bluuebunny/crossref_metadata_2025 huggingface dataset:
Postpartum Hemorrhage and Very Advanced Maternal Age [28M]
Authors: Freeman H. Austinn , Salmeen Kirsten , Shirazi Aida , Morocco Sarah
Published: April 2020

INTRODUCTION:

Postpartum hemorrhage (PPH) is an important cause of maternal morbidity. Identifying women at increased risk for PPH can help reduce morbidity. The aim of this study was to determine if women over 45 years (very advanced maternal age, VAMA) are at increased risk for PPH.

METHODS:

Retrospective study of term, nulliparous women with singleton fetuses in vertex presentation who delivered at Kaiser Permanente Northern California Hospitals from 2010-2017 with complete data recorded. Incidence of PPH (estimated blood loss >500 cc for vaginal delivery, >1,000 cc for cesarean delivery, or other definitive chart evidence) among women over 45 years was compared to incidence of PPH among younger women. Logistic regression was used to adjust for confounders.

RESULTS:

There were 98,922 women included, including 177 women over 45 years. PPH occurred in 33.3% of women >45 years as compared to 15.6% of women 45 years had significantly increased odds of PPH as compared to women <35 years (OR 1.88, 95% CI 1.35–2.61).

CONCLUSION:

These data demonstrate that VAMA is an independent risk factor for PPH. This knowledge provides physicians with an opportunity to counsel patients over 45 years regarding the risk for PPH and to prepare for delivery with strategies including optimization of blood count, planning for delivery location and procurement of appropriate blood products before delivery.
Readmission Risk Factors for New-Onset Postpartum Hypertension: A Retrospective Case-Control Study [30M]
Authors: Burns Ralph N. , Has Phinnara , Werner Erika
Published: April 2020

INTRODUCTION:

Few studies have characterized new-onset postpartum hypertensive disorders of pregnancy (HDP). We sought to identify features associated with newly diagnosed HDP requiring postpartum readmission.

METHODS:

This was an IRB-approved retrospective, single-center, case-control study of women aged 18 years or older, who were discharged after delivery without a diagnosis of HDP, between January 2013 and September 2018. Cases were women readmitted within 42 days of delivery with a new diagnosis of HDP. Non-readmitted controls were matched to cases based on mode of delivery and gestational age at delivery. We hypothesized an increased odds of readmission would be associated with a blood pressure elevation greater than or equal to 130 mmHg systolic or 80 mmHg diastolic in the 24 hours before initial hospital discharge. We targeted a sample of 100 cases, with a 2:1 control-to-case ratio, to identify an odds ratio of 2.0 with 80% statistical power.

RESULTS:

Ninety-one cases of new-onset HDP were identified and matched to 182 controls. Significant differences between cases and controls were older age (33.3 vs 29.4 years, P<.01), black race (26% vs 10%, P<.01), and adherence to IOM weight gain guidelines (27% vs 13%, P<.01), respectively. Amongst cases, 66% had a blood pressure greater than or equal to 130/80 in the 24 hours before discharge, compared to 29% of controls. This difference remained significant after adjusting for potential confounders (aOR 4.31; 95% CI 2.46–7.57).

CONCLUSION:

Among postpartum women without HDP, “subclinical” blood pressure elevations may help identify women at risk of postpartum readmission.
Reducing Postpartum Readmissions Utilizing Different Blood Pressure Interpretation Strategies [31M]
Authors: Mukhtarova Narmin , Chen Yu-Hsin , Alagoz Oguzhan , Hoppe Kara Kjersten
Published: April 2020

INTRODUCTION:

American College of Obstetricians and Gynecologists (ACOG) recommends blood pressure (BP) greater than 150/100 mmHg, on two occasions at least 4-6 hours apart for initiation of postpartum anti-hypertensive treatment whereas the utility and validity of this strategy for predicting readmission is unknown. This study aimed to determine the impact of different BP interpretation strategies and cutoffs on predicting readmission.

METHODS:

A retrospective cohort of 24,917 women who delivered at a single Midwestern academic center between 1/2009 and 6/2015. BP values measured between delivery and 72 hours postpartum were used to evaluate three different BP interpretation strategies: 1) average BP, 2) maximum BP exceeding the BP cutoff on one occasion, and 3) maximum BP exceeding the BP cutoff on two occasions at least 4 hours apart. Receiver operating characteristic curves (ROC) and the area under the curve (AUC) were used to measure the predictive performance of these strategies. The UnityPoint Health-Meriter IRB approved this study.

RESULTS:

ACOG’s recommended cutoff of 150/100 mmHg had 38% sensitivity and 95% specificity whereas the same strategy with cutoff of 140/90 mmHg demonstrated 71% sensitivity and 84% specificity. The AUC for the three strategies: AUC 0.81; 95% CI 76.95-85.08 (Strategy 1); AUC 0.79; 95% CI 74.7-82.81 (Strategy 2); AUC 0.83; 95% CI 79.83-87.24 (Strategy 3). The difference between the AUC of Strategy 2 and 3 was significant (P<.0001).

