bluuebunny/crossref_metadata_2025 huggingface dataset:
The Use of Erythropoietin in Hypoxic-Ischemic Encephalopathy: A Cost-Effectiveness Analysis [12A]
Authors: Packer Claire , Hersh Alyssa R. , Sargent James Andrew , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

A recent phase II trial demonstrated that high-dose erythropoietin with therapeutic hypothermia for hypoxic-ischemic encephalopathy (HIE) results in decreased brain injury on MRI and improved 1-year motor function in comparison to treatment with therapeutic hypothermia alone. We sought to investigate whether such an intervention is cost-effective in cases of moderate and severe HIE.

METHODS:

A TreeAge decision analytic model was designed comparing erythropoietin vs. no erythropoietin in a cohort of 10,000 term neonates with moderate and severe HIE. Rates of global brain injury and neurodevelopmental disability (NDD) were derived from a phase II trial investigating high-dose erythropoietin and hypothermia for HIE, and rates of NDD due to global brain injury were estimated from existing literature. Costs were derived from prior literature. Utilities were applied to discounted life expectancy to generate quality-adjusted life years (QALYs). All costs and QALYs were discounted at an annual rate of 3% with cost-effectiveness threshold of $100,000 per QALY. Sensitivity analyses were conducted to assess the robustness of these results.

RESULTS:

High-dose erythropoietin for the management of moderate and severe HIE resulted in lower costs and higher QALYs compared to therapeutic hypothermia alone. In our theoretical cohort, utilizing high-dose erythropoietin results in 3,900 fewer cases of major NDD. In a univariate sensitivity analysis, when varying the cost of erythropoietin, erythropoietin was found to be cost-effective across all ranges considered.

CONCLUSION:

Erythropoietin therapy with therapeutic hypothermia is a cost-effective intervention resulting in improved outcomes for neonates with hypoxic-ischemic encephalopathy.
Predictive Value of Fetal Abdominal Circumference in Diagnosing Small for Gestational Age Infants [29A]
Authors: Kopparam Rohini , Matthews Kathy , Khan Rana , Grossman Tracy B. , Gelber Shari
Published: May 2019

INTRODUCTION:

Intrauterine growth restriction is associated with adverse perinatal outcomes and implications for long term health of the newborn. Fetal abdominal circumference (AC) has been shown to detect small for gestational age (SGA) infants. We aimed to evaluate the predictive value of sonographic fetal abdominal circumference (AC) measurement from 25-36 weeks' gestation for detection of SGA infants.

METHODS:

Retrospective chart review from 2006 to 2016 following IRB approval. SGA was defined as a newborn birth weight <10th percentile on the Fenton growth curve. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AC Z-score at various gestational age ranges (25-28, 29-32 and 33-36 weeks) for a Z-score.

RESULTS:

Ultrasounds of 4801 women with 5799 pregnancies were reviewed. After excluding pregnancies with estimated fetal weight <10th percentile, SGA prevalence was 7.8%. AC Z-score of -1.28 had the highest sensitivity of 36.9% and specificity of 94.1% at 29-32 weeks' gestation. The AUROCC at this time point was 0.79.

CONCLUSION:

Fetal AC <10th percentile identifies a cohort at higher risk for SGA who may have been overlooked with estimated fetal weight <10th percentile alone. This cohort can benefit from increased surveillance and additional pre- and post-natal counseling. Further, as a high portion of these patients delivered preterm, AC can guide timing of antenatal corticosteroids for fetal lung development and transfer to tertiary care centers when necessary.
Improving 4th Trimester Care at Burlington Community Health Center [30A]
Authors: Ellis Joshua , Stephens Sarah , Headrick Emily
Published: May 2019

INTRODUCTION:

At Burlington Community Health Center (BCHC), many barriers prevent new mothers from returning to clinic for their 6-week postpartum visit (PPV). A significant amount of maternal care is being rendered by pediatricians. While baby is seen often in first months, mother is not often seen until 6-weeks postpartum.

METHODS:

Prenatal database compiled from BCHC patients who presented between 8/1/2016 and 7/31/2018. Clinic work-flow established for newborn visits at BCHC, in which a care manager used “Newborn Visit Checklists” to evaluate new mothers at newborn visit. Care manager scheduled a visit for the mother at 2- or 4-weeks postpartum. At that visit, the 6-week PPV (primary endpoint) was scheduled.

RESULTS:

120 prenatals found in chart review, who served as the comparison group. Of these, 40% (n=48) returned to BCHC for 6-week PPV. Between 8/1/2018 and 9/28/2018, 14 newborns presented to BCHC; their 14 mothers served as the intervention group. Of the 14 mothers eligible for intervention, 43% (n=6) received care elsewhere. Of the 8 remaining BCHC patients, 100% (n=8) were scheduled for, 63% (n=5) showed up for a 2- or 4-week visit. Attendance rate at 6-week PPV was 89% (n=8), a 123% increase from baseline.

CONCLUSION:

Attendance rates at 6-week PPV were higher for mothers who had already been seen by their provider at 2- or 4-weeks postpartum. Seeing mothers earlier instead of waiting until 6-weeks postpartum allows them to address concerns with provider and connect with resources earlier, improving health for mother/baby dyad.
Patient and Student Knowledge and Attitudes Regarding Pharmacotherapy During Pregnancy [33A]
Authors: Shadowen Carrie , Terplan Mishka
Published: May 2019

INTRODUCTION:

The purpose of this study was to investigate the self-reported knowledge and attitudes regarding pharmacotherapy for diabetes, bipolar and opioid use disorder in pregnancy within two distinct populations: medical students and patients receiving addiction treatment.

