bluuebunny/crossref_metadata_2025 huggingface dataset:
Integrating Doulas Into Hospital Births: Provider Perceptions of Doulas and Doula Care [22C]
Authors: Neel Kira , Goldman Roberta , Nothnagle Melissa
Published: May 2019

INTRODUCTION:

A birth doula provides continuous informational, physical and emotional support during pregnancy, labor and immediately postpartum. Existing published data on the health benefits of birth doulas, especially for low-resource, high-need patients, do not address how and why individual providers decide to utilize or encourage this model of care. This research project aims to fill a gap in the literature describing best practices of integrating doulas into hospital based maternity care teams in order to facilitate access to this evidence-based service for improving maternal health outcomes.

METHODS:

Semi-structured interviews using open-ended questions were conducted in person with 47 maternity care providers across 3 hospitals. A purposive sampling approach included OB/GYN and family medicine physicians, RNs, and nurse midwives. Interviews were audio-recorded, professionally transcribed, and analyzed using the Template Organizing style qualitative analysis approach. The organizing framework was the doula model of care.

RESULTS:

The codebook was based on the doula model of care framework, existing literature on doulas and doula care, and topics in the interview guide. Results demonstrated varied support for doula care given providers' experiences. Suggestions to facilitate good working relationships centered on three overlapping themes: education, role clarification, and mutual respect.

CONCLUSION:

Preliminary findings suggest that doula care may be well-received in hospital settings with adequate staff training on the doula model of care, explicit definition of roles, and doulas working closely with providers. Findings will inform the development of evidence-based trainings and education on how to facilitate good working relationships to incorporate doulas into maternity health care teams.
Interdisciplinary Implementation of Quantification of Blood Loss During Vaginal and Cesarean Delivery [23C]
Authors: Savoie Marissa B. , Gomez Axel , Bernstein Laurel , Delgado Ana , Newmann Sara Jeanette
Published: May 2019

INTRODUCTION:

Delayed recognition of blood loss is associated with preventable post-partum morbidity and mortality. Visual estimation of blood loss is inaccurate. Quantification of blood loss (QBL), a weight and volume-based method, was incorporated into the California Maternal Quality Care Collaborative Obstetric Hemorrhage Toolkit. We implemented QBL recommendations for vaginal and cesarean deliveries in an urban hospital-based birth center and followed compliance data over 9 months.

METHODS:

First-year medical students, as part of an interdisciplinary quality improvement team, championed the implementation of QBL for vaginal deliveries (starting December 2017), then for cesarean deliveries (starting March 2018). QBL protocols were designed by the team. Adoption of QBL was supported and evaluated by a multi-component intervention consisting of in-service and online trainings, worksheets, visual aids, surveys, and qualitative interviews. Documentation of QBL at all deliveries was assessed weekly, with a goal of 80% QBL.

RESULTS:

The average QBL compliance for vaginal and cesarean deliveries was 90% over 9 months and 85% over 6 months, respectively (772 births total). While most providers and nurses indicated that QBL was important, key issues raised included how QBL changes management during post-partum or intra-operative hemorrhage, feasibility during an emergency, and nursing workflow.

CONCLUSION:

Our multi-component intervention and evaluation process resulted in successful implementation of QBL at an urban hospital-based birth center. Medical students played a key role in the project illustrating benefits of student involvement in quality improvement work. The effect of QBL on post-partum morbidity and mortality has yet to be explored.
Management of Intraamniotic Infection After Spontaneous Vaginal Delivery: Is Nothing Really Enough? [24C]
Authors: Daifotis Helen , Smith Megan , Denoble Anna Elisabeth , Dotters-Katz Sarah
Published: May 2019

INTRODUCTION:

Current guidelines for management of intraamniotic infection (IAI) call for intrapartum antibiotic therapy, without further treatment after spontaneous vaginal delivery (SVD) except in high-risk women. High-risk criteria are not well-defined. We aim to describe the incidence of and identify risk factors for postpartum infectious complications (PPI) after SVD complicated by IAI.

METHODS:

Case control study of SVDs with clinically diagnosed IAI at a single academic center. Cases were defined as women who developed PPI, including endometritis, perineal infection, sepsis, urinary tract infection (UTI), or pyelonephritis. Cases were compared to those who did not develop PPIs (controls) using bivariate statistics. IRB approval was obtained prior to commencement of this study.

RESULTS:

Between 01/01/2014 and 12/31/2017, 346 women underwent SVD complicated by IAI. Of these, 23 (6.2%) developed PPI (endometritis n=7, UTI/pyelonephritis n=6, sepsis n=4, perineal infection n=6) within 6 weeks of delivery. No differences in demographic data or antepartum complications were observed. Women with PPI were not more likely to receive antibiotics intra- or postpartum, however were more likely to deliver prior to 32 weeks (17.4% vs 4.9%, P=.04). When controlling for antibiotic use intra- and postpartum, delivery at <32 weeks was associated with 3.8-fold increased (95% CI 1.07, 13.7) odds of PPI.

CONCLUSION:

Postpartum infectious complications occur in approximately 1/15 women delivering vaginally with IAI, with those who deliver at <32 weeks' gestation being at increased risk. Though no specific guidelines for postpartum antibiotic therapy in the setting of IAI exist, women delivering before 32 weeks may warrant consideration of postpartum antimicrobial therapy.
Maternal Weight Gain and Neonatal Outcomes in Women With Class III Obesity [29C]
Authors: Reiff Emily S. , Adkins Lamani , Tucker Ann Robin , Gatta Luke , Brown Haywood L. , Dotters-Katz Sarah Kathleen
Published: May 2019

INTRODUCTION:

Class III obesity is an independent risk factor for neonatal morbidity. Institute of Medicine (IOM) guidelines recommend 11-20 lbs of gestational weight gain (GWG) in women with obesity. We evaluated the association between GWG and neonatal outcomes in women with Class III obesity.

