bluuebunny/crossref_metadata_2025 huggingface dataset:
Bioidentical, Synthetic, and Animal Based Hormone Replacement Therapies and Risk of Breast Cancer [1M]
Authors: Abenhaim Haim Arie , Czuzoj-Shulman Nicholas , Spence Andrea R. , Azoulay Laurent , Suissa Samy , Tulandi Togas
Published: May 2017

INTRODUCTION:

Hormone Replacement Therapy (HRT) has been associated with an increased risk of breast cancer. Our study objective was to evaluate whether the increased risk is dependent on the formulation used.

METHODS:

We carried out a population-based case-control study using data from the United Kingdom Clinical Practice Research Datalink on women aged >50. Newly diagnosed breast cancer cases were age-matched with women of comparable follow-up time with no history of breast cancer at a 1:10 ratio. Exposures were classified as ever/never for the HRT formulations: Bioidentical Estrogens (BE), Conjugated Equine Estrogens (CEE), Micronized Progesterone (MP), and Synthetic Progestogens (SP). Logistic regression estimated adjusted effects of HRT formulation on breast cancer.

RESULTS:

Between 1995-2014, 43,183 cases of breast cancer were identified and matched to 431,830 controls. Compared with women who had never used HRT, HRT use was associated with an overall increased risk of breast cancer OR 1.12 (1.09-1.15), p < 0.0001. Compared to never users, estrogens were not associated with breast cancer: BE (OR 1.04 (1.00-1.09), p=0.07), CEE (OR 1.01 (0.96-1.05), p=0.78), both (OR 1.32 (0.30-5.77), p=0.25). As compared to never users, progestogens appeared differentially associated with breast cancer: MP (OR 0.99 (0.55-1.79), p=0.98), SP (OR 1.28 (1.22-1.35), p < 0.0001), both (OR 1.32 (0.30-5.77), p=0.72).

CONCLUSION:

While HRT use is associated with an overall increased risk of breast cancer, this association appears to be uniquely in women having been given synthetic progestogens. Synthetic progestogens should not be given as part of HRT and counseling regarding the risk of breast cancer should consider the effect of formulation used.
Perimenopausal Symptomatology and Menopause-Related Quality of Life [2M]
Authors: Dye Timothy , Demment Margaret , Hyrien Ollivier , Weber Miriam , Morley Christopher , Woods James
Published: May 2017

INTRODUCTION:

Increasing evidence demonstrates a gap between women's own experience of menopause and practitioners' diagnosis and treatment of menopause-related symptoms (MRS). This study aims to identify subjective symptoms in perimenopausal women and their association with menopause-related Quality of Life (MQOL).

METHODS:

Women aged 45-64 enrolled in Family Medicine- and OBGYN-based primary care settings were approached electronically to participate. Women were excluded if they had past surgical history of oophorectomy, history of breast, or endometrial cancer, or were currently pregnant. In total, 70 women completed the baseline survey which included the Greene Climacteric Scale (measuring MRS) and the Utian Quality of Life Scale (measuring MQOL). Forward stepwise linear regression analyses were used to identify MRS predictors associated with MQOL scores.

RESULTS:

Several MQOL domains were significantly associated with MRS. Psychological symptoms were significantly associated with occupational (-0.66; p < .0001), emotional (-0.48; p < .0001), and overall quality of life (-1.71; p < .0001) MQOL scores. Depression symptoms were strongly associated with menopause health MQOL (-0.95; p < .0001), and vasomotor symptoms were strongly associated with sexual MQOL (-0.40; p 0.036).

CONCLUSION:

Symptomatology significantly correlates with quality of life among women of menopausal age. As psychological and depression symptoms worsen, women report diminished quality of life. Similarly, as vasomotor symptoms increase, sexual quality of life worsens. These symptoms are common, but are often poorly understood clinically. MRS should be addressed within the clinical setting with tools such as the American College of Obstetricians and Gynecologists' Practice Bulletin and EHR-based Best Practice Alerts (BPAs).
A Single Institution Review of Appropriateness of Prophylactic Antibiotics in Hysteroscopy [9M]
Authors: Wallace Erika R. , Nitzsche Brad , Massengill Abbie , Clevenger Nicole , Cotter Thusitha
Published: May 2017

INTRODUCTION:

To examine our institution's adherence to American College of Obstetricians and Gynecologists guidelines for antibiotic prophylaxis in gynecologic surgeries for which antibiotics are not recommended.

METHODS:

A cross-sectional study of hysteroscopy cases performed at a single tertiary care center from August 2011 to September 2015 was completed. Descriptive statistics summarized patient characteristics. Chi-square tests examined antibiotic use associated with categorical variables; t- test was used for continuous variables. Multiple logistic regressions analyzed the effects of variables on the odds of receiving antibiotics of unproven benefit.

RESULTS:

Among 1,075 women who underwent hysteroscopic procedures for which antibiotics are not recommended, 196 (18.23%) received antibiotics. 770 (71.62%) women had a hysteroscopy alone, and 305 (28.37%) women had additional procedure(s) that also did not warrant antibiotics. The mean age was 45 (SD 13, Range 18-88) years. The odds of having unproven antibiotics increased by 2 percent (OR 1.02) with every one year age increase, adjusted for primary procedure, diagnosis and length of stay [95% CI, 1.76-4.58]. Age (P < .0045), primary procedure (P < .0022), primary diagnosis (P < .0019), admitted year (P < .0302) and length of stay (P < .0005) had statistically significant effects on the impact of having unproven antibiotics. Patients undergoing hysteroscopic ablation were 2.8 times more likely to receive antibiotics than hysteroscopic biopsy (P < .0001).