METHODS:

A survey was designed to assess participants' background knowledge and attitudes regarding diabetes, bipolar and opioid use disorder and their respective evidence-based pharmacotherapies (insulin, lithium, and methadone) in pregnancy. Results were reported as 5-point Likert scale and contrasted using Fischer exact test.

RESULTS:

Responses from 117 completed surveys (57 medical students 60 patients). The groups were similar by gender but differed by lived illness experience for all conditions. All but one student correctly defined the 3 disease states and their evidence-based treatment. Students were more likely to agree or strongly agree with statements that new mothers with opioid use disorder (mean Likert=4.54), diabetes (4.19) or bipolar (4.25) would face challenges than patients did (p=0.004, 0.002, 0.021, respectively). Whereas patients agreed with the statement that a woman with opioid use disorder should not get pregnant (mean Likert=4.02), medical students were more neutral (3.44, p=0.001). Both groups were similarly neutral regarding whether a woman with bipolar disorder should get pregnant. Students disagreed with the statement that a woman with diabetes should not get pregnant (mean Likert=1.83), whereas patients trended towards neutral (2.73, p=0.001).

CONCLUSION:

Knowledge and attitudes differed by both disease condition and between medical students and patients. Overall negative statements were endorsed more for opioid use disorder, reflecting addiction stigma.
In Young Infertile Women Low Serum Anti-Müllerian Hormone is Not a Good Predictor of Ongoing Clinical Pregnancy Rate [36A]
Authors: Park Selena , Brasile Deanna Rose , Dampier William , Berkowitz Karen
Published: May 2019

INTRODUCTION:

Age and serum anti-müllerian hormone (AMH) levels strongly influence treatment decisions in infertile women. We compared ongoing clinical pregnancy rates (PR) in younger (<35) versus older (> or =35) infertile women with AMH levels of <1.0 or > or =1.0 undergoing controlled ovarian hyperstimulation (COH).

METHODS:

Included: 142 infertile women aged 30-45 at a private practice from 2014-2018. Patients were stratified by age and serum AMH. Recorded: serum estradiol, follicle-stimulating hormone, AMH, age, race, BMI, number of COH cycles, medication quantities. Excluded: women with ovulatory dysfunction, PCOS, ovarian surgery, smoking, autoimmune disease, FSH levels of >40. Ongoing clinical pregnancy: live intrauterine gestation of > or =8 weeks by pelvic ultrasound.

RESULTS:

Ongoing clinical PR was different in women with AMH <1.0 when stratified by age (P<.05). Nine younger women undergoing 5 or more COH cycles attained an ongoing clinical pregnancy, while in older women, ongoing clinical PR was 50% (95% CI 36-63, N 16). In contrast, women with AMH > or =1.0 showed no difference in ongoing clinical PR when stratified by age, with PR of 69% in younger (95% CI 62-74, N 37) and 64% in older women (95% CI 58-70, N 25) after 4 COH cycles.

CONCLUSION:

We demonstrated as a proof of principle that age is a better predictor of ongoing PR than serum AMH when values are <1.0. This suggests that age is a more clinically useful parameter than AMH when counseling younger infertile women undergoing COH stimulation about their probability of ongoing clinical PR.
Characteristics of Oral Contraceptive Reminder Patterns in Young Adults: A Cross Sectional Survey [3B]
Authors: Nguyen Michaelyn M. , Yu Vivian , Nguyen Tina , Sridhar Aparna
Published: May 2019

INTRODUCTION:

The efficacy of the oral contraceptive pill relies on its timely use, and with technology's growing pervasiveness, even more resources exist to assist with pill adherence. Our aim was to identify and characterize these patterns of reminder systems among young adults in an urban gynecological practice in Los Angeles. Our secondary aim was to identify the number of missed pills among users with traditional versus technology-based reminders.

METHODS:

This is a cross-sectional study of young adults who have been on oral contraceptive pills for a minimum of 3 months. Using a paper-based survey, we identified the patterns of reminder systems and demographics among a convenient sample of 50 pill users.

RESULTS:

44% of the participants use technology-based reminder systems (setting a phone alarm) while 24% use traditional reminder systems (taking the pill as a routine at a particular time of the day or along with other medications). 48% of technology reminder users never missed a pill compared to 33% of traditional reminder users. When missed pills was reported, 50% of traditional reminder users missed only 1 pill while technology reminder users equally missed 1 pill, 2 pills, and more than 2 pills (about 33%).

CONCLUSION:

Our first phase of this study identified the patterns of reminder systems. Despite the variety of reminder systems used, our participants' less-than-perfect adherence highlights the existing risk of unplanned pregnancy. We will use this data to calculate the sample size needed to understand the relationship between reminder system type and missed pills.
Women Seeking Asylum: Multiple Traumas Inflicted by Multiple Perpetrators [6B]
Authors: Aguirre Nicole , Milewski Andrew , Kopparam Rohini , Shin Joseph , Ottenheimer Deborah
Published: May 2019

INTRODUCTION:

The WHO estimates that 1 in 3 women has experienced Gender-Based Violence (GBV). A majority of female asylum applicants in the United States are seeking relief from at least one form of GBV. We hypothesize that an analysis of female asylees' affidavits will confirm a pattern of multiple types of GBV, throughout their lives, at the hands of multiple perpetrators.

METHODS:

A retrospective review was performed of de-identified legal and medical affidavits that were prepared for adult, female asylum applicants presenting to the Weill Cornell Center for Human Rights from 1/1/2013-12/31/2014 for forensic medical evaluation. Definitions of abuse types, severities, and perpetrators were drawn from several sources to generate the coding tool that was employed to assess the affidavits.

