bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effects of Late Preterm Betamethasone in Multiple Gestations [30K]
Authors: Reynolds Krystal , Lawless Paige , Fricke Erin
Published: April 2020

INTRODUCTION:

The administration of late preterm betamethasone in singleton gestations is an effective intervention for reducing neonatal respiratory morbidity. However, this intervention has not been studied in multiple gestations, which have higher rates of pregnancy complications resulting in admission and delivery from 34 to 36 weeks gestation. We aimed to evaluate the effects of betamethasone in multiple gestations during the late preterm period.

METHODS:

We conducted a retrospective chart review of multiple gestations who delivered between 34/0 and 36/6 weeks. The study included 322 women with 645 neonates. The primary outcome was a composite respiratory outcome that included the need for any respiratory support within 72 hours after birth, as defined as the need for continuous positive airway pressure (CPAP) or high-flow nasal cannula for at least 2 consecutive hours or supplemental oxygen with a fraction of inspired oxygen of at least 30% for at least 4 continuous hours. Secondary outcomes included rates of mechanical ventilation and hypoglycemia.

RESULTS:

The primary outcome occurred in 132 of 388 infants (34%) in the betamethasone group and 75 of 249 (30.1%) in the non-betamethasone group (P=.380). There was no difference in need for mechanical ventilation (P=.987). Neonatal hypoglycemia was significantly more common in the betamethasone group (41% vs 27.3%, P=.004).

CONCLUSION:

Administration of betamethasone to women with multiple gestations did not reduce the rate of neonatal respiratory complications in the late preterm period, but increased the rate of hypoglycemia.
The Nutritional Adequacy of Prescription Versus Nonprescription Prenatal Vitamins [33K]
Authors: Kelly Rachel E. , Tian Elli Y. , Howard David
Published: April 2020

INTRODUCTION:

To descriptively compare nutritional content of prescription to nonprescription prenatal vitamins (PNVs) through consideration of the American College of Obstetricians and Gynecologists (ACOG) recommendations for a healthy pregnancy.

METHODS:

We utilized 2 publicly available online databases, Dietary Supplement Label Database and DailyMed, to obtain a list of all currently available PNVs. Inclusion criteria was based on initial search results from keyword “prenatal.” Exclusion criteria were single ingredient supplements, or duplicates. Duplicates were supplements listed separately because of different package forms for sales purposes, but were identical (i.e. same manufacturer, nutritional label/content), or those present in both databases. PNV ingredients were recorded from nutritional labels and compared to ACOG micro-nutrient guidelines.

RESULTS:

We obtained a total sample of 307 PNVs (110 prescription, 197 nonprescription). Of the prescription PNVs, 0% met calcium requirements, 100% met folic acid requirements, 82% met iron requirements, and 16% met vitamin D requirements. Of the nonprescription PNVs, 8% met calcium requirements, 98% met folic acid requirements, 11% met iron requirements, and 33% met vitamin D requirements. Each PNV was assigned a score from 0-4, based on the number of the 4 ACOG supplementation recommendations they met. Of the prescription PNVs, 12% scored ≥3, and 20% of the nonprescription PNVs scored ≥3. No single prescription PNV met all 4 ACOG recommendations, and 2 nonprescription PNVs did.

CONCLUSION:

We found no meaningful difference in nutritional adequacy of prescription versus nonprescription PNVs with respect to ACOG recommendations. Tailored supplementation should be considered as an alternative to PNVs.
The Yield of Intraoperative Fetal Monitoring During Nonobstetric Surgery [34K]
Authors: Chang Jeremy , Pluym Ilina D. , Adams Starsha , Afshar Yalda
Published: April 2020

INTRODUCTION:

While ACOG supports indicated surgery for pregnant patients, there is no clear consensus on optimal fetal monitoring for such cases. We examined whether continuous intraoperative electronic fetal monitoring (ciEFM) for nonobstetric surgeries after viability impacts decision for obstetric intervention and subsequent perinatal outcomes.

METHODS:

IRB approval was obtained for this retrospective cohort study conducted at a single academic center between January 2013 and March 2019. Demographic and outcome data were compared between ciEFM vs pre/post-procedure EFM. Multiple logistic regression was applied to adjust for clinical covariates.

RESULTS:

Of 1,060 cases reviewed, 43 (4.1%) were performed after viability (gestational age (GA) range: 23.7 to 36.4 weeks). ciEFM was used in 24 cases (56%). Two cases required intraoperative resuscitation in the ciEFM group, one with fluid bolus and one with emergent delivery (P=.49). ciEFM cases lasted longer (105 vs 40 minutes, P<.01) and were more likely to be performed under general anesthesia (83.3% vs 26.3%, P<.01). ciEFM had no association with non-reassuring postoperative EFM (18.2% vs 15.4%, P=1.00), postoperative tocolytic use (29.2% vs 10.5%, P=.26), or GA at delivery (37.1 vs 37.2, P=.92). There was no association on the rate of preterm delivery when adjusted for type, or length of surgery, and type of anesthesia (aOR 1.82, 95% CI 0.20-16.4, P=.59).

CONCLUSION:

ciEFM does not significantly affect intraoperative or postoperative obstetrical outcomes. This data can help obstetric providers allocate limited resources, reassure other surgical providers, and appropriately counsel patients who are about to undergo nonobstetric surgery.
Use, Misuse and Overuse of Antenatal Corticosteroids [39K]
Authors: Chakravarthy Shruti , Reddy Rishika , Ducey James , Fruhman Gary , Cojocaru Liviu
Published: April 2020

INTRODUCTION:

Antenatal corticosteroids (ACS) are a mainstay in the management of women at risk for preterm delivery, however previous studies raised concerns for long-term consequences including increased risk of metabolic disease and neuro-developmental effects. The purpose of this study was to review our hospital’s use of ACS in view of these possible risks.

