bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of Obstetric Telephone Triage: A Quality Improvement Project [14D]
Authors: Miller Michael , Magann Everett , Moody Heather , Schmidt Melissa , Butler Patricia , Lutgendorf Monica
Published: April 2018

INTRODUCTION:

Obstetric telephone triage is commonly used when patients call with questions or seek advice for various medical concerns. Prompt and accurate telephone triage is imperative to ensure high quality and accessible care while maintaining healthcare efficiency. We sought to determine the current accuracy of obstetric telephone triage on a labor and delivery unit compared to a standardized obstetric telephone triage call center.

METHODS:

This is an approved quality improvement project. We collected telephone triage logs for patients calling Labor and Delivery. Calls were reviewed by experienced nurses from the ANGELS call center at the University of Arkansas using standardized obstetric triage algorithms. Differences were categorized by concordant advice vs. discordant advice/less urgent and discordant advice/more urgent.

RESULTS:

We reviewed 101 calls over a 3 month period. 55% were >34 weeks, 27% were 20-34 weeks, and 2% were <20 weeks gestational age. Caller complaints included: contractions (38%), discharge/bleeding (10%), leaking fluid (10%), decreased fetal movement (6%), fever/nausea/vomiting/diarrhea (4%), and other complaints (30%). Of these calls, 80% (n = 81) were assessed with concordant advice. Of the discordant advice calls, 9% (n = 9) were less urgent, and 8% (n = 8) were more urgent. Three records (3%) were not marked with a disposition in the telephone triage log book.

CONCLUSION:

In an L&D setting, 80% of documented telephone triage advice was concordant with standardized telephone triage protocols. This presents opportunity for education and standardized obstetric telephone triage protocols to improve patient care.
Effects of Weight Gain on Delivery Outcomes in an Obese Pregnant Population [17D]
Authors: Ratan Bani M. , Sellner Allison A. , Garbarino Abigail H. , Miao Di , Hollier Lisa M.
Published: April 2018

INTRODUCTION:

The 2009 Institute of Medicine guidelines recommend 11-20 pounds weight gain for all pregnant women with a BMI ≥30. This study examines the effect of weight gain/loss on delivery outcomes in relation to class of obesity.

METHODS:

A retrospective cohort of 1,440 women receiving care at a large Medicaid clinic from 2013-2016 with pre-gravid BMI ≥30 was reviewed. Eligible women were non-smokers with a singleton pregnancy initiating care prior to 20 weeks. Multinomial logistic regression analysis compared gestational weight change to primary outcome of birth-weight percentile and secondary outcome of delivery type.

RESULTS:

Inclusion criteria were met by 889 women, with 485 in Class 1 (BMI 30-34.9), 218 in Class 2 (BMI 35-39.9), and 186 in Class 3 (BMI ≥40). Class 1 patients that lost weight were more likely to have a small-for-gestational-age (SGA) infant (P=.040) compared to Class 1 patients who had recommended weight gain. Class 2 and 3 patients had no statistically significant increase in SGA infants with weight loss or weight gain below recommendations. Class 2 patients that gained above recommendations were more likely to have a C-section during labor (P<.001) while Class 3 patients that gained above recommendations were more likely to have a scheduled C-section (P=.010).

CONCLUSION:

Class 2 and Class 3 mothers may benefit from less weight gain than current recommendations without increasing their risk of SGA infants. Further research is needed to ascertain if weight gain recommendations should be stratified based on obesity class.
Caesarean Sections in a National Referral Hospital in Addis Ababa, Ethiopia: Trends, Predictors and Outcomes [27D]
Authors: Kuzma Tamara
Published: April 2018

INTRODUCTION:

The objective of this study was to analyze Caesarean section (CS) rate trends and maternal and perinatal outcomes in an Ethiopian hospital using Robson criteria groups and subdividing further based on urgency.

METHODS:

This was a retrospective study of deliveries at a national referral hospital between 2002/01/01 and 2006/13/05 (Ethiopian calendar) using cluster sampling of deliveries of gestational age ≥28 weeks. (N=4,816). Women were categorized into 10 Robson groups (RGs) with CS deliveries further classified by urgency. Perinatal mortality and neonatal distress rates were used to characterize perinatal outcomes. Maternal morbidity rate was used to characterize maternal outcomes.

RESULTS:

The total CS rate rose from 24.5% to 32.8% (p=0.001). The only RG showing a significant change in CS rate was RG1 (15.9% - 24.1%; p= 0.02), which experienced a 51% relative increase. RG1 contributed most to the total CS rate in all 5 years (7.8%), followed by RG3 and RG5. The “Scheduled” urgency subgroup was largest within the majority of RGs. Neonatal outcomes did not significantly change over time. Overall maternal morbidity rate increased from 3.5% to 4.1% (p=0.02).

CONCLUSION:

The threshold for medically indicated CS has decreased in this publicly funded hospital, especially in low-risk women. We did not see increased complications, but CS without medical indication can result in harm and strain on already limited resources. As primary CS rates increase, more women will require repeat CS. Evidence-based interventions to reduce primary and repeat CS should be studied and implemented at this Ethiopian hospital.
Non-invasive Prenatal Testing (NIPT): The Probability of a Redraw Following a No-call [6E]
Authors: Martin Kimberly A. , Demko Zachary , Benn Peter , Valenti Elizabeth , Shah Shailen , Hedriana Herman
Published: April 2018

INTRODUCTION:

NIPT detects fetal aneuploidy with high accuracy provided the cell-free DNA fetal fraction (FF) is sufficient. For samples not receiving a result, referral for discussion of invasive testing has been suggested as the most appropriate “next step.” Alternatively, precise estimation of the success rate of a redraw NIPT sample could allow a more comprehensive discussion of management options between provider and patient.

