bluuebunny/crossref_metadata_2025_split huggingface dataset:
Are Postpartum Hemorrhage Kits Enough? Evaluating Their Impact on Maternal Blood Loss [39C]
Authors: Stark Sydney , Gibson Kelly S. 
Published: April 2018

INTRODUCTION:
Postpartum hemorrhage (PPH) is a common complication and preventable maternal mortality. We hypothesized our units PPH medication and supply kits would lead to lowered and sustained blood loss in PPH cases.

METHODS:
Retrospective cohort study of PPH cases 18 months prior to kits (PRE), 12 months after (POST-1), 12-24 months after(POST-2). Cases include women ≥18 years with PPH in perinatal database or uterotonics noted in pharmacy database. PPH defined as >500ml estimated blood loss (EBL) at vaginal, >1000ml EBL at cesarean delivery. Primary outcome was median blood loss measured qualitatively through EBL and quantitatively through hemoglobin change (Hgb). Time to medication administration was assessed. ANOVA, chi-squared, and Fisher’s exact analyses used as appropriate.

RESULTS:
195 women included (86 PRE, 42 POST-1, 67 POST-2). Groups had similar maternal age, BMI, parity, gestational age, rates of induction, and cesarean delivery. Total mean EBL vaginal deliveries (PRE 983 ±497ml, POST-1 1,035 ± 447ml, POST-2 1,075 ± 565ml, P=0.64) and cesareans (1,630 ± 755ml, 1,480 ± 780ml, 2,025 ± 1,419ml, P=0.36) were not significantly different between groups. Change in Hgb from delivery to postpartum day 1 was not significantly different (P=0.19). Times to administration and rates of medication use were similar between groups for Methergine, Carboprost, oxytocin, misoprostol, and blood transfusion.

CONCLUSION:
Introduction of PPH kits alone not associated with lower EBL or improved time to uterotonic administration. This work highlights importance of evaluating the impact of quality improvement projects after implementation. Using only portion of bundle may not lead to improved patient outcomes.
Risk of Occult Uterine Cancer in Myomectomy: A Population-Based Study [2D]
Authors: Desai Vrunda Bhavsar , Wright Jason , Gross Cary , Lin Haiqun , Schwartz Peter E. , Xu Xiao 
Published: April 2018

INTRODUCTION:
Prior research on occult uterine cancer has centered on hysterectomies. This study aimed to extend current literature by examining the prevalence of occult uterine cancer in women undergoing myomectomy in a population-based sample and identify its associated risk factors.

METHODS:
Using the New York Statewide Planning and Research Cooperative System database, women who underwent an inpatient or outpatient myomectomy in New York State in 10/1/2003-12/31/2013 were identified based on ICD-9 and CPT codes. We excluded patients with an admitting diagnosis or history of gynecologic cancer or endometrial hyperplasia, as well as those with non-gynecologic indications. Diagnosis of uterine cancer within 28 days after the index myomectomy was determined based on linked state cancer registry data.

RESULTS:
38,804 women underwent a myomectomy for presumed benign indications in our sample. The prevalence of occult uterine cancer was 0.12% (95% confidence interval [CI] 0.08-0.15%). When examined by cancer subtypes, 0.04% (95% CI 0.02-0.06%) had endometrial carcinoma, 0.08% (95% CI 0.05-0.10%) had uterine sarcoma, and 0.04% (95% CI 0.02-0.06%) had leiomyosarcoma. The risk of occult uterine cancer varied by surgical indication (0.10% in women with fibroids versus 0.05% for menstrual disorders and 8.00% for postmenopausal bleeding). Older women (e.g., 2.70% for age ≥60 years versus 0.06% for age <40 years, adjusted odds ratio [aOR]=28.08, P<.001) and Asians (0.27% in Asians versus 0.12% in non-Hispanic whites, aOR=4.04, P=.02) were at higher risk.

CONCLUSION:
The prevalence of occult uterine cancer in women undergoing myomectomy was low. However, risk of occult malignancy varied by patient age, race and surgical indication.
Intuitive Surgical Inc. Payments to Ob/Gyns Compared to Other Specialties: Analysis from 2014 Open Payments Database [4D]
Authors: Guha Paulami , Espinal Mariana , Dinh Tri , DeStephano Christopher 
Published: April 2018

INTRODUCTION:
Study Objective: To determine the payments made to Obstetricians and Gynecologists (OBGYNs) compared to other surgical specialties by the makers of the Da Vinci robot-Intuitive Surgical, Inc. in 2014.