CONCLUSION:

The strategy of using maximum BP exceeding the cutoff on two occasions at least 4 hours apart at lower cutoff can predict readmissions with higher sensitivity and/or specificity.
Stricter Hypertension Guidelines: Should We Be More Concerned Postpartum? [37M]
Authors: Weeks Corinne M. , Leung Katherine , Leftwich Heidi K.
Published: April 2020

INTRODUCTION:

Studies have shown women with hypertensive disorders of pregnancy have increased risk of hypertension and cardiovascular disease later in life. In 2017, the American College of Cardiology (ACC)/American Heart Association (AHA) developed new hypertension guidelines defining Stage I hypertension as a blood pressure greater than or equal to 130/80. We sought to identify characteristics associated with Stage I hypertension in the 3-24 months postpartum period.

METHODS:

A retrospective, IRB approved cohort study on postpartum hypertension from deliveries from 07/09-07/16. Inclusion criteria were delivery at our institution, presence of a hypertensive disorder of pregnancy, and a documented blood pressure between 3-24 months postpartum. Exclusion criteria were chronic hypertension and discharge home on antihypertensive medication. Postpartum hypertension was defined by the 2017 ACC/AHA definition. Chi-square test was used for categorical variables. Student T-test was used for continuous variables.

RESULTS:

444 women met inclusion and exclusion criteria. Of these women, 349 (79%) were identified as having hypertension 3-24 months postpartum. Women with persistent hypertension were more likely to receive antepartum antihypertensive therapy (P=.04), be older (P=.022), have a higher pre-pregnancy BMI (P=.002), and be multiparous (P=.017). There were no differences amongst other study variables.

CONCLUSION:

Approximately 79% of women in our cohort remained hypertensive. Women that were persistently hypertensive were more likely to be older, have a higher pre-pregnancy BMI, be multiparous, and be treated antepartum with an antihypertensive agent. This large incidence of postpartum hypertension as well as identifying characteristics warrants further study, as identifying these women early may improve follow up and long-term outcomes.
The Utility of Shock Index in Identifying Patients Requiring Blood Transfusions Postpartum [39M]
Authors: Shanahan Lisa K.T. , Sidle Meg Wright , Wajid Naji , Mover Kelly , Vullo John , Gurram Padmalatha
Published: April 2020

INTRODUCTION:

Early intervention for treating postpartum hemorrhage is often delayed due to compensatory mechanisms. Shock index ({SI} heart rate/systolic blood pressure) is used to predict the effects of hemorrhage in non-pregnant patients. SI>1 (normal=0.5-0.7), indicates shock requiring intervention. The objective is to establish SI threshold for patients requiring blood transfusion (BT) within 24 hours of delivery and to determine the earliest time to identify SI changes.

METHODS:

A retrospective study of patients delivered after 37 weeks between 2014 and 2019. Patients that received BT (Group 1) were compared to patients that did not (Group 2). SI at time of admission and every 4 hours for 24 hours was analyzed. SI and delta SI (change in SI between consecutive time periods) was compared between groups. IRB approval obtained.

RESULTS:

50 patients in Group 1 and 55 in Group 2 were included. Baseline characteristics were similar (P>.05). SI range for Group 1 with vaginal deliveries (VD) is .82-.87 (95% CI), and 0.75 -.80 for Group 2 regardless of time period. SI range for cesarean (CD) is .83-.87 for Group 1 and 0.76-0.80 for Group 2. Delta SI is significant between 8 to 12 hours in VD (P=.02) and 1 to 4 hours postpartum in CD (P=.01) in Group 1.

CONCLUSION:

Patients with SI>0.83 should be further assessed for interventions such as BT and changes can be detected as early as 4 hours for CD and 8 hours for VD. SI can be a valuable tool in early diagnosis of PPH.
Identifying the “Who” of the Sex-Trafficked Population of Phoenix [02F]
Authors: Segaline Nicole , Lee Maurice , Roe-Sepowitz Dominique
Published: April 2020

INTRODUCTION:

Sex-trafficking is one of the world’s fastest growing forms of crime worldwide, and yet less than 2% of victims have been identified. In 2016, there was an estimated 30% increase in reported cases of human trafficking in Arizona. The number of risks and harms endured by sex-trafficked individuals is lengthy, yet strategies and education to identify victims is not universal. The purpose of this study is to further understand the demographics and medical needs of the sex trafficked population of Phoenix.

METHODS:

Project STARFISH is a biannual drop-in center that provides resources to victims of sex- trafficking. Medical SOAP notes are written on persons who voluntarily seek medical services at these resource centers. Eighty de-identified SOAP notes were reviewed in this IRB-approved observational, qualitative study to determine demographic and medical needs of the sex-trafficked population of Phoenix.

RESULTS:

The analysis revealed a high incidence of pregnancy, polysubstance use, homelessness, sexually transmitted infections, domestic violence history, chronic pain and mental health needs. Additionally, demographics of this population were extrapolated and include a predominately female population, an average age of 35 years old, with 78% of people having health insurance, and one-third having regular contact with a primary physician.

CONCLUSION:

The evidence regarding the sex-trafficked population is limited, and this project helps gain valuable insight regarding the demographics and medical needs of this under-researched population. The impact of this project is threefold: identification of victims, education for healthcare professionals, and creation of open communication channels between victims and healthcare providers.
Implementation of Surgical Debriefing in Gynecologic Surgery [04F]
Authors: McHenry Victoria M. , Straney Jennifer
Published: April 2020

INTRODUCTION:

The surgical debrief is a standardized checklist performed near the conclusion of a surgery, similar to the pre-procedure “Time Out.” This surgeon lead debrief confirms correct procedures and specimens, addresses anesthesia concerns, patient disposition, and allows all team members to participate in discussions regarding case efficiency. It has been studied in several surgical fields and shown to improve operating room safety and communication, increase efficiency, and decrease morbidity. It also provides opportunities for educational feedback in academic institutions. The surgical debrief has not been studied in gynecologic surgery. This study evaluates the implementation of a standardized surgical debrief at a teaching hospital.

