bluuebunny/crossref_metadata_2025_split huggingface dataset:
Use of Tranexamic Acid to Prevent Postpartum Hemorrhage in Women Undergoing Cesarean Delivery: A Meta-Analysis [14H]
Authors: Vasichko Paula E. , Ireland Kayla E. , Boyd Angela R. , Acosta Ometeotl M. , Ramsey Patrick S. 
Published: April 2018

INTRODUCTION:
Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality. Multiple clinical trials evaluated tranexamic acid (TXA) for treatment and prevention of PPH, but there is currently insufficient evidence to support prophylactic use. Our objective was to conduct a systematic review and meta-analysis using available data from randomized clinical trials (RCT) that evaluated the efficacy of TXA prophylaxis during cesarean section.

METHODS:
A systematic literature review was conducted using PUBMED and MEDLINE 1966-2017 with relevant search terms. Secondary citations from retrieved papers were also reviewed. Outcome data from RCTs were abstracted and meta-analysis performed using the Mantel-Haenszel fixed effects model with test of heterogeneity.

RESULTS:
27 RCTs were identified for prophylactic use of TXA at cesarean section; which included 4728 women. Only a single study included women at high risk for PPH. Administration of TXA was significantly associated with reduction of mean estimated blood loss (EBL) (27 studies, n=4728, OR 0.45, 95% CI 0.41–0.50), PPH>1000 mL (6 studies, n= 1986, OR 0.27, 95% CI 0.18-0.43), use of blood transfusions (12 studies, n=2813, OR 0.33, 95% CI 0.20-0.54), and need for other medical interventions (9 studies, n=2577, OR 0.39, 95% CI 0.29-0.53). Only 4 cases of VTE in 4366 women were reported which occurred similarly in controls and TXA.

CONCLUSION:
In an overall low risk patient population, prophylactic TXA at cesarean section was effective in reducing mean EBL, PPH>1000, blood transfusions, and need for other medical interventions. Additional research is needed to elucidate optimal regimens to maximize efficacy and minimize risk.
Patient-Reported Breastfeeding Experience After Peripartum Hysterectomy [15H]
Authors: Keenan Karissa , Einerson Brett , Gibbins Karen J. , Silver Robert M. , Grover Bryan , Callaway Emily 
Published: April 2018

INTRODUCTION:
Peripartum hysterectomy is associated with maternal morbidity, including blood transfusions and ICU admission. The impact of this morbidity on breastfeeding has not been documented. Our objective was to assess self-reported breastfeeding and overall satisfaction in women with peripartum hysterectomy.

METHODS:
Cohort study comparing women with peripartum hysterectomy to complicated cesarean section. Exposed women were those with hysterectomy due to placenta accreta or atony. Unexposed women were those with complicated cesarean (three or more prior cesareans or placenta previa) who did not have a hysterectomy. Women were enrolled at time of diagnosis or delivery. Details of the delivery hospitalization were abstracted. Breastfeeding surveys were sent to patients at twelve months or more postpartum. Proportions were analyzed with chi-square, Fisher exact, and t-tests.

RESULTS:
At 12 months postpartum, 69 (39%) of 178 women enrolled completed the follow-up questionnaire. Women with peripartum hysterectomy had higher rates of preterm birth, EBL > 1500cc, ICU admissions, blood transfusion, and NICU admissions compared to those with complicated cesarean section. Similar rates of breastfeeding were found at 6 months (64% vs 74%, P=.40) and 12 months (52% vs 60%, P=.55) postpartum as well as access to lactation consults (64% vs 60%, P=.72) between groups. Women who had a peripartum hysterectomy were less likely to be satisfied with their breastfeeding experience compared to women who had complicated cesarean section (48% vs 76%, P=.02).

CONCLUSION:
Women who undergo peripartum hysterectomy have higher rates of dissatisfaction with breastfeeding experience at 12 month postpartum compared to those with complicated cesarean sections.
Class III Obesity and Gestational Diabetes: The Role of Early Screening [20H]
Authors: DeTeresa Catherine A. , Ramus Ronald M. 
Published: April 2018

INTRODUCTION:
Obesity is a risk factor for gestational diabetes mellitus (GDM), and current guidelines recommend early glucose screening for pregnant patients with class III obesity (BMI ≥40). This study was performed to evaluate the role of early screening on the diagnosis of GDM in a severely obese population.

