bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk of Primary Cesarean Delivery in Women With Pregnancy-Associated Hypertension [7C]
Authors: Penfield Christina A. , Wing Deborah A.
Published: May 2017

INTRODUCTION:

Despite the lack of evidence supporting cesarean delivery (CD) in the setting of pregnancy-associated hypertension (PAH), women with this diagnosis continue to have high CD rates. The aim of this study is to determine whether the higher rate of primary CD among women with PAH can be explained by the presence of other known CD risk factors.

METHODS:

A retrospective cohort study of singleton, vertex, nulliparous women delivering between 34 and 42 weeks using the 2013 US National Vital Statistics Report dataset. Rates of primary CD in women with and without PAH were compared. Multivariate logistic regression predicted CD after controlling for known risk factors, including advanced maternal age (AMA), race/ethnicity, gestational age, pre-pregnancy BMI, US residency, insurance type, prenatal care, diabetes, and eclampsia.

RESULTS:

We analyzed 1,103,999 women, including 94,332 women diagnosed with PAH. The unadjusted CD rate in women with PAH was 41.3% compared to 26.9% in those without PAH (p < 0.01). Each analyzed risk factor was significantly associated with CD (Table). However, even after controlling for these risk factors, the predicted probability of CD in a woman with PAH would be 37.2% vs 26.5% without PAH (p < 0.01). PAH remained an independent predictor for CD (aOR 1.68 [95% CI 1.65-1.71]).

CONCLUSION:

After controlling for other risk factors, diagnosis of PAH alone is a significant risk factor for CD, likely reflecting a widespread practice that is not supported by the most recent clinical evidence. Women with PAH may therefore represent an important target population for efforts that aim to reduce primary CD rates.
TAC It Up? The Impact of Taping the Abdomen at Cesarean on Wound Complications in the Morbidly Obese Patient [8C]
Authors: Fitzgerald Garrett , Crimmins Sarah , Bharadwaj Shobana , Malinow Andrew , Turan Ozhan
Published: May 2017

INTRODUCTION:

Cesarean delivery (CD) in the extremely obese patient presents significant surgical and postsurgical challenges. Available data guiding proper surgical technique are limited. Our aim is to investigate the impact of taping the abdomen at cesarean (TAC), with respect to wound complication (WC). We hypothesize that TAC will not increase risk of WC.

METHODS:

Retrospective cohort study of singleton pregnancies with morbid obesity (BMI greater than 40 kg/m2) between 37 and 42 weeks gestation delivered via non-urgent CD. Maternal demographics, comorbidities, operative data, and postpartum follow up were reviewed. Skin incision was divided in to 3 main groups; vertical (VSI), transverse (TSI) and TSI with TAC. WC were defined as surgical site infections or wound separation. The relationship between skin incision type and WC was evaluated using descriptive statistics. Adjusted odds ratio was calculated for WC controlling for confounders, BMI and incision type.

RESULTS:

A total of 174 complete records were reviewed. Median BMI was 49.2 kg/m2, 48 (27.5%) patients had intrapartum CD and 43 (24.5%) were diabetic. Skin incision incidence: 38(21.8%) were VSI, 98(56.4%) were TSI and 38 (21.8%) were TSI-TAC. Postoperatively, WC were diagnosed in 25 (14.2%) patients. After controlling for incision type and BMI, VSI showed aOR of 2.2 [1.2-4.0,P=.01] for WC. The risk of WC was similar between TSI and TSI-TAC (P=.8).

CONCLUSION:

In a cohort known for high risk of WC, TSI demonstrates lower risk. TAC does NOT significantly alter WC risk when TSI is chosen.
Small for Gestational Age in Women With Different Degrees of Chronic Hypertensive Disease [25C]
Authors: Roman Amanda , Schoen Corina , Moreno Sindy , Duge Leanne , Berghella Vincenzo
Published: May 2017

INTRODUCTION:

To evaluate the risk of small for gestational age (SGA) in women with chronic hypertension (CHTN) classified by severity of hypertension.

METHODS:

Retrospective cohort of women with CHTN that delivered at Thomas Jefferson University Hospital from January 2008 to June 2016. Women diagnosed with CHTN before pregnancy or during first 20 weeks of gestation, were classified in 3 groups: no antihypertensive medications, severe hypertension requiring antihypertensive medications or CHTN associated with renal disease. Primary outcome was incidence of SGA. Secondary outcomes were superimposed preeclampsia and preterm delivery (PTD).

RESULTS:

We identified 334 women with CHTN without medications, 210 women with severe CHTN requiring medication and 40 women with CHTN and renal disease. Maternal demographics and other comorbidities were not significantly different among the 3 groups. SGA less than 10th% was significantly increased in CHTN requiring medication [odds ratio (OR) 2.1 95% confidence interval (CI) 1.3-3.3] and CHTN and renal disease [OR 2.6 95% CI 1.2-5.8] when compared CHTN without medications. PTD less than 34 weeks was significantly increased in CHTN requiring medication [OR 1.6 95% CI 1.0-2.7] and CHTN and renal disease [OR 3.8 95%CI 1.8-7.9] when compared to CHTN without medications. Superimposed preeclampsia with severe features was increased in CHTN and renal disease [OR 2.0 95%CI 1.1-4.1] when compared to CHTN without medications.

