bluuebunny/crossref_metadata_2025 huggingface dataset:
Is Self-Reported Insulin Adherence Associated With Maternal and Neonatal Outcomes? [23I]
Authors: Sheng Jessica , Wernimont Sarah A. , Fleener Diedre , Traore Fanta , Syrop Craig , Andrews Janet
Published: April 2018

INTRODUCTION:

Diabetes in pregnancy carries significant maternal and fetal risks. Medication adherence is critical to optimize glucose control and neonatal outcomes. Outside of pregnancy, high self-reported adherence is associated with lower glycosylated hemoglobin (HbA1c) values. We hypothesized that self-reported poor medication adherence at the first prenatal visit would be associated with worse maternal glucose control and neonatal outcomes.

METHODS:

This is a prospective cohort study of insulin requiring pregnant women enrolled in a team-based perinatal diabetes program. The validated Morisky Medication Adherence Survey was administered to women at their initial prenatal visit. “Good” and “poor” self-reported adherence was defined as a score of 0 or 1 and between 2 and 8 respectively. The primary outcomes evaluated were HbA1c and a neonatal composite of hypoglycemia, large for gestational age, preterm birth and hyperbilirubinemia requiring phototherapy.

RESULTS:

Both groups had a similar proportion of women with type 1 and type 2 diabetes with younger women noted to have poor adherence. Women with good adherence had significantly better glucose control at time of delivery (HbA1c 5.68 vs 6.29, p=0.03). However, change in HbA1c from initial visit to delivery was similar between groups (-1.87 vs -1.88, p=0.98). There were no statistically significant differences in neonatal outcomes.

CONCLUSION:

Pregnant women with insulin requiring diabetes who report good medication adherence demonstrate improved glucose control at delivery compared to women who report poor adherence, although neonatal outcomes were similar. Regardless of reported adherence at initial visit, a team-based perinatal diabetes program achieves improved glucose control during pregnancy.
Sequential Compression Device Compliance During Inpatient Antepartum Management [26I]
Authors: Chen Meinuo , Palatnik Anna
Published: April 2018

INTRODUCTION:

Recently, we implemented a quality improvement protocol where each antepartum admission order set included a pre-checked order for sequential compression device (SCD). The purpose of this study was to evaluate whether this change has led to increased compliance with SCD use during antepartum admission.

METHODS:

This was a prospective observational study including all pregnant women admitted for inpatient management in a single tertiary care center. The study was conducted between May 2017 and September 2017, a year after implementation of pre-checked order for SCD in the electronic antepartum admission order set. Prior to this implementation the rate of SCD order was 46.0%. Women receiving pharmacologic thromboprophylaxis were excluded. During daily morning rounds the study investigators assessed whether SCD was ordered, was in the room and whether it was in use. Woman was considered to be compliant if she was ambulating or in bed with SCD in use.

RESULTS:

During the study period a total of 356 rounding encounters were documented for 61 women. Mean length of stay was 6.51 days ± 7.6. 73.8% of admissions had a documented SCD order with 75.6% of these orders being placed on hospital day 1. Among women who had SCD ordered, 73.9% had the machine in the room and 33.3% were compliant with its use. Non-compliance increased with repeat rounding encounters (odds ratio of 1.35 per each rounding day, 95% CI 1.15 -1.54).

CONCLUSION:

Although pre-checked order set for SCD increased physician compliance with ordering SCD, patient compliance with SCD during antepartum admission was still low.
ZIP Code Matters: An Ecological Study of Preterm Birth in Rochester, New York [28I]
Authors: Toscano Marika A. , Olson-Chen Courtney
Published: April 2018

INTRODUCTION:

Preterm birth (PTB) is not homogeneously distributed among populations. Risk factors can accumulate in discrete locations. We sought to investigate the geographical relationships between PTB and sociodemographic factors as denoted by ZIP code.

METHODS:

We conducted an ecological analysis of data from 2012 to 2014 in each Rochester ZIP code using vital statistics, hospital records and the American Community Survey. Pearson correlation coefficients (r) assessed the relationship between PTB rates and sociodemographic variables by ZIP code. Geographic information system (GIS) mapping explored the spatial relationships of PTB rates.

RESULTS:

17,876 deliveries occurred with a PTB rate of 11.3%. The PTB rate ranged from 6.8% to 15.6% across 22 ZIP codes. GIS mapping demonstrated clustering of ZIP codes with the highest PTB rates in the urban center which overlapped with high levels of poverty and crime. Increased PTB rates significantly correlated with ZIP codes containing the largest percentage of minorities (r=0.836, P<0.001). PTB rates positively correlated with inadequate prenatal care (r=0.864, P<0.001), unmarried status (r=0.857, P<.001), state-funded insurance (r=0.848, P<0.001), poverty (r=0.855, P<0.001) and teen pregnancy rates (r=0.709, P<0.001) by ZIP code. Areas with the highest PTB rates had the lowest number of obstetric providers (r = -0.385, p=0.077).