METHODS:

After Institutional Review Board approval, a retrospective chart review from January 2011 through December 2017 was performed. Pregnancies in which ACS were administered in anticipation of preterm delivery were included. Those who delivered elsewhere or had incomplete charts were excluded. Data collection and descriptive analysis were performed with Research Electronic Data Capture.

RESULTS:

ACS were administered in 432 pregnancies, of which 391 met inclusion criteria. Of these, 77.5% delivered preterm. However, 42.5% of all 391 pregnancies delivered at or above 34 weeks. Only 51.7% of all pregnancies delivered in the first seven days of administration of ACS, falling to only 35% when excluding those who delivered within 24 hours of the first dose. The most common indication for ACS administration was threatened preterm labor (70.1%). Of these, 43.8% delivered in the first seven days, falling to 24.5% when excluding those delivering in the first 24 hours.

CONCLUSION:

While three-quarters of women receiving ACS delivered preterm, a large proportion delivered at 34 weeks or greater and not within the optimal time frame of one to seven days. Further studies are needed to evaluate our administration of ACS, and particularly our assessment of preterm labor, to avoid unnecessary exposure and potential consequences.
Uterine Anomalies Associated With Intrauterine Growth Restriction and Hypertensive Disorders During Pregnancy [40K]
Authors: Gomez Fabiola Gallardo , Ruiloba Francisco J. , Arellano Fernanda Vera , Davila Jose Luis , Ramirez Santes Victor Hugo , Hernandez Cruz Rosa Gabriela
Published: April 2020

INTRODUCTION:

Congenital anomalies of the uterus have a worldwide prevalence of 2-4% in women of reproductive age, the associated perinatal outcomes are recurrent gestational loss, preterm birth, and anomalous presentations with increased risk of caesarean section. Smaller studies have suggested the link between hypertensive disorders, intrauterine growth restriction and uterine anomalies. The purpose of this study was to compare the rate of hypertensive disorders and intrauterine growth restriction in pregnant women with a known uterine anomaly to the rate in the normal pregnant population.

METHODS:

A population-based retrospective cohort of all live births in Institute of Perinatology (2018-2019) was analyzed. Clinical characteristics of patients who were gravid for more than 28 weeks, and had an uterine anomaly. The rate of hypertensive disorders and intrauterine growth restriction among women with uterine anomalies was calculated and compared among women without uterine anomalies.

RESULTS:

From January 1, 2018 to July 7, 2019, there were 95 women seen in our third level center who were gravid for more than 28 weeks and had a uterine anomaly. A greater proportion of women with a uterine anomaly had a hypertensive disorder (6.3%) and intrauterine growth restriction (11.5%) than women without a uterine anomaly (3.0%) (P=.001) and 6% 8 (P=.001) respectively.

CONCLUSION:

The prevalence of pregnancies with uterine abnormalities is increasing. Understanding the specific pregnancy outcomes that are associated with these high risk pregnancies will be crucial for appropriate management and multidisciplinary to avoid adverse perinatal outcomes.
Actual Hospital Costs Associated With Severe Maternal Morbidity Compared to Uncomplicated Pregnancies [01L]
Authors: Debbink Michelle , Metz Torri , Silver Robert R. , Varner Michael , Smid Marcela Carolina , Einerson Brett
Published: April 2020

INTRODUCTION:

Severe maternal morbidity (SMM) is rising, but true costs are unknown. We aimed to assess actual hospital costs of pregnancies complicated by SMM compared to uncomplicated pregnancies.

METHODS:

We conducted a retrospective nested case-control study at a single US institution from 1/2014–6/2017. Cases had at least one of 25 ICD-9 or 10 codes defined as SMM by the CDC. We excluded cases with transfusion as a sole SMM indicator or that were incorrectly coded on chart review. Controls were selected randomly from all deliveries +/- 60 days from case delivery at a 5:1 ratio. Cost data included actual costs/utilization compiled via time- and activity-based accounting. Total costs were computed across pregnancy episodes. Adjusted multivariate regression was used to compare costs. Covariates were identified via backward stepwise regression. Relative costs are reported. IRB approval was obtained.

RESULTS:

12,578 women delivered during the study period. 454 (3.6%) had ICD-9/10 codes meeting SMM criteria, and 170 (1.4%) had correctly-coded non-transfusion SMM events after chart review. Among cases, cesarean delivery and preterm birth were more common. In adjusted models, SMM was associated with increased hospital costs (114.5%; 95% CI 98.9%–130.1%). Predicted absolute cost increases are over $10,000/pregnancy episode. Stratified models show SMM at term is associated with a 122.7% (95% CI 108.6%–136.8%) cost increase, and preterm deliveries with a 67.9% (95% CI 33.2%–102.6%) increase.

CONCLUSION:

SMM is associated with higher hospital costs compared to uncomplicated pregnancies. Identifying preventable SMM and implementing effective reduction strategies may result in healthcare savings.
Changes in Vascular Smooth Muscle and Collagen Content in Placental Vessels in Preeclampsia [04L]
Authors: Chada Anisha R. , Lord Megan G. , Nguyen Hoang Hoa T. , Davis Justin N. , Durica Allison R. , Chappell John C.
Published: April 2020

INTRODUCTION:

Preeclampsia results in part from abnormal myometrial invasion by placental spiral arteries. It is unknown if and how fetal vessels remodel to compensate for these changes. We sought to characterize preeclampsia-associated vascular remodeling by comparing vessels within villi of placentas collected from preeclamptic and normotensive patients.