RESULTS:

25 affidavits were reviewed, of which 23 met inclusion criteria. 189 instances of abuse were identified, yielding an average of 8.2 (range 2-15) abuses per woman. Repetition of the same abuse by the same perpetrator over any time-frame (days to decades) counted as a single instance of abuse. The plurality of abuses were perpetrated by intimate partners (56/189) and immediate family (73/189). 48% of the abuses were psychological, 26% were sexual, and 26% were physical. In these respective categories, threats of serious violence, rape, and experiences of serious physical violence, were documented most often.

CONCLUSION:

These preliminary results confirm our hypothesis and suggest that the current conceptualization of GBV among female asylees as episodic abuse by a single perpetrator requires revision.
Evaluation of Phenotypic Markers of Hyperandrogenism in Patients with Preeclampsia With Severe Features [10B]
Authors: Lederer Madeline , Moore Jessica , Ortega Hector , O'Neal Dianne , Santos Janelle , Carugno Jose
Published: May 2019

INTRODUCTION:

Studies have shown an association between polycystic ovarian syndrome (PCOS), a hyperandrogenic condition, and increased risk of pre-eclampsia (PEC). Certain phenotypes, such as the ratio of the length of the second and fourth digits of the hand (2D:4D) have been suggested markers of elevated prenatal androgen exposure. This study seeks to evaluate the relationship between 2D:4D ratio, earlobe crease, feet type, and risk of developing PEC with severe features (PEC-S).

METHODS:

This is a case control study including women in the immediate post-partum period. Patients with diagnosis of PEC-S were examined in the postpartum unit, and the following were recorded: measured length of the 2D and 4D of the right hand, presence/absence of an earlobe crease, and feet type. Descriptive statistical analysis was used.

RESULTS:

150 participants were included in the study (51 cases and 99 controls). The mean 2D:4D ratio was similar in both groups 0.96 (p=0.552). There was a marginally significant relationship between presence of earlobe crease and PEC-S, with 19.6% cases having an earlobe crease compared to only 9.1% of controls (p=0.075). Concerning feet type, cases had 68.6% Egyptian, 32.5% Greek, and 7.8% Roman compared to controls 54.5%, 39.4%, 6.1% respectively (p=0.149).

CONCLUSION:

There is no significant association between the 2D:4D ratio or feet type and PEC-S. Thus, we concluded that these are not valid phenotypic markers for early identification of preeclampsia. There was a marginal association between presence of earlobe crease and PEC-S. We recommend this, and other phenotypes of hyperandrogenism be investigated further.
Does Serum Hemoglobin A1C during Early Pregnancy Predict Performance on the 1-Hour Glucose Challenge Test? [28B]
Authors: Stiewig Miranda , Jackson David N. , Howard David Leighton
Published: May 2019

INTRODUCTION:

Our objective was to determine the negative and positive predictive values of hemoglobin A1c (HgbA1c) levels, conceptualized as a screening test, in predicting abnormal 1-hour glucose challenge test (GCT) results in pregnancy.

METHODS:

This was a retrospective cohort study. We calculated the negative predictive value of HgbA1c levels in predicting normal 1-hour GCT (less than or equal to 140 mg/dl) and the positive predictive value in predicting an abnormal 1-hour GCT of greater than 140 mg/dl.

RESULTS:

We examined 635 pregnancies where the HgbA1c was measured in the same patient on the same day as or before the 1-hour GCT was performed. The median time interval between performance of the HgbA1c test and the 1-hour GCT was 95 days (IQR 56-122 days). Among women with HgbA1c levels less than or equal to 4.9, 5.0, and 5.1, the probability of their 1-hour GCT being 140 mg/dl or less was 91.3%, 91.0% and 90.1%, respectively. Among our study population, 14.5%, 22.8%, and 35.0% had HgbA1c levels less than or equal to 4.9, 5.0 and 5.1, respectively. Among women with HgbA1c levels greater than 6.1, the probability of their 1-hour GCT being greater than 140 mg/dl was 100%. However, only 0.3% of our population had HgbA1c greater than 6.1.

CONCLUSION:

Our study adds to the body of evidence that HgbA1c cannot replace the 1-hour GCT as a screening test for gestational diabetes, but low values can reliably predict a normal 1-hour GCT. Therefore, some women could be spared from doing the 1-hour GCT.
Cervical Cancer Knowledge and Screening Practices Among Undocumented Compared to Documented Hispanic Women [37B]
Authors: Mehta Naaman , Raker Christina , Robison Katina
Published: May 2019

INTRODUCTION:

To compare cervical cancer knowledge, screening practices and barriers to screening between undocumented and documented Hispanic women.

METHODS:

We administered an anonymous cross-sectional survey of self-identifying Hispanic women over age 21 in Rhode Island. The survey included demographics, immigration status, and questions related to cervical cancer knowledge, screening practices, and barriers to screening. Participants were stratified based on their immigration status. Categorical variables were compared by chi-square or Fisher exact test. Knowledge scores were compared by t-test. P-values <.05 were considered statistically significant. Study received IRB exemption.

RESULTS:

Seventy-three undocumented women and 70 documented women were included. Eighty-eight percent of undocumented women and 47% of documented women did not have health insurance (P<.0001). Undocumented women had a significantly lower mean knowledge score [3.53 SD 1.97] compared to documented women [4.43 SD 2.04)] (P=.0085), and also experienced more barriers to having a Pap smear or HPV test (P=.001). Sixty-two percent of undocumented women felt that their lack of documentation was a barrier to cervical cancer screening, compared to 28% of documented women (P<.0001). Fifty percent of undocumented and 47% of documented women had never heard of the HPV vaccine. Eighty percent of women eligible for the vaccine (between ages 21 and 32) had never received the vaccine.