CONCLUSION:

Rochester ZIP codes have a high correlation between PTB rate and sociodemographic factors, highlighting the abundance of risk factors that concentrate in geographic areas. The high risk areas seem to lack obstetric care providers. Policies and interventions should target these ZIP codes in order to improve PTB rates and access to care.
Fetal Heart Changes Following Neuraxial Analgesia in Uteroplacental Insufficiency Pregnancies [30I]
Authors: Maetzold Erin , Lambers Donna , Devaiah Ganga , Habli Mounira
Published: April 2018

INTRODUCTION:

Epidural analgesia (EA) and combined spinal epidural (CSE) can cause fetal heart rate changes due to maternal hypotension and uterine tachysystole. Previous studies have focused on CSE or EA in “healthy” pregnancies, excluding uteroplacental insufficiency (UPI) conditions. No studies have discussed the impact of EA and CSE on fetal heart rate in laboring UPI pregnancies. Our objective was to compare the impact of EA versus CSE during labor on fetal heart rate in pregnancies complicated with UPI.

METHODS:

We conducted a retrospective study of singleton pregnancies complicated with UPI that received EA (n=110) or CSE (n=127) for intrapartum pain relief in a single center from 2012-2015. UPI was defined as pregnancies with chronic hypertension, preeclampsia, and/or fetal growth restriction (IUGR) as per ACOG criteria definitions. Primary outcome was fetal heart rate abnormalities classified as normal, suspicious or pathologic as well as the NICHD criteria. Data collected included maternal demographics, blood pressure, uterine tachysystole, mode of delivery, interventions for FHR abnormalities and neonatal outcomes. Data was analyzed using Student’s t-test, Mann-Whitney U test and Chi-squared or Fisher’s exact test.

RESULTS:

There was no significant difference among groups in baseline characteristics, rate of maternal hypotension, uterine tachysystole, pregnancy outcome and fetal heart rate categories/abnormalities. When compared to the EA group, CSE had a higher rate of NICU admission (28.3% vs. 16.4%, p-value = 0.031).

CONCLUSION:

Pregnancies complicated with UPI are neither at higher risk of abnormal fetal heart pattern nor increased rate of fetal intervention.
Systematic Improvements Aimed at Improving Exclusive Breastfeeding Rates in Los Angeles County [31I]
Authors: Eskander Ramy N. , Bender Nicole , Buzad Paul , Jackson Ashaki , Saleeby Erin
Published: April 2018

INTRODUCTION:

Disparities in exclusive breastfeeding rates vary widely between institutions, with communities of low resources often demonstrating lower rates of exclusively breastfed infants. We evaluated how, in a tertiary care academic setting, systematic changes to an electronic health record system can impact the rates of exclusively breastfed, term infants, not admitted to the Neonatal ICU.

METHODS:

We collected baseline data on exclusive breastfeeding rates through discharge on women who delivered within the Los Angeles County Department of Health Services system from July 2015 through June 2016 (Group 1). Beginning July 2016, a campaign was deployed aimed at educating patients & staff on the benefits of exclusive breastfeeding (Group 2). In December 2016, in addition to education, we modified our newborn feeding protocol within the Electronic Health Record System (Group 3). We then compared baseline exclusive breastfeeding rates, to the following 6 and 12 months.

RESULTS:

While no statistical difference existed in monthly exclusive breastfeeding rates between Group 1 and Group 2, following removal of formula from system options, a summary t-test analysis revealed a notable difference in rates between Group 2 and Group 3. Group 3 had a higher rate of exclusively breastfeeding women (M=53.90, SD=5.64) than Group 2 (M=40.57, SD=3.09); t(10)=-7.41, P<.001. Exclusive breastfeeding rates rose to 54%.

CONCLUSION:

Making small, systematic changes to an electronic health record can have a significant impact on provider behavior, ultimately leading to significant increases in the rate of exclusive breastfeeding through hospital discharge.
Enhanced Recovery Program Reduces Length of Stay & Improves Value for Patients Undergoing Elective Cesarean Section [33I]
Authors: Kett Atilla , Cherot Elizabeth
Published: April 2018

INTRODUCTION:

Multiple obstetrical units in the United Kingdom introduced Enhanced Recovery Programs and demonstrated improved quality of care and significant savings with superior patient satisfaction. Our participation in the Perioperative Surgical Learning Collaborative and partnership with leading experts from the UK provides us with the unique opportunity to pioneer this pathway in the United States.

METHODS:

We enrolled low risk patients with the diagnosis of repeat Cesarean Section. Our team partnered with SeamlessMD, a leading provider of a clinical intelligence platform to develop the smartphone application to engage and empower our patients. Our solution has a wide range of capabilities, including a cross-platform application which accommodates patient education, reminders and the ability to perform remote monitoring and measure performance through an analytics dashboard including patient satisfaction and opioid use.

RESULTS:

We enrolled 110 patients in our first year. The average length of stay reduced from 3.7 to 2.45 days. We developed a financial model projecting the net direct variable costs and savings associated with the adoption of our program. Based on the implementation cost and daily direct variable cost savings, our Enhanced Recovery Program yielded a 296 % ROI during the first year and a projected 451% in subsequent years.

CONCLUSION:

Implementation of a Enhanced Recovery Program for patients undergoing elective Cesarean Sections can improve the value of care without forcing hospitals to incur a large expense. Cost savings associated with reduction in length of stay and improvement in patient outcomes and satisfaction can justify the cost associated with the implementation of the program.
Should a Private Obstetric Practice Switch Hospitals within a Tiered Hospital Payment System? [34I]
Authors: Siddiqui Zishan , Cherot Elizabeth
Published: April 2018

INTRODUCTION:

As hospitals align themselves in tiered payment systems, patients are faced with financial implications of continuing their existing relationship with their obstetrical practice. Patients may switch to a new obstetrical group and hospital. Obstetric practices are assessing if changing hospital affiliation will minimize patient attrition. Not much is understood about patient loyalty and barriers to switching providers. We conducted a patient survey to asses switch cost, loyalty and likelihood of attrition.

