bluuebunny/crossref_metadata_2025_split huggingface dataset:
Uterine Vascular Embolization Followed by Hysterectomy After Cesarean for MAP Without Extrauterine Involvement [32T]
Authors: Gatta Luke , Rodriguez Isabel Victoria , Gilner Jennifer Bushman , Grotegut Chad , Paula Lee S. , Secord Angeles 
Published: May 2019

INTRODUCTION:
To review outcomes in women with morbidly adherent placenta (MAP) managed with selective uterine vasculature embolization (SUVE) at the time of cesarean hysterectomy (CHYS).

METHODS:
In 2005, our program implemented a multidisciplinary algorithm including interventional radiology (IR) and delayed hysterectomy for women with MAP. In 2012, the algorithm was revised for cases without extrauterine placental invasion to undergo SUVE after cesarean, followed by immediate hysterectomy. Subjects treated from 12/2012-8/2018 were reviewed. Primary outcomes included pRBCs transfused and EBL. Secondary outcomes included postoperative, immediate IR, and delayed IR complications. Data obtained via chart abstraction, and descriptive statistical analysis was performed.

RESULTS:
Identified 13 subjects: 12 scheduled, 1 emergent. All surgeries occurred in the hybrid OR, at mean 35w2d. For scheduled cases, mean EBL was 1292 mL (range 500-2000, std 468). 2/12 (16.7%) were transfused, mean 1.5u pRBC. All returned to postpartum floor, and discharged on average postoperative day 3.5. The emergent subject had EBL 4800cc, requiring 4u pRBC, 2u FFP, 1u cryoprecipitate, and ICU admission for one day. 9/13 (69.2%) used neuraxial analgesia only, and 4/13 (30.8%) converted to GETA. SUVE was performed using GelFoam (n=2), or particles (n=11) with no complications including pelvic infection, post-embolization syndrome, VTE, paresthesia, or ischemia. Postoperative complications included non-infectious wound opening (n=2) and wound infection (n=2). There were no reoperations or readmissions. On pathology, 2/13 (16.7%) had accreta, 9/13 (69.2%) had increta, 1/13 (7.7%) with percreta.

CONCLUSION:
A multidisciplinary approach including use of SUVE at the time of CHYS is a safe and feasible strategy for women with MAP.
PPROM Prior to 33 0/7 Weeks: When Should Rescue Course Corticosteroids Be Given? [23R]
Authors: Zalles Laura X. , Ryan Lindsay N. , Fischer Richard L. 
Published: May 2019

INTRODUCTION:
Timely administration of corticosteroids reduces RDS of the newborn, IVH, necrotizing enterocolitis, and perinatal mortality. Corticosteroids are optimally effective 1-7 days after the first dose. A single rescue course of steroids may be given at least 1-2 weeks after the initial course. We sought to determine the optimal timing for administration of rescue course corticosteroids in women with PPROM prior to 33 weeks.

METHODS:
This was an IRB-approved retrospective cohort from 2013-2017 of 66 singleton gravidas with PPROM at 23 0/7-32 6/7 weeks. Observing when these women spontaneously labored or underwent indicated delivery, we compared hypothetical strategies for timing of rescue corticosteroids. This included administration of corticosteroids at 1, 2, 3, or 4 weeks after PPROM, versus withholding until spontaneous labor or indicated delivery. A Chi-squared test was used to compare the likelihood of delivery within the optimal window of the first dose of either the initial or rescue corticosteroids.

RESULTS:
The median interval from PPROM to delivery was 6.6 (3.3-16.4) days. Giving rescue corticosteroids 1 week after PPROM had the greatest number of deliveries occurring in the optimal window compared to 2, 3, or 4 weeks. Withholding rescue corticosteroids until spontaneous labor or indicated delivery was statistically less likely to result in deliveries during the optimal window compared to routinely giving corticosteroids 1 week after PPROM (45.5% vs 63.6%, p=0.04).

