bluuebunny/crossref_metadata_2025 huggingface dataset:
Does Antenatal Surveillance Improve Neonatal Outcomes in Women With Morbid Obesity? [34K]
Authors: Bedell James , Hosey Kathryn , Malhotra Tani , Van Wyck Laura , Hole James
Published: May 2017

INTRODUCTION:

Obesity has reached epidemic status and its effects on women of reproductive age and pregnancy cannot be overlooked. It is our hypothesis that antenatal surveillance beginning at 36 weeks' has made an effect of adverse pregnancy outcome in our practice since its implementation.

METHODS:

This is a retrospective cohort study where we compared women who presented for care prior to October 20, 2013, when antenatal surveillance was enacted at our institution, and those who underwent such surveillance. In total, 229 women met criteria for entry into the study, 120 patients in the study group and 107 patients in the control group.

RESULTS:

There were no observed demographic differences between the study and control groups. There were no differences in outcomes in either groups. Although cesarean sections occurred in 55.14% of the control group, while only comprising 44.17% of the study group, they were not statistically significant [P=.099; OR 0.6 (95% CI 0.38 – 1.09)]. Similarly, there were no differences in neonatal outcome in either group. NICU admissions were 5.61% of the control group and 8.3% of the study group, and were not statistically significant [P=0.423; OR 0.7 (95% CI 0.23 – 1.86)].

CONCLUSION:

Obesity will likely remain a major health concern for the world's population for the foreseeable future. Although our study did not find any statistically significant differences, further research is needed to determine if surveillance can lower the rate of stillbirths in this population, and, possibly, lead to statistically significant decrease in cesarean section rates.
Does a Strict Requirement of Quintero Stage Greater Than Two Matter When Performing Laser Therapy for TTTS? [35K]
Authors: Kennedy Devin , Sutton Whitney , Pandey Vishal , Lee Gene
Published: May 2017

INTRODUCTION:

We sought to see if perinatal mortality in Twin Twin Transfusion Syndrome (TTTS) differs if strict adherence to the Quintero stage greater than two is used as a uniform criteria to perform laser ablation.

METHODS:

A retrospective chart review from 2009-2015 was performed at our institution. All twin gestations with diagnosed TTTS were reviewed. Patients with fetal anomalies or lack of follow up after diagnosis were excluded. Ultrasound parameters, clinical data, and neonatal outcomes were abstracted from each patient's medical record. Strict Quintero staging and survival was determined. Outcomes were then compared to the reference group with Chi-square good of fit tests.

RESULTS:

After exclusions there were 26 patients identified with TTTS who underwent laser ablation. 19 of those patients were Quintero stage greater than two. The remaining gestations did not fit into a strict stage criteria. Among the seven remaining gestations, there was a notable absence of single twin survival and also higher dual twin death. This trend was statistically significant. However, the inclusion of these surgical cases did not alter the overall perinatal mortality when compared to a theoretical rate derived from our 19 member reference group.

CONCLUSION:

A strict indication of Quintero stage greater than two for laser ablation in TTTS would not have produced improved perinatal survival. There is a trend for increased dual twin death in TTTS cases which are not clearly stage greater than two. Further study for criteria for laser photocoagulation in TTTS is warranted when a larger pool of data is available.
Fetal Anomalies and Labor Complications [36K]
Authors: McCormick Anna , Simpson Pippa , Pan Amy , McIntosh Jennifer , Hibbard Judith
Published: May 2017

INTRODUCTION:

The purpose of this study was to evaluate labor complications and obstetric outcomes in patients diagnosed with fetal anomalies.

METHODS:

Using the Safe Labor Consortium, a retrospective dataset including labor information from 19 United States hospitals collected from 2002-2008, we compared patients diagnosed with a viable infant with a fetal anomaly to low risk singleton pregnancies. The primary outcome was need for operative vaginal delivery or cesarean delivery. Secondary outcomes include: maternal outcomes–bleeding (administration of blood products, abruption, postpartum hemorrhage, uterine rupture, hysterectomy), malpresentation, maternal ICU admission or death, chorioamnionitis/endometritis, lacerations (third- or fourth-degree), shoulder dystocia and birth injury. Chi-Square or Fisher's exact test was used to examine the association between anomaly and secondary outcomes. Odds ratios and confidence intervals were calculated.

RESULTS:

We evaluated 5360 patients with a fetal anomalies and compared them to 93,129 patients with low risk singleton pregnancies. There was no significant difference in need for operative vaginal delivery between groups (OR 0.98 95% CI 0.88, 1.10). There was a significant increase risk of cesarean delivery in the patients with anomalies (OR 1.5 95% CI 1.39, 1.62), as well as incidence of malpresentation (OR 1.27 CI 1.11,1.45) and breech presentation (OR 1.7 CI 1.41, 2.18), intrapartum fetal distress (OR 1.30 CI 1.15, 1.48) and birth injury (OR 1.88 CI 1.53, 2.30).

CONCLUSION:

Patients diagnosed with a fetal anomaly are at increased risk of cesarean delivery, malpresentation and birth injury. These increased risks should be taken into consideration in management of these patients.
Iron Deficiency Anemia in Pregnancy and Treatment Options: A Patient-Preference Study [1L]
Authors: Nguyen Vanessa , Wuebbolt Danielle , Thomas Hannah , Murphy Kellie , D'Souza Rohan
Published: May 2017

INTRODUCTION:

As many as 17% of Canadian women suffer from iron deficiency anemia (IDA) in pregnancy. Treatment options include oral ferrous salts, haem iron, intravenous (IV) iron and blood transfusions. Trade-offs pregnant women are willing to make to alleviate symptoms of IDA have not been determined. This study elicits preferences of pregnant women for health-states arising from IDA and the use of various treatment options.