CONCLUSION:

Non-indicated antibiotic use is high among gynecologic surgeons at our tertiary hospital and the use varies significantly with patient characteristics. This study supports close surveillance of antibiotic administration during gynecologic surgeries for which the drugs are of unproven benefit.
Hepatitis C Infection in Pregnancy: Maternal and Neonatal Complications [17M]
Authors: Clennon Emily , Caughey Aaron B. , Bullard Kimberley , Sharshiner Rita
Published: May 2017

INTRODUCTION:

Hepatitis C virus (HCV) infection affects thousands of pregnancies in the U.S. each year, yet there is a relative paucity of data on the outcomes of pregnancies complicated by the virus. This study analyzes recent, nationwide data on complications of pregnancy in the setting of HCV infection.

METHODS:

This retrospective cohort study examined 10,457,976 singleton deliveries in the U.S. between 2011-2013. Simple proportions of obstetric complications were compared between pregnancies complicated by Hepatitis C infection and controls. Chi squared tests and multivariable regression were used for statistical analysis, with p < 0.05 as the cutoff for significance. Comparisons were controlled for co-infection, parity, congenital abnormality, and maternal race and ethnicity, age, education attainment, cigarette use, and weight.

RESULTS:

A total of 31,200 pregnancies analyzed were complicated by maternal HCV. Infection was significantly positively associated with gestational hypertension (adj. OR: 1.09), Cesarean section (1.27), and maternal ICU stay (2.61). Many adverse neonatal outcomes were also increased with HCV infection, including overall preterm delivery (1.76), NICU stay (2.67), congenital abnormality (1.59), and neonatal seizure (3.72). Infection was negatively associated with gestational diabetes (0.77), chorioamnionitis (0.82), and macrosomia (0.79).

CONCLUSION:

HCV infection is independently associated with increased odds of many neonatal complications and several maternal complications. However, it also appears to be protective against a minority of adverse outcomes. Further investigation is required to determine if these differences are attributable to non-controlled socioeconomic factors, increased monitoring throughout pregnancy, or pathophysiologic mechanisms of infection.
Confined Placental Trisomy 18 Mosaicism Detected by Maternal Serum and Prenatal cfDNA Screening [21M]
Authors: Guy Carrie , Maxwell Megan D. , Waurin James L. , Buller-Burckle Arlene , Rabin Douglas S. , Strom Charles
Published: May 2017

INTRODUCTION:

We describe a case in which maternal serum screening (MSS) and prenatal cell-free DNA (cfDNA) screening were consistent with trisomy 18, later confirmed as confined placental mosaicism (CPM) of trisomy 18. The correlation between MSS and prenatal cfDNA screening, the common relationship of the techniques to placental function, and implications for clinical management are discussed.

METHODS:

A specimen for prenatal cfDNA screening was submitted to our laboratory with an indication of a 1:22 risk for trisomy 18 on first-trimester MSS. Prenatal cfDNA screening using massively parallel shotgun sequencing was performed and outcome information was obtained by laboratory genetic counselors.

RESULTS:

Prenatal cfDNA screening was positive for trisomy 18 in a male fetus; fetal fraction was 6.4% and the Z-score for chromosome 18 was 16. Amniocentesis was consistent with a normal male fetus on routine cytogenetic and microarray analyses. No anomalies were visualized on ultrasound. Delivery was significant for preterm labor, and the neonatal course was unremarkable. Microarray performed on placental tissue revealed mosaic trisomy 18, consistent with CPM.

CONCLUSION:

CPM identification has clinical management implications, such as the associated risk for intrauterine growth restriction (IUGR). The results of MSS and prenatal cfDNA screening in this case were consistent with trisomy 18, but were later revealed to represent CPM. It is well-established that analytes used in MSS are produced by the placenta, and that the cfDNA analyzed in prenatal screening is of feto-placental origin. This case contributes to the understanding of CPM, MSS analytes, feto-placental cfDNA, for improved clinical management.
Umbilical Cord Milking in Term Infants: Blood Volume Associated With Cut and Intact Umbilical Cords [23M]
Authors: Fay Emily , Delaney Shani , McAdams Ryan
Published: May 2017

INTRODUCTION:

Placental-to-newborn transfusion through delayed cord clamping and umbilical cord milking (UCM) is associated with reduced risk of transfusion, intraventricular hemorrhage, and necrotizing enterocolitis in preterm infants, and increased iron stores in term infants. Total blood volume (BV) transferred during UCM is not well studied. We sought to determine BV associated with both cut UCM (C-UCM) and intact UCM (I-UCM) methods in term infants.

METHODS:

Forty-five term infants were enrolled at a single center. To determine BV with C-UCM, umbilical cords from 30 infants (10 per group) were cut at 10, 20, or 30 centimeters, milked 4 times, and BV recorded. To determine BV with I-UCM, intact umbilical cords of 15 infants were milked 3 times and BV recorded. Demographic data and pregnancy data were obtained. Descriptive statistics were performed.

RESULTS:

In the C-UCM group, BV increased proportional to umbilical cord length, whereas BV/cm of cord decreased with cord length. C-UCM of a 30 cm segment contained a mean BV of 24.8±4.0 mL, or 8.0±1.3 mL/kg of birth weight. Most of the BV was obtained with the first milking (90.1±11.0%). In the I-UCM group, the mean BV was 46.3±24.1 mL, or 13.4±7.1 mL/kg of birth weight. No correlation existed between birth weight, placental weight, or BV.

