bluuebunny/crossref_metadata_2025 huggingface dataset:
Four-Year Efficacy and Safety of the Liletta® Levonorgestrel Intrauterine System [11A]
Authors: Thomas Michael , Chen Beatrice A. , Keder Lisa M. , Kimble Thomas D. , Jensen Jeffrey T. , Creinin Mitchell D.
Published: May 2017

INTRODUCTION:

Liletta is a levonorgestrel 52 mg contraceptive intrauterine system (IUS) currently approved for contraception for up to three years based on an ongoing multicenter trial evaluating the product for up to seven years of use. We evaluated four-year efficacy and safety data for Liletta.

METHODS:

Women aged 16-45 years were enrolled and followed in the clinical trial. Women aged 36-45 years received the IUS for safety evaluation only. We assessed four-year pregnancy rates (by Pearl Index and life-table analysis) and safety outcomes.

RESULTS:

Successful IUS placement occurred in 1,568 (98%) women aged 16-35 years and 146 (97%) women aged 36-45 years, including 1,011 (57.7%) nulliparous and 438 (25.1%) obese women. Among women 16-35 years at enrollment, eight pregnancies occurred including one following perforation and one following expulsion. Six (75%) pregnancies were ectopic. The eight pregnancies included three nulliparous women and one obese woman. The Pearl Index in the first year was .15 (95% CI .02-.55). Cumulative life-table pregnancy rates through years two, three and four were .49 (95% CI .22-1.09), .60 (95% CI .28-1.26) and .78 (95% CI .37, 1.60). Perforation following IUS placement occurred in two (0.1%) women; both were diagnosed within the first year. Expulsion was reported in 63 (3.7%) participants, most (50 [80.6%]) during the first year of use. Pelvic infection was diagnosed in 12 (.7%) women. Only 38 (2.2%) women discontinued due to bleeding complaints.

CONCLUSION:

Liletta is highly effective and safe over four years of use in nulliparous and parous women as well as non-obese and obese women.
Acceptance and Continuation of Immediate Postpartum LARC: Experiences From a Texas Hospital [12A]
Authors: Huff Cristina Wallace , Holcombe Sara , Duret-Uzodinma Jenny , Dillaway Chloe , Hopkins Kristine , Potter Joseph E.
Published: May 2017

INTRODUCTION:

Lyndon Baines Johnson Hospital in Houston, Texas began offering immediate postpartum placement of long-acting reversible contraception (LARC) in June 2014. We aimed to assess patient demand for this service, along with continuation and satisfaction at 3 and 6 months after delivery.

METHODS:

We conducted a cohort study of 199 postpartum women who delivered at this hospital. Publicly insured women aged 18-44 who delivered a healthy singleton, and wanted to delay childbearing for 24 months were eligible. Interviews were conducted face-to-face following delivery and by telephone at 3 and 6 months. Women receiving LARC postpartum, were asked about their continued use and satisfaction.

RESULTS:

Twenty-four women (12%) had an IUD placed immediately following delivery, and 46 (23%) had an implant placed before discharge. Forty-two (21%) had a sterilization before discharge, and 15 (8%) received an injectable. Another 10 participants (5%) said they would have accepted immediate postpartum placement of LARC, but it was not placed. Among the 170 women for whom we had complete follow-up data through 6 months, 62 were using LARC at baseline. 59 were using LARC at 3 months and 6 months. Two implants and one IUD were removed, and one IUD expelled. Of women continuing on LARC, 68% were very satisfied, and 21% somewhat satisfied.

CONCLUSION:

Acceptance of immediate postpartum LARC among low-income, predominantly Hispanic women is high. Continuation and satisfaction were also high, indicating that the Texas Medicaid rule change permitting reimbursement for postpartum LARC that went into effect in January 2016 could be of great benefit.
Survey of OBGYN Residents to Assess Awareness and Use of the U.S. CDC Medical Eligibility Criteria for Contraceptive Use [15A]
Authors: Marchin Angela , Isley Michelle
Published: May 2017

INTRODUCTION:

The CDC created the US Medical Eligibility Criteria (MEC) for Contraceptive Use in 2010 to serve as a tool for provider guidance when counseling patients with various medical conditions on safe use of contraception. Our study sought to assess US OB/GYN residents’ knowledge and use of this tool and how they choose to use it.

METHODS:

All US OBGYN residency program coordinators were emailed and asked to distribute a link to our online survey to their residents. Descriptive statistics and Fisher’s exact test were used to analyze the results.

RESULTS:

Ninety responses were obtained. Of the respondents, 91% were aware of the MEC, and 82% had used them. Of those who had used the MEC, 61% used the free smartphone app. Of those who did not use the MEC, most used UptoDate or asked a colleague to obtain contraception counseling information. There was no significant difference in use of the MEC among programs with and without Family Planning Fellowships or Ryan Programs.

CONCLUSION:

Most respondents were aware of and using the MEC, most often the downloadable smart-phone app. Due to a low response rate, additional assessment of resident use of the MEC is needed to fully understand how to improve OBGYN awareness and use of the MEC.
Development and Pilot Testing of Theory Based Comic for Intrauterine Device Information [25A]
Authors: Sridhar Aparna , Brown Alice , Roque Karen
Published: May 2017

INTRODUCTION:

A growing number of comics are being published on health-related topics. Comics use narrative communication. Translation of lived experiences into stories can be powerfully illustrated through comics.

METHODS:

The intrauterine device (IUD) comic was developed with theoretical concepts of health belief model and social cognitive theory. We tested the validity of the comic with women’s health experts. With IRB approval, the content of the comic was pilot tested among patients with a cross sectional survey. In addition to demographic information, questions in the survey had patients rate the comic on a scale of 1-5 (5= most favorable) about different aspects of the cartoon.

