bluuebunny/crossref_metadata_2025 huggingface dataset:
Pregnancy Outcomes in Women with Rheumatoid Arthritis: A Retrospective Population-Based Cohort Study [7N]
Authors: Aljary Hissah , Czuzoj-Shulman Nicholas , Spence Andrea , Abenhaim Haim Arie A.
Published: April 2018

INTRODUCTION:

Rheumatoid arthritis (RA) is a chronic autoimmune, inflammatory disease that is more commonly found in women. Our objective is to assess if pregnancies in women with RA are at a higher risk of adverse maternal and neonatal outcomes.

METHODS:

We carried out a retrospective cohort study, using the US Healthcare Cost and Utilization Project National Inpatient Sample from 2004-2013. All births were identified and women were classified as having RA or not on the basis of ICD-9 coding. Logistic regression was used to evaluate the adjusted effect of RA on maternal and neonatal outcomes.

RESULTS:

Of the total 8,417,607 births in our cohort, 6,068 were among women with RA. There was a steady increase in RA in pregnancy from 47 to 100/100,000 over the 10-year study period. Compared with women without RA, women with RA were more likely to experience pre-eclampsia/eclampsia (OR 1.70, 95% CI 1.54-1.89), gestational diabetes (OR 1.13, 95% CI 1.02-1.24), PPROM (OR 1.78, 95% CI 1.66-1.91), placental abruption (OR 1.43, 95% CI 1.16-1.76), placenta previa (OR 1.37, 95% CI 1.05-1.78), and to deliver by cesarean section (OR 1.38, 95% CI 1.31-1.45). Congenital anomalies (OR 2.11, 95% CI 1.65-2.72), small for gestational age (OR 2.36, 95% CI 2.09-2.66) and preterm birth (OR 1.81, 95% CI 1.67-1.95) were more common in neonates of women with RA.

CONCLUSION:

RA in pregnancy is associated with greater likelihood of adverse maternal and neonatal outcomes. Women with RA should be made aware of these risks and be followed as a high risk pregnancy.
Interest and Attitudes Toward Global Health Training of Prospective Obstetrics and Gynecology Residents [4O]
Authors: Hoang Christine , Felini Martha , Nguyen Nguyen
Published: April 2018

INTRODUCTION:

The benefits of global health training in clinical education have been well described in graduate medical education literature. Despite these benefits there is a lack of global health training offered by OBGYN residency programs nationally. The purpose of the study is to assess prospective OBGYN residents’ interests and attitudes toward such training and the results can potentially help develop an educational curriculum and clinical training opportunity.

METHODS:

A survey was developed to assess prospective residents’ views on global health training. Questions utilized a Likert scale response. Additional questions included demographics and prior global health experience. The anonymous, voluntary survey was distributed to our OBGYN residency applicants who interviewed in 2016-2017. Univariate and bivariate analysis was conducted. Fisher exact tests and two-sided p values were calculated to determine statistically significant differences.

RESULTS:

The response rate was 50/62. 76% were likely to participate in an offered elective. 94% agreed that residencies should offer voluntary electives. 64% expressed interest in incorporating global health into future practices. Scheduling conflicts were perceived as the greatest barrier to participation. Learning about public health systems and gaining procedural experience were the main interests. Over 50% had prior global health experience.

CONCLUSION:

Findings suggest that applicants to our OBGYN residency believe a global health elective should be offered in residency training and a majority would participate if given the opportunity. With the strong interest and positive attitudes toward a global health elective, steps can be taken to develop a curriculum and training opportunity.
Improving Resident Experience on a Gynecology Rotation by Implementing a Formal Curriculum and Feedback System [12O]
Authors: Wong Thalia , Rodriguez-Triana Valentina
Published: April 2018

INTRODUCTION:

Surgical and inpatient gynecologic training is variable between obstetrics and gynecology residency programs. As a result, resident experiences may be impacted. We sought to determine if implementing a structured curriculum and feedback system for an inpatient gynecology rotation impacts resident learning and satisfaction.

METHODS:

Prior to implementing changes on an inpatient gynecology rotation at an academic hospital, a 13 question survey, including ratings from 1 to 5 and true-false responses, was administered to residents who had completed the rotation. The following academic year, the gynecology rotation was modified to include structured learning objectives, teaching conferences, anatomy wet lab simulations, and rotation feedback. The same survey was administered to residents who completed their rotation following the modifications. Wilcoxon sum rank test and chi squared analyses were used to compare responses between the two groups.

RESULTS:

From July 2015 to July 2017, 48 residents completed the gynecology rotation. A total of 47 residents responded to the survey, 24 (51%) completed the survey prior to the changes and 23 (49%) took the survey after. Following implementation of a structured curriculum and feedback system, residents rated their experience of the rotation overall significantly higher (P = 0.01) and found pre-operative teaching conferences more structured and valuable (P < 0.001). The post-intervention group also felt they received more benign surgical feedback (P = 0.004) and mid-rotation feedback (P = 0.002).

CONCLUSION:

A formalized curriculum that consists of clear goals and expectations, structured teaching time, formalized anatomy training, and regular feedback is an effective method of improving gynecology residents’ inpatient and surgical training experience.
A Multi-Modality Pelvic Anatomy Education Program for Ob/Gyn Residents [15O]
Authors: Suh Christina , Mulheron George , O'Brien Devon , Esguerra Cybill , Pradhan Archana , Balica Adrian
Published: April 2018

INTRODUCTION:

Understanding pelvic anatomy is essential to training as an ob/gyn. In most residency programs, residents learn anatomy through self-guided reading and direct experiences in the operating room, which can be limited by time constraints and patient safety concerns. The purpose of our study was to develop and assess a novel pelvic anatomic education program for residents.

