bluuebunny/crossref_metadata_2025_split huggingface dataset:
Timing of Delivery in Intrahepatic Cholestasis of Pregnancy With Total Bile Acids ≥100 µmol/L: A Decision Analysis [38N]
Authors: Frank Zoe C. , Nienow-Birch Mary N. , Lo Jamie , Shaffer Brian L. , Caughey Aaron B. 
Published: April 2020

INTRODUCTION:
Our study models the trade-off between preterm neonatal morbidity and stillbirth for women with intrahepatic cholestasis of pregnancy (ICP) with total bile acids ≥100 µmol/L in order to determine the optimal gestational age for delivery.

METHODS:
A decision analytic model was created to compare the outcomes of delivery at 33 through 40 weeks gestation in women with total bile acids (TBA) ≥100 µmol/L. Baseline risks of stillbirth and spontaneous delivery were derived from the literature and adjusted for peak TBA. It was assumed that betamethasone was given within 48 hours of all planned preterm deliveries and before a percentage of spontaneous ones. We assumed a population of 10,000 women with ICP and calculated total quality-adjusted life years (QALYs) for each strategy, taking into account both maternal and neonatal perspectives. Univariate sensitivity analysis was performed for all variables to test the robustness of the model.

RESULTS:
In women with peak TBA ≥100 µmol/L, delivery at 34 weeks maximized QALYs. Compared to delivery at 36 weeks, it resulted in 1302.4 more QALYs, 98.2 fewer stillbirths, and 21 more cases of cerebral palsy in our theoretical cohort of 10,000 women. Sensitivity analysis demonstrated that when the relative risk of stillbirth given TBA ≥100 µmol/L fell from a baseline of 30.5 to below 26.2, delivery at 35 weeks became optimal. Monte Carlo analysis demonstrated that when variation was incorporated into the model, delivery at 34 weeks was the dominant strategy 45% of the time.

CONCLUSION:
In women with ICP with TBA ≥100 µmol/L, delivery at 34 weeks maximizes QALYs.
Association Between Antepartum Depression Score and Breastfeeding Outcomes [05O]
Authors: Chapman Erica R. , Colina Andreina , Berens Pamela D. 
Published: April 2020

INTRODUCTION:
Despite abundant evidence supporting breastfeeding benefits, over 15% of women do not initiate breastfeeding and many stop earlier than recommended. Postpartum depression has a negative association with breastfeeding outcomes. Antepartum depression could have a similar effect.

METHODS:
Our retrospective chart review included all women from the University of Texas Physicians obstetrical practice who completed an Edinburgh Postnatal Depression Scale (EPDS) and delivered between January 2017 and February 2018. IRB approval was obtained. Of 988 potentially qualifying women, 176 were included [exclusions included no EPDS during pregnancy (809) or maternal breastfeeding contraindication (3)]. Dependent variables were breastfeeding initiation and duration through the postpartum visit. Antepartum depression was defined as a pregnancy EPDS greater than or equal to 13. Multivariable logistic regression was used to determine association between antepartum depression and breastfeeding outcomes.

RESULTS:
No significant association was found between antepartum depression scores and breastfeeding outcomes. Unadjusted OR 0.62 (95% CI 0.25–1.08); adjusted OR 1.08 (95% CI 0.39–3.03) for breastfeeding initiation. Unadjusted OR 0.80 (95% CI 0.36–1.78) adjusted OR 1.02 (95% CI 0.42–2.48). Women with antepartum underlying mood disorders did have significantly reduced odds of initiation and duration of breastfeeding [initiation adjusted OR 0.24 (95% CI 0.08–0.72), duration adjusted OR 0.25 (0.08–0.75)].

CONCLUSION:
We found no association between antepartum depression scores and breastfeeding outcomes. Women with underlying mood disorders had significantly reduced odds of initiating and continuing breastfeeding at the postpartum visit. Addressing underlying mood disorders during pregnancy might be a novel strategy to increase breastfeeding rates.
Category II Fetal Monitoring in Fetuses With Congenital Heart Defects: Are They Any Different? [06O]
Authors: Bailey Erin , Lopez Julia , Smith Sarah , Woolfolk Candice , Cahill Alison , Raghuraman Nandini 
Published: April 2020

INTRODUCTION:
The majority of literature investigating continuous electronic fetal monitoring (EFM) excludes anomalous fetuses. The objective of this study was to determine if Category II EFM characteristics differed between fetuses with and without congenital heart defects (CHD).

