bluuebunny/crossref_metadata_2025_split huggingface dataset:
Fetoscopic Laser Coagulation vs. Expectant Management for Stage I Twin-Twin Transfusion Syndrome [13A]
Authors: McWhirter Amanda , Speranza Rosa J. , Thompson Jennifer Ann , Shaffer Brian , Caughey Aaron B. 
Published: May 2019

INTRODUCTION:
While fetoscopic laser coagulation (FLC) has been shown to improve outcomes in twin-twin transfusion syndrome (TTTS) at higher stages, the management of stage I TTTS remains controversial. We sought to examine the cost-effectiveness and outcomes associated with FLC versus expectant management and the resultant effects on rates of single intrauterine fetal demise (IUFD), dual IUFD, delivery <32weeks, and neurocognitive disability.

METHODS:
A cost-effectiveness model using TreeAge software was designed to compare outcomes in monochorionic diamniotic (MCDA) pregnancies complicated by stage I TTTS in twins managed with FLC versus expectant management using a theoretical cohort of 100,000 women. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000 per QALY.

RESULTS:
When twin pregnancies complicated by stage I TTTS were treated with FLC there were higher rates of single and dual stillbirth, more deliveries <32 weeks, but fewer cases of neurocognitive disability. Additionally, there would be increased costs and lower QALYs making FLC a dominated strategy. In our theoretical cohort, expectant management led to 1811.8 fewer single IUFDs, 2569.9 fewer dual IUFDs, 1133.3 fewer deliveries <32 weeks, 6370.4 more neurodevelopmental disability, and saving $20,134.29 with 1.9 increased QALYs. Sensitivity analysis of probability of IUFD after FLC, demonstrated that below a probability of 29.5%, using FLC becomes the cost effective strategy.

CONCLUSION:
In MCDA twin pregnancies affected by stage I TTTS, expectant management resulted in improved outcomes, decreased costs, and increased QALYs. Of note, the rate of neurocognitive disability was increased in the expectant management group.
Impact of the Combined Diabetes Clinic on HbA1c Changes and Outcomes in Pre-existing Diabetics in Rural Saskatchewan [14A]
Authors: Adams-White Tanner , Udayasankar Vijayalakshmi 
Published: May 2019

INTRODUCTION:
Pregnant women with pre-existing diabetes have increased risk for poor outcomes such as macrosomia, shoulder dystocia, still birth and intrapartum interventions. The Combined Diabetes Antenatal Clinic (CDAC) in Prince Albert (started in 2012) is a multidisciplinary clinic that serves rural northern Saskatchewan where the prevalence of diabetes in pregnancy is high. The goals of the CDAC are to improve euglycemia and pregnancy outcomes.

METHODS:
Retrospective cohort chart review to quantify the reduction in HbA1c after CDAC interventions and if the reduction in HbA1c improved pregnancy outcomes. Ethics approval was obtained from University of Saskatchewan.

RESULTS:
We identified 116 CDAC patients with pre-existing diabetes between 2012-2017. Majority of the population (52%) had to travel over 200 km to reach the CDAC clinic. There were high rates of obesity (71%) and high parity (28% Para 4 or more), majority were Type 2 diabetics and 87% of mothers were on insulin at the time of delivery. Women often (75%) presented to the CDAC after the first trimester. However, over 50% of patients who attended the CDAC reached the target of having an HbA1c below 6.5% prior to delivery. Mean change in HbA1c was -1.0% (SD 0.5-2.4) Mothers with HbA1c below 6.5% at the time of delivery had lower rates of shoulder dystocia (5.9% vs 2.3%) and still birth (11.8% vs 4.5%).

CONCLUSION:
The CDAC is effective in reducing the HbA1c and reductions below 6.5% is associated with improved pregnancy outcomes. We advocate pre-pregnancy counselling and booking early in pregnancy for pre-existing diabetes in this rural population
Association of Gastrointestinal Microbial Profiles and Estrogen Metabolism in Patients With Preterm Birth [21A]
Authors: Portugal Aileen , Le Nhung , Gong Yuan Yuan , Groesch Kathleen , Loret de Mola J. Ricardo , Braundmeier-Fleming Andrea 
Published: May 2019

INTRODUCTION:
Researchers have explored various causes for preterm birth (PTB); yet, the effects of maternal gastrointestinal microbiome on estrogen metabolism and its influence on pregnancy remains unknown. The aim of this study is to analyze the effects of maternal gastrointestinal microbiome on estrogen metabolism during pregnancy by correlating the estrogen metabolite bioactivity with preterm birth.

