bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of an Abdominal Closure Bundle in Patients Undergoing Cesarean Section—A Randomized Control Trial [15P]
Authors: Bruce Shaina , Rajendran Preethi , Mumford Brigid , Heidorn Elise , Smith Stephen
Published: April 2020

INTRODUCTION:

Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. Literature in Colorectal Surgery and Gynecologic Oncology have suggested lower SSI rates among patients who receive closure bundles. This study investigated whether implementation of an abdominal closure bundle reduces SSI rates in patients undergoing cesarean section.

METHODS:

We conducted a prospective randomized controlled trial of patients who underwent a scheduled cesarean section. Enrolled patients were randomized to either standard operative procedure or the abdominal closure bundle. The bundle included changing of the surgical gown and gloves, repeat scrub, and usage of new instruments for closure of fascia, subcutaneous tissue, and skin. SSI rates were assessed and predictors of SSI were determined.

RESULTS:

241 patients were included in this interim analysis. No difference in SSI was found between the control (3/130, 2.3%) and closure bundle (2/111, 1.8%) groups (P=1.00). Logistic regression indicated that smoking status and number of prior cesarean sections were statistically reliable predictors of SSI (P=.009). Former or active smokers were 8.3 times more likely to have an infection (CI 1.61 – 43.3, P=.012). Those with prior cesarean sections were 2.5 times more likely to have an infection (CI 1.0 – 6.1, P=.045).

CONCLUSION:

Implementation of an abdominal closure bundle for patients undergoing scheduled cesarean sections did not significantly reduce SSI rate. We plan to investigate the impact of the abdominal closure bundle in a higher risk population as completion of this study as designed is unlikely to reach statistical significance.
Impact of a Quality Improvement Initiative on Prescribed Opioids for Cesarean Delivery [14P]
Authors: Wang Katherine Y. , Sood Shelly , Liveright Elizabeth
Published: April 2020

INTRODUCTION:

Cesarean deliveries (CD) are one of the most common procedures performed in the United States, with patients being routinely discharged with prescriptions for opioids. Previous studies show that the amount prescribed is significantly greater than what patients require. Our objective is to decrease the number prescribed at discharge through education and monitoring of prescription practices.

METHODS:

The quality improvement initiative was introduced in May 2018 through a departmental Grand Rounds presentation. Data on post-operative prescription practices were collected by performing a retrospective chart review of all patients undergoing CD at our hospital in the month of January 2018 and in January 2019, 6 months after introduction of the initiative. IRB approval was obtained for this review.

RESULTS:

A total of 89 records of patients who underwent CD was reviewed: 42 records from January 2018 and 47 records from January 2019. A significant decrease (P<.001) in the number of pills prescribed at discharge was found, with a median of 30 (IQR 28–30) in January 2018 compared to a median of 20 (IQR 20–30) in January 2019. There was a significant difference (P<.001) in the type of opioid prescribed, shifting from oxycodone with acetaminophen (78% in January 2018 and 10% in January 2019) to oxycodone alone (7% in January 2018 compared to 74% in January 2019). There was no significant difference in refill attempts (P=.7) between January 2018 and January 2019.

CONCLUSION:

Low-cost interventions such as a department Grand Rounds and ongoing educational initiatives may be an effective strategy to decrease post-operative opioid prescription numbers.
Validation of an Algorithm to Identify Ectopic Pregnancy in a Large Integrated Health Care Delivery System Database [40N]
Authors: Getahun Darios , Alexeeff Stacey , Fassett Michael J. , Shi Jiaxiao M. , Asiimwe Alex , Raine-Bennett Tina
Published: April 2020

INTRODUCTION:

Surveillance of ectopic pregnancy (EP) using electronic databases is important. We aimed to assess the validity of an enhanced version of a previously published algorithm, which used a combination of encounters with EP related diagnostic/procedure codes and methotrexate injections. The enhanced algorithm further included ICD-10 diagnostic/procedure codes along with telephone encounters and excluded cases with only abdominal EP codes.

METHODS:

Medical records of 681 women, aged 15–44 years with membership at Kaiser Permanente Southern and Northern California between 2009–2018 with a potential EP were reviewed and true cases were identified. The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and the overall performance (Youden's index and F-score) of the algorithm were evaluated and compared to the published algorithm.

RESULTS:

There were 418 true positive, 240 false positive, and 10 uncertain EP cases with available records. True positive and true negative EP cases did not differ significantly according to maternal age, race/ethnicity and smoking status. EP cases with only one encounter and non-tubal EP were more likely to be misclassified. The sensitivity, specificity, PPV, and NPV of the enhanced algorithm for EP were 96.4%, 80.8%, 89.8%, and 92.8%, respectively. The Youden index and F-score were 77.2% and 93.0%. The sensitivity and NPV were lower at 86.8% and 79.0%, respectively, for the published algorithm.

CONCLUSION:

The specificity of the algorithm for EP in the integrated healthcare databases is adequate to allow for use in future epidemiological studies. Use of the enhanced algorithm will likely result in better capture of true EP cases.
Effect of Hysterotomy Closure With Polyglactin 910 Versus Chromic Gut Suture on Secondary Cesarean Deliveries [12P]
Authors: Mersch Michelle , Ulfers Alexander , Hood Keren , Cuadra German , Stevenson Robert , Martingano Daniel
Published: April 2020

INTRODUCTION:

The objective of this was study was to determine if hysterotomy closure with polyglactin 910 (PG) versus chromic gut (CG) suture material is associated with differences in development of adhesions and surgical complications in secondary cesarean deliveries (CD).

