bluuebunny/crossref_metadata_2025_split huggingface dataset:
Hydralazine Versus Labetalol for Acute Hypertension in the Peripartum Patient [26K]
Authors: Scholl Jessica , Chan-Akeley Rosalyn , Leizer Julie , Skupksi Daniel 
Published: May 2019

INTRODUCTION:
Women in the peripartum period with acute severe hypertension require urgent antihypertensive therapy. First-line management with either intravenous (IV) Labetalol or IV Hydralazine has been endorsed by ACOG, with the choice of antihypertensive left to the discretion of the clinician. Our objective was to assess whether IV Labetalol or IV Hydralazine has better efficacy in treating acute severe hypertension in the peripartum period.

METHODS:
This was a retrospective cohort study including patients from 2013 to 2018. We identified peripartum patients presenting with severe acute hypertension, defined as systolic blood pressure (BP) greater than or equal to 160 mmHg or diastolic BP greater than or equal to 110 mmHg. Records were reviewed for patient characteristics, treatment used, and BP effect after the initial medication dose.

RESULTS:
There were 170 patients included. In 142 cases IV Labetalol was used, and in 28 cases IV Hydralazine was used. Patient characteristics were similar between the groups, with the exceptions of a greater presence of chronic hypertension in the Labetalol group, and greater percentage of postpartum patients in the Hydralazine group. The use of Hydralazine was successful in achieving the target BP more frequently than Labetalol (71% vs 50%, P=0.04), with greater median decrease in systolic BP (18.5 mm Hg vs 11.5 mm Hg, P=0.03). There were no differences in the success of decreasing diastolic BP or mean arterial pressure.

CONCLUSION:
IV Hydralazine may provide better efficacy in BP control for the peripartum patient compared to IV Labetalol. We advocate for the conduction of a randomized controlled trial.
Hyponatremia in Patients With Intrapartum Hospital Transfer After Planning an Out-of-Hospital Birth [28K]
Authors: Kjos Kari , Stephenson-Famy Alyssa , Eschenbach David Arthur , Chandrasekaran Suchitra 
Published: May 2019

INTRODUCTION:
Most intrapartum transfers after planned out-of-hospital birth (“midwife transfers”) are for labor complications. Hyponatremia can be a consequence of prolonged labor and excessive oral hydration, and is associated with adverse maternal-neonatal outcomes. We sought to evaluate the association between obstetrical outcomes and maternal sodium levels in midwife transfers.

METHODS:
We performed a retrospective cohort study evaluating all singleton, term, midwife-transfers in labor at a single tertiary care academic medical center from 2009-2015. Maternal demographic data, sodium levels, obstetrical and neonatal outcomes were collected. Categorical variables were compared using chi-square or Fisher's exact score, and continuous variables were compared using ANOVA or Kruskal -Wallis tests.

RESULTS:
For 374 intrapartum midwife-transfers, the mean gestational age was 40 weeks, 5% (n=17) had previous cesarean section, mean duration of membrane rupture was 19 hours, and 39% (n=145) had meconium stained amniotic fluid. Ten percent (n=41) had a sodium nadir ≤130 mEq/L, 22% (n=82) had a sodium nadir >130 mEq/L and 67% (n=251) did not have a sodium level recorded. Complications in this cohort included high rates of cesarean section (50%, n=187), postpartum hemorrhage (12%, n=44), chorioamnionitis (16%, n=59), and neonatal demise (0.8%, n=3). While hyponatremia (sodium ≤130 mEq/L) was not associated with significant increase in maternal or neonatal morbidity, two symptomatic women with sodium <120 mEq/L required intensive care.

CONCLUSION:
In our cohort, midwife transfers represent a high-risk obstetrical group regardless of sodium level. Sodium levels in midwife-transfers should be obtained in those with neurologic symptoms.
Impact of CALM Initiative and Timing of AROM on NTSV Cesarean Section Rate [30K]
Authors: Gallagher Kristen , Wahl Geneva , Takhsh Eden , Lombard Emily , Reynolds Peyton , Davies Jeffrey 
Published: May 2019

INTRODUCTION:
Nulliparous, term, singleton, vertex (NTSV) cesarean section rate is an AHRQ (Agency for Healthcare Quality and Research) quality indicator and Healthy People 2020 has set a target of 23.9% for this measure. Our institution adopted this target with a goal of decreasing our rate by implementing the “Consistent Approach to Labor Management” (CALM) initiative in 2017. As part of this initiative, an effort was made to limit interventions in early labor including delay of amniotomy until 4cm dilation.