METHODS:

A cross-sectional study was conducted on pregnant women with and without IDA. Participants were presented with five vignettes representing maternal health-states arising from IDA in pregnancy. They were asked to rank these states and assign them values on a visual analogue scale, by the standard gamble, and by time trade-off methods. Utility values (preferences) of women with and without IDA, obtained from these methods were presented on a scale of 0-100 where 0 represented death and 100 represented perfect health.

RESULTS:

60 pregnant women (30 with IDA and 30 without) completed the interviews. With all three methods, utility values were lowest for blood transfusion and highest for oral iron. Regardless of the evaluation method, there was no difference in utility values for treatment with oral ferrous salts vs. haem iron or between women with or without IDA.

CONCLUSION:

Women acknowledge that symptoms of IDA in pregnancy reduce quality of life. Despite side effects and frequency of administration, oral iron is preferred over IV iron and blood transfusion. Confirmation of these findings in larger studies would directly inform clinical practice and research.
Low Back Pain in Pregnancy–Investigations, Management, and the Role of Neuraxial Analgesia: A Narrative Review [2L]
Authors: Sehmbi Herman , D'Souza Rohan , Murphy Kellie , Bhatia Anuj
Published: May 2017

INTRODUCTION:

Low back pain (LBP) is common in pregnancy affecting approximately 50% of pregnant women. Yet, there is much ambiguity with regard to the diagnostic work-up and management of pregnant women with LBP. This narrative review summarizes evidence surrounding investigations, management strategies and the considerations around performing neuraxial blocks for pregnant women with LBP to inform clinical practice.

METHODS:

MEDLINE, MEDLINE In-Process and Embase were searched from inception to November 2015. The search was limited to humans and restricted to the English language. All studies from case reports to randomized controlled trials describing diagnostic modalities, management strategies and use of neuraxial techniques during labor and delivery in pregnant women with LBP were identified.

RESULTS:

A total of 6803 records were identified through database-searching and 60 through citation-tracking, of which 77 studies were included. Of these, 32 described the use of diagnostic modalities, 56 described management strategies, and three reported the use of neuraxial techniques for labor and delivery. Magnetic resonance imaging is the safest diagnostic modality for LBP in pregnancy. Antenatal educational programs, exercise and steroid injections into the epidural space or sacroiliac joints may help with pain management. Worsening neurological deficits, vertebral fractures, and tumors may need surgical management. There is limited evidence on challenges of performing neuraxial blocks in the peripartum period but there is a potential for increased risk of neurological complications in parturients with pre-existing neurological deficits.

CONCLUSION:

This review summarizes the available evidence and provides a clinical algorithm for the diagnosis and management of pregnant women with LBP.
Management of Severe Range Blood Pressures During Obstetrical Care: A Quality Improvement Project [3L]
Authors: Piazza Adriana , Sienas Laura , Wolfe Kristen , Stricklin Melaney , Creinin Mitchell
Published: May 2017

INTRODUCTION:

Hypertensive disorders of pregnancy are a leading cause of maternal and neonatal morbidity and mortality. Timeliness of treatment improves maternal and neonatal outcomes. This study assesses the impact of implementing a program for severe range blood pressure (SRBP) management during inpatient obstetrical care.

METHODS:

We prospectively collected data from a single academic center during 2015-2016 comparing outcomes before and after a system change. The changes included 1) an algorithm to improve blood pressure (BP) recheck times (for validating SRBP) and time to intravenous medication when indicated; 2) improved medication access making all medications equally available; and 3) multidisciplinary training including simulation sessions. All patients with ICD-10 codes of pregnancy-related hypertensive disorders who had SRBP were evaluated over a three-month period before and after program implementation. SRBP treatment included intravenous labetalol or hydralazine or oral nifedipine. Primary endpoints compared time to BP recheck, time to medication when indicated and type of medication.

RESULTS:

More women had a BP recheck within one hour post-implementation (330/344, 95.9%) vs. pre-implementation (390/425, 91.7%) (P=.0025). A similar improvement occurred when evaluating BP recheck within 10 minutes (60.5% vs. 40.0%, respectively, P=.0001). For the 113 post-implementation and 89 pre-implementation SRBP events requiring treatment, time to medication did not improve (median 13 and 14 minutes, respectively, P=.40). Use of labetalol vs. hydralazine post-implementation increased from 13.3% to 38.1% (P=.0001); nifedipine was rarely used (1 and 3 patients, respectively).

CONCLUSION:

Implementation of an algorithm to treat SRBP can improve BP recheck rates and impact choice of intravenous medications.
Management of Twin Pregnancies With Short Cervix in a Single System [5L]
Authors: Buchanan Christopher , Hostetter Sarah , Volkman Emma , Miller Collin , Gavard Jeffrey , Vricella Laura K.
Published: May 2017

INTRODUCTION:

We aimed to evaluate whether twin pregnancies with cervical length ≤25 mm who received cerclage had different rates of preterm birth (PTB) < 32 weeks compared with other forms of management.

METHODS:

This is a retrospective cohort of twin pregnancies with a cervical length ≤25 mm at 14w0d-27w6d at our academic center (2013-2016). Twin pregnancies with short cervix were eligible for 4 types of management: cerclage, Inflatoball cervical pessary (pessary), vaginal progesterone (VP), or expectant management (EM). Data were analyzed on intent-to-treat basis. Primary outcome was delivery < 32 weeks. Secondary outcome was interval from diagnosis of short cervix to delivery.

