bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prophylactic Low-Molecular-Weight Heparin Versus Unfractionated Heparin at the Time of Delivery [32L]
Authors: Pluym Ilina D. , Holliman Kerry , Bermudez Ana , Afshar Yalda , Silverman Neil S. , Rao Rashmi 
Published: April 2020

INTRODUCTION:
To compare the impact of two common dosing practices of antepartum prophylactic anticoagulation on peripartum management.

METHODS:
IRB approval was obtained for this retrospective cohort study of women receiving prophylactic anticoagulation from 2014 to 2019. Two strategies were reviewed: continuation of low-molecular weight heparin (LMWH) until delivery vs transitioning from LMWH to unfractionated heparin (UFH) at 36 weeks. Strategies were compared for impact on obstetric outcomes and anesthesia for delivery.

RESULTS:
Prophylactic anticoagulation was identified in 66 women; 48 (73%) remained on LMWH until delivery and 18 (27%) were transitioned to UFH. LMWH dosing ranged from 30 to 80 mg daily (88% at 40 mg). UFH was dosed at either 5,000 U twice daily (56%) or 10,000 U twice daily (44%). Comparing outcomes, both groups had similar rates of delivery during a scheduled admission (65% vs 50%, P=.40) and receiving neuraxial analgesia (79% vs 89% P=.50). Four women receiving LMWH (8%) did not receive neuraxial analgesia due to timing of their last dose (range 5-12 hours); one of these patients received general anesthesia for a cesarean, and the other three received intravenous analgesia for labor. In the LMWH group, seven women (15%) had an estimated blood loss (EBL) >1000 cc compared to none in the UFH group (P=.18) A multiple regression model showed no effect of anticoagulation strategies on EBL when adjusted for route of delivery, maternal weight and birthweight (P=.18).

CONCLUSION:
Among women receiving prophylactic LMWH, transition to UFH before delivery did not significantly impact receipt of neuraxial analgesia or lower rates of postpartum hemorrhage.
Risk of Venous Thromboembolism After Peripartum Hysterectomy [35L]
Authors: Mauney Logan C. , Barth William H. , Clapp Mark A. 
Published: April 2020

INTRODUCTION:
Pregnancy and the postpartum period are known hypercoagulable states. The risk of VTE is higher after cesarean compared to vaginal delivery. The risk of VTE following peripartum hysterectomy is largely unknown. This study compared the incidence and risk of VTE among women who had and did not have a peripartum hysterectomy.

METHODS:
From the 2016 National Readmissions Database, women who had 1 delivery encounter at greater than 20 weeks of gestation between January 1 and November 30 and a diagnosis of a deep venous thrombosis (DVT) or pulmonary embolism (PE) during the delivery encounter or within 30 days of discharge were included in a retrospective cohort study. Incidence of VTE was compared among women who had and did not have a hysterectomy. Multivariable logistic regressions were used to estimate the associations between VTE and hysterectomy adjusted for other known VTE risk factors. Analyses used survey weights to obtain population estimates.

RESULTS:
Of the 1,760,255 women with delivery encounters, 1,903 (0.1%) underwent hysterectomy. 26 were diagnosed with VTE after hysterectomy, 17 (65%) of which occurred during the delivery admission. The incidence of VTE was higher in women who underwent hysterectomy compared to women did not (14.1 vs 0.7 per 1,000 deliveries, P<.001). Unadjusted and adjusted odds of VTE after hysterectomy were 19.7 (95% CI 12.6-30.6) and 15.6 respectively (95% CI 9.8-24.8).

CONCLUSION:
Peripartum hysterectomy is associated with significantly increased risk of VTE even when accounting for other risk factors, which prompts further investigation into the role for VTE prophylaxis postpartum after hysterectomy.
Variation in Severe Maternal Morbidity Among All Births Across Arizona, 2016-2017 [38L]
Authors: Oelkers Kaitlyn , Coonrod Dean V. , Bhattarai Bikash , Quintana Enid 
Published: April 2020

INTRODUCTION:
Given the interest in preventing maternal mortality, this study aimed to analyze differences in severe maternal morbidity (SMM) across Arizona hospitals to analyze the role of hospital characteristics in SMM frequency.

METHODS:
Based on the CDC definition of SMM, all births in Arizona for 2016-2017 were analyzed to assess for SMM with and without blood transfusion. Multiple hospital characteristics including trauma level, teaching status, and ownership were analyzed to their association with SMM. This project received an exemption from IRB review from the Maricopa Integrated Health Systems IRB.

