bluuebunny/crossref_metadata_2025 huggingface dataset:
Antepartum Monitoring of the Fetus Chronically Exposed to Opioids: What To Expect and Why Do We Intervene? [22C]
Authors: Brar Bobby , Hom Katherine , Nat Manita , Lua Lannah L. , Iriye Brian , Jackson David
Published: April 2018

INTRODUCTION:

Chronic opioid dependence for maternal pain management, methadone maintenance, or suboxone therapy is an increasing phenomenon in obstetrics. Opioids may depress fetal neurobehavioral status and may change reactivity or variability of fetal heart rate patterns. Our primary objective was to determine which fetal assessment modality best identifies the vulnerable opioid exposed fetus.

METHODS:

A retrospective review from January 2016 through April 2017 at two MFM antenatal centers identified singleton, non-syndromic fetuses with daily opioid exposure. Non-stress tests (NST), biophysical profiles (BPP), amniotic fluid index (AFI), umbilical artery Doppler’s (UAD), and serial biometry were reanalyzed. Test characteristics and frequency of interventions for abnormal monitoring were quantified.

RESULTS:

Criteria was met in 27 patients (77.8% methadone (n=21), 14.8% prescription opioid (n=4) and 7.4% suboxone (n=2)). There were 112 growth scans, 102 BPP, 112 NST, and 81 UAD measurements. Time to NST first acceleration was <20 minutes in 92.5%. Abnormal testing causing delivery occurred in 6/27 patients (22.2%), all at 36-38 weeks. Isolated oligohydramnios was 2/27 (7.4%, occurring at 37 and 38 weeks), oligohydramnios with IUGR 2/27 (7.4%, both at 36 weeks), nonreactive NST 1/27 (3.7%, 38 weeks), and BPP 6/10 1/27 (3.7%, 36 weeks). UAD did not change management. Earliest IUGR was seen at 32 weeks.

CONCLUSION:

Antenatal testing of the singleton, chronic opioid exposed fetus should include third trimester serial growth ultrasounds and BPP or NST-AFI scheduled no later than 34-35 weeks. Continuing study on a larger cohort is needed to define optimal monitoring based upon category of opioid dependence.
A Two-Delivery Model Utilizing Doula Care: A Cost-Effectiveness Analysis [25C]
Authors: Greiner Karen Scrivner , Hersh Alyssa R. , Gallagher Alexandra C. , Tilden Ellen , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Multiple studies have demonstrated the benefits of receiving doula care during labor and delivery, although analyses elucidating the cost-effectiveness of a doula’s presence are limited. We sought to study the cost-effectiveness and outcomes associated with doula care during the first delivery on the first and second deliveries.

METHODS:

A cost-effectiveness model using TreeAge software was designed to compare outcomes in women with a trained doula vs. no doula. We used a theoretical cohort of 1.8 million women, the approximate number of nulliparous term births in the US annually. The cost of a doula in Oregon is between $600-2,000 with an average of $1,000 for a healthy woman. Outcomes included mode of delivery, maternal death, uterine rupture and hysterectomy, in addition to cost and quality-adjusted life years (QALY). Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. Sensitivity analyses were used to investigate the robustness of the results.

RESULTS:

In our theoretical cohort, we found that the presence of a trained doula during the first delivery resulted in 219,530 fewer cesarean deliveries, 51 fewer maternal deaths, 382 fewer uterine ruptures, and 100 fewer hysterectomies, saving $91 million with 7,227 increased QALYs for the first and subsequent delivery. Sensitivity analyses demonstrated cost-effectiveness up to $1,452 per doula.

CONCLUSION:

The presence of a trained doula during a woman’s first delivery leads to improved outcomes, decreased costs and increased QALYs during her first and second delivery. This model argues for increased reimbursement for doula care, thereby promoting improved health for our patients.
Accuracy of Clinical Estimated Fetal Weight at Term and Effect on Clinical Management [30C]
Authors: Omuso Inara , Tell Noor , Hunter Krystal , Khandelwal Meena
Published: April 2018

INTRODUCTION:

Although Obstetrics/Gynecology residents are faced with learning a wide variety of complex skills during their training, clinical estimation of fetal weight (EFW) via Leopold's maneuvers, despite the surrounding controversy of use, is a relatively simplistic skill. We wanted to determine the correlation of clinical EFW with actual birth weight (BW) in term pregnancies, and determine if this knowledge had an impact on length of labor or mode of delivery.

METHODS:

Retrospective chart review of singleton pregnancies between 37 and 42 weeks, admitted for labor and delivery were randomly selected, between 2013 and 2016. For 80% power, 452 women were needed to detect a difference of 10% between EFW and BW. The statistical tests used were Pearson and Spearman-Rho Correlation, Mann Whitney-U Tests and Chi Square test as appropriate.

RESULTS:

Of 497 women randomly selected, 9 were excluded for missing data. The mean age of was 26.8 (+/- 6.1); 33% were African American, 30% Hispanic, 27.5% White; with macrosomia rate of 7.5%. EFW had a significant, moderate positive correlation with BW (r =.43, p<.001). The accuracy of EFW within 20% of actual BW was 89.2%. A significant relationship between mode of delivery and EFW noted (20.3% cesarean delivery in <8 lbs group while 10.5% in <8 lbs) (p=0.014). However, estimating a larger EFW did not prolong labor (367[219-580] vs 426[223-630] minutes respectively) (p=0.26).