METHODS:

Carilion Clinic IRB approval was obtained prior to patient enrollment. Singleton pregnancies complicated by preeclampsia and normotensive controls were identified on Labor and Delivery. Placental biopsies were collected following delivery. Smooth muscle (alpha-SMA) and Type III collagen (COLIII) were identified by immunostaining of cryostat sections. Confocal microscopy was used to measure areas of alpha-SMA and COLIII positivity surrounding vessels. Ratios of alpha-SMA or COLIII positivity to vessel area were calculated. These ratios, which represent relative smooth muscle and collagen content, were compared between vessels from preeclamptic and normotensive placentas.

RESULTS:

Measurements from 342 vessels from 10 placentas (from five preeclamptic patients and five controls) were included in this analysis. Compared to vessels within placentas of normotensive patients, placental vessels of preeclamptic patients demonstrated a significantly reduced area of alpha-SMA positivity (2.48 vs 3.97; P=.008). A trend was seen towards decreased collagen surrounding vessels in preeclamptic placentas, though this was not statistically significant (4.33 vs 5.66; P=.054).

CONCLUSION:

Preeclampsia is associated with a decrease in vascular smooth muscle within placental villi and may be associated with decreased collagen content. This may represent a mechanism to increase transplacental flow of oxygen in the setting of impaired spiral artery remodeling, but further studies are needed to clarify this relationship.
Connected Health-Enabled Remote Blooding Pressure Monitoring of Low-Risk Pregnancy in Rural Setting [07L]
Authors: DeNicola Nathaniel G. , Sheth Sheetal , Marko Kathryn , Woodland Mark B.
Published: April 2020

INTRODUCTION:

Connected health, or telehealth, interventions have been targeted to help reduce health care disparities in rural populations for its ability to remotely connect patients and providers.

METHODS:

In a study population at a Pennsylvania health system with both rural and urban ZIP codes, low-risk pregnant women were enrolled in an integrated technology platform, Babyscripts (BRx), with a mobile application and connected devices to remotely transmit blood pressure (BP) readings. A retrospective analysis was performed on de-identified data from patients with similar demographics from rural and urban ZIP codes to compare outcomes: average BP readings per individual, frequency of trigger BP readings (>140/90), and average interval between BP readings.

RESULTS:

Of 795 low-risk pregnant women enrolled in remote BP monitoring, 46 resided in rural ZIP codes (5.79%). Among the 46 patients in rural ZIP codes the average number of BP readings per patient was 17.8 compared to 17.6 in the urban setting (total BP readings: 823 and 13,211 respectively). The frequency of trigger BP readings >140/90 was 2.07% in our rural population compared to 2.24% in urban population. The average interval between readings was 7.99 days rural compared to 7.94 urban.

CONCLUSION:

Connected health interventions for low-risk pregnant women in a rural population resulted in healthcare engagement and remote BP monitoring comparable to that observed in the urban setting. Future controlled studies can examine the role of connected health as a driver for reducing health disparities for remote and rural communities.
Delivery and Neonatal Outcomes in Women of Very Advanced Maternal Age [10L]
Authors: Jones Cresta W. , Tessier Katelyn , Raasch Caitlin , Dharampaul Kayla , Schumer Amy
Published: April 2020

INTRODUCTION:

Little contemporary data are available on pregnancy delivery and neonatal outcomes in a diverse population of very advanced maternal age, defined as age 40 years or greater at estimated date of delivery (EDD). We examined the association of adverse delivery and neonatal outcomes in women at very advanced maternal age from 2016 to 2017.

METHODS:

This retrospective cohort study examined patients presenting for delivery in an urban academic healthcare system from 2016 to 2017. Women 40 years old or older at EDD (n=433) were compared with controls age 25-30 years (n=755). The primary outcome compared rates of cesarean delivery between the two groups. Differences in delivery and neonatal outcomes were also examined. Chi-square and Fisher exact tests were used for categorical variables; Wilcoxon rank-sum test was used for continuous variables. Logistic regression was used adjust for any demographics that were associated with age.

RESULTS:

Women age 40 or older were more likely to deliver via cesarean section than younger controls even after adjusting for demographic differences (42.7% vs 31.1%, adjusted P<.001). Secondary outcomes also identified significant associations between very advanced maternal age and an earlier gestational age at delivery (P<.001), as well as neonatal anomalies identified at birth, NICU admission and infant length of stay (all P<.05).

CONCLUSION:

Very advanced maternal age is associated with an increased risk of cesarean section, as well as an increased risk of additional delivery and neonatal complications. Prospective research is needed to determine whether these risks might be modifiable with changes in current obstetric management.
Effects of Selective Early Magnesium Cessation Protocol on Preeclampsia With Severe Features [12L]
Authors: DeYoung Tracey , Saber Barbara , Walz Sarah , Davis Karen , Blosser Colleen , Poole Aaron
Published: April 2020

INTRODUCTION:

We evaluate the effect of a selective early postpartum magnesium cessation protocol in patients diagnosed with preeclampsia with severe features.

METHODS:

A standardized protocol was implemented in March 2017 identifying patients at lower risk of postpartum eclampsia, and thus eligible for early discontinuation of magnesium sulfate at 12 hours postpartum. An IRB approved, retrospective cohort study was performed of all patients with preeclampsia with severe features 25 months before and after protocol implementation. The primary outcome assessed was the incidence of postpartum readministration of magnesium sulfate after completion of the initial course.