METHODS:

We utilized three different learning modalities: cadaveric dissection on unused cadavers from our medical school’s anatomy course, clay models of the pelvic floor, and didactic lectures. The cadaver dissection was presented in a “mock surgery” format. Learning objectives and relevant procedures were established for each year of training: abdominal wall anatomy and cesarean section for first years, pelvic spaces and abdominal hysterectomy for second years, presacral space and sacrocolpopexy for third years, and pelvic neuroanatomy for fourth years. Participants completed before and after multiple choice tests and a qualitative survey.

RESULTS:

16 residents from all 4 years of training were recruited to participate in the program. The average pre-test score was 45% and average post-test score was 50%, (p=0.22). The majority of participants strongly agreed that the program was interesting (67%), enhanced their understanding of pelvic anatomy (73%), and increased their confidence in the operating room (53%).

CONCLUSION:

Our multi-modality pelvic anatomy program improved residents’ anatomic knowledge (although this was not statistically significant) and was well received as a clinically applicable educational activity. The cadaveric lab mirrored the gynecological surgical curriculum of our residency and was cost efficient through collaboration with the anatomy department.
Uterine Sacculation of Di-Di Twin pregnancy [24O]
Authors: Sadek Seifeldin , Tendler Shlomo , Demirel Esra
Published: April 2018

INTRODUCTION:

Uterine sacculation is a rare complication of pregnancy. It may cause substantial peri-partum morbidity including pain and rarely uterine rupture. It consists of a transitory out-pouching or sac-like structure developing from an abnormal forward or backward rotation of the uterine fundus.

METHODS:

A 36 year old female with past medical history significant for Crohn’s disease, total proctocolectomy, and resolved cervical prolapse who presented at 16 weeks gestation with severe pelvic pain and intermittent urinary retention. Physical exam and confirmatory MRI revealed the suspected diagnosis of uterine incarceration. Initially there was temporary improvement with exam under anesthesia and bimanual exam to dis-impact the uterus. Repeat attempts at bimanual exam had no success. Out of concern for thick pelvic adhesions inhibiting uterine mobility and the risk of uterine rupture the patient was taken for minimally invasive surgery.

RESULTS:

After a diagnostic laparoscopy, and thorough uterine manipulation using a single hand gel port the uterus was confirmed to not be truly incarcerated, rather to have a posterior uterine sacculation likely leading to the extreme pain. Post op course was complicated by prolonged and excessive pain symptoms. PMNR specialists were brought in to assist with management for the duration of this painful pregnancy and to assist with prevention of the unfortunate sequela of prolonged opiate use. The patient ultimately also sought out non-western modalities of pain management.

CONCLUSION:

Diagnosis of uterine sacculation can be difficult. Patients can present with symptoms mimicking incarceration, including severe pain and urinary retention. There is a reported minimal risk of uterine rupture.
Clinical Management of Unknown Group Beta Streptococcus Status [30O]
Authors: Ibarra Claudia J. , Murphy Robert E. , Sirajuddin Anwar , Blackwell Sean C. , Refuerzo Jerrie S.
Published: April 2018

INTRODUCTION:

The objective of this study was to determine adherence to the Centers for Disease Control (CDC) guidelines for Group Beta Streptococcus (GBS) results available at the time of delivery.

METHODS:

A retrospective cohort review was conducted including women admitted for delivery who received prenatal care within the prior 6 weeks. Women were divided into groups including positive, negative and unknown GBS status. Source and effects of GBS status on adherence to CDC guidelines were collected.

RESULTS:

Of the 97 women who met study criteria, 20.6% (N=20) had unknown status, 26.8% (N=26) positive result and 52.6% (N=51) negative result. In 10% of women with unknown status, the result was available on electronic health record (EHR) with interface between outpatient with inpatient setting. The remaining 90% of cases did not have access to GBS results obtained in the prenatal setting. Adherence to CDC guidelines occurred in 45% (N=9) of these women in which antibiotics were administered only with known risk factors. Non-adherence occurred in 55% of cases such that 11 women received unnecessary antibiotic exposure even in the absence of risk factors. Moreover, when the GBS results were eventually available, 2 were negative.

CONCLUSION:

In our study, less than 50% of women with unknown GBS status received therapy in compliance with CDC recommendations. Efforts should be made to ensure EHR access to prenatally obtained GBS results and to educate health care providers regarding the potential harms of exposure of unindicated therapies.
Maternal and Fetal Outcomes in Pregnancies Affected by Aplastic Anemia: A Systematic Review [31O]
Authors: Idler Jay , Patek Kara , Patwardhan Sanjay
Published: April 2018

INTRODUCTION:

Aplastic anemia is a rare and potentially fatal condition, affecting between 2 and 6/1,000,000 pregnancies in the United States. The primary objective of this review was to identify adverse maternal and fetal outcomes associated with aplastic anemia complicating pregnancy.

METHODS:

We conducted a systematic review of published literature to identify all observational and randomized studies evaluating pregnancy outcomes in women diagnosed with aplastic anemia. A combination of keywords was used to identify the maximum number of relevant citations in MEDLINE, EMBASE, CINAHL and the Cochrane Database.

