bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk for Adult Obesity in Offspring of Pregnancies Affected by Hypertensive Diseases of Pregnancy [31H]
Authors: Hammad Ibrahim A. , Meeks Huong , Fraser Alison , Esplin Sean M. , Smith Ken , Varner Michael
Published: April 2018

INTRODUCTION:

To determine if hypertensive disease of pregnancy (HDP) is associated with adult obesity in offspring.

METHODS:

A retrospective cohort study design was used to identify offspring of pregnancies complicated by HDP (gestational hypertension, preeclampsia, HELLP syndrome, eclampsia) born between 1947-1997 (now >20 years old) and with at least one adult BMI recorded in the Utah Population Database. These offspring (exposed) were matched by maternal age at birth, birth year, gender, and multiple gestation with offspring of women with no history of HDP (unexposed offspring). A second analysis was done matching the exposed offspring to their unexposed sibling in order to assess and control for the familial and environmental possible confounders. Adjusted relative risk (aRR) for obesity among exposed versus unexposed offspring as well as unexposed siblings were estimated using conditional logistic regression models.

RESULTS:

A total of 18,009 exposed offspring were compared to 30,761 unexposed offspring and 12,579 exposed siblings to 26,251 unexposed siblings. The relative risk of obesity was higher for exposed versus unexposed offspring, aRR=1.44 [95%CI 1.36-1.52]. Maternal obesity increased the relative risk to aRR=2.58 [95%CI 2.41-2.77], whereas higher maternal education decreased it to 0.87 [0.80-0.95]. For the sibling analysis, the risk for obesity was similar, aRR=1.05 [95%CI 0.98-1.11], aside from being a male sibling and first born aRR=1.31 [1.23-1.40] and aRR=1.18 [95%CI 1.09-1.27] respectively, no associated factors significantly increased the risk of obesity.

CONCLUSION:

HDP is independently associated with an increased the risk of obesity in adulthood. However this independent association was not demonstrated in the family, sibling environment.
Risk Factors for Poor Perineal Outcome after Operative Vaginal Delivery [32H]
Authors: Wilkie Gianna L. , Saadeh Michael , Robinson Julian , Little Sarah
Published: April 2018

INTRODUCTION:

The aim of this study was to identify risk factors for poor perineal outcome (higher order laceration or wound breakdown) after operative vaginal delivery.

METHODS:

A retrospective cohort study was performed including all operative vaginal deliveries during 2016. Multiple gestations and failed operative deliveries were excluded. Analysis was performed with Chi-square test, T-test and a multivariate logistic regression analysis.

RESULTS:

Our cohort included 334 operative vaginal deliveries (70.7% vacuum and 29.3% forceps) and was on average 32.1 ± 4.7 years old and 87.1% were nulliparous. Fifty-four (16.2%) had a higher order perineal lacerations and 7 (2.1%) had a wound breakdown (1 of which occurred after a higher order laceration). The only significant risk factor for a higher order laceration was chorioamnionitis (aOR 2.3; 95% CI 1.1-5.0). Risk factors for perineal wound breakdown included episiotomy (4.2% vs. 0.9%; p=0.01), type of operative delivery (6.1% after forceps vs. 0.4% after vacuum; p<0.01) and the need for narcotic pain control postpartum. Overall, 25.0% of operative deliveries required narcotics postpartum, and 6.0% of those using narcotics subsequently had a perineal breakdown vs. 0.8% who did not (p=0.01). Narcotic use postpartum remained a strong predictor in adjusted analysis (OR 11.2; 95% CI 2.0-63.7). The highest risk group (forceps deliveries with an episiotomy who required narcotic pain control postpartum) had a 30% rate of perineal breakdown.

CONCLUSION:

Narcotic use after an operative vaginal delivery was associated with subsequent perineal wound breakdown. Women requiring narcotic pain control after forceps delivery with an episiotomy may benefit from close follow-up postpartum.
Does Inpatient Postpartum Blood Pressure Correlate With Outpatient Postpartum Hypertension? [36H]
Authors: Lauring Julianne , Wiese Sarah , Mehdizadeh Amir , Majid Sana , Chung Charles , Leftwich Heidi
Published: April 2018

INTRODUCTION:

We sought to identify factors that correlate with hypertension within 12 weeks postpartum.

METHODS:

This is a retrospective cohort study of women with hypertensive disorders delivering between 2009 and 2016. Comparisons were made between women with one, two or three episodes ≥160 systolic or ≥110 diastolic within 24 hours postpartum vs women with blood pressures <160/110. Comparison were also made between women with one, two or three episodes ≥150 systolic or ≥100 diastolic 24-72 hours postpartum vs women with blood pressures <150/100.

RESULTS:

For women with hypertension ≥160/110 <24 hours postpartum there was no significant difference in hypertension at ≤2 weeks or compliance with a visit at ≤2 and 2-12 weeks. Women with two or three episodes ≥160/110 <24 hours postpartum were 1.9 times more likely to be hypertensive at this 2-12 weeks visit. Women with any episode ≥150/100 24 -72 hours postpartum were more likely to have a visit ≤ 2 and 2-12 weeks than women <150/100. These women were also more likely to be hypertensive at 2-12 weeks. Women with three episodes ≥150/100 24-72 hours postpartum were 3.1 times more likely to have hypertension at the visit <2 weeks postpartum than women <150/100.

