bluuebunny/crossref_metadata_2025 huggingface dataset:
Can a Telephone Encounter Replace in Person Follow-up after IUD Insertion? [14G]
Authors: Chen Stephanie , MacIsaac Laura , Belkin Jori , Overbey Jessica , Pan Stephanie
Published: April 2018

INTRODUCTION:

Limited research informs the recommendation for a 4 - 6 week follow-up surveillance visit after IUD insertion. We explored whether surveillance could occur over the phone instead of in-person without affecting continuation rates or adverse events.

METHODS:

Subjects were offered in-person or telephone follow-up 4 - 6 weeks after IUD insertion. All subjects were called at 6 months to assess if and why they had discontinued IUD use, or if they had any adverse events including expulsion, pregnancy, or pelvic infection. Subjects were also asked about string check attempts and success and their preferred method for IUD surveillance. Group demographics and outcome measures were compared using Chi-square, Fisher’s exact, T-test and Wilcoxon tests as appropriate.

RESULTS:

47 and 131 patients enrolled respectively in the in-person and telephone follow-up groups. Demographics and medical history were not significantly different between the groups. The majority of subjects were white, college educated, privately insured, and nulliparous. Of all subjects who completed the 6-month assessment, 138 (94%) reported still having their IUD in place, 8 had discontinued, and 1 had an expulsion. Subjects in the two groups had similar IUD continuation rates at 6 months (p=0.70). Unscheduled visits and ability to feel strings were similar between the groups.

CONCLUSION:

We observed similar 6-month continuation rates, no evidence of increased unscheduled visits, expulsions or adverse events in the telephone group compared to the in-person group. More subjects chose phone follow-up. The 4 - 6 week telephone follow-up was comparable to in-person IUD follow-up in our population.
Immediate Postpartum LARC Reimbursement Increases Uptake of Effective Contraception After Pregnancy [22G]
Authors: Paul Rachel , Bayer Chelsea , Braun Emma , Mullen Mary , Frisse Ann , Robbins Camaryn Chrisman
Published: April 2018

INTRODUCTION:

Over one third of women have unfulfilled contraceptive needs during their first year postpartum, and women without health insurance are 30% less likely to use contraception. As states have begun to reimburse for immediate postpartum LARC placement (immediate post-placental IUD insertion and implant insertion before discharge), the objective of this study was to determine if LARC uptake increased in the Medicaid population after immediate postpartum reimbursement was instated.

METHODS:

Women receiving Medicaid were prospectively recruited from a postpartum service of a large, urban hospital before and after immediate postpartum reimbursement. They completed a survey regarding their contraceptive choices, and additional information was gathered from the medical record. A binary logistic regression was performed to determine if women receiving Medicaid were more likely to choose LARC as a contraceptive method after the policy took effect, adjusting for race, mode of delivery, and primiparity.

RESULTS:

178 women were included in the analysis (70 before reimbursement, 108 after reimbursement). Women were 2.5 times more likely to use LARC as postpartum birth control after immediate postpartum reimbursement was instated (95% CI: 1.26-4.79). Of the 49 women who chose LARC after immediate postpartum reimbursement, 42 (86%) received their method before hospital discharge.

CONCLUSION:

Immediate postpartum reimbursement resulted in women being more than twice as likely to choose LARC as their postpartum contraceptive method. Removing this barrier to cost and access is particularly important in a population vulnerable to unintended pregnancy and loss of healthcare coverage.
Effects of Human Papillomavirus–Related Disease on Patient Knowledge and Practices Regarding HPV Vaccination [32G]
Authors: Coleman Maame A. , Cohen Emily , Sangi-Haghpeykar Haleh
Published: April 2018

INTRODUCTION:

To evaluate whether women with a history of an abnormal Pap test are more knowledgeable about Human Papillomavirus (HPV) and HPV vaccine, and more receptive to vaccinating their children against HPV.

METHODS:

Convenience sample of 100 women attending a community health clinic October 2016 to April 2017. Mann-Whitney U test was utilized to analyze ordinal variables. P < .05 was considered statistically significant.

RESULTS:

103 surveys were completed. Women had a median age of 38 years. The majority of women were White race (30%), Hispanic ethnicity (82%) with 59% being married, 61% having a high school education or greater and 55% reporting an annual household income of less than $25,000. Women with a history of an abnormal Pap test (n = 37) were more likely to have thought that HPV was the cause when compared to women with no such history (n = 57), 86% versus 49%, respectively P < .01. No differences were noted regarding the knowledge of the impact of HPV, awareness of the HPV vaccine, or the portion of women who vaccinated their children for the virus between women with a history of abnormal Pap test and those without.

CONCLUSION:

Women with a history of an abnormal Pap test are more aware that HPV was an etiology for this; however, no impact was noted on the rate of their children receiving the HPV vaccine. Obstetrician-Gynecologists should take advantage of this “teachable moment” to educate women of the benefits of HPV immunization for their children.
Racial/Ethnic Variations in Use of Alternative Treatment Before Hysterectomy for Benign Conditions [36G]
Authors: Nguyen Nancy T. , Ritterman Weintraub Miranda M.L. , Poceta Joanna , Salyer Chelsea , Merchant Maqdooda , Zaritsky Eve
Published: April 2018

INTRODUCTION:

Hysterectomy rates for benign gynecologic conditions vary by race/ethnicity. We investigated racial/ethnic variations in rates of utilization of alternative treatments before hysterectomy for benign gynecologic indications at Kaiser Permanente Northern California (KPNC), an integrated health care system.

