bluuebunny/crossref_metadata_2025 huggingface dataset:
A Quality Improvement Project—Standardizing Postpartum Discharge Instructions With an Educational Video [16G]
Authors: O'Dell Danyelle D. , West Sian , Hoffman Jennifer , Burke Lori M.
Published: May 2019

INTRODUCTION:

The WHO estimates that, in the United States, 1,200 women experience perinatal events that prove fatal and 60,000 suffer complications that are near-fatal. Postpartum morbidity and mortality may be decreased by explicit patient education. At our institution, the maternal discharge education process was found to be variable. The objective of this project is to increase patient awareness of warning signs of postpartum complications by using a standardized discharge education video.

METHODS:

A patient survey was designed and administered to evaluate the effectiveness of the maternal discharge education procedures in our institution and the baseline results were reviewed by a team of physicians and nurses. A standardized discharge education video was created using information from ACOG and AWHONN. The video was made accessible on bedside tablet devices. All postpartum nurses were trained on the video content and how to operate the tablets. Survey responses following implementation of the video were compared with the baseline results.

RESULTS:

29 patient surveys were obtained prior to implementing the video. Patients reported that they did not understand “symptoms of losing too much blood” (48.2%) or when vaginal bleeding is “too heavy” (37.9%). Post-video surveys collected to date (n=6) reveals that 100% of patients report understanding the symptoms of “losing too much blood” and when vaginal bleeding is “too heavy.”

CONCLUSION:

The implementation of a standardized postpartum discharge education video has improved patients' knowledge regarding postpartum hemorrhage warning signs at our institution.
Effects of 17-α Hydroxyprogesterone Caproate on Recurrent Preterm Birth at an Inner City Hospital [17G]
Authors: Garcia Luis , Hudley Shakese Melina , Brown Judith
Published: May 2019

INTRODUCTION:

Preterm birth is the major determinant of infant mortality in developed countries. Meis et al showed a substantial reduction in the rate of recurrent preterm when progesterone supplementation is used. However, our patient demographic is different from that studied. Therefore, the objective of our study is to evaluate the effect of 17α-Hydroxyprogesterone Caproate (17OHP-C) on the rate of preterm delivery in our specific patient population.

METHODS:

Institutional Review Board (IRB) committee approval was obtained for this study. Electronic medical records database from January 2015 to November 2017 were retrospectively analyzed. Inclusion criteria were preterm delivery and treatment with 17OHP-C between 16 and 36 weeks gestation. The primary outcome was preterm delivery. The secondary outcome was a neonatal composite score of adverse outcomes.

RESULTS:

Baseline demographics of the experimental group (n= 88) vs the control group (n= 259) were similar. There was no reduction in the rate of delivery before 37 weeks gestation with use of 17OHP-C (37.1 days in the experimental group vs 36.7 days in the control group, P=.466), before 35 weeks gestation (30.7 days in the experimental group vs 31.0 days in the control group, P=.845), and before 32 weeks gestation (26.0 days in the experimental group vs 28.8 in the control group, P=.130). There was no significant reduction in the neonatal composite score in infants born to mothers treated with 17OHP-C (injection group 9% vs control at 15.1%).

CONCLUSION:

17OHP-C did not result in a reduction in the rate of recurrent preterm delivery in our population.
An Induction Failed on a Whim? Or, WHIM Syndrome Resulting in a Failed Induction of Labor? [25G]
Authors: Zammarrelli William A. , Petersen Scott M. , Hickey Kimberly , Walton Robert B.
Published: May 2019

INTRODUCTION:

The physiology of labor, specifically cervical dilation, likely depends on immunomodulation. Warts, Hypogammaglobulinemia, Infections, and Myelokathexis (WHIM) Syndrome, is a rare immunodeficiency syndrome with patients experiencing increased susceptibility to certain cancers, warts, and recurrent bacterial and viral infections secondary to both neutropenia and lymphopenia. Patients with immunodeficiency are more susceptible to both infection and Preterm Premature Rupture of Membranes. We report the first case of a pregnancy affected by WHIM Syndrome.

METHODS:

A 23-year-old woman, gravida 1, with a diagnosis of WHIM Syndrome was treated with filgrastim during the antenatal period with a goal absolute neutrophil count of >500. She underwent a primary low transverse cesarean section at 37 weeks and 2 days gestational age after a failed induction of labor for Oligohydramnios.

CONCLUSION:

A patient with WHIM Syndrome likely benefits from filgrastim treatment in the antenatal period. In addition, a patient with WHIM Syndrome undergoing an induction of labor has not been described in the literature. Understanding labor in this specific population may help to further elucidate the physiology and biochemistry of labor. Patients with WHIM syndrome may have an increased risk of failed induction of labor given a lack of neutrophil function, which is critical during cervical ripening.
An Uncommon Initial Presentation of Crohn’s Disease Complicating a Multi-gestation Pregnancy [26G]
Authors: Carney Alexandra C. , Wilson Karen
Published: May 2019

INTRODUCTION:

Crohn's disease most commonly presents between the ages of 20 and 29. The incidence of a primary presentation of Crohn's disease occurring in pregnancy is about 4%. This inflammatory disease has systemic/extraintestinal manifestations making it highly relevant and potentially dangerous during pregnancy especially in a multifetal gestation. We present a case of an atypical primary presentation of Crohn's disease manifested as a rare complication of the disease in a multifetal gestation.