RESULTS:

We identified 17 observational studies (70 women), which evaluated outcomes in pregnancies complicated by aplastic anemia. Overall, in 36 out of 70 (51.4%) cases at least one significant maternal complication was reported (Table 1). The most common maternal complications included antepartum and/or postpartum hemorrhage, which occurred in 11 (15.7%) cases, and postpartum relapse which developed in 13 (18.6%) cases. Three (4.3%) women experienced intracranial hemorrhage or thrombosis, while four (5.7%) women died within 1 year of pregnancy. Across these reported cases, pancytopenia was observed with a mean starting hemoglobin of 6.9g/dL, white blood cell count of 2.7x109/L and platelet count of 31x109/L. In 14 of 31 (45.2%) cases preterm birth ensued, with 20% of the women delivering prior to 34 weeks. Three cases of intrauterine fetal demise were also reported.

CONCLUSION:

This review demonstrates the significant adverse maternal and fetal outcomes in pregnancies complicated with aplastic anemia. The findings from this review may aid in counselling and managing obstetric patients suffering from this rare condition.
Use of Tranexamic Acid to Prevent Postpartum Hemorrhage in Women Undergoing Vaginal Delivery: A Meta-Analysis [36O]
Authors: Boyd Angela R. , Vasichko Paula E. , Ireland Kayla E. , Roman Tania , Acosta Ometeotl M. , Ramsey Patrick S.
Published: April 2018

INTRODUCTION:

Randomized clinical trials (RCT) have evaluated the use of tranexamic acid (TXA) for treatment and prevention of postpartum hemorrhage (PPH), but there is currently insufficient evidence to support prophylactic use. Our objective was to conduct a systematic review and meta-analysis using available data from RCTs that evaluated the efficacy of prophylactic utilization of TXA at the time of vaginal delivery.

METHODS:

A systematic literature review was conducted using PUBMED and MEDLINE from 1966-2017 using relevant search terms. Secondary citations from retrieved papers were also reviewed. Outcome data from RCTs were abstracted and meta-analysis was conducted using the Mantel-Haenszel fixed effects model with test of heterogeneity.

RESULTS:

Three RCTs were identified for the prophylactic use of TXA at the time of vaginal delivery, for a total of 659 women. Compared to placebo, prophylactic administration of TXA significantly reduced mean blood loss (MBL) (659 women, odds ratio (OR) 0.54, 95% confidence interval (CI) 0.41-0.71), decreased incidence of MBL > 500 cc (two studies, 559 women, OR 0.48, 95% CI 0.26 to 0.88), decreased incidence of PPH > 1000 cc, (two studies, 559 women, OR 0.28, 95% CI 0.1 to 0.81), and decreased the use of additional medical interventions (three studies, 659 women, OR 0.27, 95% CI 0.13 to 0.57). No thromboembolic events were reported.

CONCLUSION:

Prophylactic administration of TXA following vaginal delivery decreases MBL, decreases the incidence of PPH and reduces the need for additional medical intervention. Additional research is needed to elucidate optimal regimens to maximize efficacy and minimize risk.
Opioid Remission in Pregnancy: Effects On Maternal and Fetal Outcomes [37O]
Authors: Seymour-Willey Alicia , Zhou Clarice , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

With the rising opioid epidemic, literature has explored the effect of maintenance therapies and detoxification in opioid-dependent pregnancy. However, the outcomes of pregnancy in the opioid remit population have not yet been ascertained. This study will examine the effect of remission on maternal and fetal outcomes of pregnancy compared to a general population.

METHODS:

A retrospective cohort study of 1,853,219 singleton gestations in California compared pregnancy outcomes of women with opioid remission to general population data. Maternal outcomes comprised cesarean deliveries, placental abruption, postpartum hemorrhage, and preeclampsia/eclampsia. Neonatal outcomes included preterm delivery (<37, <34, <32 weeks), intrauterine fetal demise, neonatal death (NND), respiratory distress syndrome, hypoglycemia, jaundice, asphyxia, neonatal seizures and neonatal abstinence syndrome (NAS). Hospital outcomes measured maternal and infant length of stay (LOS). Comparisons were performed using multivariate regression analyses, and Chi-square tests; a p-value of <0.05 was considered statistically significant.

RESULTS:

Opioid remission showed a statistically significant increase in NND, NAS, maternal/infant LOS, and infant hospitalization cost. Pregnancy outcomes of women in opioid remission showed a significantly greater likelihood of maternal sepsis (OR 6.24, 95% CI 1.54-25.26), placental abruption (OR 3.34, 95% CI 2.48-4.50), and neonatal seizures (OR 7.19, 95% CI 3.39-15.24). Mean hospitalization was $7,474 more for the neonate (p <0.001). Maternal LOS (2.71 versus 2.48 days, p<0.001) and neonate LOS (4.66 versus 2.50, p<0.001) were substantially increased.

CONCLUSION:

Remission has detrimental effects on pregnancy compared to a general population, and significantly increases NND, NAS and mother-baby dyad hospitals costs. For further analysis, a prospective trial is needed.
Exam Indicated Shirodkar Versus McDonald Cerclage: A Retrospective Review [38O]
Authors: Morgan Elizabeth A. , Gill Lisa , Hart Bethany , Tessier Katelyn , Morgan Elizabeth A.
Published: April 2018

INTRODUCTION:

Cervical cerclage is an effective intervention for the prevention of preterm birth. The most commonly described techniques are McDonald and modified Shirodkar cerclage. Older literature suggests no evidence for preferential benefit between them, however more recently Shirodkar is favored as superior for history indicated placement. There are limited data comparing their use for exam indicated cerclages. We hypothesized that placement of an exam indicated Shirodkar cerclage would result in delivery at a later gestational age with a longer latency period compared to McDonald cerclage.