METHODS:

This is a quality improvement study using PDSA (plan-do-study-act) cycles to implement surgical debriefs in all gynecologic surgeries performed at this hospital. All OR team members took pre/post implementation surveys regarding OR safety and communication and received surgeon lead education regarding implementation protocols. IRB approval was obtained.

RESULTS:

In PDSA cycle 1, 59% (33/56) of eligible gynecologic surgeries completed debriefs. In PDSA cycle 2, debriefs were completed in 70% (40/57) of eligible gynecologic surgeries. Immediate resident feedback occurred in 46% of the cases that completed debriefs.

CONCLUSION:

The surgical debrief was successfully implemented into gynecologic surgery. Anonymous survey results by the vast majority of OR personnel felt the debrief enhanced OR safety, improved communication, and prompted immediate resident feedback in such a positive way, that it has been adopted routinely for all cases, amongst all surgical specialties at this institution.
Improvement of Operative Vaginal Delivery Training in Residency: A Single Institution Experience [17G]
Authors: Negi Masaru , Espinal Mariana , Holveck Beth , Mehlhaff Krista , Cron Julia , Pettker Christian Michael
Published: April 2020

INTRODUCTION:

Operative vaginal delivery (OVD) rates are decreasing in the US, creating fewer opportunities for trainee participation. Residents, not adequately trained in OVD, are less likely to use this skill after training, contributing to a growing cesarean rate. We aimed to improve resident participation in OVD.

METHODS:

Retrospective analysis from July 2017 to December 2018 of an intervention bundle applied prospectively on all OVDs performed at Yale New Haven Hospital. Staff and clinicians were interviewed to assess barriers to resident participation. Interventions applied: 1) training of residents in didactics and simulations on OVD, 2) outreach to providers to create awareness and comfort with resident participation, and 3) change of workflow on the Labor & Birth unit to improve notification to the resident team about OVD events through a mobile texting tool. Our goal was to achieve >90%; resident participation in OVD, calculated to meet the ACGME minimum. Process control and run charts were used for analysis.

RESULTS:

There were 214 OVDs. Overall mean resident coverage was 83.6%. Prior to intervention, the median attendance rate of residents at OVD was 76%. After intervention, the median monthly coverage rate was 100%. Prior to intervention, process control chart analysis shows multiple points outside control limits (outside 3 standard deviations). After intervention, there were no points outside of control limits, and >8 points were above the median consecutively, showing achievement of process control. Mean attendance rate after intervention was 98.7%.

CONCLUSION:

Resident participation in OVD increased to the target rate with implementation of low cost, low technology solutions.
Introduction of Wireless Buzzer to Improve Efficiency in Gynecology Triage: A Quality Improvement Initiative [18G]
Authors: Stansbury Nicholas , Nelson Erin , Chavez Clarisa , Taylor Marlow
Published: April 2020

INTRODUCTION:

Current workflow in GYN triage has medical students interviewing patients after triage by nursing staff. The optimal time to initiate patient contact is unclear. This confusion has led to duplication of questions to patients, interruptions for nurses and fewer patient encounters for students.

METHODS:

A Plan-Do-Study-Act approach was used. Stakeholders were medical students, nurses, Nurse Practitioners and physicians. Factors contributing to workflow slowdown: students re-asking questions of patients, interruption of nursing staff, confusion about optimal patient flow. The net result was fewer interviews completed by students. The project was introduced during clerkship orientation. Buzzers were provided on weeks 1, 3, 5 of the rotation. Weeks 2, 4, 6 no buzzers were provided as an internal control. After each clerkship, students received a survey assessing key areas of waste and workflow disruption. A focus group with ten nurses was also conducted.

RESULTS:

From February-July 2019, 30/45 surveys were completed (66%): 1. Very difficult/difficult to know when to begin the encounter: 90% without; 21.4% with buzzer P<.001; 2. Students re-asking questions: very often/often 96.7% without; 14.8% with buzzer P<.001; 3. Nursing staff interruptions: 76.7% very often/often without; 18.5% with buzzer P<.001; 4. The odds of interviewing 5 or more patients per shift are ∼10X greater using the buzzer χ2=14.2; P<.001.

CONCLUSION:

The 10 nurses interviewed unanimously favored the use of the buzzer. Introduction of a simple, low-cost restaurant-style buzzer improved triage workflow, student and nursing experience.
Performance of a Patient Engagement App for Pre-Op Education [20G]
Authors: Cherot Elizabeth , Kett Attila , Siddiqui Zishan
Published: April 2020

INTRODUCTION:

Enhanced recovery after surgery is an innovation in perioperative care with the goal to achieve better patient engagement and improved outcomes like reduced opiate use and decreased hospital stay. Features are designed to accelerate patient recovery by reducing surgical stress and support physiologic function by allowing po intake shortly before surgery, multi-modal pain management, and early mobilization. Keys to success are patient education, engagement and self-efficacy. The program is dependent on assessing several patient reported care milestones like discontinuation of the Foley catheter, ambulation and pain scores. Because this is a human resource intensive endeavor, we developed an app with the goal of better engagement, education and response tracking while reducing human resources.