METHODS:

555 patients from a single obstetrical practice were surveyed. Student t-test was used to assess the relation between self-reported likelihood for attrition (outcome) and self-reported switch cost and loyalty

RESULTS:

Only 43.5% of the patients chose the practice because they wanted a doctor at the practice, others chose to be able to deliver at the affiliated hospital. 22.8% of the patients would certainly chose hospital over the practice. Patients were likely to choose the OB practice over the hospital if they chose to join the practice for its doctors, if they extensively researched physicians, or were worried about developing a relationship with a new doctor or the logistic hassle related to switching providers.

CONCLUSION:

A large number of patients chose an obstetrics practice because of the hospital they deliver in rather than because of the physicians. This factor is an important predictor of attrition if the OB practice switch their hospital affiliation. A deep understanding of patient-mix regarding their loyalty, motivation and perceived switch cost may help a practice asses the financial implications of switching hospital affiliation.
Cesarean Wound Risk Assessment and Management: A Quality Improvement Study [35I]
Authors: Griffiths Kara M. , Nguyen Xuan-Loc , Maxwell Rose , Polenakovik Hari , Shahin Maryam , Galloway Michael
Published: April 2018

INTRODUCTION:

Surgical site infections (SSIs) represent approximately 17% of all hospital-acquired infections with an estimated 500,000 SSIs per year. Cesarean delivery is the primary contributor to SSIs, resulting in patient morbidity and increasing length of hospital stay and medical costs. Studies have shown a benefit to pre-operative antibiotics, but no studies have been done to determine the benefits of stratifying patients into risks categories to tailor management with the goal of preventing infection.

METHODS:

This is a prospective two-phase quality improvement study in which women undergoing cesarean delivery were categorized according to a risk stratification checklist into high and low-risk groups for developing SSIs. Management for the low risk group consisted of standard pre-operative intravenous antibiotics and a standard pressure dressing. Management for the high risk group consisted of 24 hours of intravenous antibiotics and a specialized Mepilex dressing. SPSS software was used for data analysis.

RESULTS:

The overall occurrence of SSIs in the low and high risk groups were 7.1% and 3.3% respectively, p-value <0.23. 20% of patients with SSIs had insulin-controlled diabetes, p-value <0.06. Logistic regression demonstrated that both diabetes and BMI were strong predictors of SSIs, p-value <0.01. The incidence of complex SSIs decreased 40% after initiation of the protocol.

CONCLUSION:

Our data suggest an overall decrease in SSIs after stratifying patients into high and low risk groups with the assigned antibiotics/dressing. Obesity and diabetes are the greatest predictors of SSIs. These risk factors should prompt consideration of use of prolonged antibiotics and a specialized dressing.
Can Body Mass Index Predict Metformin Failure in Women with Gestational Diabetes? [38I]
Authors: Persad Malini D. , Ou Jennie , Bernasko James , Garry David , Garretto Diana , Herrera Kimberly
Published: April 2018

INTRODUCTION:

To determine if pre-pregnancy body mass index (BMI) predicts metformin failure in the treatment of women with gestational diabetes (GDM).

METHODS:

A retrospective cohort study of women with GDM was conducted from 2013-2016. Included in the study were women with GDM started on metformin after a failed trial of diet therapy. Excluded from the study were women with pre-existing diabetes mellitus or initiated glyburide or insulin therapy. Women were categorized as having adequate glycemic control on metformin (metformin success) or requiring the addition of or transition to an insulin regimen (metformin failure). Metformin failure was defined as the inability to obtain glycemic control despite utilization of the maximum metformin dosage or provider discretion. Maternal characteristics and BMI were collected from the hospital’s electronic medical record and compared between groups. Parametric and nonparametric statistical analyses were performed with a p value of < 0.05 as significant. The sensitivity and the specificity of BMI as a screening test for metformin failure were analyzed and the corresponding ROC curve was plotted to assess the performance of the test.

RESULTS:

A total of 139 women with gestational diabetes were identified, of which 21 (15%) failed metformin therapy. There were no differences in maternal demographics, BMI and BMI classifications between groups. The ROC curve revealed an optimal cut-off BMI to predict metformin failure of 38.7kg/m2 with a sensitivity 38.1 % and specificity 81.4% (AUC 0.56, p=0.236).

CONCLUSION:

Pre-pregnancy BMI may have limited utility in predicting metformin failure.
Obstetric Outcomes Associated with Maternal Syphilis Infection in U.S. Deliveries [4J]
Authors: Hersh Alyssa R. , Skeith Ashley E. , Clennon Emily K. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Syphilis infections affect millions of pregnant women worldwide every year. The recent epidemic in the United States necessitates further investigation into the adverse effects of syphilis infection during pregnancy. Our goal was to examine the association of maternal syphilis infection with adverse pregnancy outcomes.

METHODS:

This was a retrospective cohort study that included 10,483,736 women with singleton gestations delivering in the United States from 2011 through 2013. Simple proportions of obstetric complications were compared between pregnant women infected with syphilis and controls. Chi square tests and multivariable regression were used for statistical analysis, with p<0.05 as the cut-off for significance. Comparisons were controlled for co-infection, parity, congenital abnormality, and maternal race and ethnicity, age, education attainment, cigarette use, and weight.