METHODS:

We reviewed FF, maternal weight (MW), gestational age (GA), and the interval between draws (IBD) for 3,116 women whose initial single-nucleotide polymorphism (SNP)-based NIPT sample resulted in a no-call due to low FF and who submitted a second sample. Parameter correlations and redraw success rates were calculated.

RESULTS:

The overall redraw success rate was 63.4%. Initial FF and IBD were positively correlated, MW inversely correlated, and GA not correlated with redraw success. The average increase in FF between draws was 1.2%. Women with initial FF below 2%, between 2% and 3%, and above 3% had redraw success rates of <30%, 55%, and >70%, respectively. Women with <200 or >200 pounds MW had 78.3% and 54.7% redraw success rates, respectively. Over the first three weeks, the redraw success rate increased by approximately 15% per week.

CONCLUSION:

Women who do not receive a result on their SNP-based NIPT may have a good chance (>60%) for a successful redraw; further, waiting to redraw may increase the likelihood of redraw success. Women with high MW or especially low FF may benefit from referral for further evaluation and discussion of other options, including invasive testing.
Outcomes of Second-line Therapies for Stage 3 Postpartum Hemorrhage at a Tertiary Care Center [25E]
Authors: Clure Cara , Ernst Amanda , Vogel Rachel Isaksson , Bojan Katelyn , Das Kamalini
Published: April 2018

INTRODUCTION:

Postpartum hemorrhage (PPH) remains a major worldwide cause of maternal morbidity and mortality. Second-line interventions including uterine tamponade, dilation and curettage, uterine artery embolization (UAE), compression or hemostatic sutures, or hysterectomy, are often required to manage severe PPH. Our study sought to evaluate the success rates and complications of second-line therapies used to treat stage 3 PPH, defined as an estimated blood loss of greater than 1500 mL by the California Maternal Quality Care Collaborative.

METHODS:

This retrospective cohort study examined all deliveries at a tertiary care center between 2007 and 2015 complicated by a stage 3 primary PPH. The timing, order, and success rates of interventions performed and the subsequent complications were evaluated. Complications examined included ICU admission, hemorrhagic shock, disseminated intravascular coagulopathy (DIC), and endometritis.

RESULTS:

Of 21,067 deliveries, 267 (1.26%) were complicated by stage 3 PPH. Second-line therapies were used in 116/267 (44%). The highest success rates were found with UAE (94%, n=18), compression sutures (73%, n=29) and balloon tamponade (72%, n=68). Patients undergoing dilation and curettage as an initial second-line management were most likely to require additional intervention (54%). Endometritis and DIC were the most common complications (8%). Endometritis was most common after successful treatment with compression sutures (29%). The use of multiple interventions was associated with a higher incidence of complications.

CONCLUSION:

For the treatment of severe PPH, the use of uterine tamponade and UAE have high success rates and low complication rates. Our results can help inform management of stage 3 PPH, as it is less standardized.
Decreasing Opiate Prescriptions on Labor and Delivery: An Exercise in Culture Change [38E]
Authors: Ulrich Nicole , Nakahara Angela , Gala Rajiv
Published: April 2018

INTRODUCTION:

Louisiana is one of the worst states in regards to the opioid epidemic (average 98.1 prescriptions per 100 persons). We aimed to change the culture around opiate prescribing practices on Labor and Delivery with the goal of making this a system-wide initiative.

METHODS:

This QI project started with educating the prescribers, nurses, and patients about postpartum narcotic expectations. The primary outcome was patient initiated encounters for pain in the postpartum period (ED/office visits, phone calls, emails). Demographics and medication use were collected via chart review. Phone calls made 1-2 weeks after delivery included a short 5 question survey evaluating pain control satisfaction. Paired T-test was used to compare each of our 4 PDSA cycle outcomes to baseline data from the two months prior to cycle 1. We continued PDSA cycles until a plateau was reached.

RESULTS:

Baseline data from 192 patients were collected. The 4 PDSA cycles included 144 combined patients. There was no difference in the number of postpartum pain encounters after the prescribing changes (p=0.604). Amount of morphine milligram equivalents (MME) prescribed upon discharge significantly decreased (84% among patients with no lacerations, 64% in those with a first degree, and 79% in those with a second degree) (p<0.0001). Patients included in the PDSA cycles maintained very high satisfaction with pain control while hospitalized and after discharge.

CONCLUSION:

We demonstrated that we can significantly reduce the amount of narcotics introduced into our community without increasing postpartum encounters for pain or decreasing patient satisfaction.
Provision of the Contraceptive Implant for Adolescents Among Primary Care Residents [8M]
Authors: Hein Julie D. W. , Stoddard Amy M.
Published: April 2018

INTRODUCTION:

The contraceptive implant is highly effective and safe for adolescents yet under-used by this population. Provision of the contraceptive implant should be within the scope of practice of primary care providers who care for teenagers, including pediatricians and family physicians. This study aims to assess the attitudes, knowledge, and provision of the contraceptive implant by pediatric and family medicine residents.

METHODS:

Researchers emailed a web-based survey to program directors or coordinators for 204 pediatric and 498 family medicine programs, with a request to forward the survey to residents in each program. Responses were recorded, and relationships between participants’ demographics, knowledge, and experience regarding contraceptive implants were assessed using chi-squared analyses.

