bluuebunny/crossref_metadata_2025 huggingface dataset:
How Do Hypertension in Pregnancy Practice Guidelines Change Hypertension Management in a Single Academic Center? [28F]
Authors: Weeks Corinne M. , Wiese Sarah , Ogamba Maureen , Kasper Rebecca E. , Leung Katherine , Leftwich Heidi
Published: April 2018

INTRODUCTION:

In November 2013, the American College of Obstetricians and Gynecologists released the “Hypertension in Pregnancy” guidelines. Hypertensive disorders are a major source of perinatal morbidity and mortality. Our objective was to assess whether these guidelines affected hypertension management at our institution.

METHODS:

We performed a secondary analysis of a retrospective cohort study on postpartum hypertension from deliveries from 07/09 to 07/16. Inclusion criteria were the presence of a documented hypertensive disorder. Exclusion criteria were discharge home on antihypertensive medication. Study variables include: gestational age at time of induction, delivery method, antihypertensive treatment, maximum systolic/diastolic blood pressures < 24 and 24-72 hours postpartum, rates of attendance to blood pressure check and postpartum visit. Chi-square test was used for categorical variables and Student T-test was used for continuous variables. “Pre-Guidelines” (7/09-10/13) and “Post-Guidelines” (2/13-7/16) were chosen to allow for policy change within our institution.

RESULTS:

470 deliveries were pre-guidelines and 237 deliveries post-guidelines. There are increased rates post-guidelines of intrapartum IV antihypertensive treatment (9.8% vs 3.2%, P<.001) and increased attendance to a postpartum blood pressure check post-guidelines (24.1% vs 15.4%, P<.01). There was no difference in all other variables studied.

CONCLUSION:

Post-guidelines, our institution noted a statistically significant increase in IV intrapartum antihypertensive therapy and postpartum blood pressure checks within two weeks of delivery. There were no statistically significant differences in the time of induction, delivery method, or antihypertensive treatments despite these guideline changes. Further research needs to be done to study the implications of these guideline changes in respect to perinatal morbidity and mortality.
Excessive Gestational Weight Gain in Women With Positive Glucose Challenge Test is Associated with Adverse Outcomes [38F]
Authors: Kumar Dipti K. , Poe Amanda , Klapholz Henry , Dangel Alissa
Published: April 2018

INTRODUCTION:

The Institute of Medicine (IOM) guidelines currently recommends targeting gestational weight gain (GWG) according to pre-pregnancy BMI. We compared the maternal and neonatal outcomes in women with a positive glucose challenge test (GCT) who gained weight in excess of the IOM guidelines to those who were adherent.

METHODS:

A retrospective single-center cohort study including all singleton, term (>37 weeks) pregnancies with a positive GCT (>140mg/dl) delivered between 2013-2016. Patients were classified as either ‘excess’ or ‘adherent’ based on IOM GWG recommendations. Primary outcome was the rate of macrosomia (>4,000g). Secondary outcomes included rates of cesarean delivery and neonatal hypoglycemia. Baseline variables were compared using t-test or chi-square test and combined in a multivariable logistic regression model.

RESULTS:

From 456 singleton-term pregnancies, 182 patients (40%) had ‘excess’ GWG. The excess cohort were younger, more likely to be African-American and have positive screening GCT with a negative diagnostic test (71% vs 58%,p<0.01). Excess cohort had greater rate of macrosomia (15% vs 5%,p<0.01), more likely to develop pre-eclampsia (10% vs 2%,p<0.01) and undergo cesarean delivery (40% vs 32%,p=0.10). The increased risk of macrosomia (OR-3.45, 95%CI 1.7-7.5) and pre-eclampsia (OR-4.8, 95%CI 1.8-15.4) remained when adjusting for age, ethnicity, and pre-pregnancy BMI. Rates of neonatal hypoglycemia were similar in both cohorts.

CONCLUSION:

Women with a positive GCT, regardless of the diagnosis of gestational diabetes, gaining weight in excess of IOM guidelines have increased risk of macrosomia and pre-eclampsia. Focused counseling regarding appropriate weight gain should be considered in all women with a positive GCT.
Twenty-Four Hour Mifepristone Combined With Vaginal Versus Buccal Misoprostol Prior to D&E [7G]
Authors: Casey Frances Elizabeth , Wegelin Jacob , Reeves Matthew
Published: April 2018

INTRODUCTION:

The goal of this study was to evaluate oral mifepristone twenty-four hours prior to vaginal versus buccal misoprostol as cervical preparation prior to second-trimester dilation and evacuation (D&E).

METHODS:

Women desiring abortion between gestational ages 16 weeks 0 days and 20 weeks 6 days were randomized to 200-mg mifepristone 20-24 hours and 400-mcg vaginal or 400-mcg buccal misoprostol 1-2 hours prior to D&E. Primary outcome was intraoperative procedure time defined as time of initial cervical dilation assessment to speculum out. Secondary outcomes included initial Pratt dilator accepted without resistance and participant and provider perceptions. The study was powered to detect a 4-minute difference in procedure time with 36 participants in each arm.

RESULTS:

Of 72 women enrolled, 70 were randomized and completed the study. Age, BMI, gestational age (mean 18.7 weeks, SD 1.39), and parity did not significantly differ. Total procedure times were 9.4 and 10.6 minutes in the vaginal and buccal groups, respectively, with difference of 1.2 (95% CI -1.2, 3.8). Initial Pratt dilation was 49.6 and 45.6 Fr in the vaginal and buccal groups, respectively, with difference of 4 Fr (95% CI -9.0, 1.0). Participant and provider perceptions did not differ. All 70 procedures were completed without hemorrhage, cervical laceration, or other observed complications.