METHODS:

This is a retrospective cohort study. All exam-indicated cerclage procedures placed between April 1, 2011 and February 1, 2017 were collected from a single center. Exposure was defined as Shirodkar or McDonald cerclage. Primary outcome was gestational age at delivery, and secondary outcome was latency period to delivery. Continuous variables were compared with t-tests, categorical variables were compared with Chi-squared and Fisher’s exact tests. Results were adjusted for co-variants with linear regression.

RESULTS:

105 exam indicated cerclages, 82 McDonald and 23 Shirodkar were included. No significant difference existed between gravidity, race, BMI, chorioamnionitis, or membrane exposure. After adjustment for antibiotic and tocolytic use, Shirodkar cerclage was associated with later gestational age at delivery (36.5 weeks vs 32.3 weeks, p=.009), and longer latency (15.9 wks vs 12.3 wks, P = . 03) than McDonald cerclage.

CONCLUSION:

Placement of exam indicated Shirodkar cerclage results in longer latency and later gestational age at delivery. These findings are consistent with previously reported superior outcomes with the Shirodkar technique in history and ultrasound indicated cerclage.
Comparison of Umbilical Artery Flow Velocity Waveforms with Fetal Perfusion Pressures in Ex Vivo Placenta Cotyledon [5P]
Authors: Pino Daniela , Bednov Andrey , Carillo Maira , Maguire Christopher , Maher James , Schlabritz-Lutsevich Natalia
Published: April 2018

INTRODUCTION:

The spectral Doppler indices obtained during antenatal sonography are used to evaluate placental resistance in vivo because direct measurement of flow volume in utero is not easily attainable. Placental perfusion pressures obtained from an ex-vivo placental cotyledon can be calculated at standardized flow rates. We sought to compare the ex vivo pressures to in utero Doppler flow indices.

METHODS:

Dual perfused ex vivo human placenta cotyledons from 28 women delivered at 37-39 weeks (IRB #L-014) were cannulated. The inflow pressure (IFP) in the fetal artery at inflow velocity of 4.5 ml/min as well as cotyledon weight were recorded. The umbilical artery flow velocity waveform analysis from routine antenatal sonography was retrospectively collected in twelve women at a mean gestational age of 35.6 +2.5 weeks. The S/D ratio, RI, and PI were obtained.

RESULTS:

The IFP correlated negatively with the cotyledon weight (r=.0485, P=.009) The raw Doppler indices were not significantly correlated with placental or fetal weight, However, if the pressure controlled for cotyledon weight was compared to Doppler index controlled for placenta weight, there was a positive correlation between Doppler RI and placental perfusion pressure. (p=.0086). There was a weak negative correlation between IFP and estimated the fetal weight at the time of ultrasound. (r=.47, p=.06).

CONCLUSION:

Small placental vessels are responsible for the resistance calculated in the umbilical artery. In the dually perfused placenta, our study suggests that the pressure in the functional placental unit of a perfused cotyledon is correlated with the Doppler flow indices on antenatal ultrasound.
When to Deliver Dichorionic Diamniotic Twins in the Setting of Preeclampsia [12P]
Authors: Walker Allison R. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Dichorionic diamniotic (DCDA) twin pregnancies are at increased risk of preeclampsia (PET), intrauterine growth restriction (IUGR) and intrauterine fetal demise (IUFD). Our study compared outcomes of induction of labor (IOL) at 34 through 37 weeks to determine the most favorable gestational age for delivery in DCDA twin pregnancies complicated by mild PET.

METHODS:

A decision analytic model was created using TreeAgePro 2017 software to compare the outcomes of expectant management versus IOL at 34 to 37 weeks of gestational age. Outcomes examined included quality adjusted life years (QALYs), cases of advancement from mild to severe PET, maternal mortality, maternal stroke, IUGR, IUFD, cerebral palsy (CP) and neonatal mortality. Probabilities, utilities, and life expectancies were derived from the literature. Univariate analyses were used to investigate the impact of labor induction at various gestational ages.

RESULTS:

In a theoretical cohort of 10,000 DCDA pregnancies complicated by PET, IOL at 34 weeks resulted in the fewest cases of severe PET (0), maternal stroke (15), maternal mortality (4), IUFD (0), and IUGR (1,183). However, this strategy was also associated with the most cases of neonatal CP (91) and neonatal mortality (87). Neonatal CP was lowest in the 37 week IOL strategy group (46) and neonatal mortality was lowest with IOL at 36 weeks (65). QALYs were highest (868,112) when IOL occurred at 36 weeks.

CONCLUSION:

DCDA twin pregnancies complicated by mild PET should be induced at 36 weeks. When compared to IOL at 37 weeks, this strategy reduces maternal and neonatal morbidity and mortality.
Preconception Cardiac Risk Factors in African American Women with Low Birth Weight Term Deliveries [22P]
Authors: Gold Kellyanne R. , Gold Robert A. , Schilling Mark , McGrady Christopher
Published: April 2018

INTRODUCTION:

Maternal history of low birth weight (LBW) (<2500 g) delivery is associated with increased maternal cardiovascular mortality. We sought to evaluate cardiovascular risk factors pre-conception in African American (AA) women for term pregnancy LBW.

