bluuebunny/crossref_metadata_2025_split huggingface dataset:
Actual Hospital Costs Associated With Severe Maternal Morbidity Compared to Uncomplicated Pregnancies [01L]
Authors: Debbink Michelle , Metz Torri , Silver Robert R. , Varner Michael , Smid Marcela Carolina , Einerson Brett 
Published: April 2020

INTRODUCTION:
Severe maternal morbidity (SMM) is rising, but true costs are unknown. We aimed to assess actual hospital costs of pregnancies complicated by SMM compared to uncomplicated pregnancies.

METHODS:
We conducted a retrospective nested case-control study at a single US institution from 1/2014–6/2017. Cases had at least one of 25 ICD-9 or 10 codes defined as SMM by the CDC. We excluded cases with transfusion as a sole SMM indicator or that were incorrectly coded on chart review. Controls were selected randomly from all deliveries +/- 60 days from case delivery at a 5:1 ratio. Cost data included actual costs/utilization compiled via time- and activity-based accounting. Total costs were computed across pregnancy episodes. Adjusted multivariate regression was used to compare costs. Covariates were identified via backward stepwise regression. Relative costs are reported. IRB approval was obtained.

RESULTS:
12,578 women delivered during the study period. 454 (3.6%) had ICD-9/10 codes meeting SMM criteria, and 170 (1.4%) had correctly-coded non-transfusion SMM events after chart review. Among cases, cesarean delivery and preterm birth were more common. In adjusted models, SMM was associated with increased hospital costs (114.5%; 95% CI 98.9%–130.1%). Predicted absolute cost increases are over $10,000/pregnancy episode. Stratified models show SMM at term is associated with a 122.7% (95% CI 108.6%–136.8%) cost increase, and preterm deliveries with a 67.9% (95% CI 33.2%–102.6%) increase.

CONCLUSION:
SMM is associated with higher hospital costs compared to uncomplicated pregnancies. Identifying preventable SMM and implementing effective reduction strategies may result in healthcare savings.
Changes in Vascular Smooth Muscle and Collagen Content in Placental Vessels in Preeclampsia [04L]
Authors: Chada Anisha R. , Lord Megan G. , Nguyen Hoang Hoa T. , Davis Justin N. , Durica Allison R. , Chappell John C. 
Published: April 2020

INTRODUCTION:
Preeclampsia results in part from abnormal myometrial invasion by placental spiral arteries. It is unknown if and how fetal vessels remodel to compensate for these changes. We sought to characterize preeclampsia-associated vascular remodeling by comparing vessels within villi of placentas collected from preeclamptic and normotensive patients.

METHODS:
Carilion Clinic IRB approval was obtained prior to patient enrollment. Singleton pregnancies complicated by preeclampsia and normotensive controls were identified on Labor and Delivery. Placental biopsies were collected following delivery. Smooth muscle (alpha-SMA) and Type III collagen (COLIII) were identified by immunostaining of cryostat sections. Confocal microscopy was used to measure areas of alpha-SMA and COLIII positivity surrounding vessels. Ratios of alpha-SMA or COLIII positivity to vessel area were calculated. These ratios, which represent relative smooth muscle and collagen content, were compared between vessels from preeclamptic and normotensive placentas.

RESULTS:
Measurements from 342 vessels from 10 placentas (from five preeclamptic patients and five controls) were included in this analysis. Compared to vessels within placentas of normotensive patients, placental vessels of preeclamptic patients demonstrated a significantly reduced area of alpha-SMA positivity (2.48 vs 3.97; P=.008). A trend was seen towards decreased collagen surrounding vessels in preeclamptic placentas, though this was not statistically significant (4.33 vs 5.66; P=.054).

CONCLUSION:
Preeclampsia is associated with a decrease in vascular smooth muscle within placental villi and may be associated with decreased collagen content. This may represent a mechanism to increase transplacental flow of oxygen in the setting of impaired spiral artery remodeling, but further studies are needed to clarify this relationship.
Connected Health-Enabled Remote Blooding Pressure Monitoring of Low-Risk Pregnancy in Rural Setting [07L]
Authors: DeNicola Nathaniel G. , Sheth Sheetal , Marko Kathryn , Woodland Mark B. 
Published: April 2020

INTRODUCTION:
Connected health, or telehealth, interventions have been targeted to help reduce health care disparities in rural populations for its ability to remotely connect patients and providers.

