bluuebunny/crossref_metadata_2025 huggingface dataset:
Relationship Between Maternal BMI and Labor Induction Outcomes [14T]
Authors: Teal Elizabeth Nicole , Lewkowitz Adam , Koser Sarah , Tran Carol , Gaw Stephanie
Published: May 2019

INTRODUCTION:

Nearly 25% of US pregnancies result in an induction of labor (IOL). The US population is increasingly obese. This study aims to assess the relationship between obesity and IOL outcomes.

METHODS:

This is a retrospective cohort study including nulliparous women with non-anomalous, singleton, vertex pregnancies who underwent IOL at an academic hospital from January 2015 to April 2017. Patients were divided by body mass index (BMI): underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9), class I obesity (30.0-34.9), and class II and III obesity (≥35). The primary outcome was IOL duration. Secondary outcomes were vaginal delivery (VD) rate, maternal morbidity (hemorrhage, transfusion, infection), and neonatal morbidity (NICU admission). The data were analyzed using the Kruskal-Wallis test and logistic regression.

RESULTS:

Of 955 patients, 673 (70.5%) delivered vaginally. Compared with normal weight women, those with BMI ≥35 had decreased odds of VD (OR 0.5, CI 0.3 - 0.9). Increasing BMI was associated with increasing IOL duration (p=.0001) with the longest median duration 37.9 hours in the BMI ≥35 group. After adjusting for potential confounders (maternal age, race, gestational age, and IOL indication), there was no association between BMI and hemorrhage, transfusion, infection, or NICU admission.

CONCLUSION:

In this cohort, increasing BMI was associated with longer IOL and BMI 35 or greater was associated with decreased odds of VD. There was no association between BMI and maternal or neonatal morbidity. This data suggests that although higher class obesity is associated with a decreased chance of VD, obese women can safely be allowed more time for IOL.
Respectful Maternity Care in the US [15T]
Authors: Patel Suha J. , Schantz-Dunn Julianna
Published: May 2019

INTRODUCTION:

To understand the status of respectful maternity care (RMC) in the U.S.

METHODS:

A cross-sectional survey of U.S. women age 18-50 in April 2018. SurveyMonkey Audience distributed this anonymous survey online. Women were eligible if they gave birth in the U.S. in the last 5 years. Participants were those who answered at least one question about RMC from their most recent birth. Quantitative survey data consisted of demographics and responses about RMC indicators and comments about their birth experience.

RESULTS:

Of 1081 eligible, 1036 women (95.8%) participated. The locations of births from this group spanned the entire U.S. Most births (95%) occurred in hospitals. 36.7% of births were cesarean deliveries. The median maternal age was 32. 19.5% of respondents felt neglected at some point during their birth experience; more than half in the postpartum phase of care only. 333 left decipherable comments. When women reported issues, they were almost always one of the following: clinical staff performance or competency, neglect, interpersonal communication issues, lack of respect for wishes, negative experience with breastfeeding services, peri-partum complications, or perceived discrimination.

CONCLUSION:

This is the first study on RMC from women who have delivered in the U.S. Overall, the women surveyed were treated with dignity during their birth experiences. However, this data suggests that care for women during their birth experiences can be more respectful and that women feel more neglected during the postpartum period. Strategies to improve quality of maternal health care in the U.S. should include attention to the provision of RMC.
The Effects of Infiltration of Liposomal Bupivacaine for Pain Control After Cesarean Delivery: A Randomized Trial [19T]
Authors: Ton Raquel , Stovall Dale W. , Rhoades-Lazenby Courtney
Published: May 2019

INTRODUCTION:

In response to the growing opioid epidemic, we determine whether the addition of liposomal bupivacaine infiltration administered above and below the fascial layer and within the subcutaneous tissue at the time of closure post cesarean delivery would reduce pain scores compared to the use of intra-thecal morphine alone.

METHODS:

Randomized, placebo-controlled, single-blinded study. Eligible women over 17 years of age and at least 34 weeks gestation, non-emergent cesarean delivery under spinal anesthesia. Random assignment to receive either intrathecal Astramorph® and saline wound infiltration or intrathecal Astramorph® and wound infiltration with liposomal bupivacaine (Exparel®). Primary outcome was post-operative pain scores measured via visual analog scale until discharge. Secondary outcomes included side effects and patient satisfaction. A t-test was used to assess differences between groups for continuous variables, and a chi-square test was used to assess differences for categorical variables. Informed consent and IRB approval obtained.

RESULTS:

Of the 22 eligible subjects identified during the study interval, 18 were randomized and completed the study. The groups were similar in regards to demographic parameters. As compared to the placebo group, the mean daily pain scores were significantly lower in the Exparel® group on post-operative days 1 and 2 (P < 0.05) and required less opioids. No significant differences between groups in satisfaction scores or the presence of side effects. No patients required additional opioid analgesia after discharge.

CONCLUSION:

Wound infiltration with liposomal bupivacaine during cesarean delivery reduced post-operative pain scores without increasing side effects. Supports the effectiveness of this multimodal approach to post cesarean delivery analgesia.
Visualizing Delivery Catchment Area for Severe Maternal Morbidity in Harris County, Texas, 2016 [25T]
Authors: Salahuddin Meliha , Eisenhart Amelia , O'Neil Molly , Byrd-Williams Courtney , Lakey David , Patel Divya A.
Published: May 2019

INTRODUCTION:

Severe maternal morbidity (SMM) reflects complex, multi-level factors. In Texas, the SMM rate was 17.0 per 1,000 deliveries in 2016. In this exploratory case study, we describe SMM by ZIP Code for select hospitals in the Texas county with the highest delivery volume, to highlight differences in SMM at a granular level.