CONCLUSION:

Women with severe CHTN requiring medications and CHTN with renal disease had increased risk of SGA, PTD and superimposed preeclampsia with severe features when compared with CHTN without medications.
Risk Factors for Early Preterm Birth in Women With Short Cervix Treated With Vaginal Progesterone [26C]
Authors: Boelig Rupsa , Villani Michela , Jiang Eva , Orzechowski Kelly , Berghella Vincenzo
Published: May 2017

INTRODUCTION:

The purpose is to identify risk factors for early preterm birth (PTB), defined as less than 34 weeks, in otherwise low risk women who have a short cervix (less than or equal to 20mm) and prescribed vaginal progesterone.

METHODS:

Retrospective cohort study from 1/2012-12/2014 of singleton gestations without a history of prior spontaneous preterm birth who underwent cervical length (CL) screening between 18 0/7-23 6/7 weeks. Women with a short cervix who took vaginal progesterone were included.

RESULTS:

3,678 women were screened, 38 women (1.0%) were diagnosed with a short cervix, 31 accepted and were started on vaginal progesterone. Of the 31 women included, 11 women (36%) had an early PTB. Among women who had an early PTB, demographic characteristics and obstetric history were similar, however mean CL was significantly lower (11.9 ±4.0 vs 16.5 ±4.1, p=0.005) and the percent of women with a CL less than 15mm was significantly higher (82% vs 15%, p < 0.001) compared to those who delivered after 34 weeks. ROC curve demonstrated that CL was predictive of a PTB < 34 weeks with an area under the curve of 0.81 (p=0.005). CL less than 15mm was associated with an increased risk of PTB < 34 weeks with an odds ratio of 25.5 (95%CI 3.6-181.6).

CONCLUSION:

A cervical length less than 15mm is highly predictive of an early PTB in women with a short cervix, despite vaginal progesterone therapy. Further studies should be done in this subgroup of women to see if they would benefit from additional interventions.
Synthetic Osmotic Dilator Prior to Induction of Labor: Outcomes From International Observational E-Registry [13C]
Authors: Saad Antonio , Gupta Janesh , Maier Josefine , Hruban Lukas , Mehta Priyanka , Baev Oleg
Published: May 2017

INTRODUCTION:

To determine rate of cesarean delivery (CD) and maternal/neonatal adverse outcomes associated with use of synthetic osmotic dilator prior to labor induction.

METHODS:

This is a multicenter international post-marketing observational study of a synthetic osmotic dilator (Dilapan-S) for cervical ripening prior to labor induction in term pregnancies. Our primary outcome was rate of CD. Data were obtained in a standardized fashion and entered into a centralized electronic data capture system for analysis.

RESULTS:

Between May 2015 and July 2016, 343 term pregnant women undergoing cervical ripening prior to labor induction were included. Median maternal age was 30 (IQR18-45) years, and average BMI was 27. 68% of participants were nulliparous, 23% had a previous vaginal delivery and 9% had previous cesarean section. The majority (64%) of women received 4-5 dilators and the CD rate was 32%. Bishop score gain was 3.7 (95% CI [3.4-3.9]) with the use of the dilator. There were no cases of uterine tachysystole or FHR abnormalities. Maternal discomfort was reported by 9% of women and the rate of chorioamnionitis was 1.5%. Meconium stained amniotic fluid was present in 11% of patients. All newborns had an Apgar score at 5 minutes ≥ 7. Arterial pH < 7.1 and neonatal intensive care admissions were < 1%.

CONCLUSION:

Compared to other cervical ripening methods, the use of synthetic osmotic dilators appears to be safe and efficient method of cervical ripening for induction of labor in term pregnant women. Randomized clinical trials are needed to compare its efficacy to other methods of cervical ripening.
Screening for Zika Virus in a High-Risk Non-Endemic Urban Population: Patient Characteristics and Testing Outcomes [19C]
Authors: Rac Martha , Eppes Catherine , Dempster Carrie , Ballas Jerasimos , Davidson Christina , Aagaard Kjersti
Published: May 2017

INTRODUCTION:

We report the characteristics and testing outcomes of women exposed to Zika Virus (ZIKV) in a non-endemic high-risk Southern U.S. urban population.

METHODS:

This is an observational study of women referred for potential ZIKV exposure between 2/2016 to 9/2016. Women were tested according to Center for Disease Control (CDC) testing criteria. Confirmed ZIKV was defined as positive PCR on maternal serum, amniocytes, placenta or cord blood. Patient characteristics and testing outcomes were recorded.

RESULTS:

A total of 105 gravidas were referred for ZIKV exposure. Most consults were for travel or prior residence in endemic areas (90%) versus secondary exposure (10%). Sixty-one (58%) patients reported partner co-travel. Most patients (55%) visited an endemic area. Mexico was the most frequent site visited (50%), followed by Central America (31%), South America, (9,9%), and the Caribbean (13%). Twenty-one (20%) patients reported the following symptoms: fever (55%), rash (55%), conjunctivitis (40%), and malaise (10%). Seventy-five (71%) patients met testing criteria. IgM serology was sent in 72 (69%) patients and PCR in 19(25%) patients. One patient tested positive by PCR, and 7 were IgM positive, for a screen-positive rate of 11%. Ninety-seven (92%) patients underwent ultrasound surveillance. Amniocentesis was performed in 6 patients for ZIKV PCR and all were negative. No neonate has met the criteria for congenital ZIKV infection of the 48(46%) gravidas delivered.

CONCLUSION:

One in 10 women screened positive for ZIKV despite no evidence of vertical transmission. Better diagnostic testing is needed to identify patients at highest risk and decrease unnecessary interventions.
Subsequent Pregnancy Outcomes Following Use of an Intrauterine Tamponade Balloon for Postpartum Hemorrhage (PPH) [24C]
Authors: Carlson Laura , Jackson Christine , Glover Angelica , Webster Carolyn , Dotters-Katz Sarah , Strauss Robert
Published: May 2017

INTRODUCTION:

Uterine tamponade balloons(UTB) reduce the need for invasive procedures in the setting of PPH; but subsequent pregnancy outcomes are unknown. We sought to examine subsequent pregnancy outcomes among women with PPH treated by UTB.