RESULTS:

Among 665 participants, 81.2% recommended the contraceptive implant to adolescents, yet 73.2% had never inserted an implant in this population. 68.5% had received lectures and 52.0% had received hands-on training regarding contraceptive implants. Compared to pediatric residents, more family medicine residents had received lectures (80.1% vs 49.0%, P<.00001) and hands-on training (77.8% vs 19.2%, P<.00001). More family medicine residents had placed one or more implants than pediatric residents (40.5% vs 9.2%, P<.00001). Most participants correctly answered three knowledge-based questions about the contraceptive implant (66.0%, 72.5%, 85.6% correct). Reported setbacks to provision of contraceptive implants included lack of training or experience, lack of patient interest, and lack of implant availability at clinical sites.

CONCLUSION:

The provision of contraceptive implants for adolescents by primary care residents is low, particularly among pediatric residents. Primary care residency programs should focus more on contraceptive implant training.
Knowledge Assessment and Screening Barriers for Breast Cancer in the Arab American Community [17M]
Authors: Ayyash Mariam , Blackwood R. Alexander , Hassouneh Samar , Hamade Hiam , Ayyash Marwa , Bahroloomi Sheena
Published: April 2018

INTRODUCTION:

Breast cancer is the most common malignancy afflicting women, with an estimated 1 out in 8 U.S. women diagnosed during their lifetime. Screening for breast cancer can reduce mortality through early cancer detection. Lack of knowledge is an important barrier leading to low screening rates. Given that the Arab American population has grown approximately 47% since 2000, this study was designed to assess breast cancer knowledge and screening barriers in an Arab American community.

METHODS:

Following (Not Regulated/Exempt) determination by the Institutional Review Board (Michigan) a survey was distributed through ACCESS, Arab Community Center for Economic and Social Services, in Dearborn, MI.

RESULTS:

175 Arab American adults participated in the study: 100 healthy women, 50 breast cancer women survivors and 25 healthy men. Deficiencies were noted in knowledge around cancer presentation and racial and ethnic differences in relative risk of disease. 72% of healthy women had a high level of knowledge, compared to 58% in survivors and 48% in men. Additionally we noted that 56% of healthy women controls over the age of 40 have not had a screening mammogram in the past 2 years with leading causes being: lack of health insurance, absence of family history and absence of symptoms.

CONCLUSION:

With the growing presence of Arabs in American communities, it is important that local physicians are aware in their medical knowledge gap to better serve this population. This study highlights some of these deficiencies especially the failure to adequately educate patients and their families while they are going through treatment.
Cervical Cancer Attitudes and Prevention in Rural Nicaragua [20M]
Authors: Wood Nicole , Pargas Anaisy , Romero Stephanie
Published: April 2018

INTRODUCTION:

In Nicaragua, cervical cancer is the leading cause of cancer-related deaths, with an estimated 18.43 deaths per 100,000 females in 2011. Prevention of cervical cancer is largely dependent on Pap testing; however, access is difficult in many Latin American countries due to limited health education and socioeconomic and cultural barriers. The objective of this study was to evaluate the epidemiology and perceptions regarding cervical cancer prevention and awareness in a rural Hispanic community.

METHODS:

Investigators evaluated a rural Nicaraguan community’s perceptions of HPV, Pap tests, and cervical cancer, measured through survey (n=40). A chart review was performed at the main local clinic, which addresses the majority of women’s health needs for the population, in order to gauge baseline community Pap test adherence and cervical cancer rates (n=564).

RESULTS:

Preliminary survey data found that 82% of women had previous knowledge of HPV, but basic questions about the disease were answered incorrectly greater than 50% of the time. Baseline chart review data indicated that 88.3% of eligible women had no Pap test data on file, and of those that did, 3% had an abnormal result possibly indicative of malignancy.

CONCLUSION:

The collected data indicates a significant deficit in both knowledge regarding cervical cancer and complete screening coverage in this community. Based on these findings, increased community health promotion would be valuable to educate women in prevention strategies and encourage greater Pap testing rates.
Shoulder Dystocia Simulation Training Improves Attending Physician Communication and Technical Skills [32M]
Authors: Chuang Meleen , Lee Yuo-yu , Friedman Frederick , Frieden Faith , Atallah Fouad , Bernstein Peter
Published: April 2018

INTRODUCTION:

Simulation has been widely adopted for resident training. The purpose of this study was to determine if an innovative shoulder dystocia simulation training program for attending physicians can improve performance.

METHODS:

Five academic medical centers with the same malpractice insurance company mandated all attending physicians to complete standardized simulation training for the management of shoulder dystocia. Baseline and post-training performance of communication and technical skills were compared in the simulated environment.

RESULTS:

288 attending physicians completed simulation training between 4/1/2016-6/22/2017. Most participants were female (69%) and had >11 years of experience (63%). Improvements in provider communication were noted in the following areas: Instructs patient (52.6% to 77.9%, P<0.001), provides explanation (49.1% to 84.2%, P<0.0001), notes time (26.7% to 47%, P<0.0001), requests rapid response (81.2% to 97%, P>0.0001), and calls for: Nursing (72.6% to 92.6%, P<0.0001), Pediatrics (70.5% to 93.7%, P<0.0001), Second OB (73.3% to 92.6%, P<0.0001), and Anesthesia (64.9% to 92.3%, P<0.0001). Provider performance of maneuvers were also noted to improve: McRobert's (93.7% to 97.5% P=0.0266), suprapubic pressure (63.2% to 93.9%, P<0.0001), rotational maneuvers (71.5% to 90.5%, P<0.0001), and posterior arm delivery (59.6% to 89.4%, P<0.0001). Significant improvements were also seen with the trainer's overall assessment of the provider's management of the emergency (66% to 95.1% P<0.0001).