METHODS:

We conducted a retrospective IRB-approved cohort study of 1,050 patients randomly selected from the 6,892 patients who underwent hysterectomies for benign gynecologic conditions between 2012 and 2014 at KPNC. Primary outcomes were use of treatments prior to hysterectomy. Demographic covariates included age and median household income. Clinical characteristics included comorbidities, benign gynecologic indication, type of hysterectomy and counseling status. Chi-square and Fisher exact tests were used for bivariate analyses and logistic regression for multivariable analyses.

RESULTS:

Of the 1,050 charts reviewed, 980 (93.3%) patients met inclusion criteria. Prior to a hysterectomy, 99.3% of patients were counseled regarding alternative treatments and 18.7% declined alternative treatment options. In bivariate analyses, there were racial/ethnic variations in the proportion of women who received alternative treatments. Among Asians, 70.5% received an alternative treatment compared to 77.8% for blacks, 84.4% for Hispanics and 82.2% for whites (p-value=0.0037). These variations did not persist in multivariate analyses, adjusting for demographic and clinical characteristics. Of the 18.7% who declined alternative treatment, the majority (41.9%) were white.

CONCLUSION:

The majority of patients were counseled about alternative treatments and 80% tried at least one prior to undergoing a hysterectomy. Unlike previous studies, there were no differences in receiving alternative treatments between whites, Asians, blacks and Hispanics within our integrated health system.
Vulvar Lichen Sclerosus in Gynecology and Dermatology Clinics: The Link between Treatment Compliance and Outcomes [37G]
Authors: Kohn Jaden R. , McClatchey Trissa M. , Chan Warren , Liang Cynthia S. , Dao Harry , Vyas Anuja
Published: April 2018

INTRODUCTION:

To investigate the relationship between topical steroids, treatment compliance, and clinical outcomes in women with vulvar lichen sclerosus (VLS).

METHODS:

We performed a cross-sectional study of women with VLS seen at dermatology, general gynecology, and vulvovaginal gynecology clinics from 2012-2017. IRB approval was obtained. Analysis included descriptive statistics and panel data logistic regression.

RESULTS:

332 women attended 1525 visits (median 4 per patient, range 1-24 visits). 65% occurred in vulvovaginal gynecology clinic, 26% in general gynecology clinic, and 8% in dermatology clinic. Mean age was 61.7±11.8 years (range 23.1-90.0). 82% were non-Hispanic white. 31% had hypothyroidism and 22% were nulliparous. Patients reported perfect use of topical steroid at 66% of visits, imperfect use at 26%, and no use at 8%. Compared to no use, perfect use strongly predicted improvement in symptoms (OR 4.5, p<0.001) and physical exam (OR 6.9, p<0.001); imperfect use had lesser improvement in symptoms (OR 2.6, p=0.017) and physical exam (OR 4.2, p=0.004). Improvement was more likely with super-high potency steroid compared to low-potency (symptoms: OR 1.74, p=0.012; physical exam: OR 1.73, p=0.039). Sexual activity was documented at 93% of vulvovaginal gynecology visits, 29% of general gynecology visits, and 0% of dermatology visits. 42% of women were sexually inactive at intake due to pain; of these, 40% became sexually active during follow-up.

CONCLUSION:

Women with VLS are more likely to improve clinically with perfect use of topical steroid, though some improvement may occur with imperfect use. Sexual activity is often documented inconsistently, limiting follow up regarding quality of life.
Improving the Post-Placental Intrauterine Device Protocol to Reduce Patient Visits [2H]
Authors: Thornton Olivia , Purusothaman Vaishnavi , Dinesman Ilanna , Plastino Kristen
Published: April 2018

INTRODUCTION:

Immediate post-partum intrauterine device (IUD) insertion is a safe and effective means of long-acting birth control. This project analyzes demographics, string visualization, and follow up of women who opted for post-partum IUD insertion and considers the need for follow up including ultrasound (TVS).

METHODS:

From March 2016 to March 2017, the Post-Placental IUD Insertion Protocol was used for immediate post-partum Mirena® and ParaGard® IUD insertion at University Hospital, San Antonio, Texas. Retrospective chart analysis was used to assess patient demographics, follow up rates, and expulsion rates.

RESULTS:

A total of 128 women received post-partum IUDs, 70 post-cesarean and 58 post-vaginal delivery. Patient age ranged from 16-43 (average = 26.76) and parity ranged from 1-10 (average = 3.1). Over 80% of the population was Hispanic. Per protocol, patients were scheduled for a string check follow up 7-14 days post insertion. Of the 89 patients who followed up, 27 were in the first three weeks of post-insertion. Over 88% (15/17) of the post-cesarean and 25% (2/8) of post-vaginal insertions did not have visible strings at the visit and 50% (44-89) eventually needed a TVS to confirm placement, 75% of which were post-cesarean. The expulsion rate was 9% (8/89) and 9 IUDs required removal per patient request or IUD not being at the uterine fundus.

CONCLUSION:

The Post-Placental IUD Insertion Protocol can be improved in efficiency and cost-effectiveness by reducing the number of post-partum visits to only one at six weeks as well as scheduling a pre-clinic TVS, especially for post-cesarean patients.
Knowledge, Attitudes, and Use of Family Planning in Rural Uganda: Comparing the Female and Male Perspectives [6H]
Authors: Deans Samantha J. , Dougherty Anne , Kayongo Alex , Mundaka John , Heil Sarah , Kalyesubula Robert
Published: April 2018

INTRODUCTION:

Unintended pregnancy is a significant modifiable factor contributing to the high maternal mortality rate in Uganda. This study compares women and men’s knowledge of and attitudes toward family planning (FP) in rural Uganda to understand potential barriers to its use.

