bluuebunny/crossref_metadata_2025_split huggingface dataset:
Routine Postpartum Rosette/Kleihauer-Betke Testing Is Unnecessary in Rh Negative Women [28B]
Authors: Peleg David , Tendler Shlomo , Warsof Steven L. 
Published: April 2018

INTRODUCTION:
A standard dose of 300 micrograms of anti-D, enough to equalize a 30 ml fetal-maternal hemorrhage, is given after vaginal and operative deliveries unless Rosette/Kleihauer-Betke testing indicates an increased fetal-maternal hemorrhage. Our objective was to determine the incidence during the previous year in which routine Rosette/Kleihauer-Betke testing indicated a fetal-maternal hemorrhage greater than 30 ml of fetal blood.

METHODS:
We reviewed the 2016 blood bank results for women delivering at a major Academic Perinatal Center. In routine fashion, cord blood from Rh negative women was collected at delivery. If the newborn was Rh positive, a Rosette test was performed, and if positive, this was followed by a Kleihauer-Betke to determine the quantity of anti-D required.

RESULTS:
There were 180 Rh negative women with Rh positive newborns. 106 women had spontaneous vaginal delivery, 65 cesarean delivery, 7 VBAC, and 2 instrumental vaginal delivery. Rosette tests performed on all 180. Of these, 166 (92.2%) were negative, 7 (3.9%) were positive, and 7 (3.9%) were invalid. Kleihauer-Betke test was performed on the 14 positive and invalid samples, all of which were negative. We were unable to demonstrate any case in which more than the standard 300 mcg dose of anti-D was required.

CONCLUSION:
In this study, the Rosette/Kleihauer-Betke model was found to be unnecessary, as there were no cases in which the fetal-maternal hemorrhage exceeded 30 ml. We anticipate extending this review for several years and if confirmed, could alter the way blood banks manage this common clinical situation, saving thousands of dollars in unneeded testing. We suggest that Rosette/Kleihauer-Betke testing be reserved for those clinical situations in which an increased fetal-maternal hemorrhage is suspected.
Implementation of Delayed Umbilical Cord Clamping Guideline for a Labor & Delivery Unit [36B]
Authors: Williams Nayo , Townsel Courtney , Assad Maushumi , Johnson Kendall , Campbell Winston , Sink David 
Published: April 2018

INTRODUCTION:
Delayed cord clamping (DCC) allows for placental transfusion and has proven benefits. Our institution’s delivery unit and Neonatal Intensive Care Unit (NICU) had no guideline for DCC despite good evidence for the practice since 2012. Working as a multi-disciplinary team, our aim was to develop, implement and monitor with quality improvement (QI) review a DCC guideline initiated in January 2017.

METHODS:
The guideline was drafted during inter-divisional perinatal-neonatal conferences using the Plan-Do-Study-Act model. The guideline included umbilical cord milking (UCM) as an option for placental transfusion. A department-wide email was sent to obstetrical and neonatal providers, as well as information sessions for the labor unit and NICU nursing staff explaining the new guideline, and exclusion criteria (unconfirmed dichorionic gestation, abruption and immediate resuscitation/stabilization of neonate and/or mother). Obstetrical residents documented whether DCC/UCM was performed. Our target was 80% of all neonates to undergo DCC/UCM. Descriptive statistics and chi-square test were utilized; P < .05 was significant.

RESULTS:
January through August 2017, 500 neonates delivered and 84.3%, of eligible neonates (408/484) underwent DCC/UCM (when DCC/UCM was not documented, we assumed it wasn’t performed). The rate increased over time, ranging from 63.5% to 98.3%. There was no statistical difference in DCC/UCM rates by preterm vs term (P=.70) or delivery route (P=.62).

CONCLUSION:
We reached our goal 80% of neonates undergoing DCC/UCM one month after initiation of the guideline. The QI review identified that documentation, communication, length of stay and hyperbilirubinemia rates are important areas for improvement and should be reevaluated with the next Plan-Do-Study-Act cycle.
Pregnancy Outcomes in Women With Primary Systemic Vasculitis [13C]
Authors: Nguyen Vanessa , Wuebbolt Danielle , Pagnoux Christian , D'Souza Rohan 
Published: April 2018

INTRODUCTION:
This study analyzes pregnancy outcomes in women with large, medium or small vessel vasculitis with the intent of aiding pre-conceptional counselling and informing antepartum and intrapartum care of these women.

