bluuebunny/crossref_metadata_2025 huggingface dataset:
Metastatic Gastric Adenocarcinoma Masked as Ectopic Pregnancy [39E]
Authors: Moon Ashley , Yu Jim G. , Henriquez Jose , Fairbairn Melissa , Chuang Linus , Andikyan Vaagn
Published: May 2019

INTRODUCTION:

The most common cause for elevated beta-hCG in reproductive aged-women is pregnancy. Rarely, malignancy may cause persistent beta-hCG levels. We present a rare case of metastatic gastric adenocarcinoma masked as an ectopic pregnancy.

METHODS:

34Y G2P2 healthy patient presented for intrauterine device removal where routine urine pregnancy test was positive. Beta-hCG was 287, which continued to plateau without sonographic evidence of intrauterine pregnancy. Methotrexate was given for suspected ectopic pregnancy. Beta-hCG fluctuated between 300-500. Ultrasound revealed solid mass in left adnexa and she underwent exploratory laparoscopy; however, intraoperative findings revealed normal fallopian tubes and bilateral corpus luteal cysts with no evidence of ectopic pregnancy. Second dose of methotrexate was given but beta-hCG continued to increase. She developed worsening abdominal pain, nausea, chest pain, dyspnea. CT chest/abdomen/pelvis revealed mediastinal, periaortic and upper abdominal lymphadenopathy, and bilateral lung nodules. AFP 111.9, CA 125 36, CA 19-9 649, CEA 11.9. Retroperitoneal lymph node biopsy and upper endoscopy revealed ulcerated, fungating gastric mass consistent with poorly differentiated adenocarcinoma. FOLFOX chemotherapy was started. Her worsening dyspnea called for CT angiography, revealing pericardial effusion, which required pericardiocentesis and a pericardial window. Pericardial fluid consisted of malignant cells and beta-hCG continued to increase, indicating worsening prognosis. She died from malignancy progression 7 weeks after diagnosis.

CONCLUSION:

Persistently elevated beta-hCG without response to methotrexate or surgical intervention may raise suspicion for rare presentations of malignancy. Our case demonstrates metastatic gastric adenocarcinoma can present with increasing beta-hCG serum levels without evidence of gynecologic disease.
Ethical Considerations in Immediate Postpartum Long-Acting Reversible Contraceptive Care [2F]
Authors: Allan Katie , Moniz Michelle , Harris Lisa Hope , Loder Charisse Marie. , Spector-Bagdady Kayte
Published: May 2019

INTRODUCTION:

Hospitals across the country are implementing immediate postpartum long-acting reversible contraceptive (LARC) programs. Our objective was to qualitatively evaluate representative services through the lens of clinical ethics.

METHODS:

We conducted a multiple case study using a literature review to identify academic hospitals providing immediate postpartum LARC. We conducted in-person, semi-structured interviews with 66 key informants across 11 facilities. Two authors independently analyzed data using a framework analysis based on the Armstrong Clinical Ethics Coding System. Authors obtained IRB exemption.

RESULTS:

Analysis revealed three significant ethical considerations. First, we found that most sites do not offer immediate postpartum LARC to all patients, instead offering it only to patients with insurance coverage for this care-generally Medicaid recipients. Service delivery thus leads to disparities in LARC access and the potential targeting of LARC to marginalized populations. Second, we identified challenges with informed consent processes: providers struggled to promote both LARC access and patient autonomy (e.g., providers grappled with the appropriateness of newly offering LARC to a laboring woman versus the paternalism of not offering LARC at all). Third, while patient needs and preferences were a major motivating factor in establishing immediate postpartum LARC programs, no site had corresponding provisions to enhance access to subsequent LARC removal.

CONCLUSION:

Hospitals offering immediate postpartum LARC contend with important ethical issues, including providing equitable access to contraceptive care, creating robust informed consent processes, and ensuring access to LARC removal. Engaging with patients and a reproductive justice framework when designing these programs may help hospitals adopt safeguards to promote patient-centered care.
Mineralocorticoid Receptor in the Primate Endometrium Throughout the Menstrual Cycle [5F]
Authors: Demirel Esra , Sabouni Reem , Pakrashi Tarita , Archer David F
Published: May 2019

INTRODUCTION:

Throughout the menstrual cycle, the endometrium undergoes morphological and biochemical changes reflecting ovarian hormone secretion. These changes are associated with specific receptors located throughout the endometrial tissue. Alongside receptors for ovarian hormones, the human endometrium contains all of the elements of renin-angiotensin-aldosterone system (RAAS). Given certain progestins play a role in RAAS modulation through anti-mineralocorticoid properties, we believe that the mineralocorticoid receptor (MR) has a significant role in the menstrual cycle and potentially in abnormal uterine bleeding (AUB).

METHODS:

Full-thickness uterine samples were obtained from adult female rhesus macaques during an artificial menstrual cycle controlled with estrogen (E) and progestin (P) implants at 3 separate points: menstrual (E-3P), proliferative (14dE) and secretory (E+5P). Tissue sections were immunohistochemically stained and evaluated under bright microscopy. ImageJ analysis software was used to analyze vasculature for integrated density and area fraction.

RESULTS:

MR is present in the endometrial endothelial cells during all three phases of the menstrual cycle in rhesus macaques. The percent area was 25.54% in the proliferative phase, 18.86% in the menstrual phase, 17.34% in the secretory phase.