METHODS:

Data were collected from villagers through surveys in rural Nakaseke District, Uganda (N=362). Participants’ socio-demographics, indicators of unmet need, and knowledge/accessibility of FP services were queried and analyzed.

RESULTS:

183 women and 179 men (average age 32.5, range 15-71) participated. All women and 98% of men reported some knowledge of FP. Most women (62%) obtained FP information from health workers; most men (73%) obtained information via radio. 64% of women and 53% of men reported ever using FP; 40% of respondents reported current use. Of these, 35% of women involved their partners in their decision, compared to 23% of men. Of participants reporting barriers to FP (n=46), women cited partner opposition as the most common obstacle (23%), whereas men reported inability to access their chosen method (39%). Women and men identified common contraceptive side-effects, e.g. vaginal bleeding (47% vs 31%), but men were more likely to report myths, e.g. increased infertility (9% vs 1%).

CONCLUSION:

Men and women in rural Uganda reported limited access to FP as a significant barrier to use. For women, partner opposition contributed significantly to limiting access. Men relied on incomplete/inaccurate sources of information, furthering their reluctance to use FP. Our study demonstrates the importance of targeting education for men and women to increase acceptance/success of FP programs.
Resident Personal Contraceptive Use and LARC Practices in Residency Training [8H]
Authors: Kellogg Emily , Breeze Janis , Evans Megan L.
Published: April 2018

INTRODUCTION:

In the United States, long acting reversible contraception (LARC) use has been steadily rising, and female physicians use LARC at a higher rate than the general population. Additionally, experience with LARC training and education can vary widely by program and region. The purpose of this study is to determine if choice of personal contraceptive use among OB-GYN residents varies with the number of LARCs placed during their training.

METHODS:

An electronic survey was distributed to all residents taking the annual OB-GYN resident in-training examination January 21st-23rd, 2016. The survey included questions about demographics, residency training experience, and personal contraceptive use. The survey was IRB-approved, voluntary, and anonymous. Experience with LARC was defined as the number of insertions performed during residency: 0, 1-10, 11-25, 26-50, >50.

RESULTS:

In total 4,316 residents completed the survey. Of these, 896 use oral contraceptive pills (OCPs), 88 use implants, and 1444 use intrauterine devices (IUDs) for contraception. All responses were included in this analysis. Overall, the highest proportion of residents using OCPs and implants inserted 1-10 IUDs (37.9%, 47.7%). Of residents who used an IUD, the highest proportion of residents inserted 11-25 IUDs (33.1%). Residents who inserted 26-50 IUDs during training were more likely to use an IUD (24.1%) than residents who used OCPs or implants (19.4%, 14.8%,). Of residents who use OCPs, implants, and IUDs, the highest proportion of residents placed 1-10 implants (43.9%, 36.4%, and 40.3%).

CONCLUSION:

Residents who use an IUD for contraception are more likely to have greater experience with insertion of these devices.
Racial Representation in United States and Australian Obstetric Research [13H]
Authors: Chern Ingrid , Yamasato Kelly , Lee Men-Jean
Published: April 2018

INTRODUCTION:

To describe racial/ethnic composition in United States (US)/Australian obstetric research, represented by the Maternal-Fetal Medicine Units Network (MFMU) and Australian Research Centre for Health of Women and Babies (ARCH) trials.

METHODS:

MFMU studies were identified through PubMed and ARCH studies through their online publication listing from 2011 to 2016. Observational and randomized cohorts and primary and secondary data analyses were included. Studies with racial/ethnic-based enrollment were excluded. Racial composition was expressed as the mean racial percentages among studies (ie: studies weighted equally regardless of sample size). Racial percentages in MFMU studies were compared to US registered births (2015) and ARCH compared to Australian census ancestry data (2016).

RESULTS:

38 MFMU studies included 580,282 women. Racial/ethnic composition (% [SD]) included White 41.7 [12.3], Hispanic 28.1 [15.4], Black 26.2 [12.3], Asian 3.6 [2.3], and American Indian/Alaskan Native (AI/AN) 0.2 [0.02]. No studies reported Native Hawaiian/other Pacific Islanders (NHOPI) separately. Comparatively, registered US births (%) were White 75.7, Hispanic 28.1, Black 16.1, Asian/Pacific Islander 7.1, and AI/AN 1.1. 20 ARCH studies included 51,873 women. The most reported groups were White (76.5 [17.4]), Asian (15.2 [14.8]), and Aboriginal/Torres Strait Islander (13.9 [30.5]), compared to the estimated population of White 88.7, Asian 9.4, and Aboriginal/Torres Strait Islander 2.8. No studies reported Black race separately.

CONCLUSION:

There is diverse racial/ethnic representation in studies by MFMU and ARCH, with possible opportunities to increase enrollment, or the reporting of Asian, AI/AN, and NHOPI races in US studies and Black race in Australian studies.
Optimal Duration Of Urinary Catheterization After Cesarean Delivery [17H]
Authors: Taha Odette , Chappelle Joseph
Published: April 2018

INTRODUCTION:

Indwelling urinary catheter placement is the standard of care in cesarean deliveries. Studies have evaluated utilizing one-time catheterization preoperatively but no studies have investigated the ideal length of catheterization. The primary outcome was to compare rates of urinary retention in women undergoing cesarean delivery who have had their urinary catheter removed at 24 vs 12 hrs.