METHODS:

Retrospective cohort of women with diagnosis of PPH at a tertiary referral center, (1/2010-6/2016). Women with an EBL ≥1000 mL who required use of uterotonic medications, and who had at least one subsequent pregnancy were considered for inclusion. Cases defined as women whose PPH was treated with UTB; the woman immediate preceding and following each case were selected as controls. Simple statistics were used as appropriate.

RESULTS:

8 women had a subsequent pregnancy after an index pregnancy requiring UTB, and were matched to 16 controls. During the index pregnancy, cases had lower median prepregnancy BMI (22.4 vs 33.1,p=0.01), but antenatal characteristics were otherwise similar. No difference between the intrapartum characteristics of cases and controls was noted, except that the EBL was higher for cases (2000 vs 1200 mL, p=0.004), and cases were more likely to require transfusion (88% vs 31%,p=0.027). Interpregnancy intervals were similar. In subsequent pregnancy, 75% of the UTB group had documented counseling regarding risk of recurrent PPH, compared with 31% of controls(p=0.082). PPH was similar between groups(38% vs 31%,p>0.99). No woman required UTB, hysterectomy, ICU admission, or had morbidly adherent placenta in subsequent delivery.

CONCLUSION:

Use of UTB for PPH does not appear to increase risk for recurrent PPH or abnormal placentation. Until larger studies can be performed, this information offers some reassurance regarding the use UTB.
Comparing Pregnancy Outcomes in Obese Diabetic and Obese Non Diabetic Women - A Retrospective Study [33C]
Authors: Hahn Shannon , Bahamon Camila , Kuffskie Martha , Varlamov Anna
Published: May 2017

INTRODUCTION:

The purpose of this study was to compare the pregnancy outcomes between obese pregnant women with and without diabetes.

METHODS:

Data from labor and delivery records gathered between 1/1/2010 and 9/1/2013 were studied. Women with BMI greater than 40 and with either gestational or type I diabetes mellitus (DM) were included and separated into two groups: Obese with DM (Group 1) and Obese without DM (Group 2).

RESULTS:

Compared to group 2: 23% of Group 1 delivered prematurely vs 14% (P < .05). Group 1 had cesarean deliveries 94% of the time vs 55% (P < .05). NICU admissions occurred in 14% of Group 1 vs 8% (P < .05) Neonates had a lower neonatal weight (3409 g ± 811 vs 3270 g ± 703 P < .05), slightly lower Apgar scores (7.0 ± 2.0 vs 7.4 ± 1.6) and neonatal pH (7.23 ± 0.9 vs 7.26 ± 0.18) compared to Group 2. 14 % of Group 1 patients developed preeclampsia vs 8% (P < .05). There was no significant difference in intrauterine fetal demise rates or shoulder dystocia rates between the two groups.

CONCLUSION:

In our study, women who are obese with DM had a higher risk of undergoing a cesarean section, delivering prematurely, developing preeclampsia, having a NICU admission, low fetal weight, low Apgar scores, and pH compared with obese women with no DM. This highlights the importance of recognizing and treating both obesity and DM in pregnancy as it has a large impact in both maternal and neonatal morbidity, as well as healthcare cost.
The Effectiveness of Teaching Obstetrical Respiratory Emergency Management Using Simulation [1D]
Authors: Patel Neil , Marko Emily , Nieves Kelsey
Published: May 2017

INTRODUCTION:

The management of amniotic fluid embolism and maternal cardiac arrest requires coordinated time-sensitive teamwork skills. The study objective was to determine the effectiveness of teaching amniotic fluid embolism and maternal cardiac arrest management to residents using simulation.

METHODS:

Obstetrics and gynecology residents received instruction using a highly interactive team-based simulation curriculum for the management of amniotic fluid embolism and maternal cardiac arrest with perimortem Cesarean-Section. The curriculum consisted of a didactic session followed by high-fidelity simulations of two scenarios. A 21-point checklist was used for baseline teamwork performance assessments. Outcomes were measured using pre-post knowledge tests and confidence surveys in the management of obstetrical respiratory emergencies. Paired t-tests and repeated measures were used for data analysis.

RESULTS:

Twenty-one residents participated in the four-hour curriculum. Mean pre-post knowledge test scores demonstrated statistically significant improvement (75.0%, 94%, p less than 0.0001). Mean pre-post confidence levels rose in the management of amniotic fluid embolus (52.33%, 78.33%, p less than 0.0001) and maternal cardiac arrest (56.0%, 81.67%, p less than 0.0001). Incidentally, residents involved in the simulation curriculum experienced a real life maternal cardiac arrest with perimortem Cesarean-Section the same afternoon and commented that their experience in simulation contributed to the clinical outcome.

CONCLUSION:

Training in both amniotic fluid embolism and maternal cardiac arrest with perimortem Cesarean-Section management is essential for obstetrical providers. Interactive team-based simulation training of these events improves knowledge, performance and confidence even when exposure to real-life obstetrical respiratory emergencies is rare.
Utilizing 3D Printing Model of Placenta Percreta to Guide Obstetric Operation [3D]
Authors: Chen Jingsi , He Hong , Song Ting , Su Chunhong , Chen Dunjin
Published: May 2017

INTRODUCTION:

Accurate antenatal diagnosis of placenta percreta condition has been employed to optimize delivery management and minimize the risk of associated complication.