RESULTS:

A total of 7,148 pregnancies in this analysis were complicated by maternal infection with syphilis. Infection was positively associated with gestational diabetes (adj. OR: 1.33), gestational hypertension (1.36), caesarean section (1.15), maternal ICU stay (2.17), preterm delivery (1.13), NICU stay (1.74), neonate ventilator use for longer than 6 hours (1.37), and congenital abnormality (1.49).

CONCLUSION:

Syphilis infection in pregnancy is associated with increased odds of several adverse obstetric outcomes and increased health care system costs. Although it has been demonstrated that screening pregnant women for syphilis to reduce adverse outcomes is cost-effective, further research is necessary to investigate the detailed mechanisms of morbidity.
Influence of Sexually Transmitted Diseases in Pregnant Adolescents on Preterm Delivery and Chorioamnionitis [5J]
Authors: Fuchs Esther , Dwiggins Maggie , Lokken Erica , Eckert Linda
Published: April 2018

INTRODUCTION:

Adolescents have increased preterm birth (PTB) and sexually transmitted infections (STIs). However, data of the impact of STIs on PTB and other infectious complications is lacking. We examined the prevalence and impact of STIs (Gonorrhea, Chlamydia and Trichomonas) on PTB and chorioamnionitis in pregnant adolescents.

METHODS:

This retrospective cohort study included patients ≤19 year old at delivery over a 5-year period in an urban hospital. Each adolescents first singleton pregnancy during the study period was included. Logistic regression was used to estimate odds ratio (OR) and 95% confidence intervals (CI) of the association between STIs and pregnancy outcomes. We controlled for potential confounding factors. Chorioamnionitis was diagnosed clinically and histologically.

RESULTS:

Of the 975 babies delivered to adolescent mothers, 739 deliveries were included in our final analysis. Overall prevalence of STIs during pregnancy was 16.5% (Chlamydia 13.1%, Trichomonas 3.7% and Gonorrhea 3.1%). Our PTB rate was high, 18.1%, (15.02% when excluding transfers from outside the two closest counties). Chlamydia, Trichomonas and Gonorrhea were not associated with increased PTB. While Gonorrhea and Chlamydia did not increase the odds of chorioamnionitis, infection with Trichomonas was associated with a statistically significant 3-fold increased likelihood, OR 2.95 (95%CI 1.29, 6.75).

CONCLUSION:

We did not find an association between STI and preterm delivery in adolescent patients who had a high PTB rate, possibly secondary to early detection and treatment. However, Trichomonas markedly increased chorioamnionitis risk, especially diagnosed on pathologic specimens. These data support routine screening of all pregnant teenagers for Trichomonas.
Depression Screening in Early Pregnancy and Associations With Pregnancy Outcomes Among a Diverse Cohort [32J]
Authors: Lundsberg Lisbet , Schwarz Eleanor Bimla , Gariepy Aileen M.
Published: April 2018

INTRODUCTION:

Depression is a common perinatal occurrence, yet research regarding how early depression can be identified and whether it differs by pregnancy outcome (delivery/abortion) is limited.

METHODS:

English- or Spanish-speaking women, aged 15–44, <24 weeks gestation seeking pregnancy testing or abortion care were enrolled in a prospective cohort study from 2014 to 2015. The Edinburgh Depression Scale (EDS) assessed depression at enrollment and 3 months later. Participants with positive depression screen (EDS ≥13) received mental health referral. Pregnancy outcomes were assessed via phone interviews and medical chart review. Women with miscarriage were excluded from this analysis.

RESULTS:

Among 100 participants with complete EDS data, women averaged 26.8 (±6.3) years and 9.3 (±4.6) weeks gestation. Seventy-nine percent presented for walk-in pregnancy testing; 21% for abortion. Participants were culturally diverse: 48.0% Hispanic, 30.6% Black, non-Hispanic, 14.3% White, non-Hispanic and 7.1% multiracial. Most (66%) continued pregnancy, 44% chose abortion. At enrollment, 21% screened positive for depression, and women choosing delivery (17%) were not statistically different from women choosing abortion (29%) (P=.138). At 3-month follow-up, 18% screened positive for depression; no difference was observed between women choosing delivery (14%) compared to abortion (27%) (P=.114). The overall proportion of women with a positive screen for depression remained stable from enrollment to 3-month follow-up (P=.549), and remained stable among women choosing delivery (P=.727) and abortion (P=>.999).

CONCLUSION:

Antenatal depression is common amongst women early in pregnancy, whether choosing delivery or abortion. Early screening may provide opportunities for early interventions. Future research should test early interventions.
Surgical Management of Placenta Percreta: Outcomes of Immediate Versus Interval Hysterectomy [33J]
Authors: Weidenbaum Emily , Cham Stephanie , Breslin Noelle , Huang Yongmei , Burke William , Perez-Delboy Annette
Published: April 2018

INTRODUCTION:

To compare the outcomes of women with placental percreta (PP) who underwent immediate hysterectomy (IMM) to those with conservative management with delayed, interval hysterectomy (INT).

METHODS:

A retrospective review with a cohort between 2011 and 2017 of cases with abnormal placentation (AP) diagnosed with US/MRI. Patients were delivered with a massive transfusion protocol and a multidisciplinary accreta team. Estimated blood loss (EBL), length of stay (LOS), and other complications were compared using SAS.