CONCLUSION:

Recurrent severe hypertension <24 hour postpartum and hypertension >150/100 24-72 hours postpartum may predict hypertension 2-12 weeks postpartum. These women may also be more likely to present for postpartum care, but with similar rate of postpartum hypertension at <2 weeks, suggesting the importance of improving compliance with short interval outpatient follow-up.
The Effectiveness of Antenatal Corticosteroids Administration in Women at Risk for Late Pre-Term Delivery [38H]
Authors: La Rosa Mauricio , Kirsch Nathan , Florence Elizabeth , Petruzzi Victoria , Saade George R. , Saad Antonio
Published: April 2018

INTRODUCTION:

The objective of this study was to determine the effectiveness of antenatal corticosteroid (ACS) administration to late preterm pregnancies, and associated adverse neonatal outcomes, after implementation of this policy at our institution.

METHODS:

Retrospective cohort of women with late preterm delivery during 2015 -2017. We compared patients before and after the implementation of the 2016 recommendations. The primary outcome was a composite of perinatal morbidity defined as: CPAP or high-flow nasal cannula for at least 12 continuous hours, supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least 24 continuous hours, ECMO or mechanical ventilation, stillbirth, or neonatal death within 72 hours after delivery. Other neonatal outcomes included respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), apnea, bronchopulmonary dysplasia (BPD), surfactant administration, need for resuscitation at birth, severe respiratory morbidity, and neonatal hypoglycemia (serum glucose ≤ 40 mg/dL). Univariable and multivariable logistic regression analyses were performed and a P<0.05 was considered statistical significant.

RESULTS:

Of 602 patients, 239 received at least one dose of ACS. The composite outcome was not significantly different between those who received versus those who did not receive ACS (1.13 95%CI [0.8-1.6] p=0.46]). All the secondary outcomes were not different between groups. Neonates in the steroid group did not have a significantly higher rate of hypoglycemia (1.28 95%CI [0.77-2.12] p=0.29). The lack of differences persisted after adjusting for potential confounders.

CONCLUSION:

We were unable to find neonatal benefit, nor increased hypoglycemia, after introduction of ACS for late preterm delivery.
Imprisoned and Pregnant: Evaluating the Use of Correctional Restraints [4I]
Authors: Fox Mallory , Best Kelly
Published: April 2018

INTRODUCTION:

The use of physical restraints in pregnant incarcerated patients is commonplace in many health care institutions. Restraints and shackles have been deemed not only unsafe but also demeaning and unnecessary for this special patient population. The American College of Obstetricians and Gynecologists (ACOG), the National Commission of Health Care standards, as well as Florida State Statues have adopted position statements opposing the use of physical restraints in pregnant patients. My project aimed to assess the baseline knowledge of the correctional guard staff implementing shackles and restraints; as well as provide an educational seminar to the correctional officers. Overall the aim of this study was to educate guard staff in efforts of aligning practices in accordance with ACOG and the state of Florida recommendations.

METHODS:

A brief educational seminar was presented to a group of correctional facility guards and Jacksonville Sherriff’s officers involved in the care of UF Health ambulatory or inpatient obstetric patients. The presentation covered the associated health risks and implications of restraint use in pregnancy. Additionally, the current practice recommendations were presented as outlined by ACOG and the Florida State Statute in FL Senate Bill No. 524. A brief anonymous pre and post IRB approved survey was administered. The rate of correct answers by question was described across time periods using counts and percentages, and analyzed using Fisher’s exact tests. Wilcoxon’s Signed Rank Test was used to compare the difference in overall score from pre to post. All analyses were performed using SAS® Version 9.4 for Windows.

RESULTS:

There were fifteen Jacksonville Sherriff’s officers and correctional guard staff that participated in the educational seminar and completed the pre and post survey. There was no significant relationship between time period (pre/post) and correct responses (p=0.2148-1.0). Additionally, there was no significant change in overall score between time periods (p=0.1052).

CONCLUSION:

Despite clear concise guidelines, the use of shackles and restraints remains commonplace in the field of OBGYN. As such, there is a need for education for patients, correctional guard staff, and health care providers. The current study showed that several guard staff are not familiar the current guidelines set forth by ACOG and the Florida State Statute. While there was not a statistically significant difference in pre and post survey answers, the need for education remains evident. Efforts should be made to limit the use of physical restraints in incarcerated pregnant women to improve quality of care and patient safety.
Informed Consent Experience Among Spanish-Speaking Patients Undergoing Gynecologic Surgery [7I]
Authors: Lo Lydia , Ruiz Maria , Taira Breena , Carranza Leslie
Published: April 2018

INTRODUCTION:

Obtaining informed consent is an ethical and legal obligation. Our goal was to conduct a pilot study to describe the informed consent experience for gynecologic surgery among Spanish-speaking patients.

METHODS:

This descriptive study is a retrospective telephone interview of patients who received gynecologic surgery at a safety net hospital in southern California between January and July 2017. Questions included self-rated understanding of the surgery received, risks and benefits, patient description of what was done and why, and details regarding the consent form.

