bluuebunny/crossref_metadata_2025 huggingface dataset:
Rates of Neonatal Sepsis by Maternal Race, Education, and Insurance [22F]
Authors: Birch Mary Nienow , Frank Zoë , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

Given the dearth of current data comparing sepsis rates among infants based on maternal demographics, clinicians have little with which to evaluate a neonate's chances of developing sepsis. This study aims to characterize the rates of sepsis stratified by maternal race, education level, and insurance status.

METHODS:

This is a retrospective cohort study of 9,676,773 non-anomalous, singleton and twin deliveries in the United States. We conducted a chi-squared analysis comparing rates of sepsis among infants stratified by maternal race, education level, and insurance status. Multivariate analysis controlled for maternal age, diabetes, chronic hypertension, preeclampsia, chorioamnionitis, postpartum hemorrhage, cesarean section, nulliparity, and gestational age.

RESULTS:

Within our cohort, rates of neonatal sepsis were significantly higher among infants born to women with Medicaid insurance than those born to women without Medicaid insurance (2.00% vs. 1.27%; p<0.001). Infants with mothers who had no college education exhibited higher rates of neonatal sepsis than infants with mothers who had some college education (1.84% vs. 1.35%; p<0.001). Additionally, multivariate analysis showed that non-Hispanic Black race and Hispanic race were predictive for neonatal sepsis (OR 1.22, 95% CI 1.16-1.29; OR 1.17, 95% CI 1.13-1.21).

CONCLUSION:

In our cohort, Hispanic and non-Hispanic Black mothers exhibited an increased risk of giving birth to an infant who developed neonatal sepsis. Rates of sepsis were also significantly higher among infants born to mothers with Medicaid and to mothers with no college education. This research highlights a need for further investigation into the association between sepsis rates and demographic factors.
Morbidly Adherent Placenta Among Women With Twin Gestation [24F]
Authors: Miller Hayley , Fox Karin , Carusi Daniela A. , Leonard Stephanie , Lyell Deirdre
Published: May 2019

INTRODUCTION:

It is unknown whether women with twin gestations have greater risk for morbidly adherent placenta (MAP). We assessed whether MAP occurs more frequently among twin versus singleton gestations by using retained placenta with postpartum hemorrhage (PPH) in the absence of uterine atony as a surrogate marker for MAP.

METHODS:

All births in California during 2007-2012 were identified from birth certificate records linked to hospital discharge databases through the California Office of Statewide Health Planning and Development. Women were included if they had both ICD-9 codes for PPH (666.X) and retained placenta or membranes without hemorrhage (667.X), and singleton or twin gestations. Women diagnosed with uterine atony (666.X) or chorioamnionitis (654.8) were excluded. Chi-square and multivariable logistic regression analyses were used to estimate odds ratios.

RESULTS:

Among 3,047, 223 women who met inclusion/exclusion criteria, the diagnosis of MAP (n=30,037) was significantly more frequent among women with twin versus singleton gestations (1,642 (1.78% twins) vs. 28,395 (0.96% singletons), p=0.<0.001). Women with twins were older with more placenta previas and a higher rate of prior cesarean delivery. When controlling for maternal age, placenta previa, and prior cesarean delivery, twin gestation was associated with a 70% increase in the odds of MAP (aOR 1.70, 95% CI 1.62-1.79).

CONCLUSION:

Twin gestation appears independently to confer an increased risk for morbidly adherent placenta, when retained placenta with hemorrhage in the absence of uterine atony is used as a surrogate marker for this diagnosis. Clinicians should be aware of this increased risk when managing retained placenta after twin delivery.
Financial Analysis of Expectant Management of Preterm Premature Rupture of Membranes to Term in a Community Hospital [28F]
Authors: Warwar Rachel E. , Kuss Brittany N. , Elliott John O. , Guinness Jessica M.
Published: May 2019

INTRODUCTION:

Recent studies have demonstrated a potential benefit of expectant management of preterm, premature rupture of membranes (PROM) during the “late preterm” period. Data from United States patient populations are lacking in this management option.

METHODS:

An IRB approved retrospective cohort study was conducted examining preterm PROM patients at or beyond 34 weeks identified from 12,598 patients on our labor and delivery service from April 2015 to April 2017. Hospital costs, neonatal infection and intensive care admissions were compared between those expectantly managed (n=67) and those induced or delivered at time of diagnosis (n=65).

RESULTS:

The cohorts were similar in terms of demographic and maternal characteristics. The expectantly managed patients were diagnosed with preterm PROM at an earlier gestational age (GA) and delivered, on average, 3.3 days (95% CI 1.3-5.3) later. There were no differences in GA at time of delivery, maternal postpartum or neonatal outcomes, specifically intensive care admissions and neonatal sepsis rates. Total hospital costs were significantly higher in those expectantly managed ($9,068 vs $5,901, P<0.001), with cost differences noted in lab, nursing and pharmacy (all P<0.001).

CONCLUSION:

We did not find benefits in terms of cost, maternal or neonatal outcomes in expectant management of preterm PROM after 34 weeks. Our data was limited by those expectantly managed gaining only 3 days latency prior to delivery. Areas of future research could include a similar cost analysis including gestational ages prior to 34 weeks where a longer latency phase between preterm PROM and delivery may be observed.
Association Between Liver Function Tests and Total Bile Acid Levels in Pregnant Women With Pruritus [29F]
Authors: Wang Tiffany , Iqbal Sara Naeem , Landy Helain J. , Smith Samuel , Huang Jim
Published: May 2019

INTRODUCTION:

Intrahepatic cholestasis of pregnancy (ICP) is diagnosed based on pruritus in pregnancy and total bile acid (TBA) levels ≥10 µmoles/L. However, TBA levels can take several days to result, potentially delaying interventions. Elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels have been used in evaluating ICP when TBA levels are not available. The objective of this study was to examine the association between AST or ALT and TBA ≥10 µmoles/L in women with pruritus in pregnancy.

