bluuebunny/crossref_metadata_2025_split huggingface dataset:
Early Detection and Intervention of Postpartum Preeclampsia With the Use of Mobile and Digital Tools [29E]
Authors: Sheth Sheetal , Morin Caitlin 
Published: May 2019

INTRODUCTION:
Hypertensive disorders in pregnancy are a leading cause of morbidity and mortality. This case series examines the ability of an integrated technology platform to augment surveillance with remote blood pressure (BP) readings in low-risk pregnant women and allow for real time intervention by providers of care.

METHODS:
Pregnant women presented at the clinic of an urban academic medical center. Patients were placed on an optimized prenatal care plan that consisted of an alternative in-clinic visit schedule and an integrated technology platform, provided by a mobile/digital health firm. Patients used the mobile app as well as collected weight and BP data weekly. The platform includes advanced remote monitoring technology to identify aberrant data points. A “trigger alert” mechanism alerts clinicians when aberrant data points are identified and enable the early detection of certain high-risk conditions, such as preeclampsia. Case 1: Patient 1, G3P1010 recorded 26 BPs antenatally; all BPs were less than 140/90. Postpartum, BPs were elevated and led to hospital readmission for magnesium sulfate. Case 2: Patient 2, G3P0020 recorded 21 BPs antenatally; all BPs were less than 140/90. Postpartum, BPs were elevated and led to hospital readmission for magnesium sulfate. 15 BPs were recorded after discharged and antihypertensives were titrated according to these data points.

CONCLUSION:
Remote monitoring of BP in low-risk pregnant women resulted in frequent recordings during the antepartum and postpartum periods. Remote monitoring of BP could offer more robust monitoring in low-risk pregnancies and allow for real time identification and intervention of high blood pressure.
Is it Time to Move the Hysteroscopy Out of the Operating Room? [30E]
Authors: Echeverri Natalia , Timmons Douglas B. , Palin Hannah , Florez Laura , Ring Sarah , Carugno Jose 
Published: May 2019

INTRODUCTION:
Traditionally, hysteroscopy has been a hospital-based procedure under general anesthesia however the emergence of small diameter hysteroscopes and the vaginoscopy approach has allowed it to be transitioned to the office setting. This study compares office versus OR operative hysteroscopy with respect to success rate and operative time.

METHODS:
Retrospective chart review of 66 hysteroscopies performed in the OR under general anesthesia compared to 22 in office hysteroscopies performed without anesthesia using the vaginoscopy "no touch' technique.

RESULTS:
Patients' characteristics were similar in both groups. The procedure was successfully completed in 80% (18/22) of the in-office group and 100% (66/66) of the OR group. Hysteroscopic office procedures indications were: 2 (9.1%) postmenopausal bleeding, 5 (22.7%) retained IUD, 7 (31.8%) for suspected polyp, 8 (36.4%) for abnormal uterine bleeding. Hysteroscopic OR indications were: 2 (3.0%) abnormal uterine bleeding, 3 (4.5%) retained IUD, 11 (16.7%) postmenopausal bleeding, 50 (75.8%) suspected polyp. Mean operative time for in office hysteroscopy was 28.3 SD ±3.3 minutes versus 88.4 SD ±23.2 minutes (p<0.001). There was no complication in either group.

CONCLUSION:
In office hysteroscopy without anesthesia, using the vaginoscopy “no touch” technique, had a significantly less operative time when compared to those performed in the OR. Encouraging practitioners to adopt in office hysteroscopy would allow to eliminate anesthesia risks and optimize utilization of OR time which could represent increased patient's satisfaction and decreased cost.
Age Related Outcomes in Patients Undergoing Cytoreductive Surgery for Advanced Stage Adnexal and Uterine Cancers [36E]
Authors: Valant Roseanna Jo , Fazzari Melissa , Laitman Lauren Elisabeth , Griffiths Courtney Sarah , Jimenez Edward A. , Chalas Eva 
Published: May 2019

INTRODUCTION:
To evaluate impact of aging on extent of surgical procedure in advanced gynecologic cancers.

METHODS:
Retrospective analysis of the ACS National Surgical Quality Improvement Program targeted gynecologic data was conducted to assess frequency of cytoreductive surgery (CRS) performed in patients with stage III and IV gynecologic cancers between 2014 and 2016 using ICD-9 and CPT codes. Complication rates examined across age groups: <65, 65-74 and 75+ years old. Frequencies of complications and procedures were compared between groups via chi-square tests, age-associated trends in rates were evaluated via Cochran-Armitage tests.