RESULTS:

Seventy-four Spanish-speaking patients completed the survey. All patients signed consents in Spanish. Sixty-one percent thought their consent was signed either in English or they did not recall. Only 15% recalled the name of their surgeon. In 72% of these patient interactions, a hospital certified interpreter was used, most commonly a certified nurse or other staff member (49%) or via telephone (45%). Only 55% of patients responded that they understood all of what was going to be done during surgery, and 52% said that they understood all of the risks and benefits of surgery. Chart review showed 15% of patients had gross errors in understanding what surgery they received. Overall satisfaction with the consent process was rated as 4.49 and satisfaction overall 4.69 out of 5. Comments reflected grateful patients but a desire for native Spanish-speaking providers.

CONCLUSION:

Our study showed than Spanish-speaking patients are at increased risk of undergoing a suboptimal informed consent process. Several workflow processes were identified for areas of improvement.
Provider Comfort With Teaching Patients and Learns about Racial and Ethnic Disparities in Ob/Gyn Outcomes [8I]
Authors: Wheeler Sarahn , Truong Tracy , Brown Haywood L.
Published: April 2018

INTRODUCTION:

Although racial and ethnic disparities are well documented in ob/gyn outcomes, it is unclear if ob/gyn providers feel adequately trained to counsel patients and teach learners about healthcare disparities.

METHODS:

An electronic survey was distributed to the ACOG District IV membership. Participants were also asked how comfortable they feel with 1) their knowledge, 2) counseling patients and 3) teaching learners about racial and ethnic disparities in ob/gyn. Participants selected a single response from a four-point scale—very or somewhat knowledgeable/comfortable, somewhat or very not knowledgeable/uncomfortable. We compared responses by years out of training using chi-square and Fisher’s exact.

RESULTS:

A total of 462 participants responded to the survey (30% response rate). The majority of respondents reported they were “somewhat knowledgeable” about racial and ethnic disparities in ob/gyn (58%) and “somewhat comfortable” counseling patients about disparities in health outcomes (45%). Only 36% felt “very comfortable” teaching learners about racial/ethnic disparities. Respondents 30 or more years out of training most often reported feeling “very comfortable” counseling patients yet most often to report they “rarely” counsel patients about disparities (table). Only 37.4% of respondents had formal training about racial and ethnic disparities and 75% reported they would like more training.

CONCLUSION:

Our survey reveals the majority of providers lack formal training about racial and ethnic disparities in ob/gyn and feel such training would be beneficial in their practice. Further research is needed to develop evidence-based educational programs to enhance provider abilities to educate patients and learners about disparities in ob/gyn outcomes.
Zika Virus Knowledge, Health Education, and Contraceptive Use Among Rural Dominican Republic Communities [12I]
Authors: Adamian Shant , Bachelor Brooke , Mittra Tricia , Andres Sarah , Hodges Fiona , Shaw Rebecca
Published: April 2018

INTRODUCTION:

Amidst the Zika virus epidemic, a team from Des Moines University traveled to four rural communities surrounding Monte Cristi, Dominican Republic to provide health services. The team assessed Zika virus knowledge, common contraceptive methods, and current methods of disseminating vital health information over a period of four days.

METHODS:

Ninety men and women provided informed consent to participate in a 12-question, verbally administered survey.

RESULTS:

Most participants had heard of Zika virus and had received their information from charlas, a local term for informal health presentations. Few knew that Zika is present in their communities, can be sexually transmitted, and is incurable. The most commonly cited contraceptive method was condoms, and thirty percent of participants did not use contraception. One patient reported long-acting reversible contraceptive (LARC) usage.

CONCLUSION:

Significant Zika knowledge deficits were present within these communities and accurate knowledge varied. Through identification of specific knowledge gaps, communities can disseminate standardized, unambiguous, and realistic recommendations to prevent infection during similar epidemics. Additionally, the limited usage of LARCs appeared, anecdotally, to be due to lack of access, rather than lack of desire for LARCs. This is particularly concerning in an environment where pregnancy prevention is the primary recommendation to prevent fetal harm. Future research should analyze charlas to identify the most effective methods for disseminating critical information in a timely manner to similar populations. In the context of inevitable future epidemics, results may not only be applicable to Dominican communities, but to rural communities globally.
Suture Material used in Cerclage and Risk of Preterm Delivery [21I]
Authors: Gill Lisa , Yamamura Yasuko
Published: April 2018

INTRODUCTION:

Several sutures are used in cerclage. Surgical literature shows an increased infection rate with braided suture compared to monofilament, and preterm birth is associated with infection. This study compares preterm delivery rates in cerclage by suture type.

METHODS:

This is a retrospective cohort study. Cerclages performed between January 1, 2011 and December 31, 2016 were collected from a single center. Exposures included use of a monofilament or braided suture. Comparison group was Mersilene tape. Primary outcomes were defined as delivery <23 weeks gestation and < 37 weeks gestation. Secondary outcomes were defined as delivery <28 and <32 weeks gestation. Odds ratios with 95% confidence intervals were calculated for each endpoint.

RESULTS:

267 cerclages were collected. Delivery information was available for 225. Monofilament was used for 83 procedures, braided for 85, and Mersilene tape for 57. Both monofilament (OR 2.47, 95% CI 0.65-9.4) and braided suture (OR 2.4, 95% CI 0.63-9.14) were associated with a non-significant increased risk of birth < 23 weeks gestation. There was no difference in risk of preterm delivery <37 weeks for either suture (OR 1.07, 95% CI 0.54-2.10; OR 1.06, 95% CI 0.52-2.08 respectively). Use of either monofilament or braided suture increased the risk of delivery prior to 28 or 32 weeks gestation. When Shirodkars were excluded, no difference in preterm delivery was noted.