CONCLUSION:

When performing C-UCM, cutting a long cord segment and milking 1 to 2 times delivers the highest BV. Compared to C-UCM, I-UCM provided greater average BV to newborn term infants. Future research should compare the clinical outcomes of infants who undergo C-UCM and I-UCM.
Correlation of BMI to Magnesium Levels in Patients With Preeclampsia [24M]
Authors: Dickerhoff Lindsay A.M. , Madden Heather , Simpson Pippa , Hibbard Judith , Cruz Meredith
Published: May 2017

INTRODUCTION:

To determine the relationship between BMI and magnesium blood levels following a 4 or 6 gram bolus of IV magnesium in preeclamptic women.

METHODS:

Retrospective chart review from 2005 to 2015 analyzing magnesium levels in preeclamptic women. Patients received IV magnesium bolus (4 or 6 grams) followed by a basal rate of 2 grams/hour. Magnesium levels were then drawn approximately 4 hours after the bolus dose. Magnesium levels from 4.8 to 8.4 mg/dL were considered therapeutic. BMI and labs (creatinine, ALT, AST, platelets) were compared between therapeutic and sub-therapeutic groups.

RESULTS:

508 patient charts reviewed; 207 met inclusion criteria. Patients with BMI less than or equal to 30 had fewer sub-therapeutic levels than therapeutic levels (Sub-therapeutic: 38.5%; Therapeutic: 61.5%; P-value less than 0.001). Patients with a BMI less than 30 had more sub-therapeutic levels than therapeutic (Sub-therapeutic: 76%; Therapeutic: 24%; P-value less than 0.001). In patients with BMI greater than 35, there were more patients in the sub-therapeutic group (Sub-therapeutic: 83%; Therapeutic: 17%; P-value 0.024). Creatinine was lower in the sub-therapeutic group compared to therapeutic group (Subtherapeutic: 0.66; Therapeutic: 0.73; P-value: 0.003). ROC curve demonstrated 4 gram magnesium bolus with BMI greater than or equal to 30 likely will not reach a therapeutic level (Sensitivity: 0.84, Specificity: 0.51), nor will 6 gram magnesium bolus with BMI greater than or equal to 35 (Sensitivity: 0.74, Specificity: 0.38).

CONCLUSION:

There is an inverse relationship between BMI and blood magnesium levels. When BMI reaches above 30, patients are more likely to be sub-therapeutic than therapeutic.
Impact of Trendelenburg Positioning During Active Labor on Mode of Delivery [25M]
Authors: Milton Sarah , Hempel Amy , Hylton Jordan , Sima Adam , DiPace Brian
Published: May 2017

INTRODUCTION:

Upright maternal position in labor has been associated with improved obstetrical outcomes. Little is known regarding the impact of alternative maternal positions on maternal and fetal outcomes. The primary aim of this study was to show a decrease in the incidence of cesarean delivery with the use of Trendelenberg position in pregnant women with a prolonged active phase of labor.

METHODS:

This study is a retrospective chart review of women admitted to the VCU Labor and Delivery Unit from 2013-2015 with a prolonged active phase of labor. A total of 2,816 subjects with a singleton viable pregnancy at term were included in the analysis. In addition to demographic data, information was collected from the medical record regarding maternal history, mode of delivery, and fetal outcomes.

RESULTS:

Of 2,816 subjects who met inclusion criteria, 768 (29.4%) were placed in Trendelenburg position. Overall, 441 (16.9%) patients in the study had a cesarean section. The rate of cesarean section in the Trendelenburg group was higher (30.7%) than in the non-Trendelenburg group (14.3%), p < 0.001. Apgar scores were lower in the Trendelenberg group than in the non-Trendelenberg group (1 minute 7.7 vs 8.3, 5 min 8.7 vs 8.9, p < 0.001).

CONCLUSION:

Use of Trendelenburg position during prolonged active labor does not decrease the incidence of cesarean delivery and may be associated with poor fetal outcomes. Prospective, randomized data on the topic of maternal positioning in labor would further elucidate the role, if any, for Trendelenburg position in labor.
Effect of Federal Regulation on Compounding of 17-hydroxyprogesterone Caproate in North Carolina [26M]
Authors: Hoopes Sarah , Nitsche Joshua F.
Published: May 2017

INTRODUCTION:

Compounding of 17-hydroxyprogesterone caproate (17P) was common until the US FDA approved the drug for sale under the brand name Makena. Although current regulation prohibits compounding of an FDA approved equivalent, safe compounding of 17P was permitted by the FDA in the year following Makena's approval. We sought to report trends in compounding and quality control of 17P across North Carolina (NC) in the year before and after Makena's approval.

METHODS:

All sterile compounding pharmacies registered in NC were called to participate in a survey regarding quality control and history of 17P compounding.

RESULTS:

150 of 210 pharmacies participated. Before Makena's introduction, 18 pharmacies compounded 17P (average cost of $73 per multi-dose vial). In the year after Makena's introduction, only 3 pharmacies continued compounding 17P at a similar rate (average cost of $68 per multi-dose vial), 7 pharmacies discontinued the practice, and 8 compounded 17P significantly less frequently. 8 of the 18 pharmacies (44%) who previously compounded 17P were accredited by the Pharmacy Compounding Accreditation Board, 13 (72%) tested for product purity, and 12 (67%) tested for potency.

CONCLUSION:

Although the cost of compounded 17P was notably lower than current price of Makena ($690/dose), not all of the pharmacies that compounded 17P regularly tested for purity and potency of the drug. Provided the price of Makena does not reduce access to the medication, its stricter quality control should improve its safety and efficacy. Further federal regulation of compounding may improve the quality and safety of compounded 17P.
Improved Estimation of Blood Loss at Time of Cesarean Section Using a Quantitative Approach [28M]
Authors: Conly Bethany , Sylla Ricci , Lee Kimberly , Wei Julia
Published: May 2017

INTRODUCTION:

In October 2009, the Kaiser Permanente Santa Clara Medical Center implemented a method of standardized, quantitative measurement of blood loss (QBL) at the time of cesarean section. The aim of this study was to determine if this QBL approach was better able to measure actual blood loss compared to the traditional visual estimation of blood loss (EBL).