CONCLUSION:

Continued practice and reinforcement of recording EFW, as part of physical examination, provides clinicians with an accurate and important tool that can aid in management of women in term labor.
Active Patient Portal Status Negatively Correlated with Preterm Birth Rate Among Patients Seen in High Risk OB Clinic [32C]
Authors: Cuff Ryan D. , Wineland Rebecca , Carter Jessica , Sullivan Scott , Johnson Donna
Published: April 2018

INTRODUCTION:

Use of remote computer patient portals is increasing and thought to improve patient satisfaction, engagement in their care, and patient-provider communication. This study sought to evaluate the county-specific correlation between active patient portal status and preterm birth rate amongst patients under high risk obstetric care.

METHODS:

Descriptive population analysis of all obstetrical patients seen by maternal-fetal medicine at a single academic center from July 2016 through July 2017. Distinct patients were categorized according to their county of residence. Patient portal status, whether active or inactive, was then similarly determined by county. Counties were included if there were greater than 20 distinct patients seen within the established time frame. Preterm birth rates were obtained for each representative county from the Center for Disease Community Health Status Indicators database. Pearson’s test was used to determine strength of correlation.

RESULTS:

841 distinct patients representing seven counties met inclusion criteria. Active patient portal status ranged from 40.4% - 73.5%, while representative county-specific preterm birth rates ranged from 13.5% - 15.3%. Patient portal activity was negatively correlated with preterm birth rate, coefficient -0.77 (p. 0.04).

CONCLUSION:

There is a strongly negative correlation between active patient portal status and preterm birth rate amongst patients under high risk obstetrical care in South Carolina. Though descriptive, this finding suggests that the use of technology in medicine or patient connectivity may be an important correlate of disparate outcomes, and may exacerbate health disparities already known to exist for rural and disadvantaged populations.
A Two-Delivery Model Examining Upright Positioning During Labor: A Cost-Effectiveness Analysis [34C]
Authors: Hersh Alyssa R. , Greiner Karen Scrivner , Gallagher Alexandra C. , Tilden Ellen , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Studies have demonstrated the benefits of an upright and mobile position during labor, including lower risk for cesarean delivery and shortened time in labor. We sought to examine the cost-effectiveness and outcomes associated with laboring upright during the first delivery and the resultant effects on the second delivery, such that the risks, benefits, and costs are framed within the public health perspective of the average US childbearing woman’s entire reproductive course.

METHODS:

A cost-effectiveness model using TreeAge software was designed using a theoretical cohort of 1.8 million women, the approximate number of nulliparous term births in the US annually, including uncomplicated deliveries with a trial of labor and with all women having a second delivery, reflecting the average number of births per woman in the US. Outcomes included mode of delivery, maternal death, uterine rupture and hysterectomy, in addition to cost and quality-adjusted life years (QALY) for both pregnancies. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY.

RESULTS:

We found that allowing women to be upright and mobile during her first labor resulted in fewer cesarean deliveries, reduced costs and improved QALYs for both the first and subsequent delivery. In our theoretical cohort, laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies, saving $785 million with 7,227 increased QALYs.

CONCLUSION:

Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second delivery.
Adderall and Pregnancy: Neonatal Outcomes Following Prenatal Prescription Mixed Amphetamine Exposure [36C]
Authors: Rose Sherrill , Borowski Kristi S. , White Wendy M. , Hathcock Matthew , Rivera-Chiauzzi Enid
Published: April 2018

INTRODUCTION:

Increasing numbers of pregnant women are being treated for ADHD. The safety of ADHD medications in pregnancy have not been well studied, although studies suggest that methylphenidate use may lower birthweight compare to unexposed newborns. Our primary outcome was to evaluate if birthweight was lower among infants of women utilizing Adderall in our academic institution.

METHODS:

Maternal and infant pairs exposed to Adderall between January 2005 and December 2015 was identified in EMR based on active medication list during pregnancy. Patients were matched 2:1 with unexposed controls of similar age, gestational age at delivery, parity, infant sex and date of delivery. All charts were reviewed for known causes of IUGR or low birthweight. Statistical analysis of infant birthweight was done using generalized estimating equation blocking on matching. Medical histories were analyzed using Chi-Square test or Fishers exact test as appropriate.

RESULTS:

We identified 53 exposed pairs. The difference in mean birthweight for exposed vs unexposed infants was 26.9g which is not statistically or clinically significant (95% CI, P-value: (-141, 195), 0.75). A statistically significant difference was noted for exposed vs unexposed mothers for comorbid psychiatric illness and history of substance abuse (p = <0.0001).

CONCLUSION:

As Adderall use increases among childbearing women, understanding the risk to infants is crucial. With a limited sample size, our study suggests no significant difference in birthweight, which is a concern for women requiring medication in pregnancy. Women using Adderall may have higher rates of comorbid psychiatric disorders and substance use and may benefit from early screening.
Antenatal Corticosteroids for Lung Maturity: Neonatal vs Obstetric Data and Improvement Opportunities [37C]
Authors: Konitzer Hollis , Fort Amber , Galvin Shelley , Coulson Carol
Published: April 2018

INTRODUCTION:

Antenatal corticosteroids (ACS) should be considered from 23 through 36.6 weeks’ gestation in women likely to deliver preterm. Two doses of betamethasone, given 24 hours apart, followed by a second 24 hours until delivery constitutes a complete course. Confirmatory data was requested by the Neonatal Chronic Lung Committee of Mission Hospital.