METHODS:

We performed a quality assurance, non-inferiority study. A survey assessed discomfort due to the catheter, time to first ambulation, and overall satisfaction. Demographic, operative and postoperative data was collected including information on re-catheterization for retention, time to first void after catheterization, pain scores, time to first ambulation, and length of stay.

RESULTS:

125 women had their catheters removed at 24 hours and 155 at 12 hours. Women in the 12 hour group took 30 minutes longer to void for the first time (3.0±1.6 vs. 3.6±1.9, p=0.002). More women in the 24 hour group (37.2% vs. 21.5%, p=0.004) would have preferred an earlier removed. Two women in the 12 hours group had urinary retention vs. 0 in the 24 hour group (p=0.2).

CONCLUSION:

There was no difference in the time to first ambulation, dysuria, or overall patient satisfaction. Earlier removal is associated with a clinically non-significant increase in time to first void and less desire for earlier removal. This study demonstrated no difference in urinary retention but a larger study would be needed to rule-out a less dramatic increase. Urinary catheterization greater than 12 hours seems to infer no medical benefits for women undergoing cesarean delivery.
Prevalence of Post-Traumatic Stress Disorder after Vaginal Delivery and in Particular after Postpartum Hemorrhage [18H]
Authors: Woodley Nicole J. , Das Kamalini , Vogel Rachel Isaksson
Published: April 2018

INTRODUCTION:

Post traumatic stress disorder (PTSD) involves intrusive thoughts, nightmares and flashbacks of traumatic events that interfere with daily activities. PTSD has been described most commonly after combat and assault, but is also described after medical intervention, particularly admission to the intensive care unit. The goal of this study was to assess prevalence of PTSD after vaginal delivery and compare women who did and did not experience postpartum hemorrhage (PPH).

METHODS:

Patients who had a singleton vaginal delivery who were English speaking and greater than 18 years old were identified between 1/1/2013 and 12/31/2014. Of these 4,738 patients, 339 had a PPH defined as an estimated blood loss greater than 500 ml. Surveys were sent to all PPH patients and 2000 of the non-PPH patients. Total response rate was 442, or 19.6%. The survey included questions regarding the delivery as well as the PCL-C, a validated PTSD questionnaire. Multivariate logistic regression models were used to compare those with clinically significant PTSD symptoms in those with and without PPH.

RESULTS:

Patients who experienced PPH were more likely to have fear of extra bleeding again (P<.0001) and fear of becoming pregnant again (P=.001). Those who had PPH were more than two times more likely to have a moderate or severe PCL-C score (OR 2.85).

CONCLUSION:

Understanding the prevalence of PTSD both after vaginal delivery and PPH will create awareness for providers to diagnose and treat these patients in the postpartum setting.
Differences in Obstetric and Neonatal Outcomes in Pregnancies Complicated by Type 1 and Type 2 Diabetes Mellitus [21H]
Authors: Ware Courtney A. , Finneran Matthew M. , Kiefer Miranda K. , Thung Stephen F. , Landon Mark B. , Gabbe Steven G.
Published: April 2018

INTRODUCTION:

There are well-known baseline differences in medical comorbidities and disease related complications between patients with pregestational type 1 and type 2 diabetes, but limited research on the comparison in obstetric outcomes between these populations.

METHODS:

Retrospective cohort study of all pregnancies complicated by pregestational diabetes from 2012-2016. Patients were categorized by diabetes type and baseline demographics were compared between groups. A multivariate regression model was used to calculate adjusted odds ratios for obstetric and neonatal outcomes controlling for gestational age at delivery and late (>26 weeks) hemoglobin A1c.

RESULTS:

There were 464 patients who met inclusion criteria during the study period. Patients with type 2 diabetes were more likely to be of non-Hispanic white race (36.2% vs. 15.2%; p<.01), advanced maternal age (40.8% vs. 19.3%; p<.01), obese (81.7 vs. 46.2%; p<.01) and have preexisting hypertension (41.0% vs. 20.1%; p<.01). However, patients with type 1 diabetes had a longer duration of disease (White’s class C/D: 62.1% vs 19.5%; p<.01) and higher rates of end organ complications (White’s class R/F:19.3% vs 3.5%; p<.01). Adverse obstetric and neonatal outcomes were more common in type 1 diabetes including prematurity (aOR:1.8, CI:1.1-2.8), NICU admission (aOR:1.9, CI:1.1-3.2), and large for gestational age birth weight (aOR:2.5, CI:1.6-4.0). Whereas, patients with type 2 diabetes had a higher burden of spontaneous abortion (6.0% vs. 0.7%; p=0.01) and fetal demise (2.5% vs. 0%; p<.06).

CONCLUSION:

Despite lower rates of baseline medical co-morbidities, patients with type 1 diabetes have higher rates of preexisting diabetes complications and adverse perinatal outcomes independent of antenatal glycemic control.
Fetal Growth Restriction - Outcome Driven Definition [23H]
Authors: Gonzalez Veronica , Chipman Zachary , Stelzl Patrick , Malone Fergal , D'Alton Mary , Bukowski Radek
Published: April 2018

INTRODUCTION:

Fetal growth abnormalities are among the main drivers of perinatal mortality and morbidity and a cornerstone of prenatal care. However they are defined based on arbitrary definitions. Our objective was to define fetal growth abnormalities based on increase risk of stillbirth.

METHODS:

In a prospective cohort of 35,251 singleton pregnancies, stillbirth was defined as fetal demise at > 20 weeks without chromosomal or structural abnormalities. Fetal growth was percentile of birth weight for gestational age at delivery. The risk of stillbirth as a function of percentile of fetal growth and gestational age was determined using logistic regression. The threshold in the relationship adjusted for gestational age at delivery was determined using the Bayesian information criterion to identify the point where the relationship’s strength changes.

