. Consideration should be given to a standard late 3rd tri growth scan in this population.
Comparison of Formulas for Estimation of Fetal Weight in Pregnancies Complicated by Gastroschisis [34P]
Authors: Tonismae Tiffany , Voirol Jenna , Schubert Frank , Shanks Anthony
Published: April 2018

INTRODUCTION:

Gastroschisis is an abdominal wall defect and it is often difficult to accurately measure the abdominal circumference. The purpose of this study is to compare formulas for estimating fetal weight by ultrasound in these infants.

METHODS:

A retrospective cohort analysis of singleton deliveries complicated by Gastroschisis. Exclusions included fetuses with additional anomalies, fetuses born at < 28 weeks, and those without available delivery data. Biometric measurements (BPD, AC, HC and FL) and estimated fetal weight were extracted from ultrasound reports. The EFW was adjusted based on a correction factor for weight gain in the third trimester. Maternal and fetal charts were reviewed for gestational age at time of delivery and birth weight.

RESULTS:

148 cases of Gastroschisis were identified. 39 were excluded based on unavailable delivery data, additional fetal anomalies, termination, and stillbirths. A total of 41 charts were reviewed with an ultrasound within 14 days of delivery (1-7 days n= 29, 8-14 days n=11). Median birth weight for those infants born within 1-7 days and 8-14 days of delivery was 2250g and 2487g. Average gestational age at time of delivery was 35 weeks 5 days and 35 weeks 6 days for those with an ultrasound between 1-7 days and 8-14 days. Average Pearson Correlation Coefficient was 0.803 (range 0.776-0.832) with the highest correlation found using Hadlock IV, JSUM, and Hadlock II. Percentage of error noted similar findings.

CONCLUSION:

As seen in other studies comparing EFW in pregnancies complicated by Gastroschisis, we noted underestimation of weight in both pregnancies with ultrasounds.
Bremelanotide for Hypoactive Sexual Desire Disorder: Age and Weight Subgroup Efficacy Analyses [1Q]
Authors: Simon James A. , Kingsberg Sheryl A. , Clayton Anita H. , Jordan Robert , Lucas Johna
Published: April 2018

INTRODUCTION:

Bremelanotide, an investigational new drug, is a melanocortin 4 receptor agonist that has demonstrated efficacy in the treatment of hypoactive sexual desire disorder (HSDD) in women. In this analysis, bremelanotide efficacy was investigated within age and weight subgroups.

METHODS:

Women from two phase 3 studies (RECONNECT) and one phase 2 study were separated into age and weight quartiles. After 4-week placebo run-in period, women self-administered 1.75 mg of bremelanotide via auto-injector pen, as desired, or equal volume placebo for 12 (phase 2) or 24 (phase 3) weeks. Efficacy was assessed using FSFI and FSDS-DAO scoring systems, with FSFI desire domain (FSFI-D) and FSDS-DAO distress resulting from low desire (Item 13) as RECONNECT co-primary endpoints.

RESULTS:

For the total integrated population (N=1337), the difference in FSFI-D mean changes from baseline (bremelanotide-placebo) was 0.38. Differences in mean FSFI-D changes from baseline for each age quartile (n-value range: 150-187) were 0.21 (19-33 y), 0.39 (>33-39 y), 0.56 (>39-44 y), and 0.34 (>44-56 y). Differences in mean FSFI-D changes for each weight quartile (n-value range: 159-181) were 0.30 (39.8-63.1 kg), 0.42 (>63.1-73.5 kg), 0.43 (>73.5-87.6 kg), and 0.34 (>87.6-189.9 kg). Significantly greater (P<0.05) changes in FSFI-D were achieved with bremelanotide vs placebo across all age and weight quartiles. FSDS-DAO Item 13 was also significantly improved across age and weight quartiles with the exception of the 39.8-63.1 kg (P=0.05) weight quartile.