METHODS:

We conducted a 3 year retrospective cohort study and reviewed charts on all women who received a secondary CD. Operative notes were reviewed and charts were separated depending if closure of the hysterotomy was performed with PG or CG. Charts were excluded if at time of primary CD, a double layer closure of hysterotomy, closure of peritoneum and rectus muscle were not performed, or additional procedure was performed. Appropriate IRB approval was obtained. Primary outcomes included operating time, surgical blood loss, and report of “dense” or “extensive” adhesions (DEA) requiring lysis of adhesions and/or enterolysis as a separate procedure.

RESULTS:

The study included 313 patients, where 181 patients had hysterotomy closures with PG and 132 had closures with CG. Baseline characteristics were not significantly different between groups including previous abdominal surgery. The CG group was associated with lower rates of DEA (19% versus 21%, P=.031) and shorter total operative time (1.1 hours versus 1.9 hours, P=.024). No difference was noted in surgical blood loss or rates of postpartum hemorrhage. After controlling for perceived confounding factors, these differences remained significant.

CONCLUSION:

In this retrospective study, hysterotomy closures with CG suture were associated with lower rates of reported adhesions and decreased total operative time when compared with PG closures.
Doula Programs Improve Cesarean Section Rate, Breastfeeding Initiation, Maternal and Perinatal Outcomes [11P]
Authors: Font Guillermo , Testani Erica
Published: April 2020

INTRODUCTION:

Doula support for socially disadvantaged women during pregnancy, childbirth and postpartum period is associated with improved outcomes, including lower rates of cesarean section, higher rates of breastfeeding initiation, and decreased maternal and perinatal complications. The purpose of our study is to report rates of primary cesarean section rate, breastfeeding initiation, and maternal and perinatal complications among socially or economically disadvantaged pregnant patients enrolled in a doula program in a large inner city setting.

METHODS:

Retrospective chart review of birth outcomes included primary cesarean section rate, breast feeding initiations, maternal and perinatal complications of patients enrolled in a certified doula support program in a large inner city setting. Outcomes were compared to local states percentages.

RESULTS:

Three hundred twenty two patients enrolled in the doula support program, 248 delivered vaginally and 74 required a cesarean section (cesarean section rate 22%), breast feeding initiation was reported in 269 patient (83% rate breast feeding initiations) and no maternal or perinatal loss was reported.

CONCLUSION:

Patients enrolled in a certified doula support programs in an inner city setting have improved cesarean section rates (22% vs 27%), breast feeding initiation rate (83% vs 80%) and improved maternal and perinatal outcomes compared to local state percentages. Our study confirms that pregnancy support by doulas are associated with improved outcomes in socially disadvantaged mothers because of racial disparities and psychosocial factors. Given these benefits certified doula support programs should be an available option during prenatal and postpartum care.
Communication, Respect, and Autonomy: Exploring Elements of a Meaningful Birth Partnership [08P]
Authors: Akpovi Eloho , Freeburg Taylor , Bocage Anne , Howard Elisabeth
Published: April 2020

INTRODUCTION:

A health system focused on person-centered maternity care should place high value on women's sense of autonomy and perception of the decision-making process. We aim to triangulate quantitative findings to better understand the role of communication in improving maternal care delivery, in order to inform development of processes that facilitate a patient-centered birth partnership.

METHODS:

A paper questionnaire was self-administered to women receiving postpartum care at a hospital in the northeast United States. The questionnaire employed the Mothers Autonomy in Decision Making (MADM) scale, the Mothers on Respect (MOR) index, and questions from the Listening to Mothers III survey in asking about communication experiences and preferences during maternity care. One-way analysis of variance (ANOVA) was used to determine which communication preferences correlated with MADM and MOR scores.

RESULTS:

155 participants consented and enrolled into the study, with a mean age of 27.1 (SD 5.5). The mean MADM and MOR scores were 36.06 (SD 6.55) and 73.76 (SD 8.78), respectively. Use of overly medicalized terminology by maternity care providers negatively correlated with perceived respect. Satisfaction with time spent with maternity care providers and encouragement of participation in care positively correlated with perceived autonomy. Websites and “Apps” with pregnancy and childbirth information were considered twice as valuable as childbirth education classes.

CONCLUSION:

Data obtained from this study will significantly add to understanding of the patient experience and will inform future interventions that encourage a patient partnership in the provision of childbirth care.
Characterizing Perioperative Blood Glucose on an Enhanced Recovery After Surgery Pathway for Cesarean Delivery [06P]
Authors: Savitsky Leah M. , Hitti Jane , Delgado Carlos M. , Bollag Laurent A. , Mills Elizabeth B. , Fay Emily E.
Published: April 2020

INTRODUCTION:

Enhanced recovery after surgery (ERAS) pathways are standardized, evidence-based approaches to the care of surgical patients. One component of ERAS pathways is maintaining euglycemia pre- and post-operatively.

METHODS:

We conducted an IRB approved retrospective cohort study evaluating capillary blood glucose (CBG) values among women on the ERAS cesarean delivery pathway (ERAS CD) during the first year of implementation (4/1/2017–3/31/2018, n=531). Pregestational diabetics on insulin prior to pregnancy were excluded. ERAS CD pathway patients received a pre-op, 1-hour post-op, and post-op day 1 and 2 CBG. We calculated average CBG and percentage of time in-range, defined as any CBG between 70–140 mg/dL for all patients on the ERAS CD pathway, and stratified for type 2 diabetics (T2DM), gestational diabetics (GDM), and non-diabetics.