CONCLUSION:

Lack of legal documentation appears to be an independent barrier to cervical cancer screening among Hispanic women. Challenges inherent to being undocumented may contribute to women's lower knowledge scores and more pronounced barriers. Future interventions should address barriers to improve health practices among undocumented Hispanic women.
Evaluation of Risk-based Colposcopy for Cervical Precancers Detection in the ASCUS LSIL Triage Study [40B]
Authors: Liu Angela H. , Schiffman Mark , Gage Julia C. , Castle Phillip E. , Wentzensen Nicolas
Published: May 2019

INTRODUCTION:

To validate previously shown improved efficiency of cervical precancers detection by risk-based colposcopy-biopsy in the Biopsy Study.

METHODS:

Included in the study were 2,453 women with ASCUS or LSIL referral cytology in the HPV triage and immediate colposcopy arms who underwent enrollment colposcopy. Enrollment cytology, HPV genotyping, and colposcopy impressions were used to establish 12 risk strata. Up to four lesion-directed cervical biopsies were taken during enrollment colposcopy. Primary outcomes were cervical intra-epithelial neoplasia grade 2 or worse disease detected by colposcopy-guided cervical biopsies at baseline and during the two-year follow up.

RESULTS:

The risk of detecting CIN2 or worse disease ranged from 1-85.5% across the 12 risk strata based on colposcopy impressions, study cytology, and HPV 16 status. As in the Biopsy Study, the lowest risk stratum (normal/acetowhite or benign abnormality, <HSIL cytology, and HPV 16 negative) falls below the clinical risk threshold to perform colposcopy by ASCCP guidelines; the same four risk strata with at least two of the high-risk categories (high-grade colposcopy impression, high-grade squamous intraepithelial lesion cytology, or HPV 16 positive) exceed the ASCCP recommended threshold for immediate treatment. Overall, 60-80% of women continued in the two-year study period. Except for the highest-risk strata, the negative predictive value of a negative enrollment colposcopy ranged 82.4-96% during follow-up.

CONCLUSION:

We show that data from the ASCUS-LSIL Triage Study confirm the risk-based colposcopy approach to improve detection of cervical precancers. Taking multiple biopsies reassures against missed disease and women with negative colposcopy may return to routine screening.
Fetal MRI: Trends in Use and the Effect on Diagnostic Accuracy of Fetal CNS Anomalies [17C]
Authors: Williamson Mary H. , Kunselman Allen , Stetter Christy , Pauli Jaimey M.
Published: May 2019

INTRODUCTION:

The study objective was to examine trends in fetal MRI (fMRI) use and compare prenatal and postnatal diagnoses of fetal central nervous system (CNS) anomalies in a regional perinatal program. Prior studies have shown that fMRI improves diagnostic accuracy of CNS anomalies, altering counseling and management.

METHODS:

This was a chart review of 51 patients with fetal CNS anomalies enrolled in a perinatal program from 1/1/12 to 7/31/17. IRB approval was obtained. The Cochran Armitage Trend test was used to trend fMRI use over time. To assess diagnostic accuracy, we categorized the prenatal and postnatal diagnoses as same, different, or same with additional findings. We used a chi-square test to compare the percentages of these categories between the fMRI and non-fMRI groups.

RESULTS:

fMRI was performed in 64.7% of patients. Compared to ultrasound, fMRI demonstrated additional findings in 54.6% of cases and different findings in 3%. There was no statistically significant increase in fMRI use (p=0.45); however, there was an increasing trend in fMRI use from 2013-2017. For fMRI patients, 15 (45.5%) had the same diagnosis postnatally, 5 (15.2%) had a different diagnosis, and 13 (39.4%) had the same diagnosis with additional findings, compared to 4 (22.2%), 5 (27.8%), and 9 (50.0%), respectively, of patients without fMRI (p=0.23).

CONCLUSION:

Despite a promising trend, fMRI use did not increase significantly. While not statistically significant, our results show a higher rate of diagnostic accuracy with fMRI compared to without. Further studies with multiple programs may delineate use of fMRI, improving quality of care and outcomes.
Adverse Pregnancy Outcomes in Sickle Cell Disease With Abnormal Placental Weight to Birthweight Ratios [27C]
Authors: Dziegielewski Claudia , D'Souza Rohan D. , Keating Sarah , Wou Karen , Shehata Nadine , Malinowski Ann Kinga
Published: May 2019

INTRODUCTION:

Low placental weight to birthweight (PW:BW) ratio is a marker of abnormal placental development, and is linked with perinatal morbidity and mortality. Sickle cell disease (SCD), the most common hemoglobinopathy worldwide, is associated with placentally-mediated complications; yet, PW:BW ratios in this context have not been studied. Our aim was to investigate PW:BW ratios in pregnancies of women with SCD, and its association with adverse pregnancy outcomes.

METHODS:

Research ethics board approval was obtained, and records of women with SCD were retrospectively reviewed between January 1, 2000 to December 31, 2017 at our institution. For twin pregnancies, neonatal data for a randomly chosen single twin was included. Significance was set at P<.05.