METHODS:

This was a retrospective cohort study of 564 women who underwent scheduled cesarean section at our facility. The EBL group included 269 women from January 1st to December 31st, 2009 and the QBL group included 295 women from January 1st to December 31st, 2012. Blood loss estimates recorded in operative reports were collected along with the pre and postoperative hematocrits for each subject. Actual blood loss was calculated using the postoperative hematocrit change and compared to the recorded blood loss estimations in both groups using Pearson correlation coefficients (r) and coefficients of determination (r^2).

RESULTS:

QBL was weakly to moderately correlated (r = 0.35, r^2= 0.124) while EBL was very weakly correlated (r = 0.16, r^2 = 0.025) with the calculated blood loss after scheduled cesarean section.

CONCLUSION:

While neither EBL nor QBL methods were strongly correlated with the actual blood loss at time of scheduled cesarean section, the QBL method was more highly correlated. These data suggest that implementation of a standardized, quantitative approach to measuring blood loss at time of cesarean section may improve the immediate postoperative assessment of operative blood loss.
Control of Postpartum Hemorrhage Using Vacuum-Induced Uterine Tamponade [31M]
Authors: Segnitz Jan , Arulkumaran Sabaratnam
Published: May 2017

INTRODUCTION:

Early arrest of postpartum hemorrhage (PPH) using a simple to use conservative technique, well before coagulopathy sets in, would reduce blood transfusions, unnecessary surgeries including hysterectomies, and maternal deaths. For cases of atonic PPH, a new device that uses vacuum force to collapse the uterus causing rapid tamponade, has been proposed. This may be a better alternative to balloon tamponade as it follows natural physiology, is easy to use, does not depend on guessing the volume of fluid to be introduced, or conceal bleeding behind the balloon. Our study sought to demonstrate safety, effectiveness, and ease of use in the deployment of this new device to treat PPH.

METHODS:

Ten women, with vaginal deliveries in a hospital setting, treated with prophylactic uterotonics plus additional uterotonics for excessive bleeding, were the subjects of the study. When conservative medical therapy was failing and tamponade therapy was indicated, our device, that generates uniform vacuum-induced tamponade within the entire uterine cavity, was used with physiologic vacuum forces of 70 mmHg.

RESULTS:

The ten women experienced 600-1,000 milliliters of blood loss before vacuum was generated. The vacuum created an immediate seal, 50-250 milliliters of blood were evacuated, the uterus collapsed and regained tone, and hemorrhaging stopped within 2 minutes in all cases. The device remained in place for an average of 2 hours.

CONCLUSION:

This preliminary investigation suggests that a device designed to create vacuum-induced uterine tamponade may be a better alternative than balloon devices used to treat atonic PPH. Additional study is needed and is in progress.
Contribution of Depression and Anxiety to Prenatal, Intrapartum, and Neonatal Outcomes [33M]
Authors: Liu James , Hage Natalie , Sugiyama Nathaniel , Jovanovski Andrew , Madan Ichchha
Published: May 2017

INTRODUCTION:

To determine independent prenatal, intrapartum, and neonatal correlates of pregnancies affected by depression and anxiety.

METHODS:

Of deliveries occurring in 2013-2014, depression or anxiety was present in 915 (5.1%), including those with depression alone (n = 315, 1.8%), anxiety alone (n = 398, 2.2%), and comorbid depression and anxiety (n = 202, 1.1%). Cases were compared to unaffected pregnancies (n = 17,024, 94.9%) using logistic regression.

RESULTS:

For depression or anxiety, independently associated prenatal factors were unmarried status (OR 1.40), non-Hispanic white race (OR 1.89), smoking (OR 1.98), asthma (OR 1.38), epilepsy (OR 2.49), migraines (OR 3.58), and hypertension (OR 1.35). For intrapartum factors, independent associations were sedative use (OR 2.14), opioid use (OR 1.33), and insulin use (OR 2.94). For neonatal factors, independent associations were neonatal abstinence syndrome (OR 11.6), five-minute Apgar score (OR 0.83), and umbilical vein pH (OR 0.14). Individual regression analysis showed that depression had the most independent associations (n = 11), followed by anxiety (n = 9), and comorbid depression and anxiety (n = 8). Psychotropic medications were used by 280 subjects (31%). The most common were selective serotonin reuptake inhibitors (n = 224, 25%), benzodiazepines (n = 38, 4.2%), other antidepressants (n = 37, 4.0%), and anti-epileptics (n = 13, 1.1%).

CONCLUSION:

Ethnic and social factors, substance use, and medical disorders are associated with depression and anxiety in pregnancy. A minority of women used psychotropic medications during pregnancy. There is a trend for more narcotic and sedative use with a resultant increased risk of neonatal abstinence syndrome.
Is Checking Fasting Plasma Glucose After Delivery a Reasonable Cost Expenditure? [38M]
Authors: Domalakes Ericka , Vircks Julie , Holland Marium
Published: May 2017

INTRODUCTION:

Gestational Diabetes (GDM) complicates 5-6% of pregnancies in the US. Current recommendations are a fasting plasma glucose (FPG) or 75 g glucose tolerance test (GTT) at 6 weeks postpartum. FPG value is often obtained in the immediate postpartum period to screen for continued hyperglycemia. There is no recommendation for this however, and given the cost of checking FPG, we questioned if this practice would routinely affect clinical outcomes or predict the outcomes of 2 hr GTT.

