bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors Associated With and Barriers to Receiving Inpatient Long-Acting, Reversible Contraception [1C]
Authors: McCarther Noria , Emily Pfeifer , Nguyen Jimmy , French Valerie , Ellerbeck Edward
Published: May 2019

INTRODUCTION:

Factors associated with inpatient long-acting, reversible contraception (LARC) placement and potential barriers to inpatient LARC placement during the immediate postpartum period are largely unknown. The objective of this study was to determine factors associated with LARC placement and barriers to LARC placement during the post-partum hospitalization.

METHODS:

We identified 3072 deliveries at an urban, academic hospital between January 1, 2017 and July 31, 2018. We randomly selected 218 cases that received a LARC and 218 controls that did not receive a LARC. We excluded 68 patients <18 years of age or in a system requiring outpatient contraception planning. We look at bivariate relationships between patient characteristics and inpatient LARC placement. Chi-square tests and Fisher's Exact tests were used to assess statistical significance.

RESULTS:

Recipients of LARC were younger (mean age of 28 versus 29.5, p<0.01). Admission by Family Medicine providers (OR 0.10, 95% CI 0.02-0.45), lack of recorded prior contraception plan (OR 0.25, 95% CI 0.17-0.39), and delivery complications (OR 0.48, 95% CI 0.32-0.71) were associated with lower odds of receiving LARC placement. Single marital status was associated with higher odds of receiving LARC placement (OR 1.50, 95% CI 1.03-2.19).

CONCLUSION:

Findings suggest that provider specialty, which may be confounded by prior procedural training, and lack of prior contraception planning present significant barriers to immediate LARC placement.
Factors Associated With Hospital Non-Admission After Outpatient Hysterectomy [12C]
Authors: Ilizaliturri Ana K. , Burton Brittany N. , Frugoni Gina Reggiardo , Gabriel Rodney A.
Published: May 2019

INTRODUCTION:

Outpatient hysterectomies have been increasing in the last two decades in an effort reduce cost and improve patient recovery. However, factors for non-admission have not been well documented. This study aims to identify demographic, preoperative, and intraoperative factors for non-admission after outpatient vaginal hysterectomy.

METHODS:

Outpatient vaginal hysterectomies from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016 were included in this retrospective observational study. The primary outcome is hospital non-admission, defined as hospital stay <1 day. Multivariable logistic regression was done to determine independent association between factors and hospital non-admission.

RESULTS:

A total of 17,086 patients were included in the study with 15,697 (91.8%) experiencing hospital stay <1 day. The final multivariable logistic regression analysis demonstrates that the odds of hospital stay <1 day was significantly lower for Black or African American race (OR 0.69, 95% CI 0.57-0.84, P<.001), Hispanic ethnicity (OR 0.50, 95% CI 0.43-0.59, P<.001), age >80 (OR 0.34, 95% CI 0.21-0.55, P<.001), history of chronic obstructive pulmonary disease (OR 0.50, 95% CI 0.34-0.75, P<.001), preoperative diagnosis of anemia (OR 0.81, 95% CI 0.69-0.94, P=.006), and duration of surgery >118 minutes (OR 0.54, 95% CI 0.47-0.63, P<.001).

CONCLUSION:

This study suggests that patient characteristics, preoperative diagnoses, and intraoperative factors are associated with non-admission after outpatient vaginal hysterectomies. As the number of outpatient hysterectomies in the U.S increases, future studies may evaluate ways to address the effects of these factors in attempt to prevent unplanned admissions.
Estimated Prevalence of Human Papillomavirus Among Women in Nigeria: A Systematic Review and Meta-Analysis [14C]
Authors: Anoruo Onyemaechi , Bristow Claire , Klausner Jeffrey D.
Published: May 2019

INTRODUCTION:

Human papillomavirus (HPV) remains the leading cause of cervical cancer worldwide. Overall HPV prevalence in Nigeria has been challenging to quantify given regional population heterogeneity and differences in diagnostic methodology.

METHODS:

We conducted a systematic review and meta-analysis of 17 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols and guidelines. We also incorporated the Meta-Analysis of Observational Studies in Epidemiology Guidelines for Reporting. Each study summarized HPV prevalence in HIV-uninfected women residing in various regions of Nigeria at the time of the study. A random effects model was used to establish an estimated pooled HPV prevalence. We calculated median values with 95% confidence intervals.

RESULTS:

The estimated pooled prevalence of HPV in Nigeria was 32% (23-41%). HPV prevalence was 29% (20-39%) among studies that detected HPV by genotype. HPV prevalence among studies that used serologic detection was 38% (12-65%). When stratified by region, studies in northeast Nigeria reported the highest prevalence of 55% (49-61%) while a study in west Nigeria reported the lowest prevalence of 22% (14-30%). For meta-analysis stratified by detection method, the P value for heterogeneity testing was .52. Stratifying by location yielded a heterogeneity test P value of P<.001.

CONCLUSION:

HPV prevalence in Nigeria was high. Heterogeneity between study regions and differing HPV detection methods may both contribute to variation in estimates. Using pooled estimates may serve to inform future strategies for epidemiological surveillance and the future design of disease prevention initiatives.
High-Normal Blood Pressure as a Predictor of Preeclampsia in Twin Pregnancies [19C]
Authors: Hill Melissa B. , Connolly Courtney T. , Klahr Rebecca A. , Zafman Kelly B. , Rebarber Andrei , Fox Nathan S.
Published: May 2019

INTRODUCTION:

Prior research examining blood pressure in twin pregnancies defined the 95th percentile for SBP and DBP for gestational age (120 systolic, 80 diastolic before 30 weeks; 130 systolic, 84 diastolic after 30 weeks). Our objective was to determine if women with twin pregnancies and BP above the 95th percentile (but normal, i.e. <140 SBP and <90 DBP) are at increased risk of preeclampsia.

