bluuebunny/crossref_metadata_2025_split huggingface dataset:
Parvovirus in the Second Trimester: A Case of Unremitting Fetal Anemia [34G]
Authors: Roser Brittany , O'Hara Shaelyn , Stone Joanne L. 
Published: April 2020

INTRODUCTION:
Parvovirus B19 has been associated with spontaneous abortion, hydrops fetalis, and stillbirth when acquired in pregnancy.[1] When fetal anemia is diagnosed prenatally, fetuses usually respond to a single transfusion. In surviving neonates, the post-natal course and timeframe for bone marrow recovery is not established.

METHODS:
A 27 year-old primigravida at 26 weeks gestation presented to her community hospital with decreased fetal movement. Work-up revealed nonimmune hydrops fetalis secondary to Parvovirus B19 infection with +IgM seroconversion, for which she transferred to our center for percutaneous umbilical blood sampling (PUBS) and transfusion. She underwent three PUBS procedures due to persistently elevated MCA Dopplers and Category II tracing prior to presenting in preterm labor at 29 weeks. Upon delivery, the neonate weighed 1490 g, Apgar scores were 4 and 7 at 1 and 5 minutes, and a venous umbilical cord gas pH was 7.45. The neonate was admitted to the NICU for prematurity and required transfusions on day of life (DOL) 0, 18, 32, and 46 for persistent Parvovirus-induced erythroblastopenia. A repeat Parvovirus B19 PCR was greater than 10,000,000 copies at DOL 43 prompting IVIG therapy. Blood counts stabilized thereafter. On DOL 73 the neonate was 3100 g and breathing on room air, discharged home without other complications. On DOL 154, the Parvovirus B19 PCR was 70,350 copies and the infant was doing well at home.

CONCLUSION:
We present a case of parvovirus infection acquired in the second trimester requiring multiple transfusions, with an unusual post-natal course that has yet to be described.
Pregnancy Outcomes in Women With Acute Porphyria: A Systematic Literature Review [35G]
Authors: Kanninen Tomi T. , Stroobant Emily , Pierce-Williams Rebecca , Berger Seth , Al-Kouatly Huda B. 
Published: April 2020

INTRODUCTION:
The porphyrias are a group of rare disorders caused by deficiencies in enzymes of heme biosynthesis. Our objective is to determine the rate of acute attacks in pregnant patients with acute porphyria and risk of preterm birth.

METHODS:
PubMed, EMBASE and ScienceDirect were screened from the inception of the databases to May 2019 resulting in 872 articles. Our primary outcome was rate of acute attacks during pregnancy and postpartum period manifesting with severe abdominal pain, neurological dysfunction and psychiatric disturbances in women with acute porphyria. Secondary outcome was the rate of preterm delivery. The Meta-analysis of Observational Studies in Epidemiology guidelines was used (MOOSE).

RESULTS:
We identified 49 case reports with a total of 59 patients. Mean maternal age was 26.7 (±5.6) years. Mean gestational age at presentation was 19 weeks. Positive urine porphobilinogen was used to diagnose 84.8% (39/46) of women. During pregnancy 71.2% of women (42/59) suffered an acute attack. The clinical spectrum of attacks were: neurologic 52% (26/59), abdominal pain 49.2% (29/59), and psychiatric 22% (13/59). Preterm delivery occurred in 29% (9/31) of women (range 30-36 weeks). The mean gestational age at delivery was 35 weeks 6 days (±32 days) with a mean birth weight of 2705.9 (±721.5) grams. Cesarean section occurred in 45.5% of women (20/44). Hematin (or Hemin) was used in only nine patients (15.3%) without complication.

CONCLUSION:
The results of our systematic review demonstrate the increased rate of acute attacks in patients with porphyria in pregnancy with nearly one third having preterm delivery.
Changing the Landscape of Obstetric Resident Education in LMIC Using Simulation Based Training [37G]
Authors: Meza Pamela K. , Bianco Katherine , Herrarte Edgar , Daniels Kay 
Published: April 2020

INTRODUCTION:
Maternal mortality continues to be one of the largest health burdens in reproductive-aged women in low- and middle-income countries (LMIC). Simulation-based training (SBT) has been previously piloted demonstrating that SBT was an accepted method of teaching skills for managing high-risk labor in LMIC.

METHODS:
An in-country simulation based education course on the management of post-partum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) were provided to three major governmental teaching hospitals in Guatemala City, Guatemala. Participants were 46 OB/GYN residents. A paired Student t-test was conducted to compare clinical knowledge regarding these obstetric emergencies at three timepoints: before SBT, one week, and six months after SBT.

