bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors of Anticipated Pain During Intrauterine Device Insertion in Adolescents and Young Women [9M]
Authors: Hunter Tegan , Sonalkar Sarita , Schreiber Courtney A. , Perriera Lisa , Sammel Mary , Akers Aletha
Published: May 2019

INTRODUCTION:

Intrauterine devices (IUDs) are highly effective contraception, but their use in adolescents remains low. Fear of pain during IUD insertion may deter use. Here, we investigate the characteristics associated with anticipated pain with IUD insertion in adolescents and young adult women.

METHODS:

We performed a secondary analysis on a single-blind randomized trial of 95 adolescents and young adult women undergoing insertion of a 13.5 mg levonorgestrel IUD while receiving either a lidocaine or sham paracervical block. We ascertained visual analog pain scores before and at 6 time points during the procedure. We performed linear regression to identify demographic, mood, and sexual/gynecologic history covariates associated with anticipated pain. We used student's t-test to test for associations between anticipated pain and perceived pain (p<0.0083 using a Bonferroni adjustment).

RESULTS:

Women with anticipated pain scores above the median have significantly higher perceived pain at 5 of 6 timepoints (p<0.008). Only Black race significantly predicted anticipated pain. Black participants (n=34) had the highest average anticipated pain scores (63.6 mm) compared to White participants (n=45; 47.0 mm) and participants of all other races (n=16; 55.0 mm, p=0.014). Black participants had an adjusted mean anticipated pain score 15.1 mm higher than for white participants (p=0.017).

CONCLUSION:

Despite recent increased IUD use, Black women are less likely than women of other races to select IUDs as their method of contraception. We identify that this population experiences greater anticipated pain with IUD insertion and may benefit from additional counseling and other efforts to reduce this barrier to IUD use.
Risk of Chronic Opioid Use Among Women With Endometriosis [16M]
Authors: Chiuve Stephanie E. , Kilpatrick Ryan D. , Petruski-Ivleva Natalia , Wegrzyn Lani R. , Snabes Michael C. , Bateman Brian T.
Published: May 2019

INTRODUCTION:

Women with endometriosis may be prescribed opioids for management of endometriosis-related pain symptoms or in the context of surgical procedures. Once exposed, these women may be vulnerable to chronic opioid use given their comorbidity profile.

METHODS:

Women with an initial claim for endometriosis (N=37,142) and women without (N=2,596,871), aged 18-50, were identified from a US commercial insurance claims database and followed for 2 years. Chronic opioid use was defined as ≥10 fills or ≥-120 days covered over 1 year. Regression models estimated the association between endometriosis and chronic opioid use, and sequelae of chronic use among women with endometriosis.

RESULTS:

The 2-year risk of chronic opioid use was 4.4% in women with endometriosis and 1.1% in women without. The relative risk (RR) for chronic opioid use in women with endometriosis v. without was 2.11 (95% CI 2.00-2.23) controlling for demographics, pain, mental health comorbidities, substance abuse, use of benzodiazepine, stimulants, antipsychotic medications and prior opioids. Among women with endometriosis, the median dose per fill increased by 50% over 2 years among chronic opioid users and 0% among non-chronic users. Chronic opioid use among women with endometriosis was associated with higher risk of an opioid dependence diagnosis (RR 8.52; 95% CI 6.67-10.9), overdose (RR 3.97; 95% CI 1.90-8.30), altered mental status (RR 2.92; 95% CI 2.16-3.93), falls (RR 2.43; 95% CI 2.02-2.92) and constipation (RR 1.87; 95% CI 1.71-2.05).

CONCLUSION:

Women with endometriosis have a greater risk of chronic opioid use and its sequelae. Physicians should consider the consequences of opioid prescribing for endometriosis-associated pain.
A Comparison of Prenatal Substance Use Screeners That Assess for Illicit Drug Use and Prescription Drug Misuse [22M]
Authors: Coleman-Cowger Victoria H. , Oga Emmanuel A. , Peters Erica , Mark Katrina
Published: May 2019

INTRODUCTION:

Prenatal substance use screening is crucial to identify pregnant women at risk of associated harmful effects. There is no universally recommended substance use screener validated for use with pregnant women.

METHODS:

This cross-sectional study enrolled a convenience sample of 500 pregnant women from two prenatal clinics in Baltimore, Maryland. All participants were administered the 4P's Plus, NIDA Quick Screen/ASSIST and SURP-P, and had biochemical testing of urine and hair at the first research visit. To assess test-retest reliability, screener administrations were repeated one week later via telephone. Sensitivity, specificity, positive predictive value, negative predictive value and test-retest reliability were computed. Results were stratified by age, race, and trimester of pregnancy.

RESULTS:

For the 4Ps Plus, sensitivity = 90.2%, specificity =29.6% and false negative rate (95% CI) = 9.8% (5.9, 15.1). For the NIDA Quick Screen/ASSIST, sensitivity = 79.7%, specificity = 82.8% and false negative rate (95% CI) = 20.3% (14.7, 26.9). For the SURP-P, sensitivity = 92.4%, specificity = 21.8% and false negative rate (95% CI) =7.7% (4.3, 12.5). Test-retest reliability (phi correlation coefficients) was 0.84, 0.77, and 0.79 for the 4P's Plus, NIDA Quick Screen/ASSIST and the SURP-P, respectively. For all screeners, there were differences in diagnostic indices by age and race, but no differences by trimester.