RESULTS:

Most patients had CBGs in-range preoperatively (n=268, 95.4%): 89.6% for T2DM, 89.8% for GDM, and 97.1% for non-diabetics. The average pre-op CBG was 87.5±15.7 mg/dL overall, 96.2±30.4 mg/dL for T2DM, 90.4±17.0 mg/dL for GDM, and 86.4±14.8 mg/dL for non-diabetics. Post-operatively, 94.3% (n=502) of patients had CBGs in-range: 66.8% for T2DM, 87.1% for GDM, and 95.5% for non-diabetics. The average post-op CBG was 90.9±17.8 mg/dL overall, 99.2±26.6 mg/dL for T2DM, 94.9±20.6 mg/dL for GDM, and 90.2±17.2 mg/dL for non-diabetics.

CONCLUSION:

Preoperatively most patients had in-range CBGs. Postoperatively, CBGs for non-diabetics and GDM remained primarily in-range, while CBGs for T2DM were more variable. For non-diabetic women it may not be useful to check pre- or post-operative CBGs as most will be within range. Further studies are needed to evaluate this aspect of care.
Association of Trial of Labor After Cesarean Delivery With Adverse Outcomes Among Late Preterm Births [05P]
Authors: McLaren Rodney Anthony , London Viktoriya , Fisher Nelli , Minkoff Howard
Published: April 2020

INTRODUCTION:

Delivery is recommended for PPROM at 34 weeks of gestation or greater, however guidance on the mode of delivery for women with one prior cesarean delivery (CD) at late preterm gestation is not clear. The objective of this study was to evaluate the association of induction in trial of labor after cesarean delivery (TOLAC) with adverse outcomes among late preterm births (LPB).

METHODS:

A retrospective cohort study of women with one prior CD who had a LPB. The study group was women who underwent TOLAC with induction and the control group was women who had a repeat CD without TOLAC. Data was extracted from the U.S. Natality Database from 2016 to 2017. Multivariate regression analysis was used.

RESULTS:

A total of 2,060 women had an induction and 42,167 had a repeat CD. The VBAC rate among inductions was 71.6%. Women undergoing an induction had risks of adverse maternal outcomes that were similar to those of women without TOLAC. However, the risks of neonatal respiratory problems were decreased among women undergoing TOLAC. Women who had failed induction and underwent CD had a higher risk of uterine rupture and receiving transfusion than women who had a repeat CD without TOLAC.

CONCLUSION:

Women at late preterm with one prior CD who undergo an induction have less respiratory problems and similar risks of adverse maternal outcomes compared to women who have a repeat CD. Patients at late preterm should be counseled about their options and the safety and risks of induction after one CD.
A Retrospective Study of Low-Risk Cesarean Delivery by Midwife Versus Obstetrician Service [02P]
Authors: Damiano Ella A , Auty Samantha , Gerjevic Kristen
Published: April 2020

INTRODUCTION:

To evaluate the variation in low risk cesarean delivery rate between the midwife and obstetrician-led services at a rural tertiary care center.

METHODS:

A retrospective cohort study of 1787 term, singleton, and vertex (TSV) deliveries without a history of cesarean delivery at a rural academic tertiary care center was performed. The primary outcome was rate of cesarean delivery among midwife and obstetrician-led services. Statistical comparisons were performed using student t-tests, chi-square tests, and multivariable logistic regression.

RESULTS:

Between January 2015 and December 2017, 1787 deliveries were analyzed with 956 (53%) managed by the midwife service and 831 (47%) managed by the obstetrician-led service. Midwife patients had significantly lower odds of having a cesarean delivery after adjustment for all maternal and delivery characteristics (aOR 0.56, 95% CI 0.30–0.82). Other factors favoring cesarean delivery include older maternal age, higher body mass index at delivery, and nulliparity. Midwife patients had higher odds of presenting in spontaneous labor (63.0% vs 53.3%, P<.001), while obstetrician patients had increased odds of receiving neuraxial anesthesia (72.3% vs 56.1%, P<.001) and were more likely to be nulliparous (56.4% vs. 50.3%, P=.01). There were no differences in frequency of APGAR scores less than 7 at five minutes between the two groups (2.5% for obstetrician vs. 1.7% for midwife, P=.204).

CONCLUSION:

In this rural academic tertiary care center, patients cared for by the midwife service have significantly lower odds of cesarean delivery than patients cared for by the physician-led service after adjustment for patient demographics and maternal medical conditions.
Use of Hand Expression of Breastmilk Within First Hour of Delivery to Increase Exclusive Hospital Breastfeeding Rate [40O]
Authors: Crowe Susan Diana , Miller Hayley , Faulkner Bethan , Lee Henry C.
Published: April 2020

INTRODUCTION:

Although most mothers in the United States initiate breastfeeding, formula supplementation during the hospital stay after delivery is common. Formula use may reflect a limited breastmilk supply. The impact of hand expression of breastmilk within 60 minutes of delivery as a means of improving breastfeeding outcomes in full term infants has not been studied.

METHODS:

Physicians and nurses were taught to instruct mothers on hand expression techniques during the first hour after delivery. Breastfeeding rates within the first hour of delivery and exclusive breastfeeding rates were determined via retrospective chart review of eligible patients admitted over a 7-month time frame. Patients were excluded if the infant was admitted to the neonatal intensive care unit. IRB waiver was obtained.