METHODS:

This was an IRB-approved multi-hospital retrospective cohort study of women with pruritus in pregnancy between 2009 and 2016. We examined maternal characteristics and laboratory values available at presentation. Variables were compared between women with TBA ≥10 µmoles/L vs TBA <10 µmoles/L. Multivariable regression models were performed to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for elevated AST or ALT, controlling for confounders.

RESULTS:

Of 287 women, 244 (85%) had an initial TBA ≥10 µmoles/L. Women with TBA ≥10 µmoles/L were more likely to have higher AST (P<0.01) and ALT (P<0.01). After adjusting for confounders, elevated ALT ≥50 units/L was associated with increased odds of TBA ≥10 µmoles/L (aOR 2.98, 95% CI 1.36-6.49). However, elevated AST ≥50 units/L was not significantly associated with TBA ≥10 µmoles/L (aOR 1.90, 95% CI 0.85-4.25).

CONCLUSION:

In women with pruritus in pregnancy, ALT ≥50 units/L was associated with initial TBA ≥10 µmoles/L. Elevated ALT may be useful in the diagnosis and management of suspected ICP when TBA levels are not immediately available.
Predicting Mode of Delivery After an Induction of Labor in Women With an Increased Body Mass Index [33F]
Authors: Demsky Ashley , Stafford Shawna M. , Birch Daniel , Sharma Arya , Schulz Jane Ann , Steed Helen
Published: May 2019

INTRODUCTION:

There is a growing body of literature outlining the adverse consequences of excess body weight in pregnancy. In particular, this has demonstrated an increased rate of cesarean delivery. To date, there is no risk stratification tool to determine which women, with obesity and who are undergoing an induction of labor, are at the greatest risk of cesarean delivery. This study aims to validate the use of a modified Edmonton Obesity Staging System (EOSS) to predict mode of delivery amongst these women.

METHODS:

A prospective-cohort study was performed at two high obstetrical volume centers in Edmonton, Alberta. A total of 345 nulliparous women, undergoing an induction of labor at term, were recruited. Participating women provided a self-reported health survey and allowed for review of their medical records. The sample population included women with a body mass index (BMI) of ≥25.0 at first antenatal visit. The primary outcome is the rate of cesarean delivery.

RESULTS:

Overall, 345 women were recruited into this study with a participation rate of 93.7%. This included a sample group of 276 women, with an increased BMI, and a control group of 69 normal-weight women. Preliminary data analysis determined a cesarean delivery rate of 30.4% for the control group and 35.8%, 29.9%, 43.2%, and 90.5% for women assigned an EOSS Stage 0, 1, 2, and 3, respectively.

CONCLUSION:

A modified version of the EOSS may help stratify the risk of cesarean delivery in nulliparous women, with an increased BMI, who are undergoing an induction of labor.
ObGyn Physician Knowledge, Comfort, and Current Practices of Firearm Safety Counseling [35F]
Authors: Rubin Nicole , Morosky Christopher
Published: May 2019

INTRODUCTION:

Homicide and suicide are two of the leading causes of maternal mortality in the United States, with firearms in the setting of intimate partner violence (IPV) responsible for the majority of these deaths. There is no published research evaluating ObGyn physicians' current practices related to firearm safety counseling.

METHODS:

We performed a pre- and post-test evaluation of ObGyn physicians following a one-hour educational intervention that reviewed maternal mortality due to gun violence, CT State Firearm Law, and best practices for safe storage and use of firearms. IRB approval was obtained through UCONN Health.

RESULTS:

A total of 78 ObGyn physicians (45 attendings, 30 residents, 3 fellows) completed the educational intervention. Of the study participants, 28.5% reported having had a patient that was killed by a firearm, with IPV accounting for 50% of these reported deaths. Only 13.5% of providers had previously received education related to firearm safety. Following the intervention, providers reported that in the setting of IPV they were more likely to change their practice knowing that there was a firearm in the home (P=.001). Additionally, the educational intervention increased provider comfort with firearm safety counseling (P<.001), knowledge of CT State Firearm Law (P<.001), and knowledge of safe storage and use of firearms (P<.001); which corresponded to the major barriers identified by providers in implementing firearm safety counseling.

CONCLUSION:

Our educational intervention increased ObGyn physician knowledge and comfort related to firearm safety counseling. Consideration should be given to incorporating education on firearm safety counseling into ObGyn graduate and continuing medical education.
Prevention of Postoperative Adhesion Formation Using Noninvasive Technology [38F]
Authors: Recanati Maurice-Andre , Kramer Katherine , Rambhatla Anupama , Berman Jay Michael , Huttemann Maik
Published: May 2019

INTRODUCTION:

Postoperative adhesions occur following laparoscopic and open procedures, cause pain, infertility, bowel obstruction and other complications. Surgically-induced tissue injury causes inflammation and hypoxia resulting in alterations in cytochrome c oxidase (COX) activity, mitochondrial membrane potential (ΔΨm) hyperpolarization and reactive oxygen species (ROS) production. ROS initiate a cascade causing the irreversible transformation of fibroblasts to adhesion phenotype in injured peritoneum. Infrared light (IRL) can modulate COX activity through the following mechanism: IRL → COX activity↓ → ΔΨm↓ → ROS↓ → TGF-β1↓→ prevention of adhesion phenotype, making adhesion-free surgery possible.