CONCLUSION:

The SURP-P and 4P's Plus had high sensitivity and negative predictive values. A clear recommendation for a clinically useful screening tool for prenatal substance use is crucial to allow for prompt and appropriate follow-up and intervention.
A Comprehensive Analysis of Allele Frequencies From 476,930 Spinal Muscular Atrophy Test Results [23M]
Authors: Evans Matthew , McCarthy Michele , Moore Rebecca , Karbassi Izabela , Alagia Damian Paul , Lacbawan Felicitas
Published: May 2019

INTRODUCTION:

Spinal muscular atrophy (SMA) is an autosomal recessive neurodegenerative disease caused by homozygous deletion of the SMN1 gene. Disease severity is related to the copy number of the highly homologous, yet functionally insufficient, pseudogene SMN2. SMA has no cure; but prognosis improves if treatment is started early in life, with the most significant gains observed when initiated pre-symptomatically. Delay in genetic confirmation of diagnosis may be a barrier to early treatment, therefore we sought to evaluate our historical SMA testing data.

METHODS:

We performed a blinded review of carrier (n=460,703) and diagnostic (n=16,227) tests submitted over a 15-year period across 4 testing sites in a US population. Allele frequencies of SMN1 and SMN2 were determined for all diagnostic and carrier SMA test results in respect to available patient demographics such as sex and age at the time of testing.

RESULTS:

The observed SMA carrier frequency was 1:53, decreased from the commonly cited rate of 1:35-1:40, but within range of previous studies. In affected individuals, age at time of testing correlate to SMN2 copy number and aligns with a delay in disease presentation with increased SMN2 copies.

CONCLUSION:

Early diagnosis and treatment of SMA is critical in order to maximize the positive impact on patient quality of life and life expectancy. These data suggest a potential delay in genetic diagnosis of SMA and, therefore, would correlate to a lag in treatment course initiation. Broad implementation of newborn screening programs and timely confirmatory testing will likely improve service to the SMA community.
Gender-Affirming Surgeries in Transmasculine People: An Individualized Decision [27M]
Authors: Abern Lauren , Cook Jake , Maguire Karla
Published: May 2019

INTRODUCTION:

The process of transitioning is a journey unique to each transgender individual. While many wish to obtain various gender-affirming surgeries and face many barriers in that process, some do not desire surgery to transition. The goal of this study is to determine if transmasculine people underwent gender-affirming surgery, reasons for not proceeding with surgery, and barriers experienced.

METHODS:

Transmasculine people ages 18-64 participated in an online survey which included demographics, surgical history, reasons for not obtaining surgery, and barriers to care.

RESULTS:

781 individuals participated. The mean age was 27 (SD 8.6). The majority was white (663, 85%) and had a college degree (344, 44%). 530 had private insurance (68%), and 413 (53%) made less than $24,000/year. 468 (60%) were on hormone therapy. 289 (37%) underwent a form of gender-affirming surgery. 357 (73%) plan to do so in the future. 262 (54%) have not had surgery due to financial reasons, and 112 (23%) as a result of insurance difficulties. 61 (13%) do not plan on having surgery, and 23 (5%) are uncertain. 61 (13%) risk losing family support if proceeding with surgery. If cost was covered, 239 (32%) said they would not proceed with bottom surgery while 242 (32%) were unsure.

CONCLUSION:

The decision to proceed with various gender-affirming surgeries is individualized, with people desiring none, some, or all surgical options. Barriers including insufficient finances and lack of insurance coverage make it difficult for those that desire surgery, despite many having private insurance. This is important to consider when counseling about transition-related care.
Detecting Preeclampsia Using Data From a Pregnancy Mobile App [30M]
Authors: Bradley Danielle , Landau Erin , Wolfberg Adam , Baron Alex
Published: May 2019

INTRODUCTION:

The objective was to create a predictive model for preeclampsia detection when app users do not report diagnosis or are not yet aware of their diagnosis.

METHODS:

A supervised machine learning algorithm, specifically, a Gradient Boosting Decision Tree algorithm, incorporating data from 77,621 users of a mobile app was used to create a model for the purpose of detecting the presence of preeclampsia.

RESULTS:

Of the total sample used to train the model, 41% had preeclampsia based on patient report of a diagnosis made by their clinician. The model used 385 different features to model the likelihood of currently having preeclampsia, even if disease status was not yet known or if diagnosis had not yet been reported in-app. Self-report data, as well as in-app calculations based on reported data, were used to create the model. The frequency of reported 'daily data' such as, health symptoms (e.g., fatigue and exhaustion, and blood pressure readings), moods, nutrition, and exercise activities were most influential to the model. Personal demographic information including age and BMI (height and weight) also contributed to the mode. The model's positive predictive value was 0.75, with 0.37 sensitivity. With a positive predictive value of 0.65, sensitivity increased to 0.79.

CONCLUSION:

A model used to identify the presence of preeclampsia was most influenced by the frequency of data logging for specific features. This model could prove highly informative for patients, especially those without access to regular healthcare, as the presence of a serious condition could be identified, prompting referral to a healthcare provider.
Patient-Physician Interactions Regarding Dyspareunia With Endometriosis: Online Survey Results [33M]
Authors: Witzeman Kathyrn A. , Flores Oscar Antunez , Renzelli-Cain Roberta , Worly Brett , Schneider Beth
Published: May 2019

INTRODUCTION:

Dyspareunia is a challenging symptom of endometriosis-related pelvic pain, exacerbated by suboptimal communication between the patient and healthcare professional (HCP). Our aim was to describe patient-HCP communications regarding diagnosis and management of dyspareunia in endometriosis patients.