CONCLUSION:
In women with PPROM prior to 33 weeks, routinely administering rescue course corticosteroids 1 week after PPROM improves the likelihood of delivery within the optimal window for corticosteroid benefit.
Postpartum Opioid Use Among Military Health System Beneficiaries: Lessons for the Nation [19R]
Authors: Watters Julie , Banaag Amanda , Massengill Jason C. , Petersen Scott M. , Koehlmoos Tracey , Staat Barton C. 
Published: May 2019

INTRODUCTION:
The opioid epidemic in the US has been given much attention in recent years. The most common source of prescription opioids, among people who misuse them, is through family or friends, implicating that healthcare providers are likely overprescribing.

METHODS:
We evaluated postpartum opioid prescriptions at discharge among patients insured by TRICARE using the Military Health System Data Repository. The primary outcome compared the prevalence of opioid prescription at discharge for postpartum patients within civilian purchased care and direct military treatment facilities. Secondary outcomes investigated mode of delivery and demographics for those receiving opioid prescriptions. We included women age 15-49 years old insured by TRICARE between 2010-2015 with a pregnancy-related postpartum discharge diagnosis. We excluded abortive pregnancy outcomes and incomplete data sets. We extracted data using ICD-9 and CPT codes, and performed logistic regression using SAS 9.4.

RESULTS:
Postpartum patients receiving civilian purchased care were more likely to be discharged with an opioid prescription compared to direct care (OR 3.9, 95% CI 3.8-3.99). Asian race was least likely to receive an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Age 15-19 had a lower odds of opioid prescription at discharge.

CONCLUSION:
Our data indicates that women who are cared for in civilian facilities were more likely to be prescribed an opioid at time of discharge when compared to military facilities. Factors such as race and age were also associated with opioid prescribing practices. OB/GYNs may be overprescribing opioids postpartum, and this study highlights areas for improvement.
Increasing Prevalence of Chronic HCV Infection in an Academic Obstetric Clinic: Evidence for Universal Screening [12R]
Authors: Lazenby Gweneth B. , Orr Cody , Guille Constance , Meissner Eric 
Published: May 2019

INTRODUCTION:
U.S. rates of hepatitis C virus (HCV) are rising in reproductive age women, and approximately 1-2.5% of pregnant women are infected. We sought to determine the prevalence of opiate abuse and/or HCV infection among pregnant women presenting for prenatal care. Our second objective was to determine how often pregnant women with HCV are referred and receive treatment for HCV. Lastly, we sought to determine how likely HCV-exposed infants were referred and received appropriate screening for perinatal HCV infection.

METHODS:
We performed a retrospective chart review from 2007-2016. Eligible subjects were pregnant women with ICD-9/10 diagnosis codes for HCV infection and/or opiate abuse. Variables related to patient characteristics and pregnancy outcomes were obtained from an institutional perinatal information system. Referral and treatment practices for women and HCV-exposed infants were obtained from the electronic health record.

RESULTS:
Mirroring the diagnosis of opiate abuse, chronic HCV infection increased significantly in 10 years (P=0.03). Patients with chronic HCV infection had a median age of 27 (IQR 24-33) and were primarily Caucasian (95%). Only 0.7% of women presenting for delivery were screened for HCV, with over 78% of women with chronic HCV going undiagnosed. Only one-third of identified HCV-exposed infants were referred for HCV testing and only 9% received HCV testing.

CONCLUSION:
Increasing HCV infection is a consequence of the U.S. opiate epidemic. Risk-based screening results in missed opportunities for diagnosis and treatment referral. Implementation of universal screening in pregnancy will likely identify additional cases and is an important strategy for addressing the HCV epidemic.
Adverse Outcomes of Nuchal Translucency Measurement ≥3 mm and <3.5 mm [13G]
Authors: Taylor Dyese , Nelson Zoe , Hussain Farrah , Lam Melissa Chu , Dawnette Lewis Lois Brustman 
Published: May 2019

INTRODUCTION:
There is a lack of data in the literature about outcomes of pregnancies with NT measurement ≥3mm and <3.5 mm. The objective of this study was to look at outcomes of these pregnancies.

METHODS:
This was an IRB approved study, from 1/2013-12/2017, of patients who presented for genetic counseling after an NT measurement of ≥3 mm and <3.5 mm. The primary outcome was the rate of abnormal prenatal testing results defined as termination of pregnancy, genetic abnormality or abnormality on fetal echocardiogram. In addition, the multiple of the median (MoM) for the gestational age was calculated and correlation with the primary outcome was tested.