METHODS:
Action plans were developed with inspiration from the California Maternal Quality Care Collaborative (CMQCC) initiatives. Data was collected from 2016, prior to the institution of our CALM initiative, and compared to 2017. Primary outcome measurements included artificial rupture of membranes (AROM) versus spontaneous rupture of membranes (SROM) and cesarean section rate.

RESULTS:
NTSV cesarean section rate in 2016 was 31.6% and 24.4% in 2017. Cesarean section rate was 39.0% in the AROM group in 2016 versus 23.8% in 2017. Rate of cesarean section in the SROM group in 2016 and 2017 were 22.6% and 22.8%, respectively. In 2017, the cesarean section rate was 41.7% if AROM was performed prior to 4cm cervical dilation and 19.4% if performed after 4cm cervical dilation. These respective rates for 2016 were 48.7% and 23.8%. The percentage of patients that had AROM prior to 4cm was decreased by 42.8% between 2016 and 2017.

CONCLUSION:
Delayed AROM until after 4cm dilation, as part of the CALM initiative implementation, resulted in a 39% decrease in NTSV cesarean section rate.
Comparison of Embryo Transfer Techniques in Assisted Reproductive Technology (ART) Cycles [35K]
Authors: Ligon Sarah , Chaffin Kimberly Ann , Pier Bruce D. , Levy Gary 
Published: May 2019

INTRODUCTION:
Different transfer techniques have been developed to optimize the embryo transfer process and maximize the probability of pregnancy after transfer. The purpose of this study is to compare the afterload (AL) embryo transfer technique and the post-mock (PM) embryo transfer technique.

METHODS:
We designed a retrospective cohort study which included women who underwent an autologous, fresh or cryopreserved embryo transfer (ET) between 01 July 2013 and 01 September 2016 at our academic center. Embryo transfer was performed with either the afterload technique (AL) or the immediate post-mock (PM) transfer technique. The primary outcome of interest was ongoing pregnancy rate (OPR) defined as fetal cardiac activity on first trimester ultrasound. This study was approved by the Tripler Army Medical Center Department of Clinical Investigation Scientific Review Committee and Institutional Review Board.

RESULTS:
There was no significant difference in OPR between patients that underwent AL transfers and PM transfers (AL 51%, PM 57%; P=.378). Ongoing pregnancy rate for frozen embryo transfers was superior for AL transfers compared to PM transfers (AL 68%, PM 31%; P=.005). Ongoing pregnancy rate was superior with the PM technique for fresh embryo transfers (AL 43%, PM 63%; P=.002). Ongoing pregnancy rate decreased with age in the AL cohort, but not in the PM cohort (P=.004).

CONCLUSION:
There appears to be no overall difference in OPR between AL and PM transfer technique. However, with vitrified embryos, the AL technique demonstrated a higher OPR, and with fresh embryos, the PM technique resulted in a superior OPR.
Inappropriate Use of Antibiotics in Benign Gynecologic Surgery [2L]
Authors: Chu Amanda , Disturco Mariella , Ahn Seungjun 
Published: May 2019

INTRODUCTION:
Preoperative antibiotic overuse contributes to unnecessary healthcare costs, harmful drug reactions and the creation of drug resistant bacteria. Study objective was to examine inappropriate antibiotic use among laparoscopic gynecologic surgeries and evaluate for targetable trends.

METHODS:
This is a single center retrospective cohort study. We examined all laparoscopic gynecologic surgeries performed at Lenox Hill Hospital from 2016-2017. There were a total of 1269 cases performed by 63 gynecologists. Cases where antibiotics were indicated were excluded; 794 cases were studied. The two sample t-test was used for continuous variables and a Fisher's exact test or chi-square test were used to compare categorical variables between groups. Results were statistically significant if p < 0.05. Analysis was conducted using SAS v. 9.4.

RESULTS:
Antibiotics were inappropriately given in 80.3% of all procedures that met criteria. Myomectomies and endometriosis surgeries were more likely to receive antibiotics than adnexal surgeries. Faculty physicians were more likely to appropriately withhold antibiotics than voluntary staff (39.7% vs 11.4%, p < 0.001), oncologists were more likely than benign gynecologists to withhold antibiotics (36.3% vs. 17.5%, p < 0.001) and low volume surgeons were more likely than high volume to withhold antibiotics (35.8% vs. 12.4%, p < 0001). Diabetes and smoking status were both examined and did not appear to influence the decision to administer antibiotics. Low rates of 30 day complications (<1%) were seen among both groups.