METHODS:
This was a retrospective cohort study of women with class III obesity who delivered at our hospital in 2016. The incidence of GDM was examined, as well as timing of screening. Early screening was identified as a 1-hour 50 gram glucose tolerance test (GTT) administered prior to 20 weeks gestation, and late screening was classified as a 1-hour GTT administered ≥30 weeks. An abnormal 50 gram result then led to a 3 hour GTT to diagnose GDM.

RESULTS:
314 women with class III obesity delivered in 2016; 18 were found to have pregestational diabetes mellitus and 31 (10.5% of obese gravidas without pre-existing diabetes) were diagnosed with GDM. Out of the women diagnosed with GDM, 11 (35.5%) were diagnosed with early screening, 16 (51.6%) were diagnosed between weeks 20-29, and 4 (12.9%) were diagnosed at ≥30 weeks. Of the women who received early screening, 11 (73.3%) were diagnosed with GDM at that time and 4 (26.7%) were diagnosed later in pregnancy.

CONCLUSION:
Diabetes and GDM are linked with neonatal morbidity. Our overall incidence of GDM was 10.5% in this high risk group. However, early screening for GDM in women with class III obesity leads to earlier detection in about 35% of cases with greater opportunity to improve prenatal glycemic control.
Phase 3 Study Evaluating Brexanolone, a GABAA Receptor Modulator, in Moderate Postpartum Depression [25H]
Authors: Kanes Stephen , Colquhoun Helen , Riesenberg Robert , Rubinow David , Maximos Bassem , Meltzer-Brody Samantha 
Published: April 2018

INTRODUCTION:
A double-blind, placebo-controlled Phase 2 study of brexanolone (USAN; formerly SAGE-547 Injection), a positive allosteric modulator of GABAA receptors, demonstrated rapid and durable improvements in postpartum depression (PPD). The current study (NCT 02942017) is one of two randomized, multi-center, double-blind, placebo-controlled Phase 3 studies that examined the efficacy and safety of brexanolone in women with PPD.

METHODS:
Approximately 100 women with moderate PPD (Hamilton Rating Scale for Depression [HAM-D] total score ≥20 and ≤25) were randomized 1:1 to a 60-hour infusion of blinded brexanolone (90 µg/kg/h) or placebo. The primary endpoint was the change from baseline in the mean HAM-D total score at Hour 60 following brexanolone compared with placebo. Durability of effect and safety were assessed through Day 30. Safety and tolerability were assessed by adverse events, vital signs, laboratory evaluations, electrocardiogram, and the Columbia Suicide Severity Rating Scale. Secondary efficacy endpoints included change from baseline in the Montgomery-Åsberg Depression Rating Scale, HAM-D response, HAM-D remission, and Clinical Global Impression-Improvement.

RESULTS:
This Phase 3 study will be completed in 2017. This presentation will be the first comprehensive reporting of primary and secondary endpoints. These data seek to validate and expand upon the Phase 2 results, which showed a rapid reduction in mean HAM-D score (Hour 60, brexanolone -21.0 vs. placebo -8.8, p=0.008) and durability through Day 30 (20.8 vs. -8.8, p=0.010).

CONCLUSION:
This study, along with a companion Phase 3 study with brexanolone in subjects with severe PPD, seeks to validate and expand upon the earlier Phase 2 data.
Oral Methergine: It’s Not Just for Postpartum Hemorrhage [30H]
Authors: Krychman Michael 
Published: April 2018

INTRODUCTION:
Abnormal vaginal bleeding has a direct impact on a woman’s quality of life; anemia, fatigue, loss of time from work and the impact on marital relations, and social obligations are a few of the common adverse effects. Methergine® is widely accepted as a front-line medication treatment for primary and secondary post-partum hemorrhage (PPH) and for the treatment of bleeding after first trimester loss. Methergine is commonly used more broadly for bleeding not only associated with pregnancy, delivery, or pregnancy loss or fetal demise, but in a variety of other medical situations most likely to prevent excessive bleeding and the associated symptomatology associated with anemia.

METHODS:
A retrospective review of Humana Claims data base 1/1/2007- 9/30/2016 and ICD-9 codes cross referenced with Methergine® and diagnosis code was conducted.