METHODS:
In a study population at a Pennsylvania health system with both rural and urban ZIP codes, low-risk pregnant women were enrolled in an integrated technology platform, Babyscripts (BRx), with a mobile application and connected devices to remotely transmit blood pressure (BP) readings. A retrospective analysis was performed on de-identified data from patients with similar demographics from rural and urban ZIP codes to compare outcomes: average BP readings per individual, frequency of trigger BP readings (>140/90), and average interval between BP readings.

RESULTS:
Of 795 low-risk pregnant women enrolled in remote BP monitoring, 46 resided in rural ZIP codes (5.79%). Among the 46 patients in rural ZIP codes the average number of BP readings per patient was 17.8 compared to 17.6 in the urban setting (total BP readings: 823 and 13,211 respectively). The frequency of trigger BP readings >140/90 was 2.07% in our rural population compared to 2.24% in urban population. The average interval between readings was 7.99 days rural compared to 7.94 urban.

CONCLUSION:
Connected health interventions for low-risk pregnant women in a rural population resulted in healthcare engagement and remote BP monitoring comparable to that observed in the urban setting. Future controlled studies can examine the role of connected health as a driver for reducing health disparities for remote and rural communities.
Delivery and Neonatal Outcomes in Women of Very Advanced Maternal Age [10L]
Authors: Jones Cresta W. , Tessier Katelyn , Raasch Caitlin , Dharampaul Kayla , Schumer Amy 
Published: April 2020

INTRODUCTION:
Little contemporary data are available on pregnancy delivery and neonatal outcomes in a diverse population of very advanced maternal age, defined as age 40 years or greater at estimated date of delivery (EDD). We examined the association of adverse delivery and neonatal outcomes in women at very advanced maternal age from 2016 to 2017.

METHODS:
This retrospective cohort study examined patients presenting for delivery in an urban academic healthcare system from 2016 to 2017. Women 40 years old or older at EDD (n=433) were compared with controls age 25-30 years (n=755). The primary outcome compared rates of cesarean delivery between the two groups. Differences in delivery and neonatal outcomes were also examined. Chi-square and Fisher exact tests were used for categorical variables; Wilcoxon rank-sum test was used for continuous variables. Logistic regression was used adjust for any demographics that were associated with age.

RESULTS:
Women age 40 or older were more likely to deliver via cesarean section than younger controls even after adjusting for demographic differences (42.7% vs 31.1%, adjusted P<.001). Secondary outcomes also identified significant associations between very advanced maternal age and an earlier gestational age at delivery (P<.001), as well as neonatal anomalies identified at birth, NICU admission and infant length of stay (all P<.05).

CONCLUSION:
Very advanced maternal age is associated with an increased risk of cesarean section, as well as an increased risk of additional delivery and neonatal complications. Prospective research is needed to determine whether these risks might be modifiable with changes in current obstetric management.
Effects of Selective Early Magnesium Cessation Protocol on Preeclampsia With Severe Features [12L]
Authors: DeYoung Tracey , Saber Barbara , Walz Sarah , Davis Karen , Blosser Colleen , Poole Aaron 
Published: April 2020

INTRODUCTION:
We evaluate the effect of a selective early postpartum magnesium cessation protocol in patients diagnosed with preeclampsia with severe features.

METHODS:
A standardized protocol was implemented in March 2017 identifying patients at lower risk of postpartum eclampsia, and thus eligible for early discontinuation of magnesium sulfate at 12 hours postpartum. An IRB approved, retrospective cohort study was performed of all patients with preeclampsia with severe features 25 months before and after protocol implementation. The primary outcome assessed was the incidence of postpartum readministration of magnesium sulfate after completion of the initial course.

RESULTS:
Preeclampsia with severe features was identified in 737 patients with exclusion of 58 patients due to postpartum preeclampsia diagnosis or eclampsia prior to initial magnesium cessation. While the rate of preeclampsia with severe features increased (3.9% vs 7.0%, p<.001) in the pre and post-implementation groups, there was no difference in the rate of eclampsia (0.03% vs 0.05%, P=.59). Analysis included 272 patients pre and 407 patients post protocol implementation. Rates of early magnesium cessation, less than 23 hours of postpartum magnesium, were 11.1% vs 55.5% pre and post protocol implementation. In patients who underwent early magnesium cessation (n=226), there was no significant difference in postpartum readministration of magnesium (1.5% vs 3%, P=.25). There was no difference in readmission for hypertensive disorders of pregnancy (1.1% vs 2.5%, P=.20).