RESULTS:

30 women who underwent an IUD insertion at student health center (mean age 24) evaluated the comic. The comic was ‘really liked’ by women (mean score 4.66). The content of the comic scored high (>4.5/5) when evaluated by patients for color, images, overall look, layout, ease of understanding the material, clarity of words and satisfaction with information. Participants strongly agreed (>4.4/5) that the comic was successful in providing information about the types of IUDs, its effectiveness, mechanism of action, risks and benefits in addition to the placement details. They strongly believed that seeing this comic prior to IUD insertion would be helpful.

CONCLUSION:

Given the growing popularity of comics for health education, comics for contraception education have promising future to become sustainable educational tool. We are disseminating these comics as booklets, webpages and mobile applications. A quasi-experimental study is being conducted to evaluate its effect on IUD knowledge.
Describing Postpartum Contraceptive Counseling and Patient Satisfaction at a Large Urban Academic Medical Center [26A]
Authors: Jou Jessica , Findley Molly , McMahon Lauren , Kapedani Arisa , Levi Erika , Benfield Nerys
Published: May 2017

INTRODUCTION:

Postpartum contraception is a powerful tool for reducing unintended pregnancy and optimizing birth spacing. In 2014 we initiated a comprehensive postpartum contraception counseling and provision program at our institution and subsequently evaluated the prevalence of counseling, satisfaction with counseling, and uptake of postpartum contraception.

METHODS:

During their postpartum hospitalization, women completed a survey assessing perinatal contraceptive counseling timing, locations, content, and satisfaction, along with demographic and labor characteristics, and subsequent contraceptive plans and uptake. A chart review confirmed medical and demographic data. Descriptive statistics were obtained and logistic regression was used to evaluate associations.

RESULTS:

Our 156 participants were primarily young, primiparous, non-white and had public insurance. 93% of women reported receiving contraceptive counseling: 82% antenatally, 69% intrapartum, and 61% postpartum. There was no difference in counseling prevalence by age, race, parity, preferred language, mode of delivery, or insurance type. 97% of patients reported high satisfaction with their contraceptive counseling. Most patients (60%) felt that counseling in antenatal care was optimal; 6% preferred intrapartum counseling. At discharge, 93% reported a plan for contraception use. 58% were discharged with a prescription for contraception, had an implant or IUD placed, or injection administered prior to discharge.

CONCLUSION:

We demonstrate that near universal contraceptive counseling is achievable in a diverse and socioeconomically disadvantaged population. This leads to a high uptake of postpartum contraception with high rates of satisfaction. Women have a preference for antenatal counseling but provision of counseling at multiple time-points allows for greater access to, and satisfaction with, counseling.
Provider Counseling and Women’s Family Planning Decisions in the Postpartum Period [30A]
Authors: Goulding Alison N. , Bauer Anna E. , Bryant Amy G. , Stuebe Alison M.
Published: May 2017

INTRODUCTION:

Provider counseling may influence women’s family planning decisions.

METHODS:

We conducted an anonymous, Internet-based survey of adult women regarding multiple topics, including prenatal/postpartum care and family planning. Participants were included if they delivered a singleton infant within the last 3-9 months and breastfed at any time. We used multivariable logistic regression to quantify the association between quantity of provider counseling (indexed as number of family planning topics from 0-6 discussed by a healthcare provider) and women’s decisions regarding contraception and birth spacing.

RESULTS:

From January to May 2016, 3,010 women completed the survey and met inclusion criteria. Among this group, 2,684 (89.2%) were white and 2,166 (72.0%) completed at least a four-year college degree. 1,417 (47.1%) desired an inter-pregnancy interval (IPI) greater than two years, and 599 (19.9%) used long-acting reversible contraception (LARC) or sterilization. The majority of women (n=1,595, 53.0%) had received counseling on 3-6 family planning topics (defined as “more counseling” in regression models). Women who received more counseling were more likely to use LARC or sterilization (AOR 1.32, 95%CI 1.08-1.61) but were not more likely to desire an IPI greater than two years (AOR 0.97, 95%CI 0.81-1.15). Desired IPI modified the association between provider counseling and contraception (P=0.06 for interaction): Among those desiring an IPI greater than two years, more counseling was associated with more use of LARC or sterilization (AOR 1.56, 95%CI 1.22-2.01), but this was not observed among those desiring a shorter IPI.

CONCLUSION:

Contraceptive decisions depend on both provider counseling and patient goals.
Assessing Immediate Postpartum and Postabortion Contraception KAP Among Healthcare Professionals in Kigali [34A]
Authors: Aimable Muzungu Munyamboneza
Published: May 2017

INTRODUCTION:

Immediate postpartum contraceptive administration is thought to be safe, effective reducing unintended pregnancies. Health staff have influence on women’s contraceptive behavior; and their knowledge and attitudes about contraception can affect women’s contraceptive behaviors. Data are lacking about the knowledge, attitude and practice of contraceptive methods among health personnel in Rwandan health facilities. The present study is designed to assess the healthcare staff awareness of immediate postabortion and postpartum contraception knowledge in Rwandan health facilities including referral hospitals and district hospitals.

METHODS:

A descriptive cross-sectional study, using anonymous questionnaire was conducted in Rwanda referral hospitals; and 3 DH, recruiting in 240 health personnel all working in maternity departments, for a period of 9 months from August, 2014 to April, 2015.