METHODS:

Data on neonatal steroid exposure compiled by the neonatology team identified infants inborn at 23+0 to 34+6 weeks since 9/1/2015, surviving to discharge, before 10/1/2016, who required respiratory support. Maternal charts were reviewed for steroid exposure, timing of last exposure to delivery, indication for delivery.

RESULTS:

150 inborn neonates were identified initially as failing to complete ACS. 134 maternal charts were reviewed, accounting for 143 neonates. 26 mothers actually completed steroids; 2 declined. Patients delivered prior to completion were most often in fulminant labor (25), required urgent delivery for fetal indications (29) or demonstrated worsening preeclampsia (13)or other maternal indications (9) precipitating delivery. NICU data included gestational age up to 34 weeks 6 days (30 mothers). Local OB practice was to administer steroids prior to 34 weeks until a late preterm steroid protocol was adopted in April 2016.

CONCLUSION:

Maternal chart review provides more robust identification of steroid completion than neonatal data alone. All providers should use the same gestational age standards in assessing ACS completion and other complementary care processes. Some preterm deliveries for maternal hypertensive disorders prior to steroid completion may be potentially preventable through adherence to the indications for delivery advised by ACOG (Hypertension in Pregnancy 2013).
Safety of Flibanserin in Women With Hypoactive Sexual Desire Disorder Taking Antidepressant Medications [1D]
Authors: Simon James A. , Kingsberg Sheryl A. , Yuan James , Kissling Robert , Clayton Anita H.
Published: April 2018

INTRODUCTION:

Flibanserin is indicated for the treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. This post hoc analysis evaluated the safety of flibanserin in women taking antidepressant medications.

METHODS:

Data from 8 randomized, double-blind, placebo-controlled studies of flibanserin in HSDD (premenopausal women, protocol violators from 5 studies and patients treated for depression in 1 study; postmenopausal women, protocol violators from 2 studies) were pooled for patients receiving flibanserin 100 mg qhs or placebo. This analysis evaluated patients taking a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) at study baseline.

RESULTS:

The analysis population included 2379 flibanserin-treated (SSRI/SNRI users, n=131) and 2690 placebo-treated (SSRI/SNRI users, n=91) patients. Incidence of adverse events (AEs) in flibanserin-treated patients was 73.3% of SSRI/SNRI users and 65.4% of nonusers; incidence in placebo-treated patients was 79.1% and 54.9%, respectively. Serious AEs in SSRI/SNRI users vs nonusers occurred in 1.5% vs 1.1% of flibanserin-treated patients, respectively, and 0.0% vs 0.7% of placebo-treated patients, respectively. AEs led to treatment discontinuation in 15.3% of SSRI/SNRI users and 11.2% of nonusers who received flibanserin, and 18.7% of users and 5.3% of nonusers who received placebo. The most common AEs in flibanserin-treated patients (overall incidence ≥10%) were dizziness (6.9% of SSRI/SNRI users vs 10.5% of nonusers) and somnolence (6.1% vs 10.4%, respectively).

CONCLUSION:

In this post hoc analysis of pre- and postmenopausal women with HSDD, SSRI/SNRI use did not appear to change the AE profile of flibanserin. Concomitant use of flibanserin with moderate/strong CYP3A4 inhibitors (eg, fluvoxamine) is contraindicated.
Enhanced Recovery After Surgery (ERAS) for Benign Minimally Invasive Gynecology [3D]
Authors: Suh Christina , Wörndle Natalie , Mollner Magdalena , Balica Adrian
Published: April 2018

INTRODUCTION:

Enhanced recovery after surgery (ERAS) protocols use evidence based strategies to optimize postoperative recovery. In colorectal surgery, ERAS has been shown to decrease length of stay and narcotic use without increasing complications or readmissions. These principles are now being applied to gynecologic surgery as well. Our objective was to identify literature published regarding ERAS protocols in benign minimally invasive gynecology.

METHODS:

Publications identified using the PubMed database, written in English and published between January 2012 and September 2017, were included for analysis. Searches were conducted using the terms “enhanced recovery after surgery” or “enhanced recovery” in combination with one of the following: gynecologic surgery, benign gynecologic surgery, minimally invasive gynecologic surgery.

RESULTS:

We identified 33 relevant publications, including 9 retrospective cohort studies, 3 randomized controlled trials, 2 case control studies, and 1 prospective cohort study. Review articles, including 2 ERAS society recommendations, were excluded from analysis. Four publications assessed benign pathology only, whereas 5 publications included benign and malignant pathology. Of the 3 publications assessing benign minimally invasive gynecology, 2 assessed vaginal hysterectomies only, as opposed to laparoscopic or robotic procedures.

Common interventions included preoperative counseling, nausea prophylaxis, multimodal analgesia, early ambulation, and early feeding. Common outcomes measured included length of stay and readmission rate.

CONCLUSION:

There is limited data evaluating the efficacy of ERAS protocols for gynecologic surgery, and there is nearly no published data for benign minimally invasive gynecology. Given the increasing numbers of minimally invasive procedures, more studies are needed to assess the potential benefits of ERAS in this field.
Dermoid Cyst Management and Pathologic Outcomes: A Review of Over 1,000 Cases at a Single Institution [9D]
Authors: Tankou Joan , Schantz-Dunn Julianna , Liu Christina Young , Melamed Alexander
Published: April 2018

INTRODUCTION:

Teratomas are the most common ovarian germ cell tumor and have a distinct appearance on imaging. Current practice frequently uses minimally invasive surgery (MIS) for management of suspected mature teratomas. This study aims to describe the clinical management, outcomes and pathologic features of over 1,000 teratomas at a single institution.

