bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Nurse Driven EMR Pathway for Treatment of Severe Hypertension in Pregnancy [OP03-5C]
Authors: Martin Courtney , Johns Kim , Yao Ruofan , Balli Kevin , Pappas James
Published: April 2020

INTRODUCTION:

The use of care pathways via EMR is emerging technology to standardize patient care. The objectives of this study was to build and assess the effect of a care pathway in the management of severe hypertension in pregnancy.

METHODS:

A nurse driven care pathway and warning system was designed and implemented in the EMR inpatient environment. The pathway protocolizes the initial management of severe hypertension in pregnancy based on ACOG guidelines. The care pathway utilizes patient vital signs, intravenous access, patient medical history, and ACOG algorithms for initial antihypertensive therapy, to make a first line recommendation that the nurse administers. Information regarding compliance with ACOG guidelines was collected for 12 months before and after the pathway was launched. The data examined was the time from the second severe range blood pressure to administration of the pathway recommended antihypertensive agent. The primary endpoint was to improve compliance with the ACOG guidelines in the management of severe hypertension. The primary outcome of interest is the difference in the compliance rate before and after the implementation of the care pathway.

RESULTS:

49% (623/1272) of patients received meds within 30 minutes of the second severe range blood pressure in the initial 12 months versus 64% (895/1394) in the 12 months after launch of the pathway (p=.0000).

CONCLUSION:

Implementation of a nurse driven, care pathway for hypertension in pregnancy reduces time to administration of antihypertensive therapy. Using EMR systems to standardize care is a novel way to provide safety infrastructure in hospitals for pregnant women.
The Relationship Between Social Deprivation and Preterm Birth [OP03-7C]
Authors: DeHority Rebecca L. , Coyne Kathryn D. , Bevan Graham H. , Lappen Justin R.
Published: April 2020

INTRODUCTION:

The United States has the highest preterm birth (PTB) rate amongst developed countries, and within the country significant geographic variability exists. Socioeconomic factors and stress are associated with the risk of PTB, however this association has not been characterized using the Social Deprivation Index (SDI), a validated national socioeconomic index. Our objective was to assess the relationship between the SDI and PTB using county-level data.

METHODS:

Using CDC Natality data from 2007-2018 we identified PTBs (20-36 weeks) in counties with populations greater than 100,000. The 2015 SDI measures and score components were extracted. Linear regression was used to assess the relationship between SDI score, its components, and PTB. The SDI score was log transformed for normalcy.

RESULTS:

A total of 37,722,326 births were analyzed, with 4,379,950 PTB in 580 counties. The median percent PTB was 11.4%. Using simple linear regression, SDI score significantly correlated with PTB (β=.0024, R2=.17, p < .001). In a secondary multiple linear regression analysis, the following components of SDI were independently significantly associated with PTB: income below the federal poverty level (1), African American race (2), and education level (3) (β1=.46, β2= .73, β3= .34, R2=.47, p < .001).

CONCLUSION:

The SDI and several of its components predict county variance in PTB. This publically available data could be used to inform resource allocation for PTB prevention.
Contraceptive Efficacy and Safety of 52 mg LNG-IUS for up to Eight Years: Year 6 Data From the Mirena Extension Trial [OP04-1D]
Authors: Jensen Jeffrey T. , Kroll Robin , Lynen Richard F. , Schulze Andrea , Lukkari-Lax Eeva
Published: April 2020

INTRODUCTION:

The Mirena Extension Trial (MET) is a multicenter, open-label, single group study being conducted in the USA investigating contraceptive efficacy and safety of 52 mg LNG-IUS (Mirena®) during extended use for up to 8 years, with analyses planned at the end of Year 6, 7 and 8.

METHODS:

We recruited and screened current users of 52 mg LNG-IUS, ≤35 years of age, after a minimum of 4 years and 6 months of use. Eligible consenting participants underwent a baseline visit 0 to 14 days before the end of Year 5. Institutional review board approval was obtained for all centers. The primary aim was to assess contraceptive efficacy (Pearl Index, PI) for up to 8 years of use. We present the results of the Year 6 analysis.

RESULTS:

Most of the 362 participants starting Year 6 completed and entered Year 7; 14 were lost to follow up and 40 discontinued. At baseline, 11.3% of women were between 18 and 25 years of age (mean=29.4 years [±3.1]). Around half (47.2%) were nulliparous. During Year 6, one pregnancy occurred for a Year 6 PI of 0.35 (CI 95% 0.01, 1.95). This pregnancy was of undetermined location, occurred with 52 mg LNG-IUS in situ and resolved without intervention. Overall, participants reported high levels of satisfaction (92.6% very satisfied, 6.4% somewhat satisfied). Treatment-emergent adverse events were reported in 166 patients, with 27 considered related to 52 mg LNG-IUS.

CONCLUSION:

52 mg LNG-IUS maintains high contraceptive efficacy during Year 6 with a favorable safety profile. Satisfaction also remains high.
Polygenic Risk Score for the Non-Invasive Prediction of Surgical Endometriosis [OP04-3D]
Authors: Ward Kenneth
Published: April 2020

INTRODUCTION:

Endometriosis commonly causes infertility, dysmenorrhea, dyspareunia, dyschezia, chronic pelvic pain, and other gynecologic symptoms. Unfortunately, history, physical exam, pelvic ultrasound, and even the “gold standard” of laparoscopic visualization/histology have limitations with regard to diagnostic sensitivity and specificity. The objective of this study is development of a predictive DNA test for endometriosis.