CONCLUSION:

A simulation program for shoulder dystocia can improve attending performance in caring for this infrequent obstetric emergency. What remains to be demonstrated is whether this will translate into improved patient outcomes.
Therapist Guided Exposure Treatment for Vaginismus: Simulation and Immersive Learning Applications [36M]
Authors: Solone Michelle , Lynd Kelsey , Williams Katherine E. , May Margaret , Nemecek Pamela , Weitlauf Julie
Published: April 2018

INTRODUCTION:

Efficacious and cost-efficient non-pharmacologic treatments, i.e., therapist guided exposure therapy for penetration disorders (GET-PEN), are available and in widespread use outside of the U.S. While therapists commonly provide guided desensitization therapy for other phobias, the GET-PEN treatment has not yet been implemented within the U.S.- largely due to a lack of medical education and training opportunities and appropriate supervisory resources. Simulation based immersive learning techniques may offer an innovative mechanism for bridging this educational gap.

METHODS:

We developed a brief simulation-based/immersive learning protocol designed to train a cohort of interdisciplinary teams (i.e., gynecology + mental health) to correctly implement GET-PEN. Next, we piloted this training protocol with our selected clinical teams who then implemented the protocol with professional simulators (PSs). All teams were evaluated on the implementation of GET-PEN by an international team of instructors. Three core outcomes were emphasized: self-efficacy for communicating with patients about sexual pain disorders, adherence to the treatment protocol, and quality of sexual education provided in response to PS’s questions.

RESULTS:

Teams showed significant pre-post training skill gains in communication self-efficacy (p < .05), quality of sexual education (p < .05), and fidelity ratings of > 85%. However, not all teams trained to adequate fidelity ratings at the same rate, and those that required additional training repeated the simulation to achieve proficiency.

CONCLUSION:

Simulation based/immersive learning techniques are an efficient mechanism for training interdisciplinary teams to implement GET-PEN. Our next steps include implementation and evaluation of this treatment in U.S. patients presenting with vaginismus.
Lower Urinary Tract and Pelvic Floor Symptoms and their Correlation with Fibroid Characteristics [39M]
Authors: Shaffer Robyn K. , Dobberfuhl Amy D. , Fast Angela M. , Vu Kim-Nhiem , Ghanouni Pejman , Chen Bertha
Published: April 2018

INTRODUCTION:

Lower urinary tract symptoms (LUTS) are prevalent in women with uterine fibroids. Research suggests that increased fibroid volume and uterine bulk is associated with more severe LUTS and pelvic floor symptoms, however the correlation between fibroid size/location, adenomyosis, and symptoms has been under-studied. We sought to investigate this correlation using MRI which provides detailed information on fibroid characteristics.

METHODS:

A retrospective chart review was conducted for patients seen at the Stanford Fibroid Clinic. Patient demographics, medical history and pelvic MRI data were collected on 60 patients with completed Uterine Fibroid Symptom (UFS) and Pelvic Floor Distress Inventory (PFDI) validated symptom surveys. Primary outcome was scaled symptom scores and sub-scores including the Urogenital Distress Inventory (UDI-6).

RESULTS:

Dominant fibroid volume correlated negatively with urinary frequency (r=-0.307, P=.030), urgency (r=−0.287, P=.043), and pelvic pain or discomfort (r=-0.281, P=.049). Longest fibroid dimension also negatively correlated with UDI-6 (r=-0.304, P=.028). Number of fibroids and uterine volume were not significantly associated with LUTS. However, higher PFDI score was significantly associated with presence of adenomyosis on MRI (mean 82.9 vs 159.6, P=.018) and serosal fibroid location (mean 139.3 vs 69.0, P=.011). Patient BMI correlated positively with UDI-6 (r=0.415, P=.002) and PFDI (r=0.371, P=.005).

CONCLUSION:

Contrary to common belief, dominant fibroid size was inversely associated with LUTS, suggesting that fibroid dimensions may not predict bulk-related symptom severity. Adenomyosis should be considered in the evaluation of LUTS in women with uterine fibroids. In accordance with current literature, BMI is associated with LUTS including incontinence, urgency, and frequency.
The Relationship Between Internalized HIV Stigma and Risky Sexual Behavior [1N]
Authors: Jones Solita , Konkle-Parker Deborah , Blackshear Chad
Published: April 2018

INTRODUCTION:

HIV stigma marginalizes HIV-infected individuals from society. Twenty-five percent of people living with HIV are women. Because stigma and discrimination could impact the willingness of a person to disclose their HIV status to their sexual partner; it would be valuable to know how much stigma is associated with unprotected sexual behavior in women and the willingness to disclose their status.

METHODS:

Data were collected through Women’s Interagency HIV Study (WIHS), a longitudinal cohort study started in 1993 of women living with HIV (WLWH) or at risk for HIV, with questions asked from April to October 2015. The relationships between HIV stigma and risky sexual behavior were analyzed using Wilcoxon rank-sum test.

RESULTS:

Among 2022 participants, 1654 (70%) were HIV positive and 453 (20%) of participants were legally/common law married. Of the HIV + participants, 389 (18%) reported engaging in risky sexual behavior defined as unprotected vaginal or anal sex. There was no statistically significant relationship between HIV disclosure rate and engagement in risky sexual behavior (p=0.119). However, those who were married reported engaging in risky sexual behavior more often than those not in committed relationships (p<.001). No relationship existed between internalized stigma and disclosure or risky sex.