METHODS:
Design: Retrospective cross-sectional study (Canadian Task force classification- II-3).

Setting:
Payments to OBGYNs in the United States compared to the total Intuitive Surgical payment amount in each state as analyzed from Centers for Medicare & Medicaid Services (CMS)’ Open Payments website.

Subjects:
General OBGYNs, OBGYN subspecialists (Gynecologic Oncology, Reproductive Endocrinology, Female Pelvic Medicine and Reconstructive Surgery, Gynecology), and providers in other specialties nationwide.

Interventions:
Compare Intuitive Surgical Inc. payments to OBGYNs versus other surgical specialties as analyzed from publicly available CMS Open Payments database.

RESULTS:
A total of 50 states received money from Intuitive Surgical Inc. in 2014. Payments to general OBGYNs totaled $5,061,439, OBGYN subspecialties received $1,591,556, and other surgical specialties that use the Da Vinci platform received $33,011,657. Total payments per state can be represented in a map diagram. The state of Texas got the highest amount. Payments to OBGYNs divided by total payments in each state can be depicted in a similar fashion, Wyoming state had the highest value.

CONCLUSION:
OBGYNs received a significant proportion of funding from Intuitive Surgical Inc. as compared to other surgical specialties in 2014. We recommend that OBGYNs update or declare any conflicts when required.
Magnesium for Fetal Neuroprotection: Should it be Started When Delivery is Not Imminent in PPROM? [12D]
Authors: Hom Katherine , Brar Bobby , Kennel Patricia , Jackson David 
Published: April 2018

INTRODUCTION:
Magnesium sulfate may decrease moderate to severe cerebral palsy or death when administered to women at risk for imminent delivery < 32 weeks. Research guidelines included restarting magnesium for fetal neuroprotection up to 34 weeks. Our purpose was to determine whether a magnesium bolus should be given to stable patients admitted with preterm premature ruptured membranes (PPROM) <34 weeks, or whether it can be delayed until delivery appears imminent.

METHODS:
Recent PPROM patients at a single, University hospital were retrospectively evaluated. Maternal demographics, delivery outcomes, and neonatal outcomes were analyzed.

RESULTS:
From January 2013 to May 2016, a total of 10,565 deliveries occurred. The incidence of PPROM <34 weeks was 0.5% (n=52). The mean gestational age of those who received magnesium was 28 6/7 weeks compared to 31 2/7 weeks in those with no magnesium (P<0.004). Precipitous deliveries for labor or fetal compromise prevented re-administration of magnesium in 83%. An unexpected trend for decreased intraventricular hemorrhage was seen in patients with PPROM receiving magnesium (1/26 = 3.8%) versus those not receiving magnesium (4/26 = 15.4%) P = .35.

CONCLUSION:
Few recent studies have investigated the timing of magnesium sulfate for fetal neuroprotection in patients with PPROM. Our data supports immediate administration of magnesium to all patients admitted with PPROM <34 weeks, including those deemed stable on admission. Further prospective studies are indicated to assess the neuroprotective benefits of magnesium for neuroprotection at 32-34 weeks in PPROM.
Management of Labor and Delivery after Fetoscopic Repair of Open Neural Tube Defect [15D]
Authors: Kohn Jaden R. , Rao Vibha , Sellner Allison A. , Sharhan Dina , Belfort Michael A. , Sanz Cortes Magdalena 
Published: April 2018

INTRODUCTION:
Fetal repair of open neural tube defect (NTD) improves motor/cognitive outcomes and decreases need for postnatal shunting. Cesarean delivery is mandated when this is done via hysterotomy. The fetoscopic approach has comparable neonatal benefits to the open hysterotomy approach, but allows for vaginal delivery. This study describes the outcomes for labor and delivery following fetoscopic repair.

METHODS:
Retrospective cohort study at a single institution from 2014-2017.