METHODS:

Using Texas all-payer inpatient hospitalization data for 2011-2016, delivery-related hospitalizations were classified as SMM based on 21 ICD-10-CM diagnosis and procedure codes. Using ArcGIS Desktop, SMM was mapped at (1) maternal residence ZIP Code for Harris County, and (2) maternal residence ZIP Code and hospital level for two hospitals with the lowest and two hospitals with the highest SMM rates.

RESULTS:

SMM remained consistent during 2011-2016 in Harris County (15.4-23.4 per 1,000 deliveries, P>.05). Among the 125 ZIP Codes with at least 100 deliveries in 2016, over one-third had SMM higher than the state rate. In the four hospitals included in this study, the SMM rate ranged from 1.9 to 33.8 per 1,000 deliveries. The hospital with the highest SMM rate included deliveries from a wide catchment area, while the other three hospitals had a relatively concentrated delivery catchment area.

CONCLUSION:

In this exploratory study, we observed differences in SMM across hospital and community settings, which reflects complex factors, including patient preexisting conditions, hospital quality of care and community characteristics. Our findings can help generate additional research to gain in-depth understanding of the relative contribution of these multi-level factors to SMM and inform development of risk adjustment approaches for SMM.
Why Do We Deliver? A Closer Look at Indicated Deliveries Scheduled Less Than 39 Weeks [28T]
Authors: Jackson David N. , Kirgan Marsha Matsunaga , Patil Pooja , Brar Bobby , Parr Ashley , Belilovets Anastasia
Published: May 2019

INTRODUCTION:

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires practice guidelines to eliminate elective near term deliveries. Our primary goal was to determine why practitioners continue to schedule non-elective (indicated) deliveries at less than 39 weeks.

METHODS:

A retrospective case series examined the incidence, indications, and outcomes for deliveries requested through our labor and delivery approval process from February 2013 thru July 2018. We analyzed these deliveries for indications, maternal demographics and neonatal outcomes between private and resident delivery services.

RESULTS:

Scheduled deliveries requested less than 39 weeks occurred for 450 viable pregnancies within 13,512 births (3.3%). Of these, 54% were by private obstetricians and 46% were by the resident service. The mean gestational age was 37.1 +/- 1.2 weeks (range 28.6 to 38.9 weeks). Frequency of key indications for delivery were intrauterine growth restriction 24.7% (n=111), hypertension related 14.9% (n=67), uncontrolled diabetes 13.3% (n=60), cholestasis 11.3% (n=51), multiple gestation 10.7% (n=48), other medical disorder 6.2% (n=28) and placenta previa 4.0% (n=18). NICU admissions occurred in 20.9% (94/450). Cesarean section occurred in 46%. There were no significant differences in demographics, indications, or frequency of NICU care in the private versus resident services.

CONCLUSION:

In an era of avoiding elective deliveries at less than 39 weeks, we found that approved, non-elective deliveries account for 3.3% of all births. Despite a mean gestational age of 37.1 weeks, NICU utilization is high at 20.9%. This series identifies opportunities for prospective studies to modify and reduce the neonatal risks within scheduled near term deliveries.
Machine Learning Algorithms Successfully Identify the Quality of Lay-Person Directed Articles Online [37T]
Authors: Dallas Kai B. , Rogo-Gupta Lisa , Elliott Christopher
Published: May 2019

INTRODUCTION:

Many patients (over 80%) research their medical condition online, but there is very little available to guide patients in assessing the quality/accuracy of the information encountered online. We applied machine learning algorithms to online material pertaining to the controversial topic of vaginal mesh, with the goal of creating a tool to assess article quality.

METHODS:

The complete text of the first 200 hits in Google for “vaginal mesh” (ie articles, blogs, advertisements etc.) were independently assessed by two FPMRS fellowship trained academicians for content quality. The Naïve Bayes algorithm was applied to predict the quality of the article. The articles were randomly partitioned into a training and testing subsets, with the models performance evaluated by its accuracy in assessing the quality of the test subset.

RESULTS:

Overall 70% of the sources were determined to be of poor quality and reviewers independently agreed 88% of the time on article quality. There was interesting difference in the frequency of commonly used words between the article types. The algorithm correctly classified quality 88% of the time with a 6% “false-negative” and “false-positive” rate. The PPV, NPV, sensitivity and specificity were 91%, 84%, 91% and 84%, respectively.

CONCLUSION:

We demonstrate that machine learning algorithms can accurately assess the quality of online articles related to vaginal mesh. This is a promising start in the development of tools to guide patients in their independent research. Future directions will be to refine our current machine learning algorithms and to expand the learning to a greater breadth of medical topics.
Young Adult Males' Perspectives of Male Hormonal Contraception [9S]
Authors: Sax Megan , Hurley Emily , Rossi Rocco , Thakore Suruchi , Hasija Abhinav , Sroga-Rios Julie
Published: May 2019

INTRODUCTION:

There is an interest and willingness among men in the United States to use Male Hormonal Contraception (MHC), however, data is limited among younger men (18 to 35 years old). Our objective is to evaluate the willingness of young males to use MHC and to determine which method (pill, injection, or transdermal gel) is most desirable.