RESULTS:
There was significant increase in scores in clinical knowledge of SD and MCA one week (M=7.83, SD=1.1) following SBT compared to baseline (M=5.96, SD=1.75); P≤.05. However, for PPH there was no increase in scores one-week (M=2.91, SD=0.94) following SBT compared to baseline (M=2.73, SD 0.65); P>.05. Additionally, the difference in scores was maintained at six months following SBT for SD and MCA (M=7.52, SD=1.09) compared to baseline (M=5.96, SD=1.75); P≤.05. PPH scores at six-months (M=3.36, SD 0.65) showed a significant increase compared to baseline (M=2.73, SD=0.65); P≤.05.

CONCLUSION:
Simulation-based training was found to be an effective method to increase cognitive clinical knowledge in LMIC for rarely seen events of MCA and SD but not with the more common event of PPH. This knowledge increase was maintained six-months after participation in the training.
Simulation to Teach Cesarean Section and Hemorrhage Management: Evaluation of a Novel High-Fidelity Simulator [38G]
Authors: Foglia Lisa M. , Eubanks Allison , Peterson Logan , Hickey Kimberly , Jackson Amanda , Deering Shad 
Published: April 2020

INTRODUCTION:
The cesarean delivery the most common surgical procedure performed within the military health system (MHS). The gold standard for training physicians to perform a cesarean section is didactics and then practicing on actual patients. The objective of this study is to evaluate the efficacy of a novel high-fidelity simulator to train physicians with limited surgical obstetric experience to perform cesarean sections and manage operative hemorrhage.

METHODS:
Gynecology, family medicine, and surgery residents were recruited for the IRB approved study. All participants received the same didactic training on performing a cesarean section and managing postpartum hemorrhage. The intervention group received additional training on a simulator to perform the procedure and management of hemorrhage. All participants were then evaluated on their ability to perform a cesarean section with operative complications using the simulator.

RESULTS:
From July 2017 to January 2019 a total of 33 participants were recruited and randomized. The intervention group had higher scores on the cesarean delivery (p-values 0.013 and 0.017), hemorrhage management (p-value .0002), and overall skill (p-value .008). There was no difference in preoperative management, postoperative management, counseling, technical skills, and teamwork.

CONCLUSION:
Participants who received training using a high-fidelity simulator performed significantly better on all procedural aspects of a cesarean section and hemorrhage management. Simulation allows trainees to gain procedural experience while eliminating patient risk. Cesarean section simulators may be useful to train and reinforce surgical skills for residents, military physicians about to deploy, ancillary providers in low-resource settings, and physicians at low-volume medical centers.
A Prospective Evaluation of Opioid Utilization After Benign Gynecological Surgery [01H]
Authors: Wright Danielle , Soper David , Korte Jeffrey 
Published: April 2020

INTRODUCTION:
Opioids provide an effective means to controlling postoperative pain. However, this medicine is overprescribed and the lack of prescribing guidelines contribute to this issue. As-Sanie et al (2007) reported gynecologists prescribed twice the amount of opioids than the average patient used after hysterectomy. Our goal, for this study, was to define the pattern of opioid utilization after benign gynecologic surgery.

METHODS:
This is a prospective cohort study. Women were deemed eligible for enrollment if they underwent hysteroscopy, laparoscopy, and hysterectomy. Patients were excluded from the study if there was suspicion for malignancy. Following discharge, a 17-question phone survey was completed 14 days post op to assess opioid consumption.

RESULTS:
A total of 109 women participated in the survey. Over all procedures, the median proportion of opioids used was 40% (IQR 13-100%) with the difference between the median MME (morphine milligram equivalent) prescribed and used being statistically significant for all procedures.

CONCLUSION:
This study highlights the practice of overprescribing, which should be a target area for improvement for benign gynecologists. We recommend using each procedure’s IQR for prescribing guidance. Adjustments in quantity can be made based on patient history and collaborative decision making.
Demonstrating Lack of Child Care as a Barrier to Health Care for Women in Parkland Health & Hospital System [04H]
Authors: Gaur Priyanka , Kuo Madyson , Kho Kimberly A. 
Published: April 2020

INTRODUCTION:
Women face significant barriers to care related to their roles as caretakers; in a prior survey, up to 20% report foregoing care because of difficulties with child care. We describe how lack of child care impacts access to health care and determine patient interest in a hospital-based day care center.