METHODS:

Retrospective cohort of women delivering a liveborn neonate at term at a single institution between 7/2013-12/2017 with a baseline BMI ≥40 in the first trimester. Pregnancies complicated by multiple gestation or fetal anomalies were excluded. Primary outcome was a neonatal composite including 5 m apgar <7, intubation, grade 3/4 IVH, sepsis or intensive care unit (NICU) admission. Secondary outcomes included NICU admission >7 days. Demographic, pregnancy & delivery characteristics of women who gained >20 lbs (mIOM) were compared to those that gained <20 lbs (lIOM) using bivariate statistics. Stepwise backward regression was used to estimate odds ratios.

RESULTS:

Of 374 women, 144 (38.5%) gained mIOM, who were less likely to be multiparous, use tobacco or have a lower BMI at delivery. The neonatal composite occurred in 30 (8.0%) neonates, 16 (11.1%) in mIOM versus 14 (6.1%) in the lIOM group (p=0.12, OR=1.93, 95% CI 0.91,4.08). When adjusted for multiparity and BMI at delivery, the aOR was 1.55 (95% CI 0.85-2.82). Neonates in the mIOM group were more likely to be admitted to the NICU (10.4% v 4.4%, p=0.03, OR=2.56, 95% CI 1.12-5.86) and have an admission >7days (6.9% v 2.2%, p=0.03, OR=3.36, 95% CI 1.12-10.03).

CONCLUSION:

In women with class III obesity, excess GWG was associated with increased odds of NICU admission and admission >7 days.
Normal Reference Values for Percent Body Fat at Term [30C]
Authors: Stark Sydney , Weatherborn Megan , Landau Daphne
Published: May 2019

INTRODUCTION:

Birth weight percentiles provide limited information on neonatal nutritional status. Body composition may be a better indicator as it provides estimates of percent lean and fat mass. We sought to create a normal reference range for percent body fat (%BF) at term.

METHODS:

On admission, all term infants in our nursery undergo assessment of percent body fat by a validated Anthropometric Model. For this analysis, infants were grouped by sex then categorized by completed gestational age (GA). Subjects with incomplete data were excluded. Data was examined for equal variance and then analyzed using the appropriate Student t test. One way ANOVA was used to compare %BF between 5 gestational age groups (37, 38, 39, 40, and 41 completed weeks) for each sex. Data was expressed by mean and SD. P<.05 was considered significant.

RESULTS:

Our total cohort included 1336 infants, 715 male and 621 female, analyzed separately. Birthweight was 3.302 kg (±0.45) in males and 3.138 kg (±0.45) in females. There was no significant difference between the mean %BF for males 12.77% (±3.53) and females 12.705% (±3.57), (P=0.72). There was a significant difference in %BF at each completed week of gestational age; this was true for both male and female infants (P<.00001).

CONCLUSION:

The results of this pilot study establish a normative reference curve for gender and gestational age-specific %BF at term. These data have potential clinical and research applications for understanding newborn nutritional status.
Osteosarcoma During Pregnancy: Case Report and Review of the Literature [32C]
Authors: Urbina Josephine Paula , Scott Elizabeth , Aikman Noelle Marie
Published: May 2019

INTRODUCTION:

To present a case report and review the literature on osteosarcoma during pregnancy

METHODS:

31 year old para 1 female with a prior history of cesarean delivery complained of dull pain in her right knee not relieved with rest during her 2nd trimester. Both x-ray and MRI revealed “abnormal appearance of distal femur,” possibly secondary to tumor or osteomyelitis. After multiple biopsies, she was diagnosed with high grade osteosarcoma. A subsequent CT chest showed nodules possibly representing metastasis. She underwent delivery by repeat cesarean at 29 weeks gestation after receiving antenatal steroids, as recommended by a multidisciplinary team. Her postpartum course was uncomplicated and she was discharged on post-op day 3. She began neoadjuvant chemotherapy with doxorubicin, cisplatin and ifosfamide within 4 weeks of delivery.

RESULTS:

5 studies were identified reporting on a total of 16 patients diagnosed with osteosarcoma during pregnancy. The age range was 16 to 38. Most common presenting symptoms were pain, enlarging mass and fractures. Metastasis were identified in 9 patients. Most patients underwent vaginal delivery at term. Four patients underwent surgical resection during pregnancy. Most patients underwent chemotherapy. 6 patients eventually succumbed to the disease. Of those, one patient was diagnosed postmortem and never received treatment.

CONCLUSION:

Osteosarcoma in pregnancy is rare. Risks and benefits of early delivery versus delaying maternal therapy have to be weighed in an aggressive malignancy such as this. Long term maternal and neonatal outcomes have to be considered. Our experience was consistent with more recently published case reports and case series.
Rates of Cesarean Conversion in Planned Vaginal Twin Deliveries: Do We Need the Operating Room? [39Q]
Authors: Mei Jenny Y. , Szlachta-McGinn Alec W. , Munoz Hector Enrique , Rao Rashmi , Datkhaeva Ilina , Afshar Yalda
Published: May 2019

INTRODUCTION:

We aimed to investigate rates of cesarean conversion for planned twin VDs and identify predictors and outcomes of conversion.

METHODS:

A retrospective cross-sectional study of women who underwent planned twin VD at a large academic hospital over four years (IRB#18-000872). Demographic and outcome data were chart abstracted. Logistic regression was used to analyze predictors of conversion and Welch two-sample t- test was used to compare outcomes.