CONCLUSION:
In patients with preeclampsia with severe features who underwent selective early magnesium cessation there was no difference in postpartum readministration of magnesium sulfate or readmission for hypertensive disorders of pregnancy.
Elevated Early Third Trimester Hemoglobin as a Predictor of Preeclampsia [14L]
Authors: Hachey Sara , Alderfer Kayla , Anasti James N. , Vigh Richard 
Published: April 2020

INTRODUCTION:
One of the early physiologic changes in pre-eclampsia (PE) is increased vascular permeability that can cause hemoconcentration. We hypothesized higher hemoglobin (Hgb) may be an early marker for development of PE.

METHODS:
During a 3 year period, records of women without known renal disease and a gestational age at delivery (GAD) >24 weeks were evaluated. PE was defined as elevated blood pressure (>140/90) and increased protein: creatinine ratio (PCR>0.29). The Hgb obtained between GA 22-32 weeks were reviewed. In addition to GAD, maternal age (MA) and body mass index (BMI) was recorded. Odds ratios (OR, 95% CI) were determined for the development of PE in women with Hgb >12.9 and >13.9 grams.

RESULTS:
Of the 10,418 deliveries, 901 (8.6%) were diagnosed with PE. Women with PE delivered earlier (37.2 ± 2.8 vs 38.6 ± 2.1 wks, P<.001) and had higher BMI (35.2 ± 7.1 vs 32.6 ± 6.2 Kg/M2, P<.001). Of the 396 women with a Hgb >12.9, 74 developed PE (OR 2.5, 1.8-3.1, P<.001). Other than GAD (34.4±5.5 vs 37.2±3.6 wks, P<.001), PE with Hgb>12.9 did not differ in MA or BMI. Of 44 women who had Hgb>13.9, 14 developed PE (OR 4.7, 2.5-8.9, P<.001). PE with Hgb>13.9 did not differ in GAD, MA or BMI, however sample size was limited.

CONCLUSION:
In this retrospective case control study, elevated Hgb was associated with PE. Most pregnant women have Hgb between 24 to 30 weeks. This inexpensive, ubiquitous test may provide an additional warning sign for the development of PE.
Incident Hypertension Diagnoses With Expansion of Criteria for Hypertension in Pregnancy [18L]
Authors: Darwin Kristin C. , Federspiel Jerome J. , Schuh Brittany L. , Baschat Ahmet A. , Vaught Arthur J. 
Published: April 2020

INTRODUCTION:
Expansion of Stage I hypertension criteria by the American College of Cardiology-American Heart Association (ACC-AHA) to systolic blood pressure (SBP) 130-139 mmHg and/or diastolic blood pressure (DBP) 80-89 mmHg increased the prevalence of hypertension in the general population. ACOG has a higher threshold for elevated blood pressure in pregnancy (SBP >140 mmHg and/or DBP >90 mmHg). Whether broadening hypertension criteria in pregnancy would result in similar expansion of diagnosis is unclear.

METHODS:
Retrospective study of pregnant women who initiated prenatal care <20 weeks’ gestation at two tertiary teaching institutions between November 2015-February 2018 and were normotensive without history of chronic hypertension. IRB approval was obtained. Cumulative incidence of hypertensive disorder, diagnosed by 20, 37, and 39 weeks, was compared with application of Stage I ACC-AHA versus ACOG criteria.

RESULTS:
There were 4,312 women included. Median intake was at 11 weeks-4 days gestation. Median age was 29 years; 36.4% were white, 31.9% black, 20.6% Hispanic, 7.1% Asian, and 4.1% another racial/ethnic classification. With application of existing ACOG criteria, incidence of hypertensive disorder diagnosis was 0.9%, 7.3%, and 15.1% at 20, 37, and 39 weeks, whereas with expansion to include Stage I ACC-AHA criteria, rates were 1.9%, 12.7%, and 21.5%.