RESULTS:
Of 2858 patients, 1336 had adnexal/peritoneal cancers and 1258 had uterine cancer. CRS was performed in 76% and 21% of each diagnosis, respectively. No statistical difference in the rate of CRS by age group. Patients undergoing CRS vs. non CRS for uterine cancer had increased risk of wound complication (p=0.001), venous thrombosis (p=0.02), transfusions (p<0.001), death (p=0.01), return to OR (p<0.001), and readmission (p<0.001). Those undergoing CRS for adnexal/peritoneal cancers had increased rates of transfusions (p=0.01) and any overall complication (p=0.01). When comparing across age groups, no statistically significant difference in the rate of the following post-operative complications: wound, venous thromboembolism, urinary tract infection, transfusion, death, return to the OR, or readmission. However, patients >75 with uterine cancer who had CRS were at increased risk for sepsis (p=0.05).

CONCLUSION:
In appropriately selected patients, age does not appear to impact rate of CRS or majority of perioperative complications. Older patients with advanced stage gynecologic cancers should be offered surgery based on sound clinical judgement.
Metastatic Gastric Adenocarcinoma Masked as Ectopic Pregnancy [39E]
Authors: Moon Ashley , Yu Jim G. , Henriquez Jose , Fairbairn Melissa , Chuang Linus , Andikyan Vaagn 
Published: May 2019

INTRODUCTION:
The most common cause for elevated beta-hCG in reproductive aged-women is pregnancy. Rarely, malignancy may cause persistent beta-hCG levels. We present a rare case of metastatic gastric adenocarcinoma masked as an ectopic pregnancy.

METHODS:
34Y G2P2 healthy patient presented for intrauterine device removal where routine urine pregnancy test was positive. Beta-hCG was 287, which continued to plateau without sonographic evidence of intrauterine pregnancy. Methotrexate was given for suspected ectopic pregnancy. Beta-hCG fluctuated between 300-500. Ultrasound revealed solid mass in left adnexa and she underwent exploratory laparoscopy; however, intraoperative findings revealed normal fallopian tubes and bilateral corpus luteal cysts with no evidence of ectopic pregnancy. Second dose of methotrexate was given but beta-hCG continued to increase. She developed worsening abdominal pain, nausea, chest pain, dyspnea. CT chest/abdomen/pelvis revealed mediastinal, periaortic and upper abdominal lymphadenopathy, and bilateral lung nodules. AFP 111.9, CA 125 36, CA 19-9 649, CEA 11.9. Retroperitoneal lymph node biopsy and upper endoscopy revealed ulcerated, fungating gastric mass consistent with poorly differentiated adenocarcinoma. FOLFOX chemotherapy was started. Her worsening dyspnea called for CT angiography, revealing pericardial effusion, which required pericardiocentesis and a pericardial window. Pericardial fluid consisted of malignant cells and beta-hCG continued to increase, indicating worsening prognosis. She died from malignancy progression 7 weeks after diagnosis.

CONCLUSION:
Persistently elevated beta-hCG without response to methotrexate or surgical intervention may raise suspicion for rare presentations of malignancy. Our case demonstrates metastatic gastric adenocarcinoma can present with increasing beta-hCG serum levels without evidence of gynecologic disease.
Ethical Considerations in Immediate Postpartum Long-Acting Reversible Contraceptive Care [2F]
Authors: Allan Katie , Moniz Michelle , Harris Lisa Hope , Loder Charisse Marie. , Spector-Bagdady Kayte 
Published: May 2019

INTRODUCTION:
Hospitals across the country are implementing immediate postpartum long-acting reversible contraceptive (LARC) programs. Our objective was to qualitatively evaluate representative services through the lens of clinical ethics.

METHODS:
We conducted a multiple case study using a literature review to identify academic hospitals providing immediate postpartum LARC. We conducted in-person, semi-structured interviews with 66 key informants across 11 facilities. Two authors independently analyzed data using a framework analysis based on the Armstrong Clinical Ethics Coding System. Authors obtained IRB exemption.

RESULTS:
Analysis revealed three significant ethical considerations. First, we found that most sites do not offer immediate postpartum LARC to all patients, instead offering it only to patients with insurance coverage for this care-generally Medicaid recipients. Service delivery thus leads to disparities in LARC access and the potential targeting of LARC to marginalized populations. Second, we identified challenges with informed consent processes: providers struggled to promote both LARC access and patient autonomy (e.g., providers grappled with the appropriateness of newly offering LARC to a laboring woman versus the paternalism of not offering LARC at all). Third, while patient needs and preferences were a major motivating factor in establishing immediate postpartum LARC programs, no site had corresponding provisions to enhance access to subsequent LARC removal.