METHODS:

Using IRB approved protocols, endometriosis associated markers were discovered using genome wide association studies (GWAS) involving 5,571 women with surgically confirmed endometriosis and 21,971 controls and whole exome sequencing (WES) of 2,904 affected women. Allele frequencies for WES markers were compared to published data [55,860 non-Finnish European in gnomAD database (Broad Institute)]. An additive prediction model was created using 71 GWAS markers combined into a single risk term using logistic regression and 550 low-frequency exome variants individually weighted using observed odds ratios. The predictive algorithm was validated using independent cohorts (1,458 Caucasian endometriosis patients and 758 population controls).

RESULTS:

The mean polygenic risk score was 1.2 in population controls and 2.9 in endometriosis patients (p<10-16). The calculated Area Under the Curve (AUC) of predictor was excellent (0.88), even though endometriosis was not excluded in population controls (10% may have endometriosis).

CONCLUSION:

Predictive DNA testing may help to reduce the under-diagnosis and delayed diagnosis documented for endometriosis today. Blood, saliva, or other cell/tissue samples can be tested using this assay. DNA tests also have the potential to provide insights regarding molecular pathways involved, likely treatment responses, malignant potential, and other disease characteristics unavailable from histology.
Relugolix Combination Improves Quality of Life in Phase 3 Studies of Symptomatic Uterine Fibroids [OP04-4D]
Authors: Lukes Andrea S. , Poindexter Alfred , Villarroel Claudio , Li Yulan , Hunsche Elke , Stewart Elizabeth A.
Published: April 2020

INTRODUCTION:

In the two phase 3 LIBERTY Institutional Review Board-approved studies, relugolix combination therapy (Relugolix-CT; once-daily relugolix 40 mg, estradiol 1.0 mg, and norethindrone acetate 0.5 mg) significantly improved heavy menstrual bleeding (HMB) and pain associated with uterine fibroids (UF). Impact of Relugolix-CT treatment on quality of life (QoL) was assessed using the validated Uterine Fibroid Symptom (UFS)-QoL questionnaire.

METHODS:

Changes from baseline to Week 24 in UFS-QoL symptom severity (SS) and health-related (HR) QoL scale scores (range 0 to 100), and HR-QoL subscale scores were assessed. Higher SS scores reflect more severe symptoms; conversely, higher HR-QoL scores indicate better QoL. Least-squares mean changes in SS and HR-QoL were compared between Relugolix-CT and placebo, by LIBERTY study, using a mixed-effects model, with treatment, visit, region, baseline menstrual blood loss volume, and treatment by visit interaction as fixed effects.

RESULTS:

At Week 24, SS improved significantly from baseline (both studies: nominal P<.0001) with Relugolix-CT vs placebo (decreases were, respectively, from 55.1 to 23.4 and from 60.3 to 49.2 [LIBERTY-1]; from 59.1 to 21.7 and from 59.2 to 45.1 [LIBERTY-2]). HR-QoL improved significantly from baseline (both studies: nominal P<.0001) with Relugolix-CT vs placebo (increases were from 37.2 to 74.0 and from 33.5 to 44.9 [LIBERTY-1]; from 38.9 to 78.7 and from 37.3 to 51.0 [LIBERTY-2]). Similar results were observed between groups in all HR-QoL subscales.

CONCLUSION:

Over 24 weeks, Relugolix-CT significantly improved HMB and pain associated with UF, with corresponding significant improvements in patient-reported SS, and HR-QoL total and subscale scores.
The Antiretroviral Pregnancy Registry: 30 Years of Monitoring for Congenital Anomalies [OP04-6D]
Authors: Albano Jessica , Scheuerle Angela , Beckerman Karen , Mofenson Lynne , Vannappagari Vani
Published: April 2020

INTRODUCTION:

Antiretroviral (ARV) treatment saves lives and prevents vertical transmission of HIV. The Antiretroviral Pregnancy Registry (APR) began prospectively monitoring prenatal ARV use for potential teratogenicity in 1989 and depends on voluntary registration of ARV exposed pregnancies (www.APRegistry.com).

METHODS:

The APR is an IRB approved, prospective exposure-registration cohort study with data from 70 countries. Prevalence of congenital anomalies (CAs) are estimated and compared to internal and external comparison groups. Twenty-two ARVs have sufficient 1st trimester exposures to detect at least a 2-fold increase in risk of CAs overall, of which 11 can detect a 1.5-fold increase.

RESULTS:

Of the 20,759 pregnancies prospectively enrolled through 31 July 2019, reported outcomes include 19,642 live births (LB) with ARV exposure at any time during pregnancy and 554 CAs. Prevalence of CAs was 2.8% (95% CI 2.6-3.1) overall, 2.8% (95% CI 2.5-3.1) among 1st trimester exposures and 2.8% (95% CI 2.5-3.2) among 2nd/3rd trimester exposures to ARVs (prevalence ratio 1.00 [95% CI 0.85-1.18]).

CONCLUSION:

The APR has not detected a significant difference in overall CA prevalence compared to two population based surveillance systems: 2.72/100 LB (95% CI 2.68-2.76) Metropolitan Atlanta Congenital Defects Program (MACDP) and 4.17/100 LB (95% CI 4.15-4.19) Texas Birth Defects Registry (TBDR). Two ARVs, didanosine and nelfinavir, have modest statistically significant increased prevalence compared to MACDP but not TBDR. The APR independent Advisory Committee concludes, “The Registry finds no apparent increases in frequency of specific defects with first trimester exposures and no pattern to suggest a common cause; however, potential limitations of registries should be recognized.”
Duration of Intrapartum Antibiotic Prophylaxis for Group B Streptococcus [06A]
Authors: Cate Jennifer , Lee Illuzzi Jessica , Cayton Colby
Published: April 2020

INTRODUCTION:

Intrapartum vertical transmission of group B streptococcus (GBS) occurs in approximately 50% of vaginal births without antibiotic prophylaxis. This prospective cohort study aimed to determine if <4 hours duration of intrapartum antibiotic prophylaxis (IAP) before delivery reduces GBS vertical transmission rates.