METHODS:

A 28 year old Gravida 5 Para 3 at 13 weeks gestation with a monochorionic, diamniotic twin gestation presented with lower abdominal pain and vomiting for two days. MRI revealed a dilated jejunum and terminal ileitis. Gastroenterology and General Surgery were consulted. The patient's symptoms improved with conservative management. On hospital day 6, fetal demise of the twin gestation occurred. Pathology of the placenta reported umbilical cord funisitis and focal placental infarct. She was readmitted 10 days later for similar abdominal pain. CT revealed a pelvic abscess. She underwent exploratory laparotomy with ileocecectomy secondary to perforation and fistulizing Crohn's disease.

CONCLUSION:

Initial presentation of inflammatory bowel disease in pregnancy is rare, and the fetal and maternal risks are exceedingly high; therefore, early identification and intervention is critical. Only 0.5% of abdominal abscesses requiring laparotomy are due to Crohn's disease and only between 10% and 30% of Crohn's patients develop an abscess in their lifetime. This case highlights the importance of maintaining a broad differential when managing a patient with abdominal pain in pregnancy, while potentially utilizing a multidisciplinary team approach.
An Unlikely Culprit of Paralysis in Pregnancy [27G]
Authors: Louise Lynes Maria Christine , North Ware Jamie L. , Looney Kimberly Rochelle , Aguinaga Maria del Pilar
Published: May 2019

INTRODUCTION:

Todd paralysis (TP) is a rare postictal condition characterized by weakness following an epileptic seizure. TP includes both motor and non-motor entities including altered cognition, psychiatric symptoms, automatic behavior, and aphasia. The etiology is unknown. The reported duration of TP varies between half-an-hour to 36 hours.

METHODS:

A 33-year-old G6P5005 at 37 weeks with past medical history of epilepsy controlled with Levetiracetam, presented with right-sided weakness and elevated blood pressure following a generalized tonic-clonic seizure. Preeclampsia workup was performed and negative. Secondary to post-ictal paralysis Neurology was consulted with the conditional diagnosis of acute stroke. Motor examination showed paralysis on her right side. Cranial Magnetic Resonance Imaging revealed significant diffusion restriction in the territory of the left Middle Cerebral Artery involving the distal branches and watershed segments. After reviewing the clinical manifestations and neuroimaging findings, the diagnosis was established as TP and antiepileptic therapy was initiated. Routine electroencephalography showed slowed left frontal-parietal activity. Patient's weakness gradually improved with recovery to her premorbid status after 48 hours. The cranial Magnetic Resonance Angiography subsequently showed no significant stenosis or occlusion of the intracranial cerebral arteries.

CONCLUSION:

The nature, duration, and severity of TP are not related to the duration or severity of the seizures nor the presence of lesions or changes on electroencephalogram. Although stroke is the leading differential diagnosis in patients with neurologic deficits; in pregnancy, TP should be included in the differential if convulsive activity is coupled with paralysis. A misdiagnosis of stroke can lead to unnecessary and potential harmful interventions.
Anterior Placentation Without Previa in Patients With Prior Cesarean Section: What Is the Risk of Accreta? [29G]
Authors: Leovic Michael Phillip , Perlow Jordan Hugh
Published: May 2019

INTRODUCTION:

In the absence of placenta previa, the risk of accreta is well documented (0: 0.03%, 1: 0.2%, 2: 0.1%, 3-4: 0.8%, >5: 4.7%) in the work of Silver et al. These frequently referenced risk metrics were derived from a cohort of patients delivered from 1999-2002 with a documented prevalence of accreta occurring in 1 in 2,625 deliveries. With the prevalence of accreta now approaching 1 in 533 deliveries, reevaluation of this risk is warranted.

METHODS:

A review of accreta cases presenting to a single, large, tertiary care center from 12/15/2011 to 08/22/2017 was performed. Records were reviewed and abstraction of data pertaining to demographics, obstetric history, placental location, delivery information, and tissue pathology was performed. For historical comparison, data from Silver et al was configured to reflect the risk of accreta in the absence of previa, stratified by number of prior cesareans. Data was summarized using SAS software, version 9.4.

RESULTS:

Of 169 AIP cases identified, there were 16 (9.5%) patients with prior cesarean delivery, anterior placentation, and no previa that had histologically-confirmed AIP. The risk of AIP after 1, 2, 3-4 and >5 prior cesarean deliveries was 50%, 75%, 77.8%, and 50%, respectively. No differences were observed comparing this risk to that of Silver et al (53.1%, 19.4%, 35.1%, 66.7%; p - 0.470).

CONCLUSION:

Our data suggests that absence of placenta previa should not be heavily relied upon for risk reduction when antenatal suspicion for AIP is raised based on other clinical variables.
Exploring Sociodemographic and Geospatial Variation in Human Papillomavirus Vaccination Uptake in Virginia [37G]
Authors: Staples Jeanine N. , Nelamangala Samhita , Morris Sean , Wells Kristen
Published: May 2019

INTRODUCTION:

Despite strong CDC recommendations and a state school requirement, nearly half of all adolescents in Virginia have not completed the HPV vaccine series. Using ArcGIS software, we aimed to explore the relationship between provider density, socioeconomic status, and HPV vaccination uptake in the state of Virginia.

METHODS:

HPV vaccination rates among adolescents 11 to 17 years were retrieved at the zip-code level from the Virginia Immunization Information System. Choropleth maps of vaccination rates were produced. The ArcGIS Hot Spot Analysis tool identified spatial clusters of zip codes with high and low vaccination rates. Student t-test was used to compare provider density and various socioeconomic indicators between statistically significant clusters of higher (RR>1.0) or lower (RR<1.0) than expected vaccination rates.