METHODS:
Study participants (IRB#14-185) were recruited at Southern Illinois University School of Medicine, Department of Ob/Gyn. Twenty-four patients identified as being at risk for a repeat, PTB were recruited. Biological samples (urine and fecal samples) were collected during each trimester and a postpartum timepoint. Fecal samples were frozen and processed for DNA isolation. Microbial analyses were performed by miSeq amplicon sequencing using the V4 region of the bacterial 16S rRNA gene. Identification of 15 estrogen metabolites (2-, 4- and 16-hydroxylation pathways) in urine samples was performed using tandem mass spectrophotometry analysis. Data was evaluated using analysis of variance (ANOVA) and then by repeat measure design.

RESULTS:
Of the 24 patients, 18 delivered at term and 6 delivered preterm (25%). Gastrointestinal microbial profiles were altered in women with subsequent PTB. Additionally, decreased urinary levels of estrone, 17-epiestriol and 17-estradiol were found as early as the first trimester in subjects who delivered prematurely.

CONCLUSION:
This study highlights the interaction of the gastrointestinal microbiome on estrogen metabolism, possibly through hormone conjugation. Unbalanced levels of estrogen during pregnancy may predispose women to PTB. This investigation may elucidate novel screening tools to identify patients at risk for PTB and enable early clinical intervention.
Neighborhood Income and Caesarean Section Rates at a Tertiary Care Center in Canada [23A]
Authors: Hodge Meryl , Shen Minxue , Xie Ri-hua , Wen Shi-Wu , Walker Mark , Chen Innie 
Published: May 2019

INTRODUCTION:
With rising rates of caesarean section (CS) in Canada and worldwide, non-clinical factors for CS warrant consideration. Our objective was to determine the association between a primigravid woman's neighborhood income and rates of CS.

METHODS:
A retrospective cohort study was conducted at an Ontario tertiary care center from January 2003 to December 2013. Rates of CS were determined using data collected from the Discharge Abstract Database. Women with singleton live births were included. The main exposure variable was neighborhood income quintile. A multivariable model was used to adjust for covariates and provide an estimate of the independent effect of neighborhood income on CS rate.

RESULTS:
The study cohort comprised 32,714 women. Compared with the lowest quintile, women in the highest quintile had increased rates of CS (Relative Risk (RR) 1.06, 95% Confidence Interval (CI) [1.02, 1.11]). Following adjustment for important confounders, there was no longer an association between neighborhood income and CS rate (adjusted RR 1.00, 95% CI [0.99-1.01]). Women in the highest quintile were more likely to have greater maternal age (P<0.001).

CONCLUSION:
Although differences in CS rates are seen by neighborhood income quintile, they appear to be related to maternal and infant clinical factors. Neighborhood income does not appear to be an independent predictor of CS.
Association Between Amphetamine Use and Pregnancy Outcomes in Women With a Hypertensive Disorder of Pregnancy [24A]
Authors: Speranza Rosa J. , Greiner Karen S. , Rincon Monica , Beeraka Sridivya S. , Burwick Richard M. 
Published: May 2019

INTRODUCTION:
Amphetamine use in pregnancy is associated with adverse outcomes, but the association with hypertensive disorders is not well categorized. The purpose of this study was to demonstrate the relationship between amphetamine use and outcomes among women with hypertensive disorders in pregnancy.

METHODS:
Retrospective cohort study of subjects with hypertensive disorders of pregnancy that delivered at a single institution (Oct. '13-April '18). Utilizing discharge codes and individual chart review, subjects were stratified into two groups by amphetamine use: current vs. non-users. We assessed final hypertensive diagnosis, severe features of preeclampsia, and neonatal or maternal outcomes. Differences were analyzed by Fisher's exact, t-test, and logistic regression, with Î±=0.05.