METHODS:

1354 GBS positive parturients presented to Yale New Haven Hospital between 10/1/2009 and 3/28/2012. Of eligible patients ≥37 weeks with singleton gestations in labor (n=1111), 316 were invited after IRB approval to participate and 240 completed the study. Maternal characteristics, labor course, delivery and neonatal outcomes were obtained. Of 240 maternal-infant dyads, 69 received <4 hours of IAP and 158 received ≥4 hours. Nine did not receive IAP. Infant oropharyngeal and rectal swabs were collected after 24 hours to detect mucosal GBS colonization.

RESULTS:

Rates of GBS transmission were equivalent in those receiving less than and greater than 4 hours of prophylaxis before delivery, respectively (1.5 vs 1.2%; P=1.0). No significant differences in GBS transmission were observed between those with and without risk factors for early neonatal GBS disease. No cases of GBS vertical transmission occurred in those who received IAP prior to membrane rupture versus 3 (3.9%) cases of transmission (P=.036) among those who received IAP after membrane rupture.

CONCLUSION:

GBS vertical transmission rates among individuals who received IAP <4 hours were equivalent to those receiving IAP ≥4 hours before delivery. Antibiotic prophylaxis duration may be less relevant than membrane rupture timing in vertical transmission and deserves further exploration to optimize newborn monitoring protocols after delivery in maternal GBS colonization.
Expedited Partner Therapy for Trichomoniasis: Prevalence and Provision at LA County Hospitals [09A]
Authors: Chang Emily , Nguyen Brian T. , Mitchell Evelyn , Jeffrey Nicholas , Long Minica
Published: April 2020

INTRODUCTION:

Trichomoniasis is the most common, non-viral sexually transmitted infection (STI) worldwide. Cases are frequently asymptomatic in men and men traditionally are not screened, possibly contributing to high rates of reinfection among women. Expedited partner therapy (EPT) is a proposed solution that provides empiric STI treatment for an infected female patient's male partner without requiring a separate healthcare visit. EPT is legal in California and commonly given for gonorrhea and chlamydia; however, EPT provision for trichomonas is inconsistent, thereby warranting further study.

METHODS:

Institutional Review Board approval was obtained. Patients testing positive for trichomonas were identified from electronic medical records within the LA County hospital network, from 1/2015 to 6/2017. Documentation of partner treatment discussion and EPT provision was identified, along with potential associated factors, e.g. patient demographics and medical specialization. Descriptive statistics and bivariate comparisons were used to describe potential associations.

RESULTS:

Of 326 female patients testing positive for trichomonas, 34.5% identified as black, 33.2% as Hispanic/Latina. Only 57.9% of patients received some form of partner counseling; only 13.3% were offered EPT. Emergency medicine providers diagnosed trichomoniasis most frequently (51.8%), but only 38.6% offered verbal partner counseling and only 6.6% offered EPT. Family medicine providers were most likely to offer verbal partner counseling (66.7%, P<.01); gynecologists were most likely to offer EPT (25.5%, P<.01).

CONCLUSION:

Patients with trichomoniasis were not routinely offered EPT nor counseled about partner treatment in this population. Healthcare providers, regardless of specialty, should be reminded to recommend the screening and treatment of male partners and/or provide EPT directly.
Fertility Preservation in Transgender and Gender Non-conforming Adults [21A]
Authors: Morong James J. , Hinz Erica
Published: April 2020

INTRODUCTION:

Obstetricians and gynecologists play an important role in providing care to all persons who desire parenthood. However, there are limited studies assessing the preferences of transgender adults in achieving parenthood. We aimed to examine the importance of parenthood and preferred means to achieve it in a transgender adult population.

METHODS:

A cross-sectional survey of patients aged ≥ 18 years and who self-identified as a gender minority at an urban academic medical center and outpatient primary care center specializing in LGBTQ health.

RESULTS:

Sixty-two people completed the survey, of which 7 (11.3%) were born male and 55 (88.7%) were born female. The average age of participants was 28.2. Only 2 (3.2%) participants had children, although 52 (88%) reported desiring parenthood. Of those who desired parenthood, 14 (29%) preferred to achieve this using their own gametes, 12 (24%) preferred adoption and 14 (29%) preferred to use a gestational carrier without using their gametes. Only 34 (56%) reported that a healthcare provider discussed oocyte cryopreservation prior to transition. The largest barriers identified to oocyte cryopreservation were desire (33%), cost (58%), and stopping cross-sex hormones (25%). 10 (16.4%) believed their ability to have children was decided without their consent.

CONCLUSION:

In this survey of adult transgender patients, the majority are desiring parenthood. Barriers previously identified in the literature such as physical examination and provocation of periods/penile tumescence were not viewed to be as significant as cost and stopping cross-sex hormones. This knowledge can improve clinical discussions and identify the barriers that transgender patients experience in achieving parenthood.
Accuracy of Estimated Fetal Weight in Third Trimester [33A]
Authors: Castro-Vasquez Bertha Alicia , Taboada Claudia
Published: April 2020

INTRODUCTION:

The aim of our study is to determine whether fetal growth scans that are performed after 37 weeks gestation can be relied upon to give an accurate estimation of fetal weight (EFW), and also help to guide antenatal management with delivery recommendations. Due to the inherent error associated with ultrasound measurements, the accepted overall margin of error between EFW and actual birth weight (ABW) is 15%.