RESULTS:

60 patients met criteria for analysis: cerclage (n=19), pessary (n=11), VP (n=11), EM (n=19). Age, race, parity and history of PTB were similar among groups. Group and pairwise comparisons showed similar rates of delivery < 32 weeks for all groups (58% cerclage, 36% pessary, 55% VP, 47% EM; P=0.7). Survival analysis was used to evaluate the interval from diagnosis to delivery, showing similar intervals when comparing all 4 interventions as a group, but pairwise comparison demonstrated greater median interval for cerclage vs EM (61.7 vs 55.0 days; P=0.04) and for VP vs pessary (65.0 vs 48.8 days; P=.01).

CONCLUSION:

No difference in delivery < 32 weeks was found in this cohort of twin pregnancies with cervical length ≤25 mm who underwent different management. Patients receiving a cerclage had a longer interval to delivery compared to expectant management. Randomized controlled trials are needed to determine the optimal management of twin pregnancies with short cervix.
Learning in Pregnancy: Patient Preferences on Education in the Antenatal Period [9L]
Authors: Friedman M. Alexandra , Heyward Quetrell , Gavarkovs Adam , Maher Melissa , Eger Renee
Published: May 2017

INTRODUCTION:

Pregnancy is a time of vast knowledge acquisition, however, in a busy clinic schedule, providers have limited time to provide anticipatory guidance. Video has been used to provide stereotyped education, however, information is lacking on the acceptability and effectiveness of video education for antepartum patients. This quality improvement project queried sources of education for antenatal patients, the potential role of video education, and the educational impact of a video currently used in a residency outpatient clinic.

METHODS:

A survey was designed to query patient usage and perceived efficacy of commonly utilized resources for information in pregnancy. Surveys were administered during patients' initial prenatal intake appointment. Patients also completed a knowledge quiz before and after watching a 10-minute video on breastfeeding.

RESULTS:

74 patients participated in the survey. Patients reported the most commonly used and most helpful sources of information were family (43), general websites (37), and friends (36). 69% of respondents reported an interest in videos about pregnancy. Patients showed a statistically significant improvement in knowledge of breastfeeding after watching a 10-minute video (2.83, 3.57 p=0.0078). Patient scores on the knowledge quiz did not differ by video preference.

CONCLUSION:

Patients report their most common and helpful sources of information do not come from professionals. Patients are amenable to video as a source of counseling in pregnancy, and show improved knowledge following education through this modality. Future studies will help to clarify specific characteristics of effective antepartum video education tools, as well as potential impacts on antepartum care.
Outcome Comparison Before & After New Protocol of DVT Chemoprophylaxis for Cesarean Section Patients [11L]
Authors: Paquet Amanda , Keerthy Madhurima
Published: May 2017

INTRODUCTION:

Venous thromboembolism is one of the leading causes of maternal morbidity and mortality. After careful review of the available literature and discussion of the recommendations of multiple national organizations (American College of Obstetricians and Gynecologists, RCOG, American College of Chest Physicians, etc.), the Quality and Safety Committee at our hospital changed the protocol for VTE prophylaxis for obstetric patients. The new policy advocates a more aggressive VTE prophylaxis of 7500U heparin BID for all Cesarean section patients starting 12 hours post-operation. One year has passed since the implementation of the new chemoprophylaxis protocol and this comparison will allow us to analyze if the benefits outweigh the potential risks.

METHODS:

Retrospective chart review of one year before and one year implementation of new DVT chemoprophylaxis protocol for benefits and complications. Rates of wound infections, hematomas, dehiscence, ER visits, readmissions, DVT, and PE were studied. Initial records were collected from February 2015 through January 2016. 288 patients before protocol implementation and 296 patients after were studied. Cohorts were uniform in regards to age, race, BMI, gravidity, parity.

RESULTS:

No statistical significance noted at 6 months with respect to wound complications, ED visits, readmission rates, DVT, or PE from before protocol implementation to after protocol implementation.

CONCLUSION:

Six month data suggest no statistical significance between the before and after protocol implementation groups. Additional data has been collected and is being analyzed out to the one year mark to determine if the policy change has benefited or adversely affected patients.
Early Initiation of 17OHPC Does Not Increase Risk for Gestational Diabetes in Women With Prior Preterm Birth [13L]
Authors: Suhag Anju , Dutta Ritu , Monga Manju , Sangi-Haghpeykar Haleh , Ramin Susan , Hollier Lisa
Published: May 2017

INTRODUCTION:

17alpha-hydroxy progesterone caproate (17OHPC) is a common intervention to prevent recurrent preterm birth (PTB). The literature is inconsistent regarding an increased risk of gestational diabetes (GDM) in women on 17OHPC. Our objective was to determine the association of gestational age at initiation of 17OHPC and risk of GDM in women with spontaneous prior PTB (sPTB).

METHODS:

A retrospective study of singleton gestations with prior sPTB, who received weekly 17OHPC injections at two large Medicaid clinics from 2/2014- 6/2016. We excluded pre-gestational diabetes, multiple gestations, and women unable to complete glucose screening by 28 weeks. The study cohort was divided into group 1 (early initiation of 17OHPC at 16-20weeks) and group 2 (late initiation of 17OHPC at 21-26weeks). Primary outcome was the rate of GDM. Secondary outcomes included the rate of normal glucose screening and glucose intolerance. P-value of < .05 was considered statistically significant.