RESULTS:

194 out of 240 healthcare providers working in maternity participated in our study. Overall, they show good attitude towards immediate contraception. The provision of immediate contraception was largely seen in referral hospital compared to District hospitals. 76% of the providers in District hospitals have never prescribed an immediate contraception. The most cited reasons for nonprovision of immediate contraception include lack of sufficient knowledge, concerns about side effects and possibility that the immediate contraception may not work.

CONCLUSION:

Healthcare staff in Rwanda have gaps in their knowledge regarding immediate postabortion and postpartum contraception. Their knowledge about the indications for prescription of immediate postabortion and postpartum contraception, and its side effects was inadequate. The continuous educational efforts for health staff should focus more on the specific aspects of contraception and patients’ needs.
Immediate Postpartum Contraception in Adolescents: Intention, Retention, and Repeat Pregnancies [35A]
Authors: Cizek Stephanie , Postlethwaite Debbie , Alabaster Amy , Greenfield Isabel , Gupta Pratima
Published: May 2017

INTRODUCTION:

Rapid repeat pregnancy (within 2 years) among young women poses serious health consequences. Long-acting reversible contraception (LARC) is safe and effective, and available to women immediately postpartum at our institution. Our primary aim was to compare the rapid repeat pregnancy rate for young women (aged 13-24 years) initiating LARC immediately postpartum versus initiating LARC within 8 weeks of delivery, and LARC versus other contraceptive methods.

METHODS:

A retrospective cohort study was conducted of 592 young women with a live birth from 2011-2013 within our healthcare system. Logistic regression models were used to determine the odds of rapid repeat pregnancy.

RESULTS:

Women using short-acting or no contraception had higher adjusted odds of rapid repeat pregnancy compared to those using LARC (aOR 2.9, 95% CI 1.5-6.0; and OR 3.2, 95% CI 1.6-7.0). Immediate postpartum LARC initiation had higher odds of rapid repeat pregnancy versus LARC initiation within 8 weeks (aOR 2.2, 95% CI 1.0-5.0). The LARC removal/expulsion rate within 2 years was 46% with immediate postpartum placement and 36% with 8 week placement. Women receiving immediate postpartum LARC were more likely to be under 18 years old, had higher gravidity, and received primarily subdermal implants.

CONCLUSION:

Overall, postpartum LARC use among young women resulted in decreased risk of rapid repeat pregnancy compared to short-acting or no contraception. However, because of early LARC removal and switching to short-acting or no method, young women initiating LARC immediately postpartum were more likely to experience a rapid repeat pregnancy than those initiating LARC around 6-8 weeks postpartum.
Using a Predictive Model of Summative, Stratified Variables to Assess Risk for Postpartum Hemorrhage [5B]
Authors: Colvin Zachary , Dabbous Firas , Sulo Suela , Fournogerakis Rachel , Asado Nahren , Iannucci Thomas
Published: May 2017

INTRODUCTION:

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality. A previous study (Dilla et al) showed statistically different hemorrhage rates among groups rated low, medium, and high risk, but each group had low overall hemorrhage rates.

METHODS:

From 9/2012-5/2013, women who delivered at Advocate Lutheran General Hospital at gestational age greater than 20 weeks were included in this retrospective case control study. Risk factors present on admission and during labor were given score of 1, 2, or 3 based on existing literature and recommendation by an expert panel. Each patient was labeled low, moderate, or high risk based on total score at time of delivery. Definition of PPH was considered estimated blood loss greater or equal to 500 cc for vaginal delivery, greater or equal to 1000 cc for cesarean section, or if uterotonic medications beyond standard Pitocin protocol were administered.

RESULTS:

Of 1227 women, 115 (9.37%) experienced a PPH. The incidence of PPH in each risk group was: low (7%), moderate (22%), and high (31%). The proportion of the total hemorrhages occurring in each group was: low (64%), moderate (32%), and high (3%).

CONCLUSION:

This predictive model was better at predicting PPH than previous studies. Future studies with larger patient populations are needed to validate these findings. This type of model using a summation of all risk factors prior to delivery may represent an improved way to predict and thus prevent PPH.
Diagnostic Testing Uptake After High-Risk cffDNA Screening [6B]
Authors: Suhag Anju , Robbins-Furman Patricia , Hollier Lisa , Monga Manju , Ramin Susan , Van den Veyver Ignatia B
Published: May 2017

INTRODUCTION:

Introduction of cffDNA screening has decreased the rate of diagnostic testing and serum screening. We hypothesized that the uptake of diagnostic testing after abnormal cffDNA depends on the type of chromosomal aneuploidy suspected. Our aim was to evaluate the uptake of diagnostic testing in women with abnormal cffDNA screening.

METHODS:

A retrospective study of singleton gestations and any abnormal cffDNA results between 10/1/2012 and 3/31/2016. We compared 3 cohorts based on high-risk cffDNA results for (1) trisomies 21, 18, 13, (2) sex chromosome aneuploidies (SCA) and (3) other (no call, unreportable). Diagnostic testing was offered to all study subjects. Primary outcome was uptake of diagnostic testing by abnormal cffDNA results. P-value < .05 was considered significant.

RESULTS:

443 women met inclusion criteria. Mean age, rate of AMA and abnormal ultrasound were higher in trisomy group compared to SCA and other category. Uptake of diagnostic testing after a positive cffDNA result in this cohort was 31.6%. Women at high-risk cffDNA for trisomies were more likely to undergo diagnostic testing compared to SCA or other category (P=.02). Similarly, women with high-risk cffDNA for trisomies were more likely to be confirmed with diagnostic testing compared to SCA and other category (P < .0001). Diagnostic testing results in the last group were more likely to be normal or discordant from screen result.