CONCLUSION:

Monofilament and braided suture may be more likely to result in preterm delivery prior to 28 or 32 weeks of gestation. No difference in preterm or previable delivery was noted with differing suture type.
The Utilization of Antenatal Late Preterm Steroids at a Tertiary Care Academic Medical Center [24I]
Authors: Nicol Casey , Monahan Rose , Boyle Annelee , Dudley Donald , Ferguson James , Pettit Kate
Published: April 2018

INTRODUCTION:

The purpose of this study was to examine the utilization of antenatal late preterm steroids (ALPS) at a single institution following publication of recent evidence suggesting neonatal benefits in the late preterm period.

METHODS:

A retrospective cohort study was performed including all patients with singleton gestations at 34 weeks to 36 weeks 5 days admitted from April 2016 through March 2017.

RESULTS:

During the study period, 102 patients met inclusion criteria. A total of 28 patients (27.5%) received ALPS. Of the entire cohort, 35 (34.3%) patients qualified for ALPS administration. Of these 35 qualifying patients, 21 (60%) received steroids and 14 (40%) did not. Seven (6.9%) patients received steroids and did not meet standard ALPS criteria. Maternal demographic characteristics and indications for admission were similar between groups. Women who received ALPS were admitted at an earlier median gestational age than women not given ALPS (p<0.005). Common contraindications to steroid administration were delivery anticipated in <12 hours (19.6%), pre-gestational diabetes (11.8%), prior steroid administration <34 weeks (11.8%), and gestational diabetes (6.9%). There were no differences in the rate of NICU admission or neonatal length of stay between groups. The rate of NICU admission in the entire cohort was 43.1% (44/102).

CONCLUSION:

One-third of patients admitted in the late preterm period met criteria for administration of ALPS. Only 60% of patients who qualified for ALPS received steroids. The rate of NICU admission in the late preterm period remains high. Increasing the appropriate use of ALPS may help to further improve neonatal outcomes in this population.
Association of Levels of Antepartum Angiogenic Factors with Severe Postpartum Hypertension [25I]
Authors: Perdigao Joana , Minhas Ruby , Chintala Sireesha , Mueller Ariel , Young Danielle , Rana Sarosh
Published: April 2018

INTRODUCTION:

Postpartum hypertension often arises from an existing hypertensive disorder of pregnancy (HDP). Limited data exists about antecedent presentation and risk factors of PPHTN, especially among African American (AA) women. We studied the association between antepartum angiogenic biomarkers (sFlt1 and PlGF) and severe PPHTN among predominantly AA women.

METHODS:

Women with HDP were enrolled upon admission. Biomarkers were measured on an automated platform from maternal blood collected within 96 hours of delivery. PPHTN was severe if systolic blood pressure (SBP) ≥160 or diastolic blood pressure (DBP) ≥110 and mild if SBP ≥140 or DBP ≥90. Descriptive statistics were assessed with a Wilcoxon Rank Sum or chi-square test, as appropriate. Univariate and multivariable logistic regression was used to assess the association between PPHTN and angiogenic factors, reporting the area under the receiver operating curve (AUC).

RESULTS:

375 women were enrolled, with 279 (74.4%) AA and 151 (40.3%) with severe PPHTN. 52.9% of women with severe PPHTN also had antepartum pre-eclampsia with severe features. The sFlt1/PlGF ratio was significantly higher for both severe and mild PPHTN compared to women with normal postpartum BPs (73.5, 46.0 and 13.0 respectively, p<0.0001). Furthermore, the highest tertile of antepartum sFlt1/PlGF ratio was associated with severe PPHTN [OR 2.52, 95% CI: 1.49-4.27; p=0.001] which persisted after adjustment [OR 2.83; p=0.001]. When predicting severe PPHTN, the adjusted AUC for sFlt1/PlGF was 0.71.

CONCLUSION:

A significant association exists between antepartum angiogenic biomarkers and severe PPHTN — a frequent manifestation in women with antepartum HDP. Further studies should evaluate the mechanisms of such association.
Socioeconomic Disparities in Knowledge and Behaviors of Zika virus in Pregnant Women [6J]
Authors: Chandrasekaran Neeraja , Marotta Mabel , Taldone Sabrina , Singh Vivek , Koru-Sengul Tulay , Curry Christine
Published: April 2018

INTRODUCTION:

Gaps in knowledge and prevention of Zika have been established in pregnant women, though it is unclear whether these gaps are further pronounced in disadvantaged populations. In this study, we aim to identify disparities in knowledge and behaviors of Zika during pregnancy.

METHODS:

A cross-sectional design was utilized. Surveys were distributed to pregnant women in the antenatal clinics of University of Miami Hospital and Jackson Health Systems. Women were divided into two groups based on socioeconomic status(SES):low(income less than $25,000 or education less than high school) and middle/high(income greater than $25,001 or education greater than high school). Data was then recorded onto REDcap and analyzed using SAS studio. Categorical variables were compared using Pearson’s chi-square or Fisher’s exact test.