RESULTS:

405 twin deliveries were identified; 60 (14.8%) were planned VD. Of these, 40 (66.7%) were cephalic/cephalic and 20 (33.3%) cephalic/breech presentation. Median maternal age was 33.9 years (IQR 31.6-35.9). Median gestational age (GA) was 36 weeks (IQR 35-38). Conversion to cesarean delivery (CD) occurred in 4 planned VDs (6.7%). Of these, 1 (1.7%) was emergent for fetal bradycardia and 3 (5%) were for malpresentation of Twin B, 2 of which involved providers inexperienced with breech extractions of second twin. There were no significant predictors of conversion to CD, including BMI, maternal age, antepartum length of stay (LOS), GA at delivery, parity, presentation, or type of OB provider. There was no correlation between conversion to CD and postpartum LOS (P=0.12). There were no correlations with neonatal APGARs at 1 and 5 minutes for twin A (P=0.26, P=0.75) or twin B (P=0.86, P=0.51).

CONCLUSION:

Successful VD is achieved in 93.3% of planned VD of twins. Need for emergent conversion to CD, requiring immediate OR availability, is very low. Planned vaginal twin deliveries can be safely performed in Labor and Delivery rooms to optimize costs and resource utilization.
Post-Partum Contraception; Does Standardized Video Counseling Increase Long Acting Reversible Contraceptive Use [2R]
Authors: McGregor Ali , Hackney David , Ugwuegbu Obinna , Akesson Cydni , Perriera Lisa
Published: May 2019

INTRODUCTION:

To assess if a standardized contraceptive counseling video increases selection of long acting reversible contraceptive (LARC) methods in the immediate postpartum period.

METHODS:

This randomized control trial assessed postpartum contraceptive choices of women receiving care at an urban clinic. On postpartum day 1, after consenting to participation, women were surveyed regarding contraceptive and breastfeeding plans, and were randomly assigned to watch a 10 minute standardized video about contraceptive options or to receive standard postpartum care. They completed a follow-up survey on postpartum day 2 to assess contraceptive choice. Chart review was completed 12 weeks postpartum to determine postpartum visit attendance and contraceptive method received. We estimated a sample size of 238 to have 90% power with an alpha of 0.05 to detect a 20% difference in LARC selection.

RESULTS:

We enrolled 127 women in the intervention group and 123 women in the control group with 38.1% and 33.3% choosing LARC methods respectively (P=0.58). There was also no significant difference in the percentage that returned for a postpartum visit (P=0.43), or that received a LARC method (P=1.0). The majority of women did not change their contraception choice between surveys 1 and 2, and 32.5% patients entered the study already wanting a LARC method.

CONCLUSION:

Watching a standardized contraceptive counseling video in the postpartum period did not increase the number of patients who chose a LARC method. Selection of contraceptive methods during antenatal care may have a higher impact on utilization of an effective method in this patient population.
Gabapentin as an Adjunct to Perioperative Pain Management for Surgical Abortion: A Randomized Controlled Trial [10S]
Authors: Hailstorks Tiffany , Cordes Sarah , Cwiak Carrie , Enriquez Christian , Moore Renee , Haddad Lisa
Published: May 2019

INTRODUCTION:

The use of gabapentin in the setting of surgical abortion has never been evaluated; however, it is used successfully in similar surgical settings as an adjunct to pain management. We sought to evaluate the impact of Gabapentin on perioperative pain during first trimester abortion with local anesthesia.

METHODS:

We conducted a randomized double-blinded placebo-controlled trial of gabapentin 600 mg given 1-2 hours pre-operatively among subjects receiving a 1st trimester surgical abortion under paracervical block. The primary outcome was pain on a 100-mm visual analog scale (VAS) measured at 6 time points perioperatively. To assess changes in pain measures, an intention to treat (ITT) mixed effects model was fit with treatment group (Gabapentin vs. Control) as a between-subjects factor and time point as a within-subjects factor plus their interaction term. Using Fisher's exact tests, we examined any group differences in the percentage of patients who reported side effects post procedure.

RESULTS:

Among the 115 randomized, most subjects were Black/African American (69.6%), average age was 26 years (+/-5.6), and mean gestational age was 61.8 days. There were no significant changes in pain score preoperatively or intraoperatively. Subjects who received gabapentin had significantly lower levels of pain at 10 minutes postsurgery [mean difference (SE) = -13.0 (-5.1), p-value = 0.01] and 30 minutes postsurgery [-10.5 (-5.1), p=0.04] as compared to subjects who received placebo. Side effects were rare, of low severity, with no significant difference between groups.

CONCLUSION:

Post-operative pain scores were lower among subjects receiving Gabapentin preoperatively compared to placebo, thus improving recovery.
Trends in Gestational Weight Gain and Birth Weight in Pre-Existing Diabetic Women [13S]
Authors: Zhang-Rutledge Kathy , Kabacka Julia , Laurent Louise , Ramos Gladys A.
Published: May 2019

INTRODUCTION:

Excessive gestational weight gain (GWG) has been linked to fetal overgrowth. Diabetes mellitus (T2DM) and obesity are known independent risk factors for abnormal fetal growth. The aim of this study is to evaluate the trend in GWG and the relationship between GWG and neonatal birthweights in women with and without T2DM.

METHODS:

This is a retrospective review of singleton gestations with T2DM who delivered at the University of California - San Diego (UCSD) from 2011 to 2017. The control population was all singleton gestations without T2DM at UCSD in 2016. Recommendations for GWG were based on Institute of Medicine (IOM) guidelines. The study was approved by the Institutional Review Board at UCSD. Statistics were performed using Pearson chi-square test.