METHODS:

An IRB-approved survey measuring willingness to use MHC was dispersed to two distinct populations: University of Cincinnati post-graduate programs (UC) and Cincinnati Health Department (CHD) clinics. Results were reported as frequencies in each population and chi-square analyses were performed to compare groups. P-values <.05 were considered significant.

RESULTS:

Of 162 total survey participants, 45% would use MHC while 30.9% were unsure and 23.5% would not use MHC. Overall, the UC survey population was more likely to be interested in using MHC than the CHD population (P<.05). The majority of both populations were most interested in using the injection form. Cited concerns deterring participants from using MHC were different between these two populations, with UC participants having concern about possible failure of contraceptive method, while CHD participants had concern about potential side effects (P<.001).

CONCLUSION:

This study suggests that there is a significant interest among young adult males to use various forms of MHC, especially in injection or pill form. Interest in MHC is more common among individuals with an advanced educational background, employed, or in a relationship. With further research and funding, MHC may serve as a significant way to decrease unintended pregnancies in the future.
Unintended Pregnancy Among People With Sickle Cell Disease or Sickle Cell Trait [5S]
Authors: Piper Kendra , McLemore Morgan , El Rassi Fuad , Kottke Melissa Jo
Published: May 2019

INTRODUCTION:

The Centers for Disease Control recognizes sickle cell disease (SCD) as a disease for which unintended pregnancy poses an unacceptable health risk. However there is a limited research on the reproductive behaviors of people with SCD and sickle cell trait (SCT).

METHODS:

Participants 18 years and older with SCD and sickle cell trait (SCT) were recruited from a sickle cell clinic in Atlanta, Georgia. We administered surveys to quantify contraceptive use and pregnancy experiences. IRB approval was obtained.

RESULTS:

The sample consisted of 271 people (49.4% male; 50.6% female). The average age was 33.4 years (SD 11.8). Over half of participants reported ever being pregnant or getting someone pregnant. Two thirds of the pregnancies (66.4%) were unplanned. There were 277 pregnancies reported which resulted in 208 live births (75.1%). The sample also reported a history of 21 abortions (7.6%), 35 miscarriages (12.6%), 9 stillbirths (3.2%) and 4 ectopic pregnancies (1.4%). For 23.1% of births, both partners had SCD or SCT, and for 16.3% of births, the partner's sickle status was unknown. There were 30 infants (14.4%) born with SCD and 111 infants (53.4%) born with SCT. Almost 50% of participants reported condom use at last sex and 21.7% reported using birth control other than condoms at last sex.

CONCLUSION:

This study found low use of condoms and hormonal birth control and a high number of unplanned pregnancies. Prevention of SCD is possible and may require increased sexual health education and service delivery to meet the unique needs of people with SCD and SCT.
The Impact of Intrauterine Lidocaine on Perceived Pain During Intrauterine Device Insertion [2S]
Authors: Grajkowski Alison , Scribner Alicia Nicole , Jasaitis Carol , Szekely Daniel
Published: May 2019

INTRODUCTION:

Intrauterine devices (IUDs) are highly effective, long-term, reversible forms of contraception that have increased in use in the United States. Many women experience significant pain during the insertion process, which can deter placement. There is evidence of decreased pain during endometrial biopsy after intrauterine insertion of 100 mg of lidocaine. The intent of this trial was to determine if intrauterine instillation of 100 mg of lidocaine decreased patient discomfort during IUD insertion.

METHODS:

In this single-blinded, randomized, controlled trial, 150 women eligible for IUD insertion were randomly assigned into 3 arms. The arms included standard IUD placement (control), pretreatment with 2.5 ml of intrauterine normal saline (placebo), and pretreatment with 2.5 ml of intrauterine 4% lidocaine solution, equating to 100 mg of lidocaine (treatment). All participants took 800 mg of ibuprofen prior to IUD insertion. Pain was assessed on an unmarked 10 cm visual analog scale before, during, and after IUD insertion. The data was evaluated using simple statistics and univariate analysis.

RESULTS:

Women who received intrauterine lidocaine had no significant difference in pain scores between the control and the placebo group both during IUD placement (P = 0.927) and after completion of the procedure (P = 0.961). Factors that were significantly associated with decreased pain scores included being postpartum, defined as less than 8 weeks since delivery, and placement of the copper IUD.

CONCLUSION:

Intrauterine lidocaine solution did not demonstrate significant improvement in pain scores during or after IUD placement.
Short Interpregnancy Interval and Desired Contraception at the Preceding Delivery: A Missed Opportunity? [1S]
Authors: Ho Stephanie , Myo Melissa Grace
Published: May 2019

INTRODUCTION:

The majority of short interpregnancy interval (IPI) pregnancies are unintended. Our study aimed to describe contraceptive desires and outcomes in women with short IPI.

METHODS:

Women with a pregnancy conception date less than 18 months after delivery of the preceding live birth were identified. We reviewed charts to determine desired contraception at time of the preceding delivery and whether patients received desired method postpartum.

RESULTS:

Overall, 334 women had IPI <18 months. 57% were Hispanic, 10% Asian, 7% black, and 18.6% white. 243 (73%) desired hormonal birth control, LARC, or sterilization at preceding delivery; 129 (39%) wanted LARC specifically. Follow-up attendance was 76%. Women who wanted LARC did not vary significantly from women who did not want LARC by race/ethnicity or parity, but were younger (25 vs 28.1, P<.01) and less likely to attend their follow-up visit (69 vs 81%, P=.03). Only 28% of women who desired LARC and attended follow-up ultimately received LARC. Reasons for not receiving LARC included: patient selected a different method, postpartum provider did not routinely place LARCs, or patient was asked to return for placement and did not.