CONCLUSION:

Bremelanotide demonstrated efficacy in women regardless of age. Bremelanotide significantly improved desire across weight quartiles and showed a trend in decreasing distress.
Opioid Use After Laparoscopic Hysterectomy: Prescribing Practices and Preoperative Predictors [5Q]
Authors: Wong Marron C. , Isaacson Keith B. , Morris Stephanie
Published: April 2018

INTRODUCTION:

Gynecologists can address the prescription opioid epidemic by prescribing appropriate quantities of postoperative opioids. Our goals were to measure opioid use after laparoscopic hysterectomy (LH) and to survey patients to identify factors that are predictive of higher opioid use.

METHODS:

We prospectively followed 60 patients undergoing LH for benign indications. Patients completed a preoperative survey including demographics, medical history, and standardized surveys measuring pain catastrophizing (PCS), anxiety (GAD-7), and depression (PHQ-9). Pain scores and pain medication usage were assessed at one and two weeks after surgery. Postoperative opioids were converted to morphine milligram equivalents (MME). Non-parametric statistical methods (Spearman correlation coefficient or Wilcoxon rank-sum test) were used to test for correlations between predictors and postoperative MME.

RESULTS:

A median of 20 opioid pills were prescribed (150 MME). Median use was 37.5 MME, equivalent to 5 tabs of 5mg oxycodone. 30% used opioids for <24 hours; 90% used no opioids after one week. 88.3% had leftover opioids (median 15 pills). Only 22.6% of leftover opioids were stored securely. Factors that were significantly associated (p<0.005) with increased opioid use included preoperative pain score, expected postoperative pain level, predicted pain medication requirement, PCS, GAD-7, PHQ-9, history of endometriosis or pelvic pain, preoperative pain medication use, and smaller uterine size.

CONCLUSION:

The average LH patient uses minimal opioids and leftover opioids are usually kept unsecured, illustrating a need to decrease prescribed opioids and educate patients about opioid disposal. Our preoperative survey shows promise for building a model to predict which patients are at risk for requiring more opioids.
Efficacy of Bremelanotide for HSDD in Women: RECONNECT Open-Label Extension Phase Results [8Q]
Authors: Clayton Anita H. , Kingsberg Sheryl A. , Simon James A. , Jordan Robert , Lucas Johna
Published: April 2018

INTRODUCTION:

Bremelanotide, an investigational new drug, is a melanocortin 4 receptor agonist that has demonstrated efficacy in treatment of hypoactive sexual desire disorder (HSDD) in premenopausal women. The objective of this analysis was to evaluate sustained maintenance of bremelanotide effect on HSDD during the open-label extension (OLE) phase of the RECONNECT Study.

METHODS:

After completion of the double-blinded, placebo-controlled, core phase of RECONNECT (301 and 302 studies), premenopausal women with HSDD were eligible to enroll in the 52-week OLE. Bremelanotide 1.75 mg was self-administered as desired via auto-injector pen. Efficacy was assessed via FSFI and FSDS-DAO questionnaires. FSFI desire domain (FSFI-D) and FSDS-DAO distress resulting from low desire (Item 13) were co-primary endpoints. Data were collected during clinic visits occurring at 4- to 8-week intervals. OLE baselines for the bremelanotide and placebo groups were core study baseline and end of core study, respectively.

RESULTS:

For the 301 study OLE, 124 subjects from the bremelanotide arm and 239 subjects from the placebo arm were enrolled. At week 4, subjects who received bremelanotide or placebo in the core phase demonstrated respective mean changes from group baseline of 1.11 and 0.80 in FSFI-D, and -1.20 and -0.60 in FSDS-DAO Item 13. The 302 study had similar OLE results. For all subjects, improvements were consistently maintained until week 52. Similar trends were also observed for multiple secondary endpoints.