CONCLUSION:

Mifepristone 24 hours prior combined with vaginal or buccal misoprostol 2 hours prior is effective as cervical preparation for D&E at 16 weeks through 20 weeks 6 days.
Assessment of Contraceptive Need and Practice of Women in the Extended Postpartum Period in Addis Ababa, Ethiopia [8G]
Authors: Asires Hailegeorgis A. , Negash Shiferaw , Getiye Yemisrach
Published: April 2018

INTRODUCTION:

Family planning is one of the most cost effective and high yield interventions to improve health outcomes in reproductive, maternal and child health. ACCESS-family planning defines the extended postpartum period as one full year post-birth. During this extended postpartum period, 95% of women in low- and middle-income countries want to avoid pregnancy within 2 years, but 70% are not using contraception. So this study is intended to identify the needs and practices of contraception among women in the extended postpartum period.

METHODS:

Institution based cross sectional study conducted using structured questionnaire, analysed with Epi-Info 7 and SPSS 21. Data categorized and summarized with descriptive statistics, bivariate and multivariate logistic regression model used to identify important determinants.

RESULTS:

A total of 833 mothers were interviewed. Mean age at their last delivery was 27.3 +/- 4.5 years. Median number of pregnancy was two with a minimum of one and maximum of seven. Regarding reproductive intention, 45.0% of mothers want to space the next pregnancy for more than 2 years. From 92.6% of mothers who wanted to use family planning, 70.9% use modern methods giving contraceptive prevalence rate of 65.7%. Less than half ever heard about lactational amenorrhea and less than 25% knew how to use it.

CONCLUSION:

Reproductive intention, resumption of menses and sexual intercourse, knowledge, discussion with partner, post-partum visit and counseling were associated with post-partum family planning practice. Government, policy makers and Health care providers should work on Improving the knowledge on long term family planning methods and lactational amenorrhea.
Nexplanon Procedure-Related Events: Final Results From the Nexplanon Observational Risk Assessment Study (NORA) [9G]
Authors: Reed Suzanne , Koro Carol , Heinemann Klaas , Westhoff Carolyn
Published: April 2018

INTRODUCTION:

To characterize the frequency of insertion- and removal-related events among Nexplanon users in the US during standard clinical practice.

METHODS:

This large, prospective, non-interventional cohort study followed 7,369 new users of Nexplanon recruited by US health care professionals (HCPs) between December 2011 and March 2014. Questionnaires were completed by patients at 6-month intervals (beginning on the day of insertion and ending 6 months after implant removal) and by HCPs who inserted or removed the implant. Data analysis characterized the frequency of procedure-related events.

RESULTS:

During 7,369 insertions, HCPs reported 208 events involving 189 patients (2.6% of the study population). Difficulty removing the needle protection cap was the most common event (93 insertions). In total, 49 patients (0.7% of the study population) reported an event at insertion. The most common event was pins/needles/numbness in the arm/hand/fingers (17 patients; 2.3 per 1,000 insertions; 95% CI, 1.3-3.7), which was significantly more likely in repeat/consecutive implant users (10.1 per 1,000 insertions; 95% CI, 4.6-19.0) than first-ever implant users (1.2 per 1,000 insertions; 95% CI, 0.5-2.4). Follow-up data through April 2017 show that 345 patients reported 592 events in the implant arm: pins/needles/numbness (190), severe pain (160), altered strength (65) and other events (e.g. bruising) (100). Of 3,551 removal procedures, 48 (1.4%) involved challenge(s): encasement in fibrotic tissue (26), multiple removal attempts (9), local migration (4), deep implant (4) and other challenges (e.g. fragmented implants) (10). Final study results will be available at ACOG.

CONCLUSION:

Insertion- and removal-related events involving Nexplanon are rare.
Understanding Long-Acting Reversible Contraceptive Decision-Making in the Immediate Postpartum Period [10G]
Authors: DeWitt Jacob D. , Ahmad Niloufar , Hoffman Shelley M. , Tucker Edmonds Brownsyne
Published: April 2018

INTRODUCTION:

To qualitatively assess factors influencing pregnant women’s desire for immediate postpartum long-acting reversible contraceptives (IPP LARCs), among women who change their minds about IPP LARC administration after delivery.

METHODS:

Data were derived from a larger cohort study evaluating the fulfillment of women’s requests for progesterone-containing LARCs in the form of the Medroxyprogesterone injection, Etonogestrel implant, or progestin intrauterine device in the immediate postpartum period. The subset of participants included in this qualitative analysis were those who changed their minds regarding contraceptive choice between the time of admission and the time of postpartum discharge. Specifically, women who changed their minds and opted out of a LARC were asked the following open-ended question: “how did you come to the original decision to use Depo/Nexplanon/Mirena?” Content analysis was used to classify participant responses.

RESULTS:

Twenty-eight patients who met the aforementioned criteria were approached. Many respondents described multiple influencing factors. The most commonly endorsed consideration was duration of effectiveness (32%). The second-largest grouping (28%) consisted of respondents whose decisions were based on desirable side-effect profiles, perceived safety, and/or ease of use associated with LARCs. Other responses indicated apprehension over non-LARC birth control methods or confidence in LARCs based on personal experience.