METHODS:

Retrospective cohort study of all twin pregnancies in a single MFM practice between 2012 and 2018. IRB approval was obtained. We identified all women with SBP or DBP >95th percentile but <140/90, excluding those with chronic hypertension. The primary outcome was development of preeclampsia.

RESULTS:

457 patients met inclusion criteria, of whom 109 (23.9%) had either SBP or DBP >95th percentile (but normal) at any time during pregnancy. These women were significantly more likely to develop preeclampsia than those without any readings >95th percentile (30.3% vs. 12.6%, p<0.001, aOR 3.0 (1.7, 5.1)). Patients with a DBP reading >95th percentile had the highest risk of developing preeclampsia (42.9% vs. 14.2%, p<0.001, aOR 4.2 (2.1, 8.4)). A SBP or DBP >95th percentile was a significant predictor of preeclampsia (AUC 0.61, 95% CI 0.54, 0.69, p=0.002).

CONCLUSION:

In women with twin pregnancies, normal SBP or DBP above the 95th percentile is associated with significantly increased risk of preeclampsia. DBP above the 95th percentile has the strongest association, with 42.9% developing preeclampsia. Women with twin pregnancies and normal BP above the 95th percentile should be observed closely for development of preeclampsia.
Increased Incidence of Small for Gestational Age Neonates Among Hispanic English Only Speaking Women [20C]
Authors: Agarwal Muskan , Dorado Jimmy Espinoza , Yallampalli Chandrasekhar , Banadakoppa Manu
Published: May 2019

INTRODUCTION:

The association of limited English proficiency and adverse perinatal outcomes is unclear. This study looked at the relationship between maternal language proficiency and birth weight.

METHODS:

Data from all Hispanic/Latino women in the database Peribank were included. The GROW-Centile calculator from the Perinatal Institute categorized neonates into 3 groups: small for gestational age (SGA), normal for gestational age, and large for gestational age (LGA). Logistic regression analysis was used to control for confounding factors (type I/II diabetes, gestational diabetes, maternal smoking, hypertension/preeclampsia, BMI, parity, country of birth, total years living in the US).

RESULTS:

Spanish only speaking patients (n=6248) had a lower incidence of SGA neonates than those with some English proficiency (n=3955) (OR .822; 95% CI .707-.954; P=.012). In contrast, English only speaking patients (n=295) had a higher incidence of SGA neonates than those with some Spanish proficiency (n=9908) (OR 1.452; 95% CI 1.045-2.019, P=.026). Of note, Spanish only speaking patients (n=6248) had a higher incidence of LGA neonates than those with some English proficiency (n=3955) (OR 1.266; 95% CI 1.052-1.523, P=.012). No association was found between English only speaking patients and LGA neonates (P=.937).

CONCLUSION:

Spanish only speaking patients were associated with larger neonates than those who have some English proficiency. One hypothesis is that higher English proficiency may be an indicator of greater assimilation into American culture, and therefore increased adoption of the American diet. As Hispanic/Latino patients become further assimilated into the American culture and diet, they may be at a higher risk of SGA neonates.
Maternal Factors Associated With Compliance in a 2-Year Birth Cohort Study [25C]
Authors: Samaha Mia , Cline Allison , Staat Mary , Morrow Ardythe , DeFranco Emily A.
Published: May 2019

INTRODUCTION:

There is a paucity of data on predictors of compliance among pregnant women participating in large clinical studies. We aimed to investigate whether socio-demographic factors may accurately identify populations that will comply with the demands of clinical studies.

METHODS:

265 pregnant women, >34 weeks, were consented to participate in a 2-year prospective birth cohort study, Pediatric Respiratory and Enteric Virus Acquisition and Immunogenesis Longitudinal Cohort (PREVAIL, www.cdc.gov/surveillance/nvsn/prevail.html). Enrollment compliance was determined by completion of an infant follow-up visit two-weeks post-delivery. Maternal socio-demographic factors were compared between women who completed enrollment and delivery specimen collection. Comparisons with p-value <0.05 were considered significant.

RESULTS:

Among the study population, 50% of women were married, 47% African-American, 9% had 80% completed the first infant biologic sample collection during delivery hospitalization. Over 95% (N=241) completed the two-week infant follow-up visit. No socio-demographic factors significantly associated with compliance with delivery-specimen collection or 2-week infant follow-up visit, all p-values >0.05.

CONCLUSION:

Among a demographically heterogeneous population of women enrolled in PREVAIL, compliance with delivery sample collection and enrollment-determining follow-up visit was high, 95.3%. No socio-demographic factors were significantly associated with compliance in enrollment study procedures. Women who are socio-economically disadvantaged and exhibit negative health behaviors were equally as likely to be compliant as compared to other participants. These data support a non-biased approach of screening and enrollment in research studies inclusive of women of all backgrounds.
Rates of ICU Admission Among Peripartum Women With Obesity at Urban and Rural Hospitals in the [40Q]
Authors: Antony Kathleen M. , Hsiang-Hui Daphne Kuo , Hartenbach Ellen , Ehrenthal Deborah
Published: May 2019

INTRODUCTION:

Women with obesity, particularly BMI ≥ 50 kg/m2, have increased risk of peripartum admission to the intensive care unit (ICU). We sought to investigate whether the rate of peripartum ICU admission for women with obesity varied by location of birth (rural versus urban).