CONCLUSION:
Expansion of diagnostic criteria for hypertension in pregnancy to include Stage I ACC-AHA hypertension nearly doubled the diagnosis of hypertensive disorder at 37 weeks. Given the resource-intense bundle of interventions associated with hypertension diagnosis (e.g., sonography, antenatal testing, and induction of labor), understanding benefits and costs of expansion will be crucial prior to contemplating policy change.
Is There an Association Between Second Trimester Blood Pressure and Pregnancy-Induced Hypertensive Disorders? [19L]
Authors: Grubman Olivia , Hussain Farrah N. , Parikh Bijal , Karotkin Liza , Schneider Emily , Brustman Lois 
Published: April 2020

INTRODUCTION:
In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) revised the guidelines for abnormal blood pressure (BP): elevated (120-129/<80), stage 1 (130-139/80-89) and stage 2 hypertension (≥140/90) on ≥2 occasions in adults. This study aims to determine a relationship between elevated and stage 1 ACC/AHA hypertension in the second trimester and pregnancy-induced hypertensive disorders (PIH).

METHODS:
In this IRB approved retrospective cohort study, we collected the highest two blood pressure measurements in second trimester for singleton pregnancies prior to the ACOG diagnosis of PIH (gestational hypertension, preeclampsia, HELLP, eclampsia). Patients were grouped by ACC/AHA criteria and compared using Pearson chi-square tests, Fisher’s exact tests, T-tests or Mann-Whitney U tests.

RESULTS:
200 patients were included; 54.9% had normal BP, 10.5% had elevated BP, and 34% had stage 1 ACC/AHA hypertension. There was no association between the severity of PIH and normal versus elevated/stage 1 BP in second trimester. Among those with elevated/stage 1 hypertension, gestational age was significantly lower at diagnosis of PIH (P<.001) and delivery (P<.001) compared to normotensive patients.

CONCLUSION:
Gestational age at PIH diagnosis and delivery were significantly lower among women with ACC/AHA elevated or stage 1 hypertension in second trimester compared to normotensive women. Therefore, further research is warranted to determine a relationship between the ACC/AHA guidelines for hypertension and PIH with the possibility of earlier recognition of the disease and intervention.
Obstetric Anal Sphincter Injuries: Compliance With ACOG Postpartum Care Recommendations [22L]
Authors: Bates Kari , Elkattah Rayan , Kharoufeh Anton 
Published: April 2020

INTRODUCTION:
Severe obstetric lacerations that include the anal sphincter complex are associated with increased risk for short and long term complications. ACOG gives postpartum care recommendations to improve outcomes, including stool softeners and oral laxatives with counseling to avoid constipation, pain management with NSAIDs and opiate-containing analgesics, and one dose of perioperative antibiotics. The objective of this study was to assess compliance with these ACOG recommendations at a tertiary care hospital in Central Illinois.

METHODS:
An IRB-approved retrospective observational study was done on patients that had vaginal deliveries complicated by OASIS in the calendar year of 2018. Compliance percentages were obtained for each recommendation. Anything less than 100% compliance was considered inadequate.

RESULTS:
A total 45 patients were found to have vaginal deliveries complicated by OASIS in 2018. One wound complication was identified to date. Compliance was less than 100% in all parameters. Only 20% received perioperative antibiotics. While inpatient, compliance rates varied from 49% to 87% of patients receiving adequate postpartum care. Upon discharge from the hospital in the postpartum period, compliance rates varied from 4% to 47% of patients receiving adequate prescriptions or counseling for medication use.

CONCLUSION:
Our results indicate that compliance with ACOG guidelines is inadequate at a busy tertiary care center in Central Illinois. Of particular concern is the lack of patients receiving adequate counseling and prescriptions for medications (stool softeners, NSAIDs, opiates) upon discharge from the hospital. Interventions are currently being investigated and the results of implementation will be a source of future studies.
Oral Nifedipine Use After Launch of Nurse Driven EMR Care Pathway for Severe Hypertension in Pregnancy [23L]
Authors: Martin Courtney , Johns Kim , Yao Ruofan , Balli Kevin , Pappas James 
Published: April 2020

INTRODUCTION:
The use of care pathways via EPIC EMR is an emerging technology to standardize patient care. Timely treatment of hypertension is critical to prevent morbidity and mortality. ACOG guidelines recommend the use of oral nifedipine as a first line medication, especially if there is no intravenous access. We evaluated the use of oral nifedipine before and after care pathway creation.

METHODS:
A nurse driven care pathway and warning system was designed and implemented in the EPIC EMR inpatient environment. The pathway protocolizes the initial management of severe hypertension in pregnancy based on ACOG guidelines. The purpose of this study was to evaluate the difference in minutes to administration of oral nifedipine after the second severe range blood pressure reading in the 12 months before and after implementation of the pathway. The second area of interest was in the change in the frequency of use.