RESULTS:

Of our cohort of 93 patients with AP, 20 (22%) had pathologically confirmed PP. Eleven (55%) women underwent IMM; 9 (45%) underwent INT. The median gestational age at delivery was 35 versus 34 for IMM versus INT (P=.97). The IMM group was more likely to have an emergent procedure compared to the INT group (27.3% versus 11.1%; P=.59). Median EBL for IMM was 2,800 mL (range 1,200–25,000 mL) versus 1,000 mL (range 300–3,700 mL) for INT group (P<.01). Median LOS in IMM versus INT was 15 versus 7 days (P=.34). There was a trend towards a higher rate of transfusion (100% versus 44%; P<.01) and cystotomy (45% versus 11%; P=.16) for IMM versus INT. The rate infection (0% versus 11%; P=.45) were similar for IMM compared to INT.

CONCLUSION:

Compared to IMM, conservative management with INT is associated with decreased EBL and a trend towards lower rates of transfusion and cystotomy than IMM in PP. There was a trend towards increased rate of infection with INT.
Wound Disruption Following Cesarean Delivery in Women With Class III Obesity, a Retrospective Observational Study [36J]
Authors: Sagi Yair , Maxwell Cynthia , Snelgrove John , D'Souza Rohan , Vernon James
Published: April 2018

INTRODUCTION:

Class III obese women are at increased risk for wound complications following cesarean delivery (CD). We evaluated the CD wound disruption rate in women with class III obesity, and identify underlying risk factors.

METHODS:

Class III obese women who underwent CD >24 weeks of gestation at our hospital, between 2011 and 2015 were included. Data on demographics, clinical history were collected. Information regarding the CD included and also Information regarding the perioperative period. Multivariable logistic regression analysis was performed to identify risk factors likely to contribute to higher wound disruption rates.

RESULTS:

Three hundred thirty-four cases of class III obese women, with mean age 32.96+5.19 and mean BMI of 48.20+7.52. The most frequently used skin incision was Pfannenstiel (75.6%). The subcutaneous tissue was most likely to be closed (65.4%). The skin was most likely to be closed with staples (66%) with the use of a pressure dressing (65%). DVT prophylaxis was administered in 71.7% of cases. We had 18% wound disruption rates. Wound disruption rates were higher if surgical time was >1 hour (odds ratio [OR]=2.03, 95% confidence interval [CI] 1.13–3.65, P=.017) and if DVT prophylaxis was used (OR=2.22, 95% CI 1.08–4.59, P=.031). On multivariable logistic regression, surgical time >1 hour (OR=1.88, P=.050), but not DVT prophylaxis (OR=1.64, P=.22) remained statistically significant.

CONCLUSION:

We found that surgical time >1 hour was the only statistically significant risk factor for wound disruption. We had 18% wound disruption rates. The role of other risk factors, in particular the use of DVT prophylaxis warrants further investigation.
Placenta Previa and Congenital Cardiac Anomalies [37J]
Authors: Aalami-Harandi Pegah , Akinola Damilola , Barton John , Khoury Aldo
Published: April 2018

INTRODUCTION:

Several studies have shown an association between placental abnormalities and neonatal complications such as major congenital abnormalities, respiratory distress syndrome, intrauterine growth restriction and preterm delivery. With increased incidence of Placenta Previa due to the increase in cesarean deliveries, advanced maternal age and multiparity, we sought to investigate an association between Placenta Previa and congenital heart disease (CHD), which in the general population occurs in 1% of live born infants.

METHODS:

A retrospective chart review was performed to assess possible association between all births with Placenta Previa and infants with congenital heart disease who delivered at St. Joseph Regional Medical Center from 2005 to 2015. In addition, placental location was reviewed for each mother who delivered an infant with CHD, over the past 10 years.

RESULTS:

For the study period, there were 321 mothers with diagnosed Placenta Previa at delivery and 2 infants had CHD (0.6%, P=.497). Furthermore, of the 202 infants with CHD, 13 of the mothers had abnormal placental location (Placenta Previa, marginal or low lying placenta) early in gestation (6.4%).

CONCLUSION:

Placenta Previa at delivery is not associated with newborn diagnosis of congenital heart disease. Abnormal placental location in early gestation however could be associated with CHD. This finding may be due to other confounding factors associated with abnormal placental location in early gestational age.
Using Lean Methodologies to Improve Efficiency in an Outpatient OB/GYN Setting [4K]
Authors: van Nes Jaclyn
Published: April 2018

INTRODUCTION:

Lean methodologies have been used in business, particularly automotive manufacturing, since the 1980's. Key concepts include just in time inventory, elimination of waste or muda, and quality improvement by focusing on customers and employees. The technique has also been applied in healthcare, particularly emergency rooms, however, data is limited in OB/GYN settings. This article focuses on a lean project in Knoxville, Tennessee.

METHODS:

Women's Specialty Care, a group of general OB/GYN academic specialists, needed to increase physician numbers in 2015. Four additional physicians were hired doubling the number of the physicians in less than 6 months. An issue arose with how to accommodate eight physicians with resources designed for four. A lean project began in early 2016. Inventory storage was organized and evaluated for overstocking. A standardized restocking system was implemented for exam rooms. Front office space was cleaned and waste eliminated. A patient flow analysis was performed and the office restructured. As staff became more involved in the process, they developed an improved check in system saving staff about 2 hours per day.

RESULTS:

After the 10 month project, all physicians could see patients in the existing space with no additional staff. Patient throughput at the main office improved from approximately forty to seventy patients per day. Additionally, staff morale improved.