CONCLUSION:

Diagnostic testing uptake is low overall but is higher in women with cffDNA screening results indicating high-risk for trisomy compared to sex chromosome aneuploidies or other category. High-risk screens for trisomies are more likely to be confirmed.
Heart Failure Symptoms in Pregnancy Related to Cardiac Structure and Function by Echocardiography [8B]
Authors: Sharalaya Zarina , Chang Patricia , Caughey Melissa , Ivester Thomas , Hinderliter Alan
Published: May 2017

INTRODUCTION:

Pregnancy is associated with physiologic changes causing alterations in cardiovascular hemodynamics, sometimes resulting heart failure (HF) symptoms which should be distinguished as physiologic or pathologic. We hypothesized that pregnant women with HF symptoms are more likely to have a difference in cardiac structure and function as determined by transthoracic echocardiogram (TTE).

METHODS:

237 pregnant women with no known cardiac history underwent TTE and questionnaires in the 3rd trimester and five months postpartum. HF symptoms were classified using modified Boston criteria (MBS), National Health and Nutrition Examination Survey (NHANES), and New York Heart Association (NYHA).

RESULTS:

48 patients (18%) had HF symptoms by MBS, 56 (24%) by NHANES, 148 (62%) had NYHA Class III/IV symptoms, and 24 patients (10%) met all 3 criteria. Self-reported symptoms including lack of energy, early satiety, and palpitations were correlated with higher HF scores on all scales (P

CONCLUSION:

The 3rd trimester brings subtle changes in cardiac structure and function that may be associated with HF symptoms. While some pregnant women meet HF criteria based on symptoms and have corresponding differences on TTE, it is reassuring that these changes resolve postpartum and likely reflect physiologic changes in pregnancy.
Highlights of Morcellation and Sarcoma Incidence in German Patients Admitted for Uterine Fibroid Surgery [12B]
Authors: Mettler Liselotte , Abdusattarova Khulkar
Published: May 2017

INTRODUCTION:

To assess the incidence and frequency of unsuspected cases of uterine sarcomas among patients undergoing surgery for benign uterine fibroids in Germany.

METHODS:

This was a retrospective single-center study at a university hospital. The records of patients with uterine fibroids and uterine sarcoma from 2003 to 2015 were reviewed.

RESULTS:

A total of 2,275 patients were included. Preoperatively, 2,269 patients had presumed benign uterine fibroids, and 6 patients had suspected uterine sarcoma. Among the 2,269 patients who underwent surgery for presumed uterine fibroids, only one patient (0.044%, 95% CI: 0.001%-0.25%) histopathologically revealed endometrial stromal sarcoma (ESS) after laparoscopic subtotal hysterectomy (LSH) with morcellation(48 years old). Six patients were diagnosed with uterine sarcoma preoperatively and underwent a direct open conventional cancer treatment. Histopathological analyses confirmed four cases of uterine leiomyosarcoma (ULMS) mean age 73.7 ± 3.9, one high-grade undifferentiated uterine sarcoma (HGUS), and one embryonal rhabdomyosarcoma (ERMS). Altogether, seven of the 2,275 women (0.31%, 95% CI: 0.12%-0. 63%) were diagnosed with uterine sarcomas over this twelve-year period.

CONCLUSION:

The frequency of unsuspected uterine sarcoma was 1/2,269 (0.044%) among the women who underwent myomectomies and hysterectomies to treat presumed benign uterine fibroids. The total incidence of uterine sarcoma was 7/2,275 (0.31%) among the women who had presumed uterine fibroids or a suspected uterine sarcoma before undergoing the surgical procedures. Shall we continue with unprotected morcellation.
High-Risk Pregnancy Support Group: Formative Work Toward Development of a Group-Based Intervention [13B]
Authors: Louis-Jacques Adetola , Torres Jessica , Vamos Cheryl , Marhefka Stephanie , Cain Mary A. , Wilson Ronee E.
Published: May 2017

INTRODUCTION:

Prolonged antepartum hospitalization can negatively affect psychological health of pregnant women. Study aims were: 1) Describe recurring themes regarding factors that impact women’s wellbeing during prolonged hospitalization in pregnancy; 2) Identify potential intervention characteristics that are desirable to women for improving their prolonged hospitalization experience.

METHODS:

In this convergent parallel mixed methods study, women who were experiencing or had previously experienced prolonged hospitalization during pregnancy, as well as key staff members (physicians, nurses, social workers, and lactation consultants) provided quantitative (survey) and qualitative (interview/focus group) data. Descriptive statistics, analyzed using SPSS 22, compared patient sociodemographic and preferred intervention characteristics. Qualitative data were analyzed with Applied Thematic Analysis.

RESULTS:

Patient respondents (N=57) were mostly white (77%), non-Hispanic (86%), married (65%) and insured (96.5%). Patients and staff (N=8) described challenges to women’s wellbeing related to: a) language/cultural barriers; b) social isolation in hospital; c) limited and/or ineffective information sharing between staff and patients; and d) anxiety and stress regarding concerns about hospitalization and competing demands at home. Narratives suggest strategies for improving women’s experiences—including interventions that involve family/friends, changes in information sharing and increased on-site services to facilitate an improved experience.