CONCLUSION:

Among the women surveyed, the dominant motivator to initially request IPP LARC was the duration of action for these types of contraception, followed by a collection of features beyond the measure of efficacy. These factors do not appear to differ substantially from those enumerated in the literature among women who have IPP LARC methods administered.
Implementing Quality Improvement Projects to Enhance Contraception and Abortion Care Training of Providers [12G]
Authors: Kassa Munir , Hailemariam Mengistu , Obermeyer Meghan , Baruda Kefelegn , Getachew Yonas , Dessie Asnakech
Published: April 2018

INTRODUCTION:

In Ethiopia, most medical graduates and midlevel health professionals lack the necessary competencies required to provide contraception and abortion care services. Since 2014, the Center for International Reproductive Health Training (CIRHT) has partnered with 11 teaching hospitals across the country to improve the quality of the pre-service education. The program aimed to improve the pre-service training through curriculum development, expanding hands on training and fostering a team science approach to research. This article summarizes the interventions used and outcomes identified in improving utilization and quality of care of abortion and contraception services to support the quality of training.

METHODS:

CIRHT created standards for model contraception and abortion care service clinics, known locally as “Michu” clinics. Quality improvement (QI) committees including faculty, residents, and nurses were established at all partner institutions. To identify major gaps in the quality of care of contraception and abortion services, each QI committee conducted a baseline audit. Using IHI’s Model for Improvement, each site defined their goals and measures to assess progress and intervention projects were tested using Plan-Do-Study-Act cycles.

RESULTS:

Currently, there are eight functional Michu clinics where residents, interns, and nurses are involved in service provision. In addition, all 11 teaching hospitals are now providing comprehensive contraception and abortion care services. The utilization for immediate post-partum family planning has doubled while safe first and second trimester medication abortion has become accessible to clients.

CONCLUSION:

CIRHT will focus its support on ensuring these model clinics and QI projects become part of the institutional structure of each teaching hospital.
Insights From the National Emergency Department Sample: Pelvic Inflammatory Disease, 2010-2014 [23G]
Authors: Byrd Tierra , Baker Regina , Chibber Shani , Phang Laura , Schon Samantha , Marsh Erica E.
Published: April 2018

INTRODUCTION:

Pelvic Inflammatory Disease (PID) is associated with long-term sequelae including infertility, ectopic pregnancy, and tubo-ovarian abscess. Although the emergency department (ED) is a common healthcare entry point, the extent of its utilization is unknown. Our objectives are to estimate utilization trends, determine economic burden and investigate factors affecting admission rates of women with PID presenting to EDs in the United States.

METHODS:

A retrospective analysis using the Nationwide Emergency Department Sample was used to assess ED visits of women ≥18 years old, between 2010 and 2014 with a primary diagnosis of PID, defined by the International Classification Diagnosis, 9th version. SAS 9.4 was used to perform chi-square and Z-tests. Admission rates were assessed by age, payer information, hospital characteristics and household income. Total charges were also analyzed.

RESULTS:

PID related ED visits decreased from 118,552 to 93,965 from 2010 to 2014 (-20.74%, P<.001). Total charges increased from $3,133.54 to $4,507.24 per visit from 2010 to 2014 (P<.0001); $1.926 billion total. In 2014, admission rates increased with age; 7.91%, 11.71%, 21.28%, 37.27% and 59.78% for women ages 18-24, 25-34, 35-44, 45-54 and 55+, respectively (P<.0001). Uninsured patients had the lowest admission rate (8.98% vs Medicaid 12.57%, private 20.99%, Medicare 27.21%, P<.0001). Admissions rates were nearly double for the highest income quartile compared to the lowest (23.41% vs 12.18%, P<.0001).

CONCLUSION:

Although the number of PID related ED visits decreased from 2010 to 2014, a significant economic burden still exists. Admission rate disparities are concerning for health inequities based on insurance status and household income.
Endometrial Evaluation in Elagolix-Treated Women With Uterine Fibroids and Heavy Menstrual Bleeding [25G]
Authors: Carr Bruce R. , Bradley Linda D. , Owens Charlotte D. , Gao Jingjing , Chwalisz Kristof , Simon James A.
Published: April 2018

INTRODUCTION:

Elagolix, an oral gonadotropin-releasing hormone antagonist, with and without add-back therapy, was evaluated in premenopausal women with heavy menstrual bleeding (HMB; >80mL/month) associated with uterine fibroids (UF).

METHODS:

This double-blind phase-2b study (NCT01817530) enrolled women 18–51y in 2 cohorts, with 4 arms/cohort: elagolix alone as 300mg twice daily (cohort 1) and 600mg once daily (cohort 2) and, in both cohorts, placebo and elagolix with add-back therapy of estradiol (E2)/norethindrone acetate (NETA) at low dose (0.5mg E2/0.1mg NETA [LDA]) or standard dose (1.0mg E2/0.5mg NETA [SDA]). Endometrial thickness and biopsies were evaluated at baseline and month 6.

RESULTS:

567 randomized patients were treated. Mean baseline endometrial thickness evaluated with transvaginal ultrasound was 6.6–7.9mm across both cohorts. At treatment month 6, mean change in endometrial thickness in both placebo groups ranged from 0.4–2.1mm, but decreased in all elagolix groups in both cohorts (–0.5 to –1.5mm), reaching significance vs placebo for elagolix 300mg+LDA (P=.018) and elagolix 600mg alone (P=.039). Mean endometrial thickness at month 6 ranged from 8.2–9.7mm in both placebo groups and 5.7–6.9mm across elagolix groups. Baseline endometrial biopsies in both cohorts were categorized as normal-quiescent/minimally-stimulated (3.1%–13.8%), proliferative (44.2%–57.1%), and normal-secretory/mixed/breakdown/menstrual (32.5%–45.5%). At month 6, there were more normal-quiescent/minimally-stimulated biopsies in all elagolix arms vs placebo: elagolix alone, 33.8%–43.1%; LDA, 21.1%–39.1%; SDA, 36.4%–41.5%; placebo, 2.6%–6.2%. No endometrial biopsies were abnormal.