METHODS:

A retrospective descriptive qualitative study with a total of 1785 cases, where the EFW was obtained within 3 weeks of delivery were compared with ABW. The significant difference between EFW and ABW was tested by paired t-test. Pearson's correlation was used to detect significant linear relationship. The difference in error rates among the weight and GA categories were assessed by chi-square test.

RESULTS:

The error rates of <15% <10% and <5% for GA of 37 to 40 weeks was seen as 86%, 68% and 38% respectively. The error rate of <15% for GA of <37 weeks was lower when compared to the GA in other categories (P=.0227).

CONCLUSION:

Our estimated fetal weight measurements at 37 weeks and beyond may be considered accurate as our error rate is below the acceptable rate of <15%. Despite the popular consensus of inaccurate late third trimester EFW, we found that with increasing gestational age and increased ABW, our EFW are within acceptable error rates. In order to utilize our EFW measurements for antenatal management and delivery recommendations, improvements in our biometric measurements should strive for improved error rates of <5–10%.
Intra-procedural Transvaginal Sonography to Decrease Retained Products of Conception [35A]
Authors: Larish Alyssa , Breitkopf Daniel C. , Hopkins Matthew , Green Isabel , Burnett Tatnai , Laughlin-Tommaso Shannon
Published: April 2020

INTRODUCTION:

Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and reoperation. Incidence of retained POC range from 1.5–3.7%. Use of procedural transvaginal sonography (TVUS) in the operating room has been proposed to help decrease this.

METHODS:

A retrospective review of first trimester uterine evacuation procedures from 1/2015–2/2017 was performed, noting use of transabdominal ultrasonography (TAUS), retained products of conception (sonographic findings requiring surgical or medical intervention), and complications. A practice change was implemented in May 2018, in which intra-procedural TVUS was routinely performed. A second retrospective chart review was conducted to assess for post-implementation incidence of retained POC, reoperation, and associated complications. Fisher's exact test was performed.

RESULTS:

Prior to implementation, 130 eligible procedures were performed during the specified timeframe, with 9/130 (6.9%) incidence of retained products of conception. TAUS was performed in 59/130 (45.4%) of procedures, and 4/9 (44.4%) of those with retained products. There were eight re-operative procedures in seven patients, and two patients were treated with misoprostol. Complications included hemorrhage, Asherman's and endometritis. Following implementation, 94 first trimester procedures were performed with transvaginal sonography, with 0 (0%) cases of retained POC (P=.01), no incidences of re-operation (P=.02), and one case of Asherman's. TVUS led to additional focused curettage in 20/94 (21.3%) of procedures. The endometrium was measured in 64 procedures, with a mean thickness of 5.5 mm (1–12 mm).

CONCLUSION:

Implementation of routine TVUS during uterine evacuation appears to reduce the incidence of retained POC and associated reoperation rates.
Low-Lying Placenta: Is a 32 Weeks Transvaginal Ultrasound Needed? [36A]
Authors: Eid Joe , Wang Amanda , Moutos Christopher , Saade George R. , Saad Antonio
Published: April 2020

INTRODUCTION:

Women with low-lying placenta (LLP) on second trimester ultrasound, are routinely followed up with a transvaginal ultrasound (TVUSG) at 32 weeks gestational age (GA), and if persistent, at 36 weeks. In this study, we describe outcomes of patients with initial diagnosis of LLP and evaluate its rate of resolution.

METHODS:

After IRB approval, we retrospectively reviewed cases of LLP diagnosed via second trimester ultrasound between August 2013 and June 2019. Patients' characteristics, ultrasound reports, maternal and neonatal outcomes were recorded. Descriptive statistics, receiver-operating characteristic (ROC), and logistic regression analysis were performed. Data were reported as median [range] or n (percentage). P<.05 was considered significant.

RESULTS:

Six hundred forty-six cases of LLP were identified at a median GA of 19 [16–25] weeks. A follow up TVUSG was performed at a median GA of 32 [29–34] weeks; 28 (4%) were found to be persistent and underwent a TVUSG at a median GA of 36 [35–37] weeks. Only 5 (0.7%) were persistent at 36 weeks. No significant difference was found in patients' characteristics, estimated blood loss, need for blood transfusions, nor neonatal outcomes between the persistent and non-persistent groups (P>.05). Second trimester ultrasound was a poor predictor of LLP (ROC analysis; area under curve: 0.67, 95% CI 0.5–0.8; P=.16).

CONCLUSION:

Our data showed favorable outcomes for LLP with a 99% resolution rate at 36 weeks. A follow up at this GA is suggested rather than 32 weeks TVUSG. This might avoid unnecessary patient discomfort with TVUSG and decrease health care costs. Further prospective trials are needed to validate this approach.
Impact of Minority Races on Clinical Trials on Aspirin for the Prevention of Preeclampsia [11C]
Authors: Chan Elena , Bailey Josianne , Davis-Nelson Shareece , Martin Courtney , Mason Danielle , Yao Ruofan
Published: April 2020

INTRODUCTION:

The objective of this study was to determine if the study populations in published literature on aspirin for the prevention of preeclampsia were diverse enough to demonstrate a benefit for minority races.