METHODS:

Mitochondrial respiration, ROS, and ΔΨm were analyzed. Adhesion markers were measured by ELISA. Electrocautery and cytobrush were used to traumatize peritoneal tissue in Sprague-Dawley rats. Tissues, evaluated and harvested on day 7, were cryosectioned, hematoxylin/eosin stained, and immunofluorescence analyzed with confocal microscopy. IRL was generated by light emitting diodes.

RESULTS:

COX activity increases in injured peritoneum. IRL significantly decreased COX activity, whole cell respiration, ΔΨm, and ROS production. Hypoxia, ischemia/reperfusion and hyperoxia increased ROS, ΔΨmand TGFβ1 in macrophages, neutrophils and fibroblasts and transformed fibroblasts to adhesion phenotype. IRL robustly decreased ROS, ΔΨmand TGF-β1 and abrogated conversion to adhesion phenotype in vitro. Rats treated with IRL following adhesion surgery had lower numbers and severity of adhesions on gross examination, less fibrosis on histology and less adhesion marker expression on immunofluorescence compared to untreated controls.

CONCLUSION:

IRL may be used to non-invasively modulate COX activity, decrease ROS and decrease the conversion of fibroblasts to adhesion phenotype limiting postoperative adhesions.
Bremelanotide for Hypoactive Sexual Desire Disorder: Contraceptive Subgroups Efficacy Analysis [15OP]
Authors: Clayton Anita H. , Kingsberg Sheryl , Simon James A. , Jordan Robert , Williams Laura , Krop Julie
Published: May 2019

INTRODUCTION:

Bremelanotide, an investigational new drug, demonstrated efficacy in premenopausal women with hypoactive sexual desire disorder (HSDD) in the RECONNECT studies. In this analysis, bremelanotide efficacy was investigated across hormonal contraceptive subgroups.

METHODS:

RECONNECT comprised two replicate, phase 3, double-blind, randomized, placebo-controlled, IRB-approved studies. Subjects self-administered bremelanotide 1.75 mg or placebo subcutaneously for 24 weeks, using an autoinjector pen on demand prior to sexual activity. Subjects were evaluated (“yes” and “no” subgroups) based on concurrent use of hormonal contraceptives (including oral contraceptives and other estrogen-containing products). Efficacy was assessed using RECONNECT co-primary endpoints: change from baseline to end-of-study (EOS) for Female Sexual Function Index-desire domain (FSFI-D) and Female Sexual Distress Scale-Desire/Arousal/Orgasm (FSDS-DAO) Item 13 scores.

RESULTS:

In the integrated population (N=1202), difference in mean change in FSFI-D and FSDS-DAO Item 13 from baseline to EOS (bremelanotide-placebo) was 0.35 and -0.33, respectively (P<.0001 for both endpoints). In the study, 18.4% (N=221) concurrently used hormonal contraceptives (“yes” subgroup). Subjects in "no" subgroup who were treated with bremelanotide (N=484) showed a statistically significant increase in FSFI-D relative to placebo (N=497; 0.39, P<.0001). Those in "yes" subgroup showed a numerical difference in favor of bremelanotide (N=112) versus placebo (N=109; 0.19, P=.1557). Change from baseline to EOS in FSDS-DAO Item 13 was statistically significant in favor of bremelanotide relative to placebo in both subgroups (-0.30 and -0.34; P=.0471 and P<.0001, respectively).

CONCLUSION:

Independent of the type of contraceptive used, bremelanotide demonstrated improvements in sexual desire and related distress in premenopausal women with HSDD.
Engaging Obstetric and Gynecology Patients in Safety and Quality through Shared Visit Notes [03OP]
Authors: Herlihy Mary , Harcourt Kendall , Fossa Alan , Folcarelli Patricia H. , Golen Toni , Bell Sigall
Published: May 2019

INTRODUCTION:

OpenNotes, a national initiative inviting patients to read their ambulatory visit notes through the patient portal reaches 27 million patients, but little is known about OBGYN patient OpenNotes experiences.

METHODS:

In a quality improvement initiative from April 2016 - September 2017, patients from generalist OBGYN and gynecologic subspecialty practices at an academic hospital who accessed their notes were invited to give feedback through a reporting tool comprised of 10 items including: understanding of their notes and care plan, identification of errors, sensitive words, and concerning labs. Two physicians with safety expertise reviewed all patient-reported errors to determine their potential to affect care.

RESULTS:

212 patients submitted 232 reports. In 92-95% of reports, patients reported understanding the notes, the care plan, and that notes accurately described their visit. Of all reports, 27% identified inaccuracies in the notes including: Symptoms: 29%; Family History 21%; Medications: 15%; Problem list 15%; Social History and Physical Exam, including elements that were documented but not performed, each 11%. Patients rated inaccuracies as important in 58% of reports, and 75% of inaccuracies had the potential to affect care on clinician review. Seven percent of reports indicated bothersome words, including: “denied” (vs “does not”) “depressed” (vs “grieving”), and “not sexually active” (vs respect for context).

CONCLUSION:

Overall, patients were positive about OpenNotes, describing appreciation for, and reassurance from, such access. Addressing bothersome words may further improve engagement. About a quarter of patient reports identified documentation inaccuracies, the majority of which were relevant to care on clinician review
MATE Survey: Men’s Attitudes Toward Menopause and Their Role in Partner’s Menopause Transition [18OP]
Authors: Parish Sharon J , Faubion Stephanie S , Weinberg Marc , Bernick Brian , Mirkin Sebastian
Published: May 2019

INTRODUCTION:

Men's perceptions about menopause are largely unknown. This survey characterized men's understanding and knowledge of their partner's menopause transition and key symptoms.

METHODS:

A 35-question, online survey was sent to men recruited from the Cint online research exchange. Men were eligible if their female partner (45-64 y) experienced â≥1 symptom(s): hot flashes, night sweats, sleepless nights, difficulty sleeping, low libido, mood swings, pain during sex, or vaginal dryness. Couples could live together full time or separately, but reside together often.