CONCLUSION:

Women who experience prolonged hospitalization during pregnancy experience many challenges that may lead to increased stress, anxiety, and depression. Facilitating opportunities for informational, appraisal, instrumental and emotional support may mitigate negative emotional impacts, reducing maternal stress and psychosocial dysfunction. This critical groundwork will inform further development and implementation of a theory- and evidence-based intervention.
Use of Gestational Surrogates for Women With Eisenmenger Syndrome: A Cost-effectiveness Analysis [17B]
Authors: Clennon Emily , Caughey Aaron B. , Pare Emmanuelle , Farwell Jennifer , Amato Paula
Published: May 2017

INTRODUCTION:

Eisenmenger Syndrome (ES) is regarded as a contraindication to pregnancy, however, women with ES continue to desire and attempt pregnancy despite risks to their health. This study compares costs and outcomes of pregnancy in women with ES to use of gestational surrogates in their pregnancies.

METHODS:

A decision-analytic model was built using TreeAge software that compared use of surrogates and pregnancy in women with ES. Maternal death and neonatal outcomes (intrauterine fetal demise, preterm birth, cerebral palsy, and death) were assessed. Probabilities and costs were derived from the literature. Utilities were discounted by 3% across expected lifespan to generate quality-adjusted life years. Univariate and multivariate sensitivity analyses were performed to evaluate robustness of the model.

RESULTS:

In a theoretical cohort of 1,000 women with ES, pregnancy would result in 360 maternal deaths, 100 stillbirths, 477 preterm births, and 157 neonatal deaths. In these pregnancies, use of surrogates would prevent 99% and 98% of maternal and neonatal death, respectively, and significantly reduce cases and costs of preterm birth and cerebral palsy. Use of a surrogate would save $518,255 per woman and gain 6.77 QALYs. Cost effectiveness is maintained if surrogacy cost reaches $150,000 and the surrogate is impregnated only 30% of the time.

CONCLUSION:

Use of surrogate mothers for those with ES is cost effective and significantly improves obstetric outcomes. These benefits are robust in the face of high surrogacy costs due to reduction in maternal mortality and preterm birth. These findings underscore the importance of broadening health care financing for medically-indicated assisted reproduction.
How Malpractice Cases Can Drive Your Safety Agenda [18B]
Authors: Mann Susan , Greenberg Penny
Published: May 2017

INTRODUCTION:

Malpractice data is a valuable tool to understand the complexities of alleged medical error. The Comparative Benchmark System (CBS) is a national database with over 350,000 medical professional liability (MPL) claims from more than 400 hospitals and 165,000 physicians across the country. Communication was identified as a factor in 30 percent of 23,658 medical malpractice cases filed between 2009-2013 in CBS, and 1,056 or 5 percent of these cases involved obstetrics.

METHODS:

Applying a Clinical Coding Taxonomy to MPL cases provides insight into specific factors driving patient harm and financial loss. Analysis of OB communication claims identified that communication failures occur among providers and/or between providers and patients, and failure types vary during throughout management of pregnancy, labor, and delivery.

RESULTS:

Identified communication failures: Antepartum -35 percent of cases involve communication failures (lab results): 63 percent are provider to provider; 57 percent are provider to patient. Intrapartum – 41 percent of cases involve communication failures in labor management and treatment of fetal distress (handoffs): 79 percent are provider to provider; 32 percent are provider to patient. Second stage or Delivery - 35 percent of cases involving the performance of the delivery involve communication issues (failure to escalate): 73 percent are provider to provider; 43 percent are provider to patient.

CONCLUSION:

Using malpractice claims to identify the need to improve the communication skills of providers can improve care and potentially reduce future malpractice claims.
Hyperreactio Luteinalis: Possible Cause of Intrahepatic Cholestasis and Disseminated Intravascular Coagulation [22B]
Authors: Luellwitz Ryan , Hawkins Jennifer , Hamber Elizabeth
Published: May 2017

INTRODUCTION:

Hyperreactio luteinalis (HL) is a rare finding in pregnancy consisting of enlarged multicystic ovaries capable of producing excess human chorionic gonadotropin (hCG) and androgens. We present a patient with HL and twin gestation complicated by intrahepatic cholestasis of pregnancy (ICP) who presented to our institution with disseminated intravascular coagulation (DIC).

METHODS:

Case Report.

RESULTS:

A 31-year-old gravida 1 para 0 at 35 weeks 5 days gestation with dichorionic/diamniotic twins, presented to our institution for evaluation due to elevated liver enzymes. On presentation, the patient was jaundiced but asymptomatic with normal vital signs. Fetal assessment revealed category three fetal heart tracing for both fetuses. The patient underwent emergent cesarean delivery. During surgery, bilateral enlarged multicystic ovaries were noted and lab values were consistent with disseminated intravascular coagulation. The patient was treated with fresh frozen plasma and cryoprecipitate then transferred to the intensive care unit. Postoperatively, the patient was noted to have elevated bile acids, bilirubin, androstenedione and aldosterone.

CONCLUSION:

Studies demonstrate that estrogens play a role in development of ICP and can impair bile acid secretion. HL produces high levels of androgens that are converted to estrogens by precursors from the fetal adrenal gland and placental aromatase. We propose estrogens produced by HL lead to the development of ICP. Excess estrogen production throughout pregnancy may lead to chronic bile acid accumulation and contribute to development of DIC.
Medical Students, Mid-Level Providers, and Physician Attitudes Towards Yoga Practice During Pregnancy [25B]
Authors: Bell Sarah , Kobernik Emily , Hammoud Maya
Published: May 2017

INTRODUCTION:

Yoga is a widely practiced form of exercise in the United States. We examined the attitudes of medical students, mid-level providers, and physicians regarding the role of yoga in obstetric patient care.

METHODS:

A 21-question survey was distributed from June 2016 to July 2016 to all second, third, and fourth year medical students, mid-level providers, (nurse practitioners, physician assistants, midwives), and Obstetrics and Gynecology and Family Medicine physicians at the University of Michigan. Bivariate analyses comparing participants who indicated they would recommend yoga to obstetric patients and those who did not was performed.