RESULTS:

Hand expression improved exclusive breastmilk feeding, even if there was no skin-to-skin care or breastfeeding within the first 60 minutes (53.3% vs 34.4%, P=.05). Hand expression resulted in significant improvements in actual breastfeeding within the first 60 minutes for both cesarean (90.1% vs 50.0%, P<.001) and vaginal deliveries (93.0% vs 68.5%, P<.001). Breastfeeding within 60 minutes of delivery was associated with a 62.2% rate of exclusive breastfeeding vs 46.3% (P<.0001) if first breastfeed took place after 60 minutes.

CONCLUSION:

Hand expression of breastmilk within the first hour of delivery was associated with increased rates of breastfeeding within that hour. Hand expression of breastmilk in the first hour was also associated with higher exclusive breastmilk feeding rates during the hospital stay. This practice could be a beneficial tool to improve breastfeeding outcomes.
Unmet Social Needs in the Prenatal Period: Effects on Birth Outcomes and Child Health [39O]
Authors: Sandoval Vida , Saleeby Erin , Jackson Ashaki , Smith Lynn , Schickedancz Adam
Published: April 2020

INTRODUCTION:

The impact of prenatal social needs, including food insecurity, on both perinatal and child health is not fully understood. It is clear that childhood social needs negatively impact child developmental and health outcomes. This study examines the extent to which prenatal social needs are associated with adverse pregnancy and child health outcomes.

METHODS:

We conducted a retrospective chart review of 268 mother-child dyads receiving prenatal and pediatric care at a large public, academically affiliated safety net medical center. All mother-child dyads who completed any pediatric clinic social need screening between October 2018 and July 2019 were included in the study. IRB approval obtained from LA-Biomed.

RESULTS:

Mothers who experienced prenatal food insecurity had higher odds of experiencing various social needs in the pediatric setting (odds ratio [OR] 3.57; 95% confidence interval [CI] 1.52–8.35, P=.003). Mothers experiencing prenatal food insecurity had 4.45 higher odds of having a child that was born premature at fewer than 36 weeks gestation (95% CI 1.33–14.91, P=.016). Mothers who had prenatal food insecurity also had children with higher counts of inpatient visits (incidence rate ratio [IRR] 2.49, 95% CI 1.07–5.82, P=.035) and missed immunizations (IRR 1.25, 95% CI 0.15–2.35, P=.026) in the first 6 months of life.

CONCLUSION:

Prenatal social needs, especially food insecurity, were found to be associated with adverse perinatal and pediatric outcomes, including prematurity, inpatient hospitalizations, and missed vaccinations. Social needs in the prenatal period may offer opportunities to intervene and reduce their impact on both perinatal and child health as well as family well-being.
The Influence of an Academic Hospitalist Model on Neonatal Outcomes [36O]
Authors: Pineles Beth , Corey Joey , Cuartas Karen , Wagner Stephen
Published: April 2020

INTRODUCTION:

Previous research has failed to demonstrate improved neonatal outcomes following implementation of a laborist model. Our goal was to examine if there was a difference in neonatal outcomes when labor and delivery was staffed with a private or academic hospitalist practice.

METHODS:

This retrospective cohort study was of a high volume community hospital labor and delivery unit. Institutional Review Board approval was obtained for this research. All deliveries by the laborist service over a six month period in 2018, three months by a private hospitalist group and three months by an academic hospitalist group, were examined. The primary outcome was a composite of neonatal morbidity that included: Apgar <3 at five minutes, shoulder dystocia, birth trauma, seizure, sepsis, necrotizing enterocolitis, intraventricular hemorrhage or mechanical ventilation Differences in outcomes were examined using chi-square tests. The results were presented as relative risk (RR) with 95% confidence interval (CI).

RESULTS:

245 patients were delivered by private physicians and 447 by academic physicians over the study period. There was no difference in a composite neonatal morbidity (9% vs 8%: 0.85 (0.49–1.46). NICU admissions were unchanged between the groups (8% vs 11%: 1.49 [0.85–2.62]). Transient tachypnea of the newborn (5% vs 7%: 1.30 [0.67–2.55]), hyperbilirubinemia (9% vs 14%: 1.52 [0.92–2.53]) and hypoglycemia (6% vs 10%: 1.68 [0.92–3.09]) were likewise similar.

CONCLUSION:

There was no difference in neonatal outcomes in patients delivered by private laborists or academic hospitalists.
Stillbirth and Fetal Autopsy Rates in the United States: Analysis of Fetal Death Certificates [35O]
Authors: Oliver Emily A , Rood Kara M. , Ma'ayeh Marwan , Berghella Vincenzo , Silver Robert R.
Published: April 2020

INTRODUCTION:

Fetal autopsy is recommended by ACOG as an important part of the evaluation of stillbirth. Stillbirth Collaborative Research Network data show that it can yield a probable or possible cause of stillbirth in approximately 80% of cases and is singularly useful in 42%. Rates of perinatal autopsy approach 100% in countries with similar resources. Our aim was to identify national rates of fetal autopsy and maternal and fetal characteristics related to consent to autopsy.

METHODS:

This is a population-based retrospective cohort study using United States Fetal Death certificates of stillbirths (20 weeks or over) delivered between January 2014 and December 2016. Multiple gestations were excluded. Fetal autopsy rates were calculated by gestational age, maternal age, race, education, and having at least one living child.