RESULTS:

The study was carried out between January 17th,2017-May 3rd,2017, and a total of 224 women were surveyed. Low SES group consisted of 107 women, and middle/high SES group consisted of 117 women. Both groups were similar in trimester and parity and differed in age, race, ethnicity, employment status, and number of children. Women in middle/high SES group answered more questions correctly about Zika symptomology and prevention compared to the lower SES group. Women in lower SES group were more likely to answer that they feel doctors should talk to their patients about risks and protection from Zika at every visit compared to women in middle/higher SES group.

CONCLUSION:

There are disparities in knowledge and behaviors regarding Zika in women of lower SES compared to women of middle/higher SES. Interventions to further educate disadvantaged women on Zika.
Cervical Length Surveillance and Optimal Timing of Antenatal Corticosteroid Exposure in Twins [11J]
Authors: Janssen Ashley , Dahlke Joshua , Hultgren Elizabeth , Hamill Neil , Connealy Brendan , Lovgren Todd
Published: April 2018

INTRODUCTION:

Cervical shortening in twins is associated with spontaneous preterm birth (sPTB), yet there is limited data on whether increased frequency of transvaginal cervical length (TVCL) surveillance in twins impacts timing of obstetric interventions or perinatal outcomes. Our objective was to determine if an association exists between the frequency of TVCL surveillance and optimal timing of antenatal corticosteroids (ACS) administration.

METHODS:

Retrospective cohort analysis of all twin pregnancies delivered in a single-tertiary care-center between 1/1/13 and 4/1/16. Those with ≥6 and <6 TVCL measurements were compared. Outcomes of interest was administration of ACS course within 7 days of delivery, magnesium sulfate for neuroprotection, and composite maternal and neonatal morbidity.

RESULTS:

359 of 424 twin pregnancies during the study period met inclusion criteria and received a total of 2,305 TVCL measurements. There were no differences in sPTB rates <34 0/7 weeks, magnesium exposure if delivery was <32 0/7 weeks, ACS within 7 days of delivery or composite maternal or neonatal morbidity were lacking. Those with ≥6 TVCL measurements were less likely to receive a first ACS course within 7 days of delivery (11/41 [27%] vs. 19/39 [49%], P=.04).

CONCLUSION:

More frequent TVCL surveillance did not improve timing of obstetric interventions or perinatal morbidity. The utility of cervical surveillance in twins remains unclear.
Primary Cesarean Rates at a Community Hospital: Differences Between Residency and Private Practice [15J]
Authors: Quinn Shantel , Butz Anh , Simpson Barbara , Stovall Dale W.
Published: April 2018

INTRODUCTION:

Reducing cesarean delivery rates remains a primary objective in obstetrics. Differences in labor management and practice environment likely contribute to variation in the rate of cesarean delivery. This research compares the rate of primary cesarean delivery of an obstetrics & gynecology residency and a private practice at the same community hospital.

METHODS:

In this retrospective cohort study, all deliveries over an 18-month period were reviewed. Demographic information including age, race, gravidity/parity, gestational age, pregnancy complications, maternal comorbidities, and indication for cesarean delivery were obtained.

RESULTS:

The residency performed 1,114 vaginal and 346 cesarean deliveries, for an overall cesarean rate of 23.7%. The private practice performed 1,223 vaginal and 482 cesarean deliveries, for an overall cesarean rate of 28.3%. Considering only primary cesarean deliveries, the residency performed 188 cases (14.4%), while the private practice performed 271 cases (18.1%). The residency performed significantly fewer primary cesarean deliveries (P = 0.009) and had a significantly lower cesarean rate overall (P = 0.004). The cohorts differed significantly in age, gravidity/parity, and indication for cesarean delivery. Delivery was indicated most often by non-reassuring fetal status for the residency cohort (48.9%) and by labor dystocia (arrest of descent or dilation) for the private practice (38.0%) (P < 0.0001). Prevalence of hypertension, diabetes, and other comorbidities did not differ between cohorts.

CONCLUSION:

Residency practice patterns might yield lower cesarean delivery rates. Further study of differences in indication for cesarean and role of age and multiparity could help identify strategies to reduce primary cesarean delivery.
Liposomal Bupivacaine at Cesarean Delivery, Minimizing Opioid use for Post-operative Pain Control [17J]
Authors: Cherot Elizabeth , Kett Atilla , Mauro Rachel
Published: April 2018

INTRODUCTION:

Cesarean delivery is the most common in-patient surgery performed in the United States. Opioids are frequently prescribed post-operatively; this can lead to misuse or even illegal distribution.

METHODS:

We infiltrated liposomal bupivacaine at the time of fascial closer of a Pfannenstiel incision, during a cesarean section. An 80cc solution was divided into four infiltrates of 5cc of Liposomal Bupivacaine, 6cc of .5% Bupivacaine and 9cc of Normal Saline each. Half of the solution was injected laterally under the fascia and the remaining was distributed evenly subcutaneously. Post-operative management was standardized with intrathecal morphine, scheduled Ketorolac and Ofirmev for the first 24 hours intravenously. Scheduled PO ibuprofen and acetaminophen were continued for forty-eight hours postoperatively. Oxycodone was ordered as needed but not scheduled. We used our SeamlessMD smartphone application to collect data on pain control and patient satisfaction. We reviewed in-patient charts and outpatient EMR records post-operatively for two weeks

RESULTS:

Of the 11 cases, five patients used no narcotics, and one outlier was identified as a potential abuser. The mean morphine equivalent was 7.5mg or one 5mg oxycodone over the inpatient and 2 week post-operative period. The average length of stay was 2.2 days. The response rate was 42% to patient satisfaction questions.