RESULTS:

94 women met inclusion criteria. Demographics were similar in both groups, except mean BMI was higher in group 1 compared to group 2 (P=.002). Mean gestational weight gain (GWG) and the rate of excessive GWG were similar in both groups. The total number of doses of 17OHPC was higher in group 1 compared to group 2 (P < .0001). The rate of GDM was similar in both groups, even after adjusting for BMI and race. Secondary outcomes were also similar in both groups.

CONCLUSION:

Initiation of 17OHPC at 16-20 weeks does not increase the risk of gestational diabetes. Further studies with a large sample size, are suggested to confirm this observation.
MAMA'S Neighborhood–Maternity Assessment Management Access & Service Synergy Through the Neighborhood for Health [16L]
Authors: Saleeby Erin , Scibetta Emily , Moini Moraya , Trang Cassandra , Young Carmen Canto , Greenwell Lisa
Published: May 2017

INTRODUCTION:

MAMA's Neighborhood (MAMAs), funded by the Strong Start for Mothers and Newborns Initiative, aims to evaluate models of prenatal care to reduce preterm (PTB) and low birth weight (LBW). Using a medical home model in high prevalence areas of Los Angeles, MAMAs sought to better assess potential social determinants of PTB and LBW and organize care to address these risks via: 1. Collaborative care teams, 2. Risk stratified case management, 3. Population health management, and 4. Community engagement and care delivery with social-service agencies.

METHODS:

Data were collected December 2013–August 2016. MAMAs implemented a novel initial assessment with evidence-based screening tools for psychosocial risk factors, risk stratification, case management and population health tracking by collaborative care teams at 6 sites. Neighborhood services were linked for individualized care planning.

RESULTS:

A total of 3,214 women enrolled. This cohort exhibited disproportionately high rates of food insecurity (15%), depression (23%), anxiety (31%) and intimate partner violence (32%) when compared to the general obstetric population. All women received risk stratified case management, allocating services weekly to 4%, monthly to 23%, and trimesterly to 74% of the cohort. Neighborhood service referrals averaged 3.7 per participant for psychosocial needs.

CONCLUSION:

MAMAs Neighborhood successfully implemented evidence-based screening tools for psychosocial risk factors into prenatal care, risk stratify and manage population health. MAMAs also developed individualized care plans for pregnant women including services delivered by community-based agencies to meet social needs. This model, involving both health system and community partners, leverages a Neighborhood approach to optimize maternal-child health outcomes.
Association Between Time of Day of Delivery and Perinatal Outcomes [17L]
Authors: Liu Lilly , Miller Emily , Yee Lynn
Published: May 2017

INTRODUCTION:

Prior work has demonstrated differences in cesarean-associated maternal morbidity based on time of delivery, but it remains unclear whether delivery mode or neonatal outcomes are associated with diurnal patterns. The objective was to determine if there is an association between delivery time and perinatal outcomes.

METHODS:

This is a retrospective cohort study of all nulliparous women delivering singleton, vertex, live births at ≥37 weeks gestation at a single center from 2014-15. Delivery time was dichotomized with nighttime deliveries designated as those occurring between 6pm and 6am. The primary outcome was delivery mode. Secondary outcomes included epidural use, labor augmentation, episiotomy and perineal lacerations, 5 minute Apgar < 7, cord umbilical artery pH < 7.0, and NICU admission. Bivariable and multivariable analyses were utilized for analyses.

RESULTS:

Of 7,691 women eligible for inclusion, 3,707 (48.2%) delivered during the night. Women undergoing night deliveries were marginally more likely to be undergoing induction of labor (20.1% vs 18.4%, p=0.06). Women delivering during the night were less likely to experience augmentation of labor (79.8% vs 81.6%, p=0.05) and had a higher frequency of cesarean delivery (20.6% vs 17.0%, p < 0.001). They were also more likely to have neonates with a 5-minute Apgar score < 7 (aOR 1.57, 95% CI 1.07-2.30) and umbilical artery pH < 7.0 (aOR 1.75, 95% CI 1.17-2.61).

CONCLUSION:

Among nulliparous women, delivery at night is associated with greater odds of cesarean delivery, low 5-minute Apgar score, and low umbilical artery pH.
Prevention and Management of Severe Obstetric Lacerations: A National Survey of Nurse Midwives [21L]
Authors: Diko Sindi , Guiahi Maryam , Carlson Nicole S. , Connell Kathleen , Reeves Shane , Hurt K. Joseph
Published: May 2017

INTRODUCTION:

There is no detailed information on US obstetric providers' understanding of risks and management of severe obstetric anal sphincter injuries (OASIS). We performed a cross-sectional national survey study to identify OASIS education gaps among certified nurse midwives (CNMs) that could improve obstetric quality.

METHODS:

We invited American College of Nurse Midwives members (ACNM; n=6909) via email, and included active ACNM members performing at least one delivery within the past year. We assessed their understanding of OASIS risks, prevention, repair, and management based on a RedCap survey instrument that was previously created and piloted within a university OB-GYN department.

RESULTS:

We received 1069 (15.5%) completed surveys; 889 (83.2%) met our inclusion criteria. Participant age, race, and gender were statistically representative of ACNM membership. Poor nutrition, nulliparity, forceps and vacuum use, and midline episiotomy were reported as the top OASIS risk factors. CNM prevention techniques included perineal support, guided delivery, avoiding episiotomies, and maternal positioning. 15.1% of respondents reported repairing OASIS personally, 78.8% referred out. Over 85% of respondent reported they did not routinely perform a rectal exam if lacerations were suspected. At discharge, CNMs recommend stool softeners, sitz baths, NSAIDS, lidocaine ointment or spray, and fiber supplements. 30% of respondents reported receiving formal education on OASIS, and 37.5% reported that their delivery sites have protocols or guidelines regarding OASIS management.