RESULTS:

There were 60,328 stillbirths meeting inclusion criteria. Fetal autopsy was performed in 20.9%. Increasing gestational age positively correlated (r=0.55; P=.003), while increasing maternal age negatively correlated with autopsy (r=-0.66; P <.001). Hispanic women had the lowest rates (17.8%), compared to non-Hispanic black (22.9%) and non-Hispanic white (20.5%) women (P<.001). Higher levels of maternal education were associated with increased rates, women with a Doctorate degree had twice the fetal autopsy rate (32.0%) than women with an educational level of 8th grade (15.3%) (P<.001). Women with at least one living child had lower rates of fetal autopsy (P<.001).

CONCLUSION:

Fetal autopsy rates are quite low throughout the US. The reasons for low autopsy rates warrant further exploration in order to inform strategies to increase availability and uptake.
Severe Fetal Acidemia Was Poorly Predicted by the Three-Tiered Fetal Heart Rate Interpretation System [33O]
Authors: Brendel Katelyn , Gan Sarah , White Chase , Goldberg Jay
Published: April 2020

INTRODUCTION:

The purpose of this study was to evaluate EFM during the hour prior to birth in babies born with an umbilical cord arterial pH <7 for predictors of severe acidemia.

METHODS:

A retrospective cohort study was performed on babies with umbilical cord arterial pH <7. The last hour of EFM was reviewed. Maternal, neonatal, labor and delivery characteristics were compared using the Chi-squared test for independence and the Fisher's Exact Test. IRB approval was obtained.

RESULTS:

30 babies were identified with umbilical cord arterial pH <7. 27%, 73%, and 0% of FHTs during the last hour of EFM of babies with severe acidemia were Category I, II, and III, respectively. 85% and 54% of the severely acidemic babies had moderate variability and accelerations, respectively. Only 8%, 8%, 19%, and 15% of severely acidemic babies had fetal tachycardia, fetal bradycardia, recurrent variable decelerations or recurrent late decelerations, respectively. Delivery was expedited only in the presence of recurrent late decelerations. The presence of a Category I tracing, moderate variability or accelerations was falsely reassuring such that delivery was less likely to be expedited.

CONCLUSION:

Usage of the three-tiered fetal heart rate interpretation system (Category I, II, and III) was not helpful in identifying babies born with umbilical arterial pH of <7. The majority of FHTs of these severely acidemic babies had moderate variability and accelerations, while less than 20% had fetal tachycardia, fetal bradycardia, recurrent variable decelerations or recurrent late decelerations.
Placental Abruption Is Not Associated With Clinically Significant Fetomaternal Hemorrhage [29O]
Authors: Boller Marie , Navarrete Emily , Hung Yun-Yi , Weintraub Miranda Ritterman , Moore Gaea S. , Schauer Galen M.
Published: April 2020

INTRODUCTION:

Fetomaternal hemorrhage (FMH) and placental abruption may both result in adverse fetal and neonatal outcomes but have differing pathophysiology. Abruption reportedly can lead to small volume FMH, but a positive test for FMH does not indicate a diagnosis of abruption.

METHODS:

We performed a case-control study within Kaiser Northern California (2008–2017), first identifying all cases of FMH within this time period (defined as a positive flow cytometry for fetal hemoglobin and adverse fetal or neonatal outcomes related to hypovolemia). Cases of FMH were compared to matched controls from the same delivery cohort. We reviewed delivery records and placental pathology reports to identify whether placental abruption was clinically suspected.

RESULTS:

Our study included 56 women in the FMH group and 132 in the control group. Concern for placental abruption was noted in 10.6% of those without FMH and in 12.5% of those with FMH, with no significant difference between the two groups (P=.71). The adjusted odds ratio was 1.33 (95% CI .49–3.62) after adjusting for maternal age and maternal race/ethnicity.

CONCLUSION:

Placental abruption is not more likely to occur in clinically significant FMH compared to other deliveries for which placental pathology is obtained. Obstetric providers should consider FMH and abruption as separate clinical entities. Flow cytometry for fetal hemoglobin should be ordered in the setting of clinical suspicion for FMH, unexplained intrauterine fetal death, or adverse outcomes related to fetal or neonatal hypovolemia. The Kleihauer-Betke and flow cytometry tests for fetal hemoglobin do not confirm or refute the possibility of abruption.
Outcome Reporting in Studies on Perinatal Venous Thromboembolism: A Systematic Review [28O]
Authors: King Alexandria , D'Souza Rohan D. , Herman Dylan , Malinowski Ann K.
Published: April 2020

INTRODUCTION:

The perinatal period places women at risk of developing venous thromboembolism (VTE). This systematic review aims to identify variation in outcome reporting in studies on the prevention and management of VTE in pregnant women, as a preliminary step towards developing a core outcome set to standardize outcome reporting in studies on perinatal VTE.

METHODS:

MEDLINE, EMBASE and www.clinicaltrials.gov were searched for clinical trials, registrations and observational studies with over 10 participants published between 1998 and 2018. Titles and full texts were screened in duplicate. Studies were classified as those focusing on VTE prevention vs. management. Reported outcomes were categorized under mortality, clinical, functional, resource use and adverse events based on a taxonomy of outcomes for medical research. Proportions of studies reporting each outcome were determined. Definitions and measurement tools were noted for each outcome.

RESULTS:

Of 7541 results screened, 69 studies (36 prevention+33 management) were included. Of the 165 outcomes, 25 were related to the fetus. Maternal outcomes mostly represented the clinical domain (96/152), with fewer adverse events (31), resource use (7), mortality (3) and functioning (3). There was very little consistency in how outcomes were defined or measured.