CONCLUSION:

Regardless of core phase treatment, bremelanotide provided treatment benefits in women with HSDD for the duration of the year-long RECONNECT OLE.
Low Rates of Insomnia Associated With Flibanserin in Premenopausal Women With Hypoactive Sexual Desire Disorder [21Q]
Authors: Simon James A. , Kupferer Elizabeth , Yuan James , Pfaus James G. , Kissling Robert , Goldstein Irwin
Published: April 2018

INTRODUCTION:

Flibanserin, a 5-HT1A agonist and 5-HT2A antagonist, is approved for treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. Insomnia is a common side effect of medications that affect central serotonergic mechanisms. This analysis examined the incidence of insomnia associated with flibanserin and other representative medications that affect central serotonergic systems.

METHODS:

Patient-level data from five 24-week, randomized, double-blind, placebo-controlled, studies in premenopausal women with HSDD were pooled to evaluate the incidence, time to onset, and duration of insomnia with flibanserin treatment. Incidence of insomnia was obtained from clinical trial data reported in the prescribing information for a commonly prescribed selective serotonin reuptake inhibitor (sertraline, steady-state treatment), serotonin-norepinephrine reuptake inhibitor (venlafaxine, steady-state treatment), and triptan (sumatriptan, acute treatment).

RESULTS:

In the pooled data (flibanserin 100 mg at bedtime, n=1,543; placebo, n=1,905), most patients (88.2%) were white and mean age was 35.8 years. Mean exposure was 139.0 days with flibanserin and 147.4 days with placebo. The incidence of insomnia was 4.9% with flibanserin and 2.4% with placebo. As context, the incidence of insomnia reported for some commonly used medications that affect the central serotonergic mechanisms ranges from <2% to 21%. Median time to onset of insomnia with flibanserin was 11.0 days from drug initiation and lasted for a median duration of 31 days (range, 1-186 days).

CONCLUSION:

The incidence of insomnia with flibanserin was 4.9%, toward the lower end of the range seen with other medications with central serotonergic effects; onset was typically within 2 weeks and resolution within 31 days.
Restoring Function with Neonatal Fluid Allograft in Cases of Endometriosis or Other Ovarian Destructive Conditions [23Q]
Authors: Karon Magdalene
Published: April 2018

INTRODUCTION:

Endometriosis, in particular endometriomas, can cause impairments in folliculogenesis or other damage to ovarian tissue in patients trying to achieve pregnancy. These patients are often tested for levels of anti-Mullerian hormone (AMH), follicle stimulating hormone, and antral follicle counts to assess “ovarian reserve” and fertility potential. Here we present use of a fluid neonatal allograft in laparoscopy to improve AMH levels and chances of conception. The allograft has a multi-specialty indication for the correction of soft tissue defects, and current research suggests it may have the potential to aid in restoration of ovarian function.

METHODS:

Three patients with moderate to severe endometriosis underwent laparoscopic resection of endometriosis and ovariolysis. Patients’ fallopian tubes were patent and fimbria intact. An amniotic fluid allograft was injected in the areas of tissue defects. Patients had blood work tested pre-operatively and 1 and 3mo post-operatively. Ultrasound was also performed pre- and post-operatively to assess antral follicle count in the beginning and middle of menstruation cycle.

RESULTS:

One patient had a rise of AMH level from 0.5ng/ml (pre-op) to 1.5ng/ml (post-op). This patient also had mature follicle on day 12 of her cycle whereas pre-operatively there was no evidence of folliculogenesis by ultrasound even with Clomid therapy. Assessments of two other patients are on-going.

CONCLUSION:

Preliminary findings show an improvement in AMH levels and folliculogenesis after ovarian treatment with a neonatal-derived fluid allograft, suggesting that this treatment may aid in restoration of ovarian function and achievement of a successful pregnancy.
Reducing Surgical Site Infections after Non-Hysterectomy Abdominal Gynecologic Surgery [25Q]
Authors: Dejbakhsh Sheila Z. , Maisonet Axeline , Allen Antoinette , Zhou Xinkai , Holschneider Christine
Published: April 2018

INTRODUCTION:

Surgical site infections (SSI) are common and a significant source of preventable morbidity in gynecologic surgery. Of the gynecological SSIs at our urban tertiary care safety-net hospital >50% had no indication for preoperative antibiotics based on current ACOG guidelines, which do not recommend antibiotics for abdominal surgeries outside of hysterectomy. In July 2016, we implemented a Quality Improvement (QI) initiative whereby Cefazolin was administered to all patients undergoing non-hysterectomy abdominal gynecologic surgery.