CONCLUSION:

In our ethnically diverse, low-income, county hospital population, the majority of women with short IPI desired birth control, particularly LARC, at time of the preceding delivery. Most women who desired LARC did not receive it, despite attending postpartum follow-up. Continued efforts should be made to increase availability of contraception and LARC immediately postpartum and at postpartum visits to increase access to desired contraception and reduce unintended pregnancy.
Physical Activity, Nutrition and Hormone Levels of Postmenopausal Women With and Without Endometrial Cancer [40R]
Authors: Podwika Sarah , Gabel Anne , Slack-Davis Jill , Shupnik Margaret , Hoehn Kyle , Modesitt Susan Carnall
Published: May 2019

INTRODUCTION:

This prospective study evaluated anthropometric data, reported physical activity, nutrition, and hormone levels between postmenopausal women undergoing hysterectomy for endometrial cancer and benign disease.

METHODS:

After IRB approval, participants completed questionnaires on physical activity, nutrition, menstrual history and hormone use, and provided preoperative blood samples.

RESULTS:

Of the 77 participants, mean age was 64.5 years, mean BMI was 35.0 kg/m2, and 80.5% had endometrial cancer. Few women (20.8%) achieved recommended weekly exercise and 47.2% did not exercise. Only 44.9% of women ate recommended servings of fruits and vegetables and 55.6% ate fast food weekly. Comparing women with and without cancer, a trend towards higher BMI (36.0 vs 31.1 kg/m2, P=.071) was noted but no significant differences with regard to gravidity, exercise, nutrition, glucose or hormone levels except that estradiol level was significantly lower in women with cancer (45.2 vs 53.8 pg/mL, P=.041). Obese women were significantly less likely to rate their health as excellent/very good (28.6% vs 56.5%, P=.022) and had statistically significant lower FSH (P=.021) and SHBG (P<0.001) but higher C-peptide (P=.019) compared to lean patients. Women were divided into 4 groups (obese or lean with and without cancer) with significant differences found in age (lean women with cancer were older, P=.006), FSH (obese women with cancer had lower levels, P=.012), SHBG (highest in lean women without cancer, P=.02) but not estradiol, androstenedione, C-peptide or diet/exercise.

CONCLUSION:

Estradiol levels in postmenopausal women with cancer were lower than benign patients and did not correlate with obesity or other diet/exercise habits.
Impact of Histology on Racial Disparities in Epithelial Ovarian Cancer Patients [39R]
Authors: Craig Eric R. , Tarney Christopher , Tian Chunqiao , Casablanca Yovanni , Darcy Kathleen
Published: May 2019

INTRODUCTION:

Epithelial ovarian cancer (EOC) is the most lethal gynecologic malignancy. Racial disparities between non-Hispanic white (NHW) and non-Hispanic black (NHB) patients with EOC has been documented, but data on the existence of disparities among other races is lacking. The objective of this study was to investigate the relationship between race, histology, and survival in EOC.

METHODS:

Data from women diagnosed with invasive EOC including serous, endometrioid, clear cell, and mucinous histology from 1990-2013 from the Surveillance, Epidemiology, and End Results (SEER) Program were used for analysis.

RESULTS:

A total of 68,206 patients were included. NHB patients had higher cancer-related mortality (CRM) than NHW patients in all histological classifications. Hispanic (HSP) and Asian Pacific Islander (API) patients had decreased risk of CRM for serous histology. API patients also had lower CRM for clear cell histology. Hazard ratio (HR) for NHB vs. NHW patients was the smallest in serous histology (HR 1.18, 95% Confidence Interval (CI) 1.12-1.26) and largest for mucinous histology (HR 1.54, 95% CI 1.34 -1.78). HSP (HR 0.91, 95% CI 0.87-0.96, P=0.0005) and API (HR 0.87, 95% CI 0.82-0.93, P<0.0001) patients had decreased risk of CRM for serous histology. API patients also had lower CRM for clear cell histology (HR 0.83, 95% CI 0.71-0.97, P<0.021).

CONCLUSION:

There are significant histologic differences among races. NHB patients have an increased risk for CRM in all histological subtypes. Recognizing these histological differences may allow for tailored therapy, which may reduce racial survival disparities observed in EOC.
Risk Factors for Inverted T Hysterotomy Incision at the Time of Cesarean Delivery [35R]
Authors: Kawakita Tetsuya , Huang Jim , Landy Helain J.
Published: May 2019

INTRODUCTION:

We sought to examine those for an inverted T hysterotomy.

METHODS:

This was a retrospective study of all women undergoing cesarean delivery at 23 weeks' gestation or greater between 2012 and 2017. We only included cases in which the hysterotomy incision was either low transverse or inverted T hysterotomy. Risk factors included age, race, repeat cesarean, gestational age, fetal presentation, large fibroid >10 cm, emergency cesarean, second stage cesarean, previa or accreta, general anesthesia, and multiple gestations. Outcomes were compared between cases with low transverse and inverted T hysterotomy. Multivariable logistic regression to obtain adjusted odds ratios (aOR) and 95% confidence interval (95% CI). MedStar Institutional Review Board approved this analysis.

