bluuebunny/crossref_metadata_2025_split huggingface dataset:
Pelvic Exam Simulation Integration into OB/GYN Medical Student Clerkship Curriculum Improves Student Confidence [27S]
Authors: Dubin Ariel Kate , Arora Chetna , Advincula Arnold Patrick 
Published: May 2019

INTRODUCTION:
The purpose of this study is to examine the impact on medical student confidence with a pelvic exam by integrating a new simulation curriculum into the orientation day of their OB/GYN clerkship rotation.

METHODS:
A pelvic exam simulation was integrated into an established orientation day at the beginning of the OB/GYN clerkship. This included direct education by a physician trained in pelvic examinations on two high-fidelity pelvic simulators and guided pelvic exams on standardized patients. Online surveys were distributed before the orientation day (pre-clerkship), at the end of the orientation day (post-simulation), and at the conclusion of the clinical rotation (post-clerkship). IRB approval was obtained.

RESULTS:
At the end of the rotation 80% of the students were no nervous about performing a pelvic exam versus 25% pre-clerkship. 3% of students felt confident performing a pelvic exam before orientation versus 56% after simulation and 62% after the clerkship. When asked if the simulation experience enhanced their understanding of the female reproductive system, 95% of students answered positively.

CONCLUSION:
We found increased medical student confidence and less anxiety about performing a pelvic exam after the integration of a simulation experience in the clerkship orientation day. The students also expressed increased satisfaction with the modification in curriculum. By removing a large barrier that often exists in the learning process of this sensitive but extremely important clinical skill, medical students may be able to more fully participate in their OB/GYN clerkship and bring these feelings of confidence and skill into their chosen specialty.
Cervical Length Following Cerclage Placement in Twin Gestations With Ultrasound Indicated Short Cervix [30S]
Authors: Arkfeld Christopher K. , Mulhall J. Connor , Shea Ashley , Dahlke Joshua D. 
Published: May 2019

INTRODUCTION:
Identification of a short-cervix during transvaginal ultrasound in the second-trimester is associated with an increased risk of spontaneous preterm birth (sPTB) in singleton pregnancies. Ultrasound indicated cerclage reduces the risk of recurrence in those with a history of sPTB. The utility of cerclage in twin-gestations is less understood. Our objective was to identify the impact of placing a cerclage in women with a twin-gestation and an ultrasound indicated short-cervix <25 mm.

METHODS:
We performed a descriptive analysis of all twin gestations delivered at a single tertiary care center with ultrasound evaluation between January 1, 2013 and September 1, 2017. Women with missing maternal or neonatal data were excluded. Outcomes of interest included midtrimester transvaginal cervical length (CL), the effect of cerclage placement on subsequent measurements and gestational age (GA) at delivery. IRB approval was obtained.

RESULTS:
Of 587 twin pregnancies, 26 patients were diagnosed with a short-cervix and received a cerclage. After placement, an average increase in CL of 7.4 mm at the first CL follow-up (P=.002) and remained significant during subsequent follow-ups. Average GA at delivery was significantly earlier for patients with a CL <15 mm compared to patients with a CL >15 mm; 33 weeks and 4-days versus 35 weeks and 4-days respectively (P=.003).

CONCLUSION:
Cerclage placement significantly increases transvaginal CL following the procedure. While the severity of the short-cervix appears to predict earlier GA at delivery it remains unclear if cerclage placement alters the GA at delivery. CL monitoring following the placement of a cerclage has unknown clinical benefit after cerclage placement in twin-gestations.
Targeted Liquid Biopsy Detects Tumor-Specific TP53 Mutations in Early and Late Stage Ovarian Cancer [29O]
Authors: Pandya Deep , Camacho-Vanegas Olga , Camacho Sandra Catalina , Dottino Peter , Martignetti John A. 
Published: May 2019

INTRODUCTION:
Ovarian cancer (OvCa) is the most lethal female reproductive tract malignancy. Despite the immediate need to detect these cancers at an earlier stage, there is no effective screening methodology or protocol. We hypothesized that the use of ultra-deep, targeted gene sequencing could detect somatic mutations in uterine lavage fluid, a next generation of liquid biopsy, as a means of molecular screening and diagnosis.