METHODS:

The purpose of this study is to perform a one-year interim analysis to assess whether pre-operative antibiotics administered for non-hysterectomy abdominal gynecologic surgery decreased the incidence of SSI as compared to a pre-intervention control group. The primary outcome was incidence of SSI, as defined by CDC guidelines. Data were collected on type of surgery, antibiotics, SSIs, and potential confounders for cases performed between November 2013 and June 2017 (n=507).

RESULTS:

The rate of SSI decreased after the implementation of the QI initiative from 7.5% (29/383) in the pre-intervention group to 3.2% (4/124) in the intervention group (P=.06). There was a significant decrease in the incidence of SSI from 8.5% (23/270) in patients that did not receive pre-operative antibiotics to 4.2% (10/237) in those that received pre-operative antibiotics (P=.03). Peri-operative variables associated with an increased incidence of SSI included increased surgical time, ASA class III and IV, and open vs laparoscopic surgical entry.

CONCLUSION:

The use of pre-operative antibiotics in non-hysterectomy abdominal gynecologic surgery resulted in a significant decrease in SSI incidence.
Methadone vs Methadone and Smoking Effect on Fetal Growth [35Q]
Authors: Farhi Farnaz , Cruz Yury , Rodriguez Alison , Berghella Vincenzo , Mercier Rebecca , Roman Amanda
Published: April 2018

INTRODUCTION:

To evaluate the incidence of intrauterine fetal growth restriction (IUGR) and small for gestational age (SGA) at birth in women on methadone maintenance therapy who smoke cigarettes compared to those on methadone maintenance therapy who do not smoke cigarettes.

METHODS:

A retrospective cohort study of women delivered at Thomas Jefferson University Hospital from 2012 to 2015. We excluded non-singleton pregnancies. We evaluated demographic and obstetric information, ultrasound measurements, including estimated fetal weight (EFW), EFW percentile, head circumference, and abdominal circumference from last ultrasound, as well as delivery and neonatal outcomes, including gestational age at delivery, birth weight (BW), BW percentile, NICU admission, and length of stay in NICU. Smoking history was collected (number of cigarettes, if quit during pregnancy, use per trimester). Primary outcome: incidence of IUGR by last ultrasound and SGA. Secondary outcomes: preterm birth <37 weeks. Adjustment for confounders for fetal growth restriction was performed.

RESULTS:

We identified 70 women in the methadone maintenance therapy, 88.5% of whom reported smoking cigarettes and 11.4% of whom did not report smoking. Demographics were not significantly different. The incidence of IUGR and SGA were not significantly different: 4.8% vs 0% P:1.0 and 24.2% vs 25.0% P:1.0, respectively. There were no significant differences in preterm birth, birth weight, NICU admission and length of stay in NICU.

CONCLUSION:

In women on methadone maintenance therapy, there is a high incidence of IUGR and SGA; however, IUGR and SGA were not significantly different during pregnancy in women who smoked cigarettes compared to those who did not smoke cigarettes.
Mifepristone and Misoprostol Labor Induction in Intrauterine Fetal Demise: Meta-Analysis [38Q]
Authors: Kanninen Tomi T. , Nasioudis Dimitrios , Moretti Michael , Lakhi Nisha
Published: April 2018

INTRODUCTION:

Systematic review and meta-analysis was conducted to assess the effectiveness of combination mifepristone and misoprostol compared to misoprostol alone for induction of labor (IOL) for intrauterine fetal demise (IUFD) after 20 gestational weeks.