CONCLUSION:

After 6 months of treatment, in both cohorts, elagolix with and without add-back therapy was associated with benign endometrial pathology and reduction in endometrial thickness vs placebo in women with HMB associated with UF.
Case Report: Topical Tranexamic Acid as Novel Treatment of Refractory Bleeding After Excisional Cervical Procedure [27G]
Authors: Burns Rebecca , Kucera Calen , Parsons Arlene , Bannon Lindsey
Published: April 2018

INTRODUCTION:

Tranexamic acid (TXA) is a derivative of the amino acid lysine that inhibits fibrinolysis by blocking binding sites of plasminogen and preventing its conversion into plasmin. It is conventionally used intravenously or orally for management of bleeding related to menorrhagia, dental extraction, epistaxis or trauma. Topical use is well established in orthopedic and otolaryngologic surgery and has been described in cardiac and dental procedures. While intravenous use has been shown to reduce hemorrhage, the use of topical TXA treatment for cervical bleeding after excisional procedure has not been described.

METHODS:

A 37-year-old woman on lifelong anticoagulation due to a prosthetic mitral valve was followed for persistent cervical dysplasia progressing despite cryotherapy. She underwent an uncomplicated loop electrocautery excisional procedure (LEEP), however she suffered continued bleeding from the surgical site and failed management with repeat electrocautery, packing, sutures, and hemostatic agents. TXA solution was directly applied to the cervix daily as a bedside procedure for ten days.

RESULTS:

Topical application of TXA to the surgical site was ultimately successful in maintaining continued hemostasis.

CONCLUSION:

For a patient in whom systemic anticoagulation cannot be held obtaining continued hemostasis of mucosal bleeding sites can be difficult. Topical use of TXA should be considered as an option for treatment in patients with refractory bleeding from biopsy sites as its application is not difficult, is well tolerated, and appears to have minimal side effects. Further study is indicated to determine ideal treatment protocols.
Bimanual Pelvic Examination is Not Sensitive for Fibroid Diagnosis [30G]
Authors: Ahmed Farah , Green Isabel , Stewart Elizabeth A. , Laughlin-Tommaso Shannon
Published: April 2018

INTRODUCTION:

Bimanual pelvic examination is often performed for symptoms related to uterine fibroids (UF). We evaluated the clinical utility of this exam at the time of UF diagnosis in a community setting.

METHODS:

Retrospective sample of women diagnosed with UF between 2006 and 2010 in the Rochester Epidemiology Project, a population-based records-linkage system. Cohort includes a sample of women who had a pelvic examination within 12 months of UF diagnosis (n=141). Abnormal pelvic exam was defined as abnormal uterine size or shape, or any adnexal mass or fullness recorded by healthcare provider. We examined clinical and imaging characteristics using chi-squared for categorical and t tests for continuous data. Data reported as percentage or mean ± standard deviation. Volumes of the uterus and largest fibroid were calculated using the prolate ellipsoid formula.

RESULTS:

Women with UF and a normal pelvic exam (n=73) were younger than women with abnormal exam (n=68) (44.7±7.1 vs 46.9±5.4 years, P=.05), and had a higher BMI (29.4 ± 6.5 vs 26.6 ± 5.0 kg/m2, P=.007). Women with abnormal exam had significantly larger uterine volumes (226.0 ± 151.8 vs 150.9 ± 97.9 cm³, P=.005) and fibroid volumes (61.1±81.1 vs 19.9±52.8 cm³, P=.005). Abnormal examination was more frequently documented by gynecology providers (57.4%) than other providers (42.7%, P=.04). Fibroid symptoms were not associated with abnormal examination.

CONCLUSION:

Fifty-two percent of women with fibroids had a normal bimanual examination. Thus, a high suspicion of fibroids should prompt imaging. Lower BMI and larger uterine and fibroid dimensions increase fibroid diagnosis on pelvic examination.
Elagolix Reduces Fatigue in Patients With Moderate-to-Severe Endometriosis Pain [34G]
Authors: Diamond Michael , Soliman Ahmed M. , Castelli-Haley Jane , Thomas James W. , Snabes Michael
Published: April 2018

INTRODUCTION:

Endometriosis-associated symptoms like menstrual and non-menstrual pelvic pain can be associated with fatigue. This study evaluated the impact of elagolix, an oral gonadotrophin-releasing hormone antagonist, on fatigue among endometriosis patients.

METHODS:

We conducted a phase III double-blind randomized placebo-controlled trial that enrolled premenopausal women with surgically-confirmed endometriosis diagnosis and moderate to severe endometriosis-related pain. A total of 872 patients were randomly assigned to placebo, elagolix 150 mg once daily (QD) or elagolix 200 mg twice daily (BID) for 6 months. Fatigue was assessed using Patient Reported Outcome Measurement Information System (PROMIS) Fatigue short form 6a at baseline, months 1, 3 and 6. Raw scores were converted to T- scores that are standardized based on a mean of 50 and a standard deviation (SD) of 10 for the general population (lower scores indicates less fatigue). Changes from baseline T-scores were compared between elagolix treatments and placebo using 1-way analysis of covariance using baseline scores as a covariate.

RESULTS:

At baseline, mean T-scores were more than one SD worse than population average [Least squared (LS) Means: 62.37, 64.16 and 63.93] for placebo, elagolix 150 mg QD and elagolix 200 mg BID, respectively. At month 3, elagolix 150 mg QD and elagolix 200 mg BID had greater improvements from baseline T-scores [LS mean change: -6.26 and -8.84 respectively; all p<0.05] compared to placebo [LS mean change:-4.61]. Improvements observed at month 3 persisted at month 6 (Each elagolix vs. placebo comparisons had p<0.01).