RESULTS:
From 10,833 deliveries, 13.7% were classified with a hypertensive disorder of pregnancy of which 2.2% actively used amphetamines during pregnancy. Active users were more likely to be diagnosed with gestational hypertension and preeclampsia with severe features (p=0.009), and more often had severe range diastolic blood pressure (p=0.009). Adverse outcomes were increased for current amphetamine users when adjusting for maternal characteristics, and the odds of any severe feature of preeclampsia was 4.17 times greater compared to non-users in the fully adjusted model (95% CI: 1.11-15.71). However, when adjusting for other substance use, the association between amphetamines and composite maternal or neonatal outcomes was attenuated.

CONCLUSION:
Amphetamine users are more likely to be diagnosed with gestational hypertension and preeclampsia with severe features. Additionally, the concomitant use of other substances highlights the need to identify these patients at risk of adverse maternal and neonatal outcomes.
Predicting Neonatal Pathologic Disposition From Cardiotocography Using Machine Learning [25A]
Authors: Freedman Isaac G. , Agarwal Akshar , Doilicho Natnael , Cohen Eli , Pettker Christian Michael , Copel Joshua A. 
Published: May 2019

INTRODUCTION:
Continuous cardiotocography (CTG) is widely used to monitor fetal heart rate and uterine contractions as a means of detecting intrapartum fetal distress. CTG use is associated with reductions in neonatal seizures and with increases in rates of cesarean sections (C-sections) and instrumental vaginal births. Given that unnecessary C-sections are associated with higher rates of morbidity and mortality, correct identification of C-section candidates is critical. However, agreement in CTG interpretation remains elusive, with high inter-and intra-observer variability in interpretation of tracings, which may lead to inappropriate interventions. Further, machine learning (ML) advances in other vital monitoring analytics have not been matched in CTG analysis. The objective of this study was to develop a cardiotocographic ML algorithm, a random forest (RF) model, which accurately predicts neonatal pathologic disposition to inform obstetric intervention.

METHODS:
We trained RF models to classify neonatal condition as healthy or pathologic on 13 summary statistics (features) from 1,831 continuous CTGs from the University of Porto SisPorto dataset. All measures of performance were calculated as out-of-bag (OOB), a statistical proxy for cross-validation, over 128 weak learner models.

RESULTS:
Our model identified healthy CTGs as not requiring obstetric intervention with an OOB sensitivity of 82.4%, a specificity of 99.4%, an accuracy of 97.9%, and a C-statistic of 0.908.

CONCLUSION:
Our model's OOB performance exceeds that of current methods and could dramatically reduce the rate of cesarean sections if widely implemented. The model is accurate, rapid, readily deployable, and extensible. Further research should test our algorithm on a larger population and in real-time.
Timing of Death and Rates of IVH, RDS, and NEC Among Infants With Neonatal Sepsis [27A]
Authors: Birch Mary Nienow , Frank Zoë , Caughey Aaron B. 
Published: May 2019

INTRODUCTION:
This study sought to evaluate infants with sepsis, stratified by preterm and term delivery, based on their rates of neonatal death (<28 days of life), infant death (28 days-one year), intraventricular hemorrhage (IVH), respiratory distress syndrome (RDS), and necrotizing enterocolitis (NEC).

METHODS:
This is a retrospective cohort study of non-anomalous, singleton and twin deliveries in the US. We compared preterm and term babies who died with sepsis. We also compared rates of IVH, RDS, and NEC among infants with sepsis. Results were analyzed using Pearson Chi-Squared tests to control for maternal race, maternal age, insurance status, education level, diabetes, chronic hypertension, preeclampsia, chorioamnionitis, postpartum hemorrhage, cesarean section, nulliparity, and gestational age.

RESULTS:
Rates of IVH, RDS, and NEC were significantly higher among infants with neonatal sepsis compared to non-septic infants. Rates of neonatal and infant death were increased in the sepsis group. These patterns are consistent among both preterm and term babies. Sepsis yielded an odds ratio of greater than 1 for all morbidities and mortalities examined. The one exception to this trend was neonatal death among preterm infants (OR: 0.52; 95% CI: 0.43-0.62%).