METHODS:

We deployed an app with the following components: multimedia education, reminders and check lists with the ability for patient reported data collection. Patients activated the app 3 weeks before surgery and used the tool for data collection pre and post operatively. We wanted to demonstrate patients consumed the educational content, responses to the surveys and compliance with our program preoperatively.

RESULTS:

We had 285 patients undergo ERAS program with 97.54% activation of our app before surgery, 92.86% response rate in the first week, 75.51% in the second week. 56.16% reported the app prevented 1 or more phone calls and 12.33% reported prevention of 1 or more visits to the hospital.

CONCLUSION:

We demonstrated both feasibility, high patient engagement and utilization for our app. One should consider using to unburdened staff and means to perform patient driven data collection.
Reducing Results Delivery Time for Couples Undergoing Carrier Screening: A “Tandem-Reflex” Strategy [24G]
Authors: Arjunan Aishwarya , Kaseniit Kristjan Eerik , Wootton Jeff , Taber Katherine Johansen
Published: April 2020

INTRODUCTION:

Obtaining carrier screening results in a timely manner is important to support reproductive decision-making. Reproductive partners are typically tested in a sequential manner: the female is tested first and if a carrier, her partner is tested. This imposes workflow challenges due to the need for a subsequent visit to draw the partner’s sample, reducing the likelihood of the partner getting screened and hampering detection of at-risk couples. We implemented a “tandem reflex” strategy wherein both partners submit samples in tandem but are tested sequentially, with the second partner’s sample tested only if the first partner was found to be a carrier.

METHODS:

The time to delivery of a combined report was measured before and after implementation of the “tandem reflex” strategy. Comparison to a simultaneous strategy, ie, both partners samples tested as soon as they are received, is also reported.

RESULTS:

Before implementing the “tandem reflex” strategy, the average time for a sequentially tested couple to receive a report was 35 days (95th percentile 76 days, N=16,785 couples). After implementation, the average time was reduced to 15 days (95th percentile 25 days, N=1,132 couples). Among 13,161 couples tested simultaneously, 42% of females were negative for all tested conditions; in this scenario, the tandem reflex strategy would have reduced unnecessary testing because it would not have triggered testing of the male partner.

CONCLUSION:

The “tandem reflex” strategy time to receipt of a combined report by half, allowing for more timely reproductive and pregnancy management.
The Silent Killer: Resident Burnout at an Inner-City Hospital in New York [25G]
Authors: Jackman Janelle , Hayfron Maame , Hwang Lewis , Riccardi MaryAnn , Valentine Menogh , Hakkim Ansi
Published: April 2020

INTRODUCTION:

Burnout defined by Maslach Burnout Inventory (MBI) is emotional exhaustion, depersonalization, and feelings of decreased personal accomplishment. Medical residents endure higher levels of burnout compared to general population. The purpose of this study is to evaluate resident’s personality traits, stress level and alleviating techniques to promote resident wellness at a single community hospital.

METHODS:

In 2017, an anonymous survey was administered to all 143 residents at the Brooklyn Hospital. It assessed personality traits, stress level and stress alleviating techniques. It contained questions from the Rosenbach Self-Esteem scale, the Perceived Stress Scale and the MBI scale, along with demographics. Participation was voluntary and 100 residents completed the survey. Statistical analysis used Chi-square test and Students t-test linear regression. P-value<0.05 was statistically significant.

RESULTS:

OBGYN residents were more likely to report higher scores in the emotional exhaustion component of the MBI vs. residents of other specialties. There were no statistically significant differences in Personal Accomplishment and Depersonalization scores across all specialties. Burnout was significantly higher in OBGYN residents compared to surgery and pediatrics residents, as well as in family medicine vs. surgery residents. Post graduate year (PGY)-4s had significantly higher self-esteem scores (SES) than other PGY residents. Surgery residents had the highest self-esteem score.

CONCLUSION:

Burnout can have unintended consequences including psychological distress, altered personal relationships and decreased quality of patient care. Interventions to improve resident well-being should promote a sustainable environment for residents to thrive in by aggressively addressing excessive workload and incorporating individualized tactics such as routine counseling and therapy sessions.
Obstetric Innovation as Indicated by Venture Capital Funding [33G]
Authors: Kogutt Benjamin K. , Satin Andrew J.
Published: April 2020

INTRODUCTION:

Venture capital (VC) is a financial industry that supports early stage companies and thus innovation. As such, VC funding has been theorized to serve as a proxy for level of innovation across multiple industries including healthcare. Innovation in obstetrics is critical to improving the lives of pregnant patients. Anecdotally however, innovation in the obstetric field is lagging. Therefore, our objective was to determine the level of VC funding in obstetrics compared to other seemingly innovative specialties.

METHODS:

We performed a retrospective cohort study utilizing propriety data (Pitchbook, Seattle, WA) to compare VC trends within Obstetrics and four additional specialties. Once cohorts were identified, “capital invested,” number of “VC-companies,” number of “deals,” number of “investors,” “exits” (IPOs), and “largest deal” were extracted and compared.

RESULTS:

Obstetrics had the lowest level of capital invested, the smallest number of funded companies, and the least amount of deals brokered between 2000 and 2018. Obstetrics was also identified as having the slowest rate of VC funding growth, but did have the third highest rate of growth in “companies” and “deal count.”