CONCLUSION:

Increased internalized HIV stigma was not found to correlate with engagement in risky sexual behavior and disclosure rates amongst WIHS participants. The level of commitment among married participants may influence behavior and risk acceptance. Further analysis of viral loads, partner serostatus and disease duration in these participants is needed.
Prevalence of Abnormal Cervical And Vaginal Cytology In HIV-Infected Women Over The Age Of 65 [5N]
Authors: Stewart Kelsey , Chesnokova Arina , Syed Fatima , Levison Judy
Published: April 2018

INTRODUCTION:

HIV-infected women are 10-11 times more likely to develop abnormal cervical cytology compared with HIV uninfected women, elevating the need for Pap smear surveillance. While guidelines for screening exist for HIV-infected women of reproductive age, there is inadequate data to guide care for women over 65. Our research evaluates the prevalence of abnormal cervical cytology/CIN and invasive neoplasia in HIV-infected women over the age of 65 with no history of abnormal Paps to aid in the creation of screening recommendations for this demographic.

METHODS:

This is a retrospective chart review of records from 2000-2015, from an urban low-income setting. We screened 254 patients, 70 of whom met inclusion criteria: HIV+, age over 65, with at least one pap test after age 65, lacking abnormal cervical/vaginal cytology screening, and lacking history of hysterectomy for non-benign reasons.

RESULTS:

Of included patients, 17.1% had at least one abnormal pap smear: 41.7% ASCUS/HPV+, 75.0% LSIL, 25.0% HSIL, with 25.0% patients having more than one abnormal result. Of those with abnormal pap, 66.7% had abnormal pathology on follow-up biopsy: 33.3% CIN/VAIN1, 16.7% CIN/VAIN2, 16.7% CIN/VAIN3. No patients had invasive cancer. Median time to first pap test after age 65 was 14.7 months. No demographic factors were significantly associated with abnormal pap. Higher viral load at time of testing was positively associated with abnormal pap.

CONCLUSION:

Our findings of high rates of abnormal pap tests and subsequent high rates of abnormal pathology suggest that pap tests in women over age 65 may be indicated.
Postoperative Opioid Use After Cesarean Delivery [15N]
Authors: Lawlor Megan , McQuerry Kristen J. , Tan Jenny , Williams Corrine M. , Hansen Wendy , Critchfield Agatha S.
Published: April 2018

INTRODUCTION:

To investigate patterns of use and optimal prescribing of post-operative outpatient opioids for pain control after cesarean delivery.

METHODS:

We performed a pilot survey study of women after cesarean delivery from August 2016 to July 2017. Inclusion criteria included women 18 years or older, post primary or repeat cesarean delivery with regional anesthesia. Exclusion criteria included general anesthesia, wound infection, patient-controlled analgesia postoperatively, and prolonged hospital stay. Patients received standardized opioid and ibuprofen prescriptions upon discharge (30 tablets of ibuprofen 600mg, and 30 tablets of oxycodone-acetaminophen 5/325mg or hydrocodone-acetaminophen 5/325mg). Participants responded to an online survey two weeks following delivery, which inquired about pain control and amounts of pain medications used. Patient demographics, medical and surgical history was collected.

RESULTS:

A total of 143 women were enrolled and 65 women participated in the online survey. 52 percent of patients had at least 10 extra opioid tablets remaining at the two-week postoperative time point. The amount of opioid tablets used after hospital discharge did not correlate with patient age, body mass index, smoking status, current or past drug abuse, hypertensive diseases, diabetes, number of previous cesarean deliveries, patients’ ability to breastfeed or provide infant care, or number of prescription refills (p>0.05). Increased number of opioid tablets used did not correlate with increased satisfaction with pain control.

CONCLUSION:

Opioid medications are potentially prescribed in excess of the amount needed for outpatient pain control. Patterns of opioid use following cesarean delivery are difficult to stratify based on patient characteristics and risk factors.
Randomized Double-Blinded Comparison of Titrated Oral Versus Vaginal Misoprostol for Labor Induction [24N]
Authors: Kennel Patricia , Fu Jessica , Frisch Donald , Hom Katherine , Allen Hilary , Matsunaga-Kirgan Marsha
Published: April 2018

INTRODUCTION:

For labor induction of an unfavorable cervix, we propose oral misoprostol, titrated to uterine response, to maximize safety and efficacy, based upon past studies.

METHODS:

Randomized double-blinded study. Identically appearing oral and vaginal study dosages were prepared containing either 25mcg misoprostol or placebo. The pharmacist randomized the study participants to receive either an “oral packet” (oral misoprostol, vaginal placebo) or a “vaginal packet” (opposite). Patients received both an oral protocol (quantity of capsules titrated to uterine contractions, every 2hrs) and vaginal protocol (25mcg/placebo every 4hrs) simultaneously. Providers and patients were blinded.

RESULTS:

Un-blinding revealed 28 oral and 22 vaginal participants, with four oral, and five vaginal participants removed (imperfect consent forms, missing data). Confounding variables had no statistical significance. Primary outcomes: 1) Time to Bishop Score > 7: Titrated oral route was 9.94 hours (Standard Deviation 5.149, 95%CI 6.82-13.05). Vaginal route was 6.59 hours (SD 1.826, 95%CI 5.06-8.11). 2) Time to NSVD: Titrated oral route was 15.52 hours (SD 5.862, 95%CI 11.98-19.06). Vaginal route was 12.74 hours (SD 4.790, 95%CI 8.74-16.74). 3) Change in Bishop score: Titrated oral route was 3.39; Vaginal route was 5.25. Several safety parameters and side effects were evaluated, showing a trend towards the oral route being safer. Approximately 25% of the oral route participants reached the maximum oral dose of 75 mcg, and none needed dosage reduction. Approximately 80% of all participants preferred oral administration because they disliked vaginal placement, while 20% preferred the vaginal administration because it “worked better” and they “dislike pills.”