RESULTS:

Preeclampsia with severe features was identified in 737 patients with exclusion of 58 patients due to postpartum preeclampsia diagnosis or eclampsia prior to initial magnesium cessation. While the rate of preeclampsia with severe features increased (3.9% vs 7.0%, p<.001) in the pre and post-implementation groups, there was no difference in the rate of eclampsia (0.03% vs 0.05%, P=.59). Analysis included 272 patients pre and 407 patients post protocol implementation. Rates of early magnesium cessation, less than 23 hours of postpartum magnesium, were 11.1% vs 55.5% pre and post protocol implementation. In patients who underwent early magnesium cessation (n=226), there was no significant difference in postpartum readministration of magnesium (1.5% vs 3%, P=.25). There was no difference in readmission for hypertensive disorders of pregnancy (1.1% vs 2.5%, P=.20).

CONCLUSION:

In patients with preeclampsia with severe features who underwent selective early magnesium cessation there was no difference in postpartum readministration of magnesium sulfate or readmission for hypertensive disorders of pregnancy.
Elevated Early Third Trimester Hemoglobin as a Predictor of Preeclampsia [14L]
Authors: Hachey Sara , Alderfer Kayla , Anasti James N. , Vigh Richard
Published: April 2020

INTRODUCTION:

One of the early physiologic changes in pre-eclampsia (PE) is increased vascular permeability that can cause hemoconcentration. We hypothesized higher hemoglobin (Hgb) may be an early marker for development of PE.

METHODS:

During a 3 year period, records of women without known renal disease and a gestational age at delivery (GAD) >24 weeks were evaluated. PE was defined as elevated blood pressure (>140/90) and increased protein: creatinine ratio (PCR>0.29). The Hgb obtained between GA 22-32 weeks were reviewed. In addition to GAD, maternal age (MA) and body mass index (BMI) was recorded. Odds ratios (OR, 95% CI) were determined for the development of PE in women with Hgb >12.9 and >13.9 grams.

RESULTS:

Of the 10,418 deliveries, 901 (8.6%) were diagnosed with PE. Women with PE delivered earlier (37.2 ± 2.8 vs 38.6 ± 2.1 wks, P<.001) and had higher BMI (35.2 ± 7.1 vs 32.6 ± 6.2 Kg/M2, P<.001). Of the 396 women with a Hgb >12.9, 74 developed PE (OR 2.5, 1.8-3.1, P<.001). Other than GAD (34.4±5.5 vs 37.2±3.6 wks, P<.001), PE with Hgb>12.9 did not differ in MA or BMI. Of 44 women who had Hgb>13.9, 14 developed PE (OR 4.7, 2.5-8.9, P<.001). PE with Hgb>13.9 did not differ in GAD, MA or BMI, however sample size was limited.

CONCLUSION:

In this retrospective case control study, elevated Hgb was associated with PE. Most pregnant women have Hgb between 24 to 30 weeks. This inexpensive, ubiquitous test may provide an additional warning sign for the development of PE.
Incident Hypertension Diagnoses With Expansion of Criteria for Hypertension in Pregnancy [18L]
Authors: Darwin Kristin C. , Federspiel Jerome J. , Schuh Brittany L. , Baschat Ahmet A. , Vaught Arthur J.
Published: April 2020

INTRODUCTION:

Expansion of Stage I hypertension criteria by the American College of Cardiology-American Heart Association (ACC-AHA) to systolic blood pressure (SBP) 130-139 mmHg and/or diastolic blood pressure (DBP) 80-89 mmHg increased the prevalence of hypertension in the general population. ACOG has a higher threshold for elevated blood pressure in pregnancy (SBP >140 mmHg and/or DBP >90 mmHg). Whether broadening hypertension criteria in pregnancy would result in similar expansion of diagnosis is unclear.

METHODS:

Retrospective study of pregnant women who initiated prenatal care <20 weeks’ gestation at two tertiary teaching institutions between November 2015-February 2018 and were normotensive without history of chronic hypertension. IRB approval was obtained. Cumulative incidence of hypertensive disorder, diagnosed by 20, 37, and 39 weeks, was compared with application of Stage I ACC-AHA versus ACOG criteria.

RESULTS:

There were 4,312 women included. Median intake was at 11 weeks-4 days gestation. Median age was 29 years; 36.4% were white, 31.9% black, 20.6% Hispanic, 7.1% Asian, and 4.1% another racial/ethnic classification. With application of existing ACOG criteria, incidence of hypertensive disorder diagnosis was 0.9%, 7.3%, and 15.1% at 20, 37, and 39 weeks, whereas with expansion to include Stage I ACC-AHA criteria, rates were 1.9%, 12.7%, and 21.5%.

CONCLUSION:

Expansion of diagnostic criteria for hypertension in pregnancy to include Stage I ACC-AHA hypertension nearly doubled the diagnosis of hypertensive disorder at 37 weeks. Given the resource-intense bundle of interventions associated with hypertension diagnosis (e.g., sonography, antenatal testing, and induction of labor), understanding benefits and costs of expansion will be crucial prior to contemplating policy change.
Is There an Association Between Second Trimester Blood Pressure and Pregnancy-Induced Hypertensive Disorders? [19L]
Authors: Grubman Olivia , Hussain Farrah N. , Parikh Bijal , Karotkin Liza , Schneider Emily , Brustman Lois
Published: April 2020

INTRODUCTION:

In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) revised the guidelines for abnormal blood pressure (BP): elevated (120-129/<80), stage 1 (130-139/80-89) and stage 2 hypertension (≥140/90) on ≥2 occasions in adults. This study aims to determine a relationship between elevated and stage 1 ACC/AHA hypertension in the second trimester and pregnancy-induced hypertensive disorders (PIH).