METHODS:
We conducted a retrospective study of women with large-, medium- or small-vessel vasculitis and documented pregnancies between 2001 and 2016, identified from the Special Pregnancy Program Database at Mount Sinai Hospital, Toronto. We obtained information from hospital records and analyzed maternal, fetal/neonatal and obstetric outcomes between the different vasculitides.

RESULTS:
We identified 60 pregnancies in 50 women including 10 with large-vessel vasculitis (Takayasu’s arteritis), five with medium-sized vessel vasculitis, 30 with small-vessel vasculitis (16 ANCA-associated vasculitis, 14 with other such as IgA vasculitis), three with central nervous system vasculitis and two with retinal vasculitis. Vasculitis flares occurred in women with large-vessel (3/12), small-vessel (13/36) and retinal (2/3) vasculitis. Pregnancy complication rates were low, with one case each of first-trimester miscarriage, congenital anomaly, stillbirth and gestational diabetes. Although seven (26.4%) viable pregnancies resulted in preterm birth, the mean gestational age, regardless of the type of vasculitis, was over 35 weeks of gestation. Fetal growth restriction only occurred with small-vessel vasculitis (10 newborns, 28.6%). Of the 44 deliveries, 22 (50%) were spontaneous vaginal deliveries. All caesarean (18, 40.9%) and assisted vaginal (7, 15.9%) deliveries were for obstetric indications.

CONCLUSION:
With multidisciplinary management, women with vasculitis can anticipate excellent maternal and fetal outcomes, although they are at increased risk for late preterm birth.
Angiogenic Factors and Preeclampsia with Severe Features Among a Primarily African American Cohort [21C]
Authors: Perdigao Joana , Minhas Ruby , Chintala Sireesha , Mueller Ariel , Young Danielle , Rana Sarosh 
Published: April 2018

INTRODUCTION:
Preeclampsia related morbidity and mortality is rising predominantly due to delayed identification of patients at risk for severe features (preE-SF). This study explored the association between angiogenic biomarkers (sFlt and PlGF) and preE-SF.

METHODS:
Women with hypertensive disorders of pregnancy (HDP) were enrolled upon admission. Blood samples were collected within 96 hours of delivery. Angiogenic markers were measured on an automated platform. Severe disease was defined by ACOG criteria as BP ≥160/110, thrombocytopenia, right upper quadrant pain/epigastric pain/transaminases, renal insufficiency, pulmonary edema, or cerebral/visual disturbances. Descriptive statistics were assessed with a Wilcoxon Rank Sum, chi-square or Fisher’s exact test, as appropriate. Univariate and multivariable logistic regression was used to assess for differences in outcomes and angiogenic markers were assessed in tertiles.

RESULTS:
Our study included 375 women with HDP, of which 127 (33.9%) had preE-SF, 115 (30.7%) had gestational hypertension, and 66 (17.6%) had chronic hypertension. Our cohort was predominantly African American (74.4%). Levels of sFlt1 (pg/ml) were significantly higher in women with severe features compared to those without (9372.5 vs. 3607.0; p<0.0001), while levels of PlGF (pg/ml) were lower (51.0 vs. 122.0; p<0.0001) and the ratio of sFlt1/PlGF was significantly higher (212.0 vs. 32.0, p<0.0001). The highest tertile of sFlt1/PlGF was strongly associated with preE-SF (OR 9.05, 95% CI: 4.25-19.24; p<0.0001) in multivariable analysis.

CONCLUSION:
This study demonstrates a significant association between an abnormal angiogenic profile and preE-SF in a primarily African American cohort. Additional evaluation of the role of angiogenic markers during assessment for HDP and disease severity is needed.
Addressing Decision Making in Progesterone Treatment for History of Preterm Delivery [27C]
Authors: Zuponcic Jacqueline , Lavin Justin , Cottrell Connie , Li Marissa 
Published: April 2018

INTRODUCTION:
The United States infant mortality rate of 6.1 deaths per 1000 live births ranks 27th worldwide. The majority of perinatal morbidity and mortality is related to preterm birth, whose only FDA approved preventive treatment is intramuscular 17-hydroxyprogesterone (17-OH-P) from 16-36 weeks of gestation. Unfortunately, many patients refuse this treatment.

METHODS:
This 12 month prospective study utilized a short survey, in combination with focus groups, to identify social, cultural, and personal reasoning that influences patients’ decisions to accept or reject 17-OH-P treatment. We hypothesized that treatment refusal is multifactorial for any given patient.