METHODS:

We will report two cases about utilizing 3D printing model of placenta percreta to guide obstetrical operation. We performed magnetic resonance imaging of anatomical structures, digital 3D reconstruction, and fabrication via 3D printing. According to the 3D printing model, a multidisciplinary team planned a cesarean hysterectomy and simulated surgery operation before the operation.

RESULTS:

We made a precise operation plan and had an adequate preoperative preparation. Our operative time and the blood loss were less than the other studies. The neonatal outcome was well. For the patients, they also more easily to understand what operation was performed on them and the dangerousness of the operation before operations.

CONCLUSION:

3D printing model is a useful tool to accurate assay the placenta percreta and plan a complex operation, which is helpful for decreasing complication and improve material and fetal outcome. In the future, it maybe will be a useful tool to preoperative assessment or guiding the obstetric and gynecological complex operation.
The Effect of Surges in Patient Volume on Resource Management of an Academic Labor and Delivery Unit [5D]
Authors: Molina Rose , Gombolay Matthew , Jonas Jennifer , Shah Julie , Golen Toni , Shah Neel T.
Published: May 2017

INTRODUCTION:

Clinical managers in charge of labor and delivery units are challenged by the need to allocate scarce resources, such as beds and nursing staff, when there are surges in patient volume. When particularly busy, managers may resort to a variety of strategies, such as calling in additional staff or delaying new admissions. The thresholds for applying strategies that preserve labor floor resources have not been previously well defined and may have significant implications for patient safety.

METHODS:

We developed a virtual labor floor environment in JAVA to simulate dynamic labor floor conditions, including the expected waxing and waning of patient acuity and volume over the course of a nursing shift. We recorded an inter-professional cohort of clinicians making resource allocation decisions over multiple simulated shifts. Using logistic regression, we determined the odds of delaying admission for patients in early labor when labor floor occupancy varied.

RESULTS:

Eight nurses played the game for 20 minutes on average, which translates to 64 simulated hours of decision-making. In a logistic regression model, we found there is an increased odds of delaying admissions for early labor as the percent of labor and delivery bed occupancy increases (unadjusted odds ratio 1.11, 95% confidence interval 1.03, 1.19).

CONCLUSION:

Early labor admissions were more often delayed with increasing bed occupancy, indicating that the care of patients on labor and delivery units may be sensitive to the total occupancy of the unit. Additional research is needed to understand the impact of resource management on patient safety.
A Novel High Fidelity Multidisciplinary Simulation Exercise to Improve Team Response to Postpartum Hemorrhage [6D]
Authors: Lutgendorf Monica A. , Miller Michael J. , Spalding Carmen N. , Morocco Kristina V. , Heaton Jason O. , Deering Shad
Published: May 2017

INTRODUCTION:

Postpartum hemorrhage affects 4-7% of all deliveries, and remains a leading cause of maternal morbidity and mortality. Our goal was to assess provider experience with peripartum hysterectomy and improve team responses with a novel postpartum hemorrhage simulation trainer.

METHODS:

As part of an ongoing quality improvement project, we conducted a high fidelity multi-disciplinary in situ simulation exercise using a novel operative postpartum hemorrhage trainer with the capability of simulating a peripartum hysterectomy. Participants completed didactic training prior to the simulation. Simulation scenarios included an emergent cesarean delivery followed by a postpartum hemorrhage requiring activation of the massive transfusion protocol, medical and operative interventions including a hysterectomy. Participants were surveyed on their experience and comfort (using a 5-point Likert scale) with managing postpartum hemorrhage and peripartum hysterectomies.

RESULTS:

We trained 135 participants over 2 days, with 40% nurses, 34% obstetric providers, 14% anesthesia, 10% corpsmen, and 3% emergency medicine. Over 60% of obstetric participants had performed less than or equal to 5 peripartum hysterectomies. Following the simulation exercise, providers reported increased comfort managing postpartum hemorrhage, scores improved by 0.43 points, from 3.64 to 4.08, p = 0.001, 95%CI 0.33-0.54. Providers also reported increased comfort managing peripartum hysterectomies, with scores improved by 0.86 points, from 2.48 to 3.34, p = 0.002, 95%CI 0.7-1.02.

CONCLUSION:

In conclusion, peripartum hysterectomies are rarely encountered in clinical practice. A high fidelity operative simulator provides a high degree of realism, can be used to teach communication and teamwork, and improves participant comfort in managing peripartum hysterectomies.
Validation of an Affordable and Accessible Alternative Simulation Technology [7D]
Authors: Auguste Tamika C. , Benda Natalie C. , Kellogg Kathryn , Fairbanks Rollin
Published: May 2017

INTRODUCTION:

The aim of this study was to determine the effectiveness of serious game computer simulation training in teaching electronic fetal monitoring (EFM) interpretation skills and the clinical action decisions associated with each abnormality. The use of novel technology like virtual reality, e-learning, and serious gaming can offer improvement in the learning outcomes.

METHODS:

OB/GYN nurses and physicians were randomized to either in-lab simulation group or serious game group in Phase 1 and received group-specific education on EFM interpretation and decision-making. After a minimum 3-month decay period participants completed Phase 2, a well-established in-situ team training drill in which they had to interpret EFM tracings and manage the patient accordingly. Participants were scored on their interpretations and decision-making of the EFM tracings during the in-situ team training drill. Participant scores were compared using the Student t test or Wilcoxon rank sum test. Survey results were analyzed with the Chi square test or Fisher's exact test.