RESULTS:

The study included 346 patients with T2DM and 1126 controls. Patients with T2DM and controls had similar rates of excessive GWG among the weight categories except in the overweight population, those with T2DM were less likely to have excessive GWG compared to controls (34.2% vs 59.1%, P=<.01). Compared to controls, those with T2DM who gained within and above the recommended GWG were more likely to have large for gestation (LGA) neonates [RR = 10.2, P<.01; RR = 4.3, P<.01, respectively]. The rate of LGA was highest in those with T2DM who gained at or above IOM guidelines.

CONCLUSION:

Patients with T2DM do not gain more weight during pregnancy when compared to normal controls, however they are more likely to have LGA neonates.
Ultrasound-Indicated Cerclage Placement in Early Preterm Birth Prevention in Women Without Prior Preterm Birth [15S]
Authors: Srinivasan Aarthi , Garneau Audrey , Love Paige Effie , Qi Ya , Critchfield Agatha
Published: May 2019

INTRODUCTION:

To determine if cervical cerclage placement plus vaginal progesterone for short cervix decreased the risk for preterm birth in singleton gestations without prior spontaneous preterm birth.

METHODS:

This was a retrospective cohort study. Electronic charts of patients with singleton gestations with short cervix between 2007-2017 at the University of Kentucky were reviewed. Those without prior preterm birth with cervical length <25 mm between 16 0/7 and 23 6/7 weeks of gestation were eligible. All women received vaginal progesterone. A subgroup also undergoing cervical cerclage were compared to those on vaginal progesterone alone. Those receiving cerclage and progesterone at a cervical length <15 mm were also compared to the medication only group. The primary outcomes were mid-trimester and early preterm birth. Secondary outcomes included mean gestational age of delivery, birth weight, 1 and 5-minute APGARS.

RESULTS:

Out of the 55 eligible patients, 20 cases who underwent cerclage and vaginal progesterone were compared with 35 women who received vaginal progesterone alone. Rates of preterm birth <28 weeks (OR, 1.73, 95% CI 0.22-13.60) and <34 weeks (OR, 2.77, 95% CI, 0.40-18.74) were similar in both groups. No difference in the rates of preterm birth <28 weeks and <34 weeks of gestation in the sub-group with a cervix <15 mm was observed as well. Mean gestational age at delivery (36.2±4.9 weeks vs. 36.7±4.3, P=0.76), mean birth weights (2907±1198 grams vs. 2929±733 grams, P=0.94), 1-minute APGAR and 5-minute APGAR scores were also similar.

CONCLUSION:

Cervical cerclage placement in addition to vaginal progesterone does not appear to be beneficial for short cervix in low risk population in the prevention of spontaneous preterm birth.
Variation in Outcome Reporting in Studies on Obesity in Pregnancy—A Systematic Review [20S]
Authors: Dadouch Rachel , Faheim Mina , Susini Orsolina , Showell Marian , D'Souza Rohan D.
Published: May 2019

INTRODUCTION:

Improving outcomes in women with obesity (BMI>30 kg/m2) in pregnancy is limited by the heterogeneous outcomes between clinical trials. This systematic review of antepartum and peripartum interventions/exposures aimed to determine outcomes and their definitions reported thus far, as a preliminary step towards the standardization of outcomes.

METHODS:

MEDLINE, Embase, CENTRAL and www.clinicalTrials.gov were searched for trials, secondary analyses and systematic reviews in English between 01 January 2000 and 20 November 2017. Grey literature and reference lists of included studies were searched. Title/abstracts and full-texts were screened in duplicate. The following data were extracted: study characteristics, primary, secondary maternal, fetal and neonatal outcomes (including composites), their definitions or measurements and outcome reporting quality (MOMENT criteria). The proportion of studies reporting each outcome, a primary outcome and variations in definitions and components of composite outcomes were determined.

RESULTS:

Of 4916 results screened, 218 full-texts were assessed and 70 included. 173 maternal/obstetric outcomes and 86 neonatal/fetal outcomes were reported. 49 of the 58 trials/registrations reported a primary outcome, 21 of which were not in a reproducible way. The most frequent maternal outcome was gestational weight gain (24 studies) with inconsistent definitions between studies. The most frequent fetal/neonatal outcome was birthweight (17 studies). There were three maternal composite outcomes, one fetal/neonatal and one combined. No maternal composite comprised the same components.

CONCLUSION:

The high number of outcomes prevents the reporting of relevant outcomes in all obesity in pregnancy studies. Further, inconsistencies and variations between outcome choices and definitions identified present challenges for study comparability and data aggregation.
Understanding Decision Making and Barriers to Fertility Preservation in Young Women With Cancer [21S]
Authors: Gadson Alexis K. , Lindsay Sarah F. , White Katharine O. , Woodhams Elisabeth J.
Published: May 2019

INTRODUCTION:

Many women recognize a cancer diagnosis as a time to evaluate their desire for future fertility. While financial barriers to fertility preservation are well documented, other barriers are not often addressed. We sought to explore patients' experiences when considering fertility preservation options after cancer diagnosis and their perceived barriers to pursing those options.

METHODS:

We conducted twenty semi-structured interviews with female oncology patients ages 18-45 years who were stable on treatment or had completed therapy within the last 24 months at an urban northeast medical center. We analyzed data using direct content analysis using the Promoting Action on Research Implementation in Health Services (PARiHS) framework. We continued participant recruitment until we reached thematic saturation.