RESULTS:

High series completion rates were noted in central Virginia and the eastern shore. Regions of northern Virginia, including Shenandoah and Page counties, had lower than expected initiation and completion rates. Clusters with significantly lower initiation rates had a lower number of primary care providers, were less educated, and had a lower median household income (MHI). Regions with significantly lower series completion rates had a higher MHI. While regions with lower rates of series completion for males had a higher concentration of providers and were more educated, there was no difference among these factors for female series completion.

CONCLUSION:

Regional socioeconomic indicators are significant predictors of HPV vaccination, but may have contrasting implications for series initiation and completion. These findings emphasize the utility of spatial analysis and GIS methodology for identifying cancer prevention disparities.
Deficiencies in Reproductive Health Counseling in Liver Transplant Patients [2H]
Authors: Ritchie Julia , Seidman Dominika , Srisengfa Yanin , Jacoby Vanessa L. , Perito Emily , Sarkar Monika
Published: May 2019

INTRODUCTION:

Over 30% of female liver transplant patients are reproductive age. Fertility is quickly restored following transplant and unplanned pregnancy is common. Data on reproductive counseling in transplant patients are lacking.

METHODS:

Women ages 14-45 years who were listed, or with previous liver transplant (n=147) at an academic medical center were invited to complete an online survey in 2018. Questions explored contraception/pregnancy counseling, patient counseling preferences, and contraception use after transplant.

RESULTS:

Fifty (34%) women completed the survey, including 11 pre- and 39 post-transplant patients. Median age was 33 years; 76% were white, 20% Hispanic. Most (79%) reported reproductive counseling as “very important” to their post-transplant care, although 71% reported insufficient counseling received. Among pre-transplant women (n=11), 4 reported never discussing future pregnancy, 2 were advised never to conceive, and 3 were informed that pregnancy after transplant was impossible. During pre-transplant years only 14/38 (36%) received any counseling, of whom only 56% described counseling received as sufficient. While counseling after transplant was more common (74%), only 47% (18/38) of women reported contraception use in the first year post-transplant, including 22% using high failure methods including condoms, withdrawal, or rhythm. Women's reported preferences for counseling included discussion with transplant providers (92%), referral to women's health (67%), and handouts (31%).

CONCLUSION:

Reproductive counseling is inconsistent in liver transplant patients, despite patient interest, and the majority used no contraception. Given maternal and fetal risks of unplanned pregnancies, systems-based interventions that optimize women's preferred means of counseling should be implemented in this medically complex population.
Effect of Group Prenatal Care on Contraceptive Use at Twelve Weeks Postpartum [5H]
Authors: Olatunde Aishat , Paoletti Andrew , Hosein Safiyah , Pitcairn-Ramirez Alexis , Gurney Elizabeth Price
Published: May 2019

INTRODUCTION:

We compared the prevalence of contraceptive use by 12 weeks postpartum among women who participated in group prenatal care (GPC) vs. traditional prenatal care (TPC) and investigated differences in contraceptive method choice by type of prenatal care.

METHODS:

We performed a retrospective review of patients who received GPC or TPC and followed up within 12 weeks of delivery, between January 1 and December 31, 2017, at our institution, after receiving IRB approval. Postpartum contraceptive methods were analyzed by effectiveness (Tier 1, long-acting reversible contraception and sterilization; Tier 2, hormonal methods; Tier 3, barrier and fertility awareness methods, withdrawal, spermicide; and no method) using Chi-square and multivariate logistic regression.

RESULTS:

122 participants in GPC and 121 in TPC were included. The prevalence of any contraceptive use by 12 weeks postpartum was 70.5% and 68.6% for GPC and TPC, respectively (P=.75). After controlling for demographic and clinical factors, there was no difference in Tier 1 versus other contraceptive use (aOR 0.92, 95% CI 0.81-1.07, P=.31). Participants in GPC were significantly more likely to select Tier 2 contraceptive methods (aOR 1.19, 95% CI 1.03-1.36, P=.02), and attendance at each additional GPC visit increased the odds of selecting a Tier 2 method (aOR 1.02, 95% CI 1.00-1.04, P=.03).

CONCLUSION:

There was no difference in the prevalence of contraceptive use at 12 weeks postpartum among women who received group compared to traditional prenatal care in this study. Participation in GPC was associated with increased use of Tier 2 contraceptive methods in a dose-dependent fashion, regardless of sociodemographics.
Examining Female Patients With Sickle Cell Disease Attitudes and Beliefs About Contraceptives [9H]
Authors: Kendra Piper , El Rassi Fuad , McLemore Morgan , Kottke Melissa Jo.
Published: May 2019

INTRODUCTION:

Sickle cell disease (SCD) is an inherited hematological disorder. The U.S. Medial Eligibility Criteria for Contraceptive Use (MEC) highlights SCD as a condition that is associated with increased risk of adverse events during pregnancy. The MEC advises that the benefits of using hormonal contraceptives usually outweigh the risks for women with SCD and does not discourage the use of any specific contraceptives. However, use of highly effective contraceptives is low in this population.

METHODS:

African American females 18 and older with SCD were recruited from a sickle cell clinic in Atlanta, Georgia. We conducted semi-structured interviews to explore participants' beliefs and attitudes towards contraceptives. IRB approval was obtained.