RESULTS:

Of 1356 surveys sent, 450 were completed (33% response rate). The majority of men were between 50 and 59 years (51%), married (90%), and were in their relationship more than 20 years (62%). Men were able to recognize their partners experienced sleepless nights/difficulty sleeping (54%), tiredness/lack of energy (48%), low libido/less desire for sexual contact (47%), mood swings (47%), and hot flashes (46%). Men attributed symptoms to menopause (55%) and associated menopause with physiological changes (53%). Men reported menopausal symptoms negatively impacted them (76%), their partner (70%), and relationship (55%). Men engaged with their partner (72%) in a predominately positive manner (85%) regarding menopausal symptoms and tried to be supportive (31%). While less than half were aware of treatment options (47%), men believed they were very/somewhat influential (74%) in their partner's seeking treatment and lifestyle modifications.

CONCLUSION:

Men are aware of the menopause transition and willing to discuss symptoms. As men may influence decisions relating to management, educating them about menopause and available treatment options should be part of menopausal care strategies.
DONALD F. RICHARDSON PRIZE PAPERComparing Risk Stratification Criteria for Predicting Lymphatic Dissemination in Endometrial Cancer [06OP]
Authors: Kilts Toni P. , Kilts Toni P. , Glaser Gretchen E. , Langstraat Carrie L. , Kumar Amanika , Weaver Amy L. , McGree Michaela E. , Gostout Bobbie S. , Podratz Karl C. , Dowdy Sean C. , Cliby William A. , Mariani Andrea , Bakkum-Gamez Jamie N.
Published: May 2019

INTRODUCTION:

To compare two published risk stratification criteria (Milwaukee Model vs. Mayo Criteria) to predict lymphatic dissemination (LD) in endometrioid endometrial cancer (EC).

METHODS:

Patients who underwent surgery for EC between 1/1/2004-9/30/2013 and had endometrioid histology without stage IV disease were included and classified as either low-risk or at-risk for LD using two independent risk stratification systems. LD was defined as positive nodes at time of surgery or lymph node recurrence within 2 years of surgery after negative lymph node assessment (LNA) or when LNA was not performed. False positive (FP) and false negative (FN) rates for each risk model were calculated.

RESULTS:

Among 1103 patients, 81 (7.3%) had LD (72 positive LN and 9 LN recurrences). Most patients (90.2%) had stage I disease. Integration of the Milwaukee Model was associated with a low at-risk rate for LD (38.1%) but a relatively high FN rate (13.6%, 95% CI 7.0-23.0). Conversely, the traditional Mayo Criteria using a tumor diameter (TD) cutoff of ≤2 cm (vs >2 cm) had a higher at-risk rate for LD (69.5%) but a FN rate of 0.0% (95% CI, 0-4.5). Modifying Mayo Criteria using a TD cutoff of ≤3 cm (vs >3 cm) identified fewer women at-risk than using ≤2 cm cutoff (56.8% vs. 69.5%), but had a higher FN rate of 3.7% (95% CI, 0.8-10.4).

CONCLUSIONS:

The Milwaukee Model had the lowest at-risk rate of LD but an unacceptable FN rate. Modifying the Mayo Criteria by increasing the TD cutoff from the traditional ≤2 cm to ≤3 cm would spare an estimated 12.7% of patients LNA, but the accompanying FN rate is unacceptably high. The traditional Mayo Criteria for low-risk EC remains the most accurate in determining which patients LNA can be omitted.
THIRD PLACE Provider Adherence to Surgical Guidelines for Risk Reducing Salpingo-oophorectomy in BRCA Mutation Carriers [08OP]
Authors: Wilhite Annelise Marie , Oestreich Makinna Caitlin , Coetzee Donna , Khalifa Mahmoud , Erickson Britt
Published: May 2019

INTRODUCTION:

The ACOG clinical management guidelines for Hereditary Breast and Ovarian Cancer Syndrome endorse the strict surgical protocol recommended by the National Comprehensive Cancer Network at the time of risk reducing salpingo-oophorectomy (RRSO) for BRCA mutation carriers. The purpose of this study is to compare the rate of provider compliance to this protocol between gynecologic oncologists (GOs) and obstetrician gynecologists (OB/GYNs).

METHODS:

This multi-center retrospective cohort study included women with deleterious BRCA mutations who underwent RRSO between 2011 and 2017. Patients were identified using ICD 9/10 codes and a regional genetic counseling database. Compliance was measured by collection of washings, complete resection of the fallopian tube, and serial sectioning with microscopic examination (SEE-FIM protocol). Statistical analysis was performed.

RESULTS:

Of the 290 patients who met inclusion criteria, 160 patients were treated by 18 GOs and 130 patients were treated by 75 OB/GYNs at 10 different hospitals within a large metropolitan area. Overall, 68.5% of cases were compliant. GOs were over twice as likely to fully comply with the surgical protocol as OB/GYNs (OR 2.2, 95% CI 1.7-3.0). Specifically, they were more likely to collect washings (94.3% vs 49.2%), resect the whole tube (99.3% vs 95.4%), and adhere to SEE-FIM protocol (97.5% vs 82.3%). Complication rates did not differ between groups.

CONCLUSION:

Despite clear surgical guidelines, only 2/3 of patients received full guideline-based care. GOs were more likely to follow national guidelines compared to general OB/GYNs. Rates of risk reducing surgery will likely continue to increase as genetic testing becomes more widespread, highlighting the importance of provider education for this important procedure.
Cost Effectiveness of Mifepristone Pretreatment for the Medical Management of Nonviable Early Pregnancy [09OP]
Authors: Nagendra Divyah , Schreiber Courtney A. , Koelper Nathanael , Sonalkar Sarita , Loza-Avalos Sandra , Harvie Heidi
Published: May 2019

INTRODUCTION:

To compare the cost effectiveness of pretreatment with mifepristone to misoprostol alone in women seeking medical management of nonviable early pregnancy.