METHODS:
This is a non-regulated cross-sectional survey of 300 women of reproductive age attending Parkland Health & Hospital System (PHHS) clinics. Outpatient clinics sampled included: Primary Care, Obstetrics & Gynecology, Oncology.

RESULTS:
Response rate was 96.7% with 52.7% reporting foregoing health care for lack of child care in the past 12 months. On average, women delayed 3.7 ± 2.7 appointments/year. 38.2% delayed care for 1 to 6 months and 30.9% for 1 week to 1 month. 86.8% missed checkups, and 31.8% missed problem visits. Lack of child care (52.7%) was the most frequently cited reason for missing care followed by lack of transportation (32.8%) and insurance (25.2%). There was an association between race/ethnicity and whether women delayed care in the past 12 months with 68.8% white, 55.0% black, and 34.3% Hispanic (P=.001). 87.9% felt a hospital-based day care would help them attend visits.

CONCLUSION:
Our study demonstrates that child care is the most significant barrier to accessing health care, affecting women of all races/ethnicities in our county-supported safety net system. A hospital-based day care center may help alleviate this barrier, and our goal is to study outcomes after the introduction of such a center at PHHS in 2020.
Does the ACS NSQIP Surgical Risk Calculator Accurately Predict Surgical Outcomes for Benign Hysterectomy? [06H]
Authors: Thigpen Brooke , Eppes Carey , Schaumberg Jordan , Johnson Emily , Sangi-Haghpeykar Haleh , Swaim Laurie S. 
Published: April 2020

INTRODUCTION:
Hysterectomy complications result in morbidity and financial burden. The American College of Surgeons NSQIP Surgical Risk Calculator (ACS NSQIP SRC) estimates the chances of postoperative complications using the National Surgical Quality Improvement Program (NSQIP) database. Our objective was to evaluate the ACS NSQIP SRC predictive ability for postoperative complications after total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy (TLH) for benign disease.

METHODS:
Preoperative and postoperative data were extracted from the records of all patients after a TAH or TLH at a single academic hospital from January 2012 to December 2015. Surgical risk scores calculated using the ACS NSQIP SRC tool and postoperative complications were correlated using logistic regression. A c-statistic and Brier score were used to assess the ability of the calculator to accurately predict complications. During the time period reviewed, an infection prevention bundle was implemented. Results were analyzed during the entire period, as well as before and after bundle implementation.

RESULTS:
Of the 700 patients reviewed, 99.7% were less than 65 years-old, 94.2% ASA class 2 or greater, and 60% obese. Most underwent TAH (61%). In all patients, the calculator performed best for predicting venous thromboembolism (VTE) (c statistic=0.96 brier 0.003). It performed well predicting surgical site infection (SSI) after bundle implementation (c statistic=0.71 brier 0.04), but not before bundle implementation. The calculator was a poor predictor of other complications, including urinary tract infection, reoperation, and readmission.

CONCLUSION:
The ACS NSQIP SRC adequately predicts VTE and SSI. The calculator did not accurately predict other complications.
Endosalpingiosis: Clinical Presentation and Coexisting Pathology [07H]
Authors: Sajnani Jocelyn , Swan Kimberly 
Published: April 2020

INTRODUCTION:
Describe the clinical presentation and coexisting pathology of women with endosalpingiosis (ES), the presence of ectopic fallopian tube-like epithelium.

METHODS:
Retrospective analysis of pathology reports containing the keyword “endosalpingiosis” for procedures performed at the University of Kansas Medical Center between 2007-2017 Demographic information, clinical characteristics, and relevant pathology were collected for patients (N=98) with pathologically confirmed ES.

RESULTS:
Patient Characteristics: the cohort had a mean age of 51 at diagnosis, 52% were post-menopausal, 52% were never smokers, their mean BMI was 32, and 59% had prior abdominal or pelvic surgery. Clinical Presentation: 43% complained of pelvic pain, 31% of the post-menopausal subgroup presented with bleeding, and 26% experienced abdominal pain or bloating. Abdominal or pelvic mass was the most frequent indication for surgery (35%), followed by evaluation of a known gynecologic malignancy (31%) of which 60% were endometrial adenocarcinoma. Pathology Findings: 79% of patients had a single ES lesion on biopsy most likely to be found in an abdominal or pelvic lymph node (38%), ovary (21%), and perimetrium (14%). All 98 women in the cohort had other pathology in addition to ES. A new gynecologic malignancy was diagnosed after surgery in 29% of which 62% were ovarian. The majority also presented with concomitant benign disease (cyst, leiomyoma, etc) and 19% had concurrent endometriosis.