CONCLUSION:

Liposomal Bupivacaine reduces opioid use in the post- operative time period for cesarean section. It increased patient satisfaction and improved pain control, shortening length of stay. Further randomized control studies to determine the best delivery method are warranted.
Comparison of Outpatient Foley Bulb Induction to Traditional Induction of Labor [18J]
Authors: Bull Mary , Hong Christina , Roth Patrick , Washburn Mark
Published: April 2018

INTRODUCTION:

More than 20% of pregnant women in the U.S. undergo induction. Due to an unfavorable cervix, many of the women presenting for induction experience longer labor times, increased rates of cesarean section and increased healthcare costs. The purpose of the study was to examine the difference in cesarean section rates, maternal and neonatal morbidity and costs for outpatient vs inpatient Foley induction.

METHODS:

We conducted a retrospective case control study using data from the Kaiser Permanente electronic medical record for the Orange County Service area. Cases were identified using a log of all patients receiving Foley bulb placement. Controls were identified through the electronic health record using Current Procedural Terminology codes and International Classification of Diseases 9th Revision codes for induction of labor from 2013-2015. Cases and controls were matched by advanced maternal age status, parity and race. Patients were excluded if they had a modified bishop score >6 or nonvertex presentation or <37 weeks gestation.

RESULTS:

Between 9/2013 and 12/2015, 283 cases were identified and matched 1:1 to controls. There was no difference between cases and controls for rate of cesarean (P>0.89) or for maternal (P>0.37) or neonatal morbidity (P<0.5). Cases were more likely to have an infant with a higher birth weight (P<0.01), have a shorter length of hospitalization for labor and delivery (P<0.01) and lower costs of hospitalization (P<0.01). Cost was quantified, with average 300 dollars per patient savings for outpatient induction.

CONCLUSION:

Outpatient Foley bulb placement is a safe, cost effective alternative for women undergoing induction of labor.
Racial Disparities in Surgical Outcomes During Peripartum Hysterectomy [26J]
Authors: Martin Kristin L. , Martin Kimberly A. , Chou Betty , Ryan Isa , Lawson Shari M.
Published: April 2018

INTRODUCTION:

Peripartum hysterectomy (PH) is a lifesaving procedure known to have increased morbidity and mortality over elective hysterectomy. Non-white surgical patients frequently have poorer outcomes than white patients undergoing the same procedure. We sought to analyze patients undergoing PH and compare intraoperative and postoperative outcomes by race.

METHODS:

We performed a retrospective analysis of female patients (age 12–55) who underwent delivery of a newborn in a US hospital and had a subsequent peripartum hysterectomy during the same admission between 2005 and 2014. Data were obtained from the Healthcare Cost and Utilization Project's National Inpatient Sample. Demographic, clinical, socioeconomic and hospital characteristics of patients were compared with respect to patient race/ethnic group.

RESULTS:

Blacks undergoing PH were 3.1 times more likely to have any in-hospital mortality. This trend persisted between both Hispanic and Asian groups (2.1 times and 2.9 times more likely, respectively). After adjusting for covariates, in-hospital mortality and cardiopulmonary complications for Black and Asian women remained significantly higher than for whites. All races (Black, Hispanic, Asian) were more likely to undergo blood transfusion than their white counterparts. Blacks were 95% percent more likely to be diagnosed with sepsis during hospitalization. Additionally, surgical site infection was not statistically significant, however blacks were more likely (69.7%) to have wound dehiscence.

CONCLUSION:

Disparities in both intraoperative and postoperative outcomes following peripartum hysterectomy were observed. Future investigation must be performed in order to identify and eliminate any modifiable contributing factors on the provider or system level.
Racial Disparities in Maternal Outcomes Among Pregnant Women With Major Depressive Disorder [35J]
Authors: Toffey David E. , Chatroux Louisa R. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

We sought to determine the differences in pregnancy outcomes among white, black, Hispanic, Asian/Pacific Islander, and Native American women with major depressive disorder (MDD).

METHODS:

A retrospective cohort of 14,489 women with MDD and singleton, non-anomalous gestations was used to examine maternal outcomes, assessed according to race. Maternal outcomes included pre-eclampsia/eclampsia (abbreviated “Any PET”), gestational diabetes (GDM), chorioamnionitis, blood transfusion, endometritis, 3rd or 4th degree lacerations, and postpartum hemorrhage (PPH). Multivariate regression analyses and χ2 tests were employed for statistical comparisons and a P-value of less than 0.05 was used to indicate statistical significance.

RESULTS:

Overall, race was associated with a statistically significant increase in the majority of investigated outcomes. Compared to white women, and after controlling for confounders, black women with MDD were more likely to experience PET, develop chorioamnionitis and endometritis, and require a blood transfusion, and trended towards greater rates of PPH. Hispanic women were more likely to develop GDM, chorioamnionitis, and endometritis, and trended towards greater rates of PET and PPH. Asian/Pacific Islander women were more likely to develop GDM, chorioamnionitis, endometritis, 3rd or 4th degree lacerations, and PPH, and trended towards lower rates of PET. Native American women had higher rates of PET and endometritis, and trended towards higher rates of GDM and PPH.