CONCLUSION:

Obstetrics has the lowest level of innovation as measured by VC funding, VC-funded companies, VC deals, and rate of growth of VC funding compared to other specialties. However, company and deal growth rates were the third highest, indicating that Obstetrics has not yet realized its full, innovative potential. This is both encouraging and demanding given the great need for urgent, innovative solutions for obstetrics’ most pressing dilemmas including the rising US maternal mortality rate.
Pregnant Women Value Advice From Providers Over That From Friends/Family Regarding Sleep, Nausea and Substance Use [36G]
Authors: Satti Mohamed A. , Power Michael L. , Reed Eda G. , Wenker Elizabeth S. , Schulkin Jay , Mackeen A. Dhanya
Published: April 2020

INTRODUCTION:

We aimed to evaluate pregnant women’s opinions of advice from healthcare providers versus from friends and/or family members, regarding nausea, sleep, and substance (alcohol, marijuana, tobacco and caffeine) use during pregnancy.

METHODS:

The is a cross-sectional study. All pregnant women who received prenatal care at Geisinger were provided surveys. Women with limited English-speaking proficiency were excluded.

RESULTS:

Of the 284 women, 87% were white, 49% married, and 61% had private health insurance. About half (47%) had prenatal care with a physician, 14% with a certified nurse midwife, and 34% with a nurse practitioner or physician assistant. Overall, women were more interested in advice about nausea, sleep and caffeine use, rather than alcohol, tobacco and marijuana use. Regarding improving sleep and decreasing nausea, 90% felt it was important to receive advice from providers and 73% felt it was important to receive advice from friends/family. With regards to substance use, 74% of women felt advice from health care providers was important compared to only 43% of women who thought advice from friends/family was important. About 20% of the women did not value advice from either source regarding alcohol, marijuana, and tobacco. For all these concerns, twice as many women felt that provider advice was more important than advice from friends/family.

CONCLUSION:

Pregnant women in this study more highly valued advice about reducing nausea, improving sleep and caffeine consumption more so than advice about tobacco, marijuana and alcohol use during pregnancy. Most believed that advice from their healthcare provider was more valuable than advice from friends/family.
The Effect of Distraction on the Quality of Patient Hand-Off [39G]
Authors: Persad Vashisht , McLaren Rodney Anthony , Joslin-Roher Sophia , Narayanamoorthy Sujatha , Silver Michael , Minkoff Howard
Published: April 2020

INTRODUCTION:

To evaluate whether distraction affects the quality of sign-out among obstetrical providers. If distractions affect the accuracy of information shared at “sign-out,” it could lead to errors in patient management.

METHODS:

A randomized, prospective study among obstetrical providers who received a recorded sign-out vignette. Provider groups either received a distraction or did not during the vignette. All providers had been told that they would be participating in a trial of two methods of sign out, although in actuality they were all signed out using a single method. In the distraction arm, the participants were exposed to a “distracting event” (a phone ring, followed by a short response) that occurred midway through the vignette. Providers answered a 14-question survey based on the vignette. The results of each group were analyzed using Fisher exact and Student t tests.

RESULTS:

Eighty-eight providers were randomized, 44 in the distraction group and 44 in the non-distracted group. The score averages on the survey were similar between groups (11.0 and 10.8, P=.57). In addition, the average scores for questions that occurred after the distraction were similar between the distracted and non-distracted groups (6.4 vs 6.2, P=.42). Proximity to the distraction did not affect scores.

CONCLUSION:

While cell phones often ring in hospital settings, we did not find that a single phone ring and a brief answer to the call affected obstetrical providers’ recall of details of a standardized sign-out. More studies are warranted to determine if more frequent distractions or longer distractions would change results.
Access to Minimally Invasive Gynecologic Surgery for Adnexal Surgery: Impact of Race and Payer Mix [03H]
Authors: Palvia Vijay , Finkelstein Mark , Zakashansky Konstantin , Brodman Michael , Ascher-Walsh Charles , Khalil Susan
Published: April 2020

INTRODUCTION:

Minimally invasive gynecologic surgery is associated with many benefits. Adoption for hysterectomy, has noticeable variation with race. The Statewide Planning and Research Cooperative System (SPARCS) is a comprehensive all payer data reporting system, the result of cooperation between healthcare industry and government including outpatient and inpatient information on procedures, diagnosis, and patient factors.

METHODS:

The (SPARCS) database was reviewed from 2011–2015, for ovarian-cystectomy with/without salpingectomy for benign indications, performed via laparotomy and laparoscopy.

RESULTS:

There were 68,029 patients included in this analysis. Average age was 43 years, with 81.3% between 18–55, 17.7% >55. Racial composition comprised of 68.7% Caucasian, 4.8% Asian, 11.2% Black, and 15.3% as other. Payor mix included 79.6% insured, 7.4% Medicaid, 8.3% Medicare, and 4.7% other or self-payment. Majority resided in metropolitan areas (90.6%), and did not travel >15 miles for care. Of the 68, 029 that were included, 54,829 were performed via laparoscopy while 13,200 were via laparotomy. Odds ratio (OR) of having procedure via laparoscopy was 0.68 for black, 0.81 for Hispanic, and 0.80 for other. Compared to insured: OR that surgery was via laparoscopy was 0.69 for Medicaid, 0.72 for Medicare, 0.92 self. At high-volume surgical facilities the OR laparoscopy was utilized was 1.83 compared to a low volume facility, and 1.49 at medium volume facilities. At institutions with major teaching affiliation the OR was 0.91 compared to non-teaching, and the OR was 1 for minor affiliation.