RESULTS:

Seventeen women were interviewed. The women endorsed conflicting views of contraceptives. Positive perceptions about contraceptives included pregnancy prevention, relief of heavy menstrual bleeding and fewer sickle cell pain crises. Conversely, negative perceptions towards hormonal contraceptives included concerns about side effects and apprehension about using hormonal contraceptives while having SCD.

CONCLUSION:

Women with SCD have both positive perceptions about contraceptives as well as concerns about using them. Awareness and acknowledgement of this tension may help clinicians provide effective and supportive contraceptive counseling for people with SCD. Using a shared decision-making model and discussing an individual's concerns as well as the potential benefits for that person may result in increased uptake and improved contraceptive utilization.
OR Team Member Perceptions Regarding Medical Students Performing Pelvic Examinations on Anesthetized Female Patients [11H]
Authors: Rice Elizabeth , White Chase , Ko Janet , Myers John , Jaspan David , Goldberg Jay
Published: May 2019

INTRODUCTION:

The purpose of this study was to determine perceptions regarding medical students performing pelvic examinations on anesthetized female patients.

METHODS:

An internet based survey was distributed to OB/GYNs, OR nurses/techs, anesthesiologists/CRNAs, and medical students at multiple hospitals. Demographic data were collected. Non-demographic answers were recorded on a 5-point scale. Characteristics between groups were statistically compared using Chi-squared test for independence and the Fisher's Exact Test.

RESULTS:

337 OR staff/students completed the questionnaire. 72% believed permission should be obtained from patients prior to EUAs by medical students. 30% of respondents believed prior consent was usually obtained. 50% believed patients would agree to have EUAs performed. 80% of respondents believed patients would be upset if made aware an EUA by a medical student had been performed without their prior consent. Medical students were less likely to believe performing EUAs had educational benefit. 57% would recommend to female relatives to allow a medical student to perform an EUA on them. Medical students were less likely to believe it was appropriate for a student to perform EUA, less likely to believe there was educational benefit, less likely to believe patients would consent, and more likely to believe patients would be upset if they learned an unconsented exam had occurred.

CONCLUSION:

Despite the perception OB/GYN OR team members on consenting prior to medical students performing pelvic examinations on anesthetized female patients, this does not usually occur. Almost 50% of medical students would not encourage their female relatives to consent to medical students performing such EUAs.
Laparoscopy in the Chronic Pelvic Pain Patient: Incidence and Outcomes of Subsequent Laparoscopies [20H]
Authors: Shukr Ghadear , Katiyar Urvashi , Cheng Monique , Eisenstein David
Published: May 2019

INTRODUCTION:

Our aim is to determine the incidence of multiple laparoscopies for chronic pelvic pain over 10 years and to compare outcomes between patients who underwent single vs multiple laparoscopies.

METHODS:

An IRB approved retrospective case-control study of women at a tertiary medical center with a diagnosis of chronic pelvic pain that underwent one laparoscopy in comparison with those who underwent multiple laparoscopies in a 10-year period. Parametric, nonparametric and descriptive statistics were employed.

RESULTS:

678 controls with single laparoscopy and 114 cases with multiple laparoscopies were identified. 400 (59%) had medical management prior to initial laparoscopy in the control group and 82 (72%) in the cases. 559 had diagnostic and 119 had extirpative laparoscopies in the single laparoscopy group vs 91 diagnostic and 23 extirpative laparoscopies in the multiple laparoscopy group. Of the patients with persistent pain after initial laparoscopy, 56 underwent hysterectomy with 22 having pain resolution, 5 persistent, 4 improved and 15 unknown. The average number of subsequent laparoscopies in the multiple laparoscopy group was 2.27. 38 patients underwent hysterectomy with 18 having pain resolution, 4 persistent, 6 improved and 12 unknown. 25 patients were identified as having pathologic evidence of endometriosis in the single laparoscopy group vs 32 in the multiple laparoscopy group.

CONCLUSION:

This study reviews the outcomes of chronic pelvic pain in relation to laparoscopic management. It suggests that majority of patients undergo nonsurgical management prior to initial laparoscopy and that patients in the multiple laparoscopy group have a greater likelihood of undergoing subsequent hysterectomy with pain resolution.
Does Adjunctive Azithromycin Cesarean Bundle Decrease the Risk of Maternal and Neonatal Outcomes? [24H]
Authors: Johnson Christina , Dagum Camilla , Persad Malini D. , Herrera Kimberly M. , Buckley Ayisha , Garretto Diana J.
Published: May 2019

INTRODUCTION:

The goal of preoperative antibiotics is to decrease and prevent postpartum infections. Recent evidence indicates that adding azithromycin (AZI) to Cefazolin as extended antibiotic coverage can decrease the risk of infectious co-morbidities for non-elective Cesarean Deliveries (nCD). November 2017 we started using AZI + cefazolin in nCD. The goal was to determine the institutional compliance to AZI administration.

METHODS:

An IRB approved retrospective cohort study over 4 months of patients undergoing nCD. ST (1st generation cephalosporin or, clindamycin and gentamycin for cephalosporin allergy). Patients in 2 groups: preEMR bundle (ST) and postEMR bundles (ST + AZI). Maternal and neonatal outcomes collected for 2 months preEMR bundle and 2 months postEMR bundles. Exclusion criteria: women undergoing elective CD, did not receive pre-operative antibiotics, AZI allergy. The primary outcome was overall compliance with AZI administration with the new EMR bundle. The composite outcome-maternal wound infection, endomyometritis, maternal morbidity, neonatal morbidity. Statistical analyses were performed with p value <0.05 significant.