METHODS:

A retrospective chart review was performed on all patients with a pathologic diagnosis of a teratoma over an 11-year period at a single academic hospital.

RESULTS:

1,055 patients were included in the study. Mean age at time of surgery was 38 (range 14-82). 72% of cysts were removed via MIS, and 63.8% via cystectomy. Spillage of cyst contents occurred in 37.2% of cases and was associated with MIS and cystectomy but not cyst size. There was 1 case of chemical peritonitis (0.09%) in a patient with spontaneous cyst rupture prior to surgery. There were 3 cases of immature teratoma (0.3%) and 12 cases of malignant transformation of dermoid (1.1%). 100 teratomas were associated with pregnancy with a rate of torsion of 9% compared to 5.2% in non-pregnant patients (p-value 0.16). Cysts larger than 5cm were more likely to undergo torsion compared to cysts < 5cm (83.1% vs 16.9%, p-value < 0.0001).

CONCLUSION:

Minimally invasive surgery and cystectomy are safe management strategies for suspected mature teratomas, and cysts larger than 5cm should be removed due to the increased risk of torsion.
Comparing Different Methods of Patient Education on Preeclampsia [13D]
Authors: Strassberg Emmie R. , Fisher Sarah M. , Mackeen A. Dhanya , Sun Haiyan , Paglia Michael J.
Published: April 2018

INTRODUCTION:

Preeclampsia is a life-threatening condition unique to pregnancy that contributes to a significant number of maternal deaths worldwide. Delays in diagnosis and treatment are causal factors for maternal deaths from preeclampsia. Patients who are informed regarding this disease process may present earlier for evaluation. We sought identify which method of patient education is most effective.

METHODS:

We compared women’s preeclampsia knowledge retention after exposure to different educational materials in a prospective randomized controlled trial. Singleton primigravid patients at a tertiary care center were given a survey regarding preeclampsia knowledge at 18-25 weeks gestation, then randomized to preeclampsia education with a graphic card, educational video, or no educational tool. They were given the same survey again at 32-37 weeks gestation. We compared the change in preeclampsia knowledge scores for each type of education.

RESULTS:

150 subjects completed both initial and follow up preeclampsia knowledge surveys. 56 received education with the graphic card, 45 were educated with the video and 49 received no further education. There was no difference in preeclampsia knowledge score when the graphic card, video or no further education groups were compared. There was a significant improvement in knowledge score for all subjects, with a mean baseline score of 51.7% and a mean follow up score of 61.4% (P = <0.001).

CONCLUSION:

There is no additional improvement of patient knowledge retention when patients receive education with a graphic card or an educational video compared to routine prenatal counseling without the addition of these educational tools. Patient knowledge regarding preeclampsia appears to improve from the second to third trimester regardless of method of patient education.
Chemotherapy and Optimal Timing of Delivery for Women with Triple Negative Breast Cancer [16D]
Authors: Senz Kayli , Kuo Kelly , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Data are limited regarding the optimal management of breast malignancy in pregnancy, particularly for the more aggressive subtype of triple negative breast cancer (TNBC). We sought to compare strategies for the management of TNBC and to determine the optimal gestational age for induction in regards to chemotherapy status and maternal-fetal outcomes.

METHODS:

A decision-analytic model was designed for women with TNBC at 20 weeks electing to continue their pregnancies, comparing 32 different strategies for scheduled delivery between 24-39 weeks gestation, with chemotherapy induction either at 24 weeks or delayed until after delivery. Baseline estimates of stage-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age.

RESULTS:

For women assigned to antepartum chemotherapy, overall QALYs were maximized with delivery at term, with minimal additional benefit beyond 37 weeks. For women with TNBC deferring chemotherapy until the postpartum period, 5-year survival was maximized by immediate delivery, although maternal QALYs were maximized with delivery at 36 weeks for stage I, 31 weeks for stage II, and 26 weeks for stage III disease. Our model was heavily driven by the baseline probability of maternal death within 5 years, in addition to the expected progression of disease and decrease in survival rates with each week of non-treatment, and remained robust across reasonable ranges for all variables of interest.

CONCLUSION:

For women with TNBC diagnosed in early pregnancy, initiation of chemotherapy and delivery at 37 weeks should be considered.
Familial Dysautonomia: Rare Disease or More Common than You Think? [20D]
Authors: Bardos Jonah D. , Terhaar Catherine , Echeverri Natalia , Longman Ryan
Published: April 2018

INTRODUCTION:

Familial Dysautonomia (FD) is an autosomal recessive disorder affecting the sensory and autonomic nervous systems causing life threatening autonomic crises, hypotonia, and progressive neuronal degeneration. Currently, carrier testing for FD is recommended for the Ashkenazi Jewish (AJ) population. A joint ACOG/ACMG statement highlighted the increasingly multi-ethnic society as consideration for pan-ethnic carrier testing, and recent ACOG committee opinion states that pan-ethnic carrier testing is a reasonable strategy. This study assesses how many non-AJ individuals screened positive for FD when pan-ethnic carrier screening was implemented.

METHODS:

Retrospective database analysis of individuals that received expanded carrier testing utilizing a genotyping panel for two pathologic variants of FD (c.2204+6T>C, R696P) was performed. Expected number of positive carriers for FD in AJ and non-AJ groups were calculated and compared to observed rates. Chi-square analysis was performed to assess for statistical significance (p < 0.01).