CONCLUSION:

Elagolix reduces fatigue in endometriosis patients with moderate to severe pain.
Long-term Effect of Elagolix on Bone Mineral Density in Women with Endometriosis-Associated Pain [38G]
Authors: Archer David , Watts Nelson , Duan W. Rachel , Peloso Paul , Wang Hui , Chwalisz Kristof
Published: April 2018

INTRODUCTION:

To evaluate the long-term effect of elagolix, an oral, non-peptide GnRH antagonist, on bone mineral density (BMD) in two 6-month (M) extension studies (Elaris EM-III and IV) of the pivotal, 6M, phase 3 studies (12M overall treatment with 150mg once daily [QD] or 200mg twice daily [BID]).

METHODS:

Women with moderate/severe endometriosis-associated pain and a baseline BMD Z-score >-1.5 were randomized to receive elagolix in the pivotal studies and continued elagolix treatment in the extension studies (treated: Elaris EM-III, n=287; Elaris EM-IV, n=282). Total hip BMD was measured by dual energy X-ray absorptiometry and reviewed/evaluated by a blinded central reader. Baseline was before dosing in pivotal studies.

RESULTS:

After 6M of elagolix treatment in the pivotal studies, the proportion of women with a decrease in total hip BMD ≥8% ranged 0–1.1% across doses/studies; these women were not eligible for extension study. Following 12M treatment, the proportion of women with a total hip BMD decrease from baseline ≥8% was 1.8% (n=2) at 150mg QD and 0.9% (n=1) at 200mg BID in Elaris EM-III and 0% (n=0) at 150mg QD and 4.6% (n=5) at 200mg BID in Elaris EM-IV. For total hip, the mean BMD Z-score at extension-M6 was within the normal range of -2.0 to +2.0 across doses/studies; no women had a total hip BMD Z-score ≤-2.

CONCLUSION:

In women with endometriosis-associated pain, long-term elagolix treatment was associated with decreases in total hip BMD, while the mean total hip BMD Z-score was within the normal range and no women had a total hip BMD Z-score ≤-2.
Towards Personalized Breast Imaging Pathways: Initial Findings from a Learning Health System [39G]
Authors: Dabbous Firas , Su Zhaohui , Donadio Gregory , Menon Vandana , Dolan James , Alsheik Nila
Published: April 2018

INTRODUCTION:

Recent advances in mammography screening demonstrate dual benefits of decreased recall rates and increased cancer detection. We describe findings from an ongoing learning health system whose goal is to develop personalized breast imaging pathways.

METHODS:

A cloud-based big data platform and robust technology infrastructure are being used to integrate and transform data from EMRs, radiology management systems, and tumor registries. The current study cohort includes data from 181,649 women (239,888 examinations) screened, between June 2015 and March 2017, at multiple centers within a large healthcare organization.

RESULTS:

The racially diverse study cohort was 60% Caucasian and 23% African American with median age 59 years; 54% of the exams were 2D and 46% were 3D screening mammography. Fifty four percent of 3D screens were in women with dense breasts (heterogeneously dense or extremely dense) compared to 40% of 2D screens. Recall rates were higher among African Americans compared to Caucasians and women of other races (11.6% versus 10.3% versus 10.1%, respectively; p<0.001), were higher in younger women [40-50y=14.8%, 50-60y=10.4%, 60-70y=9.2%, 70-80y=7.9%, 80-90y=7.1%], those with higher breast density and with higher lifetime Tyrer-Cusick Risk scores.

CONCLUSION:

This data driven platform enables large scale assessment (outcomes by pathway, and variation in care) of screening mammography in a real-world population. Initial analyses demonstrate significant differences in choice of screening modalities and outcomes by patient demographic and breast risk profile. Future analyses will focus on optimizing diagnostic pathways on the basis of risk profiles with the goal of improving outcomes in breast cancer screening.
Depth Matters: The Use of Radiofrequency for the Treatment of Gynecologic Conditions [40G]
Authors: Krychman Michael , Wilkerson Debbie , Finnieston Arica , Tomasetti Perry , Bell Stacie
Published: April 2018

INTRODUCTION:

The use of radiofrequency (RF) energy administration to the vaginal canal has been increasing, but questions regarding safety and mechanism of action remain. The type of RF, mode of administration and protocol will impact treatment outcomes. Submucosa cellular changes require that energy penetrate deep into the tissue without causes damage to the mucosal tissue. Data indicate that cryogen-cooled monopolar radiofrequency (CMRF) treatment elicits changes such as fibroblast activation and neocollagenesis while being safe to patients

METHODS:

Ovine ex vivo and in vivo studies were performed to investigate the depth of penetration and safety of CMRF treatment. Ex vivo treatment was performed on isolated vaginal and peri-vaginal tissue at different regions of the vagina. Gross observations and histopathological analyses were performed. Tissue was isolated following RF treatment and analyzed for tissue effects. Outcome measures include temperature monitoring and histopathology to evaluate the extent of treatment, cellular changes and safety.

RESULTS:

Data indicate that there are a number of cellular changes in the submucosal layers of the vagina following elevated temperature of these tissues and that these modifications result in increased structural integrity and function. Such changes are likely responsible for clinical benefit reported. In addition, when an energy titration experiment was performed with ex vivo tissue, there were no adverse tissue effects observed.

CONCLUSION:

The type of RF energy and mode of delivery will have an impact on the tissue affected and the potential clinical benefit. CMRF energy affects the deeper connective tissue in the vaginal canal while protecting the mucosal tissue
Contraceptive Use Among Reproductive Age Women with Cardiomyopathy [1H]
Authors: Krinock Derek , Louis Judette
Published: April 2018

INTRODUCTION:

We sought to evaluate the rates and predictors of contraception in reproductive age women with cardiomyopathy.