CONCLUSION:

In this example, lean techniques were used to improve efficiency in an outpatient OB/GYN setting with excellent results. Lean events should be used and evaluated in other OB/GYN settings to see if the concept is effective in this specialty.
Impact of a Novel Protocol for Management of Pregnancy-Related Iron Deficiency Anemia [7K]
Authors: Reimers Rebecca , Achebe Maureen , Cortes Sarai , Smith Nicole
Published: April 2018

INTRODUCTION:

Iron deficiency anemia is associated with risk of transfusion, preterm delivery, and cesarean birth. We aimed to optimize management of iron deficiency anemia with a novel protocol.

METHODS:

A multidisciplinary team developed an evidence-based treatment protocol for anemia in pregnancy. Resident and maternal fetal medicine (MFM) practices in a tertiary care center implemented this in October 2016. Two weeks of iron supplementation without 1g/dL hemoglobin increase prompted hematology consultation. Protocol adherence in five fields and rates of anemia in the third trimester and at delivery were compared between sites using Fisher exact and χ2 tests.

RESULTS:

Rates of third trimester anemia were significantly higher in the resident practice (29%) than MFM (15%), P=.03. Term anemia rates were similar (31% and 27%). Rates of iron supplementation in resident patients varied from 50% to 100%, and in MFM from 75% to 100%. Referral to hematology for consideration of iron infusion rates were similar between groups (20% versus 30%), P=.68, as were rates of iron infusion (11% versus 25%). Protocol adherence was inconsistent.

CONCLUSION:

Adherence to a novel pregnancy-related anemia protocol was inconsistent and did not result in a decline in iron deficiency anemia at term. Further investigation is necessary to determine whether protocol adherence could improve rates of anemia.
Does Labor Induction in Nulliparous, Term, Singleton and Vertex Pregnancies Increase the Risk of Cesarean Delivery? [12K]
Authors: Gulersen Moti , Bornstein Eran , Baum Stephanie R. , Krantz David , Minior Victoria , Divon Michael
Published: April 2018

INTRODUCTION:

Efforts have been made to reduce the rate of cesarean delivery in nulliparous, term, singleton, vertex (NTSV) pregnancies. We set out to evaluate whether labor induction in this patient population is associated with an increased risk of cesarean delivery.

METHODS:

A meta-analysis was performed analyzing fourteen randomized controlled trials that met inclusion criteria. These included all randomized controlled trials of NTSV patients with intact or ruptured membranes that were randomized to induction of labor or control (i.e. expectant management). The primary outcome was the incidence of cesarean delivery. Secondary outcomes included incidence of cesarean delivery after induction of labor in ruptured versus intact membranes, as well as incidence of NICU admission. Results were reported as odds ratio (OR) with 95% confidence interval (CI).

RESULTS:

A total of 2,706 patients were analyzed. NTSV gestations undergoing induction of labor had a similar incidence of cesarean delivery compared to controls (24.6% versus 24.6%; OR 1.095; 95% CI 0.89–1.34). Rates of cesarean delivery in patients with intact membranes (28.7% versus 30.2%; OR 1.041; 95% CI 0.81–1.32) and ruptured membranes (15.1% versus 11.9%; OR 1.321; 95% CI 0.88–1.98) undergoing induction were also similar. Likewise, the incidence of NICU admission associated with labor induction was not statistically different compared to control group (6.3% versus 6.9%; OR 0.928; 95% CI 0.59–1.46).

CONCLUSION:

Hospitals are incentivized to reduce the rate of cesarean sections in NTSV pregnancies. Patients, practitioners and hospitals can be assured that labor induction in this population does not increase the risk of cesarean delivery or NICU admission.
The Impact of Perinatal Depression on Breastfeeding Rates [15K]
Authors: Stark Elisabeth , Shim Jessica , Ross Carolyn , Miller Emily Stinnett
Published: April 2018

INTRODUCTION:

Perinatal depression complicates 1 in 7 pregnancies and has adverse consequences when untreated. These may include failure to breastfeed and its known adverse effects on mother and offspring. This study sought to determine whether maternal antenatal depression was associated with the likelihood of breastfeeding initiation and continuation until the 6-week postpartum visit.

METHODS:

This retrospective chart study included all deliveries after 20 weeks gestation at a single tertiary care institution between 2008 and 2015 with a documented antenatal depression screen using the Patient Health Questionnaire-9 per standard obstetric care. Breastfeeding initiation and continuation until 6 weeks postpartum were compared between women with and without a positive screen using bivariable analyses. Stepwise backwards elimination regressions were used to identify whether antenatal depression was independently associated with breastfeeding initiation and continuation.

RESULTS:

Of 2,871 women meeting inclusion criteria, 302 (10.5%) screened positive for antenatal depression. Women with antenatal depression were more likely to be younger, a racial/ethnic minority, obese, have public insurance or medical co-morbidity, and deliver preterm than women without depression. Women with antenatal depression were less likely to initiate breastfeeding (81.0% versus 86.3% P=.014) and continue breastfeeding at 6 weeks postpartum (54.7% versus 68.9% P<.001). After controlling for confounders, antenatal depression was not independently associated with breastfeeding initiation (aOR 0.78, 95% CI 0.52–1.16) but did remain significantly associated with reduction in breastfeeding continuation (aOR 0.67, 95% CI 0.48–0.96).