RESULTS:

A total of 71,243 individuals were tested for FD. A higher than expected number of non-AJ individuals screened positive for FD (38 observed vs 14.05 expected, p<0.001). The number of AJ individuals that screened positive was consistent with expected values (33 observed vs 32.08 expected, p<0.86).

CONCLUSION:

Non-AJ carriers of FD were more common than expected in this cohort. Pan-ethnic expanded carrier testing will increase the detection of carriers for FD compared with current ethnicity based screening recommendations. Importantly, carriers of FD, who would be missed by ethnicity based testing convention, will be identified allowing for more complete genetic counseling and family planning options for those who choose testing.
Is Participation in CenteringPregnancy Associated with Decreased Postpartum Depression in Black Women? [21D]
Authors: Watson Amelia K. , Roussos-Ross Dikea , Goodin Amie , Prieto Autumn
Published: April 2018

INTRODUCTION:

Postpartum depression (PPD) occurs in approximately 15% of women. CenteringPregnancy (CP) not only allows for greater social support compared to Traditional Care (TC), it also focuses one group session on PPD. The purpose of this study was to determine whether there was a decreased incidence of PPD in black women enrolled in CP versus TC.

METHODS:

A retrospective chart review was conducted comparing all black CP patients to a matched cohort of TC patients seen at UF Health between March 2015 and March 2017. A score of > 12 on the Edinburgh Postnatal Depression Scale was categorized positive for PPD. Logistic regression estimated the relationship between positive PPD and CP vs TC participation, adjusting for patient characteristics.

RESULTS:

There was a lower incidence of PPD in black CP patients compared to TC patients (8.96% vs 16.67%), although not statistically significant (P=0.183). Overall, patients with a history of depression were 2.17 times more likely to have PPD (95% CI 0.53-8.89), and patients taking any psychiatric medications during pregnancy were 11.56 times more likely to have PPD (95% CI 1.31-101.96).

CONCLUSION:

The incidence of PPD in the CP group was lower than that in the TC group which mirrored the general population. This difference may be related to additional social support received within CP settings and additional time spent discussing signs and symptoms of PPD and ways to access resources. More research is needed to further assess the psychosocial benefits of CP in black women.
Risk Factors for Readmission Due to Infection after Cesarean Delivery [26D]
Authors: Kawakita Tetsuya , Tefera Eshetu
Published: April 2018

INTRODUCTION:

Postpartum infections are major cause of prolonged hospital stay and burden to health care system. Wound infection or breakdown is a second most common reason for hospital readmission. Data regarding risk factors for hospital readmission due to infection are limited.

METHODS:

This is a retrospective study of women undergoing cesarean delivery at 23 weeks’ gestation or greater at MedStar Washington Hospital Center. The hospital readmission due to infection is defined as hospital readmission due to the following indications: endometritis, deep wound infection, and other infections (abdominopelvic abscess, maternal sepsis, pelvic septic thrombophlebitis, pyelonephritis, pneumonia, or meningitis) occurring after discharge and up to 6 weeks after cesarean delivery. Maternal demographics, maternal comorbidities, and labor and delivery outcomes were compared between women without hospital readmission due to infection and women with hospital readmission due to infection. Multivariable logistic regression analysis was performed to calculate adjusted odds ratio (aOR) with 95% confidence intervals (95%CI), controlling for significant variables in the bivariate analysis.

RESULTS:

Of 3805 women undergoing cesarean delivery, 30 women (0.8%) had hospital readmission due to infection. Increased risks of hospital readmission due to infection were seen with higher body mass index at admission (BMI) (aOR 1.05; 95%CI 1.01-1.10), operative time ≥60 min (aOR 2.52; 95%CI 1.13-5.58), and ruptured membrane (aOR 3.00; 95%CI 1.17-7.68). A lower risk of hospital readmission due to infection was seen with increasing maternal age (aOR 0.93; 0.87-0.996).

CONCLUSION:

Hospital readmission due to infection was associated with younger maternal age, higher BMI, operative time ≥60 min, and ruptured membrane.
Decreasing Narcotic Use After Cesarean Section with Enhanced Recovery: A Quality Improvement Project [28D]
Authors: White Kevin , Bou Zgheib Nadim , Mitchell Brenda
Published: April 2018

INTRODUCTION:

Prescription drug abuse presents a major problem to society and can impact postoperative pain management. Many patients who struggle with addiction started using while undergoing treatment of acute pain. A retrospective analysis of our patients revealed that patients used 99.9mg of oral morphine equivalents by the end of postoperative day 2 with only 27% achieving adequate pain control. We aimed to reduce opioid use and pain scores after caesarian delivery with enhanced recovery.

METHODS:

We prospectively implemented a protocol using liposomal bupivacaine injected at the time of cesarean delivery. Patients were then given 500mg acetaminophen every 4 hours, 800mg ibuprofen every 8 hours and 5mg oxycodone every 6 hours as needed. In addition, patients were ambulated 4 hours after surgery and had their catheter removed from their bladder as soon as they could safely ambulate.

RESULTS:

Patients in the treatment group utilized 58% less opioids (p<0.05) and reported 20% less pain (p<0.05). 38% achieved adequate pain control. Hospital charges were equivocal between the groups.