RESULTS:
9 patients were studied who had NT measurements ≥3 mm and <3.5 mm. In respect to the primary outcome, 27% of patients had abnormal pregnancy outcomes. 69% of patients chose to have NIPS testing while 45% of patients decided to have invasive testing. Of the patients that had NIPS, 6% had abnormal results. 27% of the patients who had invasive testing had an abnormal karyotype or microarray. All patients that had Noonan testing were negative. 76% of patients in our cohort opted to get a fetal echocardiogram. Of these patients, 19% had an abnormal echocardiogram result with the majority of abnormalities being VSDs. There was not a meaningful correlation between the nuchal translucency measurement MoM and abnormal results.

CONCLUSION:
1 in 4 pregnancies with NT ≥3mm and <3.5mm had an abnormal prenatal outcome. Patients with this NT measurement should be offered further testing, especially fetal echocardiogram, given the rate of abnormalities.
The Levonorgestrel 52 mg Intrauterine System Is Effective and Safe for Six Years [13M]
Authors: Westhoff Carolyn L. , Keder Lisa M. , Gangestad Angelina K. , Teal Stephanie Beth , Olariu Andrea I. , Creinin Mitchell D. 
Published: May 2019

INTRODUCTION:
Liletta®, a levonorgestrel (LNG) 52mg contraceptive intrauterine system (IUS), is under investigation in an ongoing multicenter trial for up to ten years of use. Here we evaluate six-year efficacy and safety data.

METHODS:
We enrolled women aged 16-45 years with participants aged 36-45 years undergoing safety evaluation only in this IRB-approved trial. After IUS placement, we followed 1,568 women aged 16-35 years and 146 women aged 36-45 years, assessing pregnancy rates through six years and safety outcomes in all women regardless of duration of use.

RESULTS:
The 16–35 year-old subjects included 986 (57.5%) nulliparous and 433 (25.3%) obese women. To date, more than 375 women have completed 6 years of use; more than 125 have completed 8 years. Nine pregnancies occurred over 6 years including two in year 1, four in year 2, one each in years 3-5, and none in year 6. Six (67%) pregnancies were ectopic. The cumulative life-table pregnancy rate through year 6 was .87 (95% CI .44-1.70). Two perforations following IUS placement were diagnosed within the first year and none since. Expulsion occurred in 68 (4.0%) participants, most (50 [73.5%]) during the first year with 2 per year in years 6 and 7. Pelvic infection was diagnosed in 15 (.9%) women, most (11 [73.3%]) occurring after 6 or more months of use. Only 40 (2.3%) women discontinued due to bleeding complaints, primarily (n=30 [75.0%]) in the first 2 years.

CONCLUSION:
The LNG 52 mg IUS is highly effective over six years of use and has an excellent extended safety profile.
Googling Abortion Pills: The Ease of Buying Misoprostol and Mifepristone Online for Home Use [1N]
Authors: Kerestes Courtney , Freese Mikayla , Stockdale Colleen K. , Hardy-Fairbanks Abbey J. 
Published: May 2019

INTRODUCTION:
In an era of increasing abortion restrictions at the state level, as well as ease of access to information online, misoprostol and mifepristone bought online has become an option for some women seeking to end their pregnancy. This study seeks to elucidate the type of information available online as well as the credibility of websites selling these medications.

METHODS:
Eight search terms were identified using top keywords related to medical abortion and self-managed abortion. IRB approval was waived. Depersonalized, delocalized searches for each of these eight terms were done using Google, Yahoo!, and Bing, and the top 50 results were recorded. Unique websites with health information about abortion were further analyzed for medical information and sales of mifepristone and/or misoprostol.

RESULTS:
Out of the 1200 search results located, there were 327 unique websites and 109 websites that met our inclusion criteria. Of these, there were 25.7% non-profits, 23.9% general information sites, 20.2% primarily selling medications, 10.1% affiliated with clinics/hospitals, 13.8% affiliated with crisis pregnancy centers, and 6.4% of other types. Over one third (34.9%) were clearly pro-abortion and 23.9% were anti-abortion. 34.9% advised taking the medications without a provider involved and 22.6% of the websites sold medications, with an average price of $214 for a pack with 200 mg mifepristone and 800 mcg misoprostol.