METHODS:

An IRB-approved 24-question online English-language survey was conducted among women 19 years or older who self-identified as having endometriosis and dyspareunia. Women were asked about their interactions with HCPs about dyspareunia. Participants were recruited via MyEndometriosisTeam (a social network for women with endometriosis); members were invited by e-mail. Other participants were solicited via invitations posted on MyEndometriosisTeam’s Facebook page. Invitation to participate included a link to an anonymous survey.

RESULTS:

Of the 32,865 invited participants, 357 US women completed the survey with an 11% open rate and 10.3% response rate. Most respondents (83%) were between 19 and 29 years old; 85% reported to have discussed painful sex with a gynecologist, while only 33% were told their condition might be dyspareunia. Among those who did not seek help, 34% indicated that they were too embarrassed, while 26% did not think anything could lessen the pain. 42% of women agreed that it would be easier to discuss painful sex if the HCP initiated the discussion. Women reported that HCPs most often recommend surgery (46%) and over-the-counter pain medication (36%) for dyspareunia, while 18% provide no advice.

CONCLUSION:

In this online survey, the majority of women reported suboptimal communication with HCPs when seeking help for dyspareunia, highlighting the need for better dialogue about dyspareunia between patients and physician.
Impact of Perinatal Depression on Contraceptive Planning [4N]
Authors: Keesara Sirina , Kim Jo , Adams Marci , Silver Richard Karl
Published: May 2019

INTRODUCTION:

Contraceptive choice may be influenced by disturbances in perinatal mood disorders, but studies have shown mixed results. We wished to assess the postpartum contraceptive choices of women at risk for perinatal depression, specifically in regard to hormonal contraception, long-acting reversible methods, and surgical sterilization.

METHODS:

This retrospective cohort study evaluated a population of women (n= 419) who participated in a calibration pilot for depression screening while pregnant and after delivery using a novel computerized adaptive diagnostic screener (CAT-MH). Maternal age, race and gestational age at delivery were used to match cases (n=64) to controls (1:2). Chart review was used to screen for choice of contraception and potential confounders including pre-pregnancy mental health disorders and/or current mental health treatments. Bivariate analyses and multiple logistic regressions were used to study the impact of depressive symptoms on contraceptive planning.

RESULTS:

No significant differences in contraceptive choice were observed between depressed and control groups. However, worsening postpartum mood was associated with the choice of non-hormonal methods when compared to stable mood after delivery (24.1% vs. 48.3%, p=0.016). This association persisted in a multivariate logistic regression which included age, race, insurance status, obstetric history, mode of delivery, and NICU admission. Women who were treated with psychiatric medications while pregnant were more likely to choose surgical sterilization (11.3% vs. 33.9%, p=.02).

CONCLUSION:

A relationship between depressed maternal mood and contraceptive planning may be mediated by preexisting mental illness and use of psychiatric medications, influencing both hormonal contraception and surgical sterilization choices.
Impact of the Ryan Program on Resident Clinical Experience and Intentions to Include Abortion in Future Practice [6N]
Authors: Steinauer Jody , Koenemann Katheryn , Coghlan Kearney , Landy Uta , Turk Jema
Published: May 2019

INTRODUCTION:

This study assessed the impact of formal, opt-out family planning training on the clinical experience and intentions to include abortion care after residency among obstetrics and gynecology (ob-gyn) residents at currently funded Ryan Programs.

METHODS:

The Ryan Program (RP) has supported 99 US and Canadian ob-gyn residency programs to establish routine opt-out training in family planning and abortion. In this analysis we report on clinical experience and post-residency plans reported by residents after the family planning training at RPs in the last five years. Data were collected using Key Survey and descriptive analyses were conducted with STATA. This study was approved by the Institutional Review Board of the University of California San Francisco.

RESULTS:

Between September 2013 and 2018, 1,254 post-rotation surveys were completed by residents for a response rate of 70%. Residents did an average of 38 abortions on the rotation, including the 18% who opted out of portions of the training: 8 medication abortions, 11 manual uterine aspirations, 14 electric uterine aspirations, and 6 dilation and evacuations. When asked about their post-residency plans, 82% intend to do abortions for medical reasons and 59% for all reasons.

CONCLUSION:

Participation in a formal, opt-out family planning rotation resulted in significant clinical exposure to abortion procedures and plans to provide abortions after residency. Studies of ob-gyn residents between 1996 and 2014 have found that 30-40% planned to provide abortions after residency, suggesting that routine training is associated with plans to integrate abortion into obstetrics and gynecology practice.
Implicit Bias and Contraceptive Counseling [7N]
Authors: Rosenblum Jessica L. , Minkoff Howard , Joslin-Roher Sophie L. , Morrell Kathleen M.
Published: May 2019

INTRODUCTION:

The unequal treatment of patients based on race/ethnicity is an ongoing problem in reproductive health. One possible reason for this is provider bias. While the relationship between explicit bias and providers' contraceptive recommendations has been studied, the relationship between those choices and provider's unconscious or implicit bias has not been examined. Our primary objective was to determine if implicit racial bias exists and if it correlates with providers' recommendations for their patients' contraceptive methods.

METHODS:

Practicing providers (attendings, residents, CNMs, PAs, etc.) who counsel on contraception participated in an IRB-approved computer-based survey at multiple hospitals in New York and at one national conference March 2018 to June 2018. The study included a demographic survey, clinical vignettes about contraception, and the racial Implicit Association Test - a validated tool designed by Project Implicit to assess implicit bias. Participants were randomized to clinical vignettes that described either White patients or Black patients.