CONCLUSION:

MR has been identified for the first time to our knowledge within the endometrial endothelial cells. Given the anti-mineralocorticoid properties of certain progestins used for contraception and their association with amenorrhea or AUB, MR antagonism specifically may explain these changes. In select patient populations, such as obese females at increased risk for hypertension and elevated aldosterone activity, the increased incidence of amenorrhea on certain progestin-only contraceptives may be related to higher degree of anti-RAAS activity within the endometrium.
Induction of Labor Compared With Expectant Management and Risk of Cesarean Delivery in Obese Women [7F]
Authors: Staudenmaier Emily K. , Chatterton Carolyn G. , Montanez Marelli , Sampino Isabella , Vullo John J. , Gurram Padmalatha
Published: May 2019

INTRODUCTION:

Obesity is a known independent risk factor for stillbirth. The obesity related stillbirth risk increases with advancing gestational age. There is no clear consensus regarding antepartum surveillance to reduce the risk of stillbirth. Therefore, the timing of delivery is a concern for the obstetric provider. The purpose of this study is to determine if obesity increases cesarean delivery rates in elective inductions at term when compared to expectant management. Antepartum, intrapartum, and neonatal complications were also compared between the groups.

METHODS:

This is a retrospective chart review of women delivered after 37 weeks gestation and with a BMI greater than 30 kg/m2 between 2015-2016 at our institution. Women admitted for elective induction of labor (N=104) were compared to those admitted in spontaneous labor (N=144). Medical indications for inductions of labor, malpresentation, fetal anomalies, and multiple gestations were excluded. Institutional Review Board approval was obtained.

RESULTS:

Maternal characteristics were similar between the two groups (p>0.05). There were no significant differences in antepartum, intrapartum and neonatal complications between the groups (p>0.05). There are no stillbirths in either group. The rate of cesarean delivery is significantly higher (p=0.029) for patients admitted for elective induction (43.3%) compared to those admitted in spontaneous labor (27.8%).

CONCLUSION:

Expectant management in obese women is associated with decreased rates of cesarean delivery without increased incidence of adverse outcomes compared to elective induction of labor.
Serologic Confirmation of Rubella Immunity During Index Pregnancy Can Eliminate Re-testing in Later Pregnancies [11F]
Authors: Kamath Shiwani , Varrey Aneesha , Landres Inna V.
Published: May 2019

INTRODUCTION:

Vaccination ended endemic rubella transmission in America with the last documented case of congenital rubella syndrome in 2004. The American College of Obstetrics and Gynecology recommends rubella susceptibility screening as a prenatal lab for all pregnancies. As no studies in the United States support or contest this, we explored whether women with documented immunity during their index pregnancy demonstrated serologic evidence of Rubella immunity during subsequent gestations.

METHODS:

A retrospective cohort study of Medicaid insured pregnant women receiving prenatal care at an urban clinic from 2012-2017 was undertaken. Only those with documented immunity during their initial antenatal visit and repeat serologies during subsequent pregnancies were included. Immunity was defined as rubella IgG antibodies titers greater than 10 IU/mL. All patient protected health information has been de-identified and patient faces are entirely covered.

RESULTS:

Five hundred women were screened for study eligibility with rubella serologies obtained in 318 during both index and subsequent pregnancies. In this cohort, 94.3% (n=300) were noted to be immune during their index pregnancy. Among this immunized population, 98.3% continued to demonstrate serologic immunity during subsequent pregnancies. There was no relationship between the time interval between pregnancies and rubella sero-conversion rates.

CONCLUSION:

Our data indicates 98% of women with rubella immunity during their first pregnancy maintain immunity during subsequent pregnancies. Given rates of retained immunity and low disease prevalence with routine vaccination, this study suggests reconfirmation of rubella immunity during subsequent pregnancies is unnecessary. Given the small sample size and retrospective nature of data, large, prospective studies evaluating the sero-conversion rate between pregnancies and the cost-effectiveness of screening prior to every pregnancy are warranted.
Outpatient Expectant Management of Premature Rupture of Membranes for Women Who Decline Augmentation [14F]
Authors: Chacon Kelly M. , Bryant Mantha Allison S. , Clapp Mark A.
Published: May 2019

INTRODUCTION:

In our institution, women with premature rupture of membranes (PROM) who decline augmentation are offered outpatient expectant management (OEM) for 24 hours. Our objective was to determine if patients who chose OEM had different time-to-delivery intervals than patients who chose admission.

METHODS:

This is a retrospective cohort of nulliparous, term women with singleton, vertex-presenting fetuses who presented with PROM from July 2016 to June 2017 at a single institution. Women were eligible for OEM if they were Group B Streptococcus negative, afebrile, had clear fluid, and reactive non-stress tests. Primary outcomes included time from PROM-to-delivery and from admission-to-delivery. Secondary outcomes included chorioamnionitis, cesarean delivery, and neonatal intensive care unit admission. Outcomes were compared using chi-squared and Wilcoxon rank-sum tests, and then adjusted for age, race, insurance, gestational age, augmentation, and provider type using multivariable regressions. IRB approval was obtained.

RESULTS:

Of 127 eligible women, 74 chose admission and 53 chose OEM. OEM patients had significantly longer PROM-to-delivery intervals than admitted patients (median 29.3 vs 19.2 hours, P<.001), but were more likely to deliver within 24 hours of admission (94.3 vs 74.6%, P=.004). In the adjusted analysis, PROM-to-delivery was 8.1 hours longer (95% CI 4.7-11.6) and admission-to-delivery was 4.5 hours shorter (95% CI 1.7-7.4) for OEM patients. There were no differences in secondary outcomes.

CONCLUSION:

Outpatient management of term PROM shortens the interval from admission-to-delivery, reducing hospital resource utilization among low-risk women. However, given the known increased risk of infection with prolonged PROM, more research is needed to assess the safety of this protocol.
Intrapartum Characteristics and Prognosis Associated With Neonatal Hypoxic-Ischemic Encephalopathy [15F]
Authors: Ravichandran Lavanya , Allen Victoria M. , Vincer Michael , Kuhle Stefan , Filliter Christopher , Baskett Thomas F.
Published: May 2019

INTRODUCTION:

Neonatal hypoxic-ischemic encephalopathy (HIE) is associated with neonatal mortality, acute neurological injury and long-term neurodevelopmental disabilities; the role of intrapartum factors remains unclear.