RESULTS:

The primary outcome was percent correct in EFM strip interpretation and decision-making recorded during the in-situ team training sessions. In comparing overall performance between the groups, the serious game participants scored 55.8% and the simulation lab participants scored 61.6%. There were no significant differences detected (p = 0.43), however this study was under powered.

CONCLUSION:

The use of serious games in delivery of education to healthcare providers is a viable alternative to delivery of education in large simulation laboratories. Our serious game participants performed similarly to our in-lab simulation participants. Studies with larger numbers of participation are needed.
Correlation of Obstetrical Skills and Confidence Level of Skilled Birth Attendants in Rural Rwanda [8D]
Authors: Pimentel Veronica Maria , Rwab Denis , Gahima John , Rulisa Stephen , Bernstein Peter , Nathan Lisa
Published: May 2017

INTRODUCTION:

The World Health Organization (WHO) advocates for the presence of skilled birth attendants (SBAs) at every birth to prevent or manage obstetric complications. Still, the WHO acknowledges that challenges exist relating to the education and practice of SBAs. This study aimed to evaluate the spontaneous vaginal delivery (SVD) and postpartum hemorrhage (PPH) competency of rural skilled-birth attendants (SBAs) and to assess correlation of skills scores with their confidence level.

METHODS:

A simulation-based study was conducted with a convenience sample of SBAs in rural Rwanda in September of 2015 to assess communication, evaluation, and management skills in SVD and PPH. Total correct skills scores were calculated. A score of ≥ 75% for each category was considered “competent.” Participants completed a confidence questionnaire prior to the simulation. Spearman rank correlation coefficients were calculated to assess correlation between simulation scores and confidence level.

RESULTS:

Of the 26 SBAs who participated in the study, 26.9% (7/26) were competent in SVD skills, 11.5% (3/26) were competent in PPH skills, 38.5% (10/26) reported knowing how to perform a SVD, 34.6% (9/26) reported feeling comfortable performing a SVD, 26.9% (7/26) reported knowing how to manage PPH, and 34.6% (9/26) reported knowing how to manage PPH. There was no significant correlation between the SBAs’ competency scores and their confidence level in SVD (P>.5, rs=-.14) or PPH (P>.5, rs=.25).

CONCLUSION:

The competency and confidence of SBAs in rural Rwanda appears to be low and their skills do not correlate with their confidence level. Comprehensive training is needed to enhance their skill-set.
Blood Transfusion Trends in Women With Abnormal Uterine Bleeding [14D]
Authors: Sangha Roopina , Keerthy Madhurima
Published: May 2017

INTRODUCTION:

Blood transfusion continues to pose serious risks to recipients. The role of blood transfusion in management of women presenting with abnormal uterine bleeding is unclear and has not been studied before. The goal of this study is to determine the predictors of existing blood transfusion practice in women with abnormal uterine bleeding.

METHODS:

Retrospective chart review of women who presented to Emergency room between 2011 and 2013 with abnormal uterine bleeding and received blood transfusion. Patients with pregnancy, critical illness, cancer, bleeding diathesis and religious beliefs precluding transfusion were excluded.

RESULTS:

A total of 212 charts were reviewed. Of the women who received transfusion for abnormal uterine bleeding, 163 were between 24-60 yrs (73%), 141 were not on any hormonal therapy for bleeding (67%), 121 had no previous procedures performed (57%). 78 (37%) women were orthostatic, 21 (10%) had a hemoglobin less than 6 gm/dL, 170 (80%) had hemoglobin between 6-8 gm/dL. Patients with cardiac comorbidities were few (8%). Most women were African American (79%) and the most common etiology was Fibroids (71%). 164 (77%) women had chronic bleeding (6 months or more) and 48 (23%) had acute bleeding. 79 (37%) women had no insurance.

CONCLUSION:

Blood transfusion trends in women with abnormal uterine bleeding in the existing practice appear to be liberal. There is a need for prospective studies for implementing blood transfusion guidelines for women with abnormal bleeding and comparing outcomes of liberal versus restrictive transfusion practice in this clinical situation.
Opioid Prescription and Patient Use Following Gynecologic Procedures [24D]
Authors: Griffith Kendall , Clark Nisse , Wright Kelly , Zuckerman Andrea , Ferzandi Tanaz
Published: May 2017

INTRODUCTION:

Gynecologists play a significant role in post-operative opioid prescription. The aim of this study was to describe opioid distribution and patient use following gynecologic procedures, and to determine if physicians prescribe or patients use less opioids for minimally-invasive hysterectomy compared to abdominal hysterectomy (AH).

METHODS:

This study was composed of a physician survey on opioid prescribing practices following gynecologic procedures, and a retrospective patient survey on opioid consumption following hysterectomy.

RESULTS:

After AH, physicians prescribed a median of 30 tabs of oxycodone (5mg) (range 5-30, SD 6.1). After laparoscopic hysterectomy (LH) or vaginal hysterectomy (VH), physicians prescribed a median of 20 tabs of oxycodone (range 5-30, SD 6.0). Physicians prescribed significantly more opioids for AH compared to LH with a mean difference of 4.5 tabs (p=0.001). 40.0% of physicians prescribe narcotic after a hysteroscopy and 19.2% after a D&C. 56 patients consented to participate in the study when called. AH patients reported being prescribed a mean of 25.7 tabs and using a mean of 8.7 tabs (SD 10.9; 33.9% used). LH or VH patients reported being prescribed a mean of 24.2 tabs, and using a mean of 10.0 tabs (SD 12.2; 41.4% used). 16.1% used zero tabs, and 64.6% used less than half of the opioids prescribed.