RESULTS:

Three hundred forty-eight (348) providers participated in the study: 191 attendings, 120 residents, 23 CNMs, 10 PAs, and 4 NPs. Of those, 149 had vignettes with White patients and 199 had vignettes with Black patients. White participants showed a pro-White bias (p<0.001), while Black participants did not show racial bias in either direction (p=.986). White participants showing more pro-White bias were less likely to recommend sterilization for White patients (p=0.14).

CONCLUSION:

Implicit racial bias and contraceptive recommendations differed based on the provider's race. It is important for providers to understand their own implicit bias and how it may affect their contraceptive counseling.
Obesity and Nutritional Challenges Encountered by Survivors of Human Trafficking [11N]
Authors: George Joshua Sunny , Potter JoNell , Mathew Megan , Caralis Panagiota , Alhajji Lujain , Symes Stephen
Published: May 2019

INTRODUCTION:

Human trafficking is a form of modern day slavery and an important public health issue globally. Survivors experience food insecurity and poor nutrition practices during their trafficking. They present with medical and psychiatric co-morbidities that compound their nutritional challenges. In Miami, survivors have access to comprehensive health care, provided through THRIVE- a multidisciplinary, trauma-informed medical-home clinic. THRIVE Clinic coordinates access to food and housing services as well as nutrition education for survivors.

METHODS:

A retrospective chart review was conducted to assess BMI at first visit, self-report exercise and dietary intake, and medical/psychiatric co-morbidities related to nutrition and diet. This review obtained IRB approval prior to data collection.

RESULTS:

Records were reviewed for 41 patients (35 women and 6 transwomen). All had a history of sex trafficking, labor trafficking, or both. Average BMI for women and transwomen were 26.7 and 33.1 respectively, with 42% of women and 50% of transwomen measuring as overweight/obese. All six transwomen were on hormone therapy. Related co-morbidities included chronic constipation, gastritis, depression, anxiety, anorexia nervosa, bulimia and PTSD. Approximately half of patients self-reported poor exercise and dietary habits.

CONCLUSION:

Our understanding of the long-term health and nutritional problems of human trafficking survivors is still developing. This review demonstrates survivors are living with obesity and other nutritional issues exacerbated by their past trauma experiences. Attention to nutritional needs during their recovery will provide a clearer understanding on how to address these co-morbidities. Attending to these complex physical and psychiatric morbidities is crucial to understanding the multiple challenges faced by survivors.
Social Support and Baby-Friendly Hospital Care: Improving Breastfeeding Rates Among African American Mothers [15N]
Authors: Ukoli Flora A.M. , Cheaves Mariah , McPherson Karmen Dionne , Ladson Gwinnett McGhee
Published: May 2019

INTRODUCTION:

Women of high education and income status are more likely to breastfeed adequately in comparison with their less educated peers. African-American mothers continue to record the lowest breastfeeding rates compared to White and Hispanic mothers.

METHODS:

We recorded demographic information from 257 pregnant African-American women aged between 15 and 42 years recruited by flyers and word-of-mouth in a breastfeeding promotion intervention, and collected their infant feeding action at birth and at 3 months and 6 months postpartum. We computed their Baby-Friendly knowledge and exposure score using a 16-item survey, recorded their Supplemental Nutrition Assistance Program (SNAP) and Women, Infant, and Children (WIC) status. Rate comparisons was by Chi-Square test using Statistical Package for Social Sciences, SPSS Version 25.0.

RESULTS:

98 (38.1%) were nulliparous, 114 (44.4%) had one or two children, and 45 (17.5%) had >2 children. Of 164 interviewed within a week of delivery, 104 (63.4%) breastfed exclusively, 38 (23.2%) mix fed, and 22 (13.4%) did not breastfeed (NBF). Exclusive breastfeeding (EBF) rates at 3-months and 6-months were 32.8% and 17.1%, with NBF rates 30.5% and 44.4% respectively. Breastfeeding rates were higher for educated, older, and married mothers, but similar across work status. NBF rates at 3 months for mothers on SNAP, SNAP & WIC, WIC only, and Neither, were 47.1%, 50.0%, 16.0% and 15.2% respectively, P<.004. The rate for exclusive breastfeeding for WIC mothers with high vs low Baby-Friendly exposure score were 38.0% vs 0.0%, P<.006.

CONCLUSION:

Policies that combine Baby-Friendly principles and nutritional assistance for all mothers, particularly low-income working mothers, will improve breastfeeding rates dramatically.
L.E.A.D.E.R. Series: Resident Well-Being Woven Into the Clinical Curriculum [18N]
Authors: Reed Vicki Rae , Jhaveri StacieAntalis , Singh Katherine
Published: May 2019

INTRODUCTION:

Across the field of medicine, there is a focus on physician well-being. We developed an innovative L.E.A.D.E.R. (Leadership, Equanimity, Acceptance, Diversity, Engagement and Resilience) series that focuses on each of these core qualities as part of our residents' training. Didactics, group activities and team based simulation are woven into our clinical curriculum.

METHODS:

Team Building Skills Sessions are a core of the LEADER series. Resident teams of varied PGY levels develop team names/slogans and worked together to perform surgical tasks. Seniors “chief” juniors through skills in an environment of collegial competition. Using iPads, standard post-activity simulation center surveys were completed by residents. Resident rated the experience 1) as a simulation, 2) the learning during the session, 3) the instructors and 4) the relevancy to practice on a scale of 0-9. Verbatim comments were request on the team based activities.

RESULTS:

In 2017, 21 of 24 captured participants completed the survey and 13 of 20 in 2018. Overall the mean score in 2017 was 8.3 and in 2018 it was 8.1. Verbatim comments included the positive impact on communication, "chiefing", team building, bonding and technical skills.