METHODS:

The CARDIA Study was initiated in 1985 to study the evolution of cardiac risk factors in young adults 18 to 30 years old. We studied first pregnancy after baseline at Years 2 and 5 in AA women. Subjects with chronic health conditions were excluded. An uncontrolled (univariate) analysis was performed with birth weight (BW) as the dichotomous variable (BW<2500 gm, BW>2500 gm) which assessed risk associated with blood pressure (BP), age, body mass index (BMI), glucose, serum lipids, parity, and tobacco usage at baseline. A second analysis with a logistic regression model was designed with BW as the dichotomous response variable as above and systolic-BP/diastolic-BP, age, BMI, smoking status, and gestational age as the explanatory variables.

RESULTS:

The uncontrolled analysis demonstrated systolic-BP 113.3 (BW<2500 gm, N=18) vs systolic-BP 106.7 (BW>2500 gm, N=255) (P<.003, two-tailed-Student-T) and current smokers 61% (BW < 2500 gm) vs nonsmokers 25% (BW>2500 gm) (P<.002). Other variables were non-significant in the uncontrolled analysis. The logistic regression model demonstrated that maternal age and BMI were not significant, whereas gestational period was significant (P<.033), smoking status was significant (P<.018) and systolic-BP was highly significant (P<.006).

CONCLUSION:

Elevated normal range systolic-BP preconception in AA women is associated with subsequent term pregnancy LBW delivery. The results suggest a possible common predisposition to both LBW and subsequent cardiovascular mortality.
Pregnancy outcomes in an obstetrical Type I Diabetic patient population, Insulin pump vs insulin injections. [24P]
Authors: Hernandez Celso , Lesser Karen , Reed Kathryn
Published: April 2018

INTRODUCTION:

Objective: To analyze pregnancy outcomes between two different methods of insulin delivery in an obstetrical type I diabetic patient population.

METHODS:

Study Design: A retrospective chart review of an obstetrical type I diabetic was analyzed from a single institution. These patients were separated into those utilizing a continuous subcutaneous insulin pump (CSI) and those receiving multiple daily injections of insulin (MDDI). Subsequently, the data pertinent to the different antenatal and postnatal outcomes was collected. Statistical analysis with student t-test and Chi square test was done as applicable.

RESULTS:

There were no statistical differences in the outcomes between these two groups when comparing age, parity, gestational age, BMI, starting weight, weight at delivery, number of years since diagnosis, weight gain during pregnancy., neonatal birthweight, neonatal hypoglycemia, shoulder dystocia, macrosomia, and primary C-section rate. The HgA1C of the CSI was statistical significant lower when compared to MDDI in first trimester(p<.003), second (p<.03) and third trimester (p<.01).The total number of insulin units needed to treat patients in the CSI was statistically significant lower when compared to MDDI in the first(p<.04), second(p<.004) and third trimester(p<.006).The weight retention at 1 year postpartum was statistically significant lower in the CSI when compared to the MDDI (p<.04).

CONCLUSION:

Pregnancy outcomes were comparable between these two methods for many variables. However, CSI appears to offer an advantage in minimizing the insulin quantity needed during pregnancy and reducing weight retention postpartum in the setting of optimal blood sugar control.
Third Trimester Detection of Fetal Growth Abnormalities in Obese Pregnant Women: A Retrospective Cohort Study [31P]
Authors: Razzaq Khadija , Cotton-Caballero Amaya , Pettit Kate , Boyle Annelee , Ferguson James , Dudley Donald
Published: April 2018

INTRODUCTION:

To determine if, in pregnant obese women, prenatal ultrasonography (US) can accurately predict abnormal birthweight (BW) in newborns.

METHODS:

We conducted a retrospective chart review of singleton deliveries of obese women between January 1, 2014 and March 31, 2015 at UVA. IUGR was defined as an EFW <10% while LGA was defined as EFW > 90%. BW was categorized into normal (2500-3999 grams), low (<2500 grams), and macrosomic (≥4000 grams). Chi squared tests and logistic regression were used for analyses.

RESULTS:

We included 307 women in our study. Indicated third trimester growth US for chronic hypertension or diabetes occurred among 17.6% (54/307) of women. Among the remaining women without these indications, 70.4% (178/253) had at least one follow up US. Overall, 22.3% (44/197) of newborns had a discordant prenatal EFW and BW. For macrosomic infants, 13.9% (5/36) were LGA prenatally, while 58.33% (21/36) appeared normal. Among low BW (LBW) newborns, 13.2% (5/38) had IUGR prenatally, while 44.8% (17/38) had a normal EFW. Normal BW infants were rarely diagnosed as IUGR (1/232, 0.5%) or LGA (5/232, 2.2%). A BMI 35-40 (OR=0.41, 95%CI: 0.18-0.96), having 2-3 US (OR=0.31, 95%CI: 0.12-0.76), and diabetes (OR=0.41, 95%CI: 0.18-0.94) reduced the odds of predicting LBW and macrosomia.

CONCLUSION:

In obese women, there is a high rate of discordance between prenatal fetal growth abnormalities and actual BW. Having a higher BMI or another comorbidity reduces the accuracy of predicting abnormal BW. Prenatal prediction of LBW or macrosomia does not improve after the first follow up growth US.
Endometrial Safety of Low Dose Vaginal Estrogens in Menopausal Women [39P]
Authors: Constantine Ginger , Mirkin Sebastian , Bernick Brian , Liu James
Published: April 2018

INTRODUCTION:

2.3 million women use low dose vaginal estrogen products to treat symptomatic vulvar and vaginal atrophy (VVA) in the US. Most women do not take a concomitant progesterone. A systematic literature search was conducted on the risk of endometrial hyperplasia/cancer and the use of unopposed vaginal estrogen products.