RESULTS:
In the 12 months before the pathway, the average time to administration of the nifedipine from the second severe range blood pressure was 40.41 minutes versus 22.75 minutes in the following 12 months (P=.023). There were less episodes of administration of nifedipine (54) before the launch, which increased significantly (186) in the 12 months after launch of the pathway (P=.012).

CONCLUSION:
Implementation of a nurse driven, care pathway for severe hypertension in pregnancy decreased the time to administration and increased the frequency of use of oral nifedipine.
Perinatal Outcomes in Preeclampsia Stratified by ABO Blood Group [24L]
Authors: Juusela Alexander , Addy Sophia , Nazir Munir , Gimovsky Martin Larry 
Published: April 2020

INTRODUCTION:
Preeclampsia is a hypertensive disorder unique to pregnancy of which the exact etiopathogenesis has yet to be elucidated. The condition is characterized by hypertension, third spacing, and the effects of arterial vasospasm induced end organ damage. The purpose of the study was to determine if in our patient population there are statistically significant differences in preeclampsia outcomes stratified by ABO blood group.

METHODS:
A retrospective cohort analysis was performed on singleton gestations that delivered at our institution between January 2010 and July 2014 and had a diagnosis of preeclampsia, eclampsia, and HELLP syndrome. 127 patients met criteria, and statistical analysis using SPSS was performed. Primary measures were maternal and fetal characteristics, method of delivery, and adverse perinatal outcomes. Demographic data were analyzed and compared. A χ2 and Fischer-Exact analysis was used for discrete variables, ANOVA was used for continuous variables, and a Kaplan-Meier Survival analysis was performed.

RESULTS:
127 patients met inclusion criteria. There was no statistically significant difference in maternal age, gestational age at delivery, preterm delivery rate, delivery route, 1 and 5 minute Apgars, or perinatal complications between the ABO blood groups.

CONCLUSION:
Contrary to published studies, our single site cohort study did not demonstrate a statistically significant difference in perinatal outcomes or EGA at delivery for Rh positive blood groups A, B or O, however, a Type 2 error may exist. Our study adds to the knowledge base in that it highlights the fact that preeclampsia is most likely a multifactorial disease involving molecular, genetic, and epigenetic factors.
Predicting Obstetric Anal Sphincter Injury (OASIS) in Women Undergoing Trial of Labor After Cesarean (TOLAC) [25L]
Authors: Gilchrist-Scott Douglas , Brown Oluwateniola , Lewicky-Gaupp Christina , Miller Emily S. , Mueller Margaret , Kenton Kimberly 
Published: April 2020

INTRODUCTION:
We aimed to evaluate the relationship between predicted success of trial of labor after cesarean (TOLAC) and obstetric anal sphincter injury (OASI) to develop a predictive model.

METHODS:
We performed a secondary analysis of the Maternal Fetal Medicine Units Network (MFMU) TOLAC prospective cohort (1999–2002) and a single-site retrospective analysis of a cohort of women with a singleton vaginal birth after cesarean (VBAC) between 2011 and 2016 (modern population [MP]) (IRB approval STU00204149). Women were stratified by the presence of OASI and characteristics were compared with bivariate analysis, including the predicted probability of achieving VBAC using the MFMU calculator. Significant risk factors were included in a backward stepwise multivariable logistic regression model to identify independent risk factors for OASI and generate a predictive model. Model performance was evaluated using concordance indices, brier scores and calibration plots. Internal validity was assessed with bootstrapping and external validation performed using MP data.

RESULTS:
12,108 women met inclusion criteria and 739 (6.1%) sustained OASI. Factors independently associated with OASI included forceps (OR 5.0 CI 4.1-6.2) and vacuum (OR 2.8 CI 2.2-3.6), along with predicted likelihood of VBAC (aOR 0.5 CI 0.4-0.6), race and smoking. The concordance index of the model and MP validation cohort was 0.79 (CI 0.77-0.81) and 0.77 (CI 0.71-0.83). The model demonstrates internal validity, but slight overcalibration within the MP cohort.

CONCLUSION:
Predicted likelihood of VBAC is inversely proportional to the likelihood of sustaining OASI. Our model provides a robust estimate of OASI risk during VBAC that can be easily utilized in counseling.