CONCLUSION:

Variation in outcome reporting and measurement in studies on perinatal VTE presents challenges for study comparison and meta-analysis. Outcomes related to fetal wellbeing, adverse events, resource use and functioning are inadequately represented. Qualitative interviews with patients and care providers to determine their perception on these outcomes is an important step in developing this core outcome set.
Obstetric Antecedents of Perinatal Clavicular Fracture [27O]
Authors: Denning Stacie , Clark Steven , Gandhi Manisha , Davidson Christina , Berra Alexandra
Published: April 2020

INTRODUCTION:

Perinatal clavicular fractures generally heal without sequelae, however their discovery may carry an inference of improper obstetric care. We sought to examine risk factors associated with the largest contemporary U.S. series of perinatal clavicular fractures.

METHODS:

A retrospective cohort study including all newborns with clavicular fracture, identified by coding data, born at our teaching institution between March 2012 and July 2019. The records of newborns with clavicular fracture were linked to their respective maternal charts. Clinical factors of interest were extracted and analyzed. Chi-square analysis was utilized.

RESULTS:

During the study time period, 132 neonatal clavicular fractures occurred in 25,760 infants born vaginally (0.51%). There was no difference in the rate of clavicular fracture when analyzed by parity, maternal diabetes, gestational age, prior cesarean delivery or length of second stage labor. A statistically significant increase in fracture was seen in macrosomic (>4,000 g) vs. non-macrosomic infants (2.13% vs. 0.41%, P<.001), attempted or successful operative vs. spontaneous vaginal delivery (0.99% vs. 0.48%, P=.014) and shoulder dystocia (3.99% vs. 0.44%, P<.001).

CONCLUSION:

Important risk factors for clavicular fracture were identified. However, the overwhelming majority of perinatal clavicular fractures occur in non-macrosomic infants with uncomplicated spontaneous deliveries following a normal second stage of labor. This highlights important biologic variability in the tolerance of infants to contraction-driven passage through the maternal pelvis without sustaining injury.
Neonatal Outcomes and Frequency of Ultrasound in Pregnant Women With Prior Bariatric Surgery [26O]
Authors: Wlodarczyk Katarzyna , Harrison Rachel , Allen Katherine , Semons-Booker Kia , Braun Emilie , Cruz Meredith
Published: April 2020

INTRODUCTION:

Infants of women who have undergone bariatric surgery are more likely to be born small for gestational age (SGA). We sought to identify whether increased ultrasound surveillance lead to better neonatal outcomes. We hypothesized that women with less than 2 ultrasounds (US) after their anatomical survey were more likely to have poor neonatal outcomes.

METHODS:

IRB approval was obtained. This was a single center, retrospective cohort study of 189 singleton pregnancies after bariatric surgery between 2005–2019. Patients were placed in 2 categories: those with less than 2 ultrasounds after fetal anatomic survey (FAS) or those with greater than or equal to 2 ultrasounds after FAS. US information and neonatal outcomes were compared between these two groups. A neonatal composite was utilized as a measure of adverse neonatal outcome.

RESULTS:

Of the 189 patients, 165 had documentation of FAS or beyond. 48 patients had less than 2 US and 117 had greater than or equal to 2 US. Women with less than 2 US had their last US at approximately 26.7 weeks (vs 36.5, P<.001), they were more likely to deliver at an earlier gestational age (36.6 vs. 38.2 weeks, P=.005), and had an increased likelihood of a composite adverse neonatal outcome (aOR 0.36, 95%CI 0.15–0.86) including NICU admission, jaundice, hypoglycemia, respiratory distress, and macrosomia, after controlling for confounders.

CONCLUSION:

Less frequent ultrasound surveillance in women with previous bariatric surgery is associated with earlier gestational age at delivery and higher rates of adverse neonatal outcomes.
Multidisciplinary OUD Group Prenatal Care Decreases NICU Admissions and Duration of Treatment for NAS [25O]
Authors: Cleary Erin , McKiever Monique , Gonzales-Brown Veronica , Hess Maryann , Talley Allison , Rood Kara M.
Published: April 2020

INTRODUCTION:

To compare neonatal characteristics among neonates born to women with opioid use disorder (OUD) on buprenorphine/naloxone medication assisted therapy (MAT) receiving traditional prenatal care (TPNC) or multidisciplinary OUD group (MOG) prenatal care.

METHODS:

A retrospective cohort analysis was performed of dyads treated with OUD on MAT who received TPNC or MOG prenatal care. MOG prenatal care is a comprehensive approach comprising of prenatal care and group counselling, social work, psychiatry, psychotherapy, mindfulness-integrated cognitive behavior therapy, pregnancy and OUD educational topics (breastfeeding, postpartum blues/depression, contraception, hepatitis C and Narcan administration).

RESULTS:

From July 2017 to June 2019, we identified 177 mother-infant dyads; 102 received TPNC and 75 received MOG prenatal care. Continuous data were analyzed for normality using the Shapiro-Wilk test. Student's t-test or Mann-Whitney U test were also employed. Categorical data analyzed with chi-square. Neonates born to mothers receiving MOG prenatal care were significantly less likely to require NICU admission (25.3% vs 41.2%, P=.048). Among neonates requiring NAS treatment, those born to mothers in MOG care had a significantly reduced duration of treatment (6 days vs 9 days, P=.001). Neonates born to mothers receiving MOG care were less likely to be treated for NAS, had a lower peak NAS score, higher birthweight and were less likely to be born prematurely; although these differences did not achieve statistical significance.