METHODS:
This was a retrospective IRB-approved cohort study of singleton, term pregnancies admitted for induction or labor with an antenatal diagnosis of fetal CHD between 2017–2019. We excluded fetuses with genetic abnormalities. Cases were matched by race and obesity in a 1:2 ratio to a historic control of term pregnancies with structurally normal fetuses. EFM characteristics in the 1 hour before delivery were extracted. The primary outcome was incidence of Category II EFM features; secondary outcome was total deceleration area (TDA).

RESULTS:
47 cases of fetal CHD were matched to 94 controls. There was no difference in advanced maternal age, other baseline demographics, or mode of delivery between groups. Fetuses with CHD were less likely to have prolonged decelerations (6.4 vs 25.5%, P<.01) or any periods of tachycardia (4.3 vs 17.0, p 0.03) compared to normal fetuses. Other Category II features were similar between groups including incidence of recurrent late and variable decelerations and minimal variability. There was no difference in TDA between groups.

CONCLUSION:
Prolonged decelerations and tachycardia were less common in CHD fetuses. The incidence of other Category II features were similar to nonanomalous fetuses. These results suggest that structural heart defects do not increase the risk of concerning EFM patterns. Future studies should evaluate the risk of acidemia with Category II EFM and CHD.
Explaining the (Over)Use of Electronic Fetal Monitoring: Evidence From a Study of Work Flow on the Unit [14O]
Authors: Low Lisa Kane , Chuey Meagan , Abdelnabi Samia , De Vries Raymond 
Published: April 2020

INTRODUCTION:
Guidelines from ACOG, AWHONN, and ACNM recommend against the routine use of electronic fetal monitoring (EFM) for low risk, healthy labors, recognizing the limited evidence of improved outcomes and its contribution to cesarean births. Yet the vast majority of healthy labors continue to be monitored with EFM rather than intermittent auscultation (IA). We explore the reasons for this disjuncture, going beyond the untested assumption that liability concerns drive EFM use to examine the place of EFM in the workflow of maternity care units.

METHODS:
A mixed methods study, at a large medical center, using 1) observations on the unit (121 hours), 2) interviews and focus groups with nurses, midwives, obstetricians, and administrators (n=47), 3) chart review, and 4) a short survey of care providers (n=140).

RESULTS:
Four areas favor EFM use: The work environment (incorrect assumptions about what others on the care team want; EFM as default order; economic and time efficiency); Patients (limited knowledge of monitoring options); Technology (emphasis on EFM training over other approaches); Fear (of missing something, of blame from colleagues, of litigation).

CONCLUSION:
In light of the recognition – by ACOG and other professional societies – of the role of EFM in the overuse of cesarean sections – it is imperative that we understand continued reliance on this technology. Our study – the first of its kind – points to practical steps needed to reduce this reliance, including open communication among maternity care team members, change in EHR order sets, training in use of IA, and patient education.
Impact of Group Prenatal Care on Neonatal Outcomes in Women With Opioid Use Disorder [17O]
Authors: Lou Kristie , McDowell Misty , Slaven James E. , Grasch Jennifer , Quinney Sara K. 
Published: April 2020

INTRODUCTION:
Opioid use disorder (OUD) is a growing problem that incurs several obstetric risks. The objective of this study was to determine the impact of group prenatal care (PNC) compared to conventional individual PNC on neonatal outcomes in women with OUD.

METHODS:
This was a retrospective cohort study evaluating a practice change to group PNC from individual PNC in pregnant patients with OUD at the Indiana University Maternal Recovery Program (MRP). IRB committee approval was obtained. Data were collected from pregnant patients at the MRP diagnosed with OUD, with initiation of care <32 weeks gestation, and receiving buprenorphine therapy. Our primary outcomes were the rate of neonatal abstinence syndrome (NAS) treatment requirement and NAS severity. Outcomes were compared between group and individual PNC patients using Student t-tests for continuous variables and chi-square tests for discrete variables.