RESULTS:

There were 100 patients meeting inclusion criteria in study time period. There were no differences in baseline demographics between groups. Only 56% of patients in the post EMR group received AZI in addition to ST. There were no significant differences in the composite outcome between groups.

CONCLUSION:

Adjunctive AZI at time of nCD does not appear to decrease the risk of maternal and neonatal outcomes; but it was only administered correctly in 56% of the eligible cases. The effect of AZI on outcomes may be improved with better adherence to the EMR bundle.
Barriers to Vaginal Progesterone in the Treatment of Incidental Short Cervix [27H]
Authors: Sutherland Monique B. , Garvey Sarah , Enakpene Christopher A. , DiGiovanni Laura M. , Della Torre Micaela
Published: May 2019

INTRODUCTION:

Barriers in obtaining vaginal progesterone (VP) may adversely affect perinatal outcomes in women with short cervix. Aim of this study is to evaluate if delay in obtaining VP was associated with increased rate of sPTB.

METHODS:

Retrospective cohort study of singleton pregnancy with incidental short cervix (ISC) ≤20mm, prescribed VP and delivered at University of Illinois at Chicago, between June 2016 and June 2018. Rates of sPTB <37 weeks in women with delay in treatment were compared to women without delay. IRB approval was obtained.

RESULTS:

A total of 74 women with ISC were prescribed VP: 69(93%) received insurance approval. Of those 69, 8 (12%) received initial claim rejection, but subsequently received approval only for oral Prometrium to use vaginally. 15/74 (22%) women did not receive VP due to barriers or other causes. 29/47 (62%) who received VP timely, delivered preterm. 12 (20%) women encountered an insurance delay in obtaining VP ≥14 days, and 4 of those experienced sPTB. There was no significant difference in sPTD rate in women who began VP <14 days versus those ≥14 days, p=0.07. Those who experienced a delay compared to those with no VP at all, still had lower rate of sPTB 4/12 (33%) versus 11/15 (73%), respectively (p=0.038).

CONCLUSION:

Despite barriers, 93% of patients had access to VP treatment. Delay ≥14 days did not impact the rate of PTBs <37 weeks. Patients who received VP, despite delay, had a lower rate of PTBs than those who did not receive it at all.
Birth Plans: The Good, the Bad and the Ugly [29H]
Authors: Urbina Josephine P. , Christie Alexandra C. , Fumia Fred
Published: May 2019

INTRODUCTION:

Birth plans became popular in the 1980s as a way to help patients identify what is important to them, to communicate their childbirth goals with their providers and ensure involvement in delivery decision making, which is an important component of childbirth satisfaction. For the provider, birth plans serve as an opportunity to inform patients about common obstetrical experiences which may occur during hospitalization. Despite the good intentions of having birth plans in place, there has been negative connotation associated with them. The purpose of this study was to examine current templates for birth plans available to women online and evaluate them for content based on various obstetrical subjects.

METHODS:

We examined the first fifty websites that appear under “birth plan” using a Google search. We analyzed birth plans for source, design and content.

RESULTS:

Fifty websites were examined and 27 birth plans met inclusion criteria. The content was grouped into 44 related topics. Twenty-five (93%) of the birth plans covered pain relief, fetal monitoring, cord clamping, breastfeeding and skin-to-skin contact. Nineteen (70%) of birth plans did not address discussion with providers. Seven (26%) had an area where discussion with a nurse or doctor could be documented.

CONCLUSION:

Documentation of communication between the patient and the provider was missing in the majority. There was no mechanism to provide feedback or discussion with the patient. Some of the birth plans advocated for practices that were not evidence-based. Ultimately, some gave unrealistic expectations to patients regarding the birth process.
Buprenorphine/Naloxone vs. Buprenorphine for Medication Assisted Therapy of Opioid Use Disorder in Pregnancy [32H]
Authors: Johnson Quinetta , O’Brien John M. , Hawk Greg , Qi Ya , Critchfield Agatha
Published: May 2019

INTRODUCTION:

Historically methadone or buprenorphine mono-therapy have been the mainstays for opioid agonist pharmacotherapy. Less is known, however, regarding the use of buprenorphine/naloxone combination therapy in pregnancy as compared to buprenorphine mono-therapy.

METHODS:

The Perinatal Assistance and Treatment Home (PATHways) program is a multispecialty comprehensive substance abuse program for pregnant and early parenting women with Opioid Use Disorder (OUD). A retrospective case-control study for all women in the program from 2015-2018 was performed with cases selected as patients who were maintained on buprenorphine/naloxone compared to a control group treated with buprenorphine alone. Other PATHways enrollees treated with methadone or those not placed on maintenance treatment were excluded. Multivariable logistic regression adjusting for maternal age, gestational age at delivery, delivery mode, breastfeeding, and smoking was performed. All statistical analyses were performed using SAS 9.4. The Institutional Review Board at the University of Kentucky approved this study.

RESULTS:

Demographic characteristics were similar between groups, however those who were on buprenorphine/naloxone were more likely to be smokers. Birth outcomes, including gestational age at delivery, birthweight and Apgar's were similar between groups. The neonates exposed to combination therapy did not have a significant increase in neonatal opioid withdrawal syndrome, 45.7% versus 37.8% (P=.14); however, those treated with buprenorphine/naloxone had a decreased rate of NICU admission (39.1% versus 48.8%, P=.047). Among neonates admitted to the NICU, there was no difference in length of stay between the two groups.