METHODS:

This within-trial comparison included 300 women with anembryonic gestation or embryonic/fetal demise randomized to off-label misoprostol 800 mcg vaginally or off-label mifepristone 200 mg followed 24 hours later by misoprostol. The primary outcome was gestational sac expulsion with one dose of misoprostol. Both healthcare and societal sector perspectives were adopted to calculate the incremental cost effectiveness ratio (ICER), expressed as cost per quality-adjusted life-year (QALY) gained. Costs included medical treatment and complications, patient and caregiver time, transportation, and lost productivity over the 30-day study period. Results are in 2018 US dollars. QALYs were based on a modified utility score, with successful medical therapy defined as 1 and need for uterine aspiration defined as 0.95. This study was approved by the University of Pennsylvania Institutional Review Board.

RESULTS:

Complete expulsion rate after one misoprostol dose was 124/148 (83.8%) with mifepristone pretreatment versus 100/149 (67.1%) after misoprostol alone. Uterine aspiration was required for 13 (8.8%) women after mifepristone pretreatment and 35 (23.5%) women after misoprostol alone. In the healthcare sector analysis mifepristone pretreatment was less expensive ($657 vs. $658 mean per-person cost) and more effective (0.08 vs. 0.07 QALYs gained) than misoprostol alone. Analysis from the societal perspective again demonstrated that mifepristone pretreatment was both less expensive ($3,807 vs. $4,819) and more effective than misoprostol alone.

CONCLUSION:

Pretreatment with mifepristone is the economically dominant strategy as it is both cost saving and more effective.
Longitudinal Effect of United States Military Policy on Contraception Use and Childbirth Among Junior Enlisted [10OP]
Authors: Roberts Timothy , Smalley Joshua , Baker Laura , Weir Larissa F. , Adelman William
Published: May 2019

INTRODUCTION:

Contraceptive use and unintentional pregnancy rates among junior enlisted vary between United States service-branches, despite equal access to no-cost contraception. Therefore, branch-specific policy may influence contraceptive use.

METHODS:

Secondary analysis of insurance records from 92,072 servicewomen, who attended basic training between 2013 and 2017, assessing the longitudinal effect of changes in branch-specific contraceptive policy on rates of: longer-acting (depot-medroxyprogesterone, implant, and intrauterine) contraception use at six months on active duty; and childbirth during the first 24-months of active duty. Multivariable Logistic (contraception use) and Cox (time to childbirth) Regression models were used to compare outcomes before and after the intervention, between the service making the intervention and the other three branches, and the interaction between these variables. IRB approved.

RESULTS:

Group contraceptive education emphasizing implantable and intrauterine methods followed by individual contraceptive consultation with a provider for all female, Navy basic trainees increased longer-acting method use (11.8% to 24.3%, Interaction Term OR: 2.14 (95% CI: 1.92-2.39), P<.001) and decreased childbirth rates (7.5% to 6.3%, HR: 0.86 (0.76-0.88), P=.015). Restricting time away from training for implant or intrauterine method insertion during Marine Corps basic training and providing education emphasizing use of depot-medroxyprogesterone for menstrual control decreased overall longer-acting method use (16.2% to 10.0%, OR: 0.43 (0.38-0.49), P<.001) and increased childbirth rates (8.0% to 9.7%, HR: 1.24 (1.02-1.51), P=.027). Allowing contraceptive implant placement during basic training increased use of longer-acting contraception among Air Force recruits 4.4% to 6.9%, OR: 1.31 (1.14-1.51), P<.001).

CONCLUSION:

Branch-specific changes in military contraceptive policy significantly impact contraceptive use and childbirth rates among junior enlisted.
Efficacy of the 1-Year Segesterone Acetate/Ethinyl Estradiol Contraceptive Vaginal System [21OP]
Authors: Westhoff Carolyn L. , Darney Philip , Jensen Jeffrey T. , Bahamondes Luis , Apter Dan , Merkatz Ruth B.
Published: May 2019

INTRODUCTION:

A novel, ring-shaped, contraceptive vaginal system (CVS) containing segesterone acetate (SA), also known as Nestorone®, and ethinyl estradiol (EE) is designed to last 1 year (13 cycles), delivering an average of SA 0.15/EE 0.013 mg/day. Efficacy was evaluated in 2 multicenter, 1-year, open-label studies (one at 15 US sites; one at 5 US/7 international sites).

METHODS:

Women (18-40 yrs) used the CVS for 21 days/cycle followed by having it out for 7 days. Women were not to remove the CVS for >2 hours during the 21 days of use. The primary efficacy outcome was the Pearl Index (PI) for women ≤35 years of age, excluding cycles with adjunctive contraception. Secondary outcomes included the PI for subgroups and intention-to-treat Kaplan-Meier life-table analyses.

RESULTS:

Of 2265 participants analyzed, 1303 (57.5%) completed. The primary PI was 2.98 (95% CI [2.13-4.06]). The PI was 2.10 (95% CI [1.37-3.06]) in women who followed use instructions versus 5.89 (95% CI [3.46-9.27]) for women who documented removals >2 hours (P=0.0024). Significantly higher PIs were also observed in subgroups by age (18-19 yrs vs ≥36yrs), parity (≥1 vs 0), race (Black vs white), ethnicity (Hispanic vs non-Hispanic), and site (non-Europe vs Europe), but not by BMI. Life-table analyses revealed the CVS is 97.3% effective in preventing pregnancy. Pregnancies did not increase across cycles.