METHODS:
Paired tumor, uterine lavage and blood samples were collected and analyzed from patients undergoing debulking surgery. Lavage fluid was separated into cellular and acellular fractions and DNA isolated. A targeted next-generation (NGS) 56 gene panel was used. To rule out potential NGS-based errors, orthogonal mutation validation was performed using dPCR and Sanger sequencing.

RESULTS:
Tumor sequencing defined the distinct mutation profiles for all 9 patients; shared between all patients was TP53 mutations. We therefore focused our efforts on detecting TP53 mutations in the collected lavage samples. Using ultra-deep sequencing, and then a combination of mutation validation technologies, the identical TP53 mutation identified in the patients' tumor was detectable in 7/9 (77.8%) of the uterine lavage samples. Notably, both stage I cancers were detected by molecular analysis of the lavage fluid.

CONCLUSION:
Using a combination of molecular assays, all based on the analysis of uterine lavage fluid, we were able to detect tumor-specific TP53 mutations from 7/9 ovarian tumors including stage I cancers. The sensitivity of this approach to detect tumor-specific mutations, even in early stage disease, highlights the potential for a molecular screening test for OvCa.
Results From an Multidisciplinary Severe Maternal Morbidity Review at a Tertiary Academic Medical Center [23P]
Authors: Campbell Katherine Harper , Grechukhina Olga , Abdel-Razeq Sonya , Raab Cheryl , Pettker Christian Michael , Lipkind Heather 
Published: May 2019

INTRODUCTION:
Due to increasing rates of severe maternal morbidity (SMM) in the United States, there is impetus from national organizations for obstetricians to develop facility-level multidisciplinary review of SMM for potential preventability. We utilized standardized guidelines to develop a SMM review process in our hospital.

METHODS:
Our SMM Committee identified cases meeting the definition of SMM (transfusion of 4 or more units of packed red blood cells and/or admission to an intensive care unit at any time from conception through 42 days postpartum) and reviewed them to recognize factors contributing to preventable SMM or develop best practices to reduce morbidity.

RESULTS:
From August 2015 - September 2018, we identified 98 SMM cases. Three cases resulted in maternal death. Seventy-two percent of the women received their maternity care at YNHH, while the rest were transferred in from outside hospitals. The mean maternal age was 32 (range 17-55) with 34% of women age 40 and above at the time of the SMM. Our cohort was primarily White (44%) and included Hispanic (25%), Black (22%), and Asian/PI (6%) women. The most common causes of SMM were obstetric hemorrhage (25%), placental hemorrhage (17%), hypertensive disorders (13%), and non-uterine infection (13%). The majority of the SMM occurred in the peripartum period (60%) and most were direct obstetric SMM (70%).

CONCLUSION:
Facility-level reviews provide critical insight to understand hospital SMM patterns, patient characteristics or lack thereof. The review process can identify factors that can be strengthened to improve institutional obstetric safety and reduce SMM among pregnant and recently pregnant women.
A Survey of Hepatitis C Virus (HCV) Screening in Pregnancy Among OBGYNs at a Tertiary Care Center [19Q]
Authors: Koniares Katherine , Fadlallah Hasan , Kolettis Diana , Vindenes Tine 
Published: May 2019

INTRODUCTION:
Hepatitis C Virus (HCV) infection among pregnant women in the US increased 89% from 2009 to 2014. The risk of a HCV infected mother transmitting the infection to her infant is approximately 4-7% per pregnancy. Infectious Disease Society of America (IDSA) and American Association for the Study of Liver Diseases (AASLD) recommend universal HCV screening in pregnancy whereas the American College of Obstetricians and Gynecologists (ACOG) recommends risk-based screening. The objective of this study was to assess the opinions and clinical practice of OBGYN providers in a tertiary care center.

METHODS:
An electronic 10 question survey was approved by the Tufts Medical Center Institutional Review Board and emailed to providers.

RESULTS:
38/41 (92.6%) provided responses and 17/38 (44.7%) were attendings, 4/38 (10.5%) were fellows, and 17/38 (44.7%) were residents. 16/37 (43.2%) of respondents agreed all pregnant women should be screened for HCV whereas 20/37 (54.1%) agreed that only pregnant women with risk factors for HCV should be screened. When asked about their clinical practice, 3/36 (8.3%) of respondents stated they do not screen pregnant patients for HCV, 5/36 (13.9%) screen all pregnant patients, and 28/36 (77.8%) screen patients based on their risk factors for HCV.