RESULTS:

Of 6,608 women undergoing cesarean delivery, inverted T hysterotomy incisions occurred in 68 (1.0%). In multivariable logistic regression, risk factors for inverted T hysterotomy included non-Hispanic black (aOR 4.85; 95%CI 1.14-20.60), repeat cesarean (aOR 1.81; 95%CI 1.04-3.16), preterm delivery (23 0/7-31 6/7 weeks' gestation [aOR 7.58; 95%CI 3.59-16.00]; 32 0/7-36 6/7 weeks' gestation [aOR 2.08; 95%CI 1.06-4.07]), malpresentation (transverse [aOR 22.29; 95%CI 9.77-50.82]; breech [aOR 2.91; 95%CI 1.49-5.67]), fibroid >10 cm (aOR 7.77; 95%CI 1.95-30.88), emergency cesarean (aOR 3.17; 95%CI 1.53-6.58), and second stage cesarean delivery (aOR 2.98; 95%CI 1.32-6.74).

CONCLUSION:

We identified independent risk factors for an inverted T hysterotomy. These findings will help clinicians identify and counsel high-risk women regarding potential implications of having a cesarean delivery.
Cesarean Section Incision Length and Post-Operative Pain [34R]
Authors: Nicholls-Dempsey Laura , Abenhaim Haim
Published: May 2019

INTRODUCTION:

Cesarean sections are a common surgical procedure and are associated with post-operative pain. The objective of this study is to describe the variability in cesarean section incision length and its association with post-operative pain, scar satisfaction and analgesia use.

METHODS:

After approval from the Institutional Review Board, we conducted a hospital-based study on women from a tertiary care center's post-partum unit who delivered by cesarean section. Written informed consent was obtained. Post-operative pain was measured using a visual analog scale from 0 to 10 at the first post-operative day. Cesarean section incision length was measured on the second post-operative day. Descriptive analyses were used to describe incision lengths and pain levels.

RESULTS:

We recruited 107 women having delivered by cesarean section. The mean incision length was 16.39 cm (SD ± 1.78 cm), ranging from 13 to 22 cm, and skewed towards longer incisions, with 20.6% having an incision ≥ 18 cm. The mean pain level on the first post-operative day was 5.7/10 (SD = ± 2.6), 4.4/10 (SD = ± 2.3) on the second day, and 1.9/10 (SD = ± 2.2) at 6 weeks post-partum. There was no significant difference in pain level according to incision length at the first (P=0.224), second (P=0.350), and 6 week (P=0.904) post-operative mark

CONCLUSION:

There is considerable variability in cesarean delivery incision length. We did not identify any significant predictor for larger incisions. Incision length was found to have no impact on the post-operative pain level at one day, two days or six weeks after cesarean delivery.
Pulse Pressure and Postepidural Complications in Women With Hypertensive Disorders of Pregnancy [33R]
Authors: Kazzi Nayla George , Triebwasser Jourdan , Kobernik Emily , Langen Elizabeth Suzanne
Published: May 2019

INTRODUCTION:

Normotensive women with narrow pulse pressure have increased risk of postepidural complications and benefit from additional fluid volume. We hypothesized that narrow pulse pressure in hypertensive women was associated with increased postepidural intervention.

METHODS:

Single-center prospective cohort study of women with singleton pregnancies and diagnosis of gestational hypertension (gHTN) or preeclampsia admitted for delivery between December 2016 and January 2018. Mean pulse pressure in the 3 hours prior to test dose was calculated (narrow defined as <45 mm Hg). Primary outcome was a composite of postepidural resuscitative measures including fluid bolus, vasopressors, supplemental oxygen, or intentional maternal position changes. Secondary outcomes included hypotension, defined as a decrease in blood pressure (BP) of 20% from baseline, or fetal heart rate (FHR) decelerations compared to 1 hour prior to epidural bolus.

RESULTS:

67 women with hypertensive disorders of pregnancy were included, with 15 (22.4%) having a narrow pulse pressure. Average systolic and diastolic BP prior to epidural for those with narrow vs. normal pulse pressure was 125 Â± 11 vs. 137 Â± 10 mm Hg (P<.001) and 86 Â± 11 vs. 81 Â± 8 mm Hg (P=.05), respectively. No observed difference in the need for postepidural resuscitation 13.3 vs. 38.5% (P=.12) or any component of the composite outcome. No observed increased risk of systolic (RR 0.74 [95%CI 0.25-2.25]) or diastolic hypotension (RR 0.89 [95%CI 0.53-1.51]) with narrow pulse pressure, nor were abnormal FHR patterns more frequent (P=.72).

CONCLUSION:

Narrow pulse pressure was not predictive of postepidural complications or resuscitation in women with gHTN or preeclampsia.
Prolonged Second Stage in the First Pregnancy and Risk of Subsequent Spontaneous Preterm Birth [30R]
Authors: Sobhani Nasim C. , Cassidy Arianna G. , Rosenstein Melissa G. , Zlatnik Marya G.
Published: May 2019

INTRODUCTION:

Preterm birth (PTB) is the leading cause of neonatal morbidity/mortality. Although some risk factors for spontaneous PTB (sPTB) are known, sPTB often occurs without identifiable risk factors. A prolonged second stage may increase sPTB risk via mechanical trauma that disrupts cervical integrity. This study examines the association between second stage length and subsequent sPTB.

METHODS:

This retrospective study included women with two consecutive singleton deliveries at one institution from 07/2012-06/2018, with the first delivery occurring at term. Prolonged second stage (PSS) was defined as 4 hours or more, based on this cohort's 75th percentile and on national recommendations. Very prolonged second stage (VPSS) was defined as 7 hours or more, based on this cohort's 95th percentile. The primary outcome was subsequent sPTB before 37 weeks. Fisher exact test, Kruskal-Wallis test, and logistic regression were used for statistical analysis.