RESULTS:
The Humana Claims data base consisted of 22.4 million claims (treatment, medical or laboratory). We found 10,952 claims which had used Methergine® as part of their treatment paradigm. 71% (7,796/10,952) were associated with primary or secondary PPH, and 29%(3,156/10,952) were non-Post-Partum Hemorrhage and non-first trimester loss use for hemorrhage prevention or excessive bleeding. The alternative ICD-9 diagnoses that were associated with Methergine® included menstruation, infection, and painful menses/dysmenorrhea.

CONCLUSION:
Methergine® is utilized in the obstetrical bleeding paradigm, given its mechanism of action, efficacy and safety profile. It is commonly prescribed in scenarios of hemorrhage or first trimester loss however up to one third of use may be for other indications. Future research is warranted to further confirm the efficacy and safety in non-obstetrical situations.
Does Time of Wound Complication Differ by Skin Closure after Cesarean Delivery? [34H]
Authors: Cooper Shontreal , Blanchard Christina , Szychowski Jeffrey , Tita Alan 
Published: April 2018

INTRODUCTION:
A high proportion of post-cesarean wound complications occur after hospital discharge. We undertook this study to evaluate the association between skin closure methods following a cesarean delivery and wound complications occurring after hospital discharge.

METHODS:
This is a secondary analysis of data from a randomized trial in which women at 24 weeks’ gestation or greater undergoing cesarean were randomized to receive metallic staples or subcuticular suture for skin closure. Staples were removed at time of hospital discharge on post-op days 3-4 for Pfannenstiel incisions or days 7-10 for vertical. The primary outcome for the current analysis was any wound complication occurring after hospital discharge. Associations were examined with chi-square and Fisher exact tests.

RESULTS:
A total of 350 patients with follow-up through 4-6 weeks postpartum were included in the analysis: n=171 received suture closure and n = 179 received staples. Baseline characteristics including BMI and ethnicity were similar between closure groups. In the primary study wound complications occurred in 14.5% (n=26) of individuals with staples and 5.9% (n=10) with sutures, p=0.008. Approximately 50% of all wound complications occurred post-hospital discharge. The incidence of wound complications occurring post-hospital discharge was 6.7% (n=12) of patients receiving staples and 5.3% (n=9) of those receiving sutures; p=0.57. The RR (95% CI) of the wound complication after hospital discharge for sutures (relative to staples) was 1.3 (0.6-2.9).

CONCLUSION:
Although suture closure compared to staples is associated with fewer wound complications after cesarean delivery, we found no significant differences in the frequency of wound complications occurring after hospital discharge.
Standard vs Customized Post-Cesarean Opioid Prescription: A Randomized Controlled Trial to Reduce Unused Opioids [39H]
Authors: Osmundson Sarah , Lam LeAnn , Kook Bradley , Raymond Britany , Thompson Elizabeth , Richardson Michael 
Published: April 2018

INTRODUCTION:
Most women have unused opioids after cesarean, a source of opioid misuse and diversion. This study examined whether customized prescribing can reduce unused opioids after cesarean.

METHODS:
Between 6/14/2017 and 8/25/2017, all English- and Spanish-speaking women >18 years undergoing a cesarean were considered for eligibility. Women with complicated cesarean or chronic opioid use were excluded. Eligible women were approached postoperative day 1 and informed consent was obtained. Enrolled women were randomized to standard post-discharge opioid prescription (30 tablets of 5mg oxycodone) or customized prescription (formula derived from a prior study, and based on inpatient opioid use). Subjects were contacted on postoperative day 14 to assess opioid tablets used and pain. The Tennessee Controlled Substance Monitoring Database was accessed to confirm dispensed opioids. The primary outcome was unused opioid tablets.

RESULTS:
Of 323 cesarean deliveries, 34 declined participation and 99 were excluded, leaving 190 (84%) for randomization. Of 172 in final analysis (18, 9.5% lost to follow-up), the proportions reporting unused opioids were 65/87 (74.7%) in customized group, 60/85 (70.6%) in standard group (p=0.74). The customized prescription group received half the opioid tablets (14 [IQR 12-16]) compared to standard group (30), used less opioids (8 [IQR 4-14] vs 15 [IQR 6-30], p<0.001), and had less unused (5 [IQR 1-8] vs 10 [IQR 0-22], p<0.001) tablets. Reported pain outcomes and analgesic satisfaction with analgesia were not statistically significant.