METHODS:

In this IRB approved retrospective cohort study, we collected the highest two blood pressure measurements in second trimester for singleton pregnancies prior to the ACOG diagnosis of PIH (gestational hypertension, preeclampsia, HELLP, eclampsia). Patients were grouped by ACC/AHA criteria and compared using Pearson chi-square tests, Fisher’s exact tests, T-tests or Mann-Whitney U tests.

RESULTS:

200 patients were included; 54.9% had normal BP, 10.5% had elevated BP, and 34% had stage 1 ACC/AHA hypertension. There was no association between the severity of PIH and normal versus elevated/stage 1 BP in second trimester. Among those with elevated/stage 1 hypertension, gestational age was significantly lower at diagnosis of PIH (P<.001) and delivery (P<.001) compared to normotensive patients.

CONCLUSION:

Gestational age at PIH diagnosis and delivery were significantly lower among women with ACC/AHA elevated or stage 1 hypertension in second trimester compared to normotensive women. Therefore, further research is warranted to determine a relationship between the ACC/AHA guidelines for hypertension and PIH with the possibility of earlier recognition of the disease and intervention.
Obstetric Anal Sphincter Injuries: Compliance With ACOG Postpartum Care Recommendations [22L]
Authors: Bates Kari , Elkattah Rayan , Kharoufeh Anton
Published: April 2020

INTRODUCTION:

Severe obstetric lacerations that include the anal sphincter complex are associated with increased risk for short and long term complications. ACOG gives postpartum care recommendations to improve outcomes, including stool softeners and oral laxatives with counseling to avoid constipation, pain management with NSAIDs and opiate-containing analgesics, and one dose of perioperative antibiotics. The objective of this study was to assess compliance with these ACOG recommendations at a tertiary care hospital in Central Illinois.

METHODS:

An IRB-approved retrospective observational study was done on patients that had vaginal deliveries complicated by OASIS in the calendar year of 2018. Compliance percentages were obtained for each recommendation. Anything less than 100% compliance was considered inadequate.

RESULTS:

A total 45 patients were found to have vaginal deliveries complicated by OASIS in 2018. One wound complication was identified to date. Compliance was less than 100% in all parameters. Only 20% received perioperative antibiotics. While inpatient, compliance rates varied from 49% to 87% of patients receiving adequate postpartum care. Upon discharge from the hospital in the postpartum period, compliance rates varied from 4% to 47% of patients receiving adequate prescriptions or counseling for medication use.

CONCLUSION:

Our results indicate that compliance with ACOG guidelines is inadequate at a busy tertiary care center in Central Illinois. Of particular concern is the lack of patients receiving adequate counseling and prescriptions for medications (stool softeners, NSAIDs, opiates) upon discharge from the hospital. Interventions are currently being investigated and the results of implementation will be a source of future studies.
Oral Nifedipine Use After Launch of Nurse Driven EMR Care Pathway for Severe Hypertension in Pregnancy [23L]
Authors: Martin Courtney , Johns Kim , Yao Ruofan , Balli Kevin , Pappas James
Published: April 2020

INTRODUCTION:

The use of care pathways via EPIC EMR is an emerging technology to standardize patient care. Timely treatment of hypertension is critical to prevent morbidity and mortality. ACOG guidelines recommend the use of oral nifedipine as a first line medication, especially if there is no intravenous access. We evaluated the use of oral nifedipine before and after care pathway creation.

METHODS:

A nurse driven care pathway and warning system was designed and implemented in the EPIC EMR inpatient environment. The pathway protocolizes the initial management of severe hypertension in pregnancy based on ACOG guidelines. The purpose of this study was to evaluate the difference in minutes to administration of oral nifedipine after the second severe range blood pressure reading in the 12 months before and after implementation of the pathway. The second area of interest was in the change in the frequency of use.

RESULTS:

In the 12 months before the pathway, the average time to administration of the nifedipine from the second severe range blood pressure was 40.41 minutes versus 22.75 minutes in the following 12 months (P=.023). There were less episodes of administration of nifedipine (54) before the launch, which increased significantly (186) in the 12 months after launch of the pathway (P=.012).

CONCLUSION:

Implementation of a nurse driven, care pathway for severe hypertension in pregnancy decreased the time to administration and increased the frequency of use of oral nifedipine.
Perinatal Outcomes in Preeclampsia Stratified by ABO Blood Group [24L]
Authors: Juusela Alexander , Addy Sophia , Nazir Munir , Gimovsky Martin Larry
Published: April 2020

INTRODUCTION:

Preeclampsia is a hypertensive disorder unique to pregnancy of which the exact etiopathogenesis has yet to be elucidated. The condition is characterized by hypertension, third spacing, and the effects of arterial vasospasm induced end organ damage. The purpose of the study was to determine if in our patient population there are statistically significant differences in preeclampsia outcomes stratified by ABO blood group.

METHODS:

A retrospective cohort analysis was performed on singleton gestations that delivered at our institution between January 2010 and July 2014 and had a diagnosis of preeclampsia, eclampsia, and HELLP syndrome. 127 patients met criteria, and statistical analysis using SPSS was performed. Primary measures were maternal and fetal characteristics, method of delivery, and adverse perinatal outcomes. Demographic data were analyzed and compared. A χ2 and Fischer-Exact analysis was used for discrete variables, ANOVA was used for continuous variables, and a Kaplan-Meier Survival analysis was performed.