CONCLUSION:
Fetal AC <10th percentile identifies a cohort at higher risk for SGA who may have been overlooked with estimated fetal weight <10th percentile alone. This cohort can benefit from increased surveillance and additional pre- and post-natal counseling. Further, as a high portion of these patients delivered preterm, AC can guide timing of antenatal corticosteroids for fetal lung development and transfer to tertiary care centers when necessary.
The Impact of Limited Prenatal Care on Pregnancy Outcomes in Women With Depression [32A]
Authors: Howard Dagnie C. , Valent Amy , Caughey Aaron B. 
Published: May 2019

INTRODUCTION:
Depression is associated with a number of risks in pregnancy. This study aimed to examine how the number of prenatal care visits impacts pregnancy outcomes in women with depression.

METHODS:
This is a retrospective cohort study of singleton, non-anomalous births in California between 2007 and 2011 to compare outcomes of all women with depression who had 5 or more prenatal care visits compared with those with less than 5 visits. Outcomes included preterm delivery, intrauterine fetal demise, neonatal death, neonatal respiratory distress syndrome, placental abruption, maternal blood transfusion, and CDC severe maternal morbidity index score. To compare outcomes, we used chi-square and multivariate logistic regression controlling for socioeconomic status, age, parity, gestational age, ethnicity, diabetes, and hypertension.

RESULTS:
Of the 18,511 women with depression in our sample, those with limited prenatal care had higher risk of placental abruption, intrauterine fetal demise, preterm delivery, low birthweight (<2500 grams), neonatal respiratory distress syndrome, and severe maternal morbidity. Rates of neonatal death were significantly higher in the chi-square analysis (0.81% vs 0.15%, p = 0.002), however this difference did not persist in the multivariate analysis when controlling for potential confounding variables.

CONCLUSION:
In women with depression during pregnancy, limited prenatal care is associated with greater odds of adverse neonatal and maternal outcomes, including intrauterine fetal demise and severe maternal morbidity. These associations should be considered when providing care to pregnant women with depression. Additionally, further examination of the obstacles limiting access to regular prenatal care in this patient population should be pursued.
National Perinatal Outcomes Among Young Donor Oocyte Recipients [35A]
Authors: Schwartz Kaia , Boulet Sheree L. , Kawwass Jennifer F. , Kissin Dmitry 
Published: May 2019

INTRODUCTION:
Previous studies demonstrated elevated risk of poor perinatal outcomes with donor versus autologous oocytes during assisted reproductive technology (ART), primarily among older women. We assessed perinatal outcomes among donor oocyte recipients <35 years old.

METHODS:
Using the Centers for Disease Control and Prevention's National ART Surveillance System, we analyzed all fresh embryo transfer cycles between 2010 and 2015 among women <35 years. Cycles using cryopreserved eggs, donated embryos, or a gestational carrier were excluded. We calculated predicted marginal proportions to estimate the unadjusted and adjusted risk ratios (aRR) and 95% confidence intervals (CI) for the association between donor versus autologous oocyte use and stillbirth, preterm delivery and low birth weight (LBW) among singleton pregnancies or births and stratified by number of embryos cryopreserved. Models were adjusted for patient and treatment characteristics.

RESULTS:
We included 71,720 singleton pregnancies occurring during 2010 to 2015. With zero embryos cryopreserved, donor versus autologous oocyte use was associated with increased risk for stillbirth (2.1% vs 0.6%), aRR 3.73 (CI 1.96-7.11); no association was found when ≥1 embryos were cryopreserved (0.54% vs 0.56%), aRR 1.15 (CI 0.59-2.25). Singletons resulting from donor oocytes were more likely to be preterm: 15.6% vs 11.0%, aRR 1.39 (CI 1.20-1.61) and LBW 11.8% vs 8.8%, aRR 1.34 (CI 1.16-1.55), no effect modification by number of embryos cryopreserved.

CONCLUSION:
Among women <35, donor oocyte use was associated with increased risk of stillbirth (with zero embryos cryopreserved), preterm delivery and LBW. Use of donor eggs, underlying reason for infertility, or both may drive this risk.
CenteringPregnancy® Increases the Likelihood of Postpartum Visit and Contraceptive Use [2B]
Authors: Yamada Rei , Wolf Abigail 
Published: May 2019

INTRODUCTION:
The postpartum visit provides an important opportunity for women to discuss contraceptive options with their provider, but as many as 40% of women do not seek postpartum care. There are limited data on postpartum visit attendance and contraceptive use among women who receive group prenatal care. We studied the postpartum visit attendance and contraceptive use among women in our CenteringPregnancy® program.