CONCLUSION:
Customized opioid prescribing was associated with reduced opioid use and fewer unused opioids after cesarean, without affecting pain management.
Parental Views on Fetal Intervention in Down's Syndrome [1I]
Authors: Allyse Megan A. 
Published: April 2018

INTRODUCTION:
Clinical trials for fetal surgery and gene therapy interventions in fetuses identified as having trisomy 21 (Down syndrome) have shown increasing success in human and animal models. These interventions vary from physical intercessions, such as cardiac repairs, to attempts at cognitive improvement, including retention and learning ability. However, these interventions have been controversial among family members and individuals living with Down syndrome. In particular, community members have argued that attempts to intervene in the natural progression of Down syndrome contravene efforts to encourage acceptance and support of individuals with Down syndrome.

METHODS:
We conducted a nation-wide, online survey of parents of individuals with Down syndrome about their opinions and willingness to accept prenatal interventions in pregnancies with Down syndrome.

RESULTS:
Parents were sharply divided on the acceptability of fetal interventions in pregnancies with Down syndrome. Parents expressed conflicts between the desire to give children every possible opportunity and the need and willingness to accept their children as they were and as complete individuals in their own right. A significant percentage reported that they would refuse prenatal gene therapy for potential cognitive intervention in pregnancies with Down syndrome.

CONCLUSION:
Significant investment is ongoing in the detection of and intervention in pregnancies affected by aneuploidies such as Down syndrome. This study emphasizes the need to include broader stakeholder populations, including families of existing individuals, in the development and translation of such therapies. Significant rejection from patient advocate populations may result from a lack of engagement.
Malpractice Risk and Vulnerabilities Ambulatory Obstetrics and Gynecology Practice [6I]
Authors: Pomerleau Mimi , Greenberg Penny , Baecher-Lind Laura 
Published: April 2018

INTRODUCTION:
Malpractice claims may play an important role in the high cost of health care and may provide a lens through which patient’s perspectives of healthcare deficiencies are revealed. Learning from potential mistakes - or from the patient’s perception of harm - can help to identify areas for improvement in patient care.

METHODS:
This is a retrospective cohort study of claims from the CRICO Strategies National Comparative Benchmarking System (CBS) for malpractice cases asserted during the period 2006 and 2016. Cases selected for this analysis were open and closed malpractice claims and lawsuits from obstetric outpatient claims. Cases meeting selection criteria were qualitatively analyzed to determine contributing factors prompting harm and/or perceived harm.

RESULTS:
Of the 113,932 malpractice claims during this ten year period, 2,730 were obstetric-related, 548 originated within the outpatient setting, and 296 were associated with severe patient harm and/or death. Of these 296 claims, the top 5 contributing factors leading to the filing of the claim were perceived lapse of clinical judgment (45%), ineffective communication (25%), poor documentation (14%), clinician behavior related (11%), and clinical systems breakdown (11%).

CONCLUSION:
This review provides insight into vulnerabilities within the outpatient obstetrics setting and identifies areas for improvement. To provide safe and effective care, clinicians and administrators need to understand malpractice vulnerabilities and develop strategies to reduce risk. Our data suggests that the development of training or tools to support clinical decision making, communication strategies, and appropriate documentation are priority areas to reduce malpractice risk in the outpatient obstetrics setting.
Epidemiology of Hepatitis C in Pregnancy in North Central Florida: A Reassessment of Risks [10I]
Authors: McDilda Katelin , Egerman Robert , Gabrilovich Sofia , Lipori Gigi , Spiryda Lisa Beth 
Published: April 2018

INTRODUCTION:
Hepatitis C virus (HCV) affects 1% - 2.5% of pregnancies. Universal screening is not recommended aside from those with risk factors including among others: intravenous or intranasal drug use, incarceration or those having a sexually transmitted infection. Our purpose was to assess the epidemiology of HCV in North Central Florida.

METHODS:
IRB approval was obtained for this retrospective descriptive study. Patients were identified through ICD-9 Diagnosis codes for HCV and pregnancy from 2009-2014. Data abstracted from medical records included demographic information, concomitant sexually transmitted infections, tobacco or substance abuse, transfusion history and tattoos.