METHODS:

This population-based cohort study employed linked obstetrical and newborn data derived from the Nova Scotia Atlee Perinatal Database (NSAPD, 1988-2015) and the Perinatal Follow-Up Program Database (2006-2015) for all pregnancies with live, non-anomalous newborns ≥35 weeks, born without pre-labor caesarean section. HIE was defined using standard definitions. Temporal trends in HIE incidence are described; Fisher's exact test and logistic regression were used to test the associations of intrapartum factors with HIE.

RESULTS:

The NSAPD identified 227 HIE cases out of a population of 226,711 pregnancies from 1988 to 2015, with a decrease in incidence from 0.14% to 0.1% through those years (P=0.01). Women with clinical chorioamnionitis in labor (OR 8.0, 95% CI 4.7-17), emergency operative delivery (OR 9.9, 95% CI 7.3-13), shoulder dystocia (OR 3.4, 95% CI 2.1-5.4), placental abruption (OR 19, 95% CI 12-29), and cord prolapse (OR 32, 95% CI 17-61) were more likely to have newborns with HIE. Two-thirds of newborns with HIE had an abnormal intrapartum FHR tracing. There was an infant mortality rate of 28% by age 3; neurodevelopmental outcomes in the surviving infants with HIE were normal in 33% and showed severe developmental delay in 37%.

CONCLUSION:

Overall, the rate of HIE was low in late-preterm and term infants. The identification of associated intrapartum factors should promote increased surveillance and careful management to optimize newborn outcomes.
Inpatient Versus Outpatient Labor Induction: A Systematic Review and Meta-analysis [19F]
Authors: D'Souza Rohan D. , Khan Maria , Hashimi Farahnosh
Published: May 2019

INTRODUCTION:

The purpose of this study was to compare clinical and cost outcomes between inpatient and outpatient labor induction.

METHODS:

A systematic review of randomized controlled trials (RCTs) that compared inpatient vs. outpatient induction was conducted. Four databases were searched for RCTs published in English, which compared any method of outpatient vs. inpatient labor induction. As significant heterogeneity between studies was anticipated, random-effects meta-analysis was conducted. Results were presented as odds ratios (OR) and mean difference (MD) with 95% confidence intervals (95% CI) as appropriate.

RESULTS:

We identified 695 studies of which 10 representing 7 RCTs (2038 patients) conducted in Australia (n=3), Canada, Portugal, the Netherlands and United States were included in the final analysis. Three RCTs compared induction using balloon catheters, two compared prostaglandins, one compared balloon catheters (outpatient) vs. prostaglandin (inpatient) and one compared outpatient amniotomy vs. inpatient induction using the obstetricians' method of choice. Outpatient vs. inpatient induction was associated with a significant reduction in admission-to-delivery duration [2 studies, 231 patients: MD 11.78 hours (7.09, 16.49)]. There was no difference in use of epidural analgesia [4 studies, 475/863 vs. 454/832, OR 1.04 (0.84, 1.27)], oxytocin [4 studies, 292/643 vs. 269/632, OR 1.143 (0.52, 2.52)], vaginal birth [5 studies, 392/708 vs. 388/697, OR 0.97 (0.70, 1.32)], hyperstimulation [4 studies, 12/643 vs. 9/632, OR 1.27 (0.52, 3.11)] or costs [MD $80.21 (-638.20, 798.61)].

CONCLUSION:

Outpatient labor induction is associated with shorter admission-to-delivery duration, with no significant differences in adverse clinical or cost outcomes and may therefore be considered as an alternative to inpatient IOL in low-risk pregnancies.
Obstetric Neuraxial Anesthesia in the Context of Immune Thrombocytopenia: A Systematic Review [20F]
Authors: Bailey Liane J. , De France Bryon , Shehata Nadine , Carvalho Jose , Malinowski Ann Kinga
Published: May 2019

INTRODUCTION:

Immune Thrombocytopenia (ITP) is characterized by preserved platelet function. The true magnitude of neuraxial hematoma risk in ITP parturients is unknown, yet obstetric neuraxial anesthesia (OBNA) is often withheld. The aim of this systematic review was to examine OBNA outcomes in ITP with platelet counts below 100x10(9)/L.

METHODS:

Relevant literature database-entries were searched to May 2018. Citations were independently screened and extracted in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale, NIH Case Series Assessment Tool and Joanna Briggs Institute Case Reports Checklist, as appropriate. Study authors were contacted for additional information.

RESULTS:

Our search yielded 954 titles/abstracts for screening with 62 full-texts reviewed, 26 included, and individual patient data obtained for 9. Of 291 individuals, 166 received OBNA; 61 at platelet counts below 80x10(9)/L. No neuraxial hematomas were reported. Median platelet counts were 80-93x10(9)/L. In a meta-analysis of 6 studies, platelets were higher in those with OBNA than those without [mean difference (MD), (95% confidence interval) 19 (3, 25) x10(9)/L; p<0.00001], but did not differ between epidural and spinal anesthesia [MD 0.4 (-14, 20) x10(9)/L; p=0.86]. The “rule of three” places the upper bound of the 95% confidence interval for neuraxial hematoma risk at 1.8%.

CONCLUSION:

Our study further supports the quest to establish safety of OBNA in ITP at lower platelet counts. It highlights the reluctance to offer OBNA below the 80x10(9)/L threshold suggested by guidelines, yet based largely on theoretical presumption of risk. Given the rarity of OBNA in ITP at progressively lower platelet counts, an international registry could prove indispensable.
Breastfeeding Success After Vaginal Delivery Versus Scheduled Cesarean Section [21F]
Authors: Liu Lilly Y. , Rekawek Patricia , Cadet Julie , Stone Joanne L.
Published: May 2019

INTRODUCTION:

The objective of this study is to identify how labor affects initiation and effectiveness of breastfeeding postpartum.