RESULTS:

Seventy-one pregnancies in 66 women, including 3 twin pregnancies, were analyzed. Low PW:BW ratio (<10th centile) is associated with male fetal sex [22/40 with low ratio (55%) vs 7/31 with normal ratio (23%), P=.006] and preterm birth [20/40 with low ratio (50%) vs 7/31 with normal ratio (23%), P=.018]. There was no association of low PW:BW with small-for-gestational-age infants [8/40 with low ratio (20%) vs 10/31 with normal ratio (32%), P=.239], stillbirth [3/40 with low ratio (8%) vs 1/31 with normal ratio (3%), P=.627], or maternal hypertensive disorders of pregnancy [5/40 with low ratio (13%) vs 7/31 with normal ratio (23%), P=.261].

CONCLUSION:

Low PW:BW ratio is more prevalent in male fetuses, and associated with preterm birth. The lack of association with other adverse pregnancy outcomes may be based on histologic placental adaptation. Further investigation is necessary to elucidate contributing factors.
Opioid Use and Pregnancy Outcomes in Women With a Hypertensive Disorder of Pregnancy [31C]
Authors: Greiner Karen S. , Speranza Rosa J. , Rincon Monica , Beeraka Sridivya S. , Burwick Richard M.
Published: May 2019

INTRODUCTION:

Opioid use in pregnancy is increasing dramatically and is associated with poor maternal and neonatal outcomes. We sought to evaluate the relationship between opioid use and pregnancy outcomes among women with hypertensive disorders in pregnancy.

METHODS:

Retrospective cohort study among subjects with a hypertensive disorder of pregnancy that delivered ≥23 weeks gestation at a single institution (October '13-April '18). After IRB approval, subjects were stratified into two groups by opioid use (heroin, methadone or Subutex): current vs. non-users (never, quit prior to or during pregnancy). Differences were analyzed by Fisher's exact, t-test, and logistic regression, with Î±=0.05.

RESULTS:

From 10,833 deliveries, 1,487 (13.7%) were classified with a hypertensive disorder of pregnancy. 41 subjects (2.8%) actively used opioids during pregnancy, 1,098 (73.8%) were non-users and 348 (23.4%) were excluded due to unknown opioid use. Subjects using opioids were more likely to be covered by public insurance and using other substances. There were no differences in final hypertensive diagnosis for opioid users vs. non-users (p=0.26), although opioid users more often had severe diastolic blood pressure (≥110 mmHg) compared to non-users (p=0.012). Opioid use was associated with both adverse maternal and neonatal outcomes, which remained significant after adjustment for maternal characteristics and other substance use (aOR: 2.99, p=0.033 and aOR: 3.13, p=0.009, respectively).

CONCLUSION:

Among women with a hypertensive disorder of pregnancy, opioid use is associated with a 2-3 times increased odds for both adverse maternal and neonatal outcomes compared to non-users. These findings highlight the need to limit opioid use in pregnancy.
Rapidly Absorbing Polyglactin 910 Versus Poliglecaprone 25 for Laceration Repair: A Randomized Controlled Trial [38Q]
Authors: Morrell Lindsay Helene , Glass Clark Stephanie Marie , Morrell Christopher , Carroll Ashley Woodward
Published: May 2019

INTRODUCTION:

To evaluate rates of pain and dyspareunia after first and second degree obstetric perineal laceration repair with rapidly absorbing polyglactin 910 compared to poliglecaprone 25.

METHODS:

This is an IRB approved randomized controlled trial comparing rapidly absorbing polyglactin 910 and poliglecaprone 25 for first and second degree obstetric perineal laceration repair. The study was conducted at a single academic medical center. Subjects were enrolled and randomized at time of delivery, prior to laceration repair. Telephone surveys were conducted during the postpartum period for primary and secondary outcomes. Subjects responded using a validated 10-point pain questionnaire to assess perineal pain at six weeks. The Female Sexual Function Index (FSFI-6) was used to elicit dyspareunia at twelve weeks. Fisher exact tests were used to perform analysis.

RESULTS:

335 women were enrolled and 276 were included in final analysis. Subjects were of similar BMI, age, gravidity, parity, and laceration type. Dyspareunia did not differ between suture types (3.49±1.47 v 3.60±1.40, P=.16). Sexual desire was significantly higher in those who received rapidly absorbing polyglactin 910 (2.51±1.04 v 2.87±1.11, P=.01). Perineal pain was not different between suture types and was minimal at six weeks postpartum.

CONCLUSION:

Dyspareunia and perineal pain are not significantly different when obstetric perineal lacerations are repaired with either rapidly absorbing polyglactin 910 or poliglecaprone 25, which supports surgeon preference. Sexual desire is higher in those receiving rapidly absorbing polyglactin 910, though additional studies are needed to further characterize this finding.
Postpartum Contraception at Bridgeport Hospital [1R]
Authors: Germain Ashley St. , Onda Saki , Laifer Julie Lauren , Presnick Carole
Published: May 2019

INTRODUCTION:

ACOG supports immediate postpartum LARC provision as a means to reduce unintended and short interval pregnancies. Immediate postpartum contraception became routinely available at Bridgeport Hospital in 2016. The aim is to determine uptake, choice, and continued use of postpartum contraception at our institution.

METHODS:

Using an EPIC-generated list of all deliveries at Bridgeport Hospital for calendar years 2015 and 2017. Institutional IRB waiver was obtained. After sorting for only clinic service deliveries we performed a systematic chart review of each patient looking at demographic data, pregnancy and delivery information, contraceptive choice antepartum and postpartum, and pregnancies within one year of delivery. Data collection for 2017 in still ongoing.