METHODS:

This was a meta-analysis by searching PubMed using the keywords: aspirin, and preeclampsia. Included studies were randomized clinical trials that identified the racial composition and risk of preeclampsia as an outcome of interest. Population level modeling was performed on the pooled result by recalculating the rate of outcome for each study if the rate of outcome of a particular race was the same between intervention and placebo arms. Pooled results that remain statistically significant after race specific adjustments suggest minimal influence from that particular race, whereas a non-significant result suggests stronger influence from that race.

RESULTS:

There were 108 clinical trials identified. 22 studies met requirement for in-depth review. Four of 22 studies reported racial composition and were included in the analysis. Aspirin decreased risk of preeclampsia (RR 0.69, 95% CI [0.52–0.92]). Race adjusted pooled result remained significant for Hispanic (RR 0.68, 95% CI [0.51–0.91]) and Asian (RR 0.75, 95% CI [0.57–0.997]), but not for white (RR 0.89, 95% CI [0.69–1.17]) or black (RR 0.80, 95% CI [0.61–1.05]).

CONCLUSION:

In studies on aspirin for the prevention of preeclampsia, Hispanic and Asian races were underrepresented, whereas white and black races were major contributors to the pooled result.
Racial/Ethnic Parity in Low-Dose Aspirin for Women With History of Preeclampsia After National Recommendations [26C]
Authors: Lauring Julianne , Flores Estefania Santamaria , Brewster Hannah
Published: April 2020

INTRODUCTION:

Hypertensive disorders of pregnancy are associated with severe maternal morbidity and maternal mortality, particularly for non-white women. Our goal was to investigate the effect of race/ethnicity on low-dose aspirin use following release of national guidelines for prevention of preeclampsia.

METHODS:

This is a retrospective cohort study of women with a history of preeclampsia delivering in a single institution from 1/1/2015 to 9/30/2017 following publication of “Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: U.S. Preventative Services Task Force Recommendation Statement.” Billing codes were used to identify women with indications for low-dose aspirin during pregnancy. A history of preeclampsia was then confirmed by chart abstraction. Race/Ethnicity as documented in the medical record and reported use of low-dose aspirin was abstracted from the electronic medical record. A one-way ANOVA was used to compare aspirin use in women identified as “white,” “Hispanic,” “black or African American,” and “other.”

RESULTS:

We identified 110 women eligible to receive low-dose aspirin based on a history of preeclampsia. 25.5% (n=28) of women with a history of preeclampsia were documented as receiving low-dose aspirin during the study period. 39.1% of women were identified as “white” (n=43), 30.9% (n=30.9) were identified as “Hispanic or Latina” (n=34), 21.8% were identified as “black or African American,” and 8.2% were identified as “Other” (n=9). There was no statistically significant difference in low-dose aspirin by race/ethnicity (P=.52).

CONCLUSION:

Immediately following recommendations for low-dose aspirin use for prevention of preeclampsia, aspirin use did not vary by reported race/ethnicity.
A Pilot Study on the Prevalence of Marijuana Use in the High Risk Obstetrics Population at the University of Florida [02E]
Authors: Roussos-Ross Kay , Briscoe Kristin E. , Cheng Xinguang
Published: April 2020

INTRODUCTION:

Marijuana is the most commonly used illicit drug in pregnancy and prevalence rates are reported to be 5–7%. With legalization of marijuana, there is concern that more women believe marijuana use is safe in pregnancy. The purpose of this pilot study was to determine prevalence of marijuana use in our high-risk obstetrics population.

METHODS:

An IRB approval was obtained. Pregnant women seen in the high-risk obstetrics clinic at University of Florida were invited to participate in an anonymous survey related to marijuana exposure. A total of 106 women were included in the study.

RESULTS:

More than a half (52.3%) of the women reported having used marijuana in the lifetime, 34.6% reported using marijuana prior to pregnancy, and 16.8% reported use after becoming pregnant. The prevalence rates of marijuana use varied by duration of pregnancy. Higher prevalence rates were noted for pregnancy of 12 weeks or less (18.2%) and 25 weeks or longer (19.4%); however, this was not statistically significant. Among the 7 women who reported using marijuana for recreational purposes, 6 used marijuana during pregnancy. Among all women who used marijuana prior to pregnancy, 48.7% continue to use after becoming pregnant and 51.3% quit.

CONCLUSION:

The prevalence of marijuana use in our high-risk obstetrics population was self-reported to be 16.8%, this is significantly higher than national self-reported data. Self-reported marijuana use did decrease when comparing use before and after identification of pregnancy. This pilot data illustrates the importance of continued research to determine adverse pregnancy outcomes related to marijuana exposure.
Insights on GABAergic Mechanism of PPD from Pivotal Studies of Brexanolone Injection and SAGE-217 [18E]
Authors: Meltzer-Brody Samantha , Deligiannidis Kristina , Colquhoun Helen , Gunduz-Bruce Handan , Dray Danielle , Kanes Stephen
Published: April 2020

INTRODUCTION:

One proposed etiology of postpartum depression (PPD) involves dysfunctional GABAergic signaling. Brexanolone injection (BRX) and SAGE-217, two neuroactive steroid GABAA receptor positive allosteric modulators, have been evaluated in a total of 4 double-blind, randomized, placebo-controlled trials (RCTs).