CONCLUSION:

Skill-based team building creates an environment of camaraderie and provides positive resident experiences. Faculty involvement in the sessions models collegiality. An example: during one simulation, our opening ceremony to our Resident Olympics involved themed music as our faculty carried I-phone torches into the simulation center full of residents. A focus on “teams” early in training, builds peer relationships that are the foundation of resilience.
Maternal Fetal Health Workshop in Cusco, Peru: Shifting From Assistance to Capacity Building [19N]
Authors: La Rosa Mauricio , Webb Camille , Hadley Emily Elizabeth , Marrs Caroline Carter , Olson-Koutrouvelis Gayle , Cabada Miguel
Published: May 2019

INTRODUCTION:

Abroad medical volunteer work by United States citizens accounts for over one billion dollars in unpaid labor annually. The effectiveness of medical volunteerism in developing countries has been questioned. Changing the paradigm from assistance to capacity building might have a bigger and more permanent impact. The aim of our study is to evaluate a training intervention performed with Peruvian Ministry of Health personnel and determine its immediate impact.

METHODS:

This 2 day hands-on workshop was given by MFM and Infectious disease fellows, and focused on obstetric and neonatal emergencies. Midwifes and general physicians were invited to participate. Pre and post-workshop tests were conducted. The tests evaluated knowledge in management of pre-eclampsia, post-partum hemorrhage, ectopic pregnancy, maternal sepsis, and neonatal respiratory support. Total and topic specific mean scores in the pre and post-tests were compared using Chi square.

RESULTS:

A total of 47 healthcare professionals participated in the workshop and 38 answered both tests. Six were physicians, 6 registered nurses, and 35 midwifes. There was a significant improvement in the total score (12.9 vs 15.9, p<0.01) as well than in the areas of preeclampsia (1.5 vs 2.7 p<0.01), maternal sepsis (1.6 vs 2.4 p<0.01) and neonatal respiratory support (3.9 vs 4.4 p 0.05).

CONCLUSION:

Comparison of the pre and post-tests scores showed improvement in knowledge in general and in preeclampsia, maternal sepsis and neonatal respiratory support. The immediate effects of this intervention were positive. Further studies should be performed to evaluate the long term effects of these multidisciplinary workshops.
Location, Location, Location: Hospital Level Predictors of Length of Stay Following Cesarean Section [21N]
Authors: Peahl Alex Friedman , Kamdar Neil , Moniz Michelle , Dasmunshi Sudipta , Low Lisa Kane , Morgan Dan
Published: May 2019

INTRODUCTION:

Length of stay (LOS) after cesarean delivery (CD) is poorly defined in different practice settings. We describe LOS in hospitals in a statewide obstetric collaborative, and evaluate for associations between LOS and hospital and patient characteristics.

METHODS:

Women who underwent CD in 2012-2016 for fetal malpresentation or prior CD were identified in an insurance claims database. LOS was defined as ≤2, 3, and ≥4 days. Multinomial logistic regression accounting for hospital clustering examined the influence of hospital and patient characteristics on post-surgical LOS.

RESULTS:

16,218 women at 66 hospitals met inclusion criteria. LOS was ≤2, 3, and ≥4 days for 40.1%, 43.1% and 16% of patients respectively. Women were more like to have a longer LOS at hospitals with 3600 deliveries/year compared to hospitals with <1200 (2 vs.3 days: >3600/year, RRR=2.34 p=0.005; 3 vs. 4 days: >3600/year RRR=2.28 p=0.001. LOS was longer for women with maternal comorbidities (2 vs. 3 days: RRR=2.11 p<0.001, 3 vs. 4 days: RRR=3.18 p>0.001), fetal comorbidities (3 vs. 4 days: RRR=5.91 p=0.035). LOS was also longer for women with severe maternal morbidity as defined by the NIH (2 vs. 3 days: RRR=2.23 p<0.001, 3 vs.4 days: RRR=3.74 p<0.001).

CONCLUSION:

LOS varies based on obstetric volume and comorbidities. Clarifying the relationship between patient and hospital level factors may inform guidelines for safe discharge after Cesarean.
Managing Women With Obesity in Pregnancy: Scope of Practice in the Wake of the Obesity Epidemic [23N]
Authors: Stafford Shawna M. , Demsky Ashley , Oster Richard , Steed Helen
Published: May 2019

INTRODUCTION:

Obesity is a complex chronic disease affecting increasing numbers of reproductive aged women. Despite ongoing research efforts, many knowledge gaps remain when caring for women with obesity in pregnancy. Currently, there is no clearly defined, comprehensive standard of care for pregnant women with obesity. Consequently, obstetrical care providers have developed different approaches. In this study, we explored these approaches and how management of women with obesity differs from that of normal weight patients.

METHODS:

Qualitative concept maps were generated through individual in-depth mapping sessions with obstetricians (n=7) in Edmonton, Alberta, Canada. Concept maps were analyzed thematically and major themes and sub-themes used to inform survey development. Institutional ethics approval was obtained.

RESULTS:

Overall, seven dominant themes emerged from our thematic analysis: 1) Obstetricians define obesity differently; 2) Communication with patients with obesity should be “direct” and “honest”; 3) Understanding fetal wellbeing is more challenging in patients with obesity in both the pre-natal and intra-partum period; 4) Obstetricians recommend induction of labor for large for gestational age fetuses but not maternal obesity; 5) Women with obesity have abnormal labor; 6) Obstetricians expect more complications, alter their surgical approach, and adjust their threshold for Cesarean deliveries in patients with obesity; and 7) Education and knowledge translation about obesity in pregnancy is inadequate.