RESULTS:

127 patients met inclusion criteria. There was no statistically significant difference in maternal age, gestational age at delivery, preterm delivery rate, delivery route, 1 and 5 minute Apgars, or perinatal complications between the ABO blood groups.

CONCLUSION:

Contrary to published studies, our single site cohort study did not demonstrate a statistically significant difference in perinatal outcomes or EGA at delivery for Rh positive blood groups A, B or O, however, a Type 2 error may exist. Our study adds to the knowledge base in that it highlights the fact that preeclampsia is most likely a multifactorial disease involving molecular, genetic, and epigenetic factors.
Predicting Obstetric Anal Sphincter Injury (OASIS) in Women Undergoing Trial of Labor After Cesarean (TOLAC) [25L]
Authors: Gilchrist-Scott Douglas , Brown Oluwateniola , Lewicky-Gaupp Christina , Miller Emily S. , Mueller Margaret , Kenton Kimberly
Published: April 2020

INTRODUCTION:

We aimed to evaluate the relationship between predicted success of trial of labor after cesarean (TOLAC) and obstetric anal sphincter injury (OASI) to develop a predictive model.

METHODS:

We performed a secondary analysis of the Maternal Fetal Medicine Units Network (MFMU) TOLAC prospective cohort (1999–2002) and a single-site retrospective analysis of a cohort of women with a singleton vaginal birth after cesarean (VBAC) between 2011 and 2016 (modern population [MP]) (IRB approval STU00204149). Women were stratified by the presence of OASI and characteristics were compared with bivariate analysis, including the predicted probability of achieving VBAC using the MFMU calculator. Significant risk factors were included in a backward stepwise multivariable logistic regression model to identify independent risk factors for OASI and generate a predictive model. Model performance was evaluated using concordance indices, brier scores and calibration plots. Internal validity was assessed with bootstrapping and external validation performed using MP data.

RESULTS:

12,108 women met inclusion criteria and 739 (6.1%) sustained OASI. Factors independently associated with OASI included forceps (OR 5.0 CI 4.1-6.2) and vacuum (OR 2.8 CI 2.2-3.6), along with predicted likelihood of VBAC (aOR 0.5 CI 0.4-0.6), race and smoking. The concordance index of the model and MP validation cohort was 0.79 (CI 0.77-0.81) and 0.77 (CI 0.71-0.83). The model demonstrates internal validity, but slight overcalibration within the MP cohort.

CONCLUSION:

Predicted likelihood of VBAC is inversely proportional to the likelihood of sustaining OASI. Our model provides a robust estimate of OASI risk during VBAC that can be easily utilized in counseling.
Prophylactic Low-Molecular-Weight Heparin Versus Unfractionated Heparin at the Time of Delivery [32L]
Authors: Pluym Ilina D. , Holliman Kerry , Bermudez Ana , Afshar Yalda , Silverman Neil S. , Rao Rashmi
Published: April 2020

INTRODUCTION:

To compare the impact of two common dosing practices of antepartum prophylactic anticoagulation on peripartum management.

METHODS:

IRB approval was obtained for this retrospective cohort study of women receiving prophylactic anticoagulation from 2014 to 2019. Two strategies were reviewed: continuation of low-molecular weight heparin (LMWH) until delivery vs transitioning from LMWH to unfractionated heparin (UFH) at 36 weeks. Strategies were compared for impact on obstetric outcomes and anesthesia for delivery.

RESULTS:

Prophylactic anticoagulation was identified in 66 women; 48 (73%) remained on LMWH until delivery and 18 (27%) were transitioned to UFH. LMWH dosing ranged from 30 to 80 mg daily (88% at 40 mg). UFH was dosed at either 5,000 U twice daily (56%) or 10,000 U twice daily (44%). Comparing outcomes, both groups had similar rates of delivery during a scheduled admission (65% vs 50%, P=.40) and receiving neuraxial analgesia (79% vs 89% P=.50). Four women receiving LMWH (8%) did not receive neuraxial analgesia due to timing of their last dose (range 5-12 hours); one of these patients received general anesthesia for a cesarean, and the other three received intravenous analgesia for labor. In the LMWH group, seven women (15%) had an estimated blood loss (EBL) >1000 cc compared to none in the UFH group (P=.18) A multiple regression model showed no effect of anticoagulation strategies on EBL when adjusted for route of delivery, maternal weight and birthweight (P=.18).

CONCLUSION:

Among women receiving prophylactic LMWH, transition to UFH before delivery did not significantly impact receipt of neuraxial analgesia or lower rates of postpartum hemorrhage.
Risk of Venous Thromboembolism After Peripartum Hysterectomy [35L]
Authors: Mauney Logan C. , Barth William H. , Clapp Mark A.
Published: April 2020

INTRODUCTION:

Pregnancy and the postpartum period are known hypercoagulable states. The risk of VTE is higher after cesarean compared to vaginal delivery. The risk of VTE following peripartum hysterectomy is largely unknown. This study compared the incidence and risk of VTE among women who had and did not have a peripartum hysterectomy.

METHODS:

From the 2016 National Readmissions Database, women who had 1 delivery encounter at greater than 20 weeks of gestation between January 1 and November 30 and a diagnosis of a deep venous thrombosis (DVT) or pulmonary embolism (PE) during the delivery encounter or within 30 days of discharge were included in a retrospective cohort study. Incidence of VTE was compared among women who had and did not have a hysterectomy. Multivariable logistic regressions were used to estimate the associations between VTE and hysterectomy adjusted for other known VTE risk factors. Analyses used survey weights to obtain population estimates.