CONCLUSION:

Results suggest our oral titrated protocol has less efficacy and side effects, although numbers didn’t reach statistical significance. Patients had strong preferences for the oral route. There is potential for future studies based upon our study. With a thorough review of recent studies, we can redesign our study in many ways, including a higher dose of oral misoprostol.
Centering Pregnancy Does Not Affect Rates of Breastfeeding at Postpartum Discharge [25N]
Authors: Hosein Safiyah , Paoletti Andrew , Pitcairn-Ramirez Alexis , Bondy Jessica , Cohen Arnold , Jaspan David
Published: April 2018

INTRODUCTION:

Centering Pregnancy, a group prenatal care model, has been shown to have many benefits including increased breastfeeding rates in postpartum adolescents. We examined if our Centering Pregnancy program demonstrated increased breastfeeding rates overall.

METHODS:

A retrospective chart review was performed on all patients who delivered at our inner city tertiary care hospital from June 2016 to June 2017. This included 267 Centering patients and 2289 patients who received routine office based prenatal care. Patients who participated in our Centering Pregnancy program did so secondary to schedule availability and patient preferences. Center Pregnancy promoted breastfeeding through educational materials and lactation consultant educational sessions. Data on breastfeeding vs. bottle feeding choice was obtained on all patients via EMR abstraction at the time of postpartum discharge. Statistical analysis was performed using Chi-squared test for independence.

RESULTS:

Of the 267 Centering Pregnancy patients, 147 (55%) were breastfeeding at time of discharge, 120 (45%) were not. Of the routine prenatal care patients, 1278 (56%) were breastfeeding at time of discharge, 1011 (44%) were not. No statistical difference was noted in breastfeeding between the two groups. A subanalysis on patients with government assistance insurance similarly showed no difference in the rate of breastfeeding.

CONCLUSION:

Centering Pregnancy did not increase breastfeeding rates at the time of postpartum discharge. It may be useful to investigate breastfeeding rates at 3 and 6 months postpartum to look at continued adherence.
Does Opioid Maintenance Therapy Decrease the Risk of Neonatal Withdrawal in Mothers with Opioid Use Disorder? [28N]
Authors: Ly Victoria , Persad Malini D. , Herrera Kimberly , Garry David , Garretto Diana
Published: April 2018

INTRODUCTION:

The objective of the study is to determine if opioid maintenance therapy decreases the risk of neonatal abstinence syndrome in pregnant women with opioid use disorder.

METHODS:

A retrospective cohort study of pregnant women with opioid use disorder was performed at a tertiary care hospital from January 2016 to June 2016. Women were identified using the hospital's delivery logs. Women were categorized by whether they were on opioid maintenance therapy or actively using opioids. Maternal demographics, medical history, social history, delivery characteristics and neonatal outcomes were collected. A composite adverse neonatal outcome score was created and defined as the presence of any of the following: preterm delivery, birthweight <2500 grams, Apgar score < 7 at 5 minutes, NICU admission, and neonatal abstinence syndrome. Parametric and nonparametric statistics were used to compare groups. A p value of < 0.05 was considered statistically significant.

RESULTS:

Of 1,927 women who delivered, 50 women qualified for the study. There were no statistically significant differences in demographic characteristics between groups. Women on opioid maintenance therapy delivered at a statistically significant higher gestational age, had a higher neonatal birth weight and lower NICU admission rate compared to active opioid users. There were no statistically significant differences in neonatal outcomes, including neonatal abstinence syndrome, between groups.

CONCLUSION:

Opioid maintenance therapy use in pregnant women with opioid use disorder does not decrease incidence of NAS, but use may decrease the risk of preterm birth, low birth weight, and NICU admission.
Genetic Counseling Services in Oncology: Recognizing the Underutilization of Referrals in At-Risk Cancer Patients [37N]
Authors: Palvia Vijay , Taylor Nicholas , Andrea Smith , Zighelboim Israel
Published: April 2018

INTRODUCTION:

Despite equal access to family history and screening guidelines, we hypothesize that there is a failure to identify “automatic referral” patients (i.e. < 50 years old, histology, and family history) for genetic counseling services among oncologic practices.

METHODS:

A retrospective chart review was completed among 3 oncologic practices (gynecologic - GO, surgical - SO and medical - MO) at St. Luke’s University Health Network (SLUHN). Inclusion criteria required an eligible cancer diagnosis. All eligible patients were screened by the National Comprehensive Cancer Network (NCCN) guidelines. Primary outcomes included the rate of “failure to identify” (FTI) patients who met criteria for referral including “automatic referral.” Secondary outcomes included rate of genetic referrals. Data collection underwent descriptive testing and comparisons were analyzed with chi-square calculations.

RESULTS:

Each oncologic practice contributed eligible patients (47 GO, 44 SO, 40 MO) to the study. The rate of “failure to identify” patients among those that met criteria for were as follows: GO - 14% (4/28), SO - 31% (5/16), and MO - 33% (3/9) (p = 0.30). Proportions of “automatic referral” patients that were unidentified were as follows: GO - 22% (4/18), SO - 40% (4/10), and MO - 17% (1/6). Referral rates by sub-specialty were as follows: GO 100%, SO 91%, and MO 66%.