METHODS:

We used 2014-2015 geocoded birth records from the National Center for Health Statistics (NCHS) to examine the rural-urban differences in ICU admission among nulliparous women delivering singleton, vertex pregnancies at term. The rates of ICU admission were assessed by geographic category (NCHS urban-rural classification) of the county of delivery. BMI was classified into eight total groups defined by WHO criteria with sub-stratification of class III obesity every 5 kg/m2 up to BMI ≥50 kg/m2.

RESULTS:

Among 2,538,994 eligible births, the overall rate of ICU admission per 1000 live births was higher for women with BMI ≥50 kg/m2 (RR 3.89, 95% CI 2.20-6.90) across all geographic categories. Compared to large metropolitan-central counties, rates of ICU admission were lower for all other counties except non-core, which had a higher ICU admission rate (RR 1.72, 95% 1.24-2.39). When evaluating the interaction of BMI and geography, the rate of ICU admission did not vary by BMI or geography except for an increased rate of ICU admission for women with BMI between 30 and 34.9 kg/m2 delivering in micropolitan areas (RR 1.81, 95% CI 1.14-2.86).

CONCLUSION:

The rate of ICU admission is similar across geographic locations and BMI strata. Whether this rate should be lower in rural areas warrants further investigation.
Time to Delivery Following Induction of Labor in Obese Versus Normal-Weight Women [11S]
Authors: Knutson Karin Britta , Leung Katherine , Allocco Elizabeth Rose , Minor Kathleen , Delpapa Ellen , Lauring Julianne
Published: May 2019

INTRODUCTION:

Increasing BMI (body mass index) has been associated with a longer first stage and longer total spontaneous labor course, however length of labor induction in obese versus normal weight women has been incompletely described. Our objective was to compare length of labor in obese versus normal weight women undergoing induction.

METHODS:

This IRB-approved secondary analysis of a retrospective cohort study included women 18-40 undergoing induction of labor at University of Massachusetts Medical Center in 2016. Our primary outcome was length of induction in hours, from first intervention to delivery. Demographic information and labor and delivery data were also collected.

RESULTS:

218 women met inclusion criteria, 97 (44.5%) normal weight and 121 (55.5%) obese. The mean length of induction in normal-weight women was 14.1 hours (SD=10.2) and 20.2 hours (SD=18.1) in obese women (p=0.047). Obese women were also more likely to be delivered by cesarean section (p=0.002). When adjusting for potential confounders including demographics, parity, birth weight percentile, gestational age, gestational weight gain adherence, obese women had an induction time that was on average 5.0 hours longer than normal weight women (p=0.026). However, when adjusting for misoprostol use there was no significant difference in length of induction.

CONCLUSION:

Obesity was associated with increased length of time to delivery during induction of labor. Induction of labor is a complex, multifactorial process which may be affected by patient characteristics and provider bias which may be difficult to predict or control for in study.
Virtual Reality for Pain Control During Labor: Patient Preferences [14S]
Authors: Cowles Steven , Norton Taylor Jeffery , Hannaford Karen Elaine , Foley Michael
Published: May 2019

INTRODUCTION:

Immersive virtual reality (VR) has recently been shown to be a valid method to treat pain and anxiety. This modality is very new to the childbirth process. One objective of this study was to show if, during labor, there is a pain level or time of day where virtual reality is less effective or desired, and what VR applications subjects enjoy using most.

METHODS:

This is a randomized control trial intended as a pilot study with 2 different arms of 10. Nurses periodically recorded information every 4 hours during latent labor and every 1 hour during active labor. VR arm patients were asked to use VR for at least 15 minutes and record pain scores again. Patients were allowed access to all standard forms of analgesia throughout labor. A brief survey was completed after delivery. IRB approval/informed consent was obtained.

RESULTS:

100% of patient stopped using VR as labor progressed, even after getting epidurals with the average pain score of 8 in non-epiduralized patients. The average number of VR uses per patient was 3.1 +/- 0.99. 80% of patients' last use of VR prior to refusal was before 2300 hrs. The most enjoyed VR experience was playing games with 67%, and nature/meditation scenes were also preferred options.

CONCLUSION:

This study suggests that VR in labor has some parameters to optimal use. Patients tend to not desire VR use with pain scores >8, or at night time. When implementing VR during labor, patient preferences should be kept in mind to optimize its effectiveness.
Up to a Third of Scheduled Labor Inductions Are Potential Candidates for Outpatient Cervical Ripening [17S]
Authors: Sverdlov Deanna , Dangel Alissa
Published: May 2019

INTRODUCTION:

Labor induction is the commonest obstetric procedure, often beginning with cervical ripening. In select patients, performing cervical ripening in the outpatient setting has the potential to reduce costs, and benefit patient satisfaction. This study aimed to assess whether the patient population in a tertiary care hospital could benefit from implementation of an outpatient cervical ripening protocol.

METHODS:

We performed a retrospective analysis of data from all 112 scheduled labor inductions over a 6 month period in 2017-18 at Tufts Medical Center, a hospital performing 1,200 deliveries annually. We collected data regarding indication for induction, maternal/fetal comorbidities, gestational age, and intake cervical exam. A poll of providers was performed to ascertain which maternal and fetal factors were generally considered contraindications to outpatient ripening.