METHODS:

Inclusion criteria: adult women, ≤6 months postpartum, diagnosed with PPD, and a qualifying HAM-D total score (BRX Studies A and B, ≥26; BRX Study C, 20–25; SAGE-217, ≥26). BRX randomization: 1:1:1 BRX 90 ug/kg/h (BRX90): BRX 60 ug/kg/h: placebo in Study B and 1:1 BRX90: placebo in Studies A/C, as 60-hour infusions, with follow-up through Day 30. SAGE-217 randomization: 1:1 SAGE-217 30 mg capsules or placebo for 14 days, with 4 weeks follow-up. Primary endpoints were change in HAM-D total score at Hour 60 (BRX) or Day 15 (SAGE-217). Adverse events (AEs) were recorded throughout the studies.

RESULTS:

Both BRX90 and SAGE-217 achieved their primary endpoints (P<.0001 and P=.0028 respectively). Significant improvements versus placebo were sustained through Day 30 (BRX90, P=.0252) and Day 45 (SAGE-217, P=.0027). AEs in all BRX (n=140) occurring in ≥5% of BRX and ≥2x the rate of placebo were sedation/somnolence, dry mouth, loss of consciousness, and flushing/hot flush. The most common AEs (≥5%) with SAGE-217 were somnolence, headache, dizziness, upper respiratory tract infection, diarrhea, and sedation.

CONCLUSION:

BRX and SAGE-217 achieved their primary endpoints of statistically significant and clinically meaningful reductions in depressive symptoms versus placebo in PPD RCTs and were generally well tolerated. These results support the role of GABAergic signaling in PPD.
Patients' Experiences With an Opioid-Sparing Protocol Following Cesarean Delivery [28E]
Authors: Peahl Alex , Lawrence Emma , Hallway Alex , Waljee Jennifer , Brummett Chad , Smith Roger
Published: April 2020

INTRODUCTION:

Overprescribing of opioids after cesarean delivery may lead to overconsumption and opioid diversion. Opioid-sparing protocols have reduced post-cesarean inpatient opioid use by over half, but how they affect post-discharge opioid use has not been explored. This study describes the impact of a post-discharge opioid-sparing protocol on home opioid use for women undergoing cesarean delivery.

METHODS:

At our academic institution, all patients undergoing cesarean delivery receive an opioid-sparing protocol, including scheduled (not as needed) acetaminophen and ibuprofen at discharge. Patients are prescribed ≤20 tabs of oxycodone for breakthrough pain. We conducted a telephone survey of post-cesarean women, 4–12 weeks after discharge on utilization of opioid and non-opioid pain medication and pain control. Data were analyzed using descriptive statistics.

RESULTS:

Of the 394 women contacted, 205 agreed to participate (52%). Most patients were multiparous (average parity=2) and had an unplanned cesarean delivery (67%). Most patients utilized ≥1 opioid alternative (75% Tylenol and ibuprofen, 14% Tylenol only, 9% ibuprofen only). Overall, 80% of patients received an opioid prescription, and 62% consumed opioids. Patients received on average 17 pills (range 0–20) and consumed 9 pills (range 0–20). Only 7% of patients received a refill. Of the 121/205 (63%) patients who reported good pain control with opioid alternatives, 56/205 (27%) still reported using opioids.

CONCLUSION:

Most patients report good pain control after cesarean with non-opioid medication and use fewer opioids than prescribed. Still, education is needed to help patients match pain needs to appropriate medication and limit unnecessary opioid exposure.
Association Between Obesity and Opioid Usage for Pain Management in Postpartum Women [05D]
Authors: McCurdy Rebekah , Mehta Vaishali
Published: April 2020

INTRODUCTION:

The objective was to assess the relationship between obesity and opioid usage for women postpartum.

METHODS:

This study was a secondary data analysis of an RCT (NCT02909582), limited to women with a BMI ≥35 kg/m2 at delivery. A standard order set for postpartum pain medications was utilized inpatient. Opioids consumed postpartum were converted to milligrams of oral morphine equivalents. Outcomes included milligrams of morphine equivalent used in the first 48 hours of delivery and the highest pain score within the first 48 hours post-delivery. Relationships were explored with correlation and linear regression (accounting for demographic factors).

RESULTS:

BMI at delivery does not correlate with the mg of morphine equivalents utilized (n=273 women, Pearson r 0.034, P=.579) or the highest pain score (r 0.028, p 0.643) in the first 48 hours postpartum. Pain scores and opioid consumption were correlated (r=0.445, P<.001). Age (RR 6.13; 95% CI 0.65, 11.61; P=.029) and race (RR -12.8; 95% CI -20.93, -4.66; P=.002) were significantly associated with opioids consumed when accounting for demographics, including mental health diagnosis. Both black and white patients had similar mean highest pain scores in the first 48 hours postpartum (6.5 vs 6.3). However, black patients used almost 1/3 less milligrams of opioids (mean 29.4 mg vs 41.1).

CONCLUSION:

The relationship between obesity and pain postpartum is complex, and includes mediating factors such as ethnicity, age, and presence of a mental health disorder. Despite a standardized pain medication order set and similar pain scores, there are racial differences in utilization of pain medications postpartum.
Risk Factors for Medical Management of Gestational Diabetes in Twin Pregnancies [35D]
Authors: Dave Eesha D. , Vani Kavita , Bodnar Lisa M. , Himes Katherine P.
Published: April 2020

INTRODUCTION:

Approximately 20–30% of singleton pregnancies affected by gestational diabetes (GDM) require medical management to achieve euglycemia (MMAE). We sought to identify the rate of and risk factors for MMAE in twin pregnancies with GDM.