RESULTS:

In 2015 and 2017, there were 326 and 202 Bridgeport Hospital OB/GYN Clinic deliveries, respectively. The demographic characteristics were similar for both cohorts. 92% in 2015 of patients had antepartum counseling on contraception compared to 97% in 2017. In 2015, 44% desired a LARC and 59% received one. Comparatively, in 2017, 53% desired a LARC and 92% received one. Over 80% of patients returned for a postpartum visit. Among patients who had their IUD or implant removed, 75% were for side effects. The percentage of short interval pregnancies in 2015 was 12% and 13% in 2017.

CONCLUSION:

LARCs were the most often requested contraception, and antepartum counseling has improved. Our hospital policy allowing immediate postpartum LARCs led to the majority of patients receiving their desired method. Whether this has led to a reduction in short interval pregnancies requires further investigation.
Examining the Validity of a Predictive Model for Vaginal Birth After Cesarean [22P]
Authors: Wong Jennifer W.H. , Yoshino Kurt D. , Kaneakua-Pia Iolana , Chang Ann L.
Published: May 2019

INTRODUCTION:

The validated Maternal-Fetal-Medicine Units (MFMU) vaginal birth after cesarean (VBAC) calculator, while accurate for candidates with a high predicted success rate, is not as accurate for poor candidates. We examined the validity of the calculator in an understudied multiracial cohort with a high proportion of poor candidates.

METHODS:

This retrospective cohort study examined women with 1 or 2 prior cesarean deliveries who attempted VBAC at a single institution from 2010 to 2016. Subjects were placed into quartiles based on MFMU predicted success rates. For each quartile, actual and predicted success rates were compared. The calculated area under the receiver operating characteristic curve (AUC) was compared to the original AUC.

RESULTS:

1,604 women were included. Actual and predicted VBAC rates were similar in the lowest and highest quartile groups, 18.2% vs 21.2% (n=11) and 87.1% vs 88.5% (n=1090) respectively. In the 51-75% predicted success rate group, actual VBAC rate was higher than the predicted rate, 69.9% vs 65.5% (n=394), but statistical significance was not achieved (P-value=0.07). In the 26-50% predicted success rate group, actual success rate was significantly higher than the predicted rate 55.1% vs 39.6% (p=0.002). The AUC was lower than the MFMU model, 0.72 (95% CI 0.69-0.75) vs 0.77 (95% CI 0.76-0.78) (P-value=0.0003).

CONCLUSION:

The MFMU VBAC calculator's predicted success rates were comparable to actual success rates if the predicted success rate was greater than 50%. The calculator was inaccurately low for subjects with predicted success rates of 50% or less. Caution should be taken when using the calculator in this group.
Factors Associated With the Publication of Registered Randomized Controlled Trials in Obstetrics [18K]
Authors: Wagner Stephen , Chauhan Suneet P. , Gupta Megha
Published: May 2019

INTRODUCTION:

In an effort to improve transparency, as part of the Food and Drug Amendment Act of 2007, Congress mandated that randomized clinical trials (RCTs) be registered on clinicaltrials.gov. The aim of this review was to identify factors associated with the publication of registered RCTs on obstetrical topics.

METHODS:

Study data was collected from the National Institutes of Health (NIH) database at clinicaltrials.gov. The database was queried by NIH recommended obstetrical terms for trials with a registered start date from 2009-2013. Self-reported descriptive data of the registered studies was abstracted. PubMed was interrogated for all self-identified completed projects for publication information by September 2018.

RESULTS:

Over the five-year study period, 412 obstetrical RCTs were registered and 266 (65%) were completed. Among the completed RCTs, 166 (62%) were published in a MEDLINE indexed journal. Compared to projects without publication, projects that resulted in publication had a larger sample size (median 179 vs 97.5 P<.005), and were more likely to be multicenter studies (P <.022). There was no difference in publication rates between United States-based or international studies (P<.56). Industry-funded projects were less likely to be published than those funded by the NIH (P<.017). Studies involving drug, device or procedure interventions were more likely to result in publication (P<.014).

CONCLUSION:

About 2 in 3 completed randomized control trials on obstetrical topics are published within five-years of being completed. Interventions may be necessary to increase the completion and publication rate of registered RCTs.
Group Prenatal Care for Pre-gestational Diabetes: A Feasibility Study for a Randomized Control Trial [22K]
Authors: Addae-Konadu Kateena Lovely , Stepanek Tricia , Hackney David , Ehrenberg Stacey
Published: May 2019

INTRODUCTION:

Group prenatal care has been shown to improve clinical outcomes, increase patient satisfaction, and reduce healthcare cost in contrast to individual prenatal care for low risk pregnancies. However, this model has not been evaluated in the high risk pregnant population. This study evaluated the feasibility of a randomized control trial (RCT) to investigate the effectiveness of group prenatal care on neonatal outcomes in a population of pregnant women with pre-gestational diabetes.

METHODS:

A prospective cohort of 68 pre-gestational diabetic women receiving prenatal care at University Hospitals were randomly assigned to either individual or group prenatal care. Group care participants met bimonthly for an integrated educational curriculum designed to deliver both prenatal and diabetes care. Sessions included self-physical assessment, education, and group discussion. Neonatal outcomes including birth weight, gestational age at delivery, NICU admission and length of stay, hypoglycemia, and RDS were compared.

RESULTS:

No significant differences were observed between women assigned to group versus individual care for rates of NICU admission 39.2% compared to 41.3%, RDS 28.6% versus 27.6%, and rates of hypoglycemia 19.3% compared to 16.2%. Similarly, no significant differences were noted between group versus individual care for mean NICU stay 3.4 days compared to 2.9 days, median gestational age at delivery 37.0 wga (IQR =35-38) versus 36.5 wga (IQR= 35.5-38), and median birth weight 3.27kg (IQR= 2.87-3.64) compared to 3.32kg (IQR=2.9-3.74]).