CONCLUSION:
Hospitals offering immediate postpartum LARC contend with important ethical issues, including providing equitable access to contraceptive care, creating robust informed consent processes, and ensuring access to LARC removal. Engaging with patients and a reproductive justice framework when designing these programs may help hospitals adopt safeguards to promote patient-centered care.
Mineralocorticoid Receptor in the Primate Endometrium Throughout the Menstrual Cycle [5F]
Authors: Demirel Esra , Sabouni Reem , Pakrashi Tarita , Archer David F 
Published: May 2019

INTRODUCTION:
Throughout the menstrual cycle, the endometrium undergoes morphological and biochemical changes reflecting ovarian hormone secretion. These changes are associated with specific receptors located throughout the endometrial tissue. Alongside receptors for ovarian hormones, the human endometrium contains all of the elements of renin-angiotensin-aldosterone system (RAAS). Given certain progestins play a role in RAAS modulation through anti-mineralocorticoid properties, we believe that the mineralocorticoid receptor (MR) has a significant role in the menstrual cycle and potentially in abnormal uterine bleeding (AUB).

METHODS:
Full-thickness uterine samples were obtained from adult female rhesus macaques during an artificial menstrual cycle controlled with estrogen (E) and progestin (P) implants at 3 separate points: menstrual (E-3P), proliferative (14dE) and secretory (E+5P). Tissue sections were immunohistochemically stained and evaluated under bright microscopy. ImageJ analysis software was used to analyze vasculature for integrated density and area fraction.

RESULTS:
MR is present in the endometrial endothelial cells during all three phases of the menstrual cycle in rhesus macaques. The percent area was 25.54% in the proliferative phase, 18.86% in the menstrual phase, 17.34% in the secretory phase.

CONCLUSION:
MR has been identified for the first time to our knowledge within the endometrial endothelial cells. Given the anti-mineralocorticoid properties of certain progestins used for contraception and their association with amenorrhea or AUB, MR antagonism specifically may explain these changes. In select patient populations, such as obese females at increased risk for hypertension and elevated aldosterone activity, the increased incidence of amenorrhea on certain progestin-only contraceptives may be related to higher degree of anti-RAAS activity within the endometrium.
Induction of Labor Compared With Expectant Management and Risk of Cesarean Delivery in Obese Women [7F]
Authors: Staudenmaier Emily K. , Chatterton Carolyn G. , Montanez Marelli , Sampino Isabella , Vullo John J. , Gurram Padmalatha 
Published: May 2019

INTRODUCTION:
Obesity is a known independent risk factor for stillbirth. The obesity related stillbirth risk increases with advancing gestational age. There is no clear consensus regarding antepartum surveillance to reduce the risk of stillbirth. Therefore, the timing of delivery is a concern for the obstetric provider. The purpose of this study is to determine if obesity increases cesarean delivery rates in elective inductions at term when compared to expectant management. Antepartum, intrapartum, and neonatal complications were also compared between the groups.

METHODS:
This is a retrospective chart review of women delivered after 37 weeks gestation and with a BMI greater than 30 kg/m2 between 2015-2016 at our institution. Women admitted for elective induction of labor (N=104) were compared to those admitted in spontaneous labor (N=144). Medical indications for inductions of labor, malpresentation, fetal anomalies, and multiple gestations were excluded. Institutional Review Board approval was obtained.

RESULTS:
Maternal characteristics were similar between the two groups (p>0.05). There were no significant differences in antepartum, intrapartum and neonatal complications between the groups (p>0.05). There are no stillbirths in either group. The rate of cesarean delivery is significantly higher (p=0.029) for patients admitted for elective induction (43.3%) compared to those admitted in spontaneous labor (27.8%).

CONCLUSION:
Expectant management in obese women is associated with decreased rates of cesarean delivery without increased incidence of adverse outcomes compared to elective induction of labor.
Serologic Confirmation of Rubella Immunity During Index Pregnancy Can Eliminate Re-testing in Later Pregnancies [11F]
Authors: Kamath Shiwani , Varrey Aneesha , Landres Inna V. 
Published: May 2019

INTRODUCTION:
Vaccination ended endemic rubella transmission in America with the last documented case of congenital rubella syndrome in 2004. The American College of Obstetrics and Gynecology recommends rubella susceptibility screening as a prenatal lab for all pregnancies. As no studies in the United States support or contest this, we explored whether women with documented immunity during their index pregnancy demonstrated serologic evidence of Rubella immunity during subsequent gestations.