RESULTS:

Among 1,032 included women, the overall subsequent sPTB rate was 3.1%. Identified in 24.4%, PSS was not associated with increased rate of sPTB (4.4% with PSS vs 2.7% without PSS, p=0.21). Identified in 4.3%, VPSS was associated with a higher rate of sPTB (9.1% with VPSS vs 2.8% without VPSS, p=0.04, OR 3.4, 95% CI 1.1-10.2).

CONCLUSION:

When dichotomized using the nationally-accepted cutoff of 4 hours, prior second stage length was not associated with subsequent sPTB. However, there was an association between increased risk of sPTB and second stage length when using a higher cutoff of 7 hours. Because that population's sample size was small, larger studies are required to confirm this association.
Progesterone Use and Regional Variation of Practice in a Nationwide Cohort [29R]
Authors: Ruma Michael S. ,   On behalf of the EQUATE Consortium
Published: May 2019

INTRODUCTION:

To determine the rate of progesterone use among women with a history of prior sPTB.

METHODS:

This study is a secondary analysis of the EQUATE trial, a prospective, observational study performed at 16 US sites designed to evaluate the utility of quantitative fetal fibronectin for predicting the risk of sPTB in a high-risk asymptomatic population. All patients with a history of sPTB and singleton pregnancy were included in this analysis. The primary outcome assessed the rate and form of progesterone use to reduce the rate of recurrent sPTB. Descriptive statistics were calculated to report the use and regional differences in practice.

RESULTS:

Of the 1546 women in the EQUATE trial, 862 (55.8%) met the inclusion criteria for this secondary analysis. Of these, 36.5% (315/862) received 17-P therapy, 17.4% (150/862) received vaginal progesterone, 1.3% (11/862) received both, while 44.8% (386/862) did not receive any progesterone during their pregnancy. Significant regional differences were noted in the cohort for progesterone use and agent selection (p-value < 0.00001).

CONCLUSION:

17-P is FDA approved and ACOG recommended for the prevention of recurrent sPTB in women with a prior sPTB. In this cohort, nearly half of patients (44.8%) - all of whom were candidates for 17-P - did not receive this intervention. Whether this is related to results of recent trials which call into question the efficacy of this intervention or challenges related to the availability and affordability of 17-P is not clear. Further studies are needed to better understand this pattern of progesterone use across the United States.
Pregnancy and Childbirth After Spinal Fusion for Adolescent Idiopathic Scoliosis [27R]
Authors: Cahill Patrick J. , Hilmara Didja , Flynn John M. , Ho Michelle
Published: May 2019

INTRODUCTION:

The current body of knowledge of pregnancy and childbirth in patients with adolescent idiopathic scoliosis treated with a spinal fusion relies on data from patients treated with outdated spinal fusion techniques. The study seeks to understand the effects of spinal fusion on pregnancy and childbirth for AIS patients.

METHODS:

Retrospective and prospective surveys were distributed to patients enrolled in a multi-center AIS study. The survey addressed the entire pregnancy experience (e.g., type of delivery, anesthesia use during labor, and post-partum recovery). Descriptive statistics were used to summarize the findings. IRB approval and informed consent was granted for all study procedures.

RESULTS:

A total of 54 babies were born to 54 patients during the study. As part of their prenatal care, only 24% of patients reported meeting with an anesthesiologist prior to delivery. The most common type of delivery was spontaneous vaginal (53%). Of the women who had spontaneous vaginal births (25 of 53 pregnancies), 12 did not receive anesthesia, 6 received intravenous intermittent narcotics, and 9 had regional anesthesia. Of 54 patients, 2 were told by their perinatal providers that anesthesia use was precluded by previous spine surgery.

CONCLUSION:

The majority of AIS patients reported not meeting with an anesthesiologist prior to giving birth. Those who had a planned C-section did so under obstetrician recommendation. Although the presence of spinal instrumentation is an important consideration, it should not dictate a patient's delivery. A multidisciplinary team consisting of obstetrician, anesthesiologist, and orthopaedic surgeon may provide the most comprehensive patient education regarding pregnancy and childbirth.
Predictive Model for Successful Induction of Labor in Early Onset Pre-Eclampsia With Severe Features [24R]
Authors: Fei Yueyang F. , Ware Courtney Abshier , McLaughlin Eric , Hade Erinn , Markham Kara B.
Published: May 2019

INTRODUCTION:

Hypertensive diseases of pregnancy complicate approximately 10% of pregnancies. Optimal timing and mode of delivery is unclear for pregnancies complicated by early onset pre-eclampsia with severe features (<34 weeks). This study aims to identify characteristics associated with the patient, fetus, and pregnancy that may affect the likelihood of successful vaginal delivery, which may guide future counseling of these patients.

METHODS:

This is a retrospective cohort study of women at a large tertiary medical center from 2012-2016. It included a total of 159 patients who delivered at <34 weeks with pregnancies complicated by pre-eclampsia with severe features. Risk factors for failed induction of labor were compared using various statistical methods. We developed and validated a predictive model using a step-wise procedure to calculate a patient's risk for having a failed induction of labor.

RESULTS:

Of 159 patients who underwent induction of labor, 77 resulted in successful vaginal deliveries. History of prior vaginal delivery, history of preterm labor, and increased parity, were associated with successful induction of labor. Conversely, elevated umbilical artery dopplers, earlier gestational age, lower bishop score, and current smoking were associated with higher rates of cesarean delivery.