CONCLUSION:
Future directions are to correct the high use of inappropriate antibiotics at our institution and target the groups most at risk.
Can the New ACGME RRC Hysterectomy Requirements Be Fulfilled at Inner City Academic Centers? [3L]
Authors: Sidduri Nishanth , Ackroyd Sarah , Rose Marisa 
Published: May 2019

INTRODUCTION:
The ACGME and ACOG promote the use of minimally invasive approaches for hysterectomy when feasible. In 2018, the ACGME Residency Review Committee increased the number of minimally invasive (MIS) hysterectomies required for trainees to graduate residency.

METHODS:
Retrospective cohort study using the 2016 hysterectomy-specific National Surgical Quality Improvement Program (NSQIP) database. Demographics, comorbidities and surgical characteristics were examined by hysterectomy type. The association between race and hysterectomy type was investigated using one and two-way analysis of variance (ANOVA).

RESULTS:
20,770 hysterectomies for benign indications were identified. Across all races, 25.7% underwent abdominal hysterectomy, 57.4% underwent laparoscopic hysterectomy and 16.9% underwent vaginal hysterectomy. Black women were more likely to undergo abdominal hysterectomy than white women (41.4% vs 20.1%, respectively, p<0.001), and less likely to undergo both laparoscopic and vaginal hysterectomy (47.5% vs 61.9% and 11.1% vs 18.0%, respectively, p<0.001). After adjusting for uterine weight (0-100g, 100-250g, and >250g), black women were still more likely to undergo abdominal hysterectomy compared to other races (p<0.001). Additionally, when adjusting for history of prior abdominal or pelvic surgeries, black women were more likely to undergo abdominal hysterectomy compared to other races (p<0.001).

CONCLUSION:
African American women disproportionately undergo higher rates of abdominal hysterectomy compared to other racial groups. Trainees at academic medical centers with high-risk and higher proportion of African American patients may experience difficulty fulfilling the number of minimally invasive hysterectomies required for graduation. Further efforts to identify the etiology of racial disparities in route of hysterectomy should be pursued.
Development and Validation of Diagnostic Hysteroscopy Simulation Curriculum [9L]
Authors: Porter Anne , Fuller Tobi , Lupo Andrew , Walsh Teresa , Kho Kimberly 
Published: May 2019

INTRODUCTION:
Hysteroscopy is a cornerstone operative skill for gynecologists. As with other technical skills, simulation training may improve performance in the OR. Cavitary foods (e.g. bell pepper) have been used as models but these have the limitation of being inflexible and short lived. We have developed a low-fidelity, reusable and reproducible training model using a clear plastic bottle for hysteroscopic simulation. This purpose of this study is to test the face and construct validity of that model.

METHODS:
This is a prospective observational study. In 2017 and 2018 first year residents in Obstetrics and Gynecology at UT Southwestern completed the curriculum, including instructional videos, pre-test and post-test surveys and a the simulation task. Expert faculty administered an objective structured assembly of technical skills (OSATS) and recorded times required to assemble the hysteroscope and perform the simulation. Residents were given 6 weeks for independent practice with the model after which the OSATS and performance times were collected again.

RESULTS:
36 first year residents and 4 faculty experts completed the simulation. Following independent practice, resident OSAT scores improved by 11 points (SD ± 8, out of 39 potential total points) on assembly of hysteroscope and 9 points (SD ± 3.5, out of 15 potential points) on simulation tasks. Resident OSATS scores improved significantly (p<0.005) between pre-test and post-test. Experts scored significantly higher than the residents on the OSATS overall (p < .001).

CONCLUSION:
Our study supports the use of our reusable hysteroscopic training model as a way to improve resident performance in a simulation environment.
Impact of Maternal Obesity on Outcomes in Late Preterm Prelabor Rupture of Membranes [11L]
Authors: Lynch Tara A. , Colihan Sarah , Malshe Amol , Varlamov Anna , Soto-Torres Eleazar , Olson-Chen Courtney 
Published: May 2019

INTRODUCTION:
Morbidity associated with preterm prelabor rupture of membranes (PPROM) is primarily related to infectious complications and gestational age at delivery. Obesity is a known risk factor for adverse pregnancy outcomes. There is no data on the impact of obesity on outcomes in pregnancies with PPROM after 34 weeks.