METHODS:

A retrospective chart review was used to collect FPG and 6 week GTT results. Logistic regression and Chi Square analysis was used to evaluate OR to determine if there was a significant correlation between FPG and 2 hr GTT. An in-patient FPG (cpt 82962) was $28.00. This was applied to the total number of GDMs to calculate cost to the system.

RESULTS:

We found no difference in 6 wk postpartum GTT results based upon FPG (OR 1.01, 95% CI 0.97-1.06). FPG was greater than 99 mg/dL in 15.6% of patients, and the pass rate for GTT was 72.5%. There were no patients who failed GTT, however 27.5% demonstrated glucose intolerance. In our limited sample (n=167), there was a total of $4,676 spent on FPG.

CONCLUSION:

We found no correlation between FPG and 2 hr GTT. Given approximately 4 million births each year with GDM rates of 5%, over $5.5 million may be spent on FPG every year. As the FPG does not appear to add useful information to a patient's care, this provides an opportunity to reduce associated costs.
Provider Attitudes, Experiences, and Practices on Childbirth Education and Birth Plans [39M]
Authors: Afshar Yalda , Fahey Jacqueline , Mei Jenny , Saeb Samia , Gregory Kimberly D.
Published: May 2017

INTRODUCTION:

Attendance at childbirth education classes (CBE) has declined, while the rate of birth plans has increased. We sought to describe the perception and practices of obstetric providers on CBE and birth plans.

METHODS:

A national online-survey was distributed through professional societies and social-media. We collected provider and patient demographics, practice-settings, and perceptions. Responses were on a Likert scale from 1 (not important) to 5 (very important).

RESULTS:

Of 567 eligible surveys, 75.7% were physicians. This cohort believed prenatal care (mean ± SD, 4.4±0.9) and CBE (3.6±1.0) are predictors of patient satisfaction. Most providers routinely recommend (69.7%) and have favorable views on CBE (84%). They had neutral views on doulas (2.9±1.2). With increasing age, providers were more likely to recommend CBEs (0.159, p=0) and birth plans (0.174, p=0). Increasing provider age correlated with believing that prenatal care (0.111, p=0.01), CBE (0.190, p=0) and birth plans (0.108, p=0.012) were predictors of satisfaction and favorable obstetrical outcomes (0.149, p=0.001). Only 26% of providers had favorable views on birth plans and most providers (66.5%) did not recommend birth plans and 31% felt they were predictors of poor obstetrical outcomes. Increasing practice-years correlated with favorable views on CBEs (0.167, p=0) and birth plans (0.205, p=0). Providers with higher obstetrical clinical volume more likely recommend birth plans (0.118, p=0.009).

CONCLUSION:

Providers view CBE as an important predictor of patient satisfaction while they have unfavorable view of birth plans. Further research is needed to understand how to improve childbirth related patient satisfaction and birth experience.
Peripartum Blood Transfusions in a High Risk Maternity Center [5N]
Authors: Patel Krunal , Martimucci Kristina , Guirguis George , Apuzzio Joseph , Gittens Lisa , Williams Shauna
Published: May 2017

INTRODUCTION:

Peripartum blood transfusions may be urgent and unpredictable. The purpose of this study is to review risk factors associated with transfusion in obstetric patients.

METHODS:

A retrospective study was performed of gravidas at gestational age 23 weeks or more, from 1/1/2012 to 12/31/2015 who delivered at a tertiary care hospital and received blood transfusion. Demographic and obstetric data, indication for transfusion and estimated blood loss (EBL) were reviewed. Student's t-test and Mann-Whitney tests were used.

RESULTS:

177 (2.74%) of 6542 obstetric patients received blood transfusion during this time period. 118 (66.7%) delivered by CD, and 6 (3.4%) had an operative vaginal delivery. Of those who had a CD, 60 (51%) were primary, 28 (24%) had one prior CD and 30 (25%) had 2 or more prior CD. 53 (88.3%) of primary CD and 26 (45%) of repeat CD patients were in labor. Indications for transfusion were acute blood loss in 58 (32.7%), predelivery anemia in 11 (6.2%), and postdelivery symptomatic anemia in 108 (61%). 57% had an admission hemoglobin of less than 10.5 g/dl, of these 44 (43%) received iron prenatally. When comparing patients who were symptomatic postpartum to the rest of the group, preadmission hemoglobin was higher (10.3+1.6 vs 9.7+1.7, p=0.04), nadir was lower (6.7+0.7 vs 7.3+1.5, p=0.0004), and discharge hemoglobin was the same (8.5+0.98 and 8.5+1.4, p=0.8).

CONCLUSION:

There is a high rate of patients who presented with anemia in this cohort. Aggressive treatment of their anemia may decrease the rate of transfusion and associated maternal morbidities. Early recognition and treatment of postdelivery symptomatic anemia may decrease morbidities in this group of patients.
Point-of-Care vs Laboratory Based Urine Protein-Creatinine Ratio as an Indicator of Proteinuria in Pregnancy [9N]
Authors: Sinno Omar , Rood Kara M. , Jones Megan , Thung Stephen , Samuels Philip , Buhimschi Irina A.
Published: May 2017

INTRODUCTION:

Proteinuria is a hallmark finding in preeclampsia and a value of 300 mg or more in a 24 hour urine collection aids the diagnosis. A random urine protein-creatinine ratio (UPCR) of at least 0.3 mg/dL has emerged as a surrogate indicator of proteinuria. Point-of-care (POC) UPCR tests have been developed and may provide a convenient and timely extrapolation of proteinuria at the bedside. Although such testing has demonstrated excellent correlation with central laboratory methods in studies of non-pregnant patients, its validity and clinical utility have yet to be established in the pregnant population. Our objective was to evaluate POC UPCR as an indicator of proteinuria in pregnancy and compare it to the central laboratory method.