RESULTS:
Acceptors (n=43) and refusals (n=7) were unable to generate sufficient power to identify statistically significant intragroup differences. However, utilizing these surveys and resultant focus groups, this study was able to identify trends within these populations which may guide future approaches to them. Patients refusing 17-OH-P often cited pain with injection, exhibited fatalistic beliefs regarding their care, and/or had personal concerns related to full term pregnancy. Acceptors were identified as candidates at the time of their previous preterm birth, coped better with treatment side effects, and/or had traumatic emotional reactions regarding their premature birth outcomes. Both groups cited barriers to their care–specifically including access and disparities within their care.

CONCLUSION:
Identifying these differences between women accepting and rejecting 17-OH-P may help to develop new approaches to improve patient acceptance of 17-OH-P therapy.
Addiction and Pregnancy, Addiction and Pregnancy: Analysis of an Intervention Protocol for Post-Cesarean Pain Control [38C]
Authors: Kunycky Christina , Callaghan Katherine , Lynch Kerry , Chase Gillian 
Published: April 2018

INTRODUCTION:
As the scope of the opioid-addiction epidemic increases, so does the need for supportive providers and for comprehensive interventions to best manage a patient’s addiction. Treating pain following cesarean section necessitates such an intervention as hyperalgesia and increased tolerance have been well established in patients treated with methadone and buprenorphine.

METHODS:
A quality improvement project was conducted to guide postoperative pain control for patients on medication assisted treatment (MAT) through the University of Massachusetts Medical School’s Green Clinic for Addiction and Recovery. Providers were instructed to administer a regimen of increased post-operative opiate pain medication for an initial cohort of Green clinic patients scheduled to undergo a primary or repeat cesarean section. A retrospective chart review was then conducted, collecting pain scores and quantity of opiate pain medication given from the time of delivery to 72 hours post-operative. Adherence to the protocol was determined by type and quantity of pain medication received.

RESULTS:
Of 16 Green clinic patients to receive the protocol, only 41% of patients received the treatment protocol and the remaining 59% received standard post-operative orders. There was no significant difference in pain scores between groups receiving the treatment protocol vs. those receiving standard postoperative orders.

CONCLUSION:
Failure to follow the protocol for patients on MAT indicates the need for more effective systems-based implementation protocols but also the need for concurrent education of healthcare workers involved in the care of patients with addiction, as stigma and knowledge gaps cannot be excluded as factors contributing to failure to follow the protocol.
Distress and Productivity Loss Associated with Uterine Fibroids: Results From a U.S. Survey [5D]
Authors: Marsh Erica E. , Al-Hendy Ayman , Kappus Dale , Galitsky Alex , Kerolous Majid , Stewart Elizabeth A. 
Published: April 2018

INTRODUCTION:
Uterine fibroids (UF) are highly prevalent among reproductive-age women with up to 50% of US women reporting symptoms that may be undiagnosed or untreated. The objective of this survey included understanding the impact of UF symptoms.

METHODS:
Female participants (≥18 years) were recruited via email from GfK KnowledgePanel®, a nationally representative panel of U.S. households, supplemented with opt-in consumer panels. The survey was 40-minutes long and used instruments such as the UFS-QoL and Aberdeen menorrhagia severity scale (AMSS).

RESULTS:
A total of 1,443 women were considered eligible and included in the study. Of the diagnosed women without hysterectomy (n=871), 68% passed blood clots, and 32% used ≥6 forms of protection/day based on the AMSS. Based on the UFS-QoL Symptom Severity Subscale, 44% and 43% of diagnosed women reported fatigue and heavy bleeding, respectively, as causing a 'great deal/very great deal' of distress. One-fifth of working women missed ≥8 work-hours monthly (21% full-time, 23% part-time workers). Of women who were undiagnosed but had UF-like symptoms ('at-risk'; n=300), only 49% were aware of UF. Approximately 84% passed blood clots, and 55% used ≥6 forms of protection/day. Of the at-risk women, 83% and 78% reported fatigue and heavy bleeding, respectively, as causing a 'great deal/very great deal' of distress. Overall, 22% full-time and 45% part-time workers missed ≥8 work-hours monthly.

CONCLUSION:
Women with UF experience distress and impaired work productivity. A substantial number of women may be undiagnosed with significant symptoms, underscoring the need for improved awareness and management of UF.
Occult Uterine Cancer in Presumed Benign Hysterectomies: A Population-Based Study [6D]
Authors: Xu Xiao , Wright Jason , Gross Cary , Lin Haiqun , Schwartz Peter E. , Desai Vrunda Bhavsar 
Published: April 2018

INTRODUCTION:
To inform proper surgical planning and policy discussion regarding uterine power morcellation, this study estimated the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications.