CONCLUSION:

Race is not the only factor associated with lower likelihood of laparoscopy, other factors such as institution type also impact likelihood.
Development of a Postoperative Opioid Prescription Practice (POPP) Algorithm for Benign Gynecologic Surgery [05H]
Authors: Thompson William , Fielden Aaron , Elmezzi Kristen , Yamasaki Meghan , Endicott Scott , Braden Jacqueline
Published: April 2020

INTRODUCTION:

Pain Management literature shows a strong correlation between days of initial opioid use and risk for chronic use. Opioid-prescribing practices vary widely within OB/GYN literature. The purpose of this study is to determine if gynecologic patients have satisfactory postoperative pain control using a novel Postoperative Opioid Prescription Practice (POPP) algorithm.

METHODS:

Patients undergoing benign gynecologic surgery at a large military treatment facility were recruited for this IRB-approved study. Patients completed a preoperative survey regarding baseline pain, substance use, chronic pain, depression or anxiety, and home pain management strategies. The quantity of opioids dispensed postoperatively was determined using the POPP algorithm. Patients completed a two-week postoperative survey assessing the number of remaining opioid tablets and their pain satisfaction. The current study group was compared to a retrospective cohort of patients treated for similar conditions.

RESULTS:

Final analysis included 68 patients from the 82 patients initially recruited. 97% of patients did not require an opioid refill and were satisfied with their postoperative pain control. 21% did not require any opioids following discharge. The POPP algorithm reduced opioid prescriptions from an average of 22.5 to 12.5 tablets.

CONCLUSION:

Use of the POPP algorithm resulted in a significantly decreased number of opioid tablets prescribed. The majority of patients were satisfied with their postoperative pain control and did not require refills of opioids despite less tablets prescribed. The POPP algorithm is a good starting point to guide gynecologic surgeons in postoperative opioid-prescribing practices. More data is needed to develop even stricter opioid prescription algorithms based on patient characteristics.
Enhanced Recovery After Surgery Among Obese Gynecology Oncology Patients [08H]
Authors: Kent Laura M. , Buras Andrea , Zhu Alina , Mallen Adrianne , Chern Jing Yi
Published: April 2020

INTRODUCTION:

Benefits of Enhanced Recovery After Surgery (ERAS) protocols are well-established for the general surgical population, but there is limited studies specifically evaluating the efficacy in obese patients. We implemented an ERAS protocol among gynecologic oncology patients undergoing laparotomy and assessed outcomes in obese (≥30) vs non-obese.

METHODS:

The gynecologic oncology department implemented an ERAS protocol as a quality improvement initiative in patients undergoing laparotomy. Data was prospectively collected on patients where ERAS was implemented and compared to historical controls (pre-ERAS). A descriptive analysis on outcomes was assessed by comparing obese (BMI>30) and non-obese patients.

RESULTS:

The average length of stay (LOS) in ERAS vs pre-ERAS is 3.5 days vs 4.7 days (P=.002). Non-obese ERAS vs pre–ERAS LOS 3.2 days vs 4.6 days (P=.05). However, obese patients tend to have longer LOS, 3.2 days vs 3.8 days (NS). Although PO analgesics were used per ERAS protocol, obese patients used patient-controlled analgesia (PCA) more often than non-obese patients (13% vs 3%). The rate of complications (9-15%) and readmissions (0-5%) was similar among all groups.

CONCLUSION:

ERAS is effective, but there is a trend towards increased LOS and PCA usage in obese patients; though there is no difference in post-op complications and readmissions. Further investigation is needed to determine how obesity affects recovery after surgery.
Factors Influencing Postoperative Morbidity in Women Undergoing Excisional Procedures of the Cervix [09H]
Authors: Davis William , Bilbao Michelle , O'Laughlin Andie , Fleischer Lindsay , Gabriel Cosette , Aikins James
Published: April 2020

INTRODUCTION:

Pain, discharge, and bleeding are common after excisional procedures of the cervix. While generally benign, they can herald complications. Our hypothesis was that age, prophylactic antibiotics, smoking and/or diabetes might be associated with these postoperative concerns.

METHODS:

Medical records for women undergoing excisional or ablative procedures of the cervix at Cooper University Hospital from January 2013 to December 2018 were reviewed. There were 621 total subjects. Seventy-eight were excluded due to inadequate follow-up, yielding 543 analyzable procedures. Records were reviewed for pain, discharge, and bleeding. Subsequent interventions were then recorded. Age, smoking status, procedure type, prophylactic vaginal metronidazole usage (off-label) as well as smoking and diabetic history were collected. Descriptive data are reported as such, and proportions were analyzed via chi-squared tests.

RESULTS:

The average age of our subjects was 40.28 years (median 36.9, standard deviation 12.4). In total, 208 women re-presented with at least one postoperative concern following their procedure. Of these, 103 required intervention. Procedure type, postoperative prophylactic antibiotic usage (n=38), age greater than the median, and active smoking status (n=115) failed to predict postoperative complications. Former smokers (n=129, P=.047) did report more concerns, although they did not require more interventions (P=.14).