CONCLUSION:

A RCT comparing group versus traditional prenatal care is feasible without increasing neonatal morbidity/mortality. A larger RCT is needed to better understand the benefits of group prenatal care for pre-gestational diabetes.
How Uncertain Are Patients in Regards to Invasive Prenatal Genetic Diagnostic Testing? [25K]
Authors: Milone Gina F. , Pastore Lisa , Davis Jay , Buckley Ayisha , Persad Malini D. , Herrera Kimberly M.
Published: May 2019

INTRODUCTION:

The purpose of this project is to determine patients' decisional certainty regarding the use of invasive prenatal genetic diagnostic testing (PGDT).

METHODS:

Cross-sectional design, IRB-approved study. Voluntary, anonymous questionnaire (Q) assessing patient decision making process in regards to invasive (CVS and/or amniocentesis) PGDT. Q (paper and online options) were distributed from 2017-2018 to those undergoing genetic testing in a university academic practice. Questions (7 items on certainty, 5-point Likert scale) were structured to evaluate patient decisional certainty, and were partly adapted from published validated Q's. Exclusion criteria: English or Spanish illiterate. Means, variances (SD), and ranges were tabulated.

RESULTS:

50 female patients returned the study; 38 (76%) completed it entirely. Patients mean age was 31.76±6.07 years and 79% were Caucasian. 75% had equal PGDT decision making with their partner. Most were referred due to a positive carrier screen, or a positive cell free DNA result. 71% of patients had already made a decision at the time of the Q. Participants expressed high certainty of their decision to do PGDT (mean 3.18 on a 1=uncertain to 5=certain scale, SD 0.79). Non-white women appeared to have greater decisional certainty than white patients (3.54 (SD 0.6) v 3.08 (SD 0.8), respectively).

CONCLUSION:

Patients are very certain in their decision-making regarding PGNT; however this may be a reflection of when they completed the survey as most did so after deciding on PGDT.
Systemic Predictors of Non-Prescription Gender Affirming Hormone Use [32K]
Authors: Stroumsa Daphna , Crissman Halley P. , Dalton Vanessa Kathleen , Richardson Caroline R.
Published: May 2019

INTRODUCTION:

Transgender people face multiple barriers to accessing needed healthcare. Use of nonprescription hormones for gender affirmation may pose significant health risks. We aim to assess systemic factors affecting nonprescription hormone use among transgender people.

METHODS:

We used data from the United States Transgender Survey, a large convenience sample of 27,000 transgender adults in the U.S., collected between August and September of 2015. Respondents who indicated that they were currently taking gender affirming hormones and were not on active military duty were included in the study (n =12,095). Weighted multivariable logistic regression and predictive margins were used to generate odds ratios.

RESULTS:

Of 12,095 people who were using gender affirming hormones and were not on active military duty, 9.36% (n=1,000) were receiving hormones from sources other than a licensed professional, and 19.71% (n=2,536) reported denial of hormone coverage by insurance. The odds of using nonprescription hormones was higher among transfeminine respondents (OR 5.08, 95% CI 3.44-7.51, P < 0.001), Asian and multiracial-identified respondents, those who were uninsured, who had negative experiences when accessing care (OR 1.58, 95% CI 1.06-2.36, P= 0.026), and those who were denied insurance coverage (OR 2.54, 95% CI 1.64-3.94, P<0.001).

CONCLUSION:

Barriers to accessing affirming care and to coverage of treatment were associated with increased risk of non-prescription hormone use. Future research is needed to explore potential interventions to decrease non-prescription use and its potential harms, such as coverage of hormone therapy, provider trainings, and harm-reduction strategies.
The Utility of Annual Pelvic Exams in Asymptomatic Women [33K]
Authors: Byron Rhiannon K. , Watkins Virginia Y. , Stiles Alexandra , Trieu Elissa , Truong Mireille D.
Published: May 2019

INTRODUCTION:

The annual pelvic exam has been a part of women's preventative health care for decades, yet the ACP and ACOG's recommendations regarding its necessity are inconsistent. Currently, there are little data to support the value of annual exams in asymptomatic, non-pregnant individuals. This study was performed to determine the utility of the pelvic exam in this population.

METHODS:

This was a retrospective cohort study of patients seen for annual gynecologic exam at an urban academic hospital performed between June 2015 and 2016. Data collected included chief complaint, history, exam findings, work-up, diagnosis, and treatment. Descriptive statistics were calculated for demographic characteristics, and frequencies were calculated for findings of interest. Pearson chi-square analyses were conducted for comparisons.

RESULTS:

Of 1,118 annual pelvic exams, a significant difference was found between the number of abnormal exam findings in symptomatic women (41.4%) and in asymptomatic women (13.2%) (P<.0001). Within the asymptomatic population alone, the diagnostic sensitivity of the exam was 77.2% with specificity of 94.9%. The majority of false negatives were associated with abnormal Pap findings given otherwise normal exams. The exam was diagnostic in 20.1% of asymptomatic cases with greater than 13% requiring treatment based on its findings. The majority of the diagnoses, however, included cervical dysplasia, infection, and atrophy.