RESULTS:
Deliveries (N=158,834) were analyzed finding an SMM with blood transfusion rate of 144.0 per 10,000 deliveries ranging from 29.4 to 412.4/10,000. SMM without transfusion was 67.7 per 10,000 ranging from 21.2 to 172.9/10,000. By ownership, government hospitals had the highest SMM with transfusion (246.5/10,000). Teaching hospitals had higher SMM with transfusion than non-teaching hospitals (188.9/10,000 vs 108.2/10,000 with transfusion). Level 1 trauma centers had 2.38 times higher SMM with blood transfusions and 1.37 times higher SMM without blood transfusion relative to lower-level trauma centers and non-trauma centers. However, there was a wide variation between hospitals in the same group, including trauma level, volume, and nursery level.

CONCLUSION:
SMM proportions varied by many hospital factors including size, residency, and trauma level. Higher SMM was seen in government-owned, teaching, and level 1 trauma hospitals. There was also variation with these groups. One possible intervention would be to reduce these variations as part of a quality improvement process.
Venous Thromboembolism in Pregnancy [39L]
Authors: Alsarraj Ghazi , Abenhaim Haim Arie , Alnoman Abdullah 
Published: April 2020

INTRODUCTION:
Venous thromboembolism is one of the leading causes of pregnancy-related maternal death in developed countries. The incidence rate is much higher during the postpartum period with an overall incidence of 2.5 to 9.9 per 1000

METHODS:
The data were obtained from the 1999-2015 Health Care Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) and used to carry out a population-based cohort study. The purpose of our study is to trend the rate of VTE during pregnancy and postpartum period and the assessment of the risk factors using a large population-based administrative database from the United States. Logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (CIs) of demographic and obstetrical determinants of VTEs.

RESULTS:
The overall incidence of VTE was in an upward trend until 2015 when it reached 20/10,000 pregnancies, with an average case fatality rate of 1.16%. VTE is associated with maternal age above 25, anemia, heart disease, hypertension, obesity, transfusion, C-section, postpartum hemorrhage and PET. Predictors of VTE fatalities included obesity, hypertension, PET, postpartum hemorrhage, PTB and DM.

CONCLUSION:
VTE is a condition with an increasing in incidence and is associated with a significant maternal morbidity and mortality. Multiple risk factors associated with VTE with obesity being the most significant in our study. Further research targeting risk factors and prevention in pregnancy is warranted.
Very Advanced Maternal Age and Obstetric Outcomes [40L]
Authors: Jones Cresta W. , Tessier Katelyn , Raasch Caitlin , Dharampaul Kayla 
Published: April 2020

INTRODUCTION:
Mean maternal age continues to increase in the United States and more women are getting pregnant in their forties or older. We aimed to examine the risk of adverse obstetric outcomes in a diverse contemporary urban population of women of very advanced maternal age, defined as age 40 years or older at estimated date of delivery (EDD).

METHODS:
This retrospective cohort study examined patients presenting for delivery in an urban Midwest academic healthcare system from 2016 to 2017. Women 40 years of age or older at EDD (n=433) were compared with controls between age 25 to 30 years at EDD (n=755), in relation to risk of adverse obstetric outcomes. Chi-square and Fisher exact tests were used to evaluate categorical variables.

RESULTS:
Women 40 years or older were more likely to experience adverse obstetric outcomes, including an increased risk of gestational diabetes, gestational hypertension, amniotic fluid abnormalities, fetal growth restriction, PPROM, preterm labor and pre-delivery hospitalization (all P<.05). No difference in the identification of prenatal fetal anomalies was seen between the two groups.

CONCLUSION:
Very advanced maternal age (≥40 years at EDD) is associated with an increased risk of adverse obstetric complications. These data will help guide management and counseling of women contemplating or achieving pregnancy at more advanced maternal age.
A Multi-Faceted Intervention to Reduce Obstetric Hemorrhage Risk at University Hospitals [01M]
Authors: Cossler Nancy , Liu James H. , Katz Tyler Jessica , Albertini Megan , Furnari Rosanne , Porter Steven 
Published: April 2020

INTRODUCTION:
We describe a systematic approach to mitigating obstetric hemorrhage risk at University Hospitals (UH), a northeast Ohio-based system of eighteen hospitals, including seven hospitals providing obstetric services and delivering approximately 8000 women/year.

METHODS:
From 2009-2015, obstetric hemorrhage (OBH) led to two maternal deaths and other harms in the form of excessive transfusions, ICU admissions, and hysterectomies as definitive treatment. OBH accounted for 11% of litigation costs ($7.4 M) during this period.
To reduce harm associated with OBH, we implemented the following interventions: 1. Clinical Practice Guideline for management of anemia in pregnancy; 2. EMR field to capture hemorrhage risk factors and prompt type and cross on admission; 3. Mandating transfer of high risk patients for delivery at a tertiary care center; 4. Clinical Practice Guideline for management of OBH (including active management of third stage of labor); 5. Shifting from estimating to quantifying blood loss by weight; and 6. Standardization of OBH carts on all L&D units.