RESULTS:

Patients struggle to process complex, future-based decision-making when coping with a cancer diagnosis. Three subthemes emerged: 1) patients' personal biases and fears, rather than data, about pregnancy post-chemotherapy contribute notably to decision making; 2) patients perceive biases from their providers against fertility preservation; and 3) fertility desires are fluid, thus patients may regret not exploring fertility preservation options.

CONCLUSION:

Decision-making regarding fertility preservation in women with a cancer diagnosis is complex. Within the current model of care, patients may not be able to fully explore their fertility preservation options, particularly in the acute diagnosis setting. A shared-decision making approach, with their own obstetrician–gynecologist, may facilitate difficult decision-making. The general obstetrician-gynecologist may play a crucial role in helping patients to navigate their desires to engage in fertility preservation options after the specialist consult.
3-D Ultrasound is Accurate for Follicular Monitoring But Does Not Reduce Time to Perform [28S]
Authors: Sauerbrun May-Tal , Ghidei Luwam , Huber Warren J. , Wu Xiaotian , Alvero Ruben , Wang Shunping
Published: May 2019

INTRODUCTION:

Objective: To assess time-savings and accuracy of 3-D versus 2-D ultrasound (US) for follicular monitoring during in vitro fertilization (IVF) cycles.

METHODS:

Patients undergoing IVF stimulation cycles at our fertility center from February 23rd to March 2nd 2018 had both 2-D and 3D US during each follicular monitoring appointment. During the 3-D US, SonoAVC software was utilized to automatically measure ovarian follicles in three dimensions. During the 2-D US, each follicle was measured in two dimensions and the mean was calculated. A Pearson's correlation test was used to compare the mean diameters of each follicle in 3d vs 2d. An equation to predict 2D mean follicular diameters from 3D data was developed using linear regression. A paired T-test was used to compare the time to perform each study.

RESULTS:

Eight ultrasounds evaluated 91 follicles with both 2D and 3D modalities. The correlation for the mean follicular diameter is 0.82 with p-value < 0.001 suggesting that the 3D and 2D follicular measurements are highly correlated. Using Linear regression we calculated a correction factor to convert 3D mean diameters (X) to 2D mean diameters (Y) and our equation is Y = 0.726X+3.987. The average time to perform the 3D and 2D study was 6.4 and 7.3 minutes respectively, which is not statistically different.

CONCLUSION:

3D follicular monitoring can substitute for 2D monitoring with consistency in terms of follicle measurements, however the shorter time to perform the study is not statistically significant. Additional studies are needed before recommending 3D Ultrasound/SonoAVC as a more efficient method.
Should ACOG Reconsider Their Criteria for the Early Diagnosis of Hypertension in Pregnancy? [32P]
Authors: Hussain Farrah N. , Grubman Olivia , Taylor Dyese , Chu Lam Melissa T. , Al-Ibraheemi Zainab Q. , Brustman Lois E.
Published: May 2019

INTRODUCTION:

In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines for the evaluation of high blood pressure (BP). These lowered definitions for hypertension include: normal (<120/80 mmHg), elevated (120-129/<80 mmHg), stage 1 (130-139/80-89 mmHg), and stage 2 hypertension (≥140/90). Conversely, ACOG defines chronic hypertension as the presence of systolic BP≥140 mmHg or diastolic BP≥90 mmHg on 2 occasions before 20 weeks' gestation. There are limited data on the impact of hypertension as defined by the ACC/AHA in pregnancy. We aim to determine if there is a relationship between elevated or stage 1 hypertension in the first trimester and pregnancy-induced hypertensive disorders (PIH).

METHODS:

In this IRB approved retrospective cohort study, we examined singleton pregnancies, registered in the first trimester and diagnosed with PIH (gestational hypertension, preeclampsia +/- severe features, and HELLP) at an urban hospital between March and September 2018.

RESULTS:

110 patients were included: 61.8% of the study population had elevated (22.7%) or stage 1 (39.1%) hypertension. The mean age was greater in normotensive patients (p=0.03). Otherwise, demographics, gestational age (p=0.27), and timing of delivery (p=0.41) were similar between hypertension groups. Neither the incidence of PIH nor the specific PIH diagnosis were associated with hypertension status in the first trimester (p=0.08).

CONCLUSION:

Our data suggests no association between ACC/AHA hypertension status in the first trimester and PIH. However, over 60% of patients would be classified as early/stage I hypertension. Therefore, further evaluation of the incidence of ACC/AHA hypertension in patients with/without PIH and comparison to ACOG criteria is warranted.
Reducing Incomplete 3rd Trimester Labs: A Multi-Modal Approach [2Q]
Authors: Roeckner Jared T.
Published: May 2019

INTRODUCTION:

The goal of 3rd trimester labs is to provide the optimal information to ensure a healthy mother and neonate. We estimated that 2% of patients at our institution were missing 3rd trimester labs prior to delivery. Our objective was to reduce the rate of missed 3rd trimester labs employing Best Practice Advisories (BPA) and other modalities in the inpatient and outpatient setting.

METHODS:

Inventions included (1) creation of an Epic-based Best Practice Advisory (BPA) in clinic and on admission to encourage providers to order the labs when missing, (2) changes to admission H&P to make the 3rd trimester labs more visible, (3) education of nursing and providers, and (4) an additional L&D Grease board column for 3rd trimester labs. These interventions were launched Feb 2018. An internal reporting system was used to report missing labs before and after the intervention. The rate of missing were compared before and after the intervention and feedback was elicited from the L&D team (nurses, midwives, residents, attendings).