CONCLUSION:

An unexpected ratio of unidentified patients that met criteria for “automatic referral” was seen. These findings should constitute the basis for a unique opportunity and comprehensive strategy aimed at identifying and better serving at-risk cancer patients within our network.
Effects of Male Partner Age on Pregnancy and Obstetric Outcomes in Frozen Oocyte Donor Cycles [40N]
Authors: Capelouto Sarah M. , Nagy Zsolt P. , Spencer Jessica B. , Shapiro Daniel , Hipp Heather S.
Published: April 2018

INTRODUCTION:

Nationally, paternal ages at conception are rising, as are concerns over potential risks in pregnancy and child health. It is unclear if advancing male age influences in vitro fertilization (IVF) success or obstetric outcomes. Frozen donor oocyte IVF offers an ideal model to study this, since oocytes come from young healthy women and intracytoplasmic sperm injection (ICSI) is performed. Thus, our objective was to examine whether paternal age affects outcomes in frozen donor oocyte IVF.

METHODS:

Data were analyzed from 852 patients undergoing embryo transfer derived from a vitrified oocyte donor bank between 2008-2015. Each recipient received a cohort of oocytes that were thawed, fertilized via ICSI, and transferred on post-fertilization day 5. Multivariate logistic regression was used to estimate rates of live birth (LBR), low birth weight (LBW), and preterm delivery (PTD) after the recipient’s first embryo transfer from the cohort.

RESULTS:

Mean age among male partners was 41.47+/-6.19 years. The LBR with male partner ages of <35, 36-40, 41-45, 46-50, and >50 years were 57.1%, 55.9%, 57.1%, 52,1%, and 56.3% respectively. After adjusting for covariates, male age was not associated with implantation, clinical pregnancy, or LBR. The rates of PTD ranged from 6.2-13.5% for male age <50. For men >50, PTD was elevated (33.3%), but this was not statistically significant after adjustment (aRR 2.49, 95% CI 0.84-7.39). The difference in LBW with men >35 was not statistically significant.

CONCLUSION:

Advancing male age is not associated with rates of live birth, low birth weight, or preterm delivery in frozen donor oocyte cycles.
A Vasectomy Training Curriculum for Ob/Gyn Residents [6O]
Authors: Gorrindo Phillip , Guo Xiaoyue , Fay Kathryn , Chang Katherine , Hall Evelyn , Hammond Cassing
Published: April 2018

INTRODUCTION:

Vasectomy is a safe and effective form of contraception. However, sterilization rates are up to three times higher in women than in men. One barrier to increased use of vasectomy is the availability of trained providers. Unfortunately, vasectomy has traditionally been excluded from the skill set of Ob/Gyns.

METHODS:

We surveyed our Ob/Gyn residents to gauge interest in a vasectomy curriculum (VC). We identified stakeholders involved in developing a VC, including Ob/Gyn residency leadership, Urology and Family Planning faculty, Graduate Medical Education leadership, and representatives from our institution's legal department. In a multidisciplinary team, we developed a VC that leveraged the expertise of Urology faculty and will soon be offered to Ob/Gyn housestaff at our institution.

RESULTS:

Thirty-eight of 48 (84%) residents responded to the survey and 58% agreed that they would like to provide vasectomies. Our multidisciplinary team discussed issues related to developing a VC, including: medicolegal, credentialing, and privileging questions, potential competition between Urology and Ob/Gyn, and ethical implications of Ob/Gyns providing vasectomies. We then developed a VC built on Urology housestaff training. We will soon offer this VC to Ob/Gyn residents, with an option to perform vasectomies in Urology clinic.

CONCLUSION:

There is substantial interest among our Ob/Gyn residents to gain vasectomy experience. Barriers to training Ob/Gyns to perform vasectomies are not insurmountable. We suggest that there is an compelling ethical argument for Ob/Gyns to be able to provide vasectomies. Finally, our VC may serve as the foundation for other institutions to begin building their own VC for Ob/Gyn housestaff.
Uncovering Female Reproductive Pathology: Horizontally Integrated Observational Cadaveric Study [10O]
Authors: Litvinova Katerina , Pruzansky Alix
Published: April 2018

INTRODUCTION:

Systems-based curricula have dominated medical school education over the recent decade, but anatomy has largely remained separate from this integration. Cadaveric dissection incorporates anatomy, histology, microbiology, pathology, and clinical significance into the early training of physicians. For pre-clinical students with particular interest in obstetrics and gynecology, a plethora of reproductive pathology can be uncovered upon close cadaveric analysis and more advanced dissection methods. Students can derive great benefit by re-visiting the anatomy lab to gain richer understanding of reproductive disease pathophysiology.

METHODS:

Ten female cadavers aged 60 to 98 (M=78 SD=12.8) from Ross University School of Medicine anatomy lab were examined for cervical, uterine, and ovarian pathology. Students reviewed pelvic anatomy and learned surgical techniques used to perform hysterectomies and cervical cone biopsies under guidance of a reproductive surgeon. Students processed harvested tissue, performed H&E staining along with HPV assays, and interpreted slides with pathologists. Through literature review and active discussion, faculty helped students relate clinical relevance of observational cadaveric study to general trends in obstetrics and gynecology.

RESULTS:

All ten female cadavers revealed reproductive pathology, spanning cervical (cervical intraepithelial neoplasia stage I, atypical cervical glandular hyperplasia, Nabothian cysts), uterine (endometrial polyp, adenomyosis, leiomyomas), and ovarian (epithelial inclusion cysts, hyalinized atrophic ovarian follicles, ovarian calcifications) findings.