CONCLUSION:

Antenatal depression is a significant risk factor for early breastfeeding cessation. Further interventions to improve breastfeeding rates should include evaluation of maternal mental health.
Postpartum Readmissions: What We Can Learn From Numbers? [18K]
Authors: Nasab Susan Hosseini , Moussa Hind N. , Alrais Mesk A. , Sibai Baha M. , Blackwell Sean C.
Published: April 2018

INTRODUCTION:

Unplanned hospital readmissions can be considered as a quality indicator for hospital care. Our objective was to describe the risk factors and indications for post-partum readmissions.

METHODS:

This is an observational study of prospectively collected data at one tertiary hospital. Patients were identified during obstetric safety rounds and physician board checkouts during 17 months.

RESULTS:

Over period of 17 months, we had 7,126 deliveries, including 4,156 vaginal and 2,970 cesareans. Study group consisted of 106 patients with total 111 post-partum readmissions, with overall readmissions rate of 1.55%. Main indications for readmissions were: hypertensive disorders (43.2%) and wound complications (18.0%). Among 47 women who were readmitted for hypertensive disorders, 19 (40%) had de-novo onset of preeclampsia, versus 28 (60%) who had a history of hypertensive disorders. Among those 19 women with de-novo onset of preeclampsia, risk factors were obesity (BMI>30) (12), history of hypertensive disorders in previous pregnancies (4), nulliparity (4), gestational diabetes mellitus (2) and twin pregnancy (1). Eighteen patients were readmitted for surgical wound complications with 20 total readmissions. Twelve of 18 had repeat cesarean. For these women, risk factors for wound infection were obesity (BMI>30) (13), prolonged labor before cesarean delivery (5), history of diabetes (4), and steroid administration (7).

CONCLUSION:

Developing protocols and improvement strategies that focus on risk factors with close surveillance and postpartum follow-ups in those identified as high-risk patients, might be a valuable key to reduce readmission rate. Reducing readmission rate gives a valuable opportunity to healthcare facilities to improve patient satisfaction and safety.
Use of Massive Transfusion Protocol: Maternal Outcomes in Patients With Severe Obstetric Hemorrhage [22K]
Authors: Lepic Molly , Greer Danielle M. , Kram Jessica J. F. , Nijhawan Niraj , Cicero Andra
Published: April 2018

INTRODUCTION:

Obstetrical hemorrhage represents the single-most significant cause of maternal mortality. As hemorrhage rates increase, Massive Transfusions Protocols (MTP) have been adopted for maternal resuscitation. We explored maternal outcomes associated with MTP utilization.

METHODS:

We retrospectively studied women who delivered with Class III-IV hemorrhage (estimated blood loss [EBL] ≥1,500 mL) at either an urban teaching-hospital serving high-risk patients (HOSP1) or a suburban hospital serving average-risk patients (HOSP2) during 2012–2015. Patient groups included: 1) no transfusion, 2) transfusion without MTP, and 3) transfusion via MTP (implemented at HOSP1 only). Between-group differences in maternal characteristics and outcomes by year and hospital were described.

RESULTS:

Women totaled 109 at HOSP1 (no transfusion: 30 [28%], transfusion: 56 [51%], MTP: 23 [21%]) and 42 at HOSP2 (no transfusion: 18 [43%], transfusion: 24 [57%]). Transfusion reactions (n=2) occurred in the transfusion group only, and no maternal deaths occurred. No statistically significant patterns were detected in length of stay (LOS) or renal, hematologic, or coagulation indices. However, notable patterns were observed at HOSP1 in mean EBL (no transfusion: 1,720 mL, transfusion: 2,048 mL, MTP: 3,417 mL) and postpartum LOS (no transfusion: 3.0 days, transfusion: 3.2 days, MTP: 4.3 days). Thrombocytopenia improved annually with MTP. Total units transfused were greater with MTP (Total 10.2, PRBC 6.6, FFP 2.6, Platelet 0.9) than transfusion (Total 3.6, PRBC 3.0, FFP 0.4, Platelet 0.1). MTP accounted for the only wasted units (mean 0.52, range 0–4).

CONCLUSION:

MTP uses more blood products. However, in class III–IV hemorrhages, MTP use may be beneficial without significant adverse outcome.
The Correlation of Involvement in Resident Education and Episiotomy Rates [28K]
Authors: Neace Sasha , Crisp Catrina , Devaiah Ganga , Marcotte Michael , Voss Deward , Holbert Michael
Published: April 2018

INTRODUCTION:

Nationally, there exists large variation in episiotomy rates among organizations and providers. The Leapfrog group has set a national goal of reducing episiotomy rates to less than 5%. The purpose of this study was to compare rates of episiotomy for providers during their private deliveries who participated in obstetric resident supervision to the rates for providers who did not supervise residents.

METHODS:

This is a retrospective study examining all private vaginal deliveries performed by physicians at an academic institution from July 1, 2015 to June 30, 2016. Deliveries with shoulder dystocia were excluded. Physician demographic information and delivery attributes were collected and analyzed.

RESULTS:

There were 3,785 private vaginal deliveries performed by 68 physicians during the study period: 31 provided resident coverage. Those providing resident supervision performed 1,578 private deliveries compared to 2,207 private deliveries among the 37 physicians not providing resident supervision. Physicians providing resident supervision performed half as many episiotomies compared to the group not involved in resident supervision, 7.5% versus 14.5% (OR 0.477, P<.001, 95% CI 0.382–0.595). There was no significant difference in physician demographics or operative vaginal delivery rates between the two groups.