CONCLUSION:

Neonates born to mothers receiving MOG care were less likely to require NICU admission and had a shorter duration of NAS treatment.
Identification of Newborns With Birth Weight of 4,500 Grams or More: The Impact of Obesity [16O]
Authors: Blackburn Bonnie , Bicocca Matthew , Le Tran , Zhang Caroline , Sibai Baha M. , Chauhan Suneet P.
Published: April 2020

INTRODUCTION:

Obesity is a known risk factor for fetal macrosomia (birth weight [BW] greater than or equal to 4,500g), but prior studies examining its effect on sonographic estimated fetal weight (SEFW) have been equivocal. Our objective was to determine the impact of obesity on sonographic detection of macrosomia.

METHODS:

We performed a multicenter retrospective cohort study of all non-anomalous singletons with SEFW greater than or equal to 4,000g. All SEFWs were performed by Registered Diagnostic Medical Sonographers within 14 days of delivery and were calculated using a Hadlock equation. Patients were grouped according to body mass index (kg/m2) at delivery (<30.0 [non-obese], 30.0–39.9 [obese], and ≥ 40.0 [morbidly obese]). The primary outcome was the detection rate (DR) of macrosomic newborns. Secondary outcomes were false positive rate (FPR) and area under the receiver operator curve (AUC).

RESULTS:

Of the 330 women included, 83 (25.2%) were non-obese, 145 (43.9%) were obese, and 102 (30.9%) were morbidly obese. Overall there were 51 (15.5%) macrosomic newborns and its prevalence varied: 8.4% among non-obese, 14.5% among obese, and 22.5% among morbidly obese women. There were no significant differences in DR (42.9%, 52.4%, 60.9%; P=.67), FPR (7.9%, 9.7%, 10.1%; P=.87), or AUC (0.79, 0.77, 0.86; P=.51) for BW greater than or equal to 4,500 g between non-obese, obese, and morbidly obese women, respectively.

CONCLUSION:

Maternal obesity does not influence sonographic detection of newborns with BW of at least 4,500 g. Clinicians should not consider maternal obesity to be a limitation for identification of macrosomic newborns.
POC Assessment of Combined Umbilical Arterial and Venous Lactate: A Potential Screening Test for Neonatal Acidosis [OP04-7D]
Authors: Yordán Nora Torres , Lewis Ayodele G. , Brewster Reginald M. , Tolan Nicole V. , McElrath Thomas F. , Greenberg James A.
Published: April 2020

INTRODUCTION:

Umbilical artery (UA) lactate and pH aid the diagnosis of neonatal acidosis. This study examines the relationship between point-of-care (POC) measurement of combined umbilical arterial and venous (CUAV) lactate and UA lactate and pH to determine whether this POC assessment could serve as an alternative screening modality for neonatal acidosis.

METHODS:

In this prospective cohort study, UA and CUAV cord blood samples were collected from vaginal and cesarean deliveries occurring between June and August 2019 at a tertiary care center. UA samples were analyzed for pH and lactate using a standard laboratory blood gas analyzer (GEM 4000). CUAV lactate was analyzed at the POC (StatStrip Xpress Lactate Meter, off-label indication, IRB-approved) as well as on the blood gas analyzer. Short-term neonatal outcomes, including 1- and 5- minute APGAR scores and NICU admission rates were also assessed.

RESULTS:

N=190. There was a statistically significant correlation between POC CUAV lactate concentrations and UA lactate concentrations (R2=0.806 P=2.2 x 10-16). Additionally, there was a statistically significant correlation between the CUAV lactate concentrations obtained using the POC device and the GEM analyzer (R2=0.934 P=2.2 x 10-16). R2=0.95 for technical replicates of POC CUAV lactate concentration measurements. There was no statistically significant association between POC CUAV lactate and UA pH (R2=0.223 P=2.4 x 10-6).

CONCLUSION:

POC testing of CUAV lactate is reliable and closely correlated with UA lactate concentrations, making POCT CUAV lactate a feasible screening test for neonatal acidosis. More data is needed to establish the sensitivity and specificity of this test and its association with clinical neonatal outcomes.
Multimodality Therapy Associated With Improved Outcomes in Patients With MSI-High Advanced Endometrial Carcinoma [33H]
Authors: McEachron Jennifer , Zhou Nancy , Spencer Christina , Chatterton Carolyn , Singhal Pankaj K. , Lee Yi-Chun
Published: April 2020

INTRODUCTION:

Evidence suggests patients with microsatellite instability-high (MSI-high) endometrial carcinoma (EC) derive greater benefit from radiation therapy than their microsatellite stable counterparts. In the present study, we evaluated outcomes of MSI-high advanced EC treated with a combination of chemotherapy-radiation (C-RT) versus chemotherapy (CT) alone to determine if there is a progression free survival (PFS) benefit associated with a particular adjuvant therapy regimen.

METHODS:

From 2000 – 2016, a multicenter retrospective analysis of patients with MSI-high, stage III/IV EC was conducted. Inclusion criteria were patients with MSI-high EC who had undergone comprehensive surgical staging, followed by adjuvant CT or C-RT. MSI status was determined by immunohistochemistry (IHC) and molecular tumor profiles. Differences in the frequencies of histology, stage and cytoreduction status were identified using Pearson’s chi-square test. PFS was defined as time of surgery to time of recurrence. PFS rates were calculated using Kaplan-Meier estimates. IRB approval was obtained.