RESULTS:

Of the 1,760,255 women with delivery encounters, 1,903 (0.1%) underwent hysterectomy. 26 were diagnosed with VTE after hysterectomy, 17 (65%) of which occurred during the delivery admission. The incidence of VTE was higher in women who underwent hysterectomy compared to women did not (14.1 vs 0.7 per 1,000 deliveries, P<.001). Unadjusted and adjusted odds of VTE after hysterectomy were 19.7 (95% CI 12.6-30.6) and 15.6 respectively (95% CI 9.8-24.8).

CONCLUSION:

Peripartum hysterectomy is associated with significantly increased risk of VTE even when accounting for other risk factors, which prompts further investigation into the role for VTE prophylaxis postpartum after hysterectomy.
Variation in Severe Maternal Morbidity Among All Births Across Arizona, 2016-2017 [38L]
Authors: Oelkers Kaitlyn , Coonrod Dean V. , Bhattarai Bikash , Quintana Enid
Published: April 2020

INTRODUCTION:

Given the interest in preventing maternal mortality, this study aimed to analyze differences in severe maternal morbidity (SMM) across Arizona hospitals to analyze the role of hospital characteristics in SMM frequency.

METHODS:

Based on the CDC definition of SMM, all births in Arizona for 2016-2017 were analyzed to assess for SMM with and without blood transfusion. Multiple hospital characteristics including trauma level, teaching status, and ownership were analyzed to their association with SMM. This project received an exemption from IRB review from the Maricopa Integrated Health Systems IRB.

RESULTS:

Deliveries (N=158,834) were analyzed finding an SMM with blood transfusion rate of 144.0 per 10,000 deliveries ranging from 29.4 to 412.4/10,000. SMM without transfusion was 67.7 per 10,000 ranging from 21.2 to 172.9/10,000. By ownership, government hospitals had the highest SMM with transfusion (246.5/10,000). Teaching hospitals had higher SMM with transfusion than non-teaching hospitals (188.9/10,000 vs 108.2/10,000 with transfusion). Level 1 trauma centers had 2.38 times higher SMM with blood transfusions and 1.37 times higher SMM without blood transfusion relative to lower-level trauma centers and non-trauma centers. However, there was a wide variation between hospitals in the same group, including trauma level, volume, and nursery level.

CONCLUSION:

SMM proportions varied by many hospital factors including size, residency, and trauma level. Higher SMM was seen in government-owned, teaching, and level 1 trauma hospitals. There was also variation with these groups. One possible intervention would be to reduce these variations as part of a quality improvement process.
Venous Thromboembolism in Pregnancy [39L]
Authors: Alsarraj Ghazi , Abenhaim Haim Arie , Alnoman Abdullah
Published: April 2020

INTRODUCTION:

Venous thromboembolism is one of the leading causes of pregnancy-related maternal death in developed countries. The incidence rate is much higher during the postpartum period with an overall incidence of 2.5 to 9.9 per 1000

METHODS:

The data were obtained from the 1999-2015 Health Care Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) and used to carry out a population-based cohort study. The purpose of our study is to trend the rate of VTE during pregnancy and postpartum period and the assessment of the risk factors using a large population-based administrative database from the United States. Logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (CIs) of demographic and obstetrical determinants of VTEs.

RESULTS:

The overall incidence of VTE was in an upward trend until 2015 when it reached 20/10,000 pregnancies, with an average case fatality rate of 1.16%. VTE is associated with maternal age above 25, anemia, heart disease, hypertension, obesity, transfusion, C-section, postpartum hemorrhage and PET. Predictors of VTE fatalities included obesity, hypertension, PET, postpartum hemorrhage, PTB and DM.

CONCLUSION:

VTE is a condition with an increasing in incidence and is associated with a significant maternal morbidity and mortality. Multiple risk factors associated with VTE with obesity being the most significant in our study. Further research targeting risk factors and prevention in pregnancy is warranted.
Very Advanced Maternal Age and Obstetric Outcomes [40L]
Authors: Jones Cresta W. , Tessier Katelyn , Raasch Caitlin , Dharampaul Kayla
Published: April 2020

INTRODUCTION:

Mean maternal age continues to increase in the United States and more women are getting pregnant in their forties or older. We aimed to examine the risk of adverse obstetric outcomes in a diverse contemporary urban population of women of very advanced maternal age, defined as age 40 years or older at estimated date of delivery (EDD).

METHODS:

This retrospective cohort study examined patients presenting for delivery in an urban Midwest academic healthcare system from 2016 to 2017. Women 40 years of age or older at EDD (n=433) were compared with controls between age 25 to 30 years at EDD (n=755), in relation to risk of adverse obstetric outcomes. Chi-square and Fisher exact tests were used to evaluate categorical variables.

RESULTS:

Women 40 years or older were more likely to experience adverse obstetric outcomes, including an increased risk of gestational diabetes, gestational hypertension, amniotic fluid abnormalities, fetal growth restriction, PPROM, preterm labor and pre-delivery hospitalization (all P<.05). No difference in the identification of prenatal fetal anomalies was seen between the two groups.