CONCLUSION:
Women with ES commonly complain of pelvic pain and the majority have a concurrent gynecologic cancer. It appears ES rarely occurs in isolation and further research is necessary to determine its role in the pathogenesis of gynecologic disease.
Patient-Reported Use of Medical Cannabis for Management of Chronic Pelvic Pain [12H]
Authors: Carrubba Aakriti R. , Spaulding Aaron C. , Ebbert Jon O. , DeStephano Christopher C. 
Published: April 2020

INTRODUCTION:
Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system can be a pharmacological target for endometriosis-related pelvic pain, as cannabis receptors are highly expressed in the uterus and other non-reproductive tissues. We hypothesize that many patients with CPP use cannabis and report improvement in symptoms.

METHODS:
An anonymous, confidential, electronic survey was performed from March through August 2019. Patients aged 18 through 89 were included if they had a diagnosis of pelvic/perineal pain, dyspareunia, or endometriosis. Subjects were approached during outpatient appointments. Study approval was obtained from the Institutional Review Board.

RESULTS:
A total of 122 of 240 (50.8%) patients responded. Of these, 113 self-reported a diagnosis of CPP (92.6%). Twenty-six patients reported cannabis use (23%). Six (24%) used Cannabidiol (CBD), 3 (12%) used tetrahydrocannabinol (THC), and 15 (60%) used a combination of CBD and THC. Frequency of use varied, with the majority using at least once per week (n=18, 69.2%). Only 5 (19.2%) utilized a State Medical Cannabis Program to obtain a certification. Of users, 24 (92.3%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. However, 21 (80.7%) reported side effects; the most common were dry mouth, sleepiness, and feeling “high.”

CONCLUSION:
Up to 23% of patients with CPP report use of cannabis as an adjunct to their prescribed therapy, and they use a variety of formulations and doses. Most report daily or weekly use. Although side effects are common, most users report improvement in symptoms.
Reducing Opioid Prescriptions Through Patient Education and Standardized Protocols [14H]
Authors: DePaula-Cox Rose , Nair Pallavi , Provost Holly 
Published: April 2020

INTRODUCTION:
Deaths due to opioid overdose continue to rise in the US. Initial exposure to opioids is largely due to surgical procedures. Our project hopes to reduce opioid needs and prescriptions after an outpatient laparoscopic procedure with a multi-disciplinary bundle pain management provided preoperatively.

METHODS:
Thirty narcotic-naïve patients undergoing laparoscopy underwent education of pain expectations, diet, bowel hygiene and exercise, and our 3 day treatment plan. Instruction was given at preoperative visit, anesthesia visit, day of procedure, and discharge. Patient inquiries about pain were made PODs #1 and after #4. Requests for opioid refills were monitored. Preop use of acetaminophen 1000 mg and gabapentin 1200 mg orally and lidocaine injected at trocar sites. Ketorolac 30 mg IV given at the end of the case. Only 6 oxycodone 5 mg tablets were prescribed for PRN needs. Three days of scheduled medication (acetaminophen, naproxen) given at discharge. IRB approval was waived.

RESULTS:
Three patients requested opioids but none were prescribed with pain management education. Six cases had endometriosis with only 2 of those patients requesting more opioids. The third patient had significant lysis of adhesions.

CONCLUSION:
This study emphasized the importance of repetitive pain management expectation discussions with patients. It also showed that having a more extensive surgery or source of preoperative pain does not require additional narcotics. 2/3 of patients with endometriosis did not request additional narcotics. This project will be expanded to all procedures while creating a standardized regimen for opioids and non-opioids postoperatively.
Robotic-Assisted Vaginal Cuff Closure Technique and Vaginal Cuff Dehiscence Rates [16H]
Authors: Tisser Danielle , Burdeaux Shayna , Guta Paulina , Staudenmaier Emily K. , Wadhwa Ruchi K. , Vullo John 
Published: April 2020

INTRODUCTION:
While the implementation of robotic surgery has improved many postoperative outcomes, an increased rate of vaginal cuff dehiscence (VCD) has been observed in colpotomy closures performed robotically compared to transvaginal or laparoscopic closures. No consensus exists for suture interval or depth of tissue in intracorporal vaginal cuff closure. A study published by O’Hanlan et al. (Minimally Invasive Surgery, 2016) proposes a suture interval and depth of 5 mm. Our study aims to assess if there is any advantage for decreasing postoperative complications with an alternative closure technique.