CONCLUSION:

CNMs report standard care for OASIS that is similar to the American College of Obstetricians and Gynecologists’ recent practice bulletin recommendations, though additional formal training on OASIS prevention and management appears warranted.
Comparing Induction of Labor With Expectant Management in Pregnancies With Congenital Anomalies [22L]
Authors: Patel Shruti , Quimby Alyssa , Twogood Sara , Pinheiro Meaghan , Brown Niquelle , Cortessis Victoria
Published: May 2017

INTRODUCTION:

Historically, induction of labor has been associated with higher rates of C-section, particularly when the starting cervical exam is unfavorable. However, recent studies have challenged this idea, showing lower rates of C-section for elective inductions in singleton cephalic pregnancies without anomalies at term compared to expectant management. This study aims to look at the rate of C-section in women with fetal anomalies who were induced at term as compared to those who were expectantly managed.

METHODS:

We conducted a retrospective review of pregnancies prenatally diagnosed with fetal anomalies delivered from 2012 to 2014 at a single referral center. Induction vs expectant management, gestational age, mode of delivery, maternal and fetal factors, and complications were evaluated.

RESULTS:

Of the 117 women included in the study, 64 were induced, while 53 were expectantly managed. 17.2% of the induced pregnancies were delivered via C-section, while 62.2% of the expectantly managed pregnancies were delivered via C-section. Further analysis including only patients delivered beyond 37 weeks, showed induction patients were 83% less likely to deliver via C-section compared to patients who were expectantly managed (95% CI [0.06, 0.48]).

CONCLUSION:

Our data suggests that patients with fetal anomalies, including patients with an “unfavorable cervix,” who are induced at term do not have higher rates of C-section as compared to those who are expectantly managed. This supports the conclusions of previous studies in regard to induction, but now can be expanded to pregnancies complicated by fetal anomalies.
The Association of Labor Induction for Advanced Maternal Age With Cesarean Section [23L]
Authors: Spiegelman Jessica , Connolly Katherine , Khander Amrin , Factor Stephanie , Stone Joanne
Published: May 2017

INTRODUCTION:

To determine if induction of labor among women ≥ 40 years for advanced maternal age (AMA) at 39 0/7–39 6/7 weeks is associated with an increased risk of cesarean section compared to women who are expectantly managed.

METHODS:

A retrospective cohort study of patients ≥ 40 years who delivered at a single tertiary care center from June 2011 through December 2014. Cesarean section rates of women who underwent induction of labor at 39 0/7-39 6/7 weeks for AMA to those who were expectantly managed were compared using chi-square and multiple logistical regression.

RESULTS:

Of 223 nulliparous women, 76 (34%) were in the induction group, and of the 263 multiparous women, 85 (32%) were in the induction group. Among the nulliparous women, there were no differences in baseline characteristics. Among the multiparous women, those in the induction group were older (median age 42 vs. 41, P=.01) and had a lower admission Bishop Score (median 9 vs. 10, P=.05). Among nulliparous women, the induction group was not at increased risk of cesarean section (OR=1.47, 95%CI 0.84, 2.58, P=.18). Among multiparous women, the induction group was not at increased risk of cesarean section (OR=1.69, 95% CI 0.71, 3.99, P=.23) after controlling for age and admission Bishop Score.

CONCLUSION:

In patients ≥ 40 years old, induction of labor for AMA was not associated with an increased risk of cesarean section. Given the concern for stillbirth in this group, this information may help guide clinicians decide whether to induce labor for AMA in the absence of other indications.
Audit of Management of Gestational Proteinuria [25L]
Authors: Sood Akanksha , Mathen Stephy
Published: May 2017

INTRODUCTION:

Studies have demonstrated that around 50% of women with isolated proteinuria in pregnancy develop preeclampsia and importantly, even in the absence of hypertension, these women are at significantly increased risk of fetal growth restriction and placental abruption.

METHODS:

Retrospective audit of cases of Isolated gestational proteinuria. A total of 50 patients were identified who had their urine protein creatinine ratio (uPCR) sent in the January to December 2015. Only cases with isolated gestational proteinuria were identified.

RESULTS:

Our results showed that 58% of women developed preeclampsia with an average interval of 11 days from first admission with isolated proteinuria. Further, 12% of babies were small for gestational age and 16% delivered less than 37 weeks. A urine culture sensitivity was performed in 76 % women with any degree of proteinuria to exclude urinary tract infection. A urine protein creatinine ratio (uPCR) was requested in 96% when greater than or equal to“+” on urine dipstick. Baseline bloods were done in 98% when urine protein creatinine ratio (uPCR) was greater than 30 mg/mmol or “++” proteinuria dipstick. Only 56% had a management care plan documented by a senior obstetrician. In women with significant proteinuria (even in the absence of hypertension) delivery was discussed and offered after 37 weeks in 86.36%.

CONCLUSION:

There was marked inconsistency in the management of gestational proteinuria. Universal guideline pathway should be made to avoid adverse outcomes like preeclampsia which is increased in this group.
Association of NSAIDs with Postpartum Blood Pressure in Women With Hypertensive Diseases in Pregnancy [26L]
Authors: Workman Pritha , Spinosa Daniel , Su Hui-Chun , Roeder Hilary
Published: May 2017

INTRODUCTION:

Based on the Hypertension in Pregnancy Task Force guidelines, we examined if NSAID administration adversely affects blood pressures in the immediate postpartum (PP) period in women with HDP (hypertensive disorders of pregnancy).