CONCLUSION:
Divergent guidelines, provider opinions, and clinical practice necessitate further research into universal HCV screening in pregnant patients. Future plans include an educational intervention on HCV for providers in the department followed by a chart review to determine the HCV detection rate before and after a change in practice to universal screening for HCV.
Evaluation of Antepartum and Postpartum Remote Blood Pressure Monitoring in Low-Risk Pregnancy [9K]
Authors: DeNicola Nathaniel G. , Ganju Nihar , Marko Kathryn I. , Sheth Sheetal 
Published: May 2019

INTRODUCTION:
Hypertensive disorders in pregnancy are a leading cause of morbidity and mortality. This study examines the feasibility of an integrated technology platform to augment surveillance with remote blood pressure (BP) readings in low-risk pregnant women.

METHODS:
2806 low-risk pregnant women in 57 offices were enrolled in an integrated technology platform with a mobile application and connected devices to remotely transmit BP readings (BabyscriptsTM (BRx) platform). Antepartum BP recordings were tabulated from 12-36 weeks gestation. Postpartum BP recordings were tabulated from 42-48 weeks gestation. All BP data was analyzed for mean systolic and diastolic BP and average interval between recordings.

RESULTS:
Antepartum monitoring of 2791 women showed a mean systolic BP of 107.3 (95% CI 102.1-112.5) and a mean diastolic BP of 68.9 (95% CI 61.7-76.1). A total of 38,443 antepartum BP readings were recorded. The average interval between recordings was 7.2 days. Postpartum monitoring of 186 women showed a mean systolic BP of 109.8 (95% CI 104.2-115.4) and a mean diastolic BP of 73.2 (95% CI 66.3-80.1). A total of 485 postpartum BP readings were recorded. The average interval between recordings was 5.1 days.

CONCLUSION:
Remote monitoring of BP in low-risk pregnant women resulted in frequent recordings during the antepartum and postpartum periods. Notably, the average frequency of postpartum recordings occurred at a shorter interval than typical clinical follow-up. This platform could offer more robust monitoring in low-risk pregnancies and could be extrapolated to high-risk pregnancies in the future.
Interdisciplinary Coaching for Rapid-Response Team Simulations [11K]
Authors: Kuhlmann-Capek Maggie J. , Munn Mary B. , Olson-Koutrouvelis Gayle 
Published: May 2019

INTRODUCTION:
Coaching and debriefing after simulated exercises are both well-established approaches to enhancing education and personal performance. Coaching may also have an important role in training interdisciplinary teams for obstetric emergencies. We sought to understand factors which create an optimal environment for coaching interdisciplinary obstetric rapid-response teams.

METHODS:
An interdisciplinary simulation drill was conducted for our institution's obstetric rapid-response team. The individuals leading the debriefing session were varied by discipline, and participants' responses in a post-simulation survey were analyzed to determine if receiving feedback from a person from one's own discipline is important to satisfaction with the assessment process. Participants were asked to rank their satisfaction with feedback on a numerical scale (1-10, 10=best). We also posed questions regarding acceptance of video recording and playback in a group setting.

RESULTS:
There was no difference among obstetricians (n=3), anesthesiologists (n=3), or nurses (n=8) regarding feedback received from a representative of their own discipline versus a representative from a different discipline. The majority believed that recording the simulation and playing it back during the team debrief would be helpful. None of the participants indicated that recording the simulation and playing it back during the debrief would deter them from participating.

CONCLUSION:
Our pilot exercise indicates that participants respond equally to feedback given by a representative of their own discipline as to feedback given by a representative of a different discipline. Interdisciplinary coaching for rapid-response team simulations was well-accepted. The addition of a video recording appears to be a welcome addition to the debrief process.
Expanding the Concept of Failure to Rescue to Address Maternal Mortality: A Public Health Approach [13K]
Authors: Restrepo Elizabeth , Fuqin Liu , Mancuso Peggy , Hamilton Patti 
Published: May 2019

INTRODUCTION:
Precision-directed, public-health evaluation of unprecedented Texas maternal mortality rates was performed using birth and death datasets to document maternal failure to rescue (FTR). FTR is a designated national quality measure, with maternal FTR focused on physiological obstetrical factors. Suicide, drug overdose, and homicide, previously overlooked, were incorporated into maternal FTR. Through expansion of the FTR concept, a public-health approach was applied. Geospatial analyses indicated areas of increased maternal mortality, enabling mapping of maternal-care deserts.