CONCLUSION:

Observational cadaveric study encourages active learning, facilitates basic and clinical science integration, and allows for evaluation of reproductive pathology trends among the older female population. This not only profoundly engages aspiring obstetrician-gynecologists, but also fortifies an institution’s research profile while optimally utilizing gross anatomy lab resources.
Safe Surgery Education: Improving Patient Care on Labor and Delivery Units [17O]
Authors: Chen Joseph , Erickson Laurie
Published: April 2018

INTRODUCTION:

In 1999, the U.S. Institute of Medicine launched a movement in healthcare to improve patient care and to decrease medical errors on a national level. These initiatives sparked dramatic changes to improve provider hand-off processes, decrease preventable errors and adverse outcomes. Similarly, observational obstetrical studies have shown that maternal morbidity and mortality can be decreased through checklists and safety steps. At our institution, we introduced Obstetrical Safe Surgery Education Program to further decrease medical errors in vaginal (VD) and cesarean deliveries (CD). This prospective study evaluated objective differences in patient care using standardized audit tools before and after program introduction at a single institution.

METHODS:

Baseline delivery audits of OBGYN physicians, nursing and anesthesia providers were performed using an institutionally-standardized checklist (VD-20 items, CD-62 items) by trained observers from January 2015-May 2016. Education of staff and physicians was provided using visual aids, formal training courses, lectures and mock drills. Following this,128 VD and CD were randomly audited. Objective measures included accuracy of instrument counts, effective communication between staff and adequate documentation of care. Scores were calculated based on total percentage of correctly performed items.

RESULTS:

Prior to the education introduction, the average percentage of correctly performed items in VD and CD were 69% and 88%, respectively. Following the educational period, the average percentages respectively increased to 81% (P=0.29), 91% (P=0.94). Improvements were observed in all objective measures.

CONCLUSION:

A multimodal approach of healthcare education can lead to clinical improvements in patient care. Larger studies are required to delineate barriers of education implementation.
Call the Midwife: Fortifying Collaborative Relationships through Simulation [18O]
Authors: Lee Mabel , Bazella Corinne
Published: April 2018

INTRODUCTION:

Few studies have evaluated the impact of inter-professional education or simulation based programs in obstetric care; fewer have investigated inter-professional simulation. A study showed that inter-professional-simulation programs may be beneficial in undergraduate medical education, but it is unclear whether such training impacts the transition from undergraduate to graduate medical education, and if there is knowledge retention from simulations.

METHODS:

We developed a paging simulation, as part of our Ob/Gyn Bootcamp, for medical (n=6) and midwifery (n=5) students to assess the ACGME milestones and core competencies for inter-professional collaborative practice. Participants completed pre- and post-surveys using Likert scales to self-report changes in attitudes towards inter-professional collaboration and readiness for residency, and medical students again performed this survey 3 months into residency.

RESULTS:

Medical students felt more confident differentiating between emergent and non-emergent situations, more able to assess patients over the phone, more comfortable working with midwives, and reported increased knowledge of Ob/Gyn after the simulation (p<0.05). In the follow up survey in residency, participants reported a significant impact (mean 4.6) in their skills and confidence in these situations as a result of the simulation. Midwifery students had a more positive perception of working with medical students and physicians and felt less intimidated.

CONCLUSION:

Inter-professional simulation based activity increases a students’ confidence in evaluating clinical situations, knowledge in OB/Gyn, preparation for residency, and comfort in inter-professional collaboration. The positive impact continues as students transition into residency. Inter-professional-simulation based programs are beneficial to students and larger studies should be performed to ensure this positive impact.
Preeclampsia with Severe Features-Assessing the Impact of Headache and Visual Disturbances [25O]
Authors: Kia Farnaaz , Rincon Monica , Beeraka Sridivya Spurthi , Burwick Richard M.
Published: April 2018

INTRODUCTION:

In pregnant women with hypertension, the presence of headache or visual symptoms may prompt early delivery due to concern for preeclampsia (PE) and eclampsia. We evaluated subjects with preeclampsia with severe features (PE-SF) to assess the impact of these symptoms on maternal and neonatal outcomes.

METHODS:

Retrospective cohort study of subjects with PE-SF, ≥23 weeks gestation at a single institution (October 2013-May 2017). Subjects were identified by ICD-9 and ICD-10 codes, with charts reviewed for diagnostic accuracy. Symptoms like headache and visual disturbances were determined by physician documentation. We compared outcomes in three groups: 1. No headache or visual disturbances; 2. Severe headache only; 3. Severe headache and visual disturbances. Significance determined by chi-square or t-test.

RESULTS:

Among 8,645 deliveries, 318 women (3.7%) delivered with PE-SF; 192 (60.4%) had no headache or visual disturbances, 68 (21.4%) severe headache only, and 39 (12.3%) both headache and visual disturbances. Maternal admission to the intensive care unit, pulmonary edema, kidney injury, or hemolysis, elevated liver enzymes, low platelet count syndrome, were no different between groups. However, those with both headache and visual disturbances had increased risk of eclampsia, p=0.016. Those with headache were delivered earlier (p<0.0001), more likely to have neonates born preterm (p=0.007) or admitted to the Neonatal Intensive Care Unit (NICU), p=0.02.

CONCLUSION:

We find that headache and visual disturbances contribute disproportionately to preterm delivery and NICU admission rates in PE-SF. However, the increased risk of eclampsia in this setting suggests that such action is justifiable.