CONCLUSION:

Non-white women with MDD experience higher rates of obstetric complications than white women, with specific complications and rates varying across races. These data suggest disparities may exist in management of pregnant women with MDD across different races.
Optimal Delivery Timing for MoMo Twin Gestations Undergoing Continuous Fetal Monitoring—Cost-Effective Analysis [38J]
Authors: Hickok Ruth A. , Walker Allison R. , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

To determine the most cost-effective gestational age of delivery for women undergoing inpatient management for monochorionic-monoamniotic (MCMA) twin gestations.

METHODS:

A decision-analytic model was created comparing timing of delivery for MCMA pregnancies undergoing inpatient continuous fetal monitoring beginning at 26 weeks. Each arm of the tree represented a different gestational age at time of induction of labor, ranging from 28 to 34 weeks. Strategies involving expectant management accounted for probabilities of intrauterine fetal demise (IUFD) and spontaneous delivery at each successive week. Examined outcomes included quality adjusted life years (QALYs), IUFD, cerebral palsy and neonatal death. All probabilities, utilities, and costs were derived from the literature. The primary outcome was the incremental cost per QALY. The cost-effectiveness threshold was set at $100,000 per QALY. Univariate and multivariate analyses were used to investigate model robustness.

RESULTS:

In a theoretical cohort of 250 MCMA twin pregnancies, delivery at 34 weeks would save $130 million compared to delivery at 28 weeks. Perinatal mortality was lowest at 30 weeks (12) and highest at 34 weeks (18). QALYs were highest at 31 week (21,146) and lowest at 28 weeks (20,799). Taken together, the most cost-effective strategy was delivery at 32 weeks gestation at $395 per QALY. Sensitivity analysis demonstrated that delivery at 32 weeks remained the optimal strategy until weekly cost of inpatient management was decreased to $4,038, at which point delivery at 33 weeks became the optimal strategy.

CONCLUSION:

Delivering at 32 weeks gestation is the most cost-effective strategy for MCMA twin gestations undergoing continuous fetal monitoring.
Hereditary Cancer Genetic Testing in Community-Based Obstetrics and Gynecology Settings [3K]
Authors: DeFrancesco Mark S. , Karanik Dana , Bernhisel Ryan , Alico Lindsey , Adkins Royce T. , Waldman Richard
Published: April 2018

INTRODUCTION:

Despite ACOG recommendations, many Obstetricians and Gynecologists (Ob/Gyns) do not routinely screen patients for hereditary cancer risk. Here we evaluate the feasibility of improving screening, genetic risk assessment, and testing services in community Ob/Gyn practices.

METHODS:

This was a prospective, single arm process intervention study at two community Ob/Gyn office sites. Data was collected during a 8 weeks pre-intervention and 8-week post-intervention period. There was a 4-week practice period following process intervention. Surveys were completed by providers and patients who underwent genetic testing.

RESULTS:

During the pre-intervention period, 3,882 patients were seen and 43 (1.1%) had genetic testing for hereditary cancer risk. In the post-intervention period, 4,107 patients were seen and genetic testing was ordered for 219 (5.3%) patients. Of those who completed genetic testing, 5.5% (9/165) were found to carry a pathogenic variant. Regarding their experience with screening and genetic testing, 98.8% (167/169) of patients were able to understand the information provided and 97.6% (165/169) were satisfied with the overall process. All providers (15/15) reported that they would continue to use this process to screen and test patients at risk for hereditary cancer and 93.3% (14/15) were satisfied with the process implementation.

CONCLUSION:

This process intervention resulted in a substantial improvement in the proportion of at-risk patients who had genetic testing, with patients and providers reporting a positive experience. This demonstrates that Ob/Gyns are capable of counseling and ordering hereditary cancer genetic testing and that integration into routine practice is feasible and beneficial in a community Ob/Gyn setting.
Zika Care Connect: Establishing a Provider Network for the Management of Zika Virus [5K]
Authors: Oduyebo Titilope , Viens Laura , Rechtman Lindsay , Ritsick Maggie , Hillard Christina , Meaney-Delman Dana
Published: April 2018

INTRODUCTION:

Access to healthcare providers with expertise in managing women with Zika virus exposure during pregnancy is critical to ensure appropriate and coordinated care, and to optimize the prenatal identification of potentially affected infants. Early diagnosis and prompt initiation of care for infants and families has the potential to mitigate the long-term impacts of Zika. Additionally, mental health services can provide support to affected families.

METHODS:

In 2017, the Zika Care Connect (ZCC) program established a provider network by identifying and enrolling providers with expertise in the management of Zika virus. ZCC engaged professional healthcare associations, health departments, and healthcare systems in 20 at-risk jurisdictions, selected based on the distribution of known Zika virus cases. Providers were contacted by phone to gauge willingness and interest; these providers could voluntarily self-enroll in the network and receive up-to-date information about emerging data on Zika virus.

RESULTS:

As of September 13, 2017, 536 total specialists are enrolled in the network, including maternal-fetal medicine (137) and obstetrics/gynecology (30). Additional specialties are care coordination, developmental pediatrics, endocrinology, infectious diseases, mental health, pediatric neurology, pediatric ophthalmology, and radiology. Data analysis regarding characteristics and geographic distribution of providers, type of practice setting, and ability to offer coordinated care is ongoing.