RESULTS:

Of 112 scheduled inductions, 74 patients (66.1%) were ineligible for outpatient cervical ripening. These included 19 patients (17%) who had a favorable Bishop score at intake and did not require cervical ripening. 26 patients (23.2%) were disqualified due to fetal conditions that were perceived by providers as requiring continuous fetal monitoring during all phases of labor induction, e.g., fetal growth restriction, oligohydramnios, and fetal anomalies. 29 patients (25.9%) were disqualified due to maternal comorbidities, including preeclampsia and preexisting medical problems. Ultimately, the remaining 38 patients (33.9%) were identified as candidates for outpatient cervical ripening.

CONCLUSION:

In a tertiary care center, 33.9% of patients undergoing scheduled labor induction may be suitable candidates for outpatient cervical ripening. Further research should be aimed at establishing the safety and benefits of outpatient cervical ripening.
Utility of First Trimester Maternal Serum Alpha Fetoprotein to Predict Placental Ischemic Disease [18S]
Authors: Dinglas Cheryl , Cochrane Elizabeth , Ram Bebu , Akerman Meredith , Heo Hye Jung , Vintzileos Anthony M.
Published: May 2019

INTRODUCTION:

While elevated second trimester maternal serum alpha fetoprotein (msAFP) has been associated with adverse pregnancy outcomes, the utility of first trimester msAFP for prediction of placental ischemic disease is not known. We sought to investigate whether first trimester msAFP correlates with pathology findings suggestive of ischemic placental disease.

METHODS:

An IRB-approved, multi-site retrospective cohort study was performed among patients with first trimester msAFP as part of routine aneuploidy screening and subsequent placental evaluation from April 2015-August 2016. Pathology report findings were reviewed and classified according to placental diagnostic criteria by the Perinatal Section of the Society for Pediatric Pathology. This classification included 1) amniotic fluid infection 2) maternal underperfusion 3) fetal vascular thrombo-occlusive disease and 4) inflammatory changes (ie. chronic villitis). Spearman correlation coefficient determined the relationship between first trimester msAFP and placental weight. Chi-square and Fisher exact test determined whether an elevated first trimester msAFP is associated with placental pathologic findings.

RESULTS:

We evaluated 368 patients with first trimester msAFP and placental pathology reports available for review. First trimester msAFP >2.0 MoM is predictive of a placental weight <10th percentile and is suggestive of placental ischemic disease 81.6% vs 57.7% (OR 3.24, 95% CI 1.37-7.66). First trimester msAFP > 2.0 is also associated with pathology findings consistent with fetal vascular occlusive disease 21.4% vs 6.1% (OR 4.17, 95% CI 1.76-9.91).

CONCLUSION:

Elevated first trimester msAFP is predictive of placental insufficiency and placental ischemic disease which can help identify at risk pregnancies in the first trimester.
Validation of the MFMU Network VBAC Calculators at an Academic Institution [19S]
Authors: Rasiah Stephen S. , Reilly Devin M. , Maines Jaimie L. , Thomas Holly J. , Pauli Jaimey M. , Ural Serdar H.
Published: May 2019

INTRODUCTION:

The MFMU Network has developed two calculators to help predict the vaginal delivery success rate of a trial of labor after cesarean section. The purpose of this study was to validate the use of these calculators at an academic institution.

METHODS:

This retrospective cohort study compared actual and predicted VBAC success rates with the online MFMU VBAC calculators. Participants were then divided into two groups based on low (<70%) and high (>70%) predicted success.

RESULTS:

Preliminary data analysis included 299 patients. 223 (75%) patients had a successful VBAC. The VBAC success rate based on information at the initiation of prenatal care was 59% (predicted=58% P=.92) in the 'low success' cohort and was 82% (predicted=83% P=.69) in the 'high success' cohort. The VBAC success rate based on information from admission for delivery was 26% (predicted=44% P=.12) in the 'low success' cohort and was 78% (predicted=96% P<.001) in the 'high success' cohort.

CONCLUSION:

The model was accurate when it incorporated data at the initiation of prenatal care. However, based on information from admission for delivery, the 'low success' cohort showed a non-significant trend towards lower observed success rates, while the 'high success' cohort showed a statistically significant trend towards lower observed success rates. The next step in this project is to determine what factors may be contributing to the decreased accuracy of the 'admission for delivery' calculator. In addition, further studies are needed to see if there may be a role for changing counseling to incorporate information from these calculators.
Whole Genome Sequencing and Gene Editing of Embryos: Are Infertility Patients Ready? [22S]
Authors: Lee Siwon , Vaughan Denis , Erlinger Adrienne , Hacker Michele , Penzias Alan , Neuhausser Werner
Published: May 2019

INTRODUCTION:

Clinical application of whole genome sequencing (WGS) appears near. In addition, gene editing using clustered regularly interspaced short palindromic repeats (CRISPR) has been applied successfully in human embryos under experimental conditions. We sought to explore the understanding and acceptance of these technologies among patients with infertility.

METHODS:

We administered a cross-sectional survey to infertile couples at a large university-affiliated IVF practice, with centers in 5 states, from April to September 2018. Approved by BIDMC IRB.

RESULTS:

There were 587 respondents, yielding an 80% response rate. The median age was 37; 68% were female and 32% were male. Respondents' political views were: 45% liberal; 36% moderate and 12% conservative. Most (73%) were Caucasian; 57% were Christian; and 65% had household income >$100,000. Whereas 45% had heard of WGS, 60% had heard of gene editing. Most did not object to research on human embryos (87%) or gene editing of embryos (75%) and most reported they would be interested in utilizing WGS and gene editing. Respondents who reported conservative political view were significantly less likely to be interested in utilizing WGS (p=0.006) or gene editing (p=0.01). History of miscarriage did not influence respondents' opinions (p=0.48).