METHODS:

We conducted a retrospective cohort study of all twin deliveries from 2005–2013 at Magee-Womens Hospital. Monochorionic monoamniotic twins were excluded. Data were obtained from a perinatal database, chart abstraction, and placental review. GDM was defined using Carpenter-Coustan Criteria or a 1-hour 50 gram Glucola equal/over 180 mg/dL. MMAE for GDM was classified as use of insulin or an oral agent. Prepregnancy obesity, parity, chorionicity, insurance product, advanced maternal age, and in vitro fertilization (IVF) were examined as risk factors. Univariate and multivariable logistic regression were performed.

RESULTS:

1,872 twin pregnancies were included in the cohort—79.3% were dichorionic, 30.8% of women were obese, 17.7% conceived with IVF and the average age was 30 years (+/-5.9 y). The overall rate of GDM was 6.1% (n=114) with 59.2% (n=67) requiring MMAE. Among the MMAE cohort, 50.7% were obese, 38.85% were 35 years or older, and 31.3% had conceived with IVF. Only prepregnancy obesity was a risk factor for MMAE (OR 2.3, 95% CI 1.1, 5.0). This remained significant when controlling for maternal age, IVF use, and insurance status (aOR 2.2, 95% CI 1.0, 5.2).

CONCLUSION:

MMAE seems twice as common in twin versus singleton gestations. Over half of GDM twin gestations required MMAE, and maternal prepregnancy obesity was predictive. This highlights the need for further studies to help risk stratify patients.
The Risk of Stillbirth at Term and Timing of Delivery in Obese Women [38D]
Authors: Eberle Alexa , Czuzoj-Shulman Nicholas , Abenhaim Haim A.
Published: April 2020

INTRODUCTION:

Studies have shown that a high body mass index (BMI), expressed in kg/m2, is an independent risk factor for stillbirth. The purpose of this study was to determine an optimal time of delivery in obese women in order to decrease the risk of stillbirth in this population.

METHODS:

We conducted a retrospective population-based cohort study using the CDC's Period Linked Birth-Infant Death and Fetal Death data. The study population included all singleton, term births with a recorded pre-pregnancy BMI that occurred between 2014 and 2017, inclusively. The risk of stillbirths in each BMI class was estimated at each gestational week from 37 weeks and onwards.

RESULTS:

Of the 12,742,980 births in our cohort that met study criteria, 46.8% were to women with a normal BMI, 26.9% were to women who were classified as overweight, 14.5% were to women in obesity class I, 7.3% in obesity class II, and 4.8% in obesity class III. As compared to women at 41 weeks with a normal BMI, there was a higher risk of stillbirth in women of obesity class I at 39 weeks (OR 1.15 95% CI 1.00–1.31), at 38 weeks for obesity class II (OR 1.21 95% CI 1.04–1.41) and at 37 weeks for obesity class III (OR 1.30 95% CI 1.11–1.52).

CONCLUSION:

As compared to women with a normal BMI, there was a higher risk of stillbirth at term in women with each increase in BMI class. Consideration should be given to early induction among these women to reduce the risk of stillbirth.
Predictors of Gestational Diabetes Among Women Living in Food Deserts [30D]
Authors: Steinmetz Leah , Hage Madeleine , Klavans Madison , Gambala Cecilia
Published: April 2020

INTRODUCTION:

Gestational diabetes mellitus (GDM) is associated with many adverse maternal and fetal outcomes. The aim of this study is to identify the relationship between GDM and access to affordable grocery stores.

METHODS:

This is a retrospective review of patients delivering at a single institution. Food insecurity was determined using patient address overlaid with USDA Food Access Research Atlas. Patients living >0.5 miles from a supermarket were identified as living in a food desert (FD). GDM clinical data was compared to FD data using chi square, regression analyses.

RESULTS:

Of 744 patients meeting inclusion criteria, 74 (9.94%) were diagnosed with GDM during their current pregnancy with 2.55% having a previous history of GDM. 517 patients lived in FD and were more likely to be multiparous and of minority race. 60.8% (45/74) of patients diagnosed with GDM during the current pregnancy lived in a FD. The frequency of GDM in women living in FDs was lower than those in Food Secure (FS) tracts (0.09% vs 1.2%, P=.1). Women living in FDs with GDM experienced greater rates of chronic hypertension than those in FS areas (15.2% vs 10.3%, P=.002). Higher order multiple gestation, advanced maternal age, preeclampsia with severe features, and history of GDM were significant predictors for GDM in women living in FD (P<.05).

CONCLUSION:

Women living in food deserts are not at an increased risk for GDM but are for having chronic hypertension if they have GDM compared to those living in FS.
Induction of Labor at 38 Weeks and Risk of Cesarean Delivery Among Obese Women: A Retrospective Propensity Match Study [21D]
Authors: Eberle Alexa , Czuzoj-Shulman Nicholas , Abenhaim Haim A.
Published: April 2020

INTRODUCTION:

The objective of this study was to determine if induction of labor (IOL) in obese women at 38 weeks decreases the risk of cesarean delivery (CD) compared to women who are expectantly managed.

METHODS:

We conducted a retrospective propensity match study using the CDC's Period Linked Birth-Infant Death data. The study population included all singleton, nonanomalous and cephalic births to obese women as of 38 weeks that occurred between 2013 and 2017, inclusively. Women who had a previous CD were excluded. The women who underwent IOL at 38 weeks were propensity matched to women, on the basis of CD risk factors, who were expectantly managed. Conditional logistic regression models were used to compare CD rates and maternal outcomes between obese women undergoing an IOL at 38 weeks and those expectantly managed.