RESULTS:
From 2015-2017, there was: 40% increase in the number of patients admitted to L&D with hemoglobin >10 mg/dl; 68% decrease in the number of obstetric patients requiring transfusions of ≥four units of packed red blood cells; 77% decrease in the number of peri-partum hysterectomies; and 91% decrease in the number of patients admitted to ICU for OBH. There were no maternal deaths from OBH and no new suits or claims related to OBH between 2014 and 2018.

CONCLUSION:
This multifaceted intervention was associated with decreased patient harm and reduced litigation costs associated with obstetric hemorrhage.
A Novel Therapeutic in the Management of Post-Episiotomy Pain [02M]
Authors: Grabie Yisroel , Jamil Nawshin (Zara) , Schwob Joseph , Uryash Arkady 
Published: April 2020

INTRODUCTION:
Although rates of episiotomy are declining, post-episiotomy pain remains a complication in obstetric care. Current management includes NSAIDs and Benzocaine, but the use of Benzocaine has been linked to iatrogenic methemoglobinemia, with greatest risk in newborns. We hypothesized that a novel drug formulation, currently being investigated in diabetic neuropathy, can be used to attenuate post-episiotomy pain.

METHODS:
This pilot study was conducted in an outpatient obstetrics clinic on postpartum women aged between 18 and 39, who underwent vaginal delivery with episiotomy. Spray bottles with the investigational product were distributed to the patients to use without regulation. A survey to assess post-episiotomy pain using the Visual Analog Scale (VAS) was administered to the patients. Pain attenuation, time to pain attenuation, and quality of pain were measured.

RESULTS:
The cohort consisted of 25 women (including 5 non-responders). In responders, pain was attenuated by 4.0 scale units. Average time to analgesia was 9.25. Average pain ratings after treatment were compared to average pain ratings before treatment using a unidirectional paired sample t test (df=24). The average pain ratings for the entire cohort after administration of Relivatrol© were significantly lower than average pain rating prior to administration t (24)=7.41, P<.0001.

CONCLUSION:
We concluded that Relivatrol© significantly decreases post-episiotomy pain. Being a pilot study had multiple limitations; we developed a protocol for a larger investigation and are currently collecting data involving a greater number of subjects, a control arm, pharmacokinetic parameters, and an analysis of quality of life impact.
Antepartum and Intrapartum Characteristics Associated With Postpartum Blood Transfusion [03M]
Authors: Farr Carly , Ogunyemi Dotun , Bauer Samuel , Karabon Patrick , Bahado-Singh Ray , Alhousseini Ali 
Published: April 2020

INTRODUCTION:
Risk assessment is the first step in an Obstetrics Hemorrhage Safety Bundle. Accurate elucidation of prenatal and intrapartum risk factors can facilitate the reduction of severe maternal morbidity and mortality due to postpartum hemorrhage.

METHODS:
Retrospective cohort study of 27,886 women evaluated for antepartum and intrapartum factors associated with postpartum blood transfusion. Univariate and multivariate logistic regression and propensity score analyses were performed, and odds ratio were derived. P-values<0.05 were considered statistically significant.

RESULTS:
245 of 27,886 mothers required blood transfusion. On multivariate logistic regression adjusting for all factors, statistically significant independent associations of blood transfusion were general anesthesia (OR 6.01; P=.0002), severe preeclampsia (OR 3.34; P<.0001), chorioamnionitis (OR 3.09; P<.0001) and the use of multiple methods for cervical ripening (OR 2.03; P=.0098). Milder independent associations were previous cesarean delivery (OR 1.83; P=.0037), gestational hypertension (OR 1.55; P=.0283), and gestational diabetes (OR 1.55; P=.0410). Using propensity score inverse probability of treatment weighting multivariable model, independent associations of blood transfusion were cervical dilation on admission <2 cm, effacement <60%, and station <-3, duration of all stages of labor (all P<.0001) and intrapartum therapy with intravenous anti-hypertensives (ORPS 2.53; P<.0001), Magnesium (ORPS 2.94; P<.0001), opioids (ORPS 2.17; P<.0001), Clindamycin/Gentamicin (ORPS 3.91; P<.0001), and uterotonics (ORPS 14.3; P<.0001).