CONCLUSION:

The SA/EE CVS is an effective 1-year, procedure-free contraceptive controlled by women that can help address an unmet worldwide contraceptive need. Counseling to ensure correct use is essential for optimizing efficacy.
Elagolix Reduced Heavy Menstrual Bleeding With Uterine Fibroids: Primary, 6-Month, Phase 3 Results [11OP]
Authors: Schlaff William , Al-Hendy Ayman , Barnhart Kurt , Owens Charlotte D. , Liu Ran , Muneyyirci-Delale Ozgul
Published: May 2019

INTRODUCTION:

The objective was to evaluate the efficacy and safety of elagolix, an oral, non-peptide, gonadotropin-releasing hormone antagonist, with add-back therapy, in women with heavy menstrual bleeding (HMB, >80 mL/cycle menstrual blood loss [MBL]) associated with uterine fibroids (UF).

METHODS:

These were two replicate, investigational, double-blind, randomized, placebo-controlled, 6-month, phase 3 studies (Elaris UF-1 and Elaris UF-2) where patients were randomized in a 1:1:2 ratio to placebo, elagolix 300 mg twice daily (BID) and elagolix 300 mg BID in combination with 1mg estradiol (E2)/0.5 mg norethindrone acetate (NETA) once daily add-back. Patients were premenopausal, 18-51 year-old women. The primary endpoint was the percentage of women at Final Month with <80 mL MBL and ≥50% reduction in MBL from baseline. Adverse events (AEs) and bone mineral density (BMD) were monitored. IRB approval was obtained.

RESULTS:

In Elaris UF-1, 412 patients were randomized and treated; 328 patients completed treatment. Elagolix with and without E2/NETA, reduced HMB at Final Month, with significantly more women achieving the primary endpoint compared with placebo (Elaris UF-1: elagolix+E2/NETA=68.5%, P<0.001; elagolix-alone=84.1%, P<0.001; placebo=8.7%). 50% of women treated with elagolix+E2/NETA experienced a treatment-related AE (elagolix-alone=80%; placebo=38%); 68-90% of women experienced any AE. The least-squared mean [SE] percentage change from baseline to month 6 for lumbar spine BMD was not significantly different from placebo for elagolix+E2/NETA (elagolix+E2/NETA=-0.75%[0.19], P=0.092; placebo=-0.21%[0.26]), but was significantly different for elagolix alone compared with placebo (-3.03%[0.28], P<0.001). Elaris UF-2 results were similar and will be presented at the meeting.

CONCLUSION:

Elagolix with and without E2/NETA reduced MBL in women with HMB associated with UF. The addition of E2/NETA attenuated BMD decreases seen with elagolix alone.
The Impact of First Trimester Sonography on Pregnancy Dating [36S]
Authors: Seasely Angela Rose , Bird Ashley , Zink Ashley , Lutich Ann , McKiever Monique , Patel Shivani R.
Published: May 2019

INTRODUCTION:

To evaluate accuracy of last menstrual period (LMP) in pregnancy dating at time of presentation for prenatal care.

METHODS:

An IRB-approved retrospective study of all women presenting in 2016 for pregnancy confirmation was performed. All women received a sonogram to confirm gestation. Dating was based on American College of Obstetricians and Gynecologists guidelines. Charts were reviewed for utilization of genetic screening and scheduled delivery. Logistic regression models assessed the association between estimated due date (EDD) changes and patient characteristics.

RESULTS:

Of 1,724 individuals presenting for pregnancy confirmation, 1,376 patients sought care in the first trimester with known LMP. Of these, 23.5% had their EDD changed based on ultrasound. When changed, 43.9% were at less than 9 weeks' gestation. 21.2% who underwent first trimester screening would have missed the opportunity for screening during the 13th week if EDD was not changed. Of the 41.6% who underwent medically indicated or elective scheduled delivery, 41.1% would have been scheduled too early if their EDD were not changed. Obese (OR 1.98, 95% CI 1.39-2.84) and underweight (OR 2.96, 95% CI 1.29-6.77) women were most likely to require alteration of EDD. There was a trend towards EDD modification with increasing gravidity and biphasic oral contraceptive use.

CONCLUSION:

Nearly 1 in 4 women presenting for prenatal care in the first trimester with known LMP required adjustment of their EDD based on first trimester ultrasound. The characteristic most significantly associated with EDD adjustment was BMI. First trimester ultrasound is vital as it affects timing of genetic screening and scheduled delivery.
Geographic Variation of Hospital Costs and Volume of Female Pelvic Reconstructive Procedures [39S]
Authors: Wang Rui
Published: May 2019

INTRODUCTION:

Studies have shown that there are vast differences in cost of care for the same type of procedure due to geographic differences in medical practice across the United States. The goal of this study is to evaluate how cost and volume of cases differ by the geographic region where female pelvic reconstructive procedures are performed.

METHODS:

The 2016 Medicare Inpatient Utilization and Payment Data includes information on utilization, payment, hospital-specific charges for U.S. hospitals across the country. Diagnosis Related Group codes were used to identify hospital charges for patients who underwent female pelvic reconstructive procedures and were admitted. The total inpatient hospital charges were converted to total cost using the Medicare cost-to-charge ratios.

RESULTS:

A total of 2,133 inpatients carrying the diagnosis of female pelvic reconstructive procedures were identified. The Northeast region had the lowest average cost ($10,888) and the West region was associated with the highest average cost ($13,766) (Table 1). Two states, Missouri and Virginia, are outliers in the average hospital costs for female pelvic reconstructive procedures (both >$20,000) compared to the median cost ($11,473) (Figure 1). Several states, Kansas, Mississippi, and Oklahoma are outliers in the volume of procedures performed per 100,000 Medicare beneficiaries (>9 compared to median of 4.06 procedures per 100,000 Medicare beneficiaries).