CONCLUSION:

Our enhanced recovery protocol is an effective alternative to traditional pain control and significantly reduced both opioid use and pain scores without any significant increase in hospital costs. More prospective research is needed in this area.
The Clinical Characteristics and Prognosis of Cerebral Venous Thrombosis During Pregnancy and Puerperium in China [29D]
Authors: Liang Zhu-Wei , Gao Wan-Li
Published: April 2018

INTRODUCTION:

Due to the specific physiology associated with pregnancy and puerperium, cerebral venous sinus thrombosis (CVT) may manifest different characteristics. This study aimed to identify the clinical manifestations and prognosis of pregnancy-associated CVT.

METHODS:

A total of 43 pregnancy-associated CVT patients were enrolled. We analysed the clinical presentations of the disease and performed a multivariate logistic regression analysis to determine which variables were associated with prognosis.

RESULTS:

Our descriptive results showed the following: 1) the incidence was 202 per 100,000 deliveries, and the mortality rate was 11.63%; 2) the most frequent symptom was headache; 3) the most frequent abnormal laboratory findings were increased levels of fibrinogen and several serum lipoproteins (including triglyceride, cholesterol, high-density lipoprotein, low-density lipoprotein, apolipoprotein A1, and apolipoprotein B); and 4) the superior sagittal sinus and transverse sinus were the most frequently affected locations. Moreover, an increased modified Rankin Scale score was positively associated with infection, seizure, intracerebral haemorrhage (ICH) and hypertensive disorders of pregnancy (HDP). Comparably, the occurrence of death was positively and significantly associated with infection, seizure and ICH.

CONCLUSION:

Consequently, timely diagnosis and treatment of pregnancy-associated CVT patients with infection, seizure, ICH or HDP are needed. Patients with infection, seizure or ICH have a greater risk of death.
Plasma Profile of Platelet Auto-antibodies in Patients with Thrombocytopenia in Pregnancy [30D]
Authors: Huang Qin , Jia Yufang , Yang Weiwen
Published: April 2018

INTRODUCTION:

To evaluate plasma levels of platelet auto-antibodies in patients with thrombocytopenia in pregnancy and assess the clinical significance.

METHODS:

A total of 54 pregnant women with thrombocytopenia, 44 normal pregnant women and 28 women with immune thrombocytopenia (ITP), as well as 31 healthy women were enrolled in this study. The plasma levels of platelet auto-antibodies against 5 platelet glycoproteins (GPIX, GPIb, GPIIIa, GPIIb and P-selectin) were detected by flow cytometric immuno-beads array. The difference was analyzed statistically, and the receiver operating curve (ROC) was constructed to assess the diagnostic value.

RESULTS:

Compared with normal pregnant women and healthy controls, the plasma levels of auto-antibodies against glycoprotein GPIX and GPIb were significantly increased in pregnant women with thrombocytopenia (P < .05), while the levels of other 3 auto-antibodies were similar. The positive rate of auto-antibodies in pregnancy women with thrombocytopenia was higher than that in normal pregnant women (59.3% vs 31.8%, P < .01). ROC analysis showed that the auto-antibody anti-GPIX had a high diagnostic value in pregnant women with thrombocytopenia over normal pregnant women with the area under the curve value of 0.779 (P < .001), the sensitivity and specificity were 76.3% and 100%, respectively.

CONCLUSION:

The plasma profile of platelet auto-antibodies in patients with thrombocytopenia in pregnancy was different from that in ITP patients. The auto-antibody anti-GPIX may be served as a biomarker of the disease.
Outcomes in Intrahepatic Cholestasis of Pregnancy Managed via a Multifaceted Protocol [31D]
Authors: Juusela Alexander , Gimovsky Martin Larry , Singh Shailini , Nazir Munir
Published: April 2018

INTRODUCTION:

Intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus, elevated bile acids, usually presents in the second or third trimesters, and is associated with Intra-uterine fetal demise (IUFD). Perinatal morbidity is the lowest at 35 weeks and rises after 36 weeks, with a stillbirth rate of 1.2% after 37 weeks. The original studies that prompted early deliveries, there were 4 IUFD among 331 cases. Subsequent meta analyses refuted that. The goal of our study was to identify factors correlated with a reassuring prognosis and permit expectant management beyond 37 weeks.

METHODS:

A retrospective chart review of women admitted to NBIMC for ICP between January 1st 2013 and December 31st 2016. CPT codes were used to identify cases of ICP. 52 charts met inclusion criteria and a statistical analysis was performed.

RESULTS:

In our series no stillbirth occurred. No single factor was identified that correlated with a reassuring outcome, therefore we conclude that a multifaceted approach with active maternal fetal surveillance and use of ursodeoxycholic acid likely contributed to a lower stillbirth rate, however, it is possible our small data set caused a Type 2 error.

CONCLUSION:

As no RCTs are available to guide management, further case series, meta analyses, or a registry could be the solution. We present our multifaceted approach to management that includes serial bile acids, liver function tests, treatment with ursodeoxycholic acid, monitoring of symptoms, and intensive fetal surveillance, which may allow pregnancy to proceed to 38 weeks or beyond.
Cesarean Hysterectomy and Prophylactic Occlusive Balloons Catheters: Is it Worth the Risk? [34D]
Authors: Mellott Elizabeth , Kram Jessica J. F. , Greer Danielle M. , Dickson Michelson Elizabeth
Published: April 2018

INTRODUCTION:

Severe hemorrhage during cesarean hysterectomy associated with abnormal placentation is a major cause of maternal morbidity and mortality in the US. Intravascular occlusive balloon catheter placement has been hypothesized to lessen blood loss during planned cesarean hysterectomy. This study explored patterns associated with balloon placement during cesarean hysterectomy

METHODS:

We retrospectively studied women ≥18 years of age who underwent cesarean hysterectomy for abnormal placental implantation within our large, community-based hospital system during 2012-2016. Three patient groups were studied: (1) balloon not placed, (2) balloon placed but not deployed, and (3) balloon placed and deployed. Data were abstracted from the electronic medical record and compared among patient groups using basic descriptive and inferential statistics.