METHODS:

A retrospective cohort study of women age 18-45 who were admitted with a known diagnosis of cardiomyopathy at a single urban tertiary care center between 5/2010 and 6/2016 was performed. Clinical charts were reviewed for clinical course, medication use and demographic data. The data was analyzed using chi-square and Mann Whitney U test. P less than 0.05 was considered significant.

RESULTS:

Among the 45 women with cardiomyopathy, 29% had an ejection fraction ≤30% and 80% were taking a medication recognized as potentially teratogenic. These included ACE inhibitors, Coumadin and others. Only 37% of the women were taking birth control. These included tubal ligation (n=11) and long acting reversible contraception (n=2). Women with a hysterectomy (n=4) were considered to have contraception. Women with contraception when compared to women without contraception were more likely to be married (53 vs 14%, p=0.04) and have a higher BMI (33 vs 27 kg/m2, p=0.04) but there was no difference in the utilization of public insurance (82 vs 75%, p=.71). They were more likely to have chronic hypertension (94 vs 50%, p=0.003) but less likely to be taking a medication which was potentially teratogenic (89 vs 64%, p=0.04). Overall, 30% of women taking a potentially teratogenic medication were on birth control.

CONCLUSION:

Among women with cardiomyopathy, contraception is underutilized. A focus in this population is warranted in order to prevent maternal and infant morbidity and mortality.
The Influence of Oral Contraceptive Hormones on Anterior Cruciate Ligament Strength [7H]
Authors: Konopka Jaclyn A. , Hsue Lauren J. , Dragoo Jason L.
Published: April 2018

INTRODUCTION:

Females are up to eight times more likely to injure anterior cruciate ligaments (ACLs) than males, and hormonal differences predispose women to ACL injury. Various hormones—including relaxin and estrogen—impact ACL strength. Oral contraceptives (OCs) alter these hormone levels; however, studies have not yet compared different OCs’ influences on ACL strength.

METHODS:

Untreated and pregnant rats were compared to rats treated with Norethindrone only, Etynodiol Diacetate-plus-Ethinyl Estradiol, or Norgestimate-plus-Ethinyl Estradiol. OC doses adjusted for bioavailabilty and body weight were administered daily via oral gavage for four estrous cycles (20 days). Thirty-two rats were sacrificed; specimens were assessed for maximum load before failure and ultimate stress. Data were analyzed with One-Way ANOVA and post-hoc Bonferroni-Holm calculations.

RESULTS:

Ultimate stress of ACLs from Norethindrone (43.46 ± 3.47 MPa) and Etynodiol Diacetate-plus-Ethinyl Estradiol-treated rats (43.62 ± 9.70 MPa) was significantly increased when compared to untreated rats (28.20 ± 7.28 MPa) (P = .0203 and P = .0298 respectively). Maximum ACL load before failure from Norethindrone-treated rats (39.14 ± 2.75 N) was increased compared to untreated rats (33.10 ± 3.70 N) (P = .0414) and Norgestimate-plus-Ethinyl Estradiol-treated rats (31.27 ± 3.43 N) (P = .0406). Pregnant rats weren’t significantly different from other rats.

CONCLUSION:

OCs influence ACL strength differently depending on formulation. Norethindrone and Etynodiol Diacetate-plus-Ethinyl Estradiol increase ACL strength compared to Norgestimate-plus-Ethinyl Estradiol, pregnant, and untreated conditions. Formulations lacking estrogen or with high progestin:estrogen ratios, like Etynodiol Diacetate-plus-Ethinyl Estradiol, may better protect the ACL than formulations with smaller ratios, like Norgestimate-plus-Ethinyl Estradiol.
Implementation of Evidence-Based Cesarean Section (CS) Technique [10H]
Authors: Kaye Madeline R. , Rieger Mary , Gavrizi Sarah , Harkins John , Keller Whitney , White Amanda
Published: April 2018

INTRODUCTION:

Despite evidence supporting specific CS operative techniques, usage is poor. We aimed to observe the effect of a QI initiative on evidence-based operative techniques uptake and its impact on postoperative pain, operative time and estimated blood loss (EBL).

METHODS:

Literature review identified blunt fascial dissection, lack of bladder flap, passive placental delivery, no peritoneal closure, and sutured skin closure as best practice operative techniques. The QI initiative identifying these practices was disseminated through written communication and large group discussion, including both faculty and trainees. Chart review abstracted demographic data, adherence to evidence-based techniques, operative time, post-operative pain scores at 48 hours, and pre- and post-operative hemoglobin for the 6 months before and after the QI initiative.

RESULTS:

509 cases met inclusion criteria; 256 prior to QI and 203 following. After QI, blunt facial dissection increased (13.4 to 41.6%, p=0.00), bladder flap creation decreased (25.4 to 12.3%, p=0.0002), manual placental extraction decreased (75.6 to 48.2%, p=0.00), peritoneal closure decreased (46.5 to 32.8%, p=0.0016), and subcuticular skin closure increased (77 to 89.7%, p=0.0001) (all controlled for baseline differences between groups). Operative time, postoperative pain measures, and EBL did not change after the QI initiative. Controlling for all other factors, blunt fascial dissection was associated with decreased operative time (p=0.00) and increased post-op pain at 48 hours (p=0.01).