METHODS:

Medline, Scopus, ClinicalTrials.gov, Embase, Science Direct, Cochrane Central Register of Controlled Trials, and Scielo were searched for the following terms: “mifepristone”, “misoprostol”, and “IUFD” from inception until September 2017. All randomized controlled trials (RCTs) examining misoprostol versus the combination of misoprostol and mifepristone were included. Primary outcome was induction to delivery interval. Intragroup differences in parity, gestational age and bishop score was examined. Meta-analysis (Review Manager v.5.3) was performed using a fixed effects model to produce summary treatment effects in terms of mean difference, with 95% confidence intervals. Heterogeneity was measured using Chi-square and I2 statistics. GRADE approach was used to assess the quality of evidence.

RESULTS:

Two RCTs, including 140 women met inclusion criteria. The combination of mifepristone and misoprostol lead to a shorter interval to delivery mean difference -4.19 hours (95% CI, -5.58, -2.81). Chi-square 0.39, I2 =0%. There was no significant difference between groups in regard to parity, gestational age and bishop score. The quality of evidence was judged as low due to lack of clear randomization, allocation concealment, and blinding.

CONCLUSION:

Combination mifepristone and misoprostol is effective and leads to a shorter induction to delivery interval as compared to misoprostol alone for IOL for IUFD after 20 gestational weeks. Further well-designed RCTs are necessary given the low quality of evidence.
Responses to Fetal Heart Rate Alarms on a Busy Tertiary Labor and Delivery Unit [12R]
Authors: Ona Samsiya , Greenberg James A.
Published: April 2018

INTRODUCTION:

Alarm fatigue is a well-recognized phenomenon that has been demonstrated to impede rather than promote patient safety. This study investigates the incidence of electronic fetal heart rate (FHR) monitor alarms and staff responses.

METHODS:

The FHR monitor database from the labor and delivery (L&D) unit was queried to determine the number and duration of alarms/day over the course of 7 consecutive days. In addition, a survey was sent to L&D care providers to determine their subjective impression of how often the alarms were activated and their action if any.

RESULTS:

Over 7 consecutive days, there were 130 deliveries associated with 4981 alarm events with a cumulative total of 103 hours of alarms (average 15 alerts/hr totaling cumulative average 7.4 hrs/day). Surveys were sent to 322 staff with responses from 159 (49%). Thirty-four (21.4%) surveys were incomplete. Of respondents 69% (110) had the subjective impression that the alarms were ringing either “often” or “almost all the time.” Of those only 59% took some action while 41% ignored or hardly noticed the alarms.

CONCLUSION:

In this study of a high-volume academic hospital L&D unit, our data show that FHR monitor alarms are ringing every 4 minutes for a cumulative total of about 1/3 of the day. However, these alerts are ignored by almost half of the staff. Consequently, we believe that either the use of FHR monitor alarms or the policies and procedure regarding those alarms should be reviewed to ensure that their use is having a positive impact on patient safety.
Gestational Weight Gain and the Risk for Operative Vaginal Delivery [13R]
Authors: Vignes Katherine S. , Williams Corrine M. , McDaniel Honour , Chavan Niraj R.
Published: April 2018

INTRODUCTION:

This study evaluates the impact of gestational weight gain (GWG) on the risk for operative vaginal delivery across the spectrum of maternal pre-pregnancy body mass index (PPBMI).

METHODS:

Vital statistics data collected by the National Center for Health Statistics (NCHS) were utilized. Using the 2015 data, GWG was calculated and the birth cohort consisting of singleton gestations delivering vaginally was classified into inadequate, adequate and excess GWG categories as per the 2009 Institute of Medicine (IOM) guidelines. Each PPBMI category was further stratified based on the adequacy of GWG. Multivariate logistic regression analyses were used to predict the risk for operative vaginal delivery in each PPBMI and GWG group while adjusting for age, race, ethnicity, education, marital status, insurance and smoking status.