CONCLUSION:

ZCC establishes a network of specialty providers dedicated to the care of families affected by Zika virus. The network is designed to help families identify local providers and healthcare services, and ensure long-term follow-up. This network can also help primary care providers identify local specialist care.
Uncovering State Sharing Practices for Birth Method-of-Delivery Data in the United States [6K]
Authors: Bradley Danielle , Landau Erin , Jesani Noreen , Baron Alex , Wolfberg Adam
Published: April 2018

INTRODUCTION:

Enabling the work of practitioners and policy makers aiming to address the US cesarean epidemic requires publicly-available, reliable, hospital-level data for birth method-of-delivery to be made available. With hospital choice being a primary determinant of birth method-of-delivery, the need for quality data to inform patient decision-making and encourage provider behavior change has never been more pertinent.

METHODS:

Reporting of birth counts and delivery methods is mandated in the US. To collect quality metric data, the investigators searched state websites and contacted vital statistics departments. States and regions were scored based on “sharing” and “barrier” metrics. “Sharing” refers to level of data shared, while “barrier” refers to data collection limitations.

RESULTS:

Twenty-eight states offered hospital-level data. Others offered method-of-delivery data on a county-of-birth-occurrence-level (10), a county-of-mother's-residence-level (6), or did not provide data (6+D.C.). Of the 44 states that shared data, 12 required a signed data use form, which outlined stipulations and limitations for data use. The West achieved the best data availability scores, while the Midwest region ranked the poorest.

CONCLUSION:

Twenty-two states and D.C. failed to share hospital-level data for method-of-delivery. Of the 28 states that shared hospital-level data, a minimum of seven do not allow public sharing of their data. Selecting a hospital based on quality metric data would improve patient outcomes, reduce the national cesarean rate, and help control healthcare costs. Availability of method-of-delivery data was highly variable across the country, contributing to the lack of transparency in the US healthcare system.
Evaluating Technology-Enabled Care Coordination During Prenatal Care for an Underserved Population [14K]
Authors: Dorton Benjamin J. , Veit Stephanie , Kleist Gina , Kuiper Jodie , Malmberg Amanda Speck
Published: April 2018

INTRODUCTION:

Care coordination can be impactful in improving quality of care for patients and improving healthcare system efficiency. This natural history study evaluates the impact of a technology-enabled care coordination system, Babyscripts Care Navigator (Babyscripts), and the effect on prenatal care attendance as well as identifying modifiable socioeconomic risk factors in an underserved, urban obstetrical population.

METHODS:

This study included 21 patients >17 year old at their first obstetrical visit. Patients were asked to participate at their first obstetrical visit and were monitored until 6 weeks after delivery. Patients were given Babyscripts, a mobile application with bidirectional messaging support from a care coordinator. Patients received daily prenatal information and real-time support ranging from informational to emotional. Empirical data was collected by monitoring 1) appointments attended or rescheduled, 2) messages sent between patients and care coordinator, and 3) modifiable, socioeconomic risk factors identified and triaged.

RESULTS:

As of September 3, 2017, 87.5% of scheduled appointments were attended or rescheduled. The average number of routine prenatal appointments attended was 7.4, compared to the practice average of 3.2 appointments. On average, 277 messages were sent between each patient and care coordinator; 18.7% originated from patients. Thirty-nine modifiable, socioeconomic factors were identified and triaged to clinical staff (15), social work staff (7), state assistance services (8), local non-profits (6), and transportation services (3).

CONCLUSION:

Technology-enabled care coordination improved attendance at prenatal care visits and provided a reliable and efficient system that was successfully implemented within an underserved, urban obstetrical population.
Therapeutic Substitution: A Cogent Response to Opioid Induced Neonatal Abstinence Syndrome (NAS) Crisis [17K]
Authors: Calhoun Byron C. , Patel Akhil , Dietz Paul , Casto Angela , DePond Jennifer , Seybold Dara
Published: April 2018

INTRODUCTION:

From July 1, 2016 to June 30, 2017 a total of 582 new obstetrical patients were seen in a resident service clinic in the Women's Medicine Center (WMC) at a tertiary care center with 52 (8.9%) screening positive for opiates by urine drug screening. These 52 patients were all offered outpatient therapeutic substitution in an obstetrical-addictions combined clinic to obtain abstinence with oral buprenorphine in a medicated tapering protocol.

METHODS:

Prospective observational study of patients receiving oral buprenorphine to obtain abstinence from July 1, 2016 to June 30, 2017 at tertiary care center.

RESULTS:

Of the 52 patients, 20 (38.5%) transferred to other maintenance programs, 11 (21.2%) patients sustained spontaneous miscarriages, 10 (19.2%) were lost to follow up, and three (5.8%) declined enrollment. Eight patients (15%) who enrolled completed the outpatient program. A total of 4 (50%) of babies were born neonatal abstinence (NAS) free, with 3 (100%) from mothers reaching abstinence by time of birth. In comparison, only 1 out of the 5 (20%) babies born to mothers who did not reach abstinence was NAS free. No adverse outcomes were noted in any patients or neonates who entered and/or completed the program. Cost savings for the 3 neonates born abstinent was estimated at over $100,000 in hospital costs alone.

CONCLUSION:

Outpatient therapeutic substitution with oral buprenorphine to obtain abstinence is possible in pregnant patients and results in significant cost savings. Ongoing efforts with more data are needed to confirm our findings and explore methods for enhanced success in obtaining abstinence.