CONCLUSION:
There are a large number of websites selling mifepristone and misoprostol for home use without a physician. This is important for physicians to be aware of since women may seek care after use of these medications.
Prevalence and Screening Perinatal Intimate Partner Violence Pregnancy Risk Assessment Monitoring System 2012-15 [12N]
Authors: Minns Annie , Peahl Alex Friedman , Kusunoki Yasamin , Terplan Mishka , Dalton Vanessa , Admon Lindsay Kennedy 
Published: May 2019

INTRODUCTION:
Current guidelines recommend screening women of reproductive age for intimate partner violence (IPV), and pregnancy is a high-risk period for IPV. Yet, in the perinatal period, little is known about prevalence of IPV, rates of screening for IPV, or healthcare utilization among affected women.

METHODS:
Using 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, we examined the prevalence of IPV in the perinatal period, rates of screening during prenatal care, and receipt of prenatal care among affected women. Adjusted logistic regression models and predictive margins were used to generate estimates and examine time-trends.

RESULTS:
2.4% (95% CI 2.3-2.6) of women reported IPV. 51.0% (95% CI 50.6-51.5) of women reported screening for IPV during prenatal care, including 47.0% (95% CI 42.3-51.6) of affected women. 98.6% (95% CI 98.0-99.2) of affected women reported some prenatal care, and 80.2% (95% CI 77.7-82.7) reported prenatal care in the first trimester.

CONCLUSION:
Only half of women reported screening for IPV during prenatal care, including less than half of affected women. High proportions of affected women engaged in prenatal care, suggesting missed opportunities to reach this vulnerable population.
Is Teaching Residents How to Code a Valuable Intervention? [16N]
Authors: Kuhlmann-Capek Maggie J. , Olson-Koutrouvelis Gayle , Munn Mary B. 
Published: May 2019

INTRODUCTION:
Appropriate documentation is an important component of quality health care. In academic medical centers, most documentation is done by residents. Given the scope of topics for resident education, a formal curriculum for documentation is often non-existent. Poor documentation has important consequences, including financial loss and compromise of quality indices. We sought to determine if instructing residents in basic coding principles improved the rate of appropriate documentation for early-term deliveries.

METHODS:
Residents were given a one-hour lecture focused on inpatient documentation, with a section on documenting appropriate justification for early-term deliveries. Subsequent documentation over a one-week period by each of the second- and third-year residents in attendance (n=7) was reviewed, and the rate of appropriate documentation for early-term deliveries was compared to similar documentation prior to the intervention for the same residents. This was compared to documentation by second- and third-year residents who did not attend the lecture (n=9).

RESULTS:
There were 153 total encounters analyzed. 29 were for patients who underwent early-term delivery. Of the pre-intervention early-term deliveries, the reasons for delivery in 8/13 (61.5%) were incorrectly documented. Of the post-intervention early-term deliveries, the reasons for delivery in 6/16 (37.5%) were incorrectly documented. 5/6 (83.3%) of the post-intervention early-term deliveries which were incorrectly documented were by residents who had not attended the lecture.

CONCLUSION:
Teaching residents coding and formal documentation is a valuable intervention. These simple interventions stand to make a significant impact on both financial and quality indices. These interventions will also serve to better prepare trainees for their transition into practice.
Maternal Near Miss Determinants at a High-Risk Maternity Hospital in Northeastern Brazil: A Prospective Study [26N]
Authors: Lima Telmo , Katz Leila , Kassar Samir , Amorim Melania 
Published: May 2019

INTRODUCTION:
To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators.

METHODS:
A prospective cohort study approved by the Ethics Committee (CAAE n. 37977014.0.0000.5011) was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016, including all pregnant women, after informed consent, and excluded those not discharged at the end of the study or those unable to contact after the 42nd postpartum day. We used the MNM criteria recommended by WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed, p values were two-tailed, and significance level was 5%.