RESULTS:
32 patients had fetoscopic repair followed by either vaginal delivery (n = 16) or cesarean (n = 16) at 38.1 (26-40.2) and 36.3 (25.5-40.5) weeks, respectively.
There were three elective cesareans (one breech with severe IUGR, one prior cesarean, one macrocephaly) at 39.0 (37.1-39.0) weeks. Thirteen cases were delivered by non-elective cesarean at 35.2 (25.5-40.5) weeks: five had urgent pre-labor indications (four abnormal FHTs, one breech with PPROM), and eight were indicated during labor (four abnormal FHTs, three suspected abruptions, one breech after labor onset).
Of sixteen vaginal deliveries, three required instrumentation and one was a VBAC. Eight had a second-degree laceration.
In total, 24 patients labored. Seven patients were induced at 39.0 (35.5-39.5) weeks; one required cervical ripening with dinoprostone while six were induced with oxytocin only. Two patients received labor augmentation with oxytocin. The most common oxytocin protocol started with 2 mU/min and increased 1-2 mU/min q45min; most cases received a maximum of 20 mU/min or less. The mean oxytocin exposure was 18.3+/-10.6 hours. No inductions failed.

CONCLUSION:
Induction of labor and vaginal delivery after fetoscopic NTD repair is safe with reduced maternal morbidity.
Cost-Effectiveness of Planned Hospital vs Out-of-Hospital Vaginal Births after Cesarean in Term Pregnancies [18D]
Authors: Shields Michelanne , Chatroux Louisa R. , Caughey Aaron B. 
Published: April 2018

INTRODUCTION:
Given the upward trend of cesarean deliveries in the last decade, more women face the decision to pursue either a trial of labor after cesarean (TOLAC) or a repeat elective cesarean delivery. Women choose to pursue TOLAC both in the hospital setting and out of the hospital. Our study sought to evaluate the cost-effectiveness of planned hospital vs out-of-hospital vaginal birth after cesarean (VBAC) in term pregnancies.

METHODS:
A decision-analytic model was built using TreeAge software with probabilities, costs, and utilities derived from the literature. The primary outcomes included: cesarean sections, hypoxic ischemic encephalopathy (HIE), cerebral palsy (CP), and neonatal mortality. Secondary outcomes included: cost per quality-adjusted life year (QALY), and maternal mortality. Sensitivity analyses were employed to determine the robustness of the results.

RESULTS:
In a theoretical cohort of 750,000 women representing yearly otherwise low-risk term attempted-VBAC in the US, planned VBAC in the hospital resulted in 282 fewer cases of neonatal HIE, 63 fewer cases of CP, and 1,419 fewer neonatal deaths when compared to intended delivery out-of-hospital. Our model suggests that planned hospital birth is cost-effective, with an incremental cost-effectiveness ratio (ICER) of $25,782/QALY. Planned hospital births also resulted in 77,550 more cesarean sections, but there was no observed difference in rates of maternal mortality.

CONCLUSION:
Planned VBAC in the hospital are more expensive than home deliveries for term pregnancies, but are cost-effective. Planned hospital births reduce neonatal morbidity and mortality, and on balance increases overall QALYs, but at the cost of an increased cesarean section rate.
Transcervical Balloon Catheter for Cervical Ripening: Weighted Traction or Tension [23D]
Authors: DeCesare Ana , Decesare Julie , Manek Kimberly 
Published: April 2018

INTRODUCTION:
The goal of induction or augmentation of labor is to achieve vaginal delivery, while balancing both maternal and fetal safety. The rate of induction of labor has more than doubled since 1990, with more than 22% of all gravid women undergoing induction of labor. Several randomized controlled trials have investigated labor outcomes when comparing transcervical balloon catheters to use of prostaglandins or oxytocin. Few studies have investigated methods of transcervical bulb set up. At our institution, mechanical cervical dilation is accomplished with the use of transcervical balloon catheters, which are inflated with 60mL of saline. It is up to provider discretion to place the balloon catheters on traction or tension.

METHODS:
The objective of this study is to compare pre- and post- transcervical balloon catheter cervical dilations and time from placement to expulsion. Patients were randomized to either the leg or bag group and Bishop score was required to be less than 6. We hypothesized that the use of transcervical balloon catheter on weighted traction would result in a larger cervical dilation and a shorter balloon catheter placement to expulsion time.

RESULTS:
A total of 73 patients were randomized, with 43 in the bag group and 30 patients in the leg group. Results showed that the intervention of the bag saved 74 minutes of time and was statistically significant, with a p value <.05. Bishop score change between the two groups was not statistically significant, with a p value = .74. At our hospital average cost for labor and delivery is $326 per hour. Average cost savings per patient using bag over leg is $400.98.