METHODS:
Women who underwent a hysterectomy in 10/1/2003-12/31/2013 were identified from the New York Statewide Planning and Research Cooperative System database which includes all inpatient and outpatient hospital discharges in the state. We excluded women with a history or admitting diagnosis of gynecologic cancer or endometrial hyperplasia, or received hysterectomy for non-gynecologic indications. Diagnosis of uterine cancer within 28 days after the index hysterectomy was determined based on linked state cancer registry data.

RESULTS:
We identified 233,979 women who underwent a presumed benign hysterectomy. The prevalence of occult uterine cancer was 1.00% (95% confidence interval [CI] 0.96-1.04%), including 0.78% (95% CI 0.74-0.81%) for endometrial carcinoma and 0.22% (95% CI 0.20-0.24%) for uterine sarcoma. The prevalence for leiomyosarcoma was 0.15% (95% CI 0.13-0.17%). The rate of occult uterine cancer ranged from 0.27% in laparoscopic supracervical hysterectomy to 1.96% in total abdominal hysterectomy; and varied from 0.15% in women undergoing hysterectomy for endometriosis to 0.64% for uterine fibroids and 8.64% for postmenopausal bleeding. After adjusting for surgical indication, the risk of occult uterine cancer was significantly higher in older women (e.g., odds ratio=25.98 for age ≥60 years versus <40 years, P<.001).

CONCLUSION:
The risk of occult uterine cancer in presumed benign hysterectomy was 1%. Older women and those who underwent total abdominal hysterectomy or with postmenopausal bleeding were at higher risk.
Laparoscopic Myomectomy vs Laparoscopically Assisted Myomectomy by Minilaparotomy: A Retrospective Study [8D]
Authors: Di Francesco Lucia , Javadian Pouya , Nezhat Farr , Nezhat Camran 
Published: April 2018

INTRODUCTION:
In this study we compared the short-term outcomes of laparoscopically assisted myomectomy by minilaparotomy (LAM) vs laparoscopic myomectomy (LM) for symptomatic leiomyomas.

METHODS:
hundred and eleven women with symptomatic leiomyomas of the uterus were included in the study. Retrospectively 51 patients with history of LM and 60 patients with history of LAM were evaluated. Patients record and history, patients characteristics, surgical course, intra and postoperative data etc. were documented and studied. Data was analyzed using SPSS. P value less than 0.05 was considered significant.

RESULTS:
There were no significant differences between groups regarding age, parity and BMI. Median diameter of largest myoma was significantly higher in LAM group (7.3±2.7 vs. 6.1±2.2, P value: 0.01). The median excised tissue weight in the LAM group (200 gr, range: 30-1400) vs LM group (78.5 gr, range: 20-990) was found statistically significant (P<0.005). The proportion of women with intramural fibroids and both intramural and subserosal fibroids was similar among the two groups. There was no statistically significant dependence between operation time (158.2±42.8 vs 153.1±48.4, P=0.55), median post-op hospital stay (380 min vs 398 min, P=0.37) and median estimated blood loss (600 cc vs 600 cc, P=0.64). No patients needed an admission to intensive care nor rehospitalization. Indeed, no patients in both group had post-op major complications.

CONCLUSION:
LAM is an acceptable alternative to LM and could have all the benefits of LM. By performing LAM, especially for larger myomas, morcellation of tissue and repair of the uterus is much easier.
Case Series of Laparoscopic Retroperitoneal Hysterectomy: Outcomes, Cost and Patient Satisfaction [11D]
Authors: Baxi Rupen , MacKoul Paul , Danilyants Natalya , van der Does Louise , Haworth Leah 
Published: April 2018

INTRODUCTION:
Laparoscopic Retroperitoneal Hysterectomy (LRH) is a minimally invasive hysterectomy approach incorporating retroperitoneal dissection to ligate the uterine arteries at the origin, lateralization of ureters, vaginal specimen extraction and transvaginal cuff closure. Our study evaluates LRH in terms of outcomes, cost, and patient satisfaction.

METHODS:
Retrospective chart review of 756 consecutive cases undergoing LRH for benign indications at a suburban hospital from 2011-2013. Data collected: patient characteristics and surgical outcomes. Direct hospital costs were estimated using a combination of micro- and gross-costing. Satisfaction surveys were mailed to the same patient population with a 12% response rate.