RESULTS:

The rate of operative vaginal delivery in this study cohort was 4.63% (116,610/2,517,605 singleton vaginal deliveries). Excess GWG significantly increased the risk for an operative vaginal delivery (OR 1.074 [95% CI 1.060 - 1.089]) irrespective of the PPBMI, in the adjusted regression analyses. In the PPBMI specific analyses - the risk for operative vaginal delivery was significantly increased in women with excess GWG in women classified as underweight OR 1.118 (95% CI 1.047-1.194), normal weight OR 1.112 (95% CI 1.092-1.134), overweight OR 1.145 (95% CI 1.112-1.179), and obese OR 1.148 (95% CI 1.108-1.189) as compared to those in the same weight categories with adequate GWG.

CONCLUSION:

Our findings demonstrate that women with excess GWG, regardless of their pre-pregnancy maternal weight category, are at increased risk of undergoing operative vaginal delivery.
Screening for Appendicitis in Pregnancy: A Cost-Effectiveness Analysis [15R]
Authors: Shields Michelanne , Chatroux Louisa R. , Hersh Alyssa R.
Published: April 2018

INTRODUCTION:

The purpose of this study was to estimate the cost effectiveness of ultrasonography and magnetic resonance imaging (MRI) as diagnostic modalities for suspected appendicitis in pregnancy. We examined the cost of ultrasound as the first-line modality with sequential MRI in the setting of a non-visualized appendix versus MRI alone.

METHODS:

A cost-effectiveness model was created using TreeAge to compare the sequential ultrasound and MRI versus MRI alone in a theoretical cohort of 100,000 women. Outcomes examined included perforation of the appendix, cesarean delivery, maternal death, fetal death, cost, and quality-adjusted life years (QALY). Probabilities, utilities, and costs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. One-way sensitivity analyses were used to evaluate the robustness of our results.

RESULTS:

When comparing sequential ultrasound and MRI versus MRI alone for diagnosis of appendicitis in pregnancy, there were 3.5 fewer fetal deaths with sequential screening. There was no difference in rate of maternal death. There were higher QALYs associated with sequential screening, but MRI alone was cost-effective. With sensitivity analysis, sequential screen became cost-effective below $200 (cost assumption in our model was $604).

CONCLUSION:

The sequential screening strategy led to fewer adverse neonatal outcomes. While this screening modality was not cost-effective, the higher QALYs make this screening algorithm worth considering in the clinical setting, especially due to improving clinician skills and the low cost of bedside ultrasound. Sequential screening is recommended as first-line imaging, and further investigation is warranted to better understand how these imaging modalities can improve clinical outcomes.
Relationships among Neonatal Mortality, Hospital Volume, Weekday Demand, and Weekend Birth [22R]
Authors: Restrepo Elizabeth , Hamilton Patti , Liu Fuqin , Mancuso Peggy
Published: April 2018

INTRODUCTION:

Previous research indicated weekend birth and mid-range hospital volume are associated with increased risk of neonatal mortality. This study investigated how the proportion of births occurring Monday through Friday affects risk for neonatal mortality from low birth volume and weekend birth.

METHODS:

For this retrospective, population-based, cohort-study design, data were obtained from 32,140 electronic birth certificate records matched with 92 death certificate records from the Texas Department of State Health Statistics. The data represented all births and neonatal deaths in one metropolitan county in Texas for the year 2012. Statistical analyses included descriptive procedures, ANOVA, t-test, logistic regression, and chi square tests of association.

RESULTS:

After adjusting for birth weight and maternal ethnicity, we found the proportion of births occurring Monday through Friday, in hospitals, remained a significant factor affecting odds of neonatal mortality, whereas hospital birth volume and weekend birth did not remain significant predictors.

CONCLUSION:

The way in which hospitals respond to demand (e.g., allocating staff and other resources) across the week plays an important role in determining neonatal mortality risk, regardless of infants’ birth weight or maternal ethnicity. The study findings could raise awareness of system-level factors and stimulate more thorough, careful assessment and planning by hospital administrators and care providers. More research is needed to determine exactly how acuity and quality interact to increase weekend risk.