METHODS:

108 urine samples from pregnant women presenting to triage for preeclampsia evaluation were collected prospectively from January to June 2015. For clinical purposes, a urine specimen was collected and sent to the laboratory for standard measurement of protein, creatinine and PC ratio using a Beckman Coulter Au5800, measuring turbidimetry by immunocomplexation with an anti-albumin antibody. A sample of the collected urine was tested via POC UPCR using Multistix Pro 11 reagent strips. Utilizing the manufacture interpretation guide, a “normal” strip ratio was defined as urine containing less than 300 mg protein/g creatinine.

RESULTS:

There was moderate agreement between POC UPCR and laboratory UPCR (k=0.512). After triage evaluation was complete, 31 women had a clinical diagnosis of preeclampsia.

CONCLUSION:

Results indicate that the POC UPCR is not reliable for the diagnosis of proteinuria when compared to the central laboratory UPCR.
Patterns of Oxytocin Use in Those Undergoing Trial of Labor After Cesarean (TOLAC) [19N]
Authors: Abraham Cynthia , Adeyekun Moyosore , Demissie Seleshi
Published: May 2017

INTRODUCTION:

Oxytocin use in the management of TOLAC is controversial. Data assessing the relationship between oxytocin use and adverse outcomes is scant.

METHODS:

Chart review of 159 patients with one prior cesarean undergoing TOLAC divided into those who were: (1) induced with oxytocin (IND, n=44), (2) augmented with oxytocin (AUG, n=37) and (3) managed expectantly after presenting in labor (SPON, n=78). Following obtained: maternal baseline characteristics, amount administered and duration of oxytocin use if used, incidence of adverse outcomes. Chi-square and ANOVA were used for statistical analysis.

RESULTS:

Baseline characteristics between groups were similar. Two cases of uterine ruptures and one of hemorrhage occurred in the IND group. All three cases had an initial Bishop score less than 5. Average total amount of oxytocin administered and duration of oxytocin use in this subgroup were 4412 milliunits and 12.7 hours. Five patients underwent cervical ripening balloon placement followed by oxytocin for induction. In this subgroup, none experienced adverse outcomes and three of the five had a successful TOLAC. Average total amount of oxytocin administered and duration of oxytocin use were 1988 milliunits and 7.3 hours. One case of uterine dehiscence necessitating surgical intervention occurred in the SPON group. There were no complications in the AUG group. No significant differences were noted among the groups regarding other outcomes including cesarean delivery rate.

CONCLUSION:

Induction of labor in the presence of an unfavorable cervix and prior cesarean is associated with adverse outcomes. Cervical ripening balloon has a role in achieving a successful TOLAC.
Preferences of Pregnant Women With Cardiac Disease for Maternal-Fetal Outcomes Related to Their Pregnancies [20N]
Authors: D'Souza Rohan , Thomas Hannah , Wuebbolt Danielle , Nguyen Vanessa , Murphy Kellie , Silversides Candice
Published: May 2017

INTRODUCTION:

The trade-offs pregnant women with cardiac disease are willing to make in order to optimize pregnancy outcomes is undetermined. This study aimed to elicit preferences of these women for maternal and fetal outcomes related to cardiac disease in pregnancy.

METHODS:

A cross-sectional study was conducted on pregnant women with cardiac disease. participants were then presented with 19 vignettes describing combined maternal and fetal outcomes related to cardiac disease. Maternal outcomes included cardiac events (arrhythmias and cardiac failure), blood clots, a combination of the two and no cardiac events; while fetal outcomes included perfect health, minor or major malformations, small-for-gestational-age (SGA) infants and fetal demise. Participants were asked to assign values to these outcomes on a visual analogue scale (VAS), by the standard gamble (SG) and time trade-off (TTO) methods. Utility values (preferences) for each state obtained from all three methods were presented on a scale of 0-100.

RESULTS:

34 pregnant women with cardiac disease completed the interviews. The median age was 31.5 [29-34] years and the median gestational age was 24 [19-35] weeks. Participants did not perceive combinations of maternal cardiac events as more severe than a solitary event. Also, they regarded SGA as more severe outcome than minor congenital malformations, but valued major malformations as bad as fetal demise.

CONCLUSION:

This study is the first to obtain preferences of pregnant women with cardiac disease for combined maternal and fetal outcomes related to their condition. These preferences should be incorporated in clinical decision-making.
Prenatal Use of Aspirin and Acetaminophen [22N]
Authors: Wing Adam Bruce , Cisneros Rebecca , Lilo Sara , Henderson Cassandra
Published: May 2017

INTRODUCTION:

Acetaminophen is widely used in pregnancy for pain management. Recently published data indicates that in-utero acetaminophen exposure may be associated with greater odds that the resulting child will develop ADHD. Aspirin may be a suitable alternative to pain management in the first and second trimesters.

METHODS:

A systematic review of English language publications using the search terms, “salicylates, pregnancy,” “congenital defects, aspirin,” acetaminophen and ADHD” was conducted to describe perinatal outcome of in utero acetaminophen and aspirin exposure studies showing only third trimester adverse effects were excluded.

RESULTS:

The search found the following publications. 1 case report, 1 meta-analysis, 2 systematic reviews, 1 case control, 1 randomized controlled trial, 4 retrospective cohort and 2 prospective cohort studies. Aspirin use during the first trimester was associated with increased risk of miscarriage and gastroschisis. There appears to be a comparable risk of cryptorchidism with both aspirin and acetaminophen use in the second trimester. The increased risk of miscarriage was significant only when the analgesic agent was taken at the time of conception. However, the increased risk of gastroschisis was heterogeneous, in the absence of controls for numerous confounders, may not be clinically significant.