CONCLUSION:

Very advanced maternal age (≥40 years at EDD) is associated with an increased risk of adverse obstetric complications. These data will help guide management and counseling of women contemplating or achieving pregnancy at more advanced maternal age.
A Multi-Faceted Intervention to Reduce Obstetric Hemorrhage Risk at University Hospitals [01M]
Authors: Cossler Nancy , Liu James H. , Katz Tyler Jessica , Albertini Megan , Furnari Rosanne , Porter Steven
Published: April 2020

INTRODUCTION:

We describe a systematic approach to mitigating obstetric hemorrhage risk at University Hospitals (UH), a northeast Ohio-based system of eighteen hospitals, including seven hospitals providing obstetric services and delivering approximately 8000 women/year.

METHODS:

From 2009-2015, obstetric hemorrhage (OBH) led to two maternal deaths and other harms in the form of excessive transfusions, ICU admissions, and hysterectomies as definitive treatment. OBH accounted for 11% of litigation costs ($7.4 M) during this period.

To reduce harm associated with OBH, we implemented the following interventions: 1. Clinical Practice Guideline for management of anemia in pregnancy; 2. EMR field to capture hemorrhage risk factors and prompt type and cross on admission; 3. Mandating transfer of high risk patients for delivery at a tertiary care center; 4. Clinical Practice Guideline for management of OBH (including active management of third stage of labor); 5. Shifting from estimating to quantifying blood loss by weight; and 6. Standardization of OBH carts on all L&D units.

RESULTS:

From 2015-2017, there was: 40% increase in the number of patients admitted to L&D with hemoglobin >10 mg/dl; 68% decrease in the number of obstetric patients requiring transfusions of ≥four units of packed red blood cells; 77% decrease in the number of peri-partum hysterectomies; and 91% decrease in the number of patients admitted to ICU for OBH. There were no maternal deaths from OBH and no new suits or claims related to OBH between 2014 and 2018.

CONCLUSION:

This multifaceted intervention was associated with decreased patient harm and reduced litigation costs associated with obstetric hemorrhage.
A Novel Therapeutic in the Management of Post-Episiotomy Pain [02M]
Authors: Grabie Yisroel , Jamil Nawshin (Zara) , Schwob Joseph , Uryash Arkady
Published: April 2020

INTRODUCTION:

Although rates of episiotomy are declining, post-episiotomy pain remains a complication in obstetric care. Current management includes NSAIDs and Benzocaine, but the use of Benzocaine has been linked to iatrogenic methemoglobinemia, with greatest risk in newborns. We hypothesized that a novel drug formulation, currently being investigated in diabetic neuropathy, can be used to attenuate post-episiotomy pain.

METHODS:

This pilot study was conducted in an outpatient obstetrics clinic on postpartum women aged between 18 and 39, who underwent vaginal delivery with episiotomy. Spray bottles with the investigational product were distributed to the patients to use without regulation. A survey to assess post-episiotomy pain using the Visual Analog Scale (VAS) was administered to the patients. Pain attenuation, time to pain attenuation, and quality of pain were measured.

RESULTS:

The cohort consisted of 25 women (including 5 non-responders). In responders, pain was attenuated by 4.0 scale units. Average time to analgesia was 9.25. Average pain ratings after treatment were compared to average pain ratings before treatment using a unidirectional paired sample t test (df=24). The average pain ratings for the entire cohort after administration of Relivatrol© were significantly lower than average pain rating prior to administration t (24)=7.41, P<.0001.

CONCLUSION:

We concluded that Relivatrol© significantly decreases post-episiotomy pain. Being a pilot study had multiple limitations; we developed a protocol for a larger investigation and are currently collecting data involving a greater number of subjects, a control arm, pharmacokinetic parameters, and an analysis of quality of life impact.
Antepartum and Intrapartum Characteristics Associated With Postpartum Blood Transfusion [03M]
Authors: Farr Carly , Ogunyemi Dotun , Bauer Samuel , Karabon Patrick , Bahado-Singh Ray , Alhousseini Ali
Published: April 2020

INTRODUCTION:

Risk assessment is the first step in an Obstetrics Hemorrhage Safety Bundle. Accurate elucidation of prenatal and intrapartum risk factors can facilitate the reduction of severe maternal morbidity and mortality due to postpartum hemorrhage.

METHODS:

Retrospective cohort study of 27,886 women evaluated for antepartum and intrapartum factors associated with postpartum blood transfusion. Univariate and multivariate logistic regression and propensity score analyses were performed, and odds ratio were derived. P-values<0.05 were considered statistically significant.

RESULTS:

245 of 27,886 mothers required blood transfusion. On multivariate logistic regression adjusting for all factors, statistically significant independent associations of blood transfusion were general anesthesia (OR 6.01; P=.0002), severe preeclampsia (OR 3.34; P<.0001), chorioamnionitis (OR 3.09; P<.0001) and the use of multiple methods for cervical ripening (OR 2.03; P=.0098). Milder independent associations were previous cesarean delivery (OR 1.83; P=.0037), gestational hypertension (OR 1.55; P=.0283), and gestational diabetes (OR 1.55; P=.0410). Using propensity score inverse probability of treatment weighting multivariable model, independent associations of blood transfusion were cervical dilation on admission <2 cm, effacement <60%, and station <-3, duration of all stages of labor (all P<.0001) and intrapartum therapy with intravenous anti-hypertensives (ORPS 2.53; P<.0001), Magnesium (ORPS 2.94; P<.0001), opioids (ORPS 2.17; P<.0001), Clindamycin/Gentamicin (ORPS 3.91; P<.0001), and uterotonics (ORPS 14.3; P<.0001).

CONCLUSION:

Treatment of intrapartum complications contribute more to the need for blood transfusion than prenatal risk factors. Avoiding general anesthesia, reducing labor induction and prolonged labor are potential preventable causes of postpartum hemorrhage requiring blood transfusion.