METHODS:

This cross sectional study examined patients with HDP who delivered at our institution from April 2012 to April 2015. Mean systolic (SBP) and diastolic (DBP) blood pressures over the first 24 hours were compared by NSAID exposure using Student's t-test or Chi-square test of proportions. Multivariable linear regression was used to adjust for confounding. Exploratory repeated measures analyses were performed.

RESULTS:

130 subjects with HDP were identified; 103 (79%) were exposed to NSAIDs. Mean SBP in NSAID exposed and unexposed was 132.5 ± 10.7 vs 140.9 ± 10.4 mmHg, respectively (p < 0.01). Mean DBP in NSAID exposed and unexposed was 79.0 0 ± 7.1 and 84.8 ± 8.4 mmHg, respectively (p = 0.01). In multivariable modeling, only magnesium exposure and earlier gestational age remained significantly associated with higher SBP. Of 46 women with severe preeclampsia, 26 (43.5%) were exposed to NSAIDs. Mean SBP in NSAID exposed and unexposed was 137.7 ± 13.0 and 143.7 ± 9.9 mmHg (p=0.09). Repeated measures analysis of blood pressures showed similar results.

CONCLUSION:

Administration of NSAIDs did not appear to be associated with higher mean SBP or DBP immediately PP. NSAID exposure was associated with significantly lower SBP and DBP. This suggests NSAIDs may not adversely affect BP immediately PP, but a randomized controlled trial is needed to provide higher level evidence.
An Incidence of Chronic Inflammatory Demyelinating Polyneuropathy in Pregnancy [28L]
Authors: Manley Charisma , Geary Franklyn
Published: May 2017

INTRODUCTION:

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is a long-term form of Guillain-Barre syndrome (GBS), an acute inflammatory autoimmune polyradiculoneuropathy linked to various infectious agents. It is a rare disease process associated with symmetric motor paralysis with or without sensory deficits, affecting between 0.8 and 7.7 per 1,000,000. There is limited representation of antepartum management of CIDP in the literature.

METHODS:

We detail our experience in a primigravid patient with previously diagnosed CIDP during an acute exacerbation in pregnancy. The clinical case was analyzed followed by a literature review of CIDP antepartum management.

RESULTS:

A 29 year old primigravid female at 18 weeks gestation with a past medical history notable for GBS presented with reports of numbness and weakness in bilateral upper and lower extremities for 1 week. The patient was assessed, admitted and underwent evaluation with electromyogram and nerve conduction studies. Studies demonstrated progression of CIDP, with worsened demyelinating features with reduced conduction velocity and axonal involvement. Due to prior poor response to intravenous immunoglobulin, treatment with a limited course of plasmapheresis to prevent disease progression was successfully conducted. The patient subsequently experienced a successful term delivery of a female neonate.

CONCLUSION:

CIDP is an autoimmune neurologic disease process that has been minimally studied in pregnancy due to its low incidence. Our case details the successful evaluation and management of CIDP with plasmapheresis during pregnancy with subsequent successful term delivery. Increased awareness of CIDP and associated management is necessary due to the debilitating nature of the disease with potential fetal and maternal effects.
A Standardized Nurse Initiated Protocol to Improve Management of Severe Hypertension in Pregnancy [29L]
Authors: Miller Michael J. , Butler Patricia , Drake Elizabeth , Taylor Anne , Lutgendorf Monica A.
Published: May 2017

INTRODUCTION:

Hypertensive disorders are a leading cause of morbidity and mortality. We developed a standardized nurse driven hypertensive protocol to improve management in pregnancy.

METHODS:

We developed a standardized nurse initiated protocol for management of severe hypertension. The protocol used nifedipine, hydralazine or labetalol sequentially. Data on time from severe blood pressure (BP) to treatment with medication, effect of treatment, and BP monitoring was collected for 3 months prior to the protocol and compared to data after.

RESULTS:

We collected data on patients before (n=47) and after the protocol (n=37). The mean time to treatment of severe BPs was significantly shorter after protocol implementation (19.6 minutes), compared to before (36.9 minutes), t=3.1, p=0.002. There was also a significantly lower mean time to repeat BP (12.8 minutes) after protocol implementation compared to before (15.7 minutes), t=2.3, p=0.02, and the maximum time to repeat BP measurement decreased, from 300 minutes before to 76 minutes after. We also noted more women (89.5%) were treated within 1 hour after the protocol compared to 35% before the protocol and more women were given oral nifedipine (67%) after the protocol compared to only 4% prior to the protocol. However, there was no significant difference in mean time to blood pressure control after protocol implementation (50.3 minutes) comparted to before (67.5 minutes), t = 1.8, p = 0.08.

CONCLUSION:

Implementation of a standardized protocol for the treatment of hypertensive emergency decreased time to treatment, decreased variation and decreased maximum time to repeat BP measurement.
Uterine Leiomyoma Do Not Appear To Be a Risk Factor for Shortened Cervical Length [30L]
Authors: Lam Melissa Chu , Quinn Sara , Wong Christina , Evans Chelsey , Row Kelsey , Wayock Christopher
Published: May 2017

INTRODUCTION:

Several studies report an increased incidence of preterm delivery (PTD) in patients with uterine leiomyoma (UL). A shortened cervical length (CL) is risk factor for PTD, although universal CL screening is not yet advocated nationally. CL studies in pregnancies complicated by UL have suffered from small sample size or lack of accurate CL measurements. Therefore it is not well known whether the risk of PTD in those women with UL can be appropriately screen utilizing CL. Therefore, we reviewed our data on transvaginal (TVS) CL in those patients with UL.