METHODS:

This is a retrospective cohort study of breastfeeding success after vaginal delivery, cesarean section after labor, and scheduled cesarean section in term, singleton deliveries in nulliparous patients at a large academic institution from 2017-2018. Breastfeeding success in the immediate postpartum period was measured by the presence of breastfeeding, the need for formula supplementation, and the neonatal percentage in weight loss over the first 2-3 days of life. This study was approved by the IRB at the Icahn School of Medicine at Mount Sinai.

RESULTS:

A total of 500 women met inclusion criteria during the study period, 339 (68%) of whom underwent spontaneous vaginal delivery (SVD), 71 (14%) of whom underwent cesarean section after labor, and 90 (18%) of whom delivered by scheduled cesarean section. Women who underwent SVD were more likely to have decreased need for formula supplementation in comparison to women who delivered via cesarean section in labor or scheduled cesarean section (57.7% vs. 75.4% and 78.5%, p<0.05), require fewer number of daily formula feedings on average (1.8+2.3 vs. 2.3+2.2 and 2.7+2.6, p<0.05), and experience a smaller percentage in neonatal weight loss over the first 2-3 days of life (4.9+2.0 vs. 7.1+2.3 and 6.4+2.8, p<0.05).

CONCLUSION:

Women who deliver by cesarean section may need more support to maintain exclusive breastfeeding postpartum than patients after vaginal delivery.
Comparison of Nutritional Content of Prescription vs Nonprescription Prenatal Vitamins [23F]
Authors: Kelly Rachel E. , Muraga Abebe H. , Howard David Leighton
Published: May 2019

INTRODUCTION:

The primary objective was to compare the nutritional content of prescription to nonprescription prenatal vitamins.

METHODS:

We obtained samples of popular prescription and nonprescription prenatal vitamins (PNVs). We then recorded the nutritional contents of each product from the nutritional label. PNV ingredients were compared to each other and to The American College of Obstetricians and Gynecologists (ACOG) recommended guidelines. To compare physical size, we focused on PNVs in pill form. To compare cost, we used pharmacy quoted cash prices of prescription PNVs and shelf prices of nonprescription PNVs

RESULTS:

We obtained a total sample of 16 PNVs (8 prescription, 8 nonprescription). All 16 PNVs examined had at least 800 mcg of folic acid. However, no PNV, prescription or nonprescription, simultaneously met all of ACOG's nutrient recommendations for calcium, folic acid, iron, and vitamin D. In terms of size, the largest prescription PNV was approximately 1 inch in length (PrimaCare), and smallest approximately 0.6 inches (Prenate Mini, Vitafol, VitaPearl, and OB Complete). For nonprescription PNVs, the largest were also approximately 1 inch in length (Alive and Nature Made), but no nonprescription with a single pill was 0.6 inches or less. In terms of cost, the cash price of the cheapest prescription PNV was almost double that of the most expensive nonprescription PNV.

CONCLUSION:

We found no meaningful difference in nutritional adequacy of prescription versus nonprescription PNVs with respect to ACOG nutrient recommendations, despite appearance of a large cost difference.
Effect of Magnesium Sulfate on B-Type Natriuretic Peptide (BNP) Levels in Hypertensive Disease of Pregnancy [26F]
Authors: Schachter Aubrey , Lai Monica , Heard Asha J. , Hagan Joseph , Grant Joshua , Stafford Irene A.
Published: May 2019

INTRODUCTION:

B type natriuretic peptide (BNP) is a sensitive marker discerning early cardiac dysfunction and has consistently demonstrated correlation with volume expansion and pressure overload in hypertensive disorders in pregnancy. Magnesium sulfate (MgSO4) has been shown to decrease occurrence of seizures among preeclamptic women, and some studies suggest this is mediated via a systemic vasodilatory effect. The purpose of this study is to evaluate the effect of MgSO4 on BNP values in women with severe preeclampsia.

METHODS:

Pregnant women greater than 20 weeks gestation and postpartum women up to 14 days after delivery with severe preeclampsia who presented at Touro Infirmary in New Orleans between April 2015 and May 2017 for hypertension evaluation and received MgSO4 were considered. After informed consent, BNP values were collected among 42 eligible patients before and after administration of MgSO4 for seizure prophylaxis. Data collection was performed as a retrospective chart review. Standards for preeclampsia diagnosis and management were defined by criteria described by the American College of Obstetrics and Gynecology.

RESULTS:

There was a significant reduction in BNP values after MgSO4 administration in preeclamptic women (n=42, p=0.011). The mean pre-MgSO4 BNP value was 119.6 pg/mL, and the mean post-MgSO4 BNP value was 85.2 pg/mL, for a mean decrease of 34.4 pg/mL.

CONCLUSION:

The data suggest that MgSO4 administration provides a beneficial effect on cardiac function in women with severe preeclampsia, potentially through a systemic vasodilatory and diuretic effect, reducing strain on the heart.
Maternal Plasma Lysophospholipid Acyltransferase 1 Protein Levels Correlate With Fetal Lung Maturity [31F]
Authors: Aras Siddhesh , Minchella Paige , Welch Kathryn C. , Patek Kara Danielle , Welch Robert Alan , Recanati Maurice-Andre
Published: May 2019

INTRODUCTION:

Respiratory distress syndrome occurs in newborns not producing enough lung surfactant. This substance is predominantly comprised of phosphatidylcholine and phosphatidylglycerol. Lysophosphatidylcholine acyltransferase 1 (LPCAT1) is the enzyme responsible for their synthesis. Our group previously demonstrated that LPCAT1 mRNA in amniotic fluid and maternal plasma correlate with the amniotic fluid lamellar body count. The purpose of the present study was to determine if LPCAT1 protein levels parallel plasma LPCAT1 mRNA copy numbers. We also measured the effect of glucocorticoids and hypoxia on LPCAT1 protein expression.