CONCLUSION:

Dissemination of recommendations from a QI initiative resulted in increased uptake of best practice operative techniques, although with varying effects on measured operative outcomes. Our project demonstrates the need for continued efforts in standardization of operative technique.
Utilization of TVUS and fFN Screening, Antenatal Steroids Use and Risk of Preterm Delivery [11H]
Authors: Lauder Jhenette , Shen Xian , Petrilla Allison , Sullivan Erin , Troeger Kathleen , Sciscione Anthony
Published: April 2018

INTRODUCTION:

This study measured use of fetal fibronectin (fFN) testing and transvaginal ultrasound (TVUS) among women with symptomatic preterm labor (PTL) and evaluated use of antenatal steroids and time to infant delivery.

METHODS:

A cohort of pregnant women with symptomatic PTL in 2012-2016 was identified; exclusion criteria included: premature rupture of membranes, pre-eclampsia, viral infection, and no record of delivery. Four patient groups were formed based on receipt of the combination of fFN testing and TVUS: fFN only, TVUS only, fFN and TVUS, neither fFN nor TVUS. Kaplan-Meier analysis and Cox Proportional Hazard model were performed to assess time to delivery following the PTL assessment.

RESULTS:

A total of 94,343 patients were included in the analysis; 6.7% patients received fFN test only, 13.3% received TVUS only, 3.2% received both fFN test and TVUS, and 76.8% received neither test. Antenatal steroids utilization ranged from 1.0% in the group receiving neither test to 7.9% in the group receiving both tests. The average time to delivery was shortest for patients who received neither test (12.1 days), followed by TVUS only (16.3 days), fFN only (31.2 days) and the fFN and TVUS (31.4 days) group. The adjusted risk for infant delivery within 7 days was approximately 50% lower for women who received fFN test and 10% lower for the TVUS only group compared to those who received neither test.

CONCLUSION:

Less than one in five eligible patients triaged for symptomatic PTL received TVUS or fFN. Among those who received fFN testing, a longer interval to birth was observed.
Is Diabetes Knowledge at Initial Prenatal Visit Associated with Maternal and Neonatal Outcomes? [12H]
Authors: Wernimont Sarah A. , Sheng Jessica , Fleener Diedre , Traore Fanta , Syrop Craig , Andrews Janet
Published: April 2018

INTRODUCTION:

Diabetes knowledge is correlated with improved glucose control outside of pregnancy. However, associations between maternal diabetes knowledge and pregnancy outcomes have not been investigated.

METHODS:

This is a prospective cohort study of women with insulin-requiring diabetes enrolled in a team-based diabetes program. Women completed the validated Michigan Diabetes Knowledge Test at their initial visit. 53 women were categorized into high (>75%, N=32), moderate (60-74%, N=13) or low knowledge (< 59%, N=8) groups based on % correct responses. We referred women with low or moderate knowledge to diabetes education courses. The primary outcomes were glycosylated hemoglobin A1c (HbA1c) and a neonatal composite of hypoglycemia, large for gestational age, preterm birth and hyperbilirubinemia requiring phototherapy. All results were analyzed by Fisher exact test or ANOVA as indicated. p<0.05 was considered statistically significant.

RESULTS:

All groups had similar baseline characteristics with high, moderate and low knowledge groups having HbA1c of 8.1%, 7.9% and 7.9%, respectively. All three groups achieved an average HgbA1c of less than 6% at time of delivery. 39 women repeated the knowledge test in the third trimester and 71% improved their scores. Neonatal outcomes were similar among the three groups.

CONCLUSION:

Regardless of initial knowledge, women enrolled in a team-based diabetes program can achieve excellent glucose control in pregnancy. Similar glucose control at delivery in all groups may be associated with targeted referral to diabetes education programs. Overall, this study provides optimism for diabetes care teams that women with low diabetes knowledge can achieve glucose control in pregnancy.
Early-Onset Severe Hypertensive Disease in Pregnancy: Who Is Screened for Antiphospholipid Syndrome? [19H]
Authors: Sobhani Nasim , Shulman Rachel , Washburn Erin , González Juan M.
Published: April 2018

INTRODUCTION:

Although a history of early preterm delivery (PTD) due to severe hypertensive disease of pregnancy is a clinical criterion for diagnosing antiphospholipid syndrome (APS), there is currently no consensus regarding screening for APS in these women. Therefore, our aim was to determine frequency of APS screening in this population and to identify characteristics that affect likelihood of screening.

METHODS:

Retrospective cohort study of iatrogenic deliveries before 34 weeks for preeclampsia with severe features, superimposed preeclampsia with severe features, HELLP syndrome, or eclampsia, at a single institution from 2012 to 2017. Charts were reviewed for APS testing, as well as gestational age (GA) at delivery, fetal complications, and severity of maternal disease. Fisher exact test and chi-squared tests were used for univariate analyses of categorical variables, rank sum for univariate analyses of continuous variables, and multivariate logistic regression for adjusted odds ratios.

RESULTS:

Among 133 cases, 19 (14.3%) received APS screening. Compared to unscreened patients, screened patients were older (32 vs 29 years, P=.04), delivered earlier (28.9 vs 31.7 weeks, P <.001), and had a higher rate of intrauterine fetal demise (15.8% vs 1.8%, P =.021). In multivariate analysis, each additional week GA was associated with a 25% decrease in the odds of screening (aOR 0.75, P <.01).

CONCLUSION:

Among women with severe hypertensive disease requiring PTD, APS screening was more likely in those with earlier PTD or intrauterine fetal demise. These patients have contraceptive, obstetrical, and long-term risks that require deviations from typical patient counseling, which may prompt changes in screening recommendations.
Impact of Texas Breastfeeding Learning Collaborative on Obstetric Related Aspects of 10 Steps [24H]
Authors: Berens Pamela D. , Stagg Julie , Erickson Tracy , Hamilton-Spence Erin , Butts-Dion Sue , Ustianov Jennifer
Published: April 2018

INTRODUCTION:

Our objective is to evaluate the effectiveness of the Texas Breastfeeding Learning Collaborative (TBLC) on performance improvement of maternity care practices supporting breastfeeding most relevant to obstetricians.