METHODS:
Secondary analysis of a multicenter retrospective cohort study of singletons with PPROM from January 2011-April 2017. Women with a delivery BMI of ≥30 kg/m2 (obese) were compared to women with a delivery BMI of <30 kg/m2 (non-obese). Pregnancies were also stratified based on hospital delivery policies of expectant management (EM) until 35 weeks versus immediate delivery (ID) ≥34 weeks. The primary outcome was neonatal ventilation. Univariate and general estimating equations models were used with p<0.05 level of significance.

RESULTS:
259 mother-infant dyads were included and 122 (47%) women were obese. Pregnancies complicated by obesity had increased need for neonatal ventilation as compared to non-obese pregnancies (15.4% in obese versus 8.2% in non-obese, adjusted p<0.001). Obesity was also associated with increased neonatal supplemental oxygen administration, surfactant administration and neonatal antibiotic use >72 hours. However, when stratified by delivery practice and obesity only neonatal antibiotic use >72 hours was significantly lower in obese pregnancies with ID (5.9%) as compared to obese pregnancies with EM (25.0%, p=0.004).

CONCLUSION:
Pregnancies complicated by PPROM and obesity have an increased risk for neonatal respiratory and infectious morbidity. These findings suggest that obesity and delivery timing impact perinatal outcomes in pregnancies with late PPROM.
Impact of Regional Variation and Practitioner Bias on Infant Mortality Rate: A Survey Study [12L]
Authors: Polen-De Clarissa , Kamath-Rayne Beena , Goyal Neera , DeFranco Emily A. 
Published: May 2019

INTRODUCTION:
Periviable birth is a primary driver of IMR in the US and varies significantly among regions. We measured practice variation in how periviable pregnancy outcomes are categorized and how this impacts reported regional IMRs.

METHODS:
We distributed a 28-item questionnaire to practitioners associated with US birth hospitals. Five clinical scenarios were included to identify how participants classify birth outcomes from 15-22 weeks. Practice characteristics potentially affecting reporting of birth outcomes were assessed. IRB approval was obtained.

RESULTS:
Of 1024 questionnaires distributed, 237 were completed (23% response rate). Responses were compared among US census regions; 8.4% from the Northeast, 56.1% Midwest, 13.9% South, 5.4% West; 16% did not disclose. Despite >90% participants classifying a 14-week loss without signs of life as a miscarriage, 19% would provide a certificate of fetal death. 51% who would not initially provide a certificate would give one upon request, yielding a potential fetal death reporting rate of 32% for a 14-week pregnancy loss. Likewise, 32% would provide a certificate of live birth for a 16-week loss with signs of life, with notable regional variation in classifying this as a live birth (41% Northeast, 44% Midwest, versus 13% South, 18% West, p=0.003).

CONCLUSION:
Practice variation in recording birth outcomes at periviable gestational ages was noted in our study. This may contribute to significant misrepresentation of the frequency of miscarriage, stillbirth and live births and could influence regional variation in reported birth outcomes.
Implementation of an Electronic Pain Management Order Set and the Effect on Postpartum Pain Control [16L]
Authors: Parsanian Lucineh Cristina , Gedeon Myrlande , Clare Camille Angela , Shilkrut Alexander G. 
Published: May 2019

INTRODUCTION:
The purpose of this project was to determine whether the implementation of an electronic pain management order set will have an effect on postpartum pain control.

METHODS:
In this IRB exempt quality improvement project, a standardized pain medication order set was implemented and an electronic version placed in the electronic medical record at New York City Health + Hospitals/Metropolitan in March 2016. A retrospective review of randomly selected charts from the postpartum unit was performed from January to December 2016, and pain management satisfaction and the completeness of a pain medication order set were recorded, pre- and post-implementation. The outcomes of the study were pain order completeness on chart review and patients' survey-reported pain management satisfaction scores.

RESULTS:
A total of 209 patient surveys and 292 charts were reviewed. 16.3% of the charts had completed pain medication entry pre-implementation of the order set compared with 78% post-implementation (p<0.0001). After the implementation of the order set, 98.4% of patients answered that pain medication was given immediately after being requested, and 96.7% of patients answered that the pain medication they received relieved their pain compared to 86.2% and 88.5%, respectively, prior to March 2016 (p<0.005 and p<0.0098). Patient pain management satisfaction in the Press Ganey HCAHPS survey was noted to increase from an average of 56% in 2013-2015 to 71.5% in 2016 (p=0.018).