RESULTS:

The average rate of missed labs was 2.8 per month prior the intervention. Rates of missed labs appear to have increased after the intervention (3.5 per month). It is unclear if increased awareness led to increased error reporting. Overall, the rate of missed 3rd trimester labs at our institution is 1.4% (28 misses/2066 deliveries).

CONCLUSION:

An approach that included EPIC-based BPA, provider and nurse education, and changes to note templates in the ambulatory and inpatient setting, resulted in no measurable improvement in the rates of missed 3rd trimester labs.
Evaluation of Smartphone Diabetes Tracking Applications for Use in Pregnancy Using the APPLICATIONS Scoring System [10K]
Authors: Quiner Trevor Elisha , Garchar Elizabeth , Perez-Yordan Jose Manuel , Rayburn William
Published: May 2019

INTRODUCTION:

To systematically evaluate the quality and functionality of smartphone diabetes tracking applications for use in pregnancies complicated by diabetes.

METHODS:

We adapted the previously described APPLICATIONS scoring system (score 0-16) with the definition of comprehensiveness as the incorporation of: ability to record blood glucose, medication use, carbohydrates, and weight gain; provide reminders for checks and/or medication; identify abnormal glucose levels; and export the collected data in reports. The Apple App Store (iPhone/iPad) and the Google Play Store (Android phones/tablets) were both searched systematically with pertinent key words to identify smartphone applications for review by three independent reviewers.

RESULTS:

Initial searches revealed 408 smartphone applications. Non-English applications and those without diabetes tracking abilities were excluded as well as applications that were not available on both operating systems, all paid applications, and those requiring institutional affiliation or proprietary equipment--leaving eight pairs of applications for evaluation. No application received a perfect APPLICATIONS score. The mean score for each was 11.3 (SD 2.1). Only one application was found to have all seven functions on both operating systems. The desired functions were available in the following percentages: blood glucose tracking (100%); medication tracking (94%); carbohydrate tracking (81%); weight tracking (75%); data exporting (75%), ability to set reminders (56%); in-app recognition of high and low glucose levels (69%).

CONCLUSION:

This systematic review using the adapted APPLICATIONS scoring system identified many diabetes tracking smartphone applications most suitable for in pregnancies complicated by diabetes. There are many excellent apps but only one app that contained all desired functions.
Does the Use of Antenatal Corticosteroids Decrease Levels of Neonatal Hyperbilirubinemia in Preterm Infants? [15K]
Authors: Amorim Melania , Brandão Danielle , Meneses Jucille , Portela Nara , França Neto Antonio Henriques , Porto Ana Maria
Published: May 2019

INTRODUCTION:

The use of prenatal corticosteroids for pregnant women between 34-36 6/7 weeks of pregnancy is recommended to reducing the morbidity of late preterm infants.

METHODS:

This is a secondary analysis of a randomized clinical trial conducted to determine the effectiveness of corticosteroids in reducing respiratory disorders in infants born at 34-36 weeks' gestation Trial registration Clinical Trials NCT00675246. This study was approved by IRB and all participants signed an informed consent term.

RESULTS:

Of 245 preterm infants, the number of newborns with gestational age 34, 35 and 36 was 30 (12.2%), 110 (45.1%), and 105 (42.7%), respectively. Jaundice occurred in 150 (62.5%) newborns and 70 among them required phototherapy during hospitalization. Late preterm infants exposed to corticosteroids started treatment with lifetime of 61.2± 33.6 h vs. 48.3± 25.3 h (p = 0.03) with similar levels of bilirubin (12.1± 3.2 mg/dL vs. 12.8± 3.7 mg/dL, p = 0.38) when compared to the control group. They required less treatment compared to the placebo group (n = 27 vs. n = 42, p = 0.025), and spent less days on phototherapy (1.7± 1.7 vs. 2.6± 2.2, p = 0.05).

CONCLUSION:

Late preterm infants exposed to prenatal corticosteroids had less need for phototherapy and shorter treatment. Also, they developed elevated level of bilirubin later. This result suggests that prenatal corticosteroids decrease the levels of hyperbilirubinemia in late preterm infants.
Haemophilus Influenzae Causing Lactational Mastitis and Sepsis During the Second Trimester of Pregnancy [23K]
Authors: Scribner Alicia Nicole , Houston Edward Joseph , McGowan Brett , Leonard Katherine
Published: May 2019

INTRODUCTION:

Lactational mastitis is a common complaint in the post-partum period, most frequently occurring within the first three months after initiating breastfeeding. Mastitis is most often caused by Staphylococcus aureus, Streptococcus species, and Escherichia coli, typically managed in the outpatient setting with oral antibiotics. Rarely, mastitis can lead to severe infections requiring hospitalization.

METHODS:

Our patient is a 23 year-old G3P2002, breastfeeding female at 15-weeks' gestation, who presented to the emergency department with breast tenderness, erythema, hypotension, and tachycardia. Emergency room evaluation excluded common sources of infection and her clinical picture was consistent with mastitis. A breast ultrasound ruled out an abscess. She was admitted to the intensive care unit with sepsis and started Vancomycin and Zosyn with aggressive fluid management. The patient's breast milk culture was positive for Haemophilus influenza. Her clinical picture improved with treatment and she was discharged from the hospital after three days. Consent was obtained from the patient to write this case report.