CONCLUSION:

Most patients use less than half of prescribed opioids leaving the majority as surplus medication that is vulnerable to abuse. Future studies should prospectively assess opioid use following gynecologic procedures so that physicians can adapt to help curb the opioid epidemic.
Identification and Resection of Endometriosis Using Indocyanine Green [26D]
Authors: Hanna Mariam , McSorley Ashley , Tam Maria Teresa
Published: May 2017

INTRODUCTION:

Endometriosis is a common cause of nonspecific pelvic symptoms, typically diagnosed through laparoscopic biopsies. An innovative technique utilizing indocyanine green (ICG), a dye that fluoresces in areas of increased vascularity such as endometriotic lesions, is used to diagnose normal-appearing, “clear” lesions of endometriosis. These lesions would have otherwise been missed by conventional laparoscopy.

METHODS:

A retrospective chart review and analysis included all patients on whom ICG was used from July 2014 to August 2016. Preoperative symptoms and postoperative localization of lesions were analyzed using the Fisher Exact test. Preoperative symptoms included abnormal uterine bleeding, pelvic pain, fibroids, and dyspareunia. Postoperative localization included lesions in the ovary, cul-de-sacs, vesicouterine peritoneum, pelvic peritoneum, uterosacral ligaments, and uterine serosa.

RESULTS:

Of 30 patients undergoing laparoscopic excision of endometriosis using ICG, twenty-one with positive fluorescence had endometriosis confirmed on pathology; eight with no ICG fluorescence had negative pathology results; and one patient had fluorescence with no identifiable endometriosis. This statistically indicates a positive predictive value of 95% with a sensitivity of 100%. The preoperative symptoms analyzed were not statistically significant for endometriosis, but clear lesions present in pelvic and vesicouterine peritoneum were statistically significant for endometriosis (p=0.001 and 0.01, respectively).

CONCLUSION:

Use of ICG fluorescence led to pathology-proven diagnosis in 29 of 30 patients. ICG is an inexpensive, non-toxic dye whose application could help change how endometriosis is diagnosed with minimal risk to patients. Future studies would benefit from larger patient recruitment by adding power to the analysis.
Obstetric Outcomes of Pregnancy Complicated by Marfan Syndrome: A Retrospective Cohort Study [28D]
Authors: Clennon Emily , Caughey Aaron B. , Teton Zoe , Shaffer Brian
Published: May 2017

INTRODUCTION:

Marfan Syndrome (MS) effects 1/3,300 individuals in the US and confers significant potential for morbidity in pregnancy. Cardiovascular complications, namely aortic dissection, have been the primary focus of previous investigations of pregnancy in women with MS. This study aims to elucidate MS-associated obstetric complications.

METHODS:

This retrospective cohort study examined singleton, non-anomalous pregnancies recorded by the California Birth Registry from 2006-2010. Of collected pregnancies, 61 were complicated by MS as identified and defined by the registry. The remaining 2,039,809 pregnancies comprised the control group. Simple rates of 17 obstetric complications were compared between groups. Chi squared tests and multivariate regression were used for statistical analysis, with p < 0.05 as the cutoff for significance.

RESULTS:

Pregnancies complicated by MS were significantly more likely to result in preterm delivery (16.4%, p=0.04), neonates small for gestational age (13.5%, p=0.027), and neonatal hypoglycemia (3.3%, p=0.022). Postpartum hemorrhage was also more likely though not significantly (6.6%, p=0.079). MS was associated with significantly decreased likelihood of gestational diabetes (0.0%, p=0.043). Intrauterine fetal demise, neonatal death, deep vein thrombosis, and uterine rupture were absent in this cohort. Maternal length of stay was not significantly longer in pregnancies with MS.

CONCLUSION:

Our results indicate MS is associated with increased likelihoods of several obstetric complications and decreased likelihood of gestational diabetes. These findings are consistent with existing literature, though an association with neonatal hypoglycemia has not been described. Several other complications were notably absent despite being reported previously. Our findings strengthen limited literature on obstetric outcomes in pregnancy complicated by MS.
Academic and Community Partnerships: Telepsychiatry for Perinatal Depression in a Rural Setting [31D]
Authors: Acosta Tatiana , Meltzer-Brody Samantha , Tolleson-Rinehart Sue
Published: May 2017

INTRODUCTION:

Perinatal depression is one of the most common complications of pregnancy, but limited access to mental health services in rural areas, especially those with underserved populations, prevents women from receiving appropriate care. Collaboration between academic institutions and safety net providers can bring effective mental health services to underserved communities through telepsychiatry. To date, telepsychiatry programs have proven successful in diverse populations, but few specific perinatal depression programs now exist. The present study examines the feasibility of collaboration among an academic institution, a federally qualified health center, and a local health department to implement a telepsychiatry program for pregnant women experiencing perinatal depression.

METHODS:

This study used literature review and in-depth structured interviews with members of the health care community who had experience as a provider or administrator in the delivery of perinatal care, mental health care, and/or telemedicine programs.

RESULTS:

Triangulation of data revealed that financial feasibility including physician reimbursement and cost of equipment and network, as well as provider/workforce capacity, are major barriers to implementation. The paucity of Spanish-speaking psychiatrists, and legal questions of licensing and credentialing are other barriers. Facilitators include any pre-existing relationships among these institutions and numerous opportunities for public and private grant funding.