CONCLUSION:

Prior to use of pain relievers during pregnancy, a thorough discussion of the known and potential risks versus the benefits of available analgesic agents should be followed by shared decision making when considering analgesic options. This has ethical and public health implications, given the reports that have associated in-utero acetaminophen exposure with an increased risk of ADHD.
Impact of Anemia on Preterm Labor in Hypothyroid Patients: A Retrospective Study [31N]
Authors: Araji Sarah , Khoury Aldo , Elkafrawi Deena , Miller Jacob , Ching Michael
Published: May 2017

INTRODUCTION:

Studies have demonstrated that hypothyroidism in pregnancy is associated with an increased risk of preterm delivery. Current literature fails to demonstrate whether the underlying cause is thyroid dysfunction or anemia of thyroid disease. A negative association between anemia and duration of gestation was reported in the majority of studies; however, the exact mechanism of action is not determined. In this retrospective study, we evaluate anemia as a risk factor for preterm labor in pregnant patients with hypothyroidism.

METHODS:

A retrospective chart review of patients delivered before 37 weeks and received prenatal care at our outpatient clinic between January 2013-August 2015 was conducted. TSH, T4, and H/H levels during the course of pregnancy and before delivery was evaluated. We indicated if patients received levothyroxine or iron supplements.

RESULTS:

Our sample size was 373 pregnant women who delivered before 37 weeks--202 of 373 were neither anemic nor hypothyroid (54.2%), 124 of 373 were anemic only (33.2%), 25 of 373 were hypothyroid and anemic (6.70%), and 23 of 373 were hypothyroid only (6.17%). Anemia had no impact on gestational age when stratified by hypothyroidism. Increasing T4 increased risk of preterm delivery starting from 35.6 weeks of gestation (P=0.00; 95% CI, -1.40 to -0.57) regardless of anemic status.

CONCLUSION:

Anemia does not play a significant role in causing preterm delivery in hypothyroid pregnant patients. T4 was directly proportional to preterm delivery in anemic and non-anemic patients. Age was inversely proportional to preterm delivery in anemic and non-anemic patients alike.
Clinical Relevance of Screening for Rare Autosomal Aneuploidies: A Case of Maternal Uniparental Disomy [33N]
Authors: Helgeson Jennifer , Sullenberger Rebecca , Macedonia Christian , Rafalko Jill , Boomer Theresa , Beruti Sue
Published: May 2017

INTRODUCTION:

Traditionally, fetal aneuploidy screening has focused on autosomal trisomies of chromosomes 21, 18, and 13. Subsequently, cell-free DNA (cfDNA) screening has expanded to include sex chromosome aneuploidies, select microdeletions, and recently genome-wide analysis. Though uncommon after the first trimester, aneuploidy of any autosome can occur in placental and fetal tissues. Some autosomal aneuploidies present at conception are rescued and restored to a euploid state. When this occurs with imprinted chromosomes, it can lead to a euploid fetus with a genetic syndrome due to uniparental disomy (UPD).

METHODS:

Maternal blood samples submitted to Sequenom® Laboratories for MaterniT® GENOME testing were subjected to DNA extraction, library preparation, and whole genome massively parallel sequencing. Data were analyzed using a novel algorithm to detect trisomies and other subchromosomal events.

RESULTS:

A 42 year old patient elected genome-wide cfDNA screening after genetic counseling. Screening was positive, indicating an increased representation of chromosome 15, consistent with mosaic trisomy 15. The patient elected amniocentesis which returned a normal fetal karyotype, 46,XX. Subsequent testing of amniocytes detected maternal UPD of chromosome 15. Maternal UPD15 is a cause of Prader-Willi syndrome.

CONCLUSION:

This case illustrates the clinical relevance of screening for esoteric trisomies with cfDNA. Though the fetus did not have trisomy 15, the cfDNA test detected a trisomy in the placenta, evidently rescued in fetal tissue, which led to maternal UPD of chromosome 15 and a fetal diagnosis of Prader-Willi syndrome. Diagnosing Prader-Willi syndrome prenatally allows patients to make reproductive decisions, including pregnancy termination, adoption, and preparing for a child with disabilities.
Apgar Score and Umbilical Cord Gas as Quality Markers for Identification of Unindicated Cesareans [35N]
Authors: Metz Torri , Hermesch Amy , Allshouse Amanda , Alston Meredith , Babcock Gilbert Sara Ann , Saade George
Published: May 2017

INTRODUCTION:

To evaluate if either a 1-minute Apgar 7 or greater, or umbilical artery (UA) pH 7.2 or greater can be used as a quality measure to identify unindicated cesarean deliveries (CD) for non-reassuring fetal heart rate (NRFHR).

METHODS:

Retrospective cohort of nulliparas with no contraindication to vaginal delivery. Individual physician CD rates were calculated. Two quality measures were investigated as indicative of normal neonatal status: (1) 1-minute Apgar 7 or greater, (2) UA pH 7.2 or greater. Pearson's correlation was calculated between individual physician CD rates and proportion of CDs performed with a primary indication of NRFHR but normal neonatal status. A random sample of 60 FHR tracings from women who had a CD for NRFHR were reviewed by 3 obstetricians blinded to Apgars and gases to determine if CD was indicated.

RESULTS:

2,224 women were included. Of 537 CDs, 181 (34%) had a primary indication of NRFHR. Individual physician CD rates and rates of CD for NRFHR with normal neonatal status were moderately correlated (Apgar rho=0.53,95%CI 0.12-0.79, UA pH rho=0.53,95%CI 0.11-0.79). CDs were identified by peer review to be unindicated in 65% of cases with a UA pH of 7.2 or greater, compared to only 28% of cases with a pH less than 7.2 (p=0.04). A high proportion of CDs with 1-minute Apgar 7 or greater were also unindicated (70% vs 57%, p=0.42).