CONCLUSION:

Excisional and ablative procedures of the cervix are essential for the prevention of cervical cancer in patients with moderate to severe cervical dysplasia. Postoperative complaints of pain, bleeding and discharge are common and bothersome for patients. Based on our retrospective review, age, prophylactic vaginal metronidazole, smoking and diabetes were not associated with worse postoperative outcomes.
Knowledge and Attitudes Towards Human Papillomavirus (HPV) Testing and Vaccination at an Urban Health Clinic [10H]
Authors: Almeida Tawany , Casey Frances
Published: April 2020

INTRODUCTION:

According to the most recent data from the U.S. Centers for Disease Control and Prevention, Latinos have higher rates of human papillomavirus (HPV) associated cancers when compared to the general population. Individuals who lack knowledge about HPV and its association with cancer may not understand the importance of preventing infection and may have less access to vaccination. This study aims to assess the knowledge regarding HPV transmission and perception of HPV vaccination in a Latino health clinic.

METHODS:

In this cross-sectional survey, a convenience sample of Latino participants in an urban free health clinic completed a survey in Spanish evaluating demographics and knowledge regarding the human papillomavirus disease, testing and vaccination using a previously validated questionnaire. Demographic characteristics were compared using chi-square and Fisher exact tests for HPV knowledge outcomes.

RESULTS:

Responses were obtained from 48 participants, 62.5% female and 37.5% male with mean age 37. 56% of the population studied had heard of HPV with only 27.8% of the males surveyed and only 33% of the population with a middle school education or less stating they had heard of HPV. A large percentage (81.5%) believed HPV could be cured with antibiotics or that if a woman tested positive for HPV she would definitely have a diagnosis of cervical cancer (45.5%).

CONCLUSION:

A large percentage of population surveyed had little knowledge about HPV testing and vaccination. Follow up research is needed to evaluate best methods/practice for dissemination of information and ensuring access to the HPV vaccine.
Nationwide Trends of Bowel Obstruction and Intussusception in Endometriosis Patients [11H]
Authors: Aldhaheri Sarah , Badeghiesh Ahmad , Suarthana Eva , Gil Yaron , Tulandi Togas
Published: April 2020

INTRODUCTION:

One of the complications of endometriosis rarely described is bowel obstruction (BO). The purpose of our study was to evaluate the incidence of BO among women with endometriosis, the trend and the demographic characteristics.

METHODS:

We used the data from the Healthcare Cost and Utilization Project—Nationwide Inpatient Sample (HCUP-NIS). We studied women with endometriosis aged 15 to 55-years from 2005-2014. Those with neoplasms in the genitourinary or gastrointestinal system were excluded.

RESULTS:

Of a total 278,613 women with endometriosis, 1386 had BO or intussusception resulting in an overall incidence of 0.5%. Although the number of hospital admission related to endometriosis were decreasing, there was a significant increase in the incidence of bowel obstruction/intussusception during the time period from 0.3% to 0.9%. Moreover, women with BO tend to be white and with higher income (P<.05). The incidence of BO in those with endometriosis in the pelvic/peritoneum and the intestine were comparable. Also, those with BO tend to have lower BMI (P<.05). In addition, there was no association between diabetes mellitus, hypertension, dyslipidemia or hospital region, and the incidence of BO.

CONCLUSION:

Although there is a downtrend in the incidence of hospital admission related to endometriosis, the incidence of endometriosis specifically in the intestine or the rectovaginal wall as well as the incidence of bowel obstruction has been slightly increasing.
Pulmonary Leiomyomatosis Following Laparoscopic Myoma Morcellation [13H]
Authors: Stemmer Shlomo M.
Published: April 2020

INTRODUCTION:

To report a case of a metastasizing myoma to the lungs diagnosed ten years following laparoscopic myoma morcellation, and review of the literature.

METHODS:

A 38 years old G3P1A2 underwent laparoscopic morcellation of a subserosal 5.5 cm myoma in 2003. Ten years later she presented with dyspnea and chest discomfort. CT chest images showed possible progressive metastatic disease from an unknown primary. Lingular wedge left lung resection revealed features compatible with metastatic leiomyoma. The pathological slides from the original myoma morcellation were reviewed and confirmed myoma origin of lung tumors. Review of the literature in PubMed (MEDLINE) for similar cases was conducted.

RESULTS:

Pulmonary benign metastasizing leiomyoma (BML) is rare and has been reported following hysterectomy and in women with leiomyoma uteri. Laparoscopic morcellation has been associated with parasitic myomas with an overall incidence of 0.12-.095%. To the best of my knowledge there are no reports of pulmonary benign metastasizing leiomyoma associated with laparoscopic morcellation.

CONCLUSION:

Complications from laparoscopic myoma morcellation are well documented, and resulted in restrictions in use of morcellators due to concerns of spreading leiomyosarcoma. The incidence of metastasizing leiomyomas to the lungs following laparoscopic myoma morcellation is presently unknown. Knowledge about benign metastasizing leiomyomas, imitating a malignant neoplasm such as lung cancer, is important to avoid over treatment and reassure the patient.
An Unusual Type of Lymphomatoid Papulosis Presenting in Pregnancy: Risk-Benefit Analysis of Antepartum Treatment [18H]
Authors: Carney Alexandra C. , Wilson Karen L. , Heuer Christopher W.
Published: April 2020

INTRODUCTION:

Lymphomatoid papulosis (LyP) has an incidence of 2 per 1,000,000 and is associated with lymphoproliferative disorders. Type E, characterized by angioinvasion, is the rarest subtype and is associated with CD30 and CD8 expression. LyP is associated with immune compromising disorders, making pregnancy a potential setting for presentation. We present one of the first cases of LyP type E in pregnancy.