METHODS:
This is a descriptive study of post-operative outcomes at our institution that was conducted via a retrospective chart review. Instances of complications including infection, reoperation and VCD rates were recorded for robotic-assisted laparoscopic hysterectomies and trachelectomies performed between 2016-2017. Robotic vaginal cuff closure was performed using V-Loc 90 suture with suture interval and depth of 10 mm. These outcome rates were compared to the complication rates published by O’Hanlan et al. IRB approval was obtained.

RESULTS:
160 patients were included in Group 1. An overall complication rate of 11.9% was noted in our study which included infection, VCD, bleeding and re-operation rates. A 2.5% VCD rate was observed with 1.25% of patient’s requiring re-operation. Postoperative infection rate in Group 1 was 3.1%.

CONCLUSION:
No significant benefit was demonstrated in patients who underwent robotic-assisted vaginal cuff closure with a suture interval and depth of 10 mm compared to previously published data by O’Hanlan et al using a closure interval and depth of 5 mm.
The Independent Contribution of Endocervical Curettage in Detecting High Grade Dysplasia at the Time of Colposcopy [17H]
Authors: Rojas Christine , Samardzic Kristen , Zammarrelli William A. , Jackson Amanda 
Published: April 2020

INTRODUCTION:
As of October 2017, consensus recommendations identified the need for re-evaluation of the indications for and performance of endocervical sampling (ECC). The primary objective of this study was to evaluate the independent contribution of ECC in detecting high grade cervical intraepithelial neoplasia at the time of colposcopy.

METHODS:
This was a retrospective review of laboratory records provided to us by LabCorp. We examined the colposcopy results of women in a large multispecialty clinic in Las Vegas, Nevada whose specimen dates were between 9/1/2017 and 5/31/2018. The outcome of interest was any scenario where the ECC was CIN2 or greater and all of the ectocervical biopsies concurrently performed were CIN 1 or less.

RESULTS:
We examined 232 ECC records. Among the 19 ECCs in women 21 to 25 years old, one was CIN 2 or greater (5.3%) compared to 3/42 (7.1%) among women 25 to 29 and 19/171 (11.1%) among women 30 and older. Among women less than 25, in 14/19 cases (73.7%), two or more ectocervical biopsies were performed with the ECC as compared to 15/42 (35.7%) and 74/171 (32.8%) cases among women 25 to 29 and 30 years and older, respectively (P=.01). When only an ECC was performed, ECC was CIN 2 or greater in 1/51 cases (2%). When one ectocervical biopsy was performed with ECC, the outcome of interest occurred in 8/96 cases (8.3%) as compared to 1/85 cases (1.2%) in which two or more ectocervical biopsies were concurrently performed (P=.01).

CONCLUSION:
Our results suggest that ECC is most clinically influential when only one ectocervical biopsy is concurrently performed.
Association of Insurance Status and Cervical Cancer Tumor Size in the United States [22H]
Authors: Erfani Hadi , Rezaei Atefeh , Shamshirsaz Alireza 
Published: April 2020

INTRODUCTION:
Health disparity based on insurance status has been of great attention recently. We sought to study the association of insurance status with cervical cancer tumor size at the time of diagnosis.

METHODS:
The US Surveillance, Epidemiology and End Results (SEER) database was accessed (1973-2016). Since the variable “Tumor Size Summary” was available only for the year of 2016, data for cervical cancer in 2016 in the United States were extracted using the case-listing procedure. Mann-Whitney U test, Chi-Square/Fisher’s exact test, and regression analyses were performed as appropriate. Statistical analyses were done using SEER*Stat 8.3.5 and R 3.6.1.

RESULTS:
Total of 3276 subjects with cervical cancer was included in this study; 155 subjects (4.7%) were uninsured. The rate for Non-Hispanic black (20.6% vs. 12.3%) and Hispanic (51.6% vs. 24.5%) race/ethnicity, Unmarried status (61.3% versus 54.8%) were higher in uninsured group (P<.05 for all). Before and after appropriate adjustments (for age, race/ethnicity, marital status and Medicaid-eligibility based on age >65) tumor sizes at the time of diagnosis [50 mm (28, 69) vs. 38 mm (15, 60); P=.04] was found to be larger in the uninsured group.

CONCLUSION:
Being uninsured is associated with having a larger tumor at the time of diagnosis of cervical cancer. An increase in insurance coverage and access to cancer screening for all women is essential.