CONCLUSION:

Existing partnerships between academic and community institutions provide a solid foundation from which to expand mental health services to rural communities. Despite partners’ marked willingness to collaborate, they must work to overcome financial, legal, and cultural barriers before we can expect a proliferation of perinatal telepsychiatry programs for underserved populations.
Case Report of Recurrent Sigmoid Volvulus in Pregnancy and Management Plan of the OB/GYN Hospitalist [35D]
Authors: Olds Scott-May , Wong Jennifer A.
Published: May 2017

INTRODUCTION:

Sigmoid volvulus is a rare and dangerous surgical complication of pregnancy that has a maternal and fetal mortality rate of 6-12% and 20-26%, respectively. We present a case report of a 31 year old gravida 3 para 2002 female at 31 5/7 weeks who was diagnosed with a recurrent sigmoid volvulus and the management plan by the OB/GYN Hospitalist in coordination with General Surgery and Neonatology.

METHODS:

At 12 weeks gestation, the patient had an endoscopic decompression of a sigmoid volvulus. The patient then presented at 31 5/7 weeks with the triad of severe abdominal pain, distention, and obstipation consistent with recurrent sigmoid volvulus, as well as preterm contractions. Determining the timing of surgical intervention and delivery were essential for optimal maternal and neonatal outcome.

RESULTS:

Patient underwent supportive and betamethasone treatment for 48 hours. At this time, recurrence of severe abdominal pain and contractions resulted in urgent surgery. Cesarean section with B-lynch suture was performed to decrease uterine size in order to facilitate sigmoid volvulus evaluation and treatment by General Surgery.

CONCLUSION:

Mother and neonate were discharged home without significant sequelae. Worldwide literature review of volvulus in pregnancy including pathophysiology, clinical diagnosis, imaging guidelines, and surgical treatment will optimize the Laborist management of this rare third trimester complication.
Optimal Delivery Timing for Intrahepatic Cholestasis of Pregnancy (ICP) [36D]
Authors: Yu Xiaoqian , Chavan Niraj R. , McQuerry Kristen , Hansen Wendy
Published: May 2017

INTRODUCTION:

While consensus exists regarding delivery timing for pregnancies affected by ICP, the differential impact of varying gestational age (GA) remains incompletely understood. This study evaluated the impact of GA at delivery in affecting maternal and neonatal outcomes in ICP.

METHODS:

We performed a retrospective cohort study of patients with ICP who were delivered at a tertiary teaching hospital from Jan 2008 to Dec 2015. The study cohort was divided into 3 groups: less than 37, at 37, greater than 37 weeks. We compared the maternal and neonatal outcomes using one way ANOVA and chi-squared / Fisher exact test for continuous and categorical data, respectively. Multivariable logistic regression analyses were performed to predict the likelihood of adverse perinatal outcomes while adjusting for sociodemographic, clinical and laboratory characteristics.

RESULTS:

Out of a total of 110 patients with ICP - 53 (48.19%) delivered at 37 weeks, with 28 (25.46%) and 29 (26.37%) patients delivered at less than 37 and greater than 37 weeks, respectively. Preterm delivery was significantly associated with higher bile acid levels, Hepatitis C, earlier diagnosis, lower Apgar scores, higher rates of hyperbilirubinemia, NICU admission, and length of NICU stay. Induction prior to 37 weeks resulted in higher cesarean rates, with vaginal delivery being higher for inductions ≥ 37 weeks.

CONCLUSION:

In our study, advanced ICP disease, often resulted in spontaneous preterm labor before a scheduled induction. Further prospective studies are warranted to characterize the influence of gestational age at delivery in modulating perinatal outcomes in ICP.
Optimal Management and Delivery Time for Intrahepatic Cholestasis of Pregnancy: Meta-analysis [37D]
Authors: Savasan Zeynep Alpay , Zeb Amna
Published: May 2017

INTRODUCTION:

To determine the risk of adverse perinatal outcomes in patients with intrahepatic cholestasis of pregnancy (IHCP) with gestational age at delivery and treatment modalities.

METHODS:

A systematic search of MEDLINE, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials was performed. The inclusion criteria consisted of randomized controlled clinical trials (RCTs) consisting of ursodeoxycholic acid (UDCA) compared with other treatments like placebo, dexamethasone, cholestyramine and SMAe for IHCP.

RESULTS:

11 RCTs were eligible for analysis. Data was analyzed on 542 patients, of which 281 received UDCA and 261 received other treatments. Use of UDCA delayed gestational age at delivery by 6 days {SMD=0.59 (95% CI: 0.08-1.09); p < 0.001}. Risk for preterm delivery and NICU admission decreased in group treated with UDCA compared to other treatments {RR=0.52 (95% CI: 0.38-0.72); p < 0.001 and RR=0.53 (95% CI: 0.29-0.97); p=0.038}, respectively. Risk of adverse perinatal outcomes was decreased for delivery at 36 weeks {RR=0.59 (95% CI: 0.39-0.90); p=0.013} compared for delivery at 37 weeks. UDCA treatment decreased the risk of meconium staining and c-section with increased birth weight but these results did not show statistical significance.

CONCLUSION:

Treatment choice of IHCP should be UDCA and 36 weeks appeared to be the optimal time of delivery.​
Use of Interventions for Prevention of Serious Pregnancy Complications: Findings From a National Study in Ethiopia [15B]
Authors: Getachew Ashebir , Ricca Jim , Rawlins Barbara
Published: May 2017

INTRODUCTION:

Reversing Ethiopia’s high maternal mortality ratio requires high access to interventions that address common causes of maternal deaths. We sought to determine levels of use of interventions and status of determinants of use that is needed by maternal health programmers.