METHODS:
A retrospective cohort study of Medicaid insured pregnant women receiving prenatal care at an urban clinic from 2012-2017 was undertaken. Only those with documented immunity during their initial antenatal visit and repeat serologies during subsequent pregnancies were included. Immunity was defined as rubella IgG antibodies titers greater than 10 IU/mL. All patient protected health information has been de-identified and patient faces are entirely covered.

RESULTS:
Five hundred women were screened for study eligibility with rubella serologies obtained in 318 during both index and subsequent pregnancies. In this cohort, 94.3% (n=300) were noted to be immune during their index pregnancy. Among this immunized population, 98.3% continued to demonstrate serologic immunity during subsequent pregnancies. There was no relationship between the time interval between pregnancies and rubella sero-conversion rates.

CONCLUSION:
Our data indicates 98% of women with rubella immunity during their first pregnancy maintain immunity during subsequent pregnancies. Given rates of retained immunity and low disease prevalence with routine vaccination, this study suggests reconfirmation of rubella immunity during subsequent pregnancies is unnecessary. Given the small sample size and retrospective nature of data, large, prospective studies evaluating the sero-conversion rate between pregnancies and the cost-effectiveness of screening prior to every pregnancy are warranted.
Outpatient Expectant Management of Premature Rupture of Membranes for Women Who Decline Augmentation [14F]
Authors: Chacon Kelly M. , Bryant Mantha Allison S. , Clapp Mark A. 
Published: May 2019

INTRODUCTION:
In our institution, women with premature rupture of membranes (PROM) who decline augmentation are offered outpatient expectant management (OEM) for 24 hours. Our objective was to determine if patients who chose OEM had different time-to-delivery intervals than patients who chose admission.

METHODS:
This is a retrospective cohort of nulliparous, term women with singleton, vertex-presenting fetuses who presented with PROM from July 2016 to June 2017 at a single institution. Women were eligible for OEM if they were Group B Streptococcus negative, afebrile, had clear fluid, and reactive non-stress tests. Primary outcomes included time from PROM-to-delivery and from admission-to-delivery. Secondary outcomes included chorioamnionitis, cesarean delivery, and neonatal intensive care unit admission. Outcomes were compared using chi-squared and Wilcoxon rank-sum tests, and then adjusted for age, race, insurance, gestational age, augmentation, and provider type using multivariable regressions. IRB approval was obtained.

RESULTS:
Of 127 eligible women, 74 chose admission and 53 chose OEM. OEM patients had significantly longer PROM-to-delivery intervals than admitted patients (median 29.3 vs 19.2 hours, P<.001), but were more likely to deliver within 24 hours of admission (94.3 vs 74.6%, P=.004). In the adjusted analysis, PROM-to-delivery was 8.1 hours longer (95% CI 4.7-11.6) and admission-to-delivery was 4.5 hours shorter (95% CI 1.7-7.4) for OEM patients. There were no differences in secondary outcomes.

CONCLUSION:
Outpatient management of term PROM shortens the interval from admission-to-delivery, reducing hospital resource utilization among low-risk women. However, given the known increased risk of infection with prolonged PROM, more research is needed to assess the safety of this protocol.
Intrapartum Characteristics and Prognosis Associated With Neonatal Hypoxic-Ischemic Encephalopathy [15F]
Authors: Ravichandran Lavanya , Allen Victoria M. , Vincer Michael , Kuhle Stefan , Filliter Christopher , Baskett Thomas F. 
Published: May 2019

INTRODUCTION:
Neonatal hypoxic-ischemic encephalopathy (HIE) is associated with neonatal mortality, acute neurological injury and long-term neurodevelopmental disabilities; the role of intrapartum factors remains unclear.

METHODS:
This population-based cohort study employed linked obstetrical and newborn data derived from the Nova Scotia Atlee Perinatal Database (NSAPD, 1988-2015) and the Perinatal Follow-Up Program Database (2006-2015) for all pregnancies with live, non-anomalous newborns ≥35 weeks, born without pre-labor caesarean section. HIE was defined using standard definitions. Temporal trends in HIE incidence are described; Fisher's exact test and logistic regression were used to test the associations of intrapartum factors with HIE.

RESULTS:
The NSAPD identified 227 HIE cases out of a population of 226,711 pregnancies from 1988 to 2015, with a decrease in incidence from 0.14% to 0.1% through those years (P=0.01). Women with clinical chorioamnionitis in labor (OR 8.0, 95% CI 4.7-17), emergency operative delivery (OR 9.9, 95% CI 7.3-13), shoulder dystocia (OR 3.4, 95% CI 2.1-5.4), placental abruption (OR 19, 95% CI 12-29), and cord prolapse (OR 32, 95% CI 17-61) were more likely to have newborns with HIE. Two-thirds of newborns with HIE had an abnormal intrapartum FHR tracing. There was an infant mortality rate of 28% by age 3; neurodevelopmental outcomes in the surviving infants with HIE were normal in 33% and showed severe developmental delay in 37%.