CONCLUSION:
In conclusion, out study demonstrated statistically significant shorter time to delivery in the bag group. This resulted in a shorter induction process, as well as a cost saving to the labor and delivery unit and will be utilized to add evidence to the most efficient method of cervical ripening. Additional research points will analyze time to active phase of labor and time to delivery of the infant
Delivery of the Posterior Arm as Initial Maneuver to Relieve Shoulder Dystocia Increased Neonatal Humeral Fractures [24D]
Authors: Gold Stacey , Hirsch Daniel , Schutzman David , Cohen Arnold , Jaspan David , Goldberg Jay 
Published: April 2018

INTRODUCTION:
Delivery of the posterior arm as the initial maneuver to relieve shoulder dystocia increased neonatal humeral fractures. To evaluate if institutionally adopting delivery of the baby’s posterior arm as the initial maneuver during shoulder dystocia has increased the rate of neonatal humeral fractures.

METHODS:
In the beginning of 2011, Einstein Medical Center Philadelphia initiated a policy of attempting to deliver the posterior arm as the initial maneuver to resolve shoulder dystocia with the aim of decreasing brachial plexus injuries. Hospital databases were searched to identify deliveries complicated by neonatal humeral fractures, as well as other delivery information. Statistical analysis was performed.

RESULTS:
Between 2004 and 2010, 3 neonatal humeral fractures were identified from 13,536 vaginal deliveries. Following initiation of the posterior arm policy, from 2011 through August of 2017, 31 humeral fractures were identified from 13,750 vaginal deliveries. Almost all humeral fractures were associated with a shoulder dystocia. The rate of neonatal humeral fractures following the intervention increased by a factor of 10.8. The rate of humeral fracture pre- and post-intervention were compared with both Chi-squared test for independence and the Fisher’s Exact Test with both p values < 0.000001.

CONCLUSION:
Initially attempting delivery of the posterior arm to resolve shoulder dystocia was associated with a significant increase in the rate of neonatal humeral fractures. Further study is warranted to determine if there was a decrease in the rate of brachial plexus injury to justify continuation of our current institutional management of shoulder dystocia.
Pregnancy Outcomes Following Liver Transplantation: A Two-Centre Retrospective Study [36D]
Authors: Zaffar Nusrat , Soete Elisabeth , Van Mieghem Tim , D'Souza Rohan 
Published: April 2018

INTRODUCTION:
This study reports pregnancy outcomes in women following liver transplantation to aid counselling and management of these women.

METHODS:
We conducted a retrospective study including women with pregnancies following liver transplantation followed at Mount Sinai Hospital, Toronto, Canada and University Hospital Leuven, Belgium between 1989 -2016. Pregnancy outcomes were reported as proportions.

RESULTS:
We identified 28 women that had 41 pregnancies following liver transplantation. The mean maternal age was 30 (±7) years and transplant-to-pregnancy interval was 8.5 (±5.1) years. Six women had received two liver transplants prior to conception, but had normal liver functions at the start of pregnancy. Immunosuppressants included tacrolimus ± azathioprine (26), cyclosporine (4) and prednisone with immunosuppressants (11). Maternal complications included hypertension (10), renal insufficiency (6), gestational diabetes (4), graft deterioration (2), infection (2) and anemia requiring blood transfusion (1). Fetal/neonatal adverse outcomes included two miscarriages, three stillbirths, one neonatal death, five small-for-gestational-age infants and one minor congenital anomaly. There were 22 term and 14 preterm infants with a mean gestational age of 36+5±4.23 weeks. Although the cesarean delivery rate was high (61%), all were performed for obstetric indications.

CONCLUSION:
With appropriate multidisciplinary care and with stable graft function at the onset of pregnancy, women with liver transplants can have successful pregnancies with low rates of graft complications, if they adhere to their immunosuppressive regimens. Graft deterioration responds well to increase in the dose of immunosuppressants and high-dose glucocorticoids. The use of these in pregnancy is not associated with adverse fetal/neonatal outcomes.
Risk Scoring Index for Development of Preeclampsia among Women: A Retrospective Cohort Study [39D]
Authors: Lim Vanessa Marie T. , Zamora Brenda Bernadette B. 
Published: April 2018

INTRODUCTION:
Worldwide, there is an increasing thrust to develop better screening methods for preeclampsia. But in the Philippines, there is limited research regarding approach to screening for development of preeclampsia. This retrospective study aimed to identify significant clinical risk factors associated with preeclampsia and develop a risk scoring index.

METHODS:
A retrospective cohort study of women with live births at a tertiary hospital, St. Luke’s Medical Center from January 2015 to April 2016 was conducted. Several variables associated with Preeclampsia were considered. Outcome measure was development of preeclampsia. A risk scoring index was developed from the results of the logistic regression analysis. Computed scores were plotted in a receiver operating characteristic curve and cut-off values were determined.