CONCLUSION:
Treatment of intrapartum complications contribute more to the need for blood transfusion than prenatal risk factors. Avoiding general anesthesia, reducing labor induction and prolonged labor are potential preventable causes of postpartum hemorrhage requiring blood transfusion.
Change in Shock Index as a Predictor of Transfusion Requirement [07M]
Authors: Schmidt Aidan , Wells Matthew , Hoffman Eva , Ramani Sangeeta , Kunzier Nadia , Vintzileos Anthony 
Published: April 2020

INTRODUCTION:
Early identification of PPH is difficult. Shock index (SI) (SI=HR/SBP) of (>0.9) has demonstrated good prediction of PPH, and identify identification of patients requiring massive transfusion. Our objective is to determine if there is a change in SI on admission to postpartum or at time of transfusion after which there is an increased transfusion requirement or morbidity.

METHODS:
IRB approved, retrospective cohort of patients who received blood transfusion at a University based hospital, 2017-2018. SI calculated; at time of admission, after delivery, and prior to transfusion. Patients with invasive carcinoma, with fetus of non-viable gestational age, and incomplete charts were excluded. Spearman correlate coefficient, univariable logistic regression, and ROC analyses were performed.

RESULTS:
160 patients; 117/160 (73%) delivered by cesarean, 37/160 (23%) vaginally, and 6/160 (4%) operative vaginal delivery. Mean admission hemoglobin was 10.8 (± 1.5). Median EBL was 1320 mL (250-6000 mL). 77/160 (48%) of patients received 2 units of PRBC, 26/160 (17%) received 3 units of PRBC, 24/160 (15%) received 4 units of PRBC and 33/160 (20%) received ≥5 units of PRBC. Change in SI from admission to postpartum had a correlation coefficient of 0.022 and a P value of .78. Change in SI from admission to pre-transfusion had a correlation coefficient of 0.128 and a P value of .11.

CONCLUSION:
Changes in SI from admission to immediately postpartum or pre-transfusion do not show any correlation or predictive value for increasing morbidity, or transfusion requirements. This demonstrates change in SI is a poor predictor of morbidity and transfusion requirements.
Does Hemorrhage Risk Stratification Correlate With Need for Intervention and Subsequent Maternal Morbidity? [13M]
Authors: Chu Tina , Rodriguez Aldeboran N. , Kleinmann Whitney , Patel Shivani R. , Horsager Robyn , Morgan Jamie L. 
Published: April 2020

INTRODUCTION:
Postpartum hemorrhage (PPH) is a leading cause of preventable maternal morbidity and mortality. In order to identify women prior to delivery at higher risk for hemorrhage, a trinary risk assessment tool has been developed. However, its utility has only been correlated to transfusion need. We sought to compare hemorrhage risk stratification with need for intervention and subsequent maternal morbidity.

METHODS:
We analyzed antepartum and intrapartum hemorrhage risk factors using the California Maternal Quality Care Collaborative’s risk score in all deliveries at our institution between January 1, 2018 and December 31, 2018. Relevant factors were used to stratify women as low, medium, or high risk which was then correlated to uterotonic administration beyond oxytocin and other hemorrhage-related morbidity. PPH was defined as blood loss exceeding 1,000 mL. Data was analyzed using standard methods of rates and proportions with P<.05 considered significant. IRB approval was obtained from the UT Southwestern Medical Center.

RESULTS:
Of 1,868 deliveries, 508 women (27.2%) experienced a PPH. Overall, 178 (9.5%) required uterotonics, 38 (2.0%) required transfusion, 7 (0.4%) needed intensive care unit (ICU) admission, and 12 (0.6%) underwent hysterectomy. Relative to low and medium risk stratifications, high risk women were 2.3 times more likely to require uterotonics. Low risk women were 83% less likely to require transfusion, ICU, or hysterectomy compared to medium and high risk groups. Conversely, high risk women had a 4.1 fold increase in these morbidities.

CONCLUSION:
Women classified as high risk for hemorrhage are indeed more likely to require uterotonics and suffer disproportionately higher maternal morbidity.
Does Increased Time Off Oxytocin Decrease Blood Loss at the Time of Cesarean Birth? [14M]
Authors: Mardy Anne , Reyes Fatima , Rosenstein Melissa 
Published: April 2020

INTRODUCTION:
Prolonged periods of oxytocin use during labor can lead to higher rates of postpartum hemorrhage due to oxytocin receptor desensitization. We aimed to determine whether increased time off oxytocin prior to cesarean birth decreased the rate of quantified blood loss (QBL).