CONCLUSION:

Over half of respondents had heard of gene editing technology. Most infertile patients were interested in WGS and open to the idea of editing their gametes to improve the likelihood of having a child unaffected by a heritable, genetic mutation. There are many technical and ethical implications to be considered before these technologies are adopted in clinical practice.
Assessing Adolescent Sexual Health Counseling Among Residents With a Novel Simulated Patient Workshop [23S]
Authors: Kaiser Jennifer E. , Shinn Alyson , Sheinberg Annabel , Sanders Jessica , Gawron Lori , Turok David Keith
Published: May 2019

INTRODUCTION:

This study evaluates changes in resident knowledge, counseling confidence, and self-efficacy through a novel adolescent-led sexual and reproductive health simulated patient workshop.

METHODS:

This is a prospective pilot study of obstetrics and gynecology (OBGYN), family medicine, and pediatric residents completing a simulated patient encounter with adolescents trained in peer sexuality education from the Planned Parenthood of Utah Association Teen Council. The workshop included an informational presentation from adolescents who then completed 15-minute, one-on-one simulated patient encounters with a resident. We guided adolescents in creating their own unique simulated patients portraying a range of sexual health chief complaints. Residents completed pre- and post-workshop surveys on adolescent sexual and reproductive health knowledge, counseling confidence, and self-efficacy. We completed descriptive analyses of participant demographics and change in knowledge (7 questions), confidence, and self-efficacy. We used Likert scales (5-point) for measuring confidence (6 questions) and self-efficacy (3 questions).

RESULTS:

A total of 16 residents participated in the workshop (n=12 OBGYN). Prior to the workshop, four residents had one or more hours of adolescent sexual health didactic time and one had a simulated patient encounter as part of their residency training. After the workshop, resident adolescent sexual health knowledge improved (mean increase 3.5/7 SDÂ±0.94). Residents also demonstrated increased total counseling confidence (mean pre-workshop 19/30 to post-workshop 24/30) and increased total counseling self-efficacy (mean pre-workshop 9/15 to post-workshop 12/15).

CONCLUSION:

The adolescent-led sexual and reproductive health workshop is a novel approach to increasing knowledge, counseling confidence, and self-efficacy in adolescent sexual health among resident physicians.
Clinical Effectiveness of Simulation in Eclampsia and Obstetrical Hypertensive Emergencies [24S]
Authors: Marko Emily , Anbazhagan Aruna , Donlan Amy
Published: May 2019

INTRODUCTION:

Simulation prepares teams for rapid response to rare obstetrical emergencies like hypertensive crisis and eclampsia. The study objective was to determine the clinical effectiveness of teamwork simulation training in eclampsia and obstetrical hypertensive emergencies.

METHODS:

A prospective quasi-experimental educational study design was used to assess the effectiveness of a simulation curriculum on eclampsia and hypertensive emergency. A high fidelity manikin was programmed to produce seizures and hypertension. Outcomes were measured using pre/post knowledge tests, performance assessment scores, safety culture surveys and clinical parameters of intensive care unit (ICU) admissions and length of stay. Internal review board exemption was obtained. Paired t-tests and repeated measures were used for data analysis.

RESULTS:

Over one year, 256 obstetrical staff participated in weekly drills in a large obstetrical hospital with over 10,000 deliveries per year. Statistically significant improvement occurred in pre-post scores of knowledge (59.86%, 93.87%, p<0.0001), performance (56.54%, 93.54%, p<0.0001) and safety culture (3.12, 1.45, 1=high 5=low, p<0.0001). Clinical outcomes for patients diagnosed with eclampsia indicated fewer ICU admissions and shorter lengths of stay (pre 4.58 days, post 3.50 days, p=0.048) as compared with the year prior to initiation of the simulation program.

CONCLUSION:

Teamwork simulation training demonstrated improved team knowledge, performance and attitudes for responsiveness to hypertensive emergencies and eclampsia. Fewer ICU admissions and shorter lengths of stay for these rare events suggest improved patient care after initiating teamwork training.
Pelvic Exam Simulation Integration into OB/GYN Medical Student Clerkship Curriculum Improves Student Confidence [27S]
Authors: Dubin Ariel Kate , Arora Chetna , Advincula Arnold Patrick
Published: May 2019

INTRODUCTION:

The purpose of this study is to examine the impact on medical student confidence with a pelvic exam by integrating a new simulation curriculum into the orientation day of their OB/GYN clerkship rotation.

METHODS:

A pelvic exam simulation was integrated into an established orientation day at the beginning of the OB/GYN clerkship. This included direct education by a physician trained in pelvic examinations on two high-fidelity pelvic simulators and guided pelvic exams on standardized patients. Online surveys were distributed before the orientation day (pre-clerkship), at the end of the orientation day (post-simulation), and at the conclusion of the clinical rotation (post-clerkship). IRB approval was obtained.

RESULTS:

At the end of the rotation 80% of the students were no nervous about performing a pelvic exam versus 25% pre-clerkship. 3% of students felt confident performing a pelvic exam before orientation versus 56% after simulation and 62% after the clerkship. When asked if the simulation experience enhanced their understanding of the female reproductive system, 95% of students answered positively.