RESULTS:

There were 61 (0.2%) non-anomalous stillbirths. At the 8.0th percentile of fetal growth the risk of stillbirth increased from 1.5 to 6.5 per 1,000 pregnancies. Risk of stillbirth at or below 8th percentile was 0.0065 (95% CI 0.0060-0.0070) and above the 8.0th percentile the risk of stillbirth was 0.0015 (95% CI 0.0013-0.0017); P<.0001 for both associations.

CONCLUSION:

Definition of fetal growth impairment based on the risk of stillbirth will result in fewer small but normal pregnancies to be misclassified as abnormally grown and thus decreasing unnecessary testing and interventions. Additionally, lower threshold 8th vs 10th percentile for defining fetal growth restriction would decrease by 2% of all pregnancies (80,000 per year in the US) the number of pregnancies requiring further testing and intervention.
Assessing Treatment Effects Using Quality of Life Questionnaires in Pregnant Women with Iron Deficiency Anaemia [26H]
Authors: Shulman Yonatan , Eckler Rebecca , Tomlinson George , D'Souza Rohan
Published: April 2018

INTRODUCTION:

There is considerable overlap between symptoms related to iron deficiency anaemia (IDA) and a normally advancing gestation, posing challenges to the use of quality of life (QoL) tools to measure treatment effects. Our aim was to determine how best to use two existing QoL tools; short-form 36 (SF36) – a general questionnaire covering eight domains and the multidimensional fatigue symptom inventory: short form (MFSI-SF) – a fatigue-specific questionnaire to assess treatment effect in pregnant women with IDA.

METHODS:

We recruited consecutive women with IDA attending the Obstetric Day Unit at Mount Sinai Hospital, Toronto, for intravenous iron infusions over six months. Consenting participants completed SF36 and MFSI-SF questionnaires at each visit and upon completion of treatment. Scores for the entire questionnaire and individual domains were summed and plotted graphically over time.

RESULTS:

29 women consented and completed at least one SF36 and MFSI-SF questionnaire, while 24 completed two, 12 completed three and four women completed four. The mean maternal age was 34 (24-46) years and the mean gestational age 29 (25-38) weeks. These women represented different ethnic groups and socio-economic strata. Although there was no consistent pattern in scores for 6/8 SF36 domains, there was a significant improvement between visits in the energy/fatigue (37.6 vs 42.8, p=0.044), and emotional wellness (62.7 vs 77.3, p<0.001) domains and in MFSI-SF scores (17.1 vs 12.2, p=0.025).

CONCLUSION:

When assessing treatment effects in pregnant women with IDA, consideration should be given to using QoL tools specifically designed to measure fatigue, such as MFSI-SF or the energy/fatigue domain in SF36.
Pregnancy After 50: Presentation of Two Cases and a Review of the Literature [27H]
Authors: Curcio Erin , Gussman Debra
Published: April 2018

INTRODUCTION:

To present two cases and review the literature on pregnant post-menopausal women.

METHODS:

Case # 1 was a 53 year old with a pregnancy achieved by advanced reproductive techniques (ART) and complicated with twin gestation and pre-eclampsia at 28 weeks. A cesarean delivery was performed. Her post-operative course was complicated by pulmonary edema, hyperglycemia, anemia requiring transfusion, and acute kidney injury.

Case # 2 was a 50 year old with a pregnancy achieved by ART and complicated with Stage 1 breast cancer, gestational hypertension, hypothyroidism, glucose intolerance, and diverticulosis. She had a cesarean delivery at 37 weeks. Data bases were searched to identify studies reporting on women who achieved pregnancy after the age of 50 using ART. Studies were examined for demographics and pregnancy outcomes.

RESULTS:

11 studies were identified reporting on a total of 1070 women 50 or older with successful ART pregnancies. The age range was 51 to 64. Singleton rate was 59% to 89%. Cesarean delivery rate was 67% to 100%. Antenatal maternal hospitalization was 40% to 48%. Gestational diabetes was 5% to 45%. Hypertension in pregnancy was 4% to 59%. Neonate intensive care admission was 11% to 15%. Neonatal death was 2.6%. One maternal death was reported.

CONCLUSION:

With the development of donor oocyte and ART, there have been an increased number of births in post-menopausal women. These pregnancies can have serious complications and require multidisciplinary approach for optimal outcomes. Our experience was consistent with published case reports and case series.
Obesity and Cerclage Efficacy [33H]
Authors: Gill Lisa , Morgan Elizabeth A. , Yamamura Yasuko
Published: April 2018

INTRODUCTION:

Obese women have an increased risk of preterm birth. Cerclage is used for prevention in a subset of these women with cervical insufficiency. We aimed to quantify the difference in risk of preterm birth in pregnancies treated with cerclage for cervical insufficiency in an obese population compared to a non-obese population.

METHODS:

This is a retrospective cohort study. All cerclage procedures from January 1, 2011 to December 31, 2016 were collected from a single center. Groups were defined as obese (BMI 30.0 or greater) and controls(BMI <30.0). The primary endpoint was defined as preterm birth <23 weeks. Secondary outcomes included preterm birth <28, 32, or 37 weeks. Groups were also compared regarding cerclage type (McDonald vs Shirodkar). Odds ratios with 95% confidence intervals were calculated for each outcome.