METHODS:

PubMed and EMBASE were searched for journal articles related to the use of vaginal estrogens in postmenopausal women published in the English language. A total of 5,593 abstracts were reviewed; 37 articles reported vaginal estrogen use and endometrial histology.

RESULTS:

There were 20 randomized studies with a total of 2,747 women exposed to vaginal estrogen for up to one year; there was no evidence of an increased risk of endometrial hyperplasia/cancer in association with vaginal estrogen products. Other interventional and observational studies identified during the systematic review do not support an increased risk of endometrial hyperplasia or endometrial cancer with low dose vaginal estrogen. The exception is a registry from Denmark that was inconsistent with other studies evaluated and of limited applicability to the US.

CONCLUSION:

The available evidence from systematic review does not support an increased risk of endometrial hyperplasia or endometrial cancer with low dose vaginal estrogen; however, there are limitations with the applicability of current reports to new lower dose products.
Investigating Antibiotic Usage in Patients Undergoing Gynecologic Surgery [2Q]
Authors: Brunozzi Sabrina C. , Wilcox Brian
Published: April 2018

INTRODUCTION:

Multiple studies have shown that indiscriminate antibiotic usage is linked to the development of antibiotic-resistant strains of bacteria. For gynecologic surgeries, the American Congress of Obstetricians and Gynecologists (ACOG) recommends the prophylactic usage of antibiotics for hysterectomy, urogynecologic procedures, hysterosalpingogram, and induced abortion. Conversely, ACOG does not recommend antibiotic prophylaxis in patients undergoing clean procedures with fewer risks for infection.

METHODS:

Based on these recommendations, a retrospective chart review was conducted of all women (N=1,338) who underwent gynecologic surgery between April 2015 and April 2016 at Moses Taylor Hospital in Scranton, PA and the use or non-use of antibiotics was analyzed in each case. Data that was collected included age, race, insurance provider, type of gynecologic procedure performed, antibiotic prescribed, and timing of administration.

RESULTS:

The results of this study showed that 161 of 167 patients (96.4%) received antibiotics appropriately when undergoing a procedure in which an antibiotic was indicated. Conversely, 210 of 1,171 patients (17.9%) received inappropriate antibiotic treatment when undergoing procedures where antibiotics were not indicated. Hysteroscopy was the most common procedure in which antibiotics were given inappropriately.

CONCLUSION:

We recently implemented a quality improvement intervention targeted to improve compliance with ACOG recommendations. This includes dissemination of the recommendations in a simplified chart in the pre-operative areas and operating rooms, and re-training of surgeons, surgical staff, and anesthesia staff. The post-intervention phase is about to begin and the results will be presented. Improvement in outcomes and lessons learned from the intervention can potentially be used as a model for other institutions.
Ulipristal Acetate Impact on Fibroid Volume: Integrated Results From VENUS I and II [11Q]
Authors: Lukes Andrea , Simon James A. , Fu Yiyong , Sniukiene Vilma , Catherino William
Published: April 2018

INTRODUCTION:

Uterine fibroids (UFs) are common benign tumors that can cause heavy menstrual bleeding (HMB). Ulipristal acetate (UPA), an oral selective progesterone-receptor modulator, suppresses uterine bleeding and reduces fibroid cell size by inducing apoptosis and breakdown of the extracellular matrix.

METHODS:

In the randomized, double-blind, placebo-controlled, Phase III VENUS I and II studies, pre-menopausal women (18-50 years of age) with ≥1 UF and HMB were randomized to placebo, UPA 5 mg, or UPA 10 mg once daily for 12 weeks (one treatment course [TC] for VENUS I and two TCs for VENUS II), with a 12-week treatment-free follow up. Efficacy endpoints included mean change from baseline in total volume of (up to) the three largest UFs (measured by transvaginal ultrasound). VENUS I and II results were pooled only for the first TC for analysis of fibroid volume changes.

RESULTS:

Integrated results after the first TC demonstrated significant fibroid volume reduction from baseline with UPA 5 mg (n=170) vs placebo (n=125) (-11.4% and +6.8%, respectively; P=.0037) and UPA 10 mg (n=165) vs placebo (-14.2% and +6.8%, respectively; P<.001). After the second TC of UPA 5 mg (n=70) and 10 mg (n=59), further volume reduction was seen (-11.7% and -23.0%, respectively), which remained reduced at the 12-week treatment-free follow up (-16.0% and -31.5%, respectively).

CONCLUSION:

Both UPA doses, vs placebo, significantly reduce fibroid volume in women with UFs, with greater reduction observed with UPA 10 mg.
The Safety of RT for the Management of FIGO Stages IA-IIA Cervical Cancer: An Updated Meta-Analysis with TSA [27Q]
Authors: Feng Ying , Zhang Zihan , Lou Tong , Wang Shuzhen , Bai Huimin , Zhang Zhenyu
Published: April 2018

INTRODUCTION:

This study aimed to evaluate the safety of RT for the management of stages IA-IIA cervical cancer and to initiate new investigations based on the findings of previous studies published in the literature.

METHODS:

The PubMed, EMBASE, Web of Science and Cochrane databases were searched to collect correlational, prospective, CCTs published in English from 1984 to April 2017. A meta-analysis and TSA were performed to evaluate the oncologic and reproductive outcomes of patients treated with RT.