CONCLUSION:

We found increased medical student confidence and less anxiety about performing a pelvic exam after the integration of a simulation experience in the clerkship orientation day. The students also expressed increased satisfaction with the modification in curriculum. By removing a large barrier that often exists in the learning process of this sensitive but extremely important clinical skill, medical students may be able to more fully participate in their OB/GYN clerkship and bring these feelings of confidence and skill into their chosen specialty.
Cervical Length Following Cerclage Placement in Twin Gestations With Ultrasound Indicated Short Cervix [30S]
Authors: Arkfeld Christopher K. , Mulhall J. Connor , Shea Ashley , Dahlke Joshua D.
Published: May 2019

INTRODUCTION:

Identification of a short-cervix during transvaginal ultrasound in the second-trimester is associated with an increased risk of spontaneous preterm birth (sPTB) in singleton pregnancies. Ultrasound indicated cerclage reduces the risk of recurrence in those with a history of sPTB. The utility of cerclage in twin-gestations is less understood. Our objective was to identify the impact of placing a cerclage in women with a twin-gestation and an ultrasound indicated short-cervix <25 mm.

METHODS:

We performed a descriptive analysis of all twin gestations delivered at a single tertiary care center with ultrasound evaluation between January 1, 2013 and September 1, 2017. Women with missing maternal or neonatal data were excluded. Outcomes of interest included midtrimester transvaginal cervical length (CL), the effect of cerclage placement on subsequent measurements and gestational age (GA) at delivery. IRB approval was obtained.

RESULTS:

Of 587 twin pregnancies, 26 patients were diagnosed with a short-cervix and received a cerclage. After placement, an average increase in CL of 7.4 mm at the first CL follow-up (P=.002) and remained significant during subsequent follow-ups. Average GA at delivery was significantly earlier for patients with a CL <15 mm compared to patients with a CL >15 mm; 33 weeks and 4-days versus 35 weeks and 4-days respectively (P=.003).

CONCLUSION:

Cerclage placement significantly increases transvaginal CL following the procedure. While the severity of the short-cervix appears to predict earlier GA at delivery it remains unclear if cerclage placement alters the GA at delivery. CL monitoring following the placement of a cerclage has unknown clinical benefit after cerclage placement in twin-gestations.
Targeted Liquid Biopsy Detects Tumor-Specific TP53 Mutations in Early and Late Stage Ovarian Cancer [29O]
Authors: Pandya Deep , Camacho-Vanegas Olga , Camacho Sandra Catalina , Dottino Peter , Martignetti John A.
Published: May 2019

INTRODUCTION:

Ovarian cancer (OvCa) is the most lethal female reproductive tract malignancy. Despite the immediate need to detect these cancers at an earlier stage, there is no effective screening methodology or protocol. We hypothesized that the use of ultra-deep, targeted gene sequencing could detect somatic mutations in uterine lavage fluid, a next generation of liquid biopsy, as a means of molecular screening and diagnosis.

METHODS:

Paired tumor, uterine lavage and blood samples were collected and analyzed from patients undergoing debulking surgery. Lavage fluid was separated into cellular and acellular fractions and DNA isolated. A targeted next-generation (NGS) 56 gene panel was used. To rule out potential NGS-based errors, orthogonal mutation validation was performed using dPCR and Sanger sequencing.

RESULTS:

Tumor sequencing defined the distinct mutation profiles for all 9 patients; shared between all patients was TP53 mutations. We therefore focused our efforts on detecting TP53 mutations in the collected lavage samples. Using ultra-deep sequencing, and then a combination of mutation validation technologies, the identical TP53 mutation identified in the patients' tumor was detectable in 7/9 (77.8%) of the uterine lavage samples. Notably, both stage I cancers were detected by molecular analysis of the lavage fluid.

CONCLUSION:

Using a combination of molecular assays, all based on the analysis of uterine lavage fluid, we were able to detect tumor-specific TP53 mutations from 7/9 ovarian tumors including stage I cancers. The sensitivity of this approach to detect tumor-specific mutations, even in early stage disease, highlights the potential for a molecular screening test for OvCa.
Results From an Multidisciplinary Severe Maternal Morbidity Review at a Tertiary Academic Medical Center [23P]
Authors: Campbell Katherine Harper , Grechukhina Olga , Abdel-Razeq Sonya , Raab Cheryl , Pettker Christian Michael , Lipkind Heather
Published: May 2019

INTRODUCTION:

Due to increasing rates of severe maternal morbidity (SMM) in the United States, there is impetus from national organizations for obstetricians to develop facility-level multidisciplinary review of SMM for potential preventability. We utilized standardized guidelines to develop a SMM review process in our hospital.

METHODS:

Our SMM Committee identified cases meeting the definition of SMM (transfusion of 4 or more units of packed red blood cells and/or admission to an intensive care unit at any time from conception through 42 days postpartum) and reviewed them to recognize factors contributing to preventable SMM or develop best practices to reduce morbidity.

RESULTS:

From August 2015 - September 2018, we identified 98 SMM cases. Three cases resulted in maternal death. Seventy-two percent of the women received their maternity care at YNHH, while the rest were transferred in from outside hospitals. The mean maternal age was 32 (range 17-55) with 34% of women age 40 and above at the time of the SMM. Our cohort was primarily White (44%) and included Hispanic (25%), Black (22%), and Asian/PI (6%) women. The most common causes of SMM were obstetric hemorrhage (25%), placental hemorrhage (17%), hypertensive disorders (13%), and non-uterine infection (13%). The majority of the SMM occurred in the peripartum period (60%) and most were direct obstetric SMM (70%).