RESULTS:

Of 17 total patients identified (mean age 37.1 years, body mass index 33.8 kg/m2, and gestational age 32.3 weeks), 11 (65%) had balloons placed and 3 (18%) had balloons deployed. Odds of balloon placement (regardless of subsequent deployment) were greater in women with placenta accreta (P=0.01), preoperative anemia (P<0.01), and larger, multidisciplinary teams of providers (P=0.02). Significant complications (thromboembolic events and/or stent placement) were experienced by 2 women who underwent balloon placement but no one in the balloon deployment group. No significant group differences were detected in provider characteristics or other outcomes (e.g., estimated blood loss, transfusion, surgery duration).

CONCLUSION:

In this community-based study, use of occlusive balloon catheters did not improve outcomes but rather increased complications directly related to placement. Prospective multicenter studies are needed to evaluate the efficacy of balloon placement and deployment.
Exercise for the Prevention of Preterm Birth: A Cost-Effectiveness Analysis [37D]
Authors: Speranza Rosa , Sargent James , Savitsky Leah , Caughey Aaron B.
Published: April 2018

INTRODUCTION:

Preterm birth (PTB) is associated with significant neonatal morbidity and healthcare expenditures. Modest exercise during pregnancy has been found to reduce the risk of PTB in overweight and obese women. We sought to investigate the cost-effectiveness of an exercise-based intervention aimed at reducing PTB.

METHODS:

We built a decision-analytic model using TreeAge Pro and incorporated probabilities, costs, and utilities from the literature to compare a modest exercise regimen with usual care. We then applied this model to a theoretical cohort of 1,000,000 women with a pre-pregnancy body mass index (BMI) ≥26kg/m2. The cost-effectiveness threshold was set at $100,000 per quality-adjusted life year (QALY), and sensitivity analyses were used to assess the robustness of the model.

RESULTS:

The estimated cost for an exercise intervention was $1,300 per pregnancy and resulted 1,400 fewer PTBs, 140 fewer neonatal deaths, and 163 fewer cases of neurodevelopmental delay. There were also 35,000 fewer cases of gestational diabetes. At baseline assumptions, standard care was the cost-effective strategy. On sensitivity analysis, the exercise intervention became cost-effective with an exercise regimen of $1,223, and, as the cost of the exercise regimen was lowered to $812, the exercise regimen became the dominant strategy. The exercise regimen was associated with $489 more per pregnancy.

CONCLUSION:

A modest exercise regimen can be a cost-effective method of decreasing PTB and improving pregnancy outcomes if the price of the intervention can be lowered below $1,223 per pregnancy. Future endeavors should focus on reducing the intervention cost without limiting utility or adherence to the program.
Prophylactic Antibiotics at the Time of Bakri Insertion is Associated with a Reduction in Endometritis [38D]
Authors: Wong Melissa , Greene Naomi , Gregory Kimberly D.
Published: April 2018

INTRODUCTION:

The aim of this study is to determine whether prophylactic antibiotics initiated at the time of placement of an intrauterine balloon tamponade (IBT) is associated with a reduction in the rate of postpartum endometritis.

METHODS:

Retrospective cohort study of patients who received an IBT from 1/1/2012 - 12/31/2016. Patients were included if the IBT remained in place at least 2 hours and were excluded if chorioamnionitis was present prior to delivery. Patients who received prophylactic antibiotics at the time of Bakri placement were compared to those who had not.

RESULTS:

124 subjects received an IBT and 11 were excluded due to chorioamnionitis. Of the remaining 113 patients, 59 received prophylactic antibiotics and 54 did not. Baseline characteristics were similar between the groups except for mode of delivery. The majority (56%) of those who had received prophylactic antibiotics had a vaginal delivery, whereas the majority (65%) of those who did not receive antibiotics had a cesarean delivery (p = 0.03). The incidence of endometritis was 15% and did not differ by mode of delivery. The incidence of endometritis was lower among those patients who received prophylactic antibiotics compared to those who did not (5% vs 26%, p <0.002; OR 6.53 [95% CI 1.76-24.25]). This association remained after adjustment for mode of delivery (OR 5.9 [95% CI 1.58-22.35]).

CONCLUSION:

Prophylactic antibiotics was associated with a reduction in the likelihood of postpartum endometritis among patients receiving an IBT. Prospective trials are needed to determine whether prophylactic antibiotics should be routinely given for IBT placement.
California State Law (SB-999) and Implementation: Dispensing a Year-long Supply of Prescription Birth Control [2E]
Authors: Nikpour Gelareh , Allen Antoinette , Rafie Sally , Rible Radhika , Chen Angela
Published: April 2018

INTRODUCTION:

Access to birth control is the cornerstone to preventing unplanned pregnancies. In California, women qualifying for state-funded reproductive insurance get yearlong supplies of contraception from participating dispensaries. A 2011 study found a 30% odds reduction in unplanned pregnancies when women received yearlong supplies of birth control as compared to one- or three-month supplies (Foster, 2011). Subsequently, in 2016, California Senate Bill-999 was passed, designating that women could receive yearlong supplies of birth control from pharmacists while requiring insurance companies to fund these prescriptions.