RESULTS:

After 1:5 propensity score matching, there were 117,136 obese women induced at 38 weeks and 585,680 obese women expectantly managed. Overall, the risk of CD among obese women who had an IOL at 38 weeks was lower than those of women managed expectantly, 0.76 (0.75–0.77). The decrease in the risk of CD was more significant in multiparas, 0.62 (0.61–0.64), compared to nulliparas, 0.96 (0.94–0.99). When stratified by BMI, the effect of IOL on CD was most pronounced in women with a BMI >40 kg/m2, 0.74 (0.71–0.77). Maternal outcomes were comparable in both groups.

CONCLUSION:

Induction of labor at 38 among obese women appears to lower the risk of CD without compromising maternal outcomes.
Toxicology Testing in Obstetrics: Which Indications Predict Positive Tests? [33C]
Authors: Perlman Nicola C. , Wilkie Gianna L. , Smith Nicole A.
Published: April 2020

INTRODUCTION:

Universal screening in pregnancy for substance use is currently recommended, however evidence is lacking regarding indications for toxicology testing. We examined documented indications for urine toxicology (UTox) to determine which were associated with a positive result.

METHODS:

We reviewed all UTox sent on obstetric patients in 2018 at a single, tertiary, academic hospital. Charts of all women who underwent UTox were examined for indications for testing and results of tests. Associations were examined with Chi-Square or Fisher's Exact tests.

RESULTS:

Among >6400 births, 178 UTox were sent on mothers. Indications included abruption (9% of ordered tests), PPROM (10%), preterm labor (19%), none (13.5%), affect (4.5%), history of substance use (20%), limited prenatal care (7%), intrauterine growth restriction (5%), pain (4.5%), “other” including stillbirth, seizure (7%). Of these only historic substance use was significantly associated with a positive UTox (P<.01). Preterm labor was associated with negative UTox (P>.01). Six women with history of substance use reported only cannabis, of whom 5 had only cannabis on their UTox. Of the 14 with opioid use disorder, 9 used medication assisted treatment, of whom 3 had a UTox positive only for their prescribed medications.

CONCLUSION:

Few urine toxicology tests sent on obstetric patients resulted in additional data beyond that provided by history alone. Current practice at our institution did not identify any obstetric indications consistently associated with substance use. Evidence based guidelines for UTox testing, particularly in the absence of substance use screening, are needed.
tPregnancy and Heart Disease: Patient and Healthcare Provider Reported Outcomes [30N]
Authors: D'Souza Rohan D. , Hall Chelsea
Published: April 2020

INTRODUCTION:

Our objective was to conduct focused interviews with patients, family members and healthcare providers to identify and compare outcomes considered important by each group with what is reported in the literature.

METHODS:

Pregnant patients with a cardiac condition and their family members were recruited from the Mount Sinai Hospital, Toronto, Canada and an international group of healthcare providers were contacted through email via contact lists assembled by study investigators. Semi-structured interviews with an emphasis on eliciting outcomes were conducted until no new outcomes were identified.

RESULTS:

Sixteen participants (13 pregnant women and three partners) completed the interviews. Cardiac conditions included arrhythmias (n=5), complex congenital heart disease (n=5) and valvular heart disease (n=3). Ten healthcare providers primarily from Europe and North America, representing cardiology (n-5), obstetrics (n=3), nursing (n=1) and anesthesiology (n=1) were also interviewed. Patients and family members reported 17 unique outcomes, the most frequent of which were: general health and well-being of baby (n=13); congenital defects (n=6); outcomes related to maternal mental health, stress and fatigue (n=5) and appropriate healthcare management (through medications, follow up, continuity of care) (n=4). Healthcare providers reported 65 outcomes, which included maternal mortality (n=7), prematurity (n=7), arrhythmias (n=6), thrombosis, mode of delivery (n=5) and heart failure (n=5). These reflected those encountered in published literature.

CONCLUSION:

Outcomes considered important by patients and their family members differ from those considered important by clinicians and researchers . Including these outcomes in a core outcome set could improve outcome reporting in studies on cardiac disease in pregnancy.
The Development of a Prediction Model for Vaginal Birth After Cesarean Section (VBAC) [34P]
Authors: Frimer Leora
Published: April 2020

INTRODUCTION:

Pregnant women who have had a previous cesarean section face the decision to either undergo a repeat elective cesarean or to attempt vaginal birth after cesarean (VBAC). The goal of this project was to determine the factors that predict success of VBAC in women with one prior cesarean section in the population of British Columbia, Canada.

METHODS:

Data were drawn from the British Columbia Perinatal Data Registry. We performed a retrospective analysis of 8291 cephalic term singleton planned vaginal births in British Columbia to women with a previous cesarean. Using block multivariate logistic regression, we analyzed the variables, both modifiable and non-modifiable, most predictive of successful VBAC. A result was considered statistically significant if its p value was <.05.

RESULTS:

Of the 8291 planned VBAC births, 5960 were successful, while 2331 resulted in cesarean deliveries. Predictive variables were: maternal age, height and BMI, whether or not she had a vaginal birth within 2 years of the planned VBAC, whether she had a recurrent indication for the prior cesarean, whether she was administered oxytocin or prostaglandins for labor augmentation or induction, whether she was given an epidural, and the size of hospital in which she gave birth.

CONCLUSION:

A prediction model, incorporating eight variables has been developed. This model can inform shared decision-making and guide individualized counselling for eligible women on the chance of VBAC success. We hope that this prediction model will contribute to the literature and ultimately lower the probability of complications and adverse outcomes in childbirth.