RESULTS:
Of 17,081 patients, 275 patients were identified with HCV (prevalence 1.6%). Mean age of those infected was 27.3 years old (range 16 to 49) with 89.1% Caucasian and 7.3% African American. Concomitant infections with Hepatitis B, HIV, chlamydia and herpes simplex occurred in 9%, 0.7%, 16% and 12% of patients, respectively. Most HCV patients smoked tobacco (89%); one third smoked cannabis (34%). A history of intravenous drug use was present in 75% and cocaine use in 37.5%. Although not a classical risk factor for HCV, prescription narcotic use was reported among 2/3 patients whereas 44% took non-prescribed narcotics. A minority of women had exposure to either tattoos 28.5% or blood transfusion 15%.

CONCLUSION:
We identified prescribed and self-administered oral narcotic medication and tobacco use as additional risks for HCV. We suspect adhering to the current screening recommendations permits cases of HCV to be missed and that more widespread if not universal screening should be considered.
Outcomes Associated With Influenza-Like Illness in the Peripartum Period [14I]
Authors: Emeruwa Ukachi N. , Nour Nawal M. , Diouf Khady 
Published: April 2018

INTRODUCTION:
Influenza-like illness (ILI) is defined as fever + cough +/- sore throat. Among women who present with these symptoms, influenza is in the differential diagnosis. This study spans 5 years following the 2009 H1N1 epidemic and aims to investigate characteristics of peripartum women with ILI, to identify risk factors for severe disease and to identify influenza-related maternal and neonatal complications.

METHODS:
Using microbiology data from Brigham and Women’s Hospital between 2012 and 2016, a retrospective analysis was done among peripartum women with influenza tests available.

RESULTS:
One hundred and twenty nine women were tested. Fourteen percent (14.0%) had a positive influenza test, of whom 10 (55.6%) had received an influenza vaccine during pregnancy. Rates of antiviral treatment were higher in women with positive tests (88.9% vs 12.6%, P<.05).
Sixty five women (50.3%) were hospitalized for non-obstetric (pneumonia and asthma exacerbation) and obstetric complications. Nine (13.8%) were admitted to the ICU. The odds of an ICU admission were higher for women who were immunosuppressed (OR 2.3, 95% CI 1.1-4.8). Women with positive tests were more likely to have respiratory failure (11.1% vs 0.9%, P=.051).

CONCLUSION:
A small proportion of women presenting with ILI had laboratory-confirmed influenza. This may reflect the poor sensitivity of the test or another viral or bacterial illness. The low rate of influenza immunization during pregnancy highlights the need for further education of providers and patients. Maternal outcomes can be improved by having a high index of suspicion and promptly treating women with ILI.
Pregnant Women’s History of Vaccination and Acceptance of Hypothetical Zika Vaccine [15I]
Authors: Alholm Zachary , Zwick Ryan , Ault Kevin , Fitzgerald Sharon , Satterwhite Catherine 
Published: April 2018

INTRODUCTION:
Promising Zika vaccines are currently in clinical trials. To prepare for public availability, the acceptability of a hypothetical Zika vaccine among pregnant women was assessed.

METHODS:
A short Likert-scale survey was administered to 100 pregnant women receiving routine prenatal care at the University of Kansas Medical Center from 07/07/2016 to 9/29/2016. Hypothetical vaccine acceptability was evaluated by calculating the proportion of respondents who strongly agreed with the statement “If a vaccine for Zika virus was available, I would get this vaccine while pregnant.”

RESULTS:
Of 100 patients surveyed, 48% expressed strong agreement to getting a hypothetical Zika vaccine while pregnant. Women indicating strong vaccine acceptance were more likely than women not indicating strong vaccine acceptance to feel strongly about the importance of a recommendation from their prenatal provider (98% vs 63%, p<0.01), the importance of children being up to date on all their vaccinations (97% vs. 83%, p=0.01) and the importance of getting recommended vaccinations during her pregnancy (97% v. 79%, p=0.03). Data suggested that women who had received vaccines during pregnancy were more likely to be strongly interested in a hypothetical Zika vaccine (Tdap vs no Tdap: 51% vs 22%, p=0.08; influenza vaccine vs. no influenza vaccine: 55% vs 36%, p=0.07).

CONCLUSION:
A Zika vaccine may be acceptable to pregnant women but would benefit from strong provider support and education about the risks and consequences of Zika infection and the benefits of vaccination.