METHODS:
Using an epidemiological, cohort design, we calculated FTR (standard method) from Texas birth and death datasets. We compared this calculation to the expanded concept of FTR, incorporating deaths from suicide, drug overdose, and homicide, tending to occur after the 42-day postpartum period. Using geospatial analysis, we identified vulnerable areas with limited access to maternal health services.

RESULTS:
We identified 713 mortalities from 1,218,205 births. Of these deaths, 475 noted underlying obstetrical risk factors for maternal mortality, leaving 238 deaths from other causes. Forty of these 238 mothers died from suicide, opioid overdose, or homicide. We obtained an unrefined FTR rate of 96 maternal deaths/100,000 births. The FTR rate, using the expanded concept, was 104 deaths/100,000 births (8% increase). Geospatial analysis demonstrated robust differences in maternal mortality by county, both rural and urban.

CONCLUSION:
This expansion of FTR can be adopted by others to examine maternal care quality using public data. We assert that the current focus on maternal physiological complications restricts thinking to hospital-based remedies to alleviate FTR and limits precision public-health strategies to decrease maternal mortality.
Factors Affecting Neonatal Birthweight in Women With History of Bariatric Surgery: A Retrospective Study [16K]
Authors: Chatterton Carolyn G. , Shanahan Lisa K T. , Kenkel Christine M. , Vullo John J. , Polavarapu Satya , Gurram Padmalatha 
Published: May 2019

INTRODUCTION:
Bariatric surgery (BS) has been shown to improve pregnancy outcomes in obese patients. Studies suggest increased incidence of small for gestational age (SGA) neonates in women with BS, without clear explanation. The objective of this study is to investigate the incidence of SGA in neonates after BS in relationship to the type of BS, time interval from surgery to delivery (TI), and maternal micronutrient deficiency.

METHODS:
This is a retrospective chart review of women with history of BS who delivered between 2013 and 2017 at our institution. The mothers with BS (N = 70) were compared with a cohort of mothers without BS (NBS) (N = 70) with similar body mass index. Type of bariatric surgery (malabsorption versus restrictive), micronutrient deficiencies (use of supplemental iron, folate, B12, and blood transfusions), and TI were analyzed for each cohort. Multiple gestations were excluded. Institutional Review Board approval was obtained.

RESULTS:
Both groups had similar maternal characteristics and perinatal and neonatal complications (p > 0.05). SGA was increased in patients with BS (14.4%) compared with NBS (2.9%). Women with restrictive BS (N=42) had an increased incidence (p = 0.04) of SGA compared to malabsorptive BS (N=27). SGA was increased in patients with TI less than 4 years (p = 0.02). There was no impact of anemia (p = 0.89) or obesity class (p = 0.92) on neonatal birthweight.

CONCLUSION:
Restrictive bariatric surgery and time interval less than 4 years is associated with increased incidence of SGA in patients with history of bariatric surgery.
Factors Associated With Infant Mortality in Two Select At-risk Counties in Texas, 2011–2014 [17K]
Authors: Patel Divya A. , Salahuddin Meliha , Elerian Nagla , Valerio Melissa , French Lesley , Lakey David 
Published: May 2019

INTRODUCTION:
While infant mortality rate (IMR) in Texas has remained below the Healthy People 2020 objective since 2012, stark differences in IMR exist within the state. Texas also has a growing prevalence of maternal chronic conditions, which are linked to poor pregnancy-related outcomes. The Healthy Families initiative, a state-funded collaboration, seeks to understand associations between maternal risk factors and infant death, and how evidence-based practices implemented in the community can improve pregnancy-related outcomes.

METHODS:
Two counties with high prevalence of maternal chronic conditions were selected as project sites, one having high IMR and the other having low IMR. Cohort-linked birth and infant death records from 2011-2014 were provided by the Texas Department of State Health Services (IRB#17-055). Logistic regression models examined associations of maternal sociodemographic and pregnancy-related factors with infant death.