CONCLUSION:
The implementation of a standardized pain management order set is associated with the increased completeness of pain management orders, as well as the improved perception of a patient's pain management satisfaction.
Incidence and Predictors of Psychiatric Illness During Pregnancy and After Delivery Among TRICARE Beneficiaries [23L]
Authors: Ranjit Anju , Androtti Tomas , Jiang Wei , Lutgendorf Monica Ann , Robinson Julian Norman , Haider Adil H. 
Published: May 2019

INTRODUCTION:
To determine the incidence and predictors of psychiatric illnesses during pregnancy and within one year after delivery.

METHODS:
This was an IRB approved protocol using TRICARE claims data to identify mothers (without previous psychiatric illness up to two years before pregnancy) who delivered between 2009-2013. The incidence of any psychiatric illness (including peripartum onset depression) during pregnancy and within one year of delivery were identified using ICD-9 codes. Predictors for the development of new psychiatric illness were determined using step-wise logistic regression models adjusted for demographic/clinical characteristics.

RESULTS:
A total of 104,866 women met the inclusion criteria. Among them, 85.4% were 20-34 years of age, 57.4% were White, 12.4% African-American, and 21.5% were active duty women. Among all, 15,636 (14.9%) and 20,566 (19.6%) were diagnosed with at least one psychiatric illness during pregnancy and within one year of delivery, respectively. In multivariable adjusted models, African-American race (aOR [CI]: 1.16 [1.10-1.22]), active duty status (aOR [CI]:1.18 [1.13-1.24]), and severe maternal morbidity during delivery (aOR [CI]: 1.16 [1.02-1.32]) were significantly associated with occurrence of any psychiatric illness within one year of delivery. Active duty women were twice as likely to be diagnosed with post-traumatic stress disorder (aOR [CI]: 2.31 [1.83-2.90]) during pregnancy or after delivery.

CONCLUSION:
In military beneficiaries, development of psychiatric conditions in pregnancy and within a year of delivery is common, and may be associated with race, active duty status and complicated births. Future studies should explore these relationships to assess timing of development of new psychiatric conditions and risk factors for screening and intervention.
Indications for Preterm Birth Stratified by Gestational Age [25L]
Authors: Haddad Andrew , Mokhtari Neggin Bayat , Iqbal Sara Naeem , Fries Melissa H. 
Published: May 2019

INTRODUCTION:
Preventive interventions such as 17 alpha hydroxyprogesterone caproate are available to decrease preterm deliveries (PTD); however the rate remains high. In order to identify other opportunities to decrease PTD, we sought to examine the indications that lead to these deliveries.

METHODS:
This was a retrospective cohort study of all PTD from June 1, 2016 to March 31, 2018. IRB number 2018-214 was approved. Causes of PTD were categorized by gestational age (GA) at delivery: category I (23 0/7-27 6/7), II (28 0/6-31 6/7), III (32 0/7-33 6/7), and IV (34 0/7-36 6/7 weeks). The causes were characterized as either fetal anomalies, fetal conditions (intrauterine growth restriction, oligohydramnios, non-reassuring status) or maternal conditions (rupture of membranes, preeclampsia, preterm labor, stillbirth). Multivariable logistic regression analyses were performed to calculate adjusted odds ratios (aOR) with 95% confidence intervals (95% CI), controlling for age, race/ethnicity, parity and body mass index. Category IV was considered as reference.

RESULTS:
Of 694 PTD, 85.6% were due to maternal causes and 14.4% to fetal causes. The rates of fetal causes were higher in category I (36.8%) compared to category IV (10.3%), P<.001. PTD in category I was associated with fetal conditions (aOR 2.24 (95% CI 1.15-4.36) and stillbirth (aOR 7.18 (95% CI 2.28-22.60), whereas PTD in categories II and III was more associated with preeclampsia (aOR 2.61 (95% CI 1.50-4.54) and aOR 1.87 (95% CI 1.09-3.20), respectively)).

CONCLUSION:
While PTD prevention currently focuses on maternal conditions, further studies that focus on fetal indications are required to decrease PTD at earlier gestational ages.