METHODS:
This is a retrospective cohort study of women with singleton pregnancies receiving at least 4 hours of oxytocin and delivering via cesarean at the University of California, San Francisco from May 2018 to June 2019. The primary exposure was the time off oxytocin to delivery, in minutes. The primary outcome was QBL, in milliliters. Secondary outcomes included need for blood transfusion, additional uterotonics, additional surgeries needed, and change in hemoglobin.

RESULTS:
338 patients had a cesarean birth after exposure to oxytocin. The mean time from stopping oxytocin to delivery was 119 minutes (IQR 62-133 minutes). The average QBL was 1179 mL (IQR 770-1492 mL). There was no significant difference in QBL based on time off oxytocin (-4.0 mL per 10 min, 95% CI −9.5 to +1.4 mL). There was an increased risk of blood transfusion in those off oxytocin for fewer than 2 hours versus more than 2 hours (14.0% vs. 4.6%, P=.010). This finding persisted after controlling for age, BMI, stage of labor, admission hemoglobin, chorioamnionitis and cumulative oxytocin dose (aOR 2.97, 95% CI 1.06-8.23).

CONCLUSION:
We did not find an association between time off oxytocin before delivery and QBL. However, there was an increased risk of blood transfusion among those off oxytocin for less than 2 hours.
Factors Associated With Hypertension 2-5 Years Postpartum in Women With Hypertensive Diseases of Pregnancy [17M]
Authors: Orr Lauren C. , Hebert Kasey , Hen Eden , Nickerson Ciarra , Leung Katherine , Leftwich Heidi K. 
Published: April 2020

INTRODUCTION:
To identify factors associated with hypertension 2-5 years following delivery complicated by a hypertensive disease of pregnancy.

METHODS:
We performed a single-center, retrospective cohort study of women with a hypertensive disease of pregnancy who delivered between 7/2009-1/2014. Women with hypertension predating the incident pregnancy and those discharged on anti-hypertensive medications were excluded. Hypertension was defined as SBP greater than 140 mmHg, and/or DBP greater than 90 mmHg, and/or office visit for management of anti-hypertensive medications. A secondary analysis using SBP greater than 130 mmHg and/or DBP greater than 80 mmHg was also performed. Data was collected through review of electronic medical record. Institutional IRB approval was obtained.

RESULTS:
284 women were eligible for analysis. Of these women, 123 (43%) were considered hypertensive at 2-5 years following delivery. They were more likely to be older (P=.001), have a higher pre-pregnancy BMI (p<.001), be of higher parity (p<.001), undergo cesarean section (P=.002), and to have higher blood pressure immediately postpartum (P=.002, P=.027). When the definition of hypertension outlined by 2017 AHA recommendations (greater than 130/80) was used, 65% of the women were found to have hypertension and the same associations existed.

CONCLUSION:
A large proportion of women with a hypertensive disease of pregnancy had evidence of hypertension at 2-5 years postpartum. This proportion was even greater when the 2017 AHA definition was applied. Some factors associated with developing hypertension were identified in this study and could be considered while addressing importance of long term follow up for women given the magnitude of effect.
Improving Access to HPV Vaccination for Inpatient Postpartum Women at Naval Medical Center San Diego [19M]
Authors: Heye Kristen , Berkley Holly , Heaton Kobjit 
Published: April 2020

INTRODUCTION:
Human Papillomavirus (HPV) is the most common sexually transmitted infection in the US and is thought to be the etiologic agent in 99.7% of cervical cancers 1, 2. Despite this, in 2016, only 51.4% of adolescents ages 13-17 have completed the full HPV vaccination series. Vaccination rates at Naval Medical Center San Diego mirror national trends. In our postpartum care, ensuring inpatient vaccination of for diseases (i.e. MMR, Tdap, VZV) is well established, however HPV vaccination was not available on the ward. We sought to develop and evaluate a process improvement program aimed at improving HPV vaccination rates by incorporating screening and administration into an established inpatient postpartum vaccination program.

METHODS:
Women ages 9 to 45 were evaluated for eligibility and offered the nine valent HPV vaccine as inpatients on the postpartum ward. An IRB exempt retrospective chart review pre- and post- intervention was conducted to determine vaccination status and rates of vaccination. The results were stratification based on active duty status and age.

RESULTS:
For all patients prior to intervention, the vaccination rate was 6.4% in the postpartum period when the vaccine was only available in the outpatient clinic. After implementation, the overall vaccination rate rose to 33.3% for postpartum patients (RR 5.2, CI 2.54-10.75, P<.0001). Women 26 years of age or younger were 11.2 times more likely to receive vaccination post-intervention (RR 11.2, CI 2.64-47.29, p=0.001).

CONCLUSION:
An inpatient postpartum HPV vaccination program is associated with increased rates of vaccination.