METHODS:

After Institutional Review Board approval and consent, forty women from 30-40 weeks gestation and non-pregnant controls were sampled. Those with diabetes, hypertension, obesity or growth restricted were excluded. LPCAT1 mRNA levels measured by reverse transcription-polymerase chain reaction and LPCAT1 protein levels measured by enzyme linked immunosorbent assay were compared. The effect of antenatal steroids on plasma LPCAT1 was also measured. In an aligned experiment, LPCAT1 was assayed in HTR placental cells exposed to 4% hypoxia and glucocorticoids.

RESULTS:

LPCAT1 protein levels parallel mRNA copy numbers in maternal plasma. Antenatal steroids also increase maternal LPCAT1 protein levels. Both steroids and 4% hypoxia increase LPCAT1 levels in HTR placental cells in vitro.

CONCLUSION:

Discovery of a correlation between LPCAT1 protein levels and mRNA data suggests a potential noninvasive bio-marker for fetal lung maturity. HTR placental cell response to antenatal steroids and 4% hypoxia may open up new avenues in perinatal research.
Compliance to the National Comprehensive Cancer Network Guidelines for Anemia in Ovarian Cancer [36F]
Authors: Prescott Lauren S. , Mehta Sumit , Hufnagel Demetra , Ezekwe Chinyere
Published: May 2019

INTRODUCTION:

The National Comprehensive Cancer Network (NCCN) recommends prompt evaluation and treatment of anemia. There are a paucity of studies evaluating compliance with the guidelines.

METHODS:

Retrospective cohort study of ovarian cancer patients diagnosed and treated at our institution from 2008-2018. Tumor-registry-confirmed cancer cases were identified. Patients were included if they were between the ages of 18 and 89, had their initial care at our institution, and had a hemoglobin (Hg) within the first 6 months of diagnosis.

RESULTS:

We identified 299 patients who met inclusion criteria. Median age was 62 years (interquartile range [IQR] 52-70). One hundred-eighty-five (62%) underwent primary surgery, 92 (31%) received preoperative chemotherapy, and 22 (7%) received no oncologic intervention. Of the 282 patients with a Hb identified prior to initiation of oncologic treatment, 61 (22%) patients were noted to be anemic at time of diagnosis. The median Hb at diagnosis was 12.5g/dL (IQR 11.4-13.4). Of the 299 patients in our study 269 (90%) were noted to be anemic within six months of diagnosis. Of these, 31 (12%) were noted to have grade 1, 115 (43%) grade 2, and 123 (46%) grade 3 anemia. The median Hb at nadir was 8.5g/dL (IQR 7.3-9.8). Thirty-six patients (13%) had iron studies performed. No patients had absolute iron deficiency and three had possible iron deficiency. 104 (36%) patients had treatment. Seventy-seven were transfused, 38 treated with oral iron and 3 with iv iron.

CONCLUSION:

Anemia is pervasive among ovarian cancer, but compliance with NCCN is low. There are opportunities for improvement in evaluation and management of anemia in ovarian cancer.
Is Sentinel Lymph Node Sampling Indicated in Endometrial Intraepithelial Neoplasia? [37F]
Authors: Emerson Jenna , Glassman Deanna , Quddus M. Ruhul , Mathews Cara A.
Published: May 2019

INTRODUCTION:

We sought to identify uterine risk factors and frequency for which lymph node sampling was indicated among women undergoing hysterectomy for a preoperative diagnosis of endometrial intraepithelial neoplasia (EIN).

METHODS:

We performed a retrospective cohort study of patients undergoing hysterectomy with a preoperative diagnosis of EIN from 2016-2017. When cancer was found, the Mayo criteria (grade 1 or 2 tumor, depth of invasion <50%, and tumor size >2 cm) were used to determine if lymphadenectomy would have been indicated. Descriptive statistics were used. Approval was obtained from the institutional IRB.

RESULTS:

Fifty-three subjects were included; mean age was 60.1 years (SD: 22.9). Hysterectomy pathology was benign in 28% (n=15), EIN in 47% (n=25), and endometrioid adenocarcinoma (EC) in 25% (n=13). All cancers were FIGO Stage IA, grade 1 (n=9) or 2 (n=4). No cases had LVSI; mean depth of invasion was 3.5% (0-22%, SD 7.1%). Four cases had tumors ≥-2 cm; one of those was confined to a large polyp. Ultimately, 7.5% (n=4/53) of EIN patients met Mayo criteria; all of these were due to tumor size >2 cm. Using historical models, the risk of lymph node positivity is <5% for each of the 4 patients who met Mayo criteria. Therefore, an overall cohort of >250 patients with EIN would require sampling to identify one patient with metastatic EC.

CONCLUSION:

In an era of pre-hysterectomy sentinel nodal sampling, these findings provide new data with which to counsel patients on the potential benefits and limited yield of SLN biopsy when undergoing surgery for EIN.
AMH is a Better Predictor of Live Birth in IVF Cycles When AMH and FSH Values Are Discordant [40F]
Authors: Ligon Sarah , Lustik Michael , Levy Gary , Pier Bruce D.
Published: May 2019

INTRODUCTION:

Follicle stimulating hormone (FSH) and anti-Mullerian hormone (AMH) assist physicians in assessing ovarian reserve during infertility evaluations and in vitro fertilization (IVF) cycles. Despite usual congruity between these biomarkers, physicians are often faced with discordant values. Our study investigates which biomarker better predicts live birth (LB) in IVF patients with discordant FSH and AMH results using the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System (SART CORS) database.