CONCLUSION:

In this study, the annual pelvic exam detected fewer abnormalities in asymptomatic patients than in those who presented with gynecologic symptoms. Its utility at the time of annual visit should be discussed with patients individually and may be unnecessary if a patient is asymptomatic.
Implementing Same-Day Discharge After Hysterectomy Within a Large, Multi-Hospital Healthcare System [1L]
Authors: Linkov Faina , Edwards Robert P. , Shalkar Adambekov , Harris John , Mansuria Suketu M.
Published: May 2019

INTRODUCTION:

Same day discharge (SDD) for minimally invasive hysterectomies (MIH) often promises to save healthcare resources and improve satisfaction among patients and providers. Previous studies established the safety of SDD, however data are limited on how to effectively integrate SDD programs in heterogeneous healthcare systems consisting of tertiary care centers and smaller community hospitals. The goal of this work is to describe the implementation of a SDD process within UPMC--a large, multi-hospital health system in Pennsylvania.

METHODS:

Implementation of SDD was studied through stakeholder interviews including surgeons, nurses, and administrators. Participants were asked about the development and implementation of the SDD program including facilitator and barrier factors at 20 hospital of various sizes, with sub-specialists as well as general gynecologists. To determine the best course for integrating SDD, small multidisciplinary working groups were established with representatives from relevant departments. University of Pittsburgh IRB approved this work.

RESULTS:

System development of the program included formation of evidence based guidelines, development of protocols, hiring of a nurse concierge, quality checks, SDD pathway introduction into EMR, surgeon performance dashboards, incentives for following the pathway, etc. The program was piloted by a small group of surgeons, followed by integration within the wider UPMC community. Provider buy-in was encouraged through surgeon education and the use of outcomes data. SDD program resulted in considerable reduction in overnight stays associated with hysterectomies.

CONCLUSION:

It is safe and feasible to implementing a SDD program for MIH within a heterogeneous health care system through a multi-step process of providing processes, systems, and education.
Length of Hospital Stay and Costs Associated With Laparoscopic Versus Vaginal Hysterectomy: Study of 1,553 Patients [4L]
Authors: Elsamadicy Emad A. , Mehta Sumit , Le Chi , Brown Kelsei , Lee Jaclyn
Published: May 2019

INTRODUCTION:

The aim of this study was to assess whether there was a difference in length of hospital stay (LOS) and total hospital costs associated with Total Laparoscopic Hysterectomy (TLH) versus Total Vaginal Hysterectomy (TVH) for benign indications.

METHODS:

Medical records of 1,553 adult women undergoing elective TLH or TVH at a major academic institution from 2010 to 2015 were reviewed. CPT codes used for TLH included [58570-58573] and for TVH included [58260-58263, 58270, 58290-58294]. Patient demographics, LOS and total hospital cost associated with hospitalization for hysterectomy were collected.

RESULTS:

Of the 1,553 patients, 988 (63.6%) underwent TLH and 565 (36.4%) underwent TVH (TLH: n=988 vs. TVH: n=565). There was significant differences in Age, with TVH cohort being older (TLH: 44.9±10.3 years vs. TVH: 53.1±13.1 years, P<.0001). The majority of patients were White, with greater proportion in TVH cohort (TLH: 77.9% vs. TVH: 86.0%, P<.0001). There were significant differences in insurance status, with TLH cohort having greater proportion of patients with Commercial/Private (31.7% vs. 23.4%, P=.0005), BlueCross/BlueShield (34.1% vs. 32.2%, P=0.446), Medicaid (14.8% vs. 11.0%, P=.034), and lesser proportion with Medicare (11.0% vs. 26.0%, P<.0001). LOS was significantly greater for TVH cohort (TLH: 1.15±0.89 days vs. TVH: 1.47±0.87 days, P<0.0001). However, TLH cohort had significantly greater mean hospital costs of approximately $10,000 compared to TVH cohort (TLH: $40,518±16,243 vs. TVH: $30,295±12,201, P<.0001).

CONCLUSION:

Our study suggests that there are significant differences in LOS and total hospital costs associated with TVH and TLH, respectively. Further studies are necessary to optimize surgical decision making for hysterectomy.
Management of Pyomyoma After Embolization of Large, Submucosal Fibroid With Emergent Vaginal Myomectomy [5L]
Authors: McKendrick Rebecca , Garneau Audrey , Hoffman Mark , Raissi Driss
Published: May 2019

INTRODUCTION:

Pyomyoma is a rare complication after uterine fibroid embolization.

METHODS:

We present a case of a 27 year old nulligravid patient who underwent uterine fibroid embolization for symptomatic uterine fibroids and subsequently developed a pyomyoma. Patient consent was obtained for submission of case report.

RESULTS:

She had a complex medical and surgical history, including osteosarcoma as a child and two previous open myomectomies for large fibroids. The second myomectomy was complicated by a pulmonary embolization during her postoperative hospitalization. Another large, 10.6 cm posterior uterine fibroid with a submucosal component was found three years after her second myomectomy. She was counseled about alternatives to myomectomy and hysterectomy, and she elected for uterine fibroid embolization. Forty-one days after an uncomplicated procedure, she presented to the emergency room with a two day history of abdominal pain, fever, and vaginal discharge. She appeared ill and diaphoretic, with a heart rate in the 130's and a leukocytosis of 31 k/uL. Imaging at that time revealed a mass containing air concerning for pyomyoma with endomyometritis. Exam under anesthesia revealed a soft, gray mass, prolapsing from her dilated cervix. She was treated with transvaginal myomectomy and intravenous antibiotics. She did well postoperatively and four months later has not required additional treatment.

CONCLUSION:

Though definitive management of a pyomyoma is hysterectomy, our patient was successfully managed conservatively with vaginal myomectomy and intravenous antibiotics. Of the six reported pyomyomas after uterine fibroid embolization, hysterectomy was performed in four cases, laparoscopic drainage in one case, and one case did not report therapy.