RESULTS:

The response rate among physicians/mid-level providers was 39% (114/294) and 33% (190/581) among medical students. Among 299 surveys eligible for analysis, 75.9% had ever practiced yoga, and 40.3% were current practitioners of yoga. Nearly two-thirds (61.4%) of participants indicated they would recommend yoga to their obstetric patients. Recommending yoga to obstetric patients was significantly associated with agreeing yoga is “a good form of exercise” (82.6% versus 42.6%, p < .0001), “safe” (89.1% versus 48.9%, p < .0001), recommending it to non-pregnant patients (82.6% versus 27.7%, p < .0001), and gender (58.4% males versus 74.9% females, p < 0.003). Among males, lifting weights was negatively associated with recommending yoga (37.0% versus 61.7%, p=0.02), and among females, running was negatively associated with recommending yoga (56.2% versus 77.3%, p=0.004).

CONCLUSION:

The majority of medical students, mid-level providers, and physicians would recommend yoga to their obstetric patients. Further research is needed to identify the specific predictors of recommending yoga to obstetrics patients.
Current Status of State-Level Maternal Mortality Review Legislation in the United States [26B]
Authors: Adesomo Adebayo , McDonald Amanda , Oben Ayamo G. , Rodriguez Emma , Ireland Kayla , Ramsey Patrick S.
Published: May 2017

INTRODUCTION:

Over the past 20 years the United States’ the maternal mortality rate has doubled. Significant racial disparities and discrepancies in reporting highlight the need for standardized case definition, uniform reporting, and comprehensive review of maternal mortality cases. Our objective was to assess the presence of state-specific legislation requiring maternal mortality reporting and review in the United States.

METHODS:

We surveyed all 50 states for existing laws, or pending legislation, requiring maternal mortality reporting by searching state government and other legislative websites for keywords and phrases “maternal mortality, maternal death, pregnancy-related death.” Additionally, state health department officials were contacted directly to confirm the presence or absence of pertinent legislation.

RESULTS:

Twenty-four of the 50 states (48%) currently have active or pending legislation regarding maternal mortality reporting. Twenty-nine of the 50 states (58%) have committees specifically designated to review maternal mortality. In states with legislation compared to states without legislation or committees there were no statistically significant differences in maternal mortality ratio (18.4 vs. 22.2), minority birth rate/1000 births (3.0 vs. 2.7) or overall birth rate/1000 births (12.3 vs. 12.1). 53% of states with a maternal mortality ratio greater than 25/100,000 have active or pending legislation.

CONCLUSION:

Less than half of states have active legislation requiring maternal mortality review. Review of maternal mortality cases in the United States needs to be standardized and universal to further elucidate the causes of the rising maternal mortality rate in the United States.
Use of Delayed Cord Clamping in Preterm Dichorionic Twin Gestations [27B]
Authors: Liu Lilly , Grobman William , Yee Lynn
Published: May 2017

INTRODUCTION:

Delayed cord clamping (DCC) for premature neonates has become standard of care in singleton gestations, but the outcomes after DCC in twin gestations are unclear. The aim of this study was to examine feasibility and outcomes associated with DCC in twins.

METHODS:

This is a retrospective cohort study of women delivering dichorionic-diamniotic twin gestations between 23-32 weeks gestation at a single center (2013-2015). In 6/2013, this institution introduced a DCC protocol for singleton neonates delivering < 32 weeks, with some dichorionic twins who also received DCC. Clinical characteristics and neonatal outcomes of twins receiving DCC were compared to those who did not. Bivariable assessments and fixed effects multivariable logistic and linear regression were utilized.

RESULTS:

Of 58 women delivering dichorionic twins < 32 weeks, 8 (13.8%) had both neonates receive DCC, resulting in 16 neonates who received DCC. DCC occurred both among those who were delivered vaginally (n=7), and by cesarean section (n=9). Neonates who received DCC, compared to those who did not, had similar umbilical artery pH, initial temperature, 5-minute Apgar score, and peak bilirubin. Additionally, there were no differences in neonatal intensive care unit length of stay, birth hematocrit, total number of blood transfusions or transfusions received in the first week, mechanical ventilation, need for pressors, death, or other adverse outcomes.

CONCLUSION:

Performance of DCC in dichorionic twin gestations born < 32 weeks is feasible and not associated with worse neonatal outcomes in this small cohort. Further investigation of expansion of DCC protocols to dichorionic twin gestations appears worthy of exploration.
Current Practice and Knowledge of Aneuploidy Screening, a Nationwide Survey [28B]
Authors: Hunter-Greaves Tiffany , Cunningham Orlando , Harriott John , Lewis Gregory , Rattray Carole
Published: May 2017

INTRODUCTION:

Aneuploidy screening is appropriate for all pregnant women as there is variable risk among all pregnancies. This study sought to determine the current approach and knowledge of aneuploidy screening among obstetricians and gynecologists in Jamaica.

METHODS:

A list of all practicing obstetricians and gynecologists was obtained from the medical council. A questionnaire was sent by mail or hand-delivered to all obstetricians and gynecologists across the country. The questions pertained to demographics, knowledge of screening and diagnostic tests available. Doctors with subspecialist training in maternal fetal medicine were excluded. The data obtained was kept anonymous.