CONCLUSION:

Overall, 48.4% of patients delivered vaginally following induction of labor in the setting of early onset pre-eclampsia with severe features. We developed a predictive model to classify patients with regards to risk for cesarean section, which included the following variables: pregnancy history, bishop score, age, smoking status, obesity. Further research can better elucidate the impact of different characteristics in predicting mode of delivery.
Potential Impact of the New Hypertension Criteria on Hypertensive Disorders of Pregnancy [22R]
Authors: Kozakiewicz Melissa L. , White Sarah E. , Burnett Brian A. , Nitsche Joshua , Denney Jeffrey M. , Brost Brian
Published: May 2019

INTRODUCTION:

In November 2017, the Task Force on Clinical Practice Guidelines of the American College of Cardiology and American Heart Association provided new criteria for the diagnosis of hypertension. We sought to determine if the new diagnostic criteria (>130/80) would impact the diagnosis and potential management of hypertensive disorders of pregnancy.

METHODS:

In a retrospective descriptive study, two groups of mother/fetus pairs were identified: 1) those with a hypertensive disorder of pregnancy diagnosis (gestational hypertension, preeclampsia with or without severe features, eclampsia or HELLP syndrome) 2) no hypertensive disorder of pregnancy diagnosis. 294 consecutive deliveries were reviewed from 2016 following IRB approval.

RESULTS:

31 patients were identified for the hypertensive disorder of pregnancy and 31 for the no hypertensive disorder of pregnancy groups. Baseline demographics of each group were similar except for body mass index. Body mass index was significantly higher in the hypertensive disorder of pregnancy group. In women with a hypertensive disorder of pregnancy diagnosis, 65% met criteria for preexisting hypertension using the new guidelines compared to 19% without a diagnosis of a hypertensive disorder of pregnancy (p=0.0008). Preexisting hypertension would have been diagnosed in 78% of those diagnosed with gestational hypertension using the new criteria.

CONCLUSION:

Our results indicate adopting the new hypertension guidelines would increase the prevalence of chronic hypertension in pregnancy, and in turn the number who require specific antepartum surveillance and intrapartum management. Utilizing the new, more sensitive criteria for diagnosing chronic hypertension would also decrease the number of patients diagnosed with gestational hypertension.
Postpartum Urinary Retention, Identifying Risk Factors to Prevent Injury [21R]
Authors: Tureson Justin R. , Farrell Maureen
Published: May 2019

INTRODUCTION:

Postpartum urinary retention (PPRT) affects between 2 and 3% of deliveries resulting in increased hospital costs and the potential for long term morbidity including need for prolonged catheter placement, intermittent self-catheterization, and future bladder dysfunction. PPRT is avoidable with medical staff awareness and intervention before bladder distention injuries occur. The project aim is to identify risk factors in patients who develop PPRT and determine the average postpartum diuresis.

METHODS:

This is a retrospective cohort study involving postpartum patients at Naval Medical Center San Diego. The study group was patients that delivered between 01JAN2017 and 01JAN2018 who had PPRT. Patients delivering between 01MAY2017 and 30MAY2017 were analyzed as the control group. Data collected included demographic information, delivery type, parity, length of second stage, infant weight, obstetric laceration, anesthesia type, comorbid conditions (hypertension, diabetes, obesity, postpartum hemorrhage), time to first void/bladder drainage and the volume.

RESULTS:

58 patients were identified as having suffered PPRT. In the study group, the average time to noting bladder over distention was 3.88 hrs with an average volume of 1142cc (353cc/hr). The control group included 244 patients with average time to void of 2.92 hrs and an average volume of 454cc (194cc/hr). Common risk factors for PPRT included primiparity, operative delivery (12.3% of PPRT versus 2.9% of controls), prolonged second stage of labor, and neuraxial analgesia.

CONCLUSION:

PPRT is an avoidable morbidity among obstetric patients. Identifying average diuresis rates and common risks factors as noted in this study will help better hone postpartum voiding trial protocols.
Does Antepartum Vitamin D3 Supplementation Prevent Gestational Diabetes Mellitus? [18R]
Authors: Persad Malini D. , Staszewski Cara , Khan Farzana , Perseleni Tatyana , Herrera Kimberly , Garretto Diana
Published: May 2019

INTRODUCTION:

To determine the if Vitamin D3 supplementation in prevents gestational diabetes (GDM).

METHODS:

A subgroup analysis of the efficacy of Vitamin D3 to prevent GDM was completed on a trial performed from 10/2016 - 5/2018. Inclusion criteria: confirmed intrauterine pregnancy 12-16 weeks gestation. Exclusion criteria: women taking Vitamin D3 supplements, or a malabsorption disorder, or carrying anomalous fetus. Women were assigned to receive daily Vitamin D3 3000IU or no supplement in addition to prenatal vitamins. Maternal demographic factors, maternal serum Vitamin D (25(OH)D) levels, and incidence of GDM were collected from charts. GDM was defined as a positive 2 hour 75 g GTT or 3 hour 100 g GTT. Parametric and nonparametric statistics were calculated with a p value of <0.05 as significant.

RESULTS:

The cohort consisted of 210 women with 103 in the Vitamin D3 supplementation group and 107 in the no supplementation group. There were no significant differences in baseline characteristics between the groups. The third trimester maternal serum 25(OH)D levels were significantly increased in the Vitamin D3 supplementation group (28.9 +/- 11.1 ng/dl vs 23.3 +/- 8.8 ng/dl, p=0.001). The overall incidence of GDM was 10.4% (22/210) and the incidence of GDM was similar between groups (7.8% Vitamin D3 supplementation vs 13.0% no supplementation, RR 0.78, 95% CI 0.79-2.46).