CONCLUSION:

Concept mapping provided insights into how present-day obstetrical care is affected by obesity. This information has led to the development of a quantitative survey for obstetricians that will more broadly assess practice patterns for the management of women with obesity in pregnancy.
Maternal and Neonatal Glycemic Response to Antenatal Corticosteroids [24N]
Authors: Fixler Joseph S. , Nickel Mara , DeFranco Emily A.
Published: May 2019

INTRODUCTION:

The influence of the timing of antenatal corticosteroid (ANCS) administration on maternal and neonatal glycemic response remains poorly defined. We sought to describe the maternal and neonatal glycemic response to ANCS as it relates to timing of ANCS administration in early and late preterm deliveries.

METHODS:

We conducted a retrospective cohort study of deliveries from 2013-2017. Analysis was limited to those receiving ANCS within 1 week of delivery. We compared the mean maternal glucose on the first and second days after ANCS in early preterm deliveries (<34 weeks) to late preterm deliveries (34 to <37 weeks). Stratifying by delivery timing and interval from ANCS to delivery, we evaluated the rate of neonatal hypoglycemia in the 2 days after delivery.

RESULTS:

618 deliveries were included. 528 were early preterm deliveries; 90 were late preterm deliveries. No difference in mean maternal glucose was observed on the first or second day after ANCS between early and late preterm deliveries. A difference in rate of neonatal hypoglycemia was found based on interval from ANCS to delivery only in early preterm deliveries, with higher rates after receiving steroids 1 day (40.9%) or 2 days (38.6%) before delivery (p=0.008). Stratifying by interval from ANCS to delivery, no significant difference in neonatal hypoglycemia was found between early and late preterm deliveries.

CONCLUSION:

Neonatal hypoglycemia appears to be influenced by proximity of ANCS to delivery in early preterm deliveries. Targeted screening for hypoglycemia may be warranted in early preterm deliveries in which ANCS are administered 1 or 2 days before delivery.
Maternal Morbidity in Patients With Preeclampsia With Severe Features at Less Than 34 Weeks Gestation [25N]
Authors: Patel Krunal P. , Romagano Matthew P. , Apuzzio Joseph , Gittens Lisa Nadine , Williams Shauna F.
Published: May 2019

INTRODUCTION:

Objective of this study is to review the maternal morbidity with expectant management compared to immediate delivery in patients with preeclampsia with severe features at less than 34 weeks.

METHODS:

This is a retrospective cohort study of all gravidas <34weeks gestation with preeclampsia with severe features who delivered at a tertiary care hospital from 1/1/2014 to 12/31/2017. Medical records were reviewed for maternal demographics, obstetric outcomes and maternal adverse events. Patients were grouped according to whether they were candidates for expectant management (Group 1: not candidates for expectant management; 2: candidate for expectant management and delivered immediately after steroid course; 3: expectant management). The composite outcome was occurrence of HELLP syndrome, abnormal LFTs, acute renal injury, eclampsia, and pulmonary edema, admission to ICU, stroke, cerebral complications, and abruption.

RESULTS:

83 patients were identified, 48 patients were not candidates for expectant management. Of the remaining 35 patients, 16 patients were delivered after steroid administration due to physician preference. 19 patients underwent expectant management and median time to delivery was 4 days from diagnosis. Composite morbidity occurred in 21 (44%) patients in group 1, 2 (12.5%) in group 2 and 3 (16%) in group 3. There were one case of each HELLP syndrome, acute renal injury, abruption, elevated LFTs and thrombocytopenia in group 3.

CONCLUSION:

Preeclampsia with severe features at less than 34weeks gestation is associated with significant maternal morbidity. Close surveillance and caution should be taken when managing patients expectantly.
Membrane Sweeping for Trial of Labor After Cesarean: A Systematic Review and Meta-analysis of RCTs [32N]
Authors: Hamidi Odessa Persia , Quist-Nelson Johanna Rachel , Xodo Serena , Berghella Vincenzo
Published: May 2019

INTRODUCTION:

Our objective was to determine effects of membrane sweeping on promoting labor in patients undergoing a trial of labor after cesarean.

METHODS:

Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials using a combination of keywords related to “membrane sweeping,” “membrane stripping,” “vaginal birth after cesarean,” and “trial of labor after cesarean” from inception of databases until April 2018. We included all RCTs of pregnancies at 36 weeks or greater that evaluated pre-labor membrane sweeping in patients undergoing TOLAC. We excluded trials that did not include patients with a prior uterine scar, or that were studies of membrane sweeping during initiation of labor induction. The primary outcome was rate of spontaneous labor. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce relative risk (RR) with 95% confidence interval (CI).

RESULTS:

Two studies met inclusion criteria and were included in our meta-analysis (n=361). Membrane sweeping did not have an effect on onset of labor (RR 1.05, 95% CI 0.92 to 1.20). There was no significant difference for rate of spontaneous vaginal delivery (RR 1.06, 95% CI 0.84 to 1.34), operative vaginal delivery (RR 0.97, 95% CI 0.25 to 3.78) or cesarean delivery (RR 1.00, 95% CI 0.87 to 1.14).