CONCLUSION:

Facility-level reviews provide critical insight to understand hospital SMM patterns, patient characteristics or lack thereof. The review process can identify factors that can be strengthened to improve institutional obstetric safety and reduce SMM among pregnant and recently pregnant women.
A Survey of Hepatitis C Virus (HCV) Screening in Pregnancy Among OBGYNs at a Tertiary Care Center [19Q]
Authors: Koniares Katherine , Fadlallah Hasan , Kolettis Diana , Vindenes Tine
Published: May 2019

INTRODUCTION:

Hepatitis C Virus (HCV) infection among pregnant women in the US increased 89% from 2009 to 2014. The risk of a HCV infected mother transmitting the infection to her infant is approximately 4-7% per pregnancy. Infectious Disease Society of America (IDSA) and American Association for the Study of Liver Diseases (AASLD) recommend universal HCV screening in pregnancy whereas the American College of Obstetricians and Gynecologists (ACOG) recommends risk-based screening. The objective of this study was to assess the opinions and clinical practice of OBGYN providers in a tertiary care center.

METHODS:

An electronic 10 question survey was approved by the Tufts Medical Center Institutional Review Board and emailed to providers.

RESULTS:

38/41 (92.6%) provided responses and 17/38 (44.7%) were attendings, 4/38 (10.5%) were fellows, and 17/38 (44.7%) were residents. 16/37 (43.2%) of respondents agreed all pregnant women should be screened for HCV whereas 20/37 (54.1%) agreed that only pregnant women with risk factors for HCV should be screened. When asked about their clinical practice, 3/36 (8.3%) of respondents stated they do not screen pregnant patients for HCV, 5/36 (13.9%) screen all pregnant patients, and 28/36 (77.8%) screen patients based on their risk factors for HCV.

CONCLUSION:

Divergent guidelines, provider opinions, and clinical practice necessitate further research into universal HCV screening in pregnant patients. Future plans include an educational intervention on HCV for providers in the department followed by a chart review to determine the HCV detection rate before and after a change in practice to universal screening for HCV.
Evaluation of Antepartum and Postpartum Remote Blood Pressure Monitoring in Low-Risk Pregnancy [9K]
Authors: DeNicola Nathaniel G. , Ganju Nihar , Marko Kathryn I. , Sheth Sheetal
Published: May 2019

INTRODUCTION:

Hypertensive disorders in pregnancy are a leading cause of morbidity and mortality. This study examines the feasibility of an integrated technology platform to augment surveillance with remote blood pressure (BP) readings in low-risk pregnant women.

METHODS:

2806 low-risk pregnant women in 57 offices were enrolled in an integrated technology platform with a mobile application and connected devices to remotely transmit BP readings (BabyscriptsTM (BRx) platform). Antepartum BP recordings were tabulated from 12-36 weeks gestation. Postpartum BP recordings were tabulated from 42-48 weeks gestation. All BP data was analyzed for mean systolic and diastolic BP and average interval between recordings.

RESULTS:

Antepartum monitoring of 2791 women showed a mean systolic BP of 107.3 (95% CI 102.1-112.5) and a mean diastolic BP of 68.9 (95% CI 61.7-76.1). A total of 38,443 antepartum BP readings were recorded. The average interval between recordings was 7.2 days. Postpartum monitoring of 186 women showed a mean systolic BP of 109.8 (95% CI 104.2-115.4) and a mean diastolic BP of 73.2 (95% CI 66.3-80.1). A total of 485 postpartum BP readings were recorded. The average interval between recordings was 5.1 days.

CONCLUSION:

Remote monitoring of BP in low-risk pregnant women resulted in frequent recordings during the antepartum and postpartum periods. Notably, the average frequency of postpartum recordings occurred at a shorter interval than typical clinical follow-up. This platform could offer more robust monitoring in low-risk pregnancies and could be extrapolated to high-risk pregnancies in the future.
Interdisciplinary Coaching for Rapid-Response Team Simulations [11K]
Authors: Kuhlmann-Capek Maggie J. , Munn Mary B. , Olson-Koutrouvelis Gayle
Published: May 2019

INTRODUCTION:

Coaching and debriefing after simulated exercises are both well-established approaches to enhancing education and personal performance. Coaching may also have an important role in training interdisciplinary teams for obstetric emergencies. We sought to understand factors which create an optimal environment for coaching interdisciplinary obstetric rapid-response teams.

METHODS:

An interdisciplinary simulation drill was conducted for our institution's obstetric rapid-response team. The individuals leading the debriefing session were varied by discipline, and participants' responses in a post-simulation survey were analyzed to determine if receiving feedback from a person from one's own discipline is important to satisfaction with the assessment process. Participants were asked to rank their satisfaction with feedback on a numerical scale (1-10, 10=best). We also posed questions regarding acceptance of video recording and playback in a group setting.

RESULTS:

There was no difference among obstetricians (n=3), anesthesiologists (n=3), or nurses (n=8) regarding feedback received from a representative of their own discipline versus a representative from a different discipline. The majority believed that recording the simulation and playing it back during the team debrief would be helpful. None of the participants indicated that recording the simulation and playing it back during the debrief would deter them from participating.