CONCLUSION:

At our organization, there exists a difference in episiotomy rates among physicians that provide and do not provide resident supervision. Although causality cannot be inferred from this retrospective study, physician involvement in obstetric resident training is associated with reduced episiotomy rates reflecting an improved quality of obstetric care based on one of the Leapfrog group's metrics.
Impact of Prior History of Intrahepatic Cholestasis of Pregnancy on Current Pregnancy [33K]
Authors: Kohari Katherine , Rekawek Patricia , Lipkind Heather S. , Ferrara Lauren
Published: April 2018

INTRODUCTION:

The purpose of this study was to determine the impact of a prior history of intrahepatic cholestasis of pregnancy (ICP) on current pregnancy course and outcome in women with subsequent ICP.

METHODS:

This is a retrospective cohort study, comparing multiparous patients with ICP who had a history of ICP in a prior pregnancy to those patients without a prior history. Data was collected from a single hospital between 2005 and 2013. All patients with a diagnosis of ICP were identified. Data collected included maternal demographics, ICP management, delivery and neonatal outcomes. Logistic regression was used to evaluate the overall odds of an adverse neonatal outcome for those with and without a history of ICP.

RESULTS:

We identified 529 multiparous pregnancies with ICP during this time, 420 (79.5%) had no prior history of ICP and 109 (20.5%) had a prior history. There were no differences in demographics between the groups. Women with a history of ICP were diagnosed 6 days sooner and were more likely to be treated with ursodiol. There were lower birthweights, higher rates of RDS, and meconium in those with a history of ICP. When adjusting for maternal demographics, prior ICP, and gestational or other diabetes, a history of ICP was not significantly associated with any adverse neonatal outcomes.

CONCLUSION:

Patients with a history of ICP have earlier diagnosis. There is a significantly higher rate of meconium, lower birthweight and a higher rate of RDS. This may be driven by delivery timing which serves as valuable information when counseling patients on pregnancy expectations.
Smoking Cessation Patterns Among Pregnant Women Who Smoke [12L]
Authors: Halpin Delaney , Spencer Noelle , Neuhoff Ronica , Turner Kielah , Rothenberger Scott , Chang Judy
Published: April 2018

INTRODUCTION:

The objective of this study was to assess smoking cessation and reduction patterns among pregnant smokers. One in ten women in the United States will continue to smoke during their pregnancy. Smoking continuation during pregnancy is one of the most preventable causes of negative health outcomes for both the mother and baby.

METHODS:

We used data from a prior study of 468 pregnant patients. In this study, participants self-identified as tobacco smokers during the visit. Data was abstracted from all obstetrics visit(s) to assess cessation or continuation of smoking. For patients who reported quitting, we noted gestational age when quit was first documented. We also assessed whether cessation was sustained through documentation in subsequent progress notes. We performed descriptive statistics using SPSS.

RESULTS:

From 468 total study patients, 167 patients (36%) admitted to smoking tobacco during the first obstetric visits. Fifty-three (31.7%) patients quit during their pregnancy. Of these 53 patients, 41.5% quit during the first trimester, 47.2% during the second trimester, and 11.3% during the third trimester. Additionally, 11 of the 53 (20.8%) had remained quit at their postpartum visit where 4 of the 53 (7.5%) claimed to have started smoking again postpartum. The remaining 38 (72%) either did not come to their postpartum visit or were not asked about their smoking status at the visit.

CONCLUSION:

Less than a third of pregnant smokers quit smoking during their pregnancy. Those that quit were more likely to do so earlier in the pregnancy. Efforts for smoking cessation should target early pregnancy visits.
Operative Vacuum Vaginal Delivery: Effect of Compliance With Recommended Checklist [19L]
Authors: Pintucci Armando , Ghidini Alessandro , Consonni Sara , Lambicchi Laura , Incerti Maddalena , Locatelli Anna
Published: April 2018

INTRODUCTION:

Rules for optimal placement and use of vacuum have not been tested in a clinical setting. We evaluated the effect of the adherence to the recommended checklist for vacuum delivery (VD) on maternal and perinatal outcomes.

METHODS:

Retrospective cohort study including all VD over 4 years. Kiwi Omni Cup was used in all cases and the operators were encouraged to follow 3 rules: recording of fetal head station and position, performing no more than 4 tractions, and no more than 3 cup applications. A checklist to record the procedure was also introduced.

RESULTS:

The overall rates of VD and cesarean delivery (CD) were respectively 4.4% and 17.9%. Cases in which the 3 rules were respected had lower incidence of III–IV degree perineal lacerations after controlling for episiotomy, nulliparity, and indication for the procedure (P=.025), but similar rates of failure of vacuum extraction (2.1% versus 2.2%, P=1) and adverse neonatal composite outcome (10.8% versus 11.7%, P=.71). Introduction of the checklist for VD resulted in an increase in the compliance to the rules (83.8% versus 62.8%, P=.000). Neither failure of vacuum nor adverse maternal or neonatal outcomes was related to occiput posterior position or high station of the head in cases respecting rules.

CONCLUSION:

Compliance with the recommended rules in VD results in a lower rate of severe perineal lacerations but it does not affect success of OVD or neonatal outcome. A continuous training program is a main factor to reach a successful procedure and reduce adverse outcome, even in cases of occiput posterior delivery.