RESULTS:
252 OUD patients presented for PNC at the MRP from September 2015 to August 2017. 104 OUD patients presented for PNC from September 2017 to October 2018, following a practice change to group PNC. Among those meeting inclusion and exclusion criteria (n=304), 76 underwent group PNC and 228 underwent individual PNC. The two groups were similar in maternal demographics, substance use history, delivery characteristics, and antenatal buprenorphine dosing. There was a significant difference in the rate of NAS treatment requirement between the two groups of 40.8% for group PNC, compared to 54.8% for individual PNC (P=.0353).

CONCLUSION:
Women receiving group PNC for OUD may benefit from improved neonatal outcomes, specifically a decreased rate of NAS treatment requirement.
In Search of Placenta and Umbilical Cord Risk Factors for Fetomaternal Hemorrhage: A Case-Control Study [18O]
Authors: Boller Marie , Hartt Angeleque , Hung Yun-Yi , Weintraub Miranda Ritterman , Moore Gaea S. , Schauer Galen M. 
Published: April 2020

INTRODUCTION:
Fetomaternal hemorrhage (FMH) is an obstetric complication associated with adverse fetal and neonatal outcomes. Few reliable risk factors other than maternal trauma have been identified. Previous research has suggested an association between potentially obstructive umbilical cord abnormalities and FMH.

METHODS:
We conducted an IRB-approved case-control study within Kaiser Permanente Northern California between January 2008 and December 2017 to investigate whether cord abnormalities were associated with FMH. Cases were defined by adverse fetal or neonatal outcomes related to hypovolemia in the setting of a positive maternal flow cytometry for fetal hemoglobin. Controls were selected based on a negative flow result at time of delivery and available placental pathology report for review, matched to gestational age and year of delivery of cases. Delivery records and pathology reports were analyzed for 56 cases and 132 controls.

RESULTS:
There was at least one cord abnormality for 23.2% of cases and 25.8% of controls (P=.71). There were no significant differences between the two groups in placental weight percentile, cord length, or cord diameter. Marginal and velamentous cord insertion occurred slightly more frequently in controls compared to cases. Cord hypercoiling was found in 7.1% of cases vs 5.3% of controls (P=.74).

CONCLUSION:
We did not identify gross placental or cord characteristics associated with FMH. However, case numbers were too small for statistical significance and our study was limited to placentas sent to pathology, which may have biased our control group towards cord lesions. Further research is required to identify whether an association exists between cord abnormalities and FMH.
Interpretation of the Fetal Heart Rate Tracing: Fetal Electrocardiogram Versus Standard Monitoring [20O]
Authors: Monson Martha , Heuser Cara C. , Esplin Isaac , Einerson Brett , Butler Allison , Esplin Sean M. 
Published: April 2020

INTRODUCTION:
A limitation of traditional intrapartum fetal heart rate (FHR) assessment includes variation in tracing interpretation between readers. We have shown that an external fetal electrocardiogram (fECG) monitoring device generates more interpretable FHR data compared to standard external Doppler monitoring (SEM), particularly in women with BMI >30. We hypothesized that fECG would provide more consistent interpretation of 10-minute FHR segments intrapartum compared to SEM.

METHODS:
Secondary analysis of randomized controlled trial at 4 Utah hospitals. 218 patients with singleton, term pregnancies, were enrolled at labor admission and randomized to fECG or SEM. We identified subjects where 10-minute FHR tracing segments were evaluated by at least 2 reviewers blinded to study device allocation. We calculated Krippendorff's alpha as a measure of inter-rater reliability. Permutation tests were performed to determine whether the derived alpha on randomized device was statistically significant.

RESULTS:
We identified 206 eligible patient tracings (97 fECG, 109 SEM). Maternal demographics and clinical outcomes were similar. Both devices generated moderate disagreement for FHR Category assignment (fECG -0.36, SEM -0.37). fECG and SEM showed moderate agreement for Acceleration (0.47, 0.46) and Prolonged Deceleration (0.41, 0.58) interpretation. fECG exhibited higher agreement for Baseline FHR (0.95, 0.92) and Recurrent Variable Deceleration interpretation (0.4, 0.15). SEM demonstrated higher agreement compared to fECG regarding FHR variability (0.14, 0.08), variable deceleration (0.6, 0.15) and late deceleration (0.7, 0.22) interpretation.