CONCLUSION:

Our pilot exercise indicates that participants respond equally to feedback given by a representative of their own discipline as to feedback given by a representative of a different discipline. Interdisciplinary coaching for rapid-response team simulations was well-accepted. The addition of a video recording appears to be a welcome addition to the debrief process.
Expanding the Concept of Failure to Rescue to Address Maternal Mortality: A Public Health Approach [13K]
Authors: Restrepo Elizabeth , Fuqin Liu , Mancuso Peggy , Hamilton Patti
Published: May 2019

INTRODUCTION:

Precision-directed, public-health evaluation of unprecedented Texas maternal mortality rates was performed using birth and death datasets to document maternal failure to rescue (FTR). FTR is a designated national quality measure, with maternal FTR focused on physiological obstetrical factors. Suicide, drug overdose, and homicide, previously overlooked, were incorporated into maternal FTR. Through expansion of the FTR concept, a public-health approach was applied. Geospatial analyses indicated areas of increased maternal mortality, enabling mapping of maternal-care deserts.

METHODS:

Using an epidemiological, cohort design, we calculated FTR (standard method) from Texas birth and death datasets. We compared this calculation to the expanded concept of FTR, incorporating deaths from suicide, drug overdose, and homicide, tending to occur after the 42-day postpartum period. Using geospatial analysis, we identified vulnerable areas with limited access to maternal health services.

RESULTS:

We identified 713 mortalities from 1,218,205 births. Of these deaths, 475 noted underlying obstetrical risk factors for maternal mortality, leaving 238 deaths from other causes. Forty of these 238 mothers died from suicide, opioid overdose, or homicide. We obtained an unrefined FTR rate of 96 maternal deaths/100,000 births. The FTR rate, using the expanded concept, was 104 deaths/100,000 births (8% increase). Geospatial analysis demonstrated robust differences in maternal mortality by county, both rural and urban.

CONCLUSION:

This expansion of FTR can be adopted by others to examine maternal care quality using public data. We assert that the current focus on maternal physiological complications restricts thinking to hospital-based remedies to alleviate FTR and limits precision public-health strategies to decrease maternal mortality.
Factors Affecting Neonatal Birthweight in Women With History of Bariatric Surgery: A Retrospective Study [16K]
Authors: Chatterton Carolyn G. , Shanahan Lisa K T. , Kenkel Christine M. , Vullo John J. , Polavarapu Satya , Gurram Padmalatha
Published: May 2019

INTRODUCTION:

Bariatric surgery (BS) has been shown to improve pregnancy outcomes in obese patients. Studies suggest increased incidence of small for gestational age (SGA) neonates in women with BS, without clear explanation. The objective of this study is to investigate the incidence of SGA in neonates after BS in relationship to the type of BS, time interval from surgery to delivery (TI), and maternal micronutrient deficiency.

METHODS:

This is a retrospective chart review of women with history of BS who delivered between 2013 and 2017 at our institution. The mothers with BS (N = 70) were compared with a cohort of mothers without BS (NBS) (N = 70) with similar body mass index. Type of bariatric surgery (malabsorption versus restrictive), micronutrient deficiencies (use of supplemental iron, folate, B12, and blood transfusions), and TI were analyzed for each cohort. Multiple gestations were excluded. Institutional Review Board approval was obtained.

RESULTS:

Both groups had similar maternal characteristics and perinatal and neonatal complications (p > 0.05). SGA was increased in patients with BS (14.4%) compared with NBS (2.9%). Women with restrictive BS (N=42) had an increased incidence (p = 0.04) of SGA compared to malabsorptive BS (N=27). SGA was increased in patients with TI less than 4 years (p = 0.02). There was no impact of anemia (p = 0.89) or obesity class (p = 0.92) on neonatal birthweight.

CONCLUSION:

Restrictive bariatric surgery and time interval less than 4 years is associated with increased incidence of SGA in patients with history of bariatric surgery.
Factors Associated With Infant Mortality in Two Select At-risk Counties in Texas, 2011–2014 [17K]
Authors: Patel Divya A. , Salahuddin Meliha , Elerian Nagla , Valerio Melissa , French Lesley , Lakey David
Published: May 2019

INTRODUCTION:

While infant mortality rate (IMR) in Texas has remained below the Healthy People 2020 objective since 2012, stark differences in IMR exist within the state. Texas also has a growing prevalence of maternal chronic conditions, which are linked to poor pregnancy-related outcomes. The Healthy Families initiative, a state-funded collaboration, seeks to understand associations between maternal risk factors and infant death, and how evidence-based practices implemented in the community can improve pregnancy-related outcomes.

METHODS:

Two counties with high prevalence of maternal chronic conditions were selected as project sites, one having high IMR and the other having low IMR. Cohort-linked birth and infant death records from 2011-2014 were provided by the Texas Department of State Health Services (IRB#17-055). Logistic regression models examined associations of maternal sociodemographic and pregnancy-related factors with infant death.

RESULTS:

During 2011-2014, IMR was 4.5 per 1,000 live births in one site and 7.6 per 1,000 live births in the other site. Similar to Texas overall, the leading cause of infant death in both sites in 2014 was congenital malformations, deformations and chromosomal anomalies. In both sites in 2011-2014, pre-pregnancy diabetes mellitus was significantly associated with infant death (adjusted ORs: 2.70 and 4.36). Additionally, in one site, pre-pregnancy hypertension was also significantly associated with infant death (OR=3.72).

CONCLUSION:

In this study, maternal chronic conditions were significantly associated with infant mortality in two Texas counties. Findings from the Healthy Families initiative will help identify key strategies to address preconception and interconception health, which can inform broader statewide efforts aimed at improving pregnancy-related outcomes.