CONCLUSION:
Overall, the rate of HIE was low in late-preterm and term infants. The identification of associated intrapartum factors should promote increased surveillance and careful management to optimize newborn outcomes.
Inpatient Versus Outpatient Labor Induction: A Systematic Review and Meta-analysis [19F]
Authors: D'Souza Rohan D. , Khan Maria , Hashimi Farahnosh 
Published: May 2019

INTRODUCTION:
The purpose of this study was to compare clinical and cost outcomes between inpatient and outpatient labor induction.

METHODS:
A systematic review of randomized controlled trials (RCTs) that compared inpatient vs. outpatient induction was conducted. Four databases were searched for RCTs published in English, which compared any method of outpatient vs. inpatient labor induction. As significant heterogeneity between studies was anticipated, random-effects meta-analysis was conducted. Results were presented as odds ratios (OR) and mean difference (MD) with 95% confidence intervals (95% CI) as appropriate.

RESULTS:
We identified 695 studies of which 10 representing 7 RCTs (2038 patients) conducted in Australia (n=3), Canada, Portugal, the Netherlands and United States were included in the final analysis. Three RCTs compared induction using balloon catheters, two compared prostaglandins, one compared balloon catheters (outpatient) vs. prostaglandin (inpatient) and one compared outpatient amniotomy vs. inpatient induction using the obstetricians' method of choice. Outpatient vs. inpatient induction was associated with a significant reduction in admission-to-delivery duration [2 studies, 231 patients: MD 11.78 hours (7.09, 16.49)]. There was no difference in use of epidural analgesia [4 studies, 475/863 vs. 454/832, OR 1.04 (0.84, 1.27)], oxytocin [4 studies, 292/643 vs. 269/632, OR 1.143 (0.52, 2.52)], vaginal birth [5 studies, 392/708 vs. 388/697, OR 0.97 (0.70, 1.32)], hyperstimulation [4 studies, 12/643 vs. 9/632, OR 1.27 (0.52, 3.11)] or costs [MD $80.21 (-638.20, 798.61)].

CONCLUSION:
Outpatient labor induction is associated with shorter admission-to-delivery duration, with no significant differences in adverse clinical or cost outcomes and may therefore be considered as an alternative to inpatient IOL in low-risk pregnancies.
Obstetric Neuraxial Anesthesia in the Context of Immune Thrombocytopenia: A Systematic Review [20F]
Authors: Bailey Liane J. , De France Bryon , Shehata Nadine , Carvalho Jose , Malinowski Ann Kinga 
Published: May 2019

INTRODUCTION:
Immune Thrombocytopenia (ITP) is characterized by preserved platelet function. The true magnitude of neuraxial hematoma risk in ITP parturients is unknown, yet obstetric neuraxial anesthesia (OBNA) is often withheld. The aim of this systematic review was to examine OBNA outcomes in ITP with platelet counts below 100x10(9)/L.

METHODS:
Relevant literature database-entries were searched to May 2018. Citations were independently screened and extracted in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale, NIH Case Series Assessment Tool and Joanna Briggs Institute Case Reports Checklist, as appropriate. Study authors were contacted for additional information.

RESULTS:
Our search yielded 954 titles/abstracts for screening with 62 full-texts reviewed, 26 included, and individual patient data obtained for 9. Of 291 individuals, 166 received OBNA; 61 at platelet counts below 80x10(9)/L. No neuraxial hematomas were reported. Median platelet counts were 80-93x10(9)/L. In a meta-analysis of 6 studies, platelets were higher in those with OBNA than those without [mean difference (MD), (95% confidence interval) 19 (3, 25) x10(9)/L; p<0.00001], but did not differ between epidural and spinal anesthesia [MD 0.4 (-14, 20) x10(9)/L; p=0.86]. The “rule of three” places the upper bound of the 95% confidence interval for neuraxial hematoma risk at 1.8%.

CONCLUSION:
Our study further supports the quest to establish safety of OBNA in ITP at lower platelet counts. It highlights the reluctance to offer OBNA below the 80x10(9)/L threshold suggested by guidelines, yet based largely on theoretical presumption of risk. Given the rarity of OBNA in ITP at progressively lower platelet counts, an international registry could prove indispensable.