RESULTS:
The overall prevalence of preeclampsia was 4.5%. Among the variables evaluated, presence of chronic hypertension (OR 4.179, 95% CI 7.572-563.181) and respiratory tract infection (OR 3.128, 95% CI 4.196-124.263) showed the strongest significant association with development of Preeclampsia. The odds of developing preeclampsia were also increased in patients who had gestational diabetes mellitus (OR 1.222, 95% CI 1.559-7.389), urinary tract infection (OR 2.455, 95% CI 5.723-23.678), and vaginal infection (OR 1.577, 95% CI 2.126-11.020). The formulated preeclampsia risk scoring index was 5.75, specificity of 91.8%, sensitivity of 74.5%, positive likelihood ratio of 9.2.

CONCLUSION:
Maternal age, and presence of chronic hypertension, gestational diabetes mellitus, and maternal infection significantly affect development of preeclampsia among women studied. Women are more likely to develop preeclampsia 9 times more with a risk score of greater than or equal to 5.75.
Referral Patterns for Genetic Counseling for Hereditary Breast and Ovarian Cancer Syndromes [40D]
Authors: Hong Leah , Roberson Jacquelyn , Sangha Roopina 
Published: April 2018

INTRODUCTION:
BRCA 1 or 2 mutation carriers have a 45–85% risk of developing breast cancer and a 39–46% risk of developing ovarian cancer by age 70.

METHODS:
A retrospective electronic chart review was conducted to identify women who were referred to the Henry Ford Health System Genetics department for counseling, as new consultations between 01/01/16 to 12/31/16 with a diagnosis that contained “breast”, “ovarian”, “ovary”, or “adnexa”. Women with a known cancer diagnosis were excluded. Information on age, race, if genetic testing was collected including if testing was offered and/or accepted, results of genetic testing, insurance type and referring provider specialty.

RESULTS:
A total of 184 women with an average age of 46 years was included. 93 (50.5%) referrals were from obstetricians/gynecologists, 44 (23.9%) from internal medicine, 23 (12.5%) from family medicine, 13 (7.1%) from surgery, and 11 (6%) self-referrals. Of the 20 women who were not offered genetic testing, 5 (25%) had federal assisted insurance. The reasons documented for lack of genetic testing was due to inability to meet Medicare criteria or lack of clinical indication. 164 women were offered genetic testing, of which 147 accepted. Of the 147/164 (89.6%) a total of 14/147 (9.5%) women identified with positive hereditary breast and ovarian cancer mutation. 10/147 (6.8%) women were noted to have a variant mutation.

CONCLUSION/IMPLICATIONS:
Patients at high risk for hereditary cancer syndromes should be provided with a referral for genetic counseling based on extensive review of family history on both sides, including the ages of onset of cancer.
Immediate Postpartum LARC Placement May Decrease the Risk of Short-Interval Pregnancy [3E]
Authors: Higgins Stephanie , Morosky Christopher , Nelson Amy 
Published: April 2018

INTRODUCTION:
Short interval pregnancies are associated with an increased incidence of preterm birth, low birth weight, and small for gestational age infants. LARC devices have been shown to be safe and effective in helping women achieve an optimal inter-pregnancy interval, however those studies did not evaluate LARC placed in the immediate postpartum time period.

METHODS:
This is a retrospective cohort study of clinic patients who delivered at Hartford Hospital and requested immediate postpartum LARC. LARC devices were supplied by periodic shipments from the Ryan program. Near the end of shipment periods, there were often insufficient devices to meet demand. This led to a pseudo-random intervention in which some patients received their requested LARC device immediately postpartum and others were given a temporary method and asked to follow-up for outpatient LARC placement. The primary outcome was the percentage of patients in each group who experienced a short interval pregnancy

RESULTS:
345 women qualified for study inclusion. 264 of those women received immediate postpartum LARC (76.5%). The overall number of short interval pregnancies was 39 (11.3%). Among women who received LARC, the percentage of short interval pregnancy was 9.8%. Among women who did not receive LARC, the percentage was 16.0%. Chi-squared comparison resulted in P=0.12

CONCLUSION:
Due to a lower than expected overall incidence of short interval pregnancy, this study was underpowered to detect its primary outcome. This study may serve as a useful pilot study to aid future prospective studies examining the effect of immediate postpartum LARC placement on short interval pregnancy.