RESULTS:
During 2011-2014, IMR was 4.5 per 1,000 live births in one site and 7.6 per 1,000 live births in the other site. Similar to Texas overall, the leading cause of infant death in both sites in 2014 was congenital malformations, deformations and chromosomal anomalies. In both sites in 2011-2014, pre-pregnancy diabetes mellitus was significantly associated with infant death (adjusted ORs: 2.70 and 4.36). Additionally, in one site, pre-pregnancy hypertension was also significantly associated with infant death (OR=3.72).

CONCLUSION:
In this study, maternal chronic conditions were significantly associated with infant mortality in two Texas counties. Findings from the Healthy Families initiative will help identify key strategies to address preconception and interconception health, which can inform broader statewide efforts aimed at improving pregnancy-related outcomes.
GCT Cut-Off in Women With GDM Based on Pre-pregnancy BMI [20K]
Authors: Angras Kajal , Young Amanda , Mackeen Awathif D. 
Published: May 2019

INTRODUCTION:
A universal cut-off for the 1-hour 50-g glucose challenge test (GCT) does not take into consideration pre-pregnancy body mass index (BMI). Our objective was to determine the optimal GCT cut-off for the screening of gestational diabetes mellitus (GDM) based on pre-pregnancy BMI.

METHODS:
An-IRB approved retrospective cohort analysis of singleton pregnancies at Geisinger between January 2003-December 2017 was performed. GCT > 20 weeks was used. Using receiver operator curve (ROC), we sought to determine the optimal GCT cut-off for each BMI category that would predict the development of GDM. ROC curve was generated by calculating the sensitivity and specificity for the GCT value in each BMI category. Youden Index was used for cut-point analysis.

RESULTS:
22,266 women with a GCT were identified. Of those, 1,027 were diagnosed with GDM. 312 with BMI <25 kg/m2, 282 overweight, 215 class I obese, 133 class II obese, and 85 class III obese women were diagnosed with GDM. Gestational diabetes was predicted at GCT cut-off of 131 mg/dL and an area under the curve (AUC) of 0.93 (BMI < 25), 131 mg/dL and an AUC of 0.92 (overweight BMI), 133 mg/dL and an AUC of 0.88 (class I BMI), 130 mg/dL and an AUC of 0.88 (class II BMI), and 134 mg/dL and an AUC of 0.85 (class III BMI).

CONCLUSION:
AUC ranged from 0.85 to 0.93 with 85% or greater sensitivity for GCT cut-off for each of the BMI categories. The findings support a GCT cut-off of 130 mg/dL for GDM screening regardless of BMI.
Glycemic Efficacy With U-500 Insulin in Pregnancy: A Retrospective Cross-Over Study [21K]
Authors: Vasquez Bertha A. , Sarumi Mojirayo , Shultz Lori , Bedell James , Gherman Robert , Johnson Mary Jo 
Published: May 2019

INTRODUCTION:
Pre-gestational diabetes, one of the most challenging complications of pregnancy, may require over 200 units per day in patients with severe insulin resistance, resulting in compliance and absorption issues. The purpose of this study was to determine if conversion to U-500 led to improved glycemic efficacy in pregnancies complicated by severe insulin resistance.

METHODS:
A retrospective review of pregnant patients managed with (Humulin R) U-500 from 2014 to 2018 was conducted. Maternal and neonatal demographics were abstracted. Primary objective was to compare fasting and postprandial glycemic efficacy, insulin injections per day and number of hypoglycemic episodes pre- and post- conversion to U-500 assessments. Wilcoxon two tailed signed ranks tests was used for the qualitative data analysis, P value <.05 was considered statistically significant.

RESULTS:
Ten patients were identified. Mean gestational age was 24 weeks (16.2 to 33.4) and mean insulin dose was 301.8 U (64 to 522) at time of conversion to U-500. Post-conversion to U-500, a decrease in the percent-above-range fasting glucose levels (65.61% vs 51.56%, P=.047) and insulin injections per day (4.8 vs 3.5 P <.01) was noted. An increase in percent-above-range postprandial glucose levels was noted post-conversion (45.26% vs 54.42%, P=.114). A trend towards decreased number of hypoglycemic episodes was noted (7.50 vs 3.80, P=.089).

CONCLUSION:
U-500 insulin use is associated with improved fasting glycemic efficacy with decreased number of injections per day in pregnancies complicated by pre-gestational diabetes. Additional experience with U-500 in pregnancy is warranted to determine its safety profile in terms of maternal and neonatal outcomes.