RESULTS:

267 cerclage procedures were collected. Delivery documentation was complete for 225 (109 obese, 116 non-obese controls). Gestational age at delivery did not differ significantly (33 weeks in obese vs 34.33 weeks in non-obese, p = 0.14). Risk of preterm delivery for obese women undergoing cerclage was not significantly different from controls. When cerclage type was compared, obese women undergoing Shirodkar cerclage were at increased risk of preterm delivery compared to controls(OR 4.29, 95% CI 1.14-16.2), this difference was not noted in those undergoing McDonald cerclage.

CONCLUSION:

Obesity does not increase the rate of preterm delivery with cerclage, but Shirodkar-type cerclage independently increases the risk of prematurity in this population.
Screening for Obstructive Sleep Apnea during Pregnancy in Rural New Mexico [35H]
Authors: Izquierdo Francisco , Izquierdo Luis A. , Blue Nathan R. , Jaramillo-Huff Ashely
Published: April 2018

INTRODUCTION:

Obstructive sleep apnea (OSA) is a condition that has been proven to have significant effects on the human body. This study is a pilot study in our State that will seek to identify the prevalence of OSA in pregnancy in New Mexico.

METHODS:

One hundred women in our rural outreach perinatal clinics were given the Berlin questionnaire in order to determine how many of them have symptoms of OSA. Maternal demographics including age, weight, height, and gestational age were analyzed. T tests were used for continuous variables, chi-square for dichotomous variables, and logistic regression analysis to assess for correlation.

RESULTS:

Eighty four patients successfully completed the questionnaire. Sixteen questionnaires were not completed or were missing vital information. The mean age was 30.49 years, the mean height was 1.61 m (SD 0.06 m), the mean weight was 81.51 kg (SD 20.05), and the mean body mass index (BMI) was 31.44 (SD 8.18). In our sample, 26 women (30.9%) had a positive OSA screen. Unexpectedly, there was no correlation between the number of positive screening questions and BMI, (correlation coefficient, r=0.29), or between maternal age and BMI (r=0.10).

CONCLUSION:

In a high risk pregnancy clinics in New Mexico, around 30% of obese, pregnant women had symptoms consistent with OSA at around 20 weeks of gestation. This study provides researchers cause to further investigate the prevalence of OSA in pregnancy in New Mexico and, subsequently, its impact on the mother and fetus.
Paternal Consent and Research During Pregnancy: A Comparison With Dual-Parent Consent in Pediatric Research [2I]
Authors: Little Maggie , Wickremsinhe Marisha , Lyerly Anne
Published: April 2018

INTRODUCTION:

The US regulation on research with pregnant women, “Subpart B”, requires paternal consent, in addition to the woman’s (i.e. dual-parent consent), if the research offers the prospect of direct benefit (PDB) to the fetus but not to her. We sought to investigate the ethical underpinnings of this requirement by exploring dual-parent consent requirements for research with children in “Subpart D,” which governs pediatric research.

METHODS:

We reviewed the requirements for dual-parent consent in Subparts B and D to analyze the ethical underpinnings of each regulation. Consent requirements were assessed in using conceptual methods from ethical theory and research ethics literature.

RESULTS:

We identified a critical difference between the considerations for dual-parent consent in Subparts B and D. Subpart D requires dual-parent consent when research offers no prospect of direct benefit to the child and presents greater than minimal risk, presumably as an extra measure of protection to the future offspring; research offering the prospect of direct benefit to the child requires only one parent’s consent. Conversely, Subpart B requires dual-parent consent when, and only when, research offers potential benefit to the fetus while not the woman.

CONCLUSION:

The requirement for paternal consent in research with pregnant women does not mirror the requirement for dual-parent consent for research with children. The regulations problematically burden access to the direct benefit that research might offer a future child in a way that they do not burden access to such benefit with born children.
Investigating Industry Payments of OB/GYN Practice Bulletin Committee Members and Contributing Authors [5I]
Authors: Wright Micah , Checketts Jake , Vassar Matt , Guevara Carlos , Smith Larissa , Frye Lance
Published: April 2018

INTRODUCTION:

Our study evaluates payments received by ACOG Obstetrics and Gynecology practice bulletin committee members, physicians who author the ACOG Obstetrics and Gynecology practice bulletins, and for comparison the authors of an ACOG established Task Force on Hypertension guideline, compares disclosure statements for accuracy, and determines whether the pharmaceutical companies from which authors received payments manufactured products related to the guidelines. We also investigate payments from top contributors and ties to the specialty

METHODS:

We conducted a cross-sectional study of the Open Payments database. We limited our search from 2014 to present (Open Payment data are not available prior to 2014). We included all general payments and research payments reported from 2014-2015, which included direct payments, indirect payments or other transfers of value made to physicians by applicable manufacturers. We calculated total general payments and also research payment averages and ranges and averages within each group of authors separately

RESULTS:

Of the 60 authors evaluated, 34 received at least one reported industry payment. In total general financial payments amounted to $289,407.36 with a mean of 977.73 per author. Of the 34 authors receiving payments, only 2 authors received specific research payments. Top contributing companies were identified and products related to the specialty were listed.

CONCLUSION:

In absence of other factors, such as level of evidence, financial conflicts do not seem to play a large role in ACOG practice bulletin limitations. Evaluation of the structure of practice bulletin committees would suggest that a large amount of influence is controlled by only a select few.
Who Has Syphilis in Pregnancy? Evaluating National Trends and Behavioral Risk Factors, United States, 2012-2016 [9I]
Authors: Trivedi Shivika , Williams Charnetta , Torrone Elizabeth , Kidd Sarah
Published: April 2018

INTRODUCTION:

Syphilis is associated with significant complications, particularly among pregnant women. Congenital syphilis (CS) can cause stillbirth and long-term health sequelae. CS is avoidable with the timely screening and treatment of pregnant women.