METHODS:

This IRB-approved retrospective cohort study compared live birth rate (LBR) with FSH and AMH values in patients who completed at least one cycle of autologous IVF as reported to SART CORS in the years 2013 and 2015. Chi-square test was used to compare the incidence of LB among the study cohorts.

RESULTS:

44,696 patient charts met inclusion criteria. LBR was higher in patients with elevated FSH (>10mIU/mL) and normal AMH (>1 ng/dL) opposed to patients with normal FSH (<10) and low AMH (<1) (39% versus 26%, P<.001). In a multivariate logistic regression model of patients with normal FSH, low AMH had a lower risk of LB than patients with normal AMH, with relative risk of .87 (95% CI .83-.91). IVF cycle cancellation was higher in patient with normal FSH and low AMH compared to elevated FSH and normal AMH (30% versus 8%, P<.001).

CONCLUSION:

AMH is a stronger predictor of live birth in patients undergoing IVF when FSH and AMH values are discordant. Lower AMH is also associated with higher IVF cycle cancellation rates than those seen with elevated FSH values.
Patient Outcomes in a Large Hospital System During the Implementation of a Same Day Discharge for Hysterectomies [16OP]
Authors: Linkov Faina , Shalkar Adambekov , Qi Meiyuzhen , Harris John , Mansuria Suketu M. , Edwards Robert P.
Published: May 2019

INTRODUCTION:

Same day discharge (SDD) for minimally invasive hysterectomies is attractive to healthcare systems due to reduced costs and excellent patient outcomes. This study investigated outcome and safety data associated with the implementation of SDD protocols in a large healthcare system in Pennsylvania, UPMC, as well as to evaluate the uptake of SDD among different hospitals (tertiary care, community) and specialty types (general ob/gyn, minimally invasive gynecologic surgery (MIS), urogynecology, and gynecologic oncology).

METHODS:

Retrospectively, all medical records for hysterectomies that qualified for SDD at UPMC hospitals between 2014 (year of SDD pathway implementation) and 2017 were identified. We evaluated trends in health care outcomes (complications, return visits, and readmissions) by year using Cochrane Armitage test for trend. University of Pittsburgh IRB approved this work.

RESULTS:

5575 cases of women qualified for SDD have been evaluated. For minimally invasive hysterectomies, the rate of SDD went from 29% in 2014 to 75% in 2017 (ptrend <0.0001). The rate of complications decreased over time (ptrend <0.0001). Overall LOS (length of stay in minutes) decreased over time. SDD implementation was not associated with an increase in readmissions and return visits. All specialty types adopted the program over the years, with the degree of adoption varying among specialty types (MIS having the highest degree of adoption).

CONCLUSION:

Implementing a SDD program for hysterectomy within a large heterogeneous health care system can occur rapidly across all sizes of hospitals and among different subspecialists. At UPMC, this program resulted in decreased LOS without increase in complications.
The Cost of Elective Labor Induction in The MFMU ARRIVE Trial [19OP]
Authors: Einerson Brett D.
Published: May 2019

INTRODUCTION:

The ARRIVE trial compared labor induction to expectant management in nulliparas at term. We measured the relative costs.

METHODS:

A cost evaluation of all 1,230 Utah participants enrolled in ARRIVE from antenatal randomization to 6 weeks after delivery. Actual costs were measured using advanced analytics and time-derived activity-based costing at two Utah tertiary healthcare systems involved in the trial. The primary outcome was total cost associated with maternal and neonatal care. Cost outcomes were compared in each arm using generalized linear models, controlling for differences in cost between systems. Costs were normalized and presented as the relative cost in the induction arm vs expectant management arm.

RESULTS:

Total costs were similar between arms: +3.7% (95% CI -3.0% - +10.8%). Neonatal costs were similar: -1.5% (95% CI -16.9% - +16.8%). Costs associated with maternal care were 7.3% higher in the induction arm (95% CI +2.3% - +12.5%). Total costs and neonatal costs did not differ between arms when stratified by advanced maternal age, obesity, unfavorable cervix, or need for ripening. In obese women, maternal costs were 9.7% higher in the induction arm (95% CI +1.4% - +18.6%). In women with an unfavorable cervix (Bishop score less than 5), maternal costs were 10.6% higher in the induction arm (95% CI +3.3% - +18.5%). The relative cost of induction was similar at both health systems despite different costing methodologies.

CONCLUSION:

The cost of elective labor induction at term was similar to expectant management.
State Based Perinatal Quality Collaborative Pilot-Statewide Reduction of Colorado Primary Cesarean Delivery Rate [04OP]
Authors: Donnelly Meghan Ann , Peterson Anne , Fennimore Robin MacColl , Schneider Emily Nicole , Griffith Nancy
Published: May 2019

INTRODUCTION:

The Colorado Perinatal Care Quality Collaborative performed a pilot quality improvement project to increase adherence to guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery in a statewide cohort of hospitals to safely reduce their nulliparous, term, singleton, vertex (NTSV) cesarean delivery (CD) rate.

METHODS:

This quality improvement initiative was performed at 6 community hospitals across Colorado. Pre (January 2017 to May 2018) and post intervention (June to Oct 2018) NTSV CD and composite maternal and neonatal morbidity rates were determined for each hospital and the overall cohort using Colorado State Vital Statistics data. Interventions included distributing institution and provider specific NTSV CD rates, education for providers and nurses, implementation of a pre-cesarean labor dystocia checklist, and convening two forums for collaboration between hospitals. NTSV CD and composite maternal and neonatal morbidity rates were compared before and after the interventions for each hospital and the cohort.

RESULTS:

The 6 participating hospitals perform 19% of live births in Colorado. Pre-intervention hospital NTSV CD rates ranged from 19.3% to 33.8%. The cohort pre-intervention NTSV CD rate was 24.6%, and decreased to 21.9% post-intervention (P=0.04, 95% CI 0.77-0.99). There was no significant increase in composite maternal or neonatal morbidity post-intervention (8.6% vs 7.1% and 7.1% vs 6.8% respectively).