RESULTS:
1,094 pregnant women were studied, 682 (62.4%) without adverse maternal outcomes and 412 (37.6%) with those outcomes, 352 potentially life-threatening conditions (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1,002 live births were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1,000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy.

CONCLUSION:
These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.
Morbidly Adherent Placentation: Predictive Value of Ultrasound and MRI Using a Scoring System [36N]
Authors: Winfrey Olivia K. , Brekke Emily , Lee James T. , Hendrix Nancy W. , Chavan Niraj R. 
Published: May 2019

INTRODUCTION:
Ultrasound and MRI are useful modalities to diagnose morbidly adherent placentation (MAP). This study aimed to integrate imaging features and maternal risk factors into a model to predict MAP.

METHODS:
We conducted an IRB-approved retrospective cohort study between January 2015 and June 2018 of patients with suspicion of MAP. Demographics, obstetric history, and clinical/histopathologic outcomes were obtained. A blinded maternal-fetal medicine physician reviewed 69 ultrasounds from 25 patients to catalog MAP-associated features. Of these 25, 16 had an MRI reviewed by an abdominal radiologist. Chi-square test of independence and Fisher exact test determined associations between maternal variables, imaging features, and diagnosis. Using logistic regression modeling, a scoring system was created based on statistically significant predictors.

RESULTS:
Of 361 patients with clinical or sonographic concern for MAP, 25 had high index of suspicion. Of these, 20 (80%) had clinical diagnosis of MAP at delivery. Twelve (60%) required cesarean hysterectomy; ultrasound alone identified MAP in 8 (66%). Of those having MRI, it was diagnostic in 6/10 (60%), with histopathologic confirmation. Placenta previa (P=.001), loss of retroplacental clear zone (P=.05), placental lacunae (P=.005), and bladder invasion (P=.001), as well as color Doppler (P=.03) and transvaginal imaging (P=.018) were significantly associated with histopathologic MAP. No MRI features were significant. Using a threshold score of ≥3, the scoring system predicted 9/12 (75%) MAP cases requiring cesarean hysterectomy.

CONCLUSION:
Several sonographic features were significantly associated with histopathologic MAP. Further research is warranted to assess the added value of MRI to improve the predictive accuracy of the scoring system.
The Use of Erythropoietin in Hypoxic-Ischemic Encephalopathy: A Cost-Effectiveness Analysis [12A]
Authors: Packer Claire , Hersh Alyssa R. , Sargent James Andrew , Caughey Aaron B. 
Published: May 2019

INTRODUCTION:
A recent phase II trial demonstrated that high-dose erythropoietin with therapeutic hypothermia for hypoxic-ischemic encephalopathy (HIE) results in decreased brain injury on MRI and improved 1-year motor function in comparison to treatment with therapeutic hypothermia alone. We sought to investigate whether such an intervention is cost-effective in cases of moderate and severe HIE.

METHODS:
A TreeAge decision analytic model was designed comparing erythropoietin vs. no erythropoietin in a cohort of 10,000 term neonates with moderate and severe HIE. Rates of global brain injury and neurodevelopmental disability (NDD) were derived from a phase II trial investigating high-dose erythropoietin and hypothermia for HIE, and rates of NDD due to global brain injury were estimated from existing literature. Costs were derived from prior literature. Utilities were applied to discounted life expectancy to generate quality-adjusted life years (QALYs). All costs and QALYs were discounted at an annual rate of 3% with cost-effectiveness threshold of $100,000 per QALY. Sensitivity analyses were conducted to assess the robustness of these results.

RESULTS:
High-dose erythropoietin for the management of moderate and severe HIE resulted in lower costs and higher QALYs compared to therapeutic hypothermia alone. In our theoretical cohort, utilizing high-dose erythropoietin results in 3,900 fewer cases of major NDD. In a univariate sensitivity analysis, when varying the cost of erythropoietin, erythropoietin was found to be cost-effective across all ranges considered.

CONCLUSION:
Erythropoietin therapy with therapeutic hypothermia is a cost-effective intervention resulting in improved outcomes for neonates with hypoxic-ischemic encephalopathy.