CONCLUSION:

Performance of a CD for NRFHR with UA pH 7.2 or greater may help identify physicians with higher CD rates and cases that may benefit from peer review.
Clinical Characteristics & Patient Preferences Among Women Planning Out-of-Hospital Births (OOHB) [36N]
Authors: Afshar Yalda , McCulloch Jeanette , Korst Lisa M. , Fridman Moshe , Saeb Samia , Gregory Kimberly D.
Published: May 2017

INTRODUCTION:

We describe socio-demographics, clinical characteristics and patient preferences among women who plan OOHB.

METHODS:

We performed a systematic literature review for patient-reported outcomes in childbirth and collaborated with community partners to hold focus groups to determine birth preferences. Nielsen recruited nationally and administered a survey to pregnant women. A multiple logistic model was fitted to examine characteristics associated with planned delivery location. Odds ratios (OR) and 95% confidence intervals are reported.

RESULTS:

We surveyed 2,757 women; 2,056 planned a vaginal delivery, and 79 (3.8%) planned OOHB. No differences were found in age, race, or gestational age. Women who planned OOHB were more likely to want to avoid interventions (OR 4.7, 2.47-9.05). They were more likely to have multiple gestation (OR 4.27, 1.93-9.47) and to want a choice of laboring positions (OR 3.40, 1.47-7.88). Women who planned OOHB favored use of a shower/tub (OR 6.39, 2.98-13.72) and birthing ball/stool (OR 10.94, 2.19-54.55). Women who planned in-hospital births were more likely to identify their pregnancy as high-risk (OR 1.99, 1.00-3.96), to have previously labored (OR 1.94, 1.07-3.51), to want comfort/reassurance from providers (OR 5.66, 1.70-18.85), and were more likely to describe their mental health as poor/fair (OR 7.72, 1.20-53.28).

CONCLUSION:

Women planning OOHB reported having lower clinical risk, better mental health, and specified distinct birthing preferences relative to women planning hospital birth. Given the increasing rate of planned OOHB, an understanding of the preferences of women who choose this experience is essential to identifying patient-specific strategies for improving inpatient satisfaction and outpatient safety.
Characteristics Associated with Attempted External Cephalic Version– A Descriptive Cohort Study [39N]
Authors: Limaye Meghana , Abdullahi Najma , Has Phinnara , Froehlich Rosemary , Werner Erika
Published: May 2017

INTRODUCTION:

External cephalic version (ECV) can decrease the rate of cesarean delivery (CD) but is underutilized. We sought to assess the characteristics of women who undergo ECV compared to those who do not.

METHODS:

This was a retrospective cohort study of women with singleton gestations and non-cephalic presentations at term. Women with contraindications to vaginal delivery (VD) were excluded. Women who had attempted ECVs were compared to women who did not. Factors associated with successful ECV were also examined. The study was powered to detect a 20% difference in ECV rate among women with history of VD compared to those without. Fisher's exact test compared categorical variables and Wilcoxon rank-sum test compared continuous variables.

RESULTS:

212 women were included in the study, 52 (24.5%) underwent ECV. Women who had ECV compared to those who did not were more likely to have had prior VDs (67 v 36%, p < 0.001), be multiparous (67 v 49%, p=0.03), have posterior placentas (46 v 24%, p=0.03), and be seen in academic practices (17 v 6%, p=0.02). Among women who had ECV, the success rate was 56%, and 44% went on to have VDs compared to 7% of women who did not have ECV (p < 0.001). There was no difference between successful and unsuccessful ECV with regard to use of terbutaline, IV pain medication, or neuraxial anesthesia.

CONCLUSION:

Nulliparous women and women without a history of VD are less likely to undergo ECV. Education and quality initiatives should specifically encourage discussion of ECV in these groups.
Transgender Health Care: Multi-Disciplinary Team Approach Prior to Female to Male Confirmation Surgery [3O]
Authors: Bachmann Gloria , Baras Jackie , Berner Nicole , Marshall Ian , Salwitz James , Moffa Salvatore
Published: May 2017

INTRODUCTION:

Healthcare providers and medical centers are often challenged in comprehensively caring for the transgender population in a safe environment. In response to the Affordable Care Act supporting increased access to healthcare, it is important that the appropriate templates are put into place by all medical centers to ensure this community is provided with optimal clinical care and customer service.

METHODS:

An FTM individual was to be admitted to Robert Wood Johnson University Hospital for confirmation surgery (hysterectomy). To ensure the patient's clinical and customer service needs would be met during the hospitalization, it was decided that representatives from all possible points of interaction would meet to formulate a template of care before patient admission. This group included representation from Obstetrics/Gynecology, Urology, Endocrinology, Psychiatry, Anesthesiology, Nursing staff, Security, Registration, Pre-Admission Testing, Perioperative Services, Bio-Ethics, Patient Relations, Food & Nutrition services, and Housekeeping.

RESULTS:

This multi-disciplinary team approach allowed the medical team to prepare a customized care plan, which will now be used for transgender individuals admitted for confirmation surgery. It also was a venue during which the entire team could weigh in on how best to address issues such as continuation of current hormonal therapy (pre and post-operatively) and emotional and social support post-procedure.

CONCLUSION:

The gathering of a multi-disciplinary team assisted in the development of a template of care for transgender services that supports the delivery of quality patient care and exemplary customer service. This multi-disciplinary meeting prior to hospitalization is strongly recommended for all medical centers.