RESULTS:

67 out of 100 (67%) doctors responded to the questionnaire. 63/67 (94.0%) reported that less than 25% of their patients had aneuploidy screening (95% confidence interval [CI], 88.3–99.7). 20.9% (95% CI, 11.2–30.6%) of respondents offered screening to all their patients while 35% offered to women 35 years or older. The frequency of screening tests was 37.3%, 16.4%, 11.9%, 6.0%, 6.0% and 3.0% for the QUAD screen, Triple screen, Second trimester ultrasound, First trimester screen, Free fetal DNA and Nuchal translucency respectively. Of the 6 knowledge questions asked, 4 questions had greater than 70% (95% CI, 59.0–81.0%) answered correctly.

CONCLUSION:

Obstetricians and gynecologists are aware of the risks of aneuploidy and screening tests available, however, only a small fraction of their patients received these tests. This suggests the need for further physician education on available tests, increased affordability of tests, patient education and studies on patient views on screening.
Does Timing of Administration of Vaginal Misoprostol for Cervical Ripening Affect Cesarean Delivery Rate? [32B]
Authors: Reisner Jenny , Pachtman Sarah , Rochelson Burt
Published: May 2017

INTRODUCTION:

To determine whether the timing of initiation of vaginal misoprostol induction has an effect on delivery mode in nulliparous women.

METHODS:

Retrospective cohort study evaluated nulliparas with singleton gestations who underwent cervical ripening with vaginal misoprostol. Exclusion criteria included multiple gestation, previous delivery, age less than 18 years, Bishop score greater than 7, or induction prior to 39 weeks. Induction for rupture of membranes, chorioamnionitis, oligohydramnios, diabetes, preeclampsia, or growth restriction were excluded. The primary outcome was delivery mode. Chi-squared test was performed to determine if the time of start of induction is associated with cesarean in 6-hour intervals.

RESULTS:

226 subjects met inclusion criteria and 107 (47.3%) had a cesarean delivery. 106 patients (46.9%) were scheduled between 6:00pm and 11:59pm, and 48.1% delivered via cesarean. 80 patients (35%) were scheduled between 12:00am and 5:59am, and 52.5% delivered via cesarean. 40 patients (17.6%) were scheduled between 6:00am and 5:59pm, and 37.5% delivered via cesarean. Results of Chi-Square test failed to show an association between time interval induction and delivery mode among 226 subjects (p=0.23). Subgroup analysis was performed on patients with Bishop score less than or equal to 4, and 57.7% delivered via cesarean. Chi-Squared test also failed to show an association between start time and delivery mode.

CONCLUSION:

Timing of cervical ripening with vaginal misoprostol is not associated with delivery mode in uncomplicated, nulliparas after 39 weeks. Scheduling of inductions at the discretion of patient or provider, or based on availability of institutional resources does not increase risk of cesarean delivery.
Immediate Postpartum Urinary Retention: A Chart Review [34B]
Authors: Christie Alexandra C. , Urbina Josephine , Valthaty Rebekah
Published: May 2017

INTRODUCTION:

Postpartum urinary retention is an unexpected common complication. In previous studies about a 1.7 -17 percent incidence of urinary retention was reported. We defined urinary retention as absence of spontaneous micturition within six hours of vaginal delivery or within six hours of removal of catheter after cesarean delivery. Our hypothesis is that operative deliveries increase the incidence of urinary retention in the immediate postpartum period.

METHODS:

A retrospective chart review was conducted over two years in a hospital setting with a suburban population . The data collected included the method of delivery, anesthesia received during delivery, complications following delivery or prior to delivery such as indications for a cesarean-section, Foley required after patient was discharged and parity of patient. Women with recent urinary tract infection, pyelonephritis during pregnancy, diabetes and neuropathy were excluded from the study.

RESULTS:

Based on our 2 year chart review we found 65 % of patients with retention had cesarean delivery and 15 % had operative vaginal deliveries , 62.5 percent were primiparous, 12 % had birth weight of >4000 grams, 68 percent received an epidural for anesthesia , 9.3 % required Foley postpartum.

CONCLUSION:

Postpartum urinary retention is a relatively common condition. Some of the risk factors identified in our study include cesarean delivery, operative births, primiparous women and birth weight of > 4000 grams, epidural analgesia. This is an ongoing study and further multicenter study is required to confirm these risk factors.
Vaginal Length After Laparoscopic Hysterectomy: Laparoscopic Versus Vaginal Closure. Randomized Trial Update [39B]
Authors: Nezhat Camran , Main Jillian , Falik Rebecca , Di Francesco Lucia , Farrimond Frances , Nezhat Azadeh
Published: May 2017

INTRODUCTION:

The purpose of our study is to observe the change in vaginal length after total laparoscopic hysterectomy with laparoscopic cuff closure (LC) versus vaginal approach to cuff closure (VC).

METHODS:

This is an update on our prospective, randomized study of women undergoing total laparoscopic hysterectomy. Vaginal length was measured pre-operatively and at 6-12 weeks, 6 months and then 12 months postoperatively.

RESULTS:

A total of 76 patients were included in the study (37 women in the vaginal group, 39 women in the laparoscopic group). The median preoperative vaginal lengths were not statistically significant: VC 10.7cm vs LC 11.8 cm; (P=.31). The difference in median vaginal lengths at 6-12 weeks were: VC 9.8cm versus LC 9.7 cm (P=.92). The median vaginal lengths at 6 months were 10.5cm in the VC and 10.2cm in the LC (P=.63). The median vaginal lengths at 12 months were 11.0 cm in the VC and 11.2 cm in the LC (P=.65). The cuff closure time was significantly longer in the LC group (15.6 min versus 7.9 minutes in the VC, P < .05). There were zero cases of vaginal cuff dehiscence. 13.5% of women in the VC group developed granulation tissue vs 2.5 % in the LC group (P < .05).