CONCLUSION:

A quality improvement effort led by a state-based Perinatal Quality Collaborative was effective at safely reducing NTSV CD rates across multiple hospitals. Future efforts will aim at expanding the number of participating hospitals and sustainability.
Estetrol Combined with Drospirenone: A New Oral Contraceptive With a Favorable Hemostatic Profile [20OP]
Authors: Creinin Mitchell D. , Rosing Jan , Jost Maud , Kinet Virginie , Chatel Guillaume , Foidart Jean Michel
Published: May 2019

INTRODUCTION:

Estetrol (E4) is a natural human estrogen with selective action in different tissues. A combined oral contraceptive (COC) with E4 15 mg and Drospirenone (DRSP) 3mg is in Phase 3 trials. Here, we report its effects on hemostatic markers.

METHODS:

In this IRB-approved, randomized, open-label study, women received E4 15 mg/DRSP 3mg (n=38), ethinyl-estradiol (EE) 30 mcg/Levonorgestrel-(LNG) 150 mcg (n=29) or EE-20 mcg/DRSP-3 mg (n=31). We compared changes of hemostasis parameters between baseline and cycle 6 with a P<.05 considered significant.

RESULTS:

Pro-coagulant factors increased similarly in E4/DRSP, EE/LNG and EE/DRSP users for fibrinogen (+10%, +5% and +16%, respectively) and prothrombin (+7%, +13% and +7%, respectively). Anti-coagulant factors decreased significantly less with E4/DRSP and EE/LNG compared to EE/DRSP for Protein S activity (-4%, -5% and -30%, respectively) and free Protein S antigen (+5%, -3%; and -23%, respectively). The fibrinolysis marker, tissue-plasminogen activator, changed significantly more favorably with E4/DRSP than EE/LNG or EE/DRSP (-7%, -33% and -40%, respectively). Prothrombin fragment 1+2, a marker of ongoing coagulation, changed significantly less with E4/DRSP than other COCs (+23%, +71% and +64%, respectively). Endogenous thrombin potential (ETP) activated protein C resistance (APCr) increased significantly with EE/LNG (+78%) and EE/DRSP (+121%) compared to E4/DRSP (+3.0).

CONCLUSION:

Coagulation parameter changes over 6 months demonstrate mostly similar changes for E4/DRSP and EE/LNG, both of which are less thrombogenic than EE/DRSP. For some factors, primarily anticoagulant and fibrinolysis markers, ETP-APCr, and prothrombin fragment 1+2, E4/DRSP is more favorable than EE/LNG. The differences between E4/DRSP and EE/DRSP demonstrate that the choice of estrogen is important when considering thrombosis risk.
SECOND PLACE Therapeutic Hypothermia in Severe Hypoxic-Ischemic Encephalopathy: A Cost-Effectiveness Analysis [23OP]
Authors: Packer Claire , Hersh Alyssa R. , Sargent James Andrew , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

Previous literature has demonstrated that therapeutic hypothermia (cooling) begun within six hours of life decreases neonatal mortality and long-term neurodevelopmental disability (NDD) in neonates with hypoxic-ischemic encephalopathy (HIE). We sought to investigate whether such an intervention is cost-effective in cases of severe HIE.

METHODS:

A TreeAge decision analytic model was designed comparing cooling vs. no cooling in a cohort of 10,000 term neonates with HIE. Rates of death and NDD were estimated from a Cochrane meta-analysis. Costs were derived from the literature. Utilities were applied to discounted life expectancy to generate quality-adjusted life years (QALYs). All costs and QALYs were discounted at an annual rate of 3% with a cost-effectiveness threshold of $100,000 per QALY. Sensitivity analyses were conducted to assess the robustness of these results.

RESULTS:

Cooling for the management of severe HIE resulted in increased costs and higher QALYs, with an incremental cost-effectiveness ratio (ICER) of $4,366/QALY. Cooling resulted in 1,600 fewer neonatal deaths, but even with a lower rate of NDD in the survivors, there were 100 additional cases with cooling. In univariate sensitivity analysis, when varying the probability of a healthy child with cooling, cooling was found to be the cost-effective strategy across all ranges and the dominant (lower costs, higher QALYs) strategy above 0.675.

CONCLUSION:

Therapeutic hypothermia is the cost-effective intervention with improved outcomes for neonates with severe perinatal HIE over a wide range of assumptions. Despite the increased cost, more neonates survive morbidity free when compared with standard care.
Sonographic Measurement of the Inferior Vena Cava (IVC) to Assess Postpartum Hypovolemia: A Pilot Study [35S]
Authors: Spiegel Tirtza Nechama
Published: May 2019

INTRODUCTION:

Increased respiratory variation in IVC diameter is used to detect hypovolemia in critical care settings, including early warning of excessive perioperative blood loss. One study examined the relationship between IVC diameter and postpartum hemorrhage, in a cohort of women after vaginal delivery. We aimed to evaluate if respiratory variation in IVC diameter after cesarean delivery was associated with intraoperative hemorrhage or postoperative complications from hypovolemia.

METHODS:

The difference in IVC diameter between inspiration and expiration was measured sonographically in the supine position, 1-2 hours after cesarean delivery. Demographic and delivery data were collected. We hypothesized that respiratory variation would be increased in patients with complications related to hypovolemia

RESULTS:

4/26 patients (15.3%) had postoperative complications from hypovolemia (oliguria and/or hemorrhage). Their mean IVC diameter variation was 2.9 mm compared with 4.4 mm in the uncomplicated group. Mean respiratory diameter variation was 2.2 mm for patients with intraoperative blood loss >1,000 ml versus 4.6 cm for patients with â‰¤ 1,000 ml blood loss.