Using secret shopper methods, we will conduct a cross-sectional survey of California pharmacies to inquire whether they are able to comply with SB-999.

METHODS:

19,693 pharmacies met our inclusion criteria: commercial retail pharmacies in California. 13,660 were excluded for revoked/cancelled licenses or because they were affiliated with managed care or publicly funded networks. Based on our pilot study, for a power of 80%, 600 pharmacies were randomly selected from the remaining 6033. Using a secret shopper technique, these pharmacies are called and asked whether they can dispense yearlong supplies of prescription birth control to customers.

RESULTS:

We are currently collecting date. Based on preliminary review of 200 pharmacies called, with approximately 80% completed calls, 44% of pharmacists have not heard of SB-999. The top two obstacles to dispensing yearlong supplies of birth control quoted were insurance coverage (37%) and company policy (16%).

CONCLUSION:

Implementation of new laws take time and require institutional accountability. In revealing obstacles to accessing yearlong supplies of birth control, we aim to expedite implementation of SB-999.
Expanded Carrier Screening and Professional Society Guidelines: One Laboratory’s Experience [7E]
Authors: Westemeyer Maggie , Saucier Jennifer , Gold Bert , Hedriana Herman , Martin Kimberly A.
Published: April 2018

INTRODUCTION:

In the recent ACOG Committee Opinion (no. 690), expanded carrier screening (ECS) was acknowledged as an acceptable carrier screening strategy. In addition, ECS panel development was proposed, in part, to include conditions with a carrier frequency of at least 1:100. However, carrier frequency data are limited for many conditions proposed for ECS. Using a general population, we determined carrier frequencies for 22 genes associated with conditions proposed by ACOG for ECS panel inclusion and examined if other genes/conditions met ACOG ECS criteria.

METHODS:

Carrier frequencies for 274 genes screened were calculated using 41,898 positive cases from general population carrier screening samples run at a reference laboratory.

RESULTS:

Observed general population carrier frequencies for 22 ACOG-proposed ECS panel genes were: HBA1/2=1:101, HBB=1:29, BLM=1:408, ASPA=1:450, CFTR=1:27, IKBKAP=1:363, ABCC8=1:260, FANCC=1:453, FMR1= 1:200, GALT=1:144, GBA=1:117, G6PC=1:321, TMEM216=1:653, ACADM=1:88, BCKDHA=1:856, BCKDHB=1:534, MCOLN1= 1:812, SMPD1= 1:185, PAH=1:42, DHCR7=1:68, SMN1= 1:58, and HEXA=1:197. Of 252 tested genes not proposed by ACOG, nine had observed carrier frequencies greater than 1:100 (GJB2=1:16, MEFV=1:31, ATP7B=1:71, SLC26A4=1:71, F11= 1:74, USH2A=1:74, GAA=1:80, PMM2=1:83, and GALC=1:86), and 11 had carrier frequencies between 1:100–1:150 (ACSF3=1:102, ALDOB=1:110, EYS=1:110, PKHD1= 1:110, HOGA1= 1:114, SLC12A3=1:114, CAPN3=1:130, SLC22A5=1:134, PEX6=1:145, GLDC=1:147, and CEP290=1:149).

CONCLUSION:

We demonstrated general population carrier frequencies for ACOG-proposed ECS conditions. Sixteen ACOG-proposed genes had general population carrier frequencies less than the 1:100 cutoff. Twenty ECS genes not recommended in the Committee Opinion No. 690 meet or are near the 1:100 cutoff and could be considered for ECS, given frequency and condition severity.
Understanding Commercially Sexually Exploited Youths’ Attitudes and Beliefs Towards Contraception and Pregnancy [8E]
Authors: Kelly Mikaela , Bath Eraka , Godoy Sarah , Ports Kayleen , Abrams Laura , Barnert Elizabeth
Published: April 2018

INTRODUCTION:

Given the high reproductive health risks faced by commercially sexually exploited youth (CSEY), we sought to understand their attitudes and beliefs towards contraception and pregnancy.

METHODS:

We conducted semi-structured interviews with 21 female CSEY. Participants were recruited through group homes and a juvenile specialty court serving CSEY. Interviews were audio-recorded, transcribed, and coded for emergent themes using in-depth thematic content analysis.

RESULTS:

Overall, CSEY report relatively easy access to contraception. The youth intensely valued autonomy and expressed a strong preference for condoms as the primary form of contraception. Most respondents described an aversion towards hormonal birth control, attributed to personal experiences and peer accounts of side effects. Many also shared a common belief that hormonal methods are “unnatural,” cause infertility, and have low efficacy. Coupled with a preference for condom use was the reporting of frequent unprotected sex. Most had an attitude towards pregnancy of “if it happens, it happens.” Those who had been pregnant described confusion related to prenatal care and birthing, as well as frequent visits to the emergency room for pregnancy-related concerns.

CONCLUSION:

Given risks associated with their exploitation, to reduce unplanned pregnancy in CSEY, increased utilization of hormonal contraception is a promising option, in addition to reinforcing the importance of consistent condom use. For CSEY, contraceptive education that dispels prevailing myths, sets clear expectations regarding side effects, and emphasizes autonomy is most likely to be effective. Additionally, enhancing education about pregnancy and child-rearing can help CSEY appreciate the significance of their decisions regarding contraceptive use.