CONCLUSION:

Herein, we present the first reported case of mastitis caused by H. Influenza. Our patient also developed mastitis while currently in her early second trimester of pregnancy, something not commonly seen. Early identification of sepsis and initiation of appropriate antibiotics were necessary for a positive outcome. Rapid recognition of sepsis, early initiation of broad-spectrum antibiotics, and aggressive fluid management are critical for survival of women with complications of this typically minor condition.
Hypertensive Disorders of Pregnancy Increase Neonatal Intensive Care Unit Admission in Growth Restricted Fetuses [27K]
Authors: Nwabuobi Chinedu , Kuznicki Michelle , Pargas Anaisy , Sinkey Rachel G. , Odibo Anthony O.
Published: May 2019

INTRODUCTION:

The vast majority of pregnancies with fetal growth restriction (FGR) are in normotensive women. We aimed to determine whether hypertensive disorders of pregnancy (HDP) result in worse perinatal outcomes in pregnancies complicated by FGR.

METHODS:

This is a retrospective cohort study of non-anomalous, singleton, growth restricted fetuses - defined as estimated fetal weight (EFW) < 10th% - delivered in a single tertiary referral center from 01/2011 to 12/2016. Institutional Review Board approval was obtained. HDP included chronic hypertension, gestational hypertension, and all forms of preeclampsia. Perinatal outcomes examined include: cesarean delivery, neonatal intensive care unit (NICU) admission, and composite adverse neonatal outcomes (5 min Apgar < 7, respiratory distress syndrome, necrotizing enterocolitis, hypoglycemia, intraventricular hemorrhage grade 3, periventricular leukomalacia, and neonatal death). Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) for each outcome between the groups.

RESULTS:

594 pregnancies with FGR met inclusion criteria of which 137 (23.1%) were complicated by HDP. The rates of cesarean delivery, NICU admission, and the composite adverse neonatal outcomes were: 40.9%, 34.3% and 24.8%, respectively. HDP was independently associated with increased risk of NICU admission (aOR 2.37, 95% Confidence Interval 1.51-3.72) even after adjusting for gestational age at delivery. In contrast, HDP was not associated with increased risk of cesarean delivery or composite adverse neonatal outcomes.

CONCLUSION:

Women with HDP and FGR are at a significantly increased risk of NICU admission. This information can be useful for counseling patients and helpful in anticipating the need for additional neonatal support at the time of delivery.
Impact of a Standardized Clinical Assessment and Management Plan on Labor Induction Outcomes [29K]
Authors: Boardman Lori A. , Peach Daniel , Lanier Shelley
Published: May 2019

INTRODUCTION:

Induction of labor (IOL) occurs in more than one in five births in the U.S. Choice of induction method depends on national guidelines, local protocols, clinical factors, and provider practice. Because of the potential for marked variation in care, we used SCAMP methodology to develop a clinician-designed algorithm to promote care standardization. The purpose of this study was to evaluate the impact of the algorithm on clinical outcomes and resource utilization.

METHODS:

A decision-tree algorithm was developed by a multidisciplinary committee; at each decision node, a preferred choice was indicated. If an alternative option was selected, providers were to indicate their rationale. Prior to piloting the algorithm, the Care Transformation team oriented clinicians and nurses to the project and use of data collection forms. Outcomes included the vaginal birth rate, length of stay, and choice of pharmacologic cervical ripening agent.

RESULTS:

SCAMP forms were completed for 37.9% (320/845) of patients undergoing induction. Using combined data from the two hospitals and comparing the same period (11/27-4/16) in 2017-2018 to 2016-2017, we realized a 12% (10.6 hour) decrease in ALOS, an increase in the vaginal birth rate from 73% to 80%, and a shift favoring use of misoprostol over dinoprostone (52% to 70%). With extended follow-up through 7/10/18, improvements seen in the pilot were maintained or surpassed (e.g., misoprostol use rose to 74%).

CONCLUSION:

Significant improvements in clinical outcomes and provider practice were seen with use of an internally created IOL algorithm. Cost analyses and expansion to two other hospitals are underway.
Women's Healthcare Providers' Experiences and Perceptions of Discussing Obesity: A Needs Assessment Survey [34K]
Authors: Schmuhl Nicholas B. , Antony Kathleen M. , Braun Emilie J. , Brown Heidi W. , Guan Wen , Williams Makeba L.
Published: May 2019

INTRODUCTION:

Obesity is the most common co-morbidity occurring in women across their lifespans, associated with reproductive health problems, gynecologic and breast cancers, and numerous chronic conditions. Maternal obesity is associated with pregnancy complications, infant mortality, and childhood obesity. The goals of this study were to assess obstetrics and gynecology (Ob-Gyn) providers' experiences, attitudes, and practices pertaining to obesity counseling and to identify target areas for further training.

METHODS:

A needs assessment survey was distributed to 85 Ob-Gyn providers at a mid-sized academic medical center. Participants included physicians, trainees, and advanced practice providers.

RESULTS:

One quarter (25.6%) of respondents had never been trained to communicate with patients about obesity while 43.6% had not received training beyond medical or professional school. Fewer than half (45.2%) said they were at least somewhat comfortable addressing the topic of obesity, and only 18% felt at least somewhat successful (0% felt very successful). Providers who were more comfortable talking about obesity were also more confident about their patients' success, as well as their own success in counseling patients. A majority of providers (52.1%) discuss obesity often or always with pregnant patients with obesity (PWOs), while only 27.0% discuss obesity often or always with non-pregnant PWOs. Comorbidities and severity of obesity were the two most influential factors in deciding whether to discuss obesity. Pregnancy status and upward trend in weight gain were also important factors.