RESULTS:

Final analysis included 37 patients; 55% (n=20) C-RT and 29.5% (n=17) CT. The median age was 62 years (range 51-81); histology included 48.6% endometrioid, 40.5% serous, and 10.7% clear cell tumors. 92% of patients underwent optimal cytoreduction. There was no difference in the frequency of histologic subtypes (P=.83), stage (P=.12) or cytoreduction status (P=.73) between treatment regimens. There was a significant improvement in PFS in patients receiving C-RT (24 months) versus CT (17 months) which demonstrated a superior 2-year PFS compared to CT (40.0% vs 29.5%; P=.04).

CONCLUSION:

Multimodal adjuvant therapy with C-RT was associated with improved PFS in patients with MSI-high advanced EC.
Pediatric Gynecologic Malignancy and DICER1: A Case Series That Further Elucidates the Phenotype [35H]
Authors: Hayes Katherine , French Amanda
Published: April 2020

INTRODUCTION:

Pediatric gynecologic malignancies are rare and may be linked to genetic syndromes. DICER1 syndrome, an emerging entity first described in pleuropulmonary blastoma, was more recently identified as a hereditary tumor predisposition syndrome that can be associated with gynecologic malignancies. Gynecologic manifestations of DICER1 syndrome have been described in single or small case reports with an array of pathologic findings. We seek to better define tumor pathology that should prompt testing for DICER1.

METHODS:

An IRB approved, retrospective chart review was conducted for all female patients less than 25 years old with sex cord stromal tumors at our institution between 1990 and 2019. Patients were included if they had a diagnosis of DICER, Sertoli-Leydig tumor, rhabdomyosarcoma, gynandroblastoma, or mixed sex cord stromal tumor.

RESULTS:

We identified 21 patients meeting inclusion criteria. Histologic descriptions were noted to be similar across all tumor types with all but one having numerous similarities. Seventeen had genetic testing of any type, although not all were identified for DICER1 testing. Nine of these (53%) had a somatic or germline DICER1 mutation.

CONCLUSION:

DICER1 syndrome is not well known in the gynecologic community. Although the histology of these tumors is complex and variable, a clear pattern emerges from our series. We present this as a phenotype that should prompt testing for DICER1, as the implications of germline mutations are lifelong. Obstetrician/gynecologists play an important role in testing, surveillance and diagnosis of additional primary tumors as the risk begins with conception and continues throughout the lifespan.
Preoperative Intrathecal Opioid Injection on Postoperative Analgesia Requirements in Gynecologic Oncology [37H]
Authors: Hou Eileen , Wheeler Michelle , Ioffe Yevgeniya , Yao Ruofan , Nour Mohamed , Hong Linda
Published: April 2020

INTRODUCTION:

Decreasing opioid use during postoperative period is a topic of great ongoing interest. We aimed to determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduced intravenous (IV) opioid use after exploratory laparotomy in gynecologic oncology surgeries.

METHODS:

A retrospective chart review with institution IRB approval of 314 consecutive gynecologic oncology patients undergoing exploratory laparotomy from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were self-reported post-operative pain levels and IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. The relationship between ITO and primary outcomes of interest were determined using longitudinal regression analysis and adjusted for confounding variables.

RESULTS:

34% (107/314) received ITO preoperatively. There were no differences in patient age, BMI, number of prior abdominal surgeries, history of opioid dependence, or EBL between the ITO and control groups. Preoperative ITO was associated with significantly lower IV opioid requirement between 0-6 hours after surgery (9.7±8.1 vs 14.3±11.5, P<.0001) and between 6-12 hours after surgery (2.7±3.8 vs 5.4±9.5, P=.0054). In addition to reduced IV opioid use in ITO group, no differences in self-reported postoperative pain levels were noted in the first 48 hours post-operatively.

CONCLUSION:

Preoperative ITO reduced postoperative opioid requirement for pain control without negatively affecting patients’ self-reported pain level.
“I’m Not Going to Jail for This,” an Analysis of Anesthesia Providers’ Responses to Georgia’s 22-Week Abortion Ban [01I]
Authors: Reeves Jennifer A. , Goedken Peggy , Cwiak Carrie , Hall Kelli
Published: April 2020

INTRODUCTION:

State-level legal regulations affect abortion provision in the United States. Anesthesia providers participate in abortion care, and their understanding of legal regulations may impact their willingness to participate in hospital-based abortion care.

METHODS:

In-depth qualitative interviews were conducted with currently-practicing anesthesia providers, who care for obstetric (OB) patients. A semi-structured interview guide elicited information on providers’ personal abortion attitudes through case-based examples and a discussion of Georgia’s (GA) 22-week abortion ban. Data were analyzed in an iterative fashion using both inductive and deductive approaches.

RESULTS:

Thematic saturation of the primary aim occurred after 15 interviews. Participants represented many provider types, including anesthesiologists, certified and student registered nurse anesthetists, certified anesthesiology assistants, and anesthesiology residents. Most participants practiced general or OB anesthesiology in a hospital setting (n=14). Two-thirds of participants reported prior participation in abortion (n=10). Most providers had little to no prior knowledge of GA’s 22-week abortion ban (n=11) and perceived an overall neutral or negative impact of the law on OB practice (n=13). Prominent themes that emerged from the data included “fear of criminality,” “transfer of responsibility to the law,” and “retroactive versus proactive medical care,” which described how anesthesia providers reacted to state-specific legislation on abortion.

CONCLUSION:

Anesthesia providers are not well-informed of state-specific abortion legislation and demonstrate a mixed response to such laws. After introduction of GA’s 22-week ban, many participants reported a more conservative approach to participating in hospital-based abortion care, which affects abortion access in this setting.