CONCLUSION:
Considerable heterogeneity exists with respect to FHR interpretation agreement, regardless of FHR monitoring device type. fECG monitoring does not provide more consistent FHR interpretation compared to SEM.
Maternal and Neonatal Outcomes Among Pregnant Women With Myasthenia Gravis [22O]
Authors: Nicholls-Dempsey Laura , Abenhaim Haim A. 
Published: April 2020

INTRODUCTION:
Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction marked by weakness and fatiguability of skeletal muscle. MG has an unpredictable course in pregnancy. Our purpose was to evaluate the effect of MG on maternal and neonatal outcomes.

METHODS:
Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2015, we conducted a population-based retrospective cohort study consisting of women who delivered during that period. Multivariate logistic regression was used to compare maternal and neonatal outcomes among pregnancies in women with and without MG, while adjusting for baseline maternal characteristics. IRB approval was not required for this study.

RESULTS:
During the 17-year study period, 1087 deliveries were to women with MG. Women with MG were more likely to be older, Caucasian, obese, have Medicare insurance and be discharged from an urban teaching hospital. Women with MG were also more likely to be smokers, have chronic hypertension, pre-gestational diabetes, hypothyroidism and display chronic steroid use. Women with MG were at greater risk for acute respiratory failure (OR 15.7, 95% CI 10.6–23.3) and increased length of hospital stay (OR 2.6, 95% CI 2.0–3.3). No significant difference was observed in the risk of preterm premature rupture of membranes, cesarean section or instrumental vaginal delivery. Neonates of women with MG were also more likely to be premature (OR 1.4, 95% CI 1.1–1.6).

CONCLUSION:
MG in pregnancy is a high-risk pregnancy condition associated with adverse maternal and newborn outcomes. Management in a tertiary care center with obstetrical, neurological and anesthesia collaboration is recommended.
Trial of Labor After Two Cesarean Sections Versus Repeat Cesarean Section: A Retrospective Cohort Study [37P]
Authors: Horgan Rebecca , Hossain Saif , Fulginiti Adriana , Massaro Robert , Graebe Robert 
Published: April 2020

INTRODUCTION:
Greater than 90% of women with a previous cesarean section in the USA deliver by repeat cesarean section and one third of hospitals no longer offer a trial of labor after cesarean section (TOLAC). We sought to assess maternal and neonatal outcomes amongst women with two prior cesarean sections who opted to undergo TOLAC versus repeat cesarean section.

METHODS:
This retrospective cohort study was undertaken at a community medical center from January 1st 2008 to December 31st 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a prior classical uterine incision or abdominal myomectomy, history of uterine rupture, placenta previa or invasive placentation, non-vertex presentation, or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test.

RESULTS:
A total of 796 patients fulfilled study criteria. 69% of women who underwent TOLAC (N=85) had a successful vaginal delivery. There were no differences in neonatal intensive care unit admissions (5.7% vs 5.9%, P=1.0) or mean APGAR scores at one (P=.38) and five (P=.42) minutes amongst women who opted for TOLAC versus repeat cesarean section. Moreover, no difference in maternal morbidity was noted with regards to blood transfusion rates (2.3% vs 2.1%, P=.71), bowel injury (0% vs 0.1%, P=1.0), bladder injury (1.1% vs 0.1%, P=.21), immediate postpartum infection (0% vs 0.8%, P=1.0) and hysterectomy (0% vs 0.1%, P=1.0).

CONCLUSION:
TOLAC following two cesarean sections has comparable maternal and neonatal morbidity with repeat cesarean section.
Racial Disparities in Neonatal Mortality Among Both Singleton and Multiple Gestations [32O]
Authors: Copeland Timothy P. , Handal-Orefice Roxane C. 
Published: April 2020

INTRODUCTION:
Previous studies have noted racial disparities in neonatal mortality. This study seeks to clarify the extent to which multiple gestation moderates the association between race and mortality risk.

METHODS:
Kid's Inpatient Database (2016), which includes a nationally representative sample of all births, was used for this analysis. A multivariate logistic regression controlling for hospital-level factors (i.e. region, size, ownership, teaching status, and local population density) and patient insurance type was used to assess the interaction between race and neonatal mortality among liveborn singleton (n=2,682,478) and twin (n=82,201) deliveries without congenital anomalies. Neonatal death among twins was defined as at least one neonatal death within each pair.