RESULTS:

A total of 5 prospective CCTs with 818 patients were ultimately pooled in this analysis. The recurrence and death rates were similar between RT and RH. Patients with a tumor 2-4 cm in diameter were more likely to be treated with RH than RT, which might be a potential contributor to the higher ratio of postoperative adjuvant chemotherapy in this patient group. Additionally, RH was associated with a significantly higher risk of intraoperative blood transfusion. The TSA indicated that the cumulative number of patients failed to fulfill the required sample size. Promising negative section margins were obtained through RAT, but patients with a tumor 2-4 cm in diameter were more likely to be treated with RH. Moreover, the clinical outcomes of RAT were slightly more favorable than those of RVT.

CONCLUSION:

RVT is safe and feasible for early-stage cervical cancer patients with a tumor less than 2 cm in diameter. RAT could be cautiously recommended as an alternative for patients with a tumor 2-4 cm in diameter. However, further CCTs are warranted to validate these results.
Pregnancy After Bone Marrow Transplantation for Aplastic Anemia [37Q]
Authors: Idler Jay , Patwardhan Sanjay , Gonik Bernard
Published: April 2018

INTRODUCTION:

Patients with a past history of aplastic anemia treated by bone marrow transplantation (BMT) and immunosuppression are rarely seen in pregnancy. As there is limited literature on the role of prenatal screening, and the management of these patients, we are reporting unusual outcomes of a pregnancy in a patient with a remote history of treated aplastic anemia.

METHODS:

A systematic retrospective chart review was performed for a patient identified in our high risk clinic who was noted have aplastic anemia, previously treated with bone marrow transplantation and immunomodulators. We followed her through the entirety of her pregnancy and are now reporting on her outcomes.

RESULTS:

A 35-year-old patient with a history of aplastic anemia treated with BMT and immunosuppressive therapy presented in her first trimester for prenatal care. Noninvasive prenatal testing (NIPT) was uninterpretable, and QUAD screening was low risk, with the exception of an elevated maternal serum alpha-fetoprotein (MSAFP). Early intrauterine fetal growth restriction (IUGR) was diagnosed at 21 weeks’ gestation which persisted through the rest of her gestation. Cesarean delivery was performed at 28 weeks 3 days gestation, for recurrent fetal heart rate decelerations.

CONCLUSION:

Selective use of cffDNA (cell free fetal DNA) technology for NIPT should be utilized for patients who have undergone BMT in the past. SNP testing relies on hematopoietic derived cells for analysis, which does not reflect the patient’s germline (ova), therefore should not be obtained. The observed fetal growth restriction may have been influenced by the pre-transplant whole body radiation including the maternal pelvic structures.
Post-Operative Pain Control: A Retrospective Study Investigating the Impact of Anesthetic Choice for TAP block [2R]
Authors: Morrison Christopher , Schuler Kevin , Devaiah Ganga , Maetzold Erin , Crisp Catrina
Published: April 2018

INTRODUCTION:

Transversus abdominis plane (TAP) block has been shown to decrease narcotic requirements, lower pain scores, and decrease length of hospital stay in the post-operative setting. Variation exists regarding choice of anesthetic agent used to perform the block. We investigate the impact of anesthetic choice on TAP block in gynecologic oncology patients undergoing laparotomy via midline vertical incision.

METHODS:

This is a retrospective cohort study involving 70 patients from a large academic referral center from 2014-2017 undergoing TAP block for perioperative pain control. Subjects received either bupivacaine or liposomal bupivacaine for TAP. Narcotic use for post-operative day 0-3 was the primary outcome, with post-operative pain scores and hospital length of stay as secondary outcomes.

RESULTS:

Average age was 56 years with the bupivacaine group being older: 58 vs. 52 years (p=0.012). No significant differences were found among post-operative narcotic requirements. Pain scores at regular intervals up to 72 hours between groups were also not different. When analyzing timing of the TAP, there was no difference in narcotic requirements or pain scores when the TAP was performed before or after the surgical procedure. Lastly, choice of anesthetic did not impact hospital length of stay.

CONCLUSION:

No significant differences were found between bupivacaine and liposomal bupivacaine with regard to post-operative narcotic requirements, pain scores, or length of hospital stay in gynecologic oncology patients undergoing laparotomy. A prospective approach to investigate anesthetic choice and timing would be needed in order to better investigate timing and anesthetic choice.
Characteristics and Outcomes of Unexecuted Postpartum Sterilization in High Risk Low Income Obstetrical Patients [10R]
Authors: Persad Malini D. , Staszewski Cara , Ly Victoria , Garry David , Quirk J. Gerald
Published: April 2018

INTRODUCTION:

To determine the characteristics and outcomes associated with unexecuted postpartum sterilizations in high risk low income obstetrical patients.

METHODS:

A retrospective cohort study of pregnant women desiring postpartum sterilization from a high risk, Medicaid based, obstetrical practice was undertaken at a university based hospital from January-June 2014. Women who did not undergo postpartum sterilization were compared to those who underwent the postpartum procedure during the hospital stay. Maternal demographic factors, medical history, obstetrical history and mode of delivery were extracted from the medical record. Women who did not undergo sterilization were assessed for contraception utilized, obstetrical follow up, unintended pregnancy rate and subsequent adverse pregnancy outcomes. Groups were compared with the use of parametric and non-parametric tests with a p <0.05 as statistically significant.