CONCLUSION:

Neonatal outcomes appear favorable for women treated with buprenorphine/naloxone for OUD in pregnancy and this treatment strategy deserves additional study.
Case Report: Rare Hemoglobin Variant Causes Elevated A1c, False Diagnosis of Pre-gestational Diabetes in Pregnancy [33H]
Authors: Olp Robert J. , Carty Jenava , Schmiedecke Stacey Stevens , Pates Jason A.
Published: May 2019

INTRODUCTION:

Hemoglobin variants result from missense mutations that lead to substitution of amino acids within globin proteins, altering the structure of the hemoglobin molecule. Hemoglobin A1c (HbA1c) is commonly used to diagnosis and assess control of diabetes mellitus and can be falsely affected by hemoglobinopathies, hyperbilirubinemia, and hypertriglyceridemia.

METHODS:

We present a case of an obese Caucasian 27 year-old Gravid 3 Para 0020 with early HbA1c of 10.0 percent at 9-weeks gestation. The patient was diagnosed with pre-gestational diabetes, and referred for nutrition counseling with initiation of four times daily home blood sugar monitoring notable for consistently normal fasting and postprandial values. Due to continued discordant results in HbA1c level with her glucometer log and random glucose testing, hemoglobin electrophoresis was performed at 22-weeks gestation with findings suggestive of Hemoglobin Wayne, a rare hemoglobin variant that is clinically silent. Hemoglobin Wayne results from a frameshift mutation within the alpha chain resulting in a net charge that is similar to HbA1c. This common charge manifests as similar retention times on cation-exchange high-performance liquid chromatography, leading to an overestimation of HbA1c concentration. Genetic sequencing was pursued and the patient completed appropriately timed routine screening for gestational diabetes with normal results.

CONCLUSION:

Our case, the first reported in a pregnant patient, should remind clinicians of the few conditions that can lead to misrepresentation of HbA1c levels. Remaining vigilant in clarifying such an atypical patient presentation will decrease the risk of mismanaging, particularly over-treating, patients believed to be high-risk for diabetes.
Cerclage Suture Type and Association With Gestational Age at Delivery [34H]
Authors: Love Heather R. , Afuape Nicole O. , Plevyak Michael , Rastegar Vida , Schoen Corina N.
Published: May 2019

INTRODUCTION:

Cervical incompetence is associated with preterm delivery and poor obstetric outcomes. Placement of cervical cerclage may mitigate these risks but standard of care choice of suture material is not well established in the literature.

METHODS:

This retrospective cohort study at a single tertiary care center between 2001-2016 evaluated singleton pregnancies with cerclage placement. Women included had placement prior to 24 weeks, met appropriate indication for cerclage placement and delivered at our institution. Patients were excluded if pregnancy terminated or induced preterm for medical indication. Patients were grouped by cerclage indication and suture type (thick-braided suture, monofilament or tape). Primary outcome was gestational age at delivery time analyzed by type of suture material and cerclage indication. Secondary outcomes include vaginal delivery, 5 minute Apgar <7, birthweight, chorioamnionitis, preterm rupture of membranes and adverse neonatal outcomes.

RESULTS:

218 singleton pregnancies underwent transvaginal cerclage placement prior to 24 weeks. 117 were history-indicated, 64 were ultrasound-indicated. 37 received physical-exam indicated cerclage. There were no demographic differences between suture types used. No tape suture was used for physical exam indicated cerclage. There was no difference in gestational age at delivery for any suture types regardless of indication of cerclage. There were no differences in the secondary outcomes reported.

CONCLUSION:

Gestational age at delivery does not appear to be associated with choice of thick braided suture or monofilament at time of cerclage. Due to small number of tape used, limited conclusions can be drawn for that suture. Suture type may be left to surgeon discretion during cerclage placement.
Does Resident Bullying Affect Patient Care? [1I]
Authors: Nhundu Belinda Juliana , Kim Soorin , Desai Vrunda Bhavsar
Published: May 2019

INTRODUCTION:

Workplace bullying has been demonstrated to affect mental health especially in high stress environments. Workplace bullying in healthcare has implications on physician mental health and patient care. Resident physicians are especially vulnerable, given the hierarchy of medicine. Our objective is to characterize the extent of bullying experienced by resident in Obstetrics and Gynecology and implications on patient care.

METHODS:

The Negative Acts Questionnaire-Revised (NAQ-R), a previously validated tool to assess was distributed to program coordinators at 13 residency programs in the American College of Obstetricians and Gynecologist (ACOG) District 1.

RESULTS:

Twenty-three percent of District one residents completed the survey. Most respondents were women (79.7%), interns (31.9%) and came from large residency programs (56.5%). Sixty-one percent of residents report having their clinical opinions ignored daily (7.1%), weekly (19%) and monthly (26.2%). Fourteen percent of residents cited having clinically valuable information withheld on a weekly (10%) basis. When asked if residents ever felt pressure to not report a near miss incident or critical patient error, 13% said yes. The most common sources of bullying came from attending physicians within the department (31.7%) co-residents (22.5%) and nursing staff (16.1%). Sixteen percent of patients reported considering quitting residency due to workplace bullying.