CONCLUSION:

Contrary to our hypothesis, respiratory variation in IVC diameter was not increased in patients with postoperative complications from hypovolemia or intraoperative hemorrhage. A larger patient sample is needed before determining the utility of this technique. Our preliminary findings may reflect aggressive intraoperative fluid resuscitation in patients with excessive blood loss.
Fibroid Surgery and Long Term Improvement in Bladder Symptoms [38S]
Authors: Simula Natasha K. , Rikhraj Kiran , Koenig Nicole , Lee Terry , Geoffrion Roxana
Published: May 2019

INTRODUCTION:

Several studies have demonstrated a short term benefit in urinary symptoms after fibroid debulking surgery with one year being the longest follow up reported in the literature. This study assessed the long term impact of fibroid debulking surgery on urinary symptoms several years after the procedure.

METHODS:

This is a follow up of a study which prospectively investigated improvement in urinary symptoms after fibroid debulking surgery in 61 women. A demographics questionnaire and the Urinary Distress Inventory (UDI) were completed. Changes in total UDI scores and UDI subscale scores from preoperative baseline to long term follow up were calculated using Wilcoxon signed rank test, t-test, Fisher's exact test and Chi square test. The study was approved by the Providence Health Care Research Ethics Board (H11-02621).

RESULTS:

Thirty four women participated. Mean follow up time was 5.3 years. There was a statistically significant improvement in total UDI scores (p<0.001), and obstructive (p<0.001) and irritative (p<0.001) subscale scores. Stress subscale scores significantly improved in a subgroup analysis of patients that had significant stress urinary symptoms at baseline (p=0.04). Six of 8 women (75%) were cured of moderate to severe symptoms of urge incontinence and 2 of 8 (25%) were cured of moderate to severe symptoms of stress incontinence.

CONCLUSION:

This is the first study demonstrating long term benefit of fibroid debulking surgery on bothersome urinary symptoms several years after the procedure. Women with urinary symptoms secondary to fibroids and refractory to medical management should be counselled on the potential benefits of surgery on their symptoms.
Promoting Labor Progress to Prevent the Primary Cesarean—Before and After Educational Intervention [2T]
Authors: Johnson Christina , Karkala Nikitha , Garretto Diana J. , Hines Heather Findletar , Russel Jessica , Liot Michele
Published: May 2019

INTRODUCTION:

Primary Cesarean sections (CD) pose greater risks of mortality and morbidity than vaginal delivery for nulliparous, term, singleton, vertex (NTSV) women. There is 15 fold variation in NTSV cesareans in US hospitals, suggesting an opportunity for change at the institutional level. In January 2016, Stony Brook started a QI initiative (QI-i) to lower the rate of CD in NTSV via grand rounds education for identifying active labor as 6 cm of dilation, encouraging optimal patient positioning to promote the progress of labor, and introduction of a volunteer doula program.

METHODS:

An IRB approved retrospective cohort study was performed comparing 2015 (before the QI-i) to 2016- 2018 (after the QI-i). Inclusion criteria nulliparous (no prior deliveries ≥20 weeks), term (≥37 weeks), singleton, vertex presentation women delivering from January 2015 - June 2018. The primary outcome: NTSV CD. Secondary outcomes: 1 minute APGAR <7, 5 minute APGAR 0-3, cesarean rate for NTSV inductions, CD among NTSV with midwife care.

RESULTS:

There were no differences in the demographics of age, presence of a midwife in the care, birthweight, 1 or 5 minute APGAR scores. The NTSV cesarean rate was higher after the QI intervention (23% vs. 27%, p = 0.005). NTSV women had a statistically significant increased induction of labor (IOL) after 2015, via Cervidil, Cytotec, Foley balloon, AROM, and Pitocin (p<.0001, <.0001, <.0001, <.0001, <.0001 respectively).

CONCLUSION:

The CD rates in NTSV women continue to increase despite QI initiatives. IOL also increased and can be an area to improve the CD rates.
Quality Improvement Project to Reduce Primary Cesarean Delivery Rates in Low Risk Women [7T]
Authors: Wendlandt Megan , Alizadeh Pouneh , Donnelly Meghan Ann , Fennimore Robin MacColl
Published: May 2019

INTRODUCTION:

The primary cesarean delivery (CD) rate in low risk women, defined as nulliparous, term, singleton, vertex (NTSV), has increased at Saint Joseph Hospital (SJH) from 20% to 24% between 2015 and 2017. SJH partnered with the Colorado Perinatal Care Quality Collaborative in an effort to reduce cesarean delivery rates in this low risk population by increasing surgeon adherence to nationally accepted labor dystocia guidelines.

METHODS:

Quality improvement intervention included the distribution of institution and provider specific NTSV CD rates, education for providers and nurses, and implementation of a preoperative labor dystocia checklist. Pre (January 2017 to May 2018) and post intervention (June to Sept 2018) NTSV CD rates were compared. Composite maternal and neonatal morbidity rates pre and post intervention were determined for SJH using Colorado State Vital Statistics data. A convenience sample of 40 cases of NTSV CD for labor dystocia were selected to compare guideline adherence pre and post intervention (20 cases pre and 20 post-intervention).

RESULTS:

The primary CD rate at SJH decreased from 24% to 21.7% after intervention. Adherence to labor dystocia guidelines significantly increased from 35% to 76% (p=0.0001) pre vs. post-intervention respectively. There was no significant difference between rates of composite maternal and neonatal morbidities pre and post-intervention.

CONCLUSION:

Participation of SJH in this statewide pilot quality improvement project significantly improved provider adherence to ACOG guidelines for CD for labor dystocia in low risk patients and has led to a decreasing NTSV CD rates. Future efforts will aim at sustainability of this initiative.