RESULTS:
White twin neonates (n=50,003) had 4.86 times the odds of death (95% CI 4.31, 5.48) compared to white singleton neonates (n=1,523,110). Black neonates had twice the odds of death compared to white singleton neonates (n=398,006; 95% CI 1.88, 2.25) and twin neonates (n=14,569; 95% CI 1.67, 2.40). Hispanic neonates also had an elevated mortality risk in both singleton (n=589,260; aOR 1.20; 95% CI 1.03, 1.27) and twin (n=12,927; aOR 1.51; 95% CI 1.10, 1.68) contexts relative to whites. Mortality among Asian singletons (n=172,103) was not significantly different from white singletons, but Asian twins (n=4,702) had 1.56 times the odds of death (95% CI 1.08, 2.25) compared to white twins.

CONCLUSION:
Black and Hispanic singleton and twin neonates without congenital anomalies had higher mortality rates compared to white neonates. The association between race and neonatal mortality is further moderated by multiple gestations.
Rates of Indicated Nulliparous, Term, Singleton, Vertex Cesarean Deliveries Among Practice Models [31P]
Authors: Brown Inga E. , Wang Tiffany , Kawakita Tetsuya , Moxley Michael 
Published: April 2020

INTRODUCTION:
There has been an increased focus on strategies to reduce the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rate since March 2014 when the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine published Obstetric Care Consensus (OCC) guidelines on the safe prevention of the primary cesarean delivery. The purpose of this study was to determine if performance of NTSV cesarean deliveries meeting OCC guidelines differed between provider practice models at Virginia Hospital Center (VHC).

METHODS:
We conducted an IRB-approved retrospective cohort study of all NTSV cesarean deliveries from January 2014 to December 2017 at VHC. A third-party reviewer determined if the indication for each delivery met OCC guidelines. Adherence was compared according to practice model (in-house providers with resident involvement, in-house providers without resident involvement, and non-in-house providers without resident involvement). Fisher exact test was used to determine whether performance of NTSV cesarean deliveries meeting OCC guidelines differed among practice models.

RESULTS:
There were 1,833 NTSV cesarean deliveries, of which 743 (40.5%) met OCC guidelines for delivery and 1,090 (59.5%) did not. Performance of NTSV cesarean deliveries meeting OCC guidelines was statistically different among provider practice models. Providers without resident involvement, in-house providers without resident involvement, and in-house providers with resident involvement had 37% (472 out of 1,271), 47% (178 out of 379), and 51% (93 out of 183), respectively, of NTSV cesarean deliveries meeting OCC guidelines (P<.001).

CONCLUSION:
In-house provider coverage and resident involvement are associated with increased performance of NTSV cesarean deliveries meeting OCC guidelines.
Preventing the Primary Cesarean: Adherence to SMFM/ACOG Guidelines by Use of Intrauterine Pressure Catheter [29P]
Authors: Gilmore Emma , Escobar Christina , Anzai Yuzuru , Arslan Alan , McClelland Spencer 
Published: April 2020

INTRODUCTION:
In order to reduce the primary Cesarean delivery (CD) rate, SMFM and ACOG offer guidelines for diagnosing arrest of dilation (AOD) and failed induction of labor (FIOL). At our institution, adherence to these guidelines is low, at 28%, but there is limited understanding of contributing factors. The intrauterine pressure catheter (IUPC) is a recognized, helpful component of labor induction protocols, but few studies have examined whether its use is related to CD rates and adherence to labor guidelines. The objective of this study is to evaluate IUPC utilization and its relationship to SMFM/ACOG guideline adherence rates.

METHODS:
A retrospective cohort analysis was conducted at our institution of all singleton primary CDs performed for AOD or FIOL between March 1st 2014 and July 3rd 2018. Cases were defined as being adherent or non-adherent to published guidelines. A chi square test was used to compare the association of guideline adherence to IUPC use.

RESULTS:
Baseline characteristics were similar between adherent and non-adherent groups. For CDs that were non-adherent to ACOG guidelines, IUPCs were utilized in 208/767 cases (27.1%). For CDs that were adherent to ACOG guidelines, IUPCs were utilized in 123/295 cases (41.7%) (P less than 0.001).

CONCLUSION:
We observed a significantly greater rate of IUPC use in CDs that were adherent to SMFM/ACOG guidelines. Overall, adherent physicians performed fewer CDs. This finding suggests that IUPC utilization may be a helpful adjunct for improving labor management and lowering primary CD rates. Interventions around physician education are needed to increase appropriate IUPC use.