CONCLUSION:

The cost of inpatient care for female pelvic reconstructive surgeries differs across geographic region within the U.S. There are several outlier states with much higher average cost per patient or higher volume of inpatient admissions following these surgeries adjusted for size of Medicare population.
Pregnancy-Induced Atypical Hemolytic Uremic Syndrome: Case Report and Review of the Literature [1T]
Authors: Alex Maya , Collazo-Maldonado Roberto , Stovall Dale W. , Lytvak Irina
Published: May 2019

INTRODUCTION:

Pregnancy-induced atypical hemolytic uremic syndrome (p-aHUS), a disease caused by hyperactivation of the alternative complement pathway, can lead to renal ischemia and ESRD. We present two cases of p-aHUS and discuss both the disease process and treatment options.

METHODS:

The first case, a 31 yo female, underwent a cesarean delivery at 29 weeks due to preterm labor with breech presentation. She developed elevated BP, thrombocytopenia, and elevated serum creatinine postpartum. A nephrology consult confirmed the diagnosis of p-aHUS with elevated LDH and normal ADAMST13 levels. The second case is a 32 yo who underwent a suction D&C due to retained placenta after delivery of an IUFD. Laboratory values revealed thrombocytopenia and acute kidney injury (AKI). Again, Nephrology diagnosed p-aHUS. Both patients underwent plasmapheresis and Eculizumab therapy as soon as p-aHUS was diagnosed. Literature review for p-aHUS revealed the following conclusions: 1) risk factors include postpartum period, history of a cesarean delivery, and a genetic mutation in the CFH gene; 2) other causes of thrombocytopenia, AKI, and hemolytic anemia in pregnancy include pre-E and TTP 3) TTP can be ruled out with a normal ADAMST13 and pre-E can be ruled out by an LDH <1000; and 4) immediate diagnosis and treatment helps to prevent kidney injury.

CONCLUSION:

Given the rarity of the disease, there is little research involved in p-aHUS. However it is it is important for clinicians to have a strong suspicion for p-aHUS and to initiate treatment immediately to decrease morbidity including ESRD.
Primary Cesarean Birth Rates Among Women With Obesity at Urban and Rural Hospitals in the [6T]
Authors: Antony Kathleen M. , Hsiang-Hui Daphne Kuo , Greene Madelyne , Shrider Emily , Hartenbach Ellen , Ehrenthal Deborah
Published: May 2019

INTRODUCTION:

Studies have demonstrated that the rate of Cesarean birth (CB) is increased among women with obesity. 14% of births among women with class III obesity occur in rural areas. We aimed to investigate whether the relative risk of CB for women with obesity varied by location of birth (rural versus urban).

METHODS:

The Natality Data Set of live births in the United States between 2014 and 2015 was queried for nulliparous, vertex, term births. BMI was classified into eight groups defined by WHO criteria with sub-stratification of class III every 5 kg/m2 up to BMI ≥50 kg/m2. Rates of CB were assessed according to the National Center for Health Statistics' county-level urban-rural classification scheme.

RESULTS:

The rate of CB per 1000 live births increased with BMI across all geographic categories (highest RR 3.89 (95%CI 2.20-6.90) for BMI 50+). The rate of CB among women with BMI between 40 and 44.9, 45 and 49.9 and ≥50 kg/m2 was proportionally higher than expected (due to BMI alone) for rural hospitals (RR 1.21 (95% CI 1.17-1.25), RR 1.33 (95% CI 1.27-1.39), and RR 1.30 (95% CI 1.23-1.37), respectively). A higher proportion of all deliveries at rural hospitals occurred among women with obesity compared to urban hospitals.

CONCLUSION:

The relative risk of CB for women with BMI ≥-40 kg/m2 was higher than expected in rural hospitals. Rural hospitals proportionally deliver more women with obesity of all strata. This indicates that rural facilities require operative equipment to accommodate obesity and may indicate rural-urban disparities that warrant further investigation.
Racial Differences in Hypertensive Disorders of Pregnancy: The Role of Sleep-Disordered Breathing [8T]
Authors: Greco Patricia , Pitts D'Angela , O'Brien Louise
Published: May 2019

INTRODUCTION:

Hypertensive disorders of pregnancy vary by race. Pregnancy-onset sleep disordered breathing (SDB), has emerged as an independent risk factor for hypertensive disorders of pregnancy. We examined whether the contribution of SDB to hypertensive disorders of pregnancy differed by race.

METHODS:

Pregnant women were recruited from a tertiary medical center and queried about the presence of SDB, defined as snoring at least 3 nights per week. Only African American and Caucasian women were in the analysis as there was insufficient numbers of other racial groups. Logistic regression analyses were conducted to determine the contribution of SDB to pre-eclampsia after adjusting for history of gestational hypertension/pre-eclampsia, chronic hypertension, type II diabetes mellitus, maternal age, body mass index, parity, and smoking.

RESULTS:

The sample size was 1563 (81.5% Caucasian, 18.5% African American). In unadjusted analyses, pregnancy-onset, but not chronic SDB was associated with development of pre-eclampsia in Caucasian women, OR 2.1 (95%CI 1.4-3.0). Conversely, chronic SDB, but not pregnancy-onset SDB was associated with development of pre-eclampsia in African American women, OR 2.8 (95%CI 1.3-5.9). In adjusted analyses, while chronic hypertension, history of gestational hypertension/pre-eclampsia, and smoking were significantly related to the development of pre-eclampsia, pregnancy-onset SDB remained independently associated with pre-eclampsia in Caucasian women (aOR 1.6, 95%CI 1-1-2.6). In African American women the association with chronic SDB and pre-eclampsia was no longer significant after adjustment.