CONCLUSION:

Residents in Obstetrics and Gynecology commonly experience workplace bullying. Workplace bullying has detrimental effects to patient care due to withheld information and unreported near misses. Addressing the sources of bullying can improve patient care and reduce burnout of residents.
Pregnancy of Unknown Location in a Cohort of Patients Treated With Methotrexate [17I]
Authors: Shukr Ghadear , Zwain Omar , Kulkarni Sanjana , Eisenstein David
Published: May 2019

INTRODUCTION:

To determine the prevalence of pregnancy of unknown location (PUL) in patients treated with Methotrexate (MTX) for nonsurgical diagnosis of ectopic pregnancy (EP). To determine the beta-hCG treatment outcomes.

METHODS:

IRB approved retrospective cohort study of patients who received MTX for treatment of EP over a 10-year period in an urban-based healthcare system. Wilcox test was used for statistical analysis.

RESULTS:

A total of 150 pregnancies were identified as treated with MTX over a 10-year period. Pregnancies were classified based on reviews of ultrasound as pregnancy of unknown location (PUL), ectopic pregnancy (EP), or Intrauterine pregnancy (IUP). 47 were classified as PUL, 101 EP, 2 IUP. Approximately 1/3 of patients treated with MTX were PULs. The average baseline beta-hCG was 2960 MIU/ML and the average B-hCG at treatment was 4188 MIU/ML for the entire cohort. Resolution of beta-hCG levels with one dose of MTX differed between pregnancy types with PULs prescribed MTX at a lower B-hCG level on day of treatment (56% vs 27% at beta-hCG of less than 1000 MIU/ML) compared to EP. Additionally, 61% of the entire cohort were treated with 2 data points or less. 38% of PUL were treated with 1 to 2 beta-hCG values and 82% PUL were treated at beta-hCG <2000 MIU/ML. Of the two IUPs, beta-hCG level at treatment was 6267 MIU/ML and 13353 MIU/ML.

CONCLUSION:

There may be an underappreciated risk of inadvertent administration of Methotrexate to patients with early IUP. A minimum of three beta-hCG assays over seven days in the diagnostic algorithm for EP would decrease treatment of PUL.
Differences in Length of Hospital Stay and Cost Associated With Hysterectomy Having a Uterus Greater Than 250 Grams [19I]
Authors: Brown Kelsei , Elsamadicy Emad A. , Le Chi , Lee Jaclyn , Mehta Sumit
Published: May 2019

INTRODUCTION:

We sought to assess whether there is a difference in healthcare utilization costs associated with total laparoscopic hysterectomy (TLH) compared to total vaginal hysterectomy (TVH) with uterus size greater than 250 grams.

METHODS:

The medical records of 227 adult (18 years old) women undergoing an elective hysterectomy at a major academic medical center from 2010 to 2015 were reviewed. CPT codes used for removal of uterine size > 250 grams with TLH approach were [58572-58573] and for TVH approach [58290-58294]. Patient demographics, length of hospital stay (LOS) and total hospital cost were collected.

RESULTS:

Of the 227 patients, 119 (75.3%) patients underwent TLH and 39 (24.7%) underwent TVH with uterus > 250g (TLH: n=119 vs. TVH: n=39). There was a significant difference in Age, with the TVH cohort being older (TLH: 44.9±7.5 years vs. TVH: 50.4±7.5, P=.0002). The majority of patients were White for both cohorts (TLH: 63.0% vs. TVH: 59.0%, P=.651). There were no significant differences in insurance status between the cohorts, including Medicaid (P=0.889), Commercial/Private (P=.779), BlueCross/BlueShield (P=.717), and Medicare (P=.860). LOS was significantly different, with the TVH cohort having a longer LOS (TLH: 1.2±0.8 days vs. TVH: 1.6±0.7 days, P=.0096). However, the TLH cohort had a significantly greater mean hospital cost than the TVH cohort (TLH: $41,473.3±15,331.1 vs. TVH: $35,050.9±16,084.4, P=.0324).

CONCLUSION:

Our study suggests that there are significant differences in LOS and healthcare costs associated with hysterectomy approach with uterus greater than 250 grams. Further studies are necessary to better patient care and reduce overall healthcare costs.
Don't Forget the Clitoris: Two Cases of Anorgasmia Due to Clitoral Dysgenesis [21I]
Authors: Humes Jamie Christine , Hole Steven R. , Rodriguez Patricia J. , Keyser Erin A. , Baker Tieneka Mary
Published: May 2019

INTRODUCTION:

Existing reports of clitoral dysgenesis are sparse. The few cases reported in the literature are associated with genetic syndromes or midline defects. Women with sexual dysfunction often present to their OB/GYN provider for evaluation. Historically treatment has centered around adjusting medications that can have a negative effect on sexual function, adding medications to enhance sexual function, and assistance with behavioral health or sex therapy. Structural abnormalities or dysgenesis of the clitoris have not previously been described as a causal factor of sexual dysfunction or anorgasmia.

METHODS:

Two patients, both in their mid-twenties, presented within six months of each other to a single facility with primary anorgasmia and lack of sexual arousal. Initial pelvic exams revealed normal appearing female genitalia. Upon subsequent workup, a more detailed exam of each patient confirmed a well-formed clitoral hood but concern for lack of clitoral gland with no sensory response. Magnetic resonance imaging (MRI) was performed which showed diminutive clitoral crura and bodies which did not converge into a glans.