METHODS:

We performed a retrospective review of patients found to have UL on routine second trimester anatomic survey ultrasounds after establishing a CL screening program. Patient demographics, UL (number and size), TVS-CL and pregnancy outcomes were collected.

RESULTS:

We obtained data on 224 antepartum patients with UL. Mean age was 34.9 ± 4.9 y, and BMI 29.1 ± 6.6 kg/m2. Prior PTD was noted in 21/224 (9.3%). Multiple UL were noted in 67/224 (29.9 %) with an individual's largest UL diameter of 4.5 ± 2.6 cm. Screening occurred at 21 ± 3.2 wks. Mean TVS-CL was 3.9 ± 0.8 cm. Shortened cervix (less than 2.5 cm) occurred in 2/224 (0.9%). Delivery less than 37 weeks occurred in 38/224 (17%) and before 35 weeks in 18/224 (8%). The cesarean delivery was performed in 85/224 (37.9%).

CONCLUSION:

TVS-CL in pregnancies complicated by UL do not appear to be significantly shortened. However, the incidence of PTD in patients with UL remains increased compared to national rates.
Disparities in Postnatal Treatment of Congenital Renal Anomalies [31L]
Authors: Block-Abraham Dana , Seravalli Viola , Miller Jena , Segev Dorry , Baschat Ahmet , Kucirka Lauren
Published: May 2017

INTRODUCTION:

Congenital renal anomalies (CRAs), including dysplastic kidneys, lower urinary tract obstruction, and infantile recessive polycystic kidney disease, are often identifiable on antenatal ultrasound and generally confer a poor prognosis for the affected fetus. We sought to evaluate social determinants influencing the postnatal course of infants with CRAs.

METHODS:

900 infants with CRAs who developed end-stage renal disease (ESRD) in the first 6 months of life between 1995-2012 were identified in the United States Renal Data System. This information was then linked to the Social Security Master Death File and the United Network for Organ Sharing. Cox proportional hazards models were used to examine associations between race, insurance, and 1) survival and 2) receipt of a kidney transplant.

RESULTS:

Survival: Black infants with CRAs who developed ESRD in the first 6 months of life had a 1.34-fold higher hazard of death compared to white infants, even after adjusting for insurance type (p=0.02). Private insurance was associated with a non-significant 0.84-fold lower hazard of death. Receipt of a Kidney Transplant: Black and Hispanic infants had 0.59 and 0.79-fold lower rate of transplant compared to white infants, respectively (p < 0.02), even after adjusting for insurance type. Patients with private insurance had a 1.3-fold higher rate of transplant compared to those with public or no insurance (p < 0.001).

CONCLUSION:

Significant racial disparities exist in the outcomes of CRAs. More research is warranted to discern what patient-level factors are contributory. Outcomes of CRAs by insurance status also suggest a role of system-based factors in postnatal mortality.
Maternal and Neonatal Outcomes in Women With Congenital Heart Disease at a Single Academic Center [32L]
Authors: Pippen Jessica , Koonce Jennifer , Frischhertz Benjamin , Markham Larry , Thompson Jennifer
Published: May 2017

INTRODUCTION:

Maternal congenital cardiac disease contributes to maternal and neonatal morbidity and mortality. We sought to describe both maternal and neonatal outcomes in women with congenital heart disease delivering at an academic medical center.

METHODS:

We conducted a retrospective review of pregnancies occurring in women with congenital heart disease who received prenatal care and delivered at Vanderbilt University Medical Center between 2009 – 2015.

RESULTS:

A total of 48 women experiencing 52 pregnancies were included. Majority of subjects were Caucasian (76.9%) who utilized public insurance (65.4%). 39 women (75%) had surgically repaired lesions and 14 (26.9%) reported a prior cardiac event. The majority of lesions were WHO class I/II (75%). Maternal ICU admissions occurred in 13.5% of patients and 3.8% of patients had postpartum readmission. 11.5% patients had a cardiac event during peripartum period. Obstetrical complications included preterm birth (15.7%); fetal growth restriction (22%); and admission to NICU (16%). Congenital heart disease was diagnosed in 14% of infants. 49% were delivered via cesarean delivery with an additional 15.7% having operative vaginal deliveries. Epidural anesthesia was administered in 74% of patients.

CONCLUSION:

Pregnancy in women with congenital heart disease is associated with increased maternal and neonatal morbidity and mortality. Our results are similar to previously published data regarding risks of maternal cardiac events, preterm birth, fetal growth restriction and recurrent congenital heart disease. A collaborative care model with adult congenital cardiology, obstetric anesthesia, neonatology, and maternal fetal medicine is necessary to evaluate maternal and neonatal risk in women with congenital heart disease.
Impact of Heart Disease During Pregnancy on Maternal Cardiac and Obstetric Outcomes [33L]
Authors: Owens Amanda , Lima Fabio V. , Nie Lizhou , Yang Jie , Avila Cecilia , Stergiopoulos Kathleen
Published: May 2017

INTRODUCTION:

Heart Disease (HD) is the leading cause of morbidity and mortality among pregnant women in developed countries. The impact of HD and obstetric complications on outcome requires investigation.

METHODS:

Statewide Planning and Research Cooperative System database from New York State was used to characterize inpatient singleton deliveries, 2000-2014. Primary outcome was maternal Major Adverse Cardiac Events (MACE), a composite of death, cardiac arrest, myocardial infarction, heart failure, and arrhythmia. Obstetric complications included antepartum and postpartum hemorrhage, eclampsia/preeclampsia, placental insufficiency, and preterm delivery (less than 37 weeks gestation). ANOVA and Pearson's Chi-squared test were used for comparison.