METHODS:

Funded by Texas Department of State Health Services and facilitated the National Institute for Children’s Health Quality (NICHQ), TBLC included three 2-day learning sessions, technical support and the use of Plan, Do, Study, Act (PDSA) cycles for learning and performance improvement. Seventy-four Texas hospitals were enrolled in three consecutive cohorts from 2012 to 2017.

RESULTS:

Run chart rules revealed favorable shifts from baseline median and/or trends in all Cohorts for prenatal education, breastfeeding support, feeding on cue, skin-to-skin (vaginal and cesarean delivery (CD)), rooming-in, pacifiers and artificial nipple education and referral to community supports at discharge. Prenatal education, skin-to-skin, and rooming-in emerged as process measures with the most opportunity for additional improvement with median performances ranging 52-72% whereas median performance for remaining process measures ranged 77-92%. All Cohorts maintained high median rates of overall breastfeeding (87%, 86%, 84%) and Cohorts A&B had favorable shifts from baseline median for Exclusive Breastfeeding and Supplementation measures.

CONCLUSION:

The Texas Breastfeeding Learning Collaborative changed maternity practices that impacted process and outcome measures despite regional differences in baseline uptake of practices. Obstetricians can influence steps with greatest opportunity for additional improvement at project completion (prenatal education, skin-to-skin, and rooming-in). We encourage obstetricians continued support of these steps and enlist their assistance with future improvement.
Do Self-Help-Style Activity Sheets Promote Breastfeeding Among Pregnant Mothers? [22H]
Authors: Massa Katherine , Amorado Patricia , Miller Collin , Gavard Jeffrey A. , Shyken Jaye
Published: April 2018

INTRODUCTION:

Studies examining the role of antenatal education in improving breastfeeding rates have produced modest results. We designed a low-cost intervention that could be widely implemented to improve breastfeeding self-efficacy and behavior.

METHODS:

This is a randomized trial using activity sheets to prepare pregnant women for breastfeeding. Subjects completed assessments of their breastfeeding intent and self-efficacy prior to and after an intervention of three activity sheets. Postpartum surveillance assessed breastfeeding 6 weeks postpartum.

RESULTS:

One hundred seventy-six subjects were randomized to the intervention group and 159 to the control group, with follow up to 6 weeks postpartum in 151 and 137 subjects respectively. Initial feeding plans were similar between groups. There was no difference at six weeks postpartum in breastfeeding rates between intervention and control groups (n=60, 39.7% versus n=57, 41.6%, p=0.747). Baseline self-efficacy scores were similar between the intervention group and control group (median 85.0 [IQR 68.0,94.5] versus 84.0 [IQR 74.0.96.0]) and there was no difference in the change in scores between groups. Median self-efficacy scores were higher among breastfeeding subjects at baseline (92.0 [IQR 77.0,98.0]) and prior to delivery (94.0 [IQR 80.0,99.0]) than among subjects not breastfeeding (80.0 [IQR 66.0,81.5] and 82.0 [IQR 74.5,91.5]), p<0.01).

CONCLUSION:

Our intervention did not impact prenatal breastfeeding self-efficacy, feeding plans or duration of breastfeeding. In spite of sub-optimal breastfeeding, self-efficacy scores were high relative to the study in which the scale was validated. However, self-efficacy predicted success in breastfeeding. Improvement of self-efficacy may be a fruitful focus of breastfeeding promotion.
Racial Disparities in Low PAPP-A Levels and Pregnancy Outcomes [29H]
Authors: Shand Muhammed F. , Gimovsky Alexis , Macri Charles
Published: April 2018

INTRODUCTION:

Pregnancy-associated plasma protein A(PAPP-A) is associated with adverse pregnancy outcomes: preterm birth, growth restriction, stillbirth and preeclampsia. The association of low PAPP-A and pregnancy outcomes based on race is unknown. The objective of this study was to determine if low PAPP-A is associated with labor dysfunction in different racial populations.

METHODS:

Retrospective study of pregnant women with PAPP-A ≤5%ile between 7/2013-7/2016. Outcomes of non-Hispanic white (NHW) women were compared to non-Hispanic black (NHB) women. Primary outcome: cesarean delivery (CD) rate. Secondary outcomes: indication for CD, perinatal outcomes. Exclusion: women with fetuses with known or suspected aneuploidy.

RESULTS:

114 women were included; 69 NHW women and 45 NHB women. Demographical differences included maternal age at delivery (35.0 ± 4.1 weeks in the NHW group vs.30.5 ± 5.6 in the NHB group, p<0.001), gravidity (1.9 ± 1.3 in the NHW group vs. 3.1 ± 1.9 in the NHB group, p<0.001), parity (0.5 ± 0.7 in the NHW group vs. 1.1 ± 1.3 in the NHB group, p=0.002), and BMI (28.7 ± 4.9 in the NHW group vs. 34.3 ± 9.1 in the NHB group, p<0.001). There was no difference noted in CD rate (18/69(26.1%) vs. 13/45(28.9%), p=0.6) or fetal indication for CD (5/18(29.6%) vs. 4/13(33.3%), p=0.9). Neonatal morbidity composite score was different between groups (12/69, 17.4% in the NHW group vs. 20/45, 44.4% in the NHB group, p=0.002).

CONCLUSION:

No racial association with delivery mode or indication for cesarean delivery. Increased neonatal morbidity during labor noted among NHB women with low PAPP-A.