CONCLUSION:

Membrane sweeping in patients planning a trial of labor after cesarean was not found to be effective promoting the onset of labor. This systematic review highlights the limited data addressing the utility of membrane sweeping for women with prior cesarean delivery.
Multidisciplinary Management of Morbidly Adherent Placenta Reduces Blood Loss [38N]
Authors: Podwika Sarah , Wang Connor , Zuber Matthew , Cortez Briana , Chisholm Christian , Dudley Donald J.
Published: May 2019

INTRODUCTION:

We implemented a multidisciplinary team approach including prophylactic internal iliac artery (IIA) catheterization to manage patients at high risk of obstetric hemorrhage due to morbidly adherent placentation (MAP).

METHODS:

We performed an IRB approved, retrospective cohort study of patients (2000-2018) who underwent cesarean hysterectomy for suspected MAP. We compared outcomes before and after the implementation of a multidisciplinary treatment team approach with data from the electronic medical record.

RESULTS:

There were 12 cases of MAP prior to implementation of the multidisciplinary approach and 24 cases after. IIA catheters were placed preoperatively in 54% of the patients in the multidisciplinary team cohort. There were no differences between groups in mean maternal age (35.2 vs 31.7, P=.14), gravidity (4.4 vs 3.8, P=.51), parity (2.6 vs 1.9, P=.12), or number of prior cesareans (2.5 vs 1.8, P=.09). There were no differences in postoperative length of stay (9.7 vs 4.8 days, P=.09), 30-day readmission (8.3% vs 12.5%, P=.071), 5 minute Apgar <7 (P=.16) or birth weight (P=.88). We observed a significant difference in estimated blood loss (4,558 mL vs 2,215 mL, P=.02) and mean number of units of packed red blood cells transfused (12.75 vs 4.5, P=.03).

CONCLUSION:

The multidisciplinary approach, specifically the addition of IIA catheterization, results in reduced total blood loss and units of blood transfused. This intervention may be high yield at other centers.
Myomectomy Route and Adhesions at Subsequent Cesarean Delivery [39N]
Authors: Taggart Ashley A. , Carusi Daniela A. , Gargiulo Antonio R. , Srouji Serene S.
Published: May 2019

INTRODUCTION:

To compare adhesions at cesarean delivery following open vs laparoscopic myomectomy.

METHODS:

In this retrospective cohort study, patients with an abdominal myomectomy were compared to those having conventional or robot-assisted laparoscopic myomectomy with regard to dense adhesions at the time of cesarean delivery. Logistic regression was used to control for potential confounders.

RESULTS:

141 patients met inclusion criteria: 65 with abdominal and 76 with laparoscopic myomectomies. Patients in the abdominal group were more likely to have an anterior (72% vs 49%, P < .01) or posterior (74% vs 58%, P=.05) vs fundal uterine incision, and had more endometrial entry (43% vs 22%, P < .01), more fibroids removed (median 7 vs 2, P < .01), and more preexisting dense adhesions (28% vs 11%, P < .01). Patients in the laparoscopic group were more likely to have been exposed to barbed suture (15% vs 2%, P < .01) and uncontained power morcellation (96% vs 11%, P < .01) with no difference in the use of adhesion barriers. The abdominal group developed significantly more dense adhesions (56% vs 12%, P < .01), even after controlling for surgical factors plus age, race, and obesity (OR 9.88, 95% CI 1.54-63.39). The abdominal myomectomy group experienced more vertical skin incisions or hysterotomies (17% vs 1% for both, P < .01) and longer incision to delivery times (median 12 vs 9 min, P < .01), but no difference in neonatal Apgar scores.

CONCLUSION:

Prior abdominal myomectomy confers more risk for dense adhesions at the time of cesarean delivery than laparoscopic procedures.
Analyzing Patient Experiences of Crisis Pregnancy Centers in Los Angeles County From Social Media [2A]
Authors: Chan Elaine , Korotkaya Yelena , Woodson Ryan , Sridhar Aparna
Published: May 2019

INTRODUCTION:

Crisis Pregnancy Centers (CPCs) are non-profit organizations that claim provision of pregnancy counseling resources. As more patients utilize online reviews to select healthcare providers, we aimed to evaluate patient experiences of CPCs through analysis of social media, specifically Yelp.

METHODS:

We conducted a mixed method study. The quantitative part analyzed the star rating based on pregnancy intentions and political affiliations of reviewers. The qualitative component analyzed reviews using grounded theory via Dedoose.

RESULTS:

Using California Pro-life Council official website, 196 CPCs were identified, 26 based in LA county. 8 of these CPCs had established listings on Yelp. Positive and negative experiences were analyzed. Four themes emerged. Healthcare access: Those who wished to continue the pregnancy felt supported because of the services offered, staff attitudes and access to care (4.67/5 stars, 17 reviews). Those who intended to terminate the pregnancy felt pressured to change their decision and were given inaccurate information, if any information, about their options (1.62/5 stars, 11 reviews). Political affiliation: Those who identified as pro-choice rated CPC's negatively (1.29 stars, 10 reviews). Emotional outcome: Reviewers reported that the CPCs made them “feel guilty,” “uncomfortable,” and “disregarded” for entertaining any option other than pregnancy continuation or adoption. Deceptive advertising: Some CPCs advertised the term “abortion services” while not providing them.

CONCLUSION:

CPCs do not offer comprehensive women's healthcare. Social media sites can increase transparency about the services offered to women at CPCs.
Adjuvant 17-Hydroxyprogesterone Caproate in Ultrasound-Indicated Cerclage: A Systematic Review & Meta-Analysis [17A]
Authors: Lichter Katie , Graham Ernest M. , Eke Ahizechukwu C.
Published: May 2019

INTRODUCTION:

To assess the additional benefits of 17-hydroxyprogesterone caproate (17-OHPC) therapy in preventing recurrent spontaneous preterm birth in women with an ultrasound-indicated cerclage.