METHODS:

Case: 30-year-old G5P3, with a pregnancy complicated by a history of hemolysis, elevated liver enzymes and low platelet count syndrome in a previous pregnancy, presented in early pregnancy with a two month history of diffuse painful skin lesions. As the pregnancy progressed, the lesions spread and would blister and ulcerate before resolving. Biopsy returned with CD30+ angioinvasive LyP type E. Prednisone and topical steroids provided minimal symptomatic improvement. Peginterferon alfa-2a was offered as an alternative therapy; however, was deferred until after delivery.

CONCLUSION:

Appropriate diagnosis of LyP and subtype as well as multi-disciplinary follow-up is essential given possible associated lymphoproliferative disorders. Treatment may involve more risk than benefit and has not been proven to prevent associated malignancy necessitating individualized risk-benefit analysis. Conservative treatment is preferred, even in significantly symptomatic pregnant patients. In some severely symptomatic patients, peginterferon alfa-2a may be considered with a better safety profile compared to other agents in pregnancy. The angiodestructive nature of type E may be associated with pregnancy complications including those on the preeclampsia spectrum. These pregnancies may require closer monitoring and the consideration of aspirin prophylaxis. Early diagnostic biopsy will allow for timely intervention.
A Risky Excess? Opioid Use, Storage, and Disposal Practices Among Post-operative Gynecologic Oncology Patients [21H]
Authors: Kunycky Christina , Nickerson Ciarra , Leung Katherine , Pelkofski Elizabeth , Zweizig Susan , Korets Sharmilee
Published: April 2020

INTRODUCTION:

Inappropriate storage and disposal of unused opioids presents a growing public health and safety issue. This is of special interest when caring for women undergoing surgery for gynecologic conditions, such as cancer, as there is increasing evidence of overprescribing in the post-operative period. This study investigates opioid storage and disposal practices among post-operative gynecologic oncology patients.

METHODS:

We developed and administered a cross-sectional survey among patients who underwent surgery for gynecologic cancer or cancer precursors between October 2017–January 2019. The survey tool assessed self-reported opioid use, storage, and disposal practices as defined according to FDA guidelines. Additional data was abstracted regarding inpatient opioid requirement prior to discharge and baseline risks factors for opioid misuse. IRB approval was obtained.

RESULTS:

297 patients met inclusion criteria. The average opioid requirement on the day of discharge was 12.9 MME (morphine milligram equivalents) with average discharge amount prescribed being 180.4 MME. 70.4% reported use of 50% or less of the opioids prescribed, and 62% reported keeping their unused opioids. 75% reported unsafe storage. 26% reported personally using leftover opioid pain medication for reasons unrelated to the surgery. Only 30.4% reported using a designated drop site for opioid disposal. Only 38.3% recalled receiving information on safe opioid storage and disposal during their care.

CONCLUSION:

There is significant overprescribing of opioids in gynecologic oncology patients postoperatively. Increased collaborative patient and prescriber education regarding safe opioid storage and disposal is paramount for future efforts to prevent diversion, accidental ingestion, and chronic opioid use.
Cerebellar Hemangioblastoma Management in Pregnancy: A Case Report [20H]
Authors: Hattink Cantey , Martinuzzi Kurt , Krishna Iris , Platner Marissa H.
Published: April 2020

INTRODUCTION:

We present a rare case of sporadic cerebellar hemangioblastoma diagnosed in pregnancy.

METHODS:

A 37-year-old gravida 3 para 2002 with no significant history reported nausea and throbbing, bitemporal headaches at her 15 week visit. They were most bothersome in the evenings and upon waking. At her 21 week visit she reported persistent headaches with new onset dizziness. An echocardiogram and laboratory studies were normal. She was referred to neurology. At 23 weeks she had right and left beating nystagmus on exam and an unsteady gait. MRI revealed a 4 cm cystic lesion within the right cerebellum, mass effect on the fourth ventricle, and mild hydrocephalus with tonsillar and upward transtentorial herniation consistent with a hemangioblastoma. Neurosurgery planned urgent craniotomy and resection.

RESULTS:

The patient underwent uncomplicated surgery and pathology confirmed hemangioblastoma. Her postoperative course was uneventful with reassuring fetal status throughout admission. Her balance was markedly improved and neurologic exam was normal four weeks postoperatively. Testing for Von Hippel-Lindau syndrome was negative. The remainder of her pregnancy was uncomplicated. The team determined that she was a candidate for vaginal delivery. She underwent elective induction of labor at 39 weeks and progressed to vaginal delivery of a healthy female infant weighing 3370 g with Apgar scores of 9 and 9. She was discharged home with her infant on postpartum day one.

CONCLUSION:

Headaches, vomiting, and dizziness are common in pregnancy. Patients with severe, unrelenting symptoms require imaging and neurology consultation. Excellent outcomes are possible with a multidisciplinary approach involving obstetrics, maternal fetal medicine, neurology, and neurosurgery.