RESULTS:

We studied 3,871 women with HD and 2,280,173 without HD, with singleton births. 17% had cardiomyopathy (CDM), 40% valvular HD, 35% congenital HD, and 8% pulmonary hypertension (PH). Compared with women without, women with HD had significantly more MACE (16.1 vs 0.4%), more cesarean delivery (45.1 vs 31.0 %), more eclampsia/preeclampsia (11.0 vs 4.2%), more preterm delivery (14.2 vs 5.5%), longer length of stay (4.8±7.3 vs 2.9±2.2 days) and higher total hospital charges ($21,384±47,037 vs 10,175±9,698, all P < .0001). Among women with HD, highest MACE rates were observed in women with CDM and PH (45.9 and 25.0% respectively), and lowest in women with congenital HD (6.1%). Women with CDM and PH also had highest rate of eclampsia/preeclampsia (25.3 and 23.3%, respectively).

CONCLUSION:

Pregnant women with CDM and PH had the highest rates of MACE during hospitalization for delivery. Eclampsia/preeclampsia was significantly more common in pregnant women with HD, particularly in women with CDM and PH.
Association Between Preeclampsia and Congenital Heart Defects [38L]
Authors: Bears Breanne , Crimmins Sarah , Harman Chris , Turan Shifa
Published: May 2017

INTRODUCTION:

Emerging research supports a common dysfunctional angiogenic mechanism that manifests in mothers as preeclampsia (PE) and in fetuses as congenital heart defects (CHD).

METHODS:

CHD fetuses came from patients assessed by UMMC's Fetal Heart Program. Controls were identified retrospectively from our ultrasound database, and those with known chromosomal or non-CHD anomalies were excluded. PE was diagnosed by the American College of Obstetricians and Gynecologists’ 2013 guidelines and categorized as early (delivery < 34 weeks) or late. Contributors to early and late PE were assessed and compared with controls using binary logistics regression and Chi-square analysis.

RESULTS:

Of 2856 meeting inclusion criteria, 215 (7.5%) had CHD. PE occurred in 182 (6.4%) cases, early PE in 28 (1%) and late PE in 153 (5.4%). CHD cases had no increased risk for early PE (OR:2.07 CI:0.71-6.01) or late PE (OR:0.85 CI:0.44-1.64) compared to controls. In the CHD group, developing late PE was significantly increased by diabetes (OR:7 (1.9-26) p=0.0005), or chronic hypertension (CHT) (OR:15 (3.7-63) p< 0.0001). In the CHD group, CHT was the major determinant of late PE (Logistic regression R2=0.23 p < 0.0001). In patients with CHT, CHD significantly determined late PE (OR:3.43 CI:1.3-9.1 p=0.001.) In those without CHD, late PE was not increased by diabetes (OR:1.4 CI: 0.93-2.11 p=0.11) or CHT (OR: 1.4 CI: 0.79-2.32 p=0.26). No maternal characteristics significantly correlated with early PE in either cohort.

CONCLUSION:

Fetal CHD did not solely predict an increased risk of PE. However, in women with CHT, fetal CHD increases risk of PE. Enhanced surveillance and treatment appear warranted in these women.
Sonohysterogram and Uterine Neoplasia: The Significance of the Changes in Endometrial Findings [3M]
Authors: Rotenberg Ohad , Escobar Pamela , Fridman Dmitry , Doulaveris George , Renz Malte , Dar Pe'er
Published: May 2017

INTRODUCTION:

We assessed the significance of variations in endometrial echo (EE) findings between transvaginal sonogram (TVS) and saline infusion sonohysterogram (SIS).

METHODS:

A prospective study of 440 women 50 years and older, who underwent TVS, SIS and pathological sampling for endometrial assessment. Endometrial findings and measurements on TVS and SIS were evaluated and assessed in benign and Cancer/hyperplasia cases.

RESULTS:

Patients median age was 60.1+/-8.1 (range 50-91) and mean BMI was 33.3+/-7.2. The main indication for evaluation was bleeding (87.3%) and 34/440 (7.7%) had either cancer or hyperplasia. In 4/34 (11.8%) cases with cancer or hyperplasia the EE was poorly visualized on TVS and 3/34 (8.8%) had intracavitary fluid. Only 3 (8.8%) had EE between 4-5mm and the rest had “thick EE.” On SIS 23/34 (67.6%) had polyps, 10/34 (29.4%) had focal thickening and only 1/34(2.9%) had diffuse thickening. As for EE thickness on SIS, 13/27 (48.1%) had EE <5mm and in 11/27 (40.7%) cases it was <4mm. The mean EE on TVS was 14.7±8.6mm as compared to 5.9±3.7mm, on SIS (p < 0.0001). In 319/440 (92.3%) of cases with benign pathology, the TVS EE was significantly thicker than sis, even after excluding cases with polyps (n=159), focal thickening (n=62) and submucosal fibroids (n=35): 6.5±4.3mm on TVS vs 3.9±2.4mm on SIS, (n=63, p=0.001). EE conversion formula was created using scatterplot of the measurements with regression line: TVSEE =1.41×SISEE.

CONCLUSION:

SIS EE was significantly thinner than TVS EE both in the cancer/hyperplasia and the benign groups. The EE conversion formula is: TVS EE=1.41xSIS EE. This finding suggests that the current interpretation of thin endometrium on TVS may not be applied in SIS.