CONCLUSION:

These findings were used to design department-wide educational and faculty development opportunities intended to improve provider comfort and efficacy in discussing obesity.
Estradiol-to-Gonadotropin Ratio as Predictor of In Vitro Fertilization Success [36K]
Authors: Beyer Christopher D. , Gounko Dmitry , Pan Stephanie , Joseph Lee , Copperman Alan , Stein Daniel
Published: May 2019

INTRODUCTION:

There are currently no markers that effectively correlate with cycle-specific oocyte yield, euploid embryo yield, and ultimately, in vitro fertilization (IVF) success. We hypothesize that patients with a greater response to gonadotropin stimulation, as demonstrated by the ratio of peak estradiol (E2) level to total dose of gonadotropins (G), will have better odds of achieving a higher yield of euploid embryos than will poor responding patients.

METHODS:

Patients who underwent IVF and pre-implantation genetic testing for aneuploidy (PGT-A) from 6/25/2015 to 5/20/2017 were included in this retrospective study. 1,885 cycles were evaluated for peak E2 (pg/ml), total dose of gonadotropins (G, IU), E2/G ratio (pg/ml-IU), and confounders including age, anti-mullerian hormone level (AMH, ng/ml), and body mass index (BMI, kg/m2). The primary outcome was total number of euploid embryos; secondary outcomes were number of retrieved oocytes, mature oocytes, and fertilized oocytes. Odds of additional embryo or oocyte were modeled by multivariable logistic generalized estimating equations.

RESULTS:

Accounting for confounders, E2/G ratio was significantly and positively associated with all outcomes. A 0.5-unit increase in E2/G above the mean was associated with one additional euploid embryo (odds ratio [OR] 1.74, 95% CI 1.53-1.98, P<.001), higher counts of oocytes retrieved (OR 3.13, 95% CI 2.65-3.70, P<.001), mature oocytes (OR 2.92, 95% CI 2.43-3.49, P<.001) and fertilized oocytes (OR 1.92, 95% CI 1.65-2.24, P<0.001).

CONCLUSION:

Optimal stimulation is essential to achieving IVF success. The association between E2/G and yield of euploid embryos may serve as a novel marker and predictive tool for patients undergoing IVF with PGT-A.
Perinatal Characteristics of Women With Uncontrolled Pregestational Diabetes [38K]
Authors: Thayer Sydney Marie , Owens Sarah N. , Skeith Ashley , Valent Amy , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

Uncontrolled diabetes in pregnancy carries risk of adverse maternal and neonatal outcomes. Glycemic control is a modifiable perinatal risk factor. Identifying demographics that are at higher risk of having uncontrolled diabetes in pregnancy is vital for improving health outcome disparities. Our objective was to compare perinatal characteristics of pregnant women with controlled and uncontrolled pregestational diabetes in a large cohort in California state.

METHODS:

This is a retrospective cohort study of singleton gestations among women with pregestational diabetes between 2007 and 2011 using linked vital statistics and ICD-9 data. Chi-square tests were used to compare perinatal characteristics between patients with controlled and uncontrolled diabetes during pregnancy. Uncontrolled diabetes status was defined by the delivering clinician. Multivariable logistic regression was used to estimate adjusted odds ratio (aOR), controlling for maternal age, education, parity, previous diagnosis of chronic hypertension, race, insurance status and tobacco use.

RESULTS:

In a cohort of 18,198 pregnant women consisting of 785 uncontrolled diabetics and 17,413 controlled diabetics, we found that pregnant women with uncontrolled diabetes were more likely to be black women, less than 20 years of age, hold a diagnosis of chronic hypertension, or have attended less than 5 prenatal visits. The other examined characteristics of interest did not show statistical significance.

CONCLUSION:

Teenage pregnancy, black race, chronic hypertension, and limited prenatal care are associated with uncontrolled pregestational diabetes. To improve health outcome disparities, these populations should be specifically targeted with planned resource allocation for the treatment of diabetes in pregnancy.
A Mature Cystic Teratoma on the Ovary Does Not Alter in Vitro Fertilization Success Rate [39K]
Authors: Hernandez-Nieto Carlos , Alkon Tamar , Lee Joseph , Gonzalez Katherine , Copperman Alan B. , Sandler Benjamin
Published: May 2019

INTRODUCTION:

Patients who undergo surgical excision of a dermoid-cyst prior to in vitro fertilization may be at risk of resection of healthy ovarian tissue. Our objective was to analyze ovarian reserve, response to stimulation, and IVF success rates in patients with a dermoid-cyst versus those who underwent a cyst removal prior to undergoing IVF.

METHODS:

The retrospective cohort analysis included patients who underwent IVF with fresh blastocyst transfer from 2005 to 2018. Patients with a history of oophorectomy and/or donated oocytes were excluded. Patients were segregated in to 3 cohorts: (group 1: Resected dermoid-cyst, group 2: Present dermoid-cysts, and group 3: a matched control group). Comparative statistics and an adjusted multivariable logistic regression were used to analyze collected data. Study was approved by the Western Institution Review Board.

RESULTS:

119 patients were included, 54.6% (n=65) had an active dermoid-cyst during IVF cycle(s) while 45.4% (n=54) underwent cystectomy prior to treatment. 352 patients were included as a control. Demographic characteristics, ovarian reserve, stimulation parameters and pregnancy rates were comparable among cohorts. After controlling for age, BMI, AMH, endometrial thickness, blastocysts transferred and cyst size, no association was found with the odds of implantation (OR 1.56, P 0.58), clinical pregnancy (OR 2.52, P 0.63) ongoing pregnancy (OR 1.3, P 0.84) pregnancy loss (OR 0.76, P 0.84) or multiple pregnancy rates (OR 0.6, P 0.84) among patients with a dermoid-cyst.

CONCLUSION:

The presence or removal of an ovarian dermoid cyst did not adversely influence ovarian reserve or IVF success. Clinicians can be reassured that the presence of a dermoid cyst is not a barrier to assisted reproduction treatment success.