METHODS:

We analyzed national case report data for 2012–2016 to assess trends among pregnant women with all stages of syphilis and evaluated reported behavioral risk factors for syphilis.

RESULTS:

During 2012–2016, the number of syphilis cases among pregnant women increased 61%, from 1,561 to 2,508. CS cases increased 88% from 334 to 628, and syphilitic stillbirths increased 173%, from 15 to 41. The largest increases among pregnant women were observed in the West (292%) and among American Indians/Alaska Natives (420%), non-Hispanic Whites (108%) and Hispanics (92%). However, the majority of cases were reported in the South (56%) and among non-Hispanic Black women (48%).

Many pregnant women with syphilis denied any risk factors. For example, 57% denied ever having had a sexually transmitted disease and 68% denied having multiple sex partners in the past year. Of fifteen queried risk factors, including high-risk sexual behaviors and drug use, 49% of women did not report any in the past year.

CONCLUSION:

CS and syphilis cases among pregnant women are steadily increasing. It is essential that practitioners adhere to CDC recommendations to screen all pregnant women for syphilis at the first prenatal visit. CDC also recommends repeat screening based on risk factors and geography. Our findings emphasize that patient-reported risk factors may not sufficiently identify all those at risk for syphilis in pregnancy.
Maternal Characteristics of Congenital Syphilis [13I]
Authors: Whitham Megan , Bandy Sohini , Eppes Catherine , Rac Martha
Published: April 2018

INTRODUCTION:

We describe the maternal characteristics and pregnancy outcomes of seropositive gravidas who delivered an infant with and without congenital syphilis.

METHODS:

This is a retrospective chart review of gravidas diagnosed with syphilis at our county hospital system from January 2011 to December 2016. Maternal stage of syphilis was diagnosed according to CDC guidelines and the diagnosis of congenital syphilis was assigned by the managing clinician in the prenatal period and at delivery respectively. Maternal characteristics, stage of syphilis, treatment history, delivery and infant outcomes were recorded. Characteristics of patients who delivered a child that required treatment for congenital syphilis were compared to those who did not. Standard statistical analysis was performed.

RESULTS:

94 gravidas were diagnosed with syphilis and 17 (18%) delivered an infant who required treatment for congenital syphilis. Most women had latent syphilis (n=15, 88%) and 2(11.8%) were diagnosed with serofast syphilis. Eight (47%) did not receive antenatal treatment. For those that did, gestational age at treatment was 26.4 + 11.4 weeks. Women with infants diagnosed with congenital syphilis were more likely to have no prenatal care, be diagnosed and treated later in pregnancy, have less time from treatment to delivery and receive treatment less than 4 weeks prior to delivery (p<0.01). Age, race, prevalence of co-morbidities, gestational age at delivery, and rate of prematurity were similar between the two groups.

CONCLUSION:

Consistent with prior research, poor prenatal care and delayed antenatal treatment confers a higher risk of congenital syphilis. In the prevention of congenital syphilis, time is of essence.
First Report of Cryptogenic Klebsiella Pneumoniae Liver Abscess in Pregnancy [17I]
Authors: Schmiedecke Stacey Stevens , Estrada Sarah , Napolitano Peter
Published: April 2018

INTRODUCTION:

Pyogenic liver abscesses are a rare clinical entity occurring in an estimated 2.3 per 100,000 of the population. Klebsiella pneumoniae-associated liver abscess syndromes are extremely rare and have not been previously reported in the medical literature during pregnancy.

METHODS:

We had a medical librarian perform a professional search using the key words, “pyogenic liver abscess”, “pregnancy”, “pregnant”, “postpartum”, “pyogenic hepatic abscess”, and “Klebsiella pneumoniae” in the English language. We found that pyogenic liver abscesses (PLA) in the antenatal and postpartum period are rare, finding only five cases that have been previously reported in the puerperium. We discovered no cases of Klebsiella pneumoniae liver abscess in pregnancy.

RESULTS:

We report a 29 year-old G2P1001 who presented at 11 weeks and 1 day for fever, fatigue, body aches and headache. An infectious workup was initiated and preliminary blood cultures returned with gram negative rods; final cultures results confirmed heavy Klebsiella pneumoniae. During her workup for Klebsiella bacteremia of unknown source, an ultrasound of the liver showed a 4 cm abscess, later confirmed with MRI. She subsequently underwent percutaneous drainage of the liver abscess with culture confirming Klebsiella pneumoniae. Following diagnosis, she received an echocardiogram and an ophthalmology evaluation to rule out invasive disease. She was treated with a two week course of intravenous ceftriaxone therapy and oral metronidazole therapy. She was then transitioned to oral cefixime for a total of four weeks of therapy until abscess resolution was confirmed on follow-up imaging. For the remainder of her pregnancy, she was followed in the high-risk obstetric clinic and delivered a viable female infant at term. At approximately two months postpartum, she continues to be followed closely for mild transaminitis and is otherwise well.