CONCLUSION:

This report represents two occurrences of isolated clitoral dysgenesis and highlights a cause of primary orgasmic disorder not previously described. It is important that providers keep this diagnosis on the differential for female sexual dysfunction. An MRI should be considered during evaluation for anorgasmia to evaluate the clitoris especially if no sensory response following direct palpation of the clitoral hood.
Electromyographic Response of the Pelvic Floor Muscles in Female Sex Workers [23I]
Authors: Amorim Melania , Mariz Raiana , Macedo Lorena , França Neto Antonio Henriques , Vasconcelos Danilo , Katz Leila
Published: May 2019

INTRODUCTION:

Sex workers are exposed to situations of vulnerability and may have intercourse many times a day. This intense, constant sexual activity may result in changes to the vagina, overburdening the perineum and other pelvic muscles. Various studies have evaluated PF muscle function in different groups of women.

METHODS:

A cross-sectional, observational study was conducted with 30 female sex workers aged 18-56 years. The study was approved by local IRB. All the women underwent electromyographic evaluation.

RESULTS:

A negative correlation was found between electromyographic activity of the pelvic floor muscles and age (r = -0.369; p=0.045), weight (r = -0.401; p=0.028), body mass index (r = -0.412; p=0.024) and number of pregnancies (r = -0.399; p=0.029). Electromyographic activity of the external pelvic floor muscles was greater in the women who worked longer hours compared to those working fewer hours/day (p<0.001). No statistically significant difference was found in relation to skin color, time working in the profession or number of partners per day.

CONCLUSION:

No correlation was found between the frequency and intensity of sexual activity and electromyographic activity of the pelvic floor muscles in this group of female sex workers; however, electromyographic activity of the external pelvic floor muscles was greater in the women who worked longer hours.
Clinically Significant Fetomaternal Hemorrhage: Incidence and Recurrence Rate [26I]
Authors: Boller Marie J. , Hung Yun-Yi , Varghese Reshma , Weintraub Miranda Ritterman , Moore Gaea S. , Schauer Galen M.
Published: May 2019

INTRODUCTION:

Clinically significant fetomaternal hemorrhage (CS-FMH) occurs in 1/1000-1/5000 pregnancies and has an unknown risk of recurrence. We sought to establish recurrence rate by analyzing reproductive histories of patients with CS-FMH confirmed by flow cytometry in a large integrated health care system over a 10-year period (375,864 total births).

METHODS:

We conducted an IRB-approved retrospective case series of patients with a positive flow result (>0.1% fetal red cells in maternal circulation) from January 2008 through May 2018 within Kaiser Permanente Northern California (KPNC). For cases of CS-FMH we collected indication for testing, adverse outcomes, reproductive history and demographics.

RESULTS:

Of over 19,000 patients tested, 1105 had a positive flow result. Of these, 7.4% had a result > 1.0%, with 85.4% of these identified as CS-FMH. Of CS-FMH cases, 28.6% had a fetal demise, 71.4% had a symptomatic neonate, and 4.3% had a neonatal demise. 58.6% presented with decreased fetal movement. Excluding cases of fetal demise, 90.0% had an abnormal fetal heart rate tracing (14.0% sinusoidal). Autopsy supported CS-FMH in all but one case of demise. There were no predictive demographic characteristics for CS-FMH. There were no cases of recurrent CS-FMH. Collectively, affected patients had 126 additional pregnancies with 75 liveborns. At term, a flow result ≥4.0% had a positive predictive value (PPV) of 100% for CS-FMH. For preterm deliveries, a result ≥ 1.0% had a PPV of 100%.

CONCLUSION:

The incidence of CS-FMH in our diverse KPNC population is 0.19/1000. We did not find an increased risk of recurrence in future pregnancies.
Congenital Syphilis Rates Correlate With Increased Maternal Syphilis Rates in a New Orleans Tertiary Care Center [30I]
Authors: Berra Alexandra , Roitsch Charles , Fontenot Virginia E. , Kopkin Rachel , Rodrigue Eliza Langford , Stafford Irene A.
Published: May 2019

INTRODUCTION:

In recent years, the number of congenital syphilis (CS) cases in the United States increased from 8.4 to 11.6 cases per 100,000 live births. In 2017, Louisiana reported the highest rates of CS in the country. This study aims to determine provider management patterns for newborns at risk for CS.

METHODS:

All cases of maternal syphilis from 2013-2017 at Touro Infirmary in New Orleans, LA were identified using ICD-9 and ICD-10 codes. Women who were serofast were excluded. Seventy-three mother child pairs were identified with available records. Charts were reviewed for stage of syphilis, treatment regimen during pregnancy, interval from treatment to delivery and other variables. Newborn information including neonatal intensive care unit (NICU) admission, physical and radiologic exam findings, nontreponemal titers, treatment regimen and other outcomes were recorded. Variables were summarized using means with standard deviations and frequencies expressed as percentages.

RESULTS:

Of the 73 newborn charts reviewed, 8.96% (n=6) were found to be symptomatic, however only 83.3% of them were admitted to the NICU. Only 29.6% of infants were adequately treated with an extended penicillin regimen if the mother did not receive appropriate treatment. Furthermore, only 63.0% of newborns had a nontreponemal titer performed. Only twenty six percent (n=16) of asymptomatic newborns (n=61) considered low risk for CS received single dose penicillin.

CONCLUSION:

With the rising rates of both maternal and CS, strict adherence to the CDC guidelines for treatment of CS must be maintained. Attention to maternal treatment guidelines and vigilant follow up are necessary to ensure treatment success.