RESULTS:

Over the 6-month period, 73 high risk low income women were identified, with 40% failing to undergo postpartum sterilization during their hospital stay. Women were less likely to undergo sterilization if they were younger, single, and had a vaginal birth. In those not undergoing the procedure, 31.0% received an alternative form of contraception, 6.9% received interval sterilization, 27.5% had unintended pregnancies of which 12.5% had a subsequent adverse pregnancy outcome and 31.0% were lost to follow up.

CONCLUSION:

Failure to perform postpartum sterilization results in a high unintended pregnancy rate and adverse subsequent pregnancy outcomes. In those with unfulfilled procedures, efforts should be made to provide alternative contraception and planned follow up prior to discharge.
Nomogram Use to Predict Obstetric Anal Sphincter Injuries prior to Term Vaginal Delivery [14R]
Authors: Kim Youngwu , Leung Katherine , Leftwich Heidi , Hebert Kasey , Masiero Jessica , Moore Simas Tiffany A.
Published: April 2018

INTRODUCTION:

Obstetric anal sphincter injuries (OASIs) following vaginal delivery are a significant complication. We previously identified and published significant independent risk factors for OASIs. A validated OASIs prediction model for women with known risk factors planning vaginal delivery is needed to facilitate patient counseling and shared treatment decision-making.

METHODS:

We performed a retrospective cohort study including women having had vaginal deliveries (2006-2015), with demographic and obstetric data abstracted through medical record review. Results were adjusted for potential confounding factors. Nomogram developed using logistic regression analyses that included risk factors taken from published OASIs literature. Dataset was divided into training and test datasets for internal validation. Prediction nomogram was constructed using regression-based coefficient scoring system with a correlated probability of OASIs.

RESULTS:

Among 16,024 included vaginal delivery, 1106 (6.9%) were complicated with an OASIs. Predictors identified in the train cohort were: Asian race, nulliparous status, increased age, birth-weight, birthweight-maternal body mass index ratio (BW:BMI), smoking status, gestational age, parity, episiotomy, trial of labor after cesarean, and operative vaginal deliveries. The constructed nomogram was internally validated.

CONCLUSION:

This study confirmed known OASIs risk factors among women having term vaginal deliveries. Furthermore, we established and validated a novel nomogram for the prediction of OASIs for the women giving vaginal deliveries with known risk factors for severe perineal laceration. If nomogram is externally validated, it would be an excellent counseling tool for women with increased probability of OASIs.
Fetal Myelomeningocele: Antenatal Characteristics and Pregnancy Outcomes [19R]
Authors: Munoz Jessian , Bishop Elaine , Singh Katherine
Published: April 2018

INTRODUCTION:

Spina bifida is the most common fetal anomaly of the central nervous system, which affect 1:1000 live births in the United States. Myelomeningocele is the most common presentation of spina bifida, representing half of these cases. Given the meningeal membrane sac may contain spinal cord, cerebrospinal fluid and nerve roots, this defect results in significant morbidity to infants and major life-long disabilities. In this study we aimed to identify maternal and fetal characteristics associated with expectant management or termination of pregnancy in the setting of antenatally diagnosed Myelomeningocele.

METHODS:

A retrospective cohort analysis was performed with patients who had presented to the Cleveland Clinic Fetal Care Center between 2005-2017. Live births then followed up at the pediatric Myelomeningocele clinic within our institution.

RESULTS:

Our data showed 40% of patients with antenatally diagnosed Myelomeningocele elected for second trimester terminations vs. 60% who chose to continue either by cesarean section or vaginal delivery. Based off ultrasound findings, there were no significant differences among these two groups. Maternal body mass index was significantly higher in those who continued pregnancies (p<0.05). In addition, the fetal diagnostic methods chosen by patients was significantly different. Those who elected to terminate were more likely to pursue amniocentesis instead of MRI characterization of the fetus (p<0.02).

CONCLUSION:

Taken together, we conclude, in the setting of antenatally diagnosed Myelomeningocele, patients often rely less on the associated ultrasonographic findings and depend more on maternal characteristics as well as fetal diagnostics in determining whether to continue or terminate pregnancy in the second trimester.
Efforts and Interventions for Reducing Cesarean Delivery in China [25R]
Authors: Wang Yue J. , Ayers Charletta , Bachmann Gloria A.
Published: April 2018

INTRODUCTION:

The rate of cesarean section (CS) delivery, has been generally increasing worldwide. Although the US has been cited for this increasing rate, the trend is more pronounced in areas of China, which has drawn substantial efforts from the Chinese government and health care professionals to try to reduce the CS rate to the WHO recommended level. This abstract will review the major causes associated with high cesarean rate in China and explore effective interventions addressing the issue.

METHODS:

A literature review was conducted in WHO world reports, Chinese government statistics, PubMed and Chinese databases WANFANG and VIP using the key terms “cesarean section”, “intrapartum management”, “psychological intervention”.

RESULTS:

The leading medical indications of CS in China were fetal distress, cephalopelvic disproportion, malpresentation, previous cesarean delivery, elderly primigravida and suspected macrosomia, which were comparable to the US data. Notably, cesarean delivery also occurred in 10-38.4% of the total CS number, largely resulting from sociological and psychological reasons, such as best outcome for one child family. Interventions to reduce CS in China include 1) Government and regional health commissions implementing incentives and regulations to set target CS rate limits for hospitals; 2) Prenatal patient education, focusing on understanding the course and mode of delivery; 3) Full intrapartum accompaniment by an experienced nurse or midwife.

CONCLUSION:

Reducing cesarean deliveries beyond medical necessity is a multifactorial, challenging task, faced by many countries, and is not limited to the US. China also is implementing initiatives to stem the high cesarean delivery rate.