METHODS:
We conducted a retrospective chart review of 90 CenteringPregnancy® participants who delivered their babies between June 2017 and June 2018 at an urban university hospital. We sent an online survey to the 58 participants who were between 3 and 6 months postpartum during the data collection period to ask about their current contraceptive use. This work was approved by Thomas Jefferson University's Institutional Review Board.

RESULTS:
Of the 90 participants, 88% (79) attended their individual postpartum visit in the first 90 days after delivery. Thirty-one surveys were completed between 3 and 6 months postpartum; 77% (24) reported using a contraceptive method. Of those, 54% (13) reported using a long-acting reversible contraceptive, and 88% (21) were happy with their contraceptive method. Of the 25 participants who reported being sexually active, 84% (21) reported contraceptive use.

CONCLUSION:
In our population, CenteringPregnancy® increased attendance at the postpartum visit. The additional contact time and structured educational content in CenteringPregnancy® create more opportunities for providers to counsel women about contraceptive options and may lead to increased uptake of long-acting reversible contraceptives compared to traditional prenatal care.
Perspectives on Pregnancy and Abortion Restrictions From Women Experiencing Intimate Partner Violence [5B]
Authors: O'Connor-Terry Carly , Gowda Tejasvi , Chang Judy 
Published: May 2019

INTRODUCTION:
In recent years, legislation restricting abortion has become commonplace. Recent studies have identified that one third of women seeking abortion services have experienced intimate partner violence (IPV). The purpose of this study is to gather opinions and experiences of women who have experienced IPV on pregnancy and recent legislative trends restricting abortion.

METHODS:
Qualitative, semi-structured interviews were conducted with women seeking services for IPV at the Women's Center and Shelter in Pittsburgh. Interviews gathered information regarding feelings on pregnancy and specific abortion restrictions. After transcription, two independent reviewers identified themes from each interview.

RESULTS:
Nine interviews were conducted and coded. Participants described the occurrence of reproductive coercion in their relationships and influence of the partner in decision-making regarding pregnancy. The women voice concerns regarding policies requiring spousal notification of abortion and described such policies as a violation of the woman's privacy and autonomy. The 24-hour waiting period had mixed views: some participants viewed the waiting period as a time for reflection; others argued partners would have more control if women had to wait to get an abortion. While many argued that state-mandated counseling would be helpful, some participants felt that it would not change the person's mind and could add additional trauma to the situation.

CONCLUSION:
Women experiencing IPV are particularly vulnerable to recent policies and restrictions on abortion. Spousal notification requirements risk potential danger and further disempowerment. Varied perceptions of mandated waiting periods and counseling may be related to difference in the context or type of IPV experiences.
Medical School Curricular Development: Sex Trafficking, Adverse Childhood Experiences, and Trauma-Informed Care [7B]
Authors: Borham Kristina , Dawgert Francis , Triano Mary 
Published: May 2019

INTRODUCTION:
The purpose of this study is to develop and assess second year medical students' ability to create a broad differential and think critically about the impact social factors may have on clinical presentation, specifically in sex trafficking victims. The lecture places emphasis on the relationship between adverse childhood experiences (ACEs) and trafficking as well the importance of trauma-informed screening techniques and care with these patients. There is a lack of training available to healthcare professions and therefore, a lack of awareness of the prevalence of human trafficking that results in a missed opportunity to better care for this unique patient population.

METHODS:
IRB approval was obtained via expedited review. Second year medical students at GCSOM completed an identical online pre- and post-survey online that evaluates attitudes and knowledge on sex trafficking. Students will be administered a second post-survey 6 months later, following a case based learning exercise.

RESULTS:
Students showed greater than 75% improvement in knowledge regarding specific care and treatment of sex trafficking victims immediately following the lecture, most notably comfort with identification and resources. Students will be evaluated to assess long term retention and application at six months post.

CONCLUSION:
Current medical school curricula does an excellent job at teaching aspects of psychosocial care at baseline. However, trafficking is not included in these discussions. Utilization of peer driven didactics help to improve student engagement and retention of knowledge regarding sex trafficking. Future curricula could be student driven or proposed as elective journal clubs/discussions to facilitate learning.