METHODS:

We randomly selected 19 hospitals from a total list of hospitals in Ethiopia from which a total of 192 labors and 126 antenatal care counseling sessions were observed for use of interventions recommended by the World Health Organization regarding prevention of prolonged labor, postpartum hemorrhage, preeclampsia, & puerperal sepsis. Data on selected determinants of use were collected using key informant interviews & facility visits. Frequencies & means were computed using Excel software. Study was approved by Ethiopian Public Health Association & Johns Hopkins Bloomberg School of Public Health Ethical Review Boards.

RESULTS:

Only 41% of pregnant mothers were screened for preeclampsia; partograph & active management third stage of labor & infection prevention practices were used correctly in 13%, 28% & 85% of labors, respectively. Majority of providers have received in-service training on key interventions, availability of drugs was 85%. While national guideline is up to date, was not found in study health facilities.

CONCLUSION:

We found low use of interventions recommended for prevention of maternal complications. We recommend reviewing the quality of in-service training & availing national guidelines.
Obstetric Patient Self-Perception of Body Size and Obesity at First Prenatal Visit [2K]
Authors: Lutz Elizabeth A. , Street Kathleen , Simmons Kimberly , Furniss Anna
Published: May 2017

INTRODUCTION:

The objective of this study is to evaluate (1) perceived body weight and body size of participants versus actual body weight and body size, and (2) participant application of recommended weight gain for themselves during pregnancy.

METHODS:

Potential study participants were identified at the initial prenatal visit and offered enrollment prior to triage. Thereafter a 13 question survey was completed with regard to perceived pre-pregnancy and current weight, body size, and knowledge of recommended weight gain for pregnancy. Subsequently actual participant height and weight were recorded and BMI was calculated.

RESULTS:

101 women completed the 13-question survey. Only six (13.6%) of the 44 participants classified as obese according to calculated BMI correctly identified themselves as obese; the majority (68%) classified themselves as overweight. This error in classification was statistically significant (p < 0.001) when compared to the non-obese population. 85 participants responded to questions regarding the estimation of recommended weight gain for their pregnancy. Calculated weight gain category was associated with inaccuracy regarding weight gain recommendations (p=0.02).

CONCLUSION:

Pregnant women who are obese may not recognize themselves as obese when asked to classify their body size. Compared to non-obese pregnant patients, obese pregnant patients are also more likely to over-estimate recommended weight gain for pregnancy.
Estimating Risk Factors for Cesarean Delivery in a Teenage Population [5K]
Authors: Oben Ayamo G. , Rodriguez Emma , Nkele Chika , Springer Lauren , Acosta Ometeotl
Published: May 2017

INTRODUCTION:

Factors such as advanced age, increased body mass index, extremes of neonatal birth weight among others are predictors of delivery via cesarean section. However, some of these predictors may not applicable to a teenage population. As such, our objective was to identify modifiable predictors for prevention of the primary cesarean delivery, in a nulliparous teen population of a tertiary care center.

METHODS:

We performed a retrospective cohort chart review of all teenage deliveries (≤19 years old) at one institution over a 2-year period. The inclusion criteria were all singleton births from July 2014 to July 2016 among mothers at term who delivered via non-elective cesarean section. Exclusion criteria included fetal malpresentation, presentation to prenatal care at gestational age >20 weeks and pregnancies complicated by fetal anomalies.

RESULTS:

Of the 322 included deliveries, 14.6% delivered by non-elective C-section. The population was 90% Hispanic with a mean age of 17.7 years ± 1.31. Only neonatal birth weight was significantly associated with delivery via cesarean section in bivariate analysis and remained a predictor. Mothers of neonates with extremes of birth weights (< 2500, >4000 g) had higher odds of having a cesarean delivery, compared to neonates with normal birth weight (OR 4.7 95%CI 2.3 – 9.4 and OR 4.6 95% CI 1.1 – 19.4).

CONCLUSION:

Among adolescent nulliparous patients, birth weight of the neonate was found to be a risk factor that places the gravid teen at increased risk for cesarean delivery. Further research with a greater sample size over a 10-year period is under way.
Evaluating Severity of Postpartum Hemorrhage Retrospectively Based on Risk Factors [9K]
Authors: Amaya Stephanie , Mattox John , Tussey Christina , Kang Paul
Published: May 2017

INTRODUCTION:

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Currently, all patients receive oxytocin in the third stage of labor to prevent PPH. Several studies have identified risk factors for PPH secondary to uterine atony, but with little evidence to support additional prophylaxis for patients with these risk factors. Therefore, the objective of this study is to compare risk factors to determine which cause a more severe PPH.

METHODS:

Blood loss amount and risk factors were obtained from medical records of patients diagnosed with PPH between December 2011-to-December 2014 from Banner University Medical Center-Phoenix. Diagnosis was based on measured blood loss greater than 500 mL (vaginal delivery) or greater than 1000 mL (cesarean section (CS)). Only patients with uterine atony were studied.

RESULTS:

Among 366 patients, 254 and 112 delivered vaginally or CS, respectively. Using a multivariate linear regression, the estimated mean difference of blood loss during delivery demonstrated statistically significant increases with the following risk factors: fetal macrosomia (p=0.011), multiple gestation (p=0.043), parity (p=0.014), and prolonged labor (p=0.049). Patients who observed precipitous labor of less than 3 hours showed a statistically significant negative relationship of blood loss during delivery (beta= -225.7, p=-0.028).

CONCLUSION:

While these risk factors influence PPH occurrence, some may cause more severe PPH. Risk factors that cause over-distention of the uterus lead to a more severe form of hemorrhage compared to others such as use of oxytocin, chorioamnionitis, magnesium use, and preeclampsia. This provides evidence to support more aggressive prophylaxis in patients with these risk factors.