RESULTS:
Mean uterine size: 328.9g (SD 343.1), ranging from 20g to 9,314g. Mean operating time (OT): 61.8 min (SD 31.0). Average length of stay (LOS) 0.2 (SD 0.5) days with 88% discharged same day. Intraoperative and postoperative complication rates: 2.2% and 3.2%, respectively. Conversion to mini-laparotomy (<5cm) = 1.2% (9 cases). Conversion to laparotomy (>5cm) = 0.0%. Zero use of power morcellation. Average cost per case $4,061. Postoperative survey indicated 87.2% overall patient satisfaction rate.

CONCLUSION:
A distinguishing aspect of the LRH procedure is a standard retroperitoneal dissection with delineation of the ureter and control of the blood supply by uterine artery ligation at its origin. This technique is key to low complication rates, which minimizes OT, LOS, and costs, and contributes to patient satisfaction, and costs, and contributes to patient satisfaction. Further studies comparing LRH to the most widely performed minimally invasive hysterectomy approaches are warranted for this effective and cost-efficient procedure.
Contribution of Previable Births to Racial Disparity in Infant Mortality Rates the United States [22D]
Authors: Lee MacKenzie , Hall Eric , DeFranco Emily 
Published: April 2018

INTRODUCTION:
All live births that occur <20weeks contribute to Infant Mortality Rates (IMRs) as all result in death. We aim to describe racial variation in US IMRs attributed to infant deaths among previable (<20week) live born infants.

METHODS:
Population-based retrospective cohort study of all US live births from 2007-2014, using CDC WONDER database’s Linked Birth/Infant Death Records. Data were stratified by maternal race and gestational age (GA) at birth. We compared the proportion of infant deaths within previable and periviable/viable (≥20weeksGA) categories. The US reported IMR (births at all GAs including <20weeks) was compared to an adjusted IMR (≥20weeks), and the difference (≥IMR) was calculated for each race/ethnicity.

RESULTS:
Previable infant deaths represented 4.12%, 7.69%, and 4.99% of total deaths for non-Hispanic White, non-Hispanic Black, and Hispanic groups, respectively. The contribution of previable deaths to the total IMR of these racial/ethnic groups are .21, .89, and .26 per 1000 live births, respectively, P<.0001. Adjusted IMRs of the groups are 4.98, 10.85, and 4.69 deaths per 1000 live births.

CONCLUSION:
There are significant racial/ethnic differences in the relative contribution of previable births to each group’s IMR in the US. Non-Hispanic Black mothers had the largest number of previable births and the largest IMR if a lower GA cutoff of 20 weeks is considered. One potential method of standardizing IMR on the regional, national, and international levels is to impose a minimum gestational age for infant mortality calculations. However, this approach may obscure the disproportionate contribution of previable births to IMRs among the non-Hispanic black population.
Electronic Fetal Monitoring Predicts Severe Fetal Acidemia (Umbilical Cord Arterial pH [25D]
Authors: Gan Sarah , Goldberg Jay 
Published: April 2018

INTRODUCTION:
The purpose of this study was to determine how frequently intrapartum electronic fetal monitoring (EFM) was interpreted as concerning, with delivery expedited, in babies with severe acidemia (umbilical cord arterial pH < 7).

METHODS:
A retrospective cohort study was performed on babies with umbilical cord arterial pH < 7. Two groups were identified: (1) expedited delivery (either operative vaginal delivery or urgent/emergent cesarean section) and (2) non-expedited delivery (spontaneous vaginal delivery, scheduled or non-urgent cesarean section). Maternal, labor, and neonatal characteristics between the groups were compared using Chi-squared test for independence and the Fisher’s Exact Test.

RESULTS:
30 babies were identified with umbilical cord arterial pH < 7. 47% were delivered in expedited fashion. 53% were delivered in non-expedited fashion. Of the expedited delivery group, 79% were delivered by cesarean section and 21% by operative vaginal delivery. Of the non-expedited delivery group, 56% were delivered by cesarean section (scheduled or non-urgent). There was no statistical difference between groups in average umbilical cord arterial pH or base excess, gestational age, if labor was induced, length of labor, Pitocin usage for labor augmentation, sentinel events, 5 minute Apgar score or neonatal length of stay.

CONCLUSION:
Only 47% of babies with umbilical cord arterial pH of < 7 delivered in expedited fashion. There was no statistical difference in maternal, labor or neonatal characteristics between the expedited and non-expedited delivery groups. Poor sensitivity of EFM in predicting intrapartum hypoxia and acidemia limits the ability to expedite delivery in the presence of fetal acidemia.