CONCLUSION:

Pyogenic liver abscesses are an uncommon etiology of fever in pregnancy. Cryptogenic PLAs are often associated with non-specific symptoms that overlap common pregnancy complaints. Accurate diagnosis requires a thorough fever workup until a source is identified. Our case is the first report of Klebsiella pneumoniae PLA in pregnancy.
Venous Thromboembolism Prophylaxis After Cesarean Section: A Quality Improvement Project [27I]
Authors: Pierce-Williams Rebecca , Cohen Isabelle , D'Adamo Chris , Ehsanipoor Robert
Published: April 2018

INTRODUCTION:

To create and implement a venous thromboembolism (VTE) calculator for post-cesarean section patients at a community hospital, and analyze its association with subsequent rates of pharmacologic thromboprophylaxis use.

METHODS:

A risk calculator was developed, with points weighted based on the severity of the risk factor. Use of a paper form of the calculator was initiated in May 2015 (phase 1), and of an electronic form in August 2016 (phase 2). Data from 50 subjects each prior to the intervention (phase 0), during phase 1, and during phase 2 were collected (total n=150). Rates of pharmacologic thromboprophylaxis were compared with risk categories using Fisher exact test. Logistic regression models of these associations adjusting for key covariates (age, body mass index greater than 40, chorioamnionitis) were also constructed.

RESULTS:

There was a statistically significant increase in the use of pharmacologic prophylaxis after the intervention (phase 1 and 2), when compared to phase 0 (p=0.02). There was also a statistically significant decrease in high risk patients not receiving prophylaxis (p <0.0001). The association between phase and use of prophylaxis remained statistically significant after adjustment for covariates.

CONCLUSION:

Use of our calculator has led to a significant increase in prescription of pharmacologic thromboprophylaxis, particularly in moderate and high risk patients. To our knowledge, there have been no thromboembolic events since the start of the intervention.
C-reactive Protein Levels, Waist Circumference, and Pregnancy Outcomes in Overweight and Class 1 Obese Women [37I]
Authors: Rives Ted , Glass Alicia , Robbins Reiesha , Street Linda , Denney Jeffrey M.
Published: April 2018

INTRODUCTION:

To determine effects of adipose distribution and baseline CRP in 1st trimester on development of pregnancy-related conditions of GDM, GHTN, and preeclampsia in pregnancies with normal BMI compared to BMI 25-35 stratified by waist circumference (WC).

METHODS:

Prospective study including 3 cohorts: Group I Controls (BMI 18.5-25); Group II Subcutaneous Adiposity (BMI 25-35, WC < 35 in), and, Group III Visceral Adiposity (BMI 25-35 with WC> 35 in). Patients were eligible if enrollment <14wks GA and BMI 18.5-35 but excluded for antibiotic/corticosteroid use or rheumatologic/immunodeficiency disorders. Outcome measures included: GHTN, preeclampsia, GDM. Given cost, CRP measurement was limited to 24 patients (9 GI, 5 GII, 10 GIII). Univariate/multivariate analysis used where appropriate.

RESULTS:

134 patients enrolled: GI (n=51), GII (n=24), and GIII (n=57). Mean wks GA at delivery (GI 38.5, GII 38.3, and GIII 38.4; p=0.9) and gestational weight gain lbs (GI 28.0, GII 29.1, and GIII 21.0; p=0.16) were similar by group. GIII patients had a higher likelihood of developing GDM (GI 2.4%, GII 0%, GIII 12.5%; p=0.06, OR 4.5). Controlling for confounders (HTN, DM, smoking) intake CRP correlated with BMI (R=0.85) and was higher with BMI >30 (p=0.01), noting intake mean CRP (GI 1.7, GII 1.4, GIII 4.7). CRP>3.0 in 1st trimester increased risk for GHTN/preeclampsia (OR 3.35).

CONCLUSION:

Visceral adiposity increases systemic inflammation defined by elevated intake CRP and risk for GDM. Increased incidence of complications in obese mothers may be rooted in inflammatory insults to early placental development. Future studies may assess CRP utility as a risk stratification tool.
Severe Maternal Morbidity and Mortality During Delivery Hospitalization of Class I, II, III, and Super Obese Women [39I]
Authors: Platner Marissa , Ackerman Christina M. , Xu Xiao , Campbell Katherine , Pettker Christian , Lipkind Heather S.
Published: April 2018

INTRODUCTION:

Previous studies show that obesity predisposes patients to higher risks of adverse pregnancy outcomes. Data on the relationship between increasing degrees of obesity and risks of severe maternal morbidity, including mortality (SMM), are limited. The purpose of this study was to examine the association of different classes of obesity with SMM during delivery hospitalization.

METHODS:

Using New York City linked birth certificates and hospital discharge data, this study identified delivery hospitalizations for singleton, live births from 2008 through 2012. Women were classified as obese (Class I, II, III or super obesity), as opposed to normal weight or overweight, based on pre-pregnancy body mass index (BMI). Cases of SMM were identified based on ICD-9 diagnosis and procedure codes according to CDC criteria. Multivariable logistic regression was used to evaluate the association between obesity classes and SMM, adjusting for maternal socio-demographic and medical comorbidities.

RESULTS:

There were 539,870 live singleton births with available information on pre-pregnancy BMI. After adjusting for maternal characteristics, women with Class I (adjusted odds ratio (aOR) 1.07; 95% confidence interval (CI) 1.02-1.13), Class II (1.13; 1.05-1.21), Class III (1.26; 1.15-1.38), and super obesity (1.68; 1.32-2.11) were all significantly more likely to have SMM compared to normal and overweight women. Increasing BMI was associated with specific SMM indicators including: renal failure, blood transfusion, and heart failure in the adjusted analysis.

CONCLUSION:

There is a significant dose-response relationship between increasing obesity class and risk of SMM at delivery hospitalization. This relationship persisted even after accounting for potential confounding effects of comorbid conditions.