METHODS:

Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, Scielo and the Cochrane Central Register of Controlled Trials) were searched for studies published before September 2018. Keywords included “preterm birth,” “ultrasound-indicated cerclage,” “pregnancy” and “17-hydroxyprogesterone caproate.” The primary outcome was preterm birth at <35 weeks of gestation. Meta-analysis was performed using DerSimonian and Laird procedures. Risk of bias and quality assessment was performed using the ROBINS-I and GRADE tools respectively.

RESULTS:

Four studies met inclusion criteria and were included in the final analysis. Of the 332 women, 115 (34.6%) received ultrasound-indicated cerclage alone, and 217 (65.4%) received adjuvant 17-OHPC. The primary outcome, preterm birth <35 weeks of gestation, was present in 87/217 singleton pregnancies. Though there was a trend towards a reduced risk of preterm birth, the summary estimate of effect was not statistically significant when comparing cerclage alone to cerclage plus 17-OHPC at <35 weeks (RR: 0.95, 95% CI: 0.77-1.17). Similarly, we found no differences in preterm birth at <24 weeks (RR: 0.30, 95% CI: 0.06-1.60), <28 weeks (RR: 0.57, 95% CI: 0.13-2.53) and <32 weeks (RR: 0.99, 95% CI: 0.44-2.27) when comparing cerclage alone to cerclage plus 17-OHPC. There were no differences in fetal birth weight, intraventricular hemorrhage and necrotizing enterocolitis comparing cerclage alone to cerclage plus 17-OHPC.

CONCLUSION:

Intramuscular 17-OHPC in combination with ultrasound-indicated cerclage in women with prior preterm birth had no additional effect in reducing spontaneous recurrent preterm birth or improving perinatal outcomes.
Chronic Peripheral Inflammation and Perinatal Depression in High Risk Pregnancies [18A]
Authors: Onyewuenyi Ticara , Addo Jennifer , Le Nhung , Ghareeb Allen , Loret de Mola J. Ricardo , Braundmeier-Fleming Andrea
Published: May 2019

INTRODUCTION:

Perinatal depression is one of the leading causes of maternal morbidity and mortality, with severe cases leading to suicide. An imbalance between immune tolerance and inflammatory mediators may cause peripartum women to become vulnerable to depression; however, little research has been done to explore this theory.

METHODS:

Patients considered high risk for preterm birth (PTB) were recruited from the Department of Ob/Gyn at SIU School of Medicine. Following exclusion for non-compliance and intrauterine fetal demise, 7 patients (4 term; 3 preterm) were assessed to date. Peripheral blood and depression questionnaires (QIDS) were collected at various timepoints during gestation (8-12 weeks, 20-24 weeks and 32-36 weeks). Lymphocyte buffy coats were extracted and flow cytometry analyses identified specific immune populations (nTregs, iTregs and Th17). Correlations between depression status and immune profiles were performed for each pregnancy outcome.

RESULTS:

With our limited patient dataset, no correlation between inflammatory immune profiles and depression status was noted. However, patients who subsequently delivered preterm did report more depressive events, throughout gestation, than patients who delivered at term. Finally, patients with an inflammatory immune profile during the first trimester maintained this status throughout gestation. Additionally, we aim to assess if a patient's microbial dynamics are associated with depression in this population.

CONCLUSION:

While the role of inflammation in depression has not been elucidated, little is known about how depression may alter the maternal-fetal immunological profile. Improving our understanding regarding the context of depression and its implications during the perinatal period will lead to better mother-infant attachment and improve health outcomes.
Resolving the Preterm Birth Phenotype Using Electronic Health Records and Genomic Biobanks [20A]
Authors: Abraham Abin , Bejan Cosmin Adrian , Edwards Digna , Capra John
Published: May 2019

INTRODUCTION:

About 10% of annual births are preterm, and up to 34% of infant deaths are attributable to prematurity. Although preterm birth (PTB) is heritable, our understanding of the genetic basis of PTB remains limited. We hypothesize that characterizing comorbidities will yield insights into PTB genetics.

METHODS:

Using international classification of diseases (ICD9/10) codes, we identified 53,063 females with deliveries in Vanderbilt's electronic health records (EHRs). 298 codes were enriched for PTB by chi-squared test after multiple testing correction (P < 3.2*10^-5) and grouped using hierarchical clustering. To explore the genotype-phenotype relationships, a phenome wide association study (PheWAS) was conducted for single nucleotide polymorphisms (SNPs) associated with gestational age. These SNPs were also queried in the UK Biobank (UKBB) using GeneATLAS for phenotype associations.

RESULTS:

ICD9 codes enriched for PTB reproduced known (twin pregnancy, cervical insufficiency) and unexpected associations across multiple systems (hypertension, renal failure, sickle cell). PheWAS resulted in significant association with hematemesis (rs1735537, P=5.4*10^-7, OR=1.79) and schizophrenia (rs6556350, P=2.8*10^-6, OR=0.48). Attention deficit/hyperactive disorder (P=7.9*10^-6) was nominally significant. In the UKBB, height (rs3820282, P>1*10^-40), adiposity traits, and female reproductive tract disorders were significantly associated (P>1*10^-8) with gestational length.

CONCLUSION:

Using billing codes identified a large cohort of females with deliveries within the EHRs. ICD codes enriched for PTB captured several unexpected phenotypes that warrant further study. The PheWAS analysis suggests a shared genetic basis between several traits and gestational length. In particular, height is known to influence birth timing. SNP rs3820282 suggests a pleiotropic locus influence both traits.