CONCLUSION:

Pregnancy-onset SDB is an independent predictor of pre-eclampsia in Caucasian women but SDB does not appear to be independently associated with the development of pre-eclampsia in African American women.
Patient Portal Use for Secure Messaging During Pregnancy [9T]
Authors: Ukoha Erinma , Feinglass Joseph , Yee Lynn
Published: May 2019

INTRODUCTION:

Use of electronic patient portals and in particular secure messaging during pregnancy is rapidly expanding. Our objective was to qualitatively examine secure messaging between pregnant women and providers and explore how these differed based on which party initiated the message.

METHODS:

This is a retrospective cohort study of women who received prenatal care at an academic medical center and were enrolled in the EMR patient portal. Women were included if they exchanged at least one message with an obstetrics-affiliated medical provider during pregnancy or immediately postpartum. Messages were organized into threads, defined as a group of messages related to an original message by successive replies. We performed a qualitative analysis of the threads, eliciting themes and comparing threads based on the initiating party.

RESULTS:

This cohort of 384 women participated in 1349 message threads. Of these message threads, 884 (65.5%) were patient-initiated. Threads were categorized into six themes: results, medications, administrative, patient education, symptoms, and social/emotional support. The majority (73%) of provider-initiated threads involved results, compared to only 17.3% of those initiated by patient. Additionally, 2.4% of provider-initiated messages were regarding symptoms as opposed to 24% of patient messages involving this theme.

CONCLUSION:

Women commonly use secure messaging via patient portals during pregnancy. The content and frequency of messaging vary widely. Emerging research suggests portal use may be associated with improved outcomes. As patient portals become more prevalent in pregnancy, it is imperative for providers to understand how we can best harness this application as a resource to empower women and improve outcomes.
Racial Disparities in Obstetric Outcomes Within Traditional Prenatal Care Versus CenteringPregnancy [10T]
Authors: Leung Andrea , Paoletti Andrew , Goldberg Jay
Published: May 2019

INTRODUCTION:

CenteringPregnancy is an innovative model of group prenatal care that aims to improve outcomes among high-risk women. The purpose of this study was to determine if discrepancies in obstetrical outcomes among non-Hispanic black (NHB) and non-Hispanic white (NHW) women are reduced with CenteringPregnancy, as compared to traditional care (TC).

METHODS:

A retrospective chart review was performed of patients who delivered at Einstein Medical Center Philadelphia from 1/1/2014 to 9/1/2018. The primary outcome was preterm birth (<37 weeks). The secondary outcome was breastfeeding rates. A Pearson Chi-square test was used to compare the outcomes of interest between NHW women receiving TC (n=409), NHB women receiving TC (n=1,972), and NHB women in CenteringPregnancy (n=266). NHW women in CenteringPregnancy were not included due to an insufficient sample (n=30).

RESULTS:

Data was analyzed from 2,647 pregnancies. A non-significant increase in preterm birth was observed among NHB women receiving TC as compared to NHW women receiving TC (15.2% vs 11.5%, p = 0.055). No significant difference in incidence of preterm birth was observed among NHB women in Centering as compared to NHW women receiving TC (12.8% vs. 11.5%, p = 0.614). No significant difference in incidence of breastfeeding was observed among NHW and NHB women receiving TC (56.3% vs. 52.9%, p = 0.197), or among NHW women receiving TC and NHB women in CenteringPregnancy (56.3% vs. 60.1%, p = 0.321).

CONCLUSION:

No statistically significant difference in incidence of preterm delivery or breast feeding was observed between NHB and NHW women receiving either traditional prenatal care or Centering Pregnancy.
Relationship Between Buprenorphine Dose, Timing of Dosing to Delivery and Neonatal Opioid Withdrawal Syndrome [13T]
Authors: Srinivasan Aarthi , Bauer John , Shook Lori , Qi Ya , Critchfield Agatha
Published: May 2019

INTRODUCTION:

To determine a relationship between the timing of buprenorphine dosing to delivery and subsequent Neonatal Opioid Withdrawal Syndrome (NOWS).

METHODS:

This was a pilot retrospective cohort study. Pregnant women with opioid use disorder (OUD) on opioid maintenance therapy (OMT) through a perinatal OUD treatment program (PATHways) were enrolled. Prior PATHways data revealed improved neonatal outcomes in women on a mean buprenorphine dosing of 12 mg/day.12 mg was utilized as a cut point for high vs low dose. High dose cases on 16 mg/day were compared with low dose controls (0.5 - 12 mg/day). Timing of last dose of medication received was evaluated. Primary outcome was the presence of medication requiring NOWS post-delivery

RESULTS:

Twenty-three high dose cases and 30 low dose controls were included. There was no significant difference in the incidence of treatment requiring NOWS (30% vs 40%, P=0.45). The duration between buprenorphine dose and delivery was not significantly different (6.4± 2.6 hours vs.11.5± 6 hours, P=0.06). However, within the high dose OMT group, the time interval between buprenorphine dose and delivery in women with infants treated for NOWS was significantly shorter than those where infants were not treated for NOWS (10± 3.8 hours vs. 6.4± 2.6 hours, P= 0.038). Peak Finnegan scores (15 ± 4 vs. 9± 4, P= 0.025) and hospital stay (21± 12 days vs. 5± 0.7 days, P=0.01) were significantly higher when patients received buprenorphine close to delivery.

CONCLUSION:

These findings suggest a relationship between the timing of buprenorphine and NOWS at higher doses and serves as a pilot data for a future prospective trial.