CONCLUSION:

Vaginal length at 6 and 12 months did not differ based on method of vaginal closure. Laparoscopic closure times are longer than vaginal cuff closures and neither method had cases of vaginal cuff dehiscence. Vaginal closure is associated with an increased risk of developing granulation tissue.
Risk Factors for Obstetric Anal Sphincter Injury in a Diverse Population [1C]
Authors: Woo Victoria G. , Hung Yun-Yi , Ramm Olga
Published: May 2017

INTRODUCTION:

We evaluated risk factors for obstetric anal sphincter injuries (OASIS) and determined the effect of duration of second stage of labor (DSS) on OASIS risk.

METHODS:

We included term, singleton, cephalic vaginal deliveries within Kaiser Permanente Northern California over two years. Bivariate analysis identified OASIS risk factors. Multiple logistic regression helped eliminate confounding. Classification and Regression Tree (CART) recursive partitioning created decision nodes based on risk factors. DSS was grouped into 15-minute intervals to examine effect magnitude.

RESULTS:

Of 22,741 deliveries included, 93.8% were spontaneous and 6.2% were vacuum-assisted. The OASIS rate was 4.9%. Multiple logistic regression identified Asian race (OR 2.4, CI 2.1-2.8), vacuum delivery (OR 4.6, CI 3.9-5.4), DSS greater than 75 minutes (OR 2.4, CI 2.1-2.8), VBAC (OR 2.8, CI 2.1-3.8), and nulliparity (OR 1.7, CI 1.4-2.1) as independent risk factors for OASIS. DSS ranged from 0-680 minutes. Median length was 95 minutes for nulliparous and 27 minutes for multiparous women. The first CART decision node was DSS greater than 75 minutes. Each additional 15 minutes of pushing resulted in 1.07 (p < 0.001) increase in the odds of OASIS in nulliparous women and 1.14 (p < 0.001) in multiparous women. CART analysis identified Asian women delivered via vacuum after a greater than 75 minute second stage as the subpopulation with highest risk of OASIS at 43%.

CONCLUSION:

Risk factors for highest rates of OASIS were identified. Each incremental increase in DSS confers an increase in OASIS risk. Changing management based on our findings could improve outcomes for laboring women.
Tdap in Pregnancy: A Quality Improvement Project [2C]
Authors: Holdt Somer Sarah J. , Bruder Karen , Louis Judette
Published: May 2017

INTRODUCTION:

Current recommendations are for Tdap vaccination during each pregnancy to induce immunity in the neonate. Administration rates were low at a prenatal clinic in Tampa, Florida and so a quality improvement project was undertaken to improve coverage. We sought to evaluate the effectiveness of a protocol to improve the rates of prenatal Tdap vaccine administration.

METHODS:

This project was implemented at a single publicly funded obstetric clinic and its affiliated academic hospital. Women receiving care at the clinic are predominately underserved minorities and working poor. The clinic's providers include physicians, nurses, midwives, and nurse practitioners. The intervention had several components: In February 2016, clinic providers received education about current recommendations regarding Tdap vaccination in pregnancy. Posters were placed throughout the clinic to motivate the patients. Finally, the hospital's administration agreed to redirect money previously used for inpatient postpartum vaccinations to instead cover the cost of vaccination for uninsured patients during prenatal visits, when the vaccine is most effective. Vaccination rates were then compared between the four months before and after implementation.

RESULTS:

In the four months preceding the project, a total of 273 prenatal Tdap vaccines were given at the clinic; in the four months after, 380 were given. When divided by the total number of clinic patients delivered during these time frames, rates of vaccination improved from 40% to 63% (p < 0.001), respectively.

CONCLUSION:

Education, awareness, and financial assistance resulted in a significant increase in the Tdap vaccination rate at the clinic. Further Plan-Do-Study-Act cycles are planned to further improve vaccination rates.
Risk Factors for Postpartum Hemorrhage Following Nulliparous Induction of Labor [3C]
Authors: Ainsworth Alessandra J. , Holman Michelle A. , McGree Michaela , Weaver Amy , Torbenson Vanessa , Tolcher Mary Catherine
Published: May 2017

INTRODUCTION:

Postpartum hemorrhage is the leading cause of maternal mortality worldwide. There are multiple known risk factors, including induction of labor.

METHODS:

A retrospective cohort study was completed with review of nulliparous women undergoing labor induction at term, from July 2006 to May 2011. Baseline maternal variables and risk factors for postpartum hemorrhage were assessed. All combinations of methods of induction were sequential rather than concurrent. The need for additional uterotonics (beyond routine oxytocin) was used as a surrogate for postpartum hemorrhage. Variables were evaluated for an association with additional uterotonic use based on fitting logistic regression models.

RESULTS:

A total of 785 women were included in the study. Additional uterotonics were required for 84/785 (11%) of women. Based on univariate analysis, only birth weight and presence of meconium were significantly (p < 0.05) associated with additional uterotonic use, while method of induction approached statistical significance (p=0.06). The mean (SD) birth weight was 3668 (584) vs. 3463 (500) grams in those with and without additional uterotonic use. Multivariate analysis showed an increased risk of additional uterotonics with higher birth weight (adjusted odds ratio (aOR) 1.44 per 500 gram increase in birth weight; 95% CI 1.15, 1.82) and use of Foley plus oxytocin (aOR 4.40; 95% CI 1.36, 14.23).

CONCLUSION:

In our model, higher birth weight and induction method of Foley followed by oxytocin were associated with increased need for additional uterotonics. This data adds detail to previous studies that have broadly identified induction of labor as a risk factor for postpartum hemorrhage.