CONCLUSION:

Antepartum Vitamin D3 supplementation raises baseline maternal serum 25(OH)D levels, but does not reduce the incidence of GDM.
Risk Factors for Surgical Site Infection After Cesarean in the Era of Extended Spectrum Preoperative Antibiotics [13R]
Authors: La Rosa Mauricio , Costantine Maged , Babazade Rovnat
Published: May 2019

INTRODUCTION:

To determine risk factors associated with surgical site infections (SSI) after cesarean delivery (CD) using a contemporary cohort after the introduction of azithromycin.

METHODS:

Retrospective cohort study of women who underwent cesarean delivery (CD) in 2017 at a single university medical center, after the introduction of adjunctive azithromycin prophylaxis protocol. We excluded women younger than 18 years of age and those in which documentation of postpartum clinic follow up was not available. Our primary outcome was SSI defined according to the CDC criteria. Univariable and multivariate logistic regression analysis was performed and a P<0.05 was considered statistically significant.

RESULTS:

1365 women were included in the study. Out of 172 who developed SSI, 85% had superficial SSI. The use of preoperative antibiotics was almost universal and did not differ between the two groups. Women who developed SSI were heavier and more likely to be African American, have chronic hypertension, to have their CD done non-electively and after the onset of labor, and to receive blood transfusion. The duration of CD was longer in the group who developed SSI, their skin closed with staples, and prolonged hospital length of stay. On multivariable analysis, BMI (aOR 1.07, 95% CI 1.04-1.09, P<0.001), blood transfusion (aOR 4.37, 95% CI 2.07-9.22, p<0.001), and undergoing a CD non-electively after the onset of labor (aOR 1.58, 95% CI 1.10-2.28, p=0.01) remained significantly associated with SSI.

CONCLUSION:

Undergoing CD non-electively after the onset of labor, maternal obesity, and the need for pRBC transfusion are risk factors for SSI in women undergoing CD.
Simulation-Based Education for Contraception Counseling: A Crossover Study [10R]
Authors: Jackson Araba A. , Marko Emily , Perez-Visona Sira
Published: May 2019

INTRODUCTION:

Healthcare providers are responsible for identifying women at risk of unintended pregnancy and providing counseling regarding contraceptive options through shared decision-making. The purpose of this study was to determine if a simulation-based curriculum will improve confidence and competence in contraception counseling compared with traditional instruction.

METHODS:

A randomized prospective crossover study was performed using two groups of third year medical students in the same clerkship rotations. All students received the same curriculum but had competency assessments at different times (group 1=pre-simulation, group 2=post-simulation). All underwent objective structured clinical exams (OSCEs) at the end of the clerkship. Instructional strategies included standardized patients and faculty feedback. Outcomes were measured using pre-post confidence surveys, competency assessment scores, and OSCE results. Institutional review board exemption was obtained

RESULTS:

Seventy-two students participated in the study over 1 year. Significant improvement was noted in pre-post confidence scores of both groups (group 1 pre=3.27, post=1.79, p=0.0005, group 2 pre=3.20, post=1.63, p<0.0001). The post-simulation crossover group demonstrated competency assessments that were significantly higher than the pre-simulation group (group 1 at 48.61% vs. group 2 at 79.40%, p<0.0001). Both groups completed the clerkship with similar OSCE scores (group 1 at 84.38% vs. group 2 at 83.12%) with group 1 demonstrating significant improvement from the pre-simulation competency assessment (48.61% vs. 84.38%, p<0.0001).

CONCLUSION:

Simulation significantly improved contraception counseling competencies in medical students. Providing learners with the ability to practice these shared decision-making skills through a simulated patient encounter may better prepare them to counsel real patients regarding contraception and hopefully prevent unintended pregnancies.
Second Trimester Induction in the Setting of a Prior Cesarean Delivery [9R]
Authors: Uribe Katelyn A. , Nguyen Anh Q. , Burke Anne E. , Johnson Clark
Published: May 2019

INTRODUCTION:

Second trimester induction is considered an appropriate alternative to dilation and evacuation (D&E) when indicated, although the presence of a uterine scar potentially increases risks. One prior cesarean delivery (CD) is not associated with increased risk of uterine rupture, although insufficient evidence exists when multiple prior CD have occurred. We sought to further evaluate the safety of induction in the second trimester with a prior uterine scar.

METHODS:

We present a retrospective cohort evaluation of 125 women who underwent induction between 14 weeks and 23 weeks at the Johns Hopkins Hospital between 2013 and 2016. Induction was performed with either prostaglandins, Pitocin, osmotic dilators, or a combination of agents. Outcomes evaluated were infection, hemorrhage, blood transfusion, and retained placenta. IRB approval was obtained.

RESULTS:

29 of the patients had a prior CD, with 8 of the patients having multiple prior CD. No uterine ruptures occurred in any group. One prolonged induction required conversion to D&E. The rate of retained placenta was lower in the group with a prior CD, but this finding was not significant. While the rate of hemorrhage is similar in both groups, the rate of transfusion is higher in the women with prior CD, but is not statistically significant. When isolating the patients with two or more prior CD, outcomes are not significantly different.

CONCLUSION:

Our results are consistent with established guidelines that induction in the second trimester with a prior CD is safe and feasible. Multiple prior CD appear to have similar associated risks, but further research is warranted.