bluuebunny/crossref_metadata_2025_split huggingface dataset:
Fibroid Surgery and Long Term Improvement in Bladder Symptoms [38S]
Authors: Simula Natasha K. , Rikhraj Kiran , Koenig Nicole , Lee Terry , Geoffrion Roxana 
Published: May 2019

INTRODUCTION:
Several studies have demonstrated a short term benefit in urinary symptoms after fibroid debulking surgery with one year being the longest follow up reported in the literature. This study assessed the long term impact of fibroid debulking surgery on urinary symptoms several years after the procedure.

METHODS:
This is a follow up of a study which prospectively investigated improvement in urinary symptoms after fibroid debulking surgery in 61 women. A demographics questionnaire and the Urinary Distress Inventory (UDI) were completed. Changes in total UDI scores and UDI subscale scores from preoperative baseline to long term follow up were calculated using Wilcoxon signed rank test, t-test, Fisher's exact test and Chi square test. The study was approved by the Providence Health Care Research Ethics Board (H11-02621).

RESULTS:
Thirty four women participated. Mean follow up time was 5.3 years. There was a statistically significant improvement in total UDI scores (p<0.001), and obstructive (p<0.001) and irritative (p<0.001) subscale scores. Stress subscale scores significantly improved in a subgroup analysis of patients that had significant stress urinary symptoms at baseline (p=0.04). Six of 8 women (75%) were cured of moderate to severe symptoms of urge incontinence and 2 of 8 (25%) were cured of moderate to severe symptoms of stress incontinence.

CONCLUSION:
This is the first study demonstrating long term benefit of fibroid debulking surgery on bothersome urinary symptoms several years after the procedure. Women with urinary symptoms secondary to fibroids and refractory to medical management should be counselled on the potential benefits of surgery on their symptoms.
Promoting Labor Progress to Prevent the Primary Cesarean—Before and After Educational Intervention [2T]
Authors: Johnson Christina , Karkala Nikitha , Garretto Diana J. , Hines Heather Findletar , Russel Jessica , Liot Michele 
Published: May 2019

INTRODUCTION:
Primary Cesarean sections (CD) pose greater risks of mortality and morbidity than vaginal delivery for nulliparous, term, singleton, vertex (NTSV) women. There is 15 fold variation in NTSV cesareans in US hospitals, suggesting an opportunity for change at the institutional level. In January 2016, Stony Brook started a QI initiative (QI-i) to lower the rate of CD in NTSV via grand rounds education for identifying active labor as 6 cm of dilation, encouraging optimal patient positioning to promote the progress of labor, and introduction of a volunteer doula program.

METHODS:
An IRB approved retrospective cohort study was performed comparing 2015 (before the QI-i) to 2016- 2018 (after the QI-i). Inclusion criteria nulliparous (no prior deliveries ≥20 weeks), term (≥37 weeks), singleton, vertex presentation women delivering from January 2015 - June 2018. The primary outcome: NTSV CD. Secondary outcomes: 1 minute APGAR <7, 5 minute APGAR 0-3, cesarean rate for NTSV inductions, CD among NTSV with midwife care.

RESULTS:
There were no differences in the demographics of age, presence of a midwife in the care, birthweight, 1 or 5 minute APGAR scores. The NTSV cesarean rate was higher after the QI intervention (23% vs. 27%, p = 0.005). NTSV women had a statistically significant increased induction of labor (IOL) after 2015, via Cervidil, Cytotec, Foley balloon, AROM, and Pitocin (p<.0001, <.0001, <.0001, <.0001, <.0001 respectively).

CONCLUSION:
The CD rates in NTSV women continue to increase despite QI initiatives. IOL also increased and can be an area to improve the CD rates.
Quality Improvement Project to Reduce Primary Cesarean Delivery Rates in Low Risk Women [7T]
Authors: Wendlandt Megan , Alizadeh Pouneh , Donnelly Meghan Ann , Fennimore Robin MacColl 
Published: May 2019

INTRODUCTION:
The primary cesarean delivery (CD) rate in low risk women, defined as nulliparous, term, singleton, vertex (NTSV), has increased at Saint Joseph Hospital (SJH) from 20% to 24% between 2015 and 2017. SJH partnered with the Colorado Perinatal Care Quality Collaborative in an effort to reduce cesarean delivery rates in this low risk population by increasing surgeon adherence to nationally accepted labor dystocia guidelines.

METHODS:
Quality improvement intervention included the distribution of institution and provider specific NTSV CD rates, education for providers and nurses, and implementation of a preoperative labor dystocia checklist. Pre (January 2017 to May 2018) and post intervention (June to Sept 2018) NTSV CD rates were compared. Composite maternal and neonatal morbidity rates pre and post intervention were determined for SJH using Colorado State Vital Statistics data. A convenience sample of 40 cases of NTSV CD for labor dystocia were selected to compare guideline adherence pre and post intervention (20 cases pre and 20 post-intervention).

RESULTS:
The primary CD rate at SJH decreased from 24% to 21.7% after intervention. Adherence to labor dystocia guidelines significantly increased from 35% to 76% (p=0.0001) pre vs. post-intervention respectively. There was no significant difference between rates of composite maternal and neonatal morbidities pre and post-intervention.

CONCLUSION:
Participation of SJH in this statewide pilot quality improvement project significantly improved provider adherence to ACOG guidelines for CD for labor dystocia in low risk patients and has led to a decreasing NTSV CD rates. Future efforts will aim at sustainability of this initiative.
Reduction in Exposure to Opioids in Postoperative Obstetrical Patients [12T]
Authors: Arditti Lauren , Gallagher Kristen , Score Samantha Anne , Takhsh Eden 
Published: May 2019

INTRODUCTION:
Post-operative pain management has been named a major contributing factor in the opioid crisis in America. With success of pain management in ERAS (Enhanced Recovery After Surgery) protocol for gynecologic and general surgery patients, similar ideology was introduced to post-operative obstetrical patients after cesarean section. Through education of the medical staff, we hoped to see an uptake of a modified ERAS protocol and fewer opioids for our postpartum obstetrical patients.

METHODS:
The intervention consisted of two elements: (1) the adoption of a modified ERAS protocol as a standard of practice for the unit through education of medical and nursing staff and (2) evaluation of the overall reduction of opioid medication use among post-operative patients with adequate pain control. Oral and PCA intravenous administration of morphine was the primary opioid included in the analysis.

RESULTS:
A total of 1,152 patients were included in the study between April 2017 and March 2018. The protocol was initiated in October of 2017. Morphine PCA use decreased by over 94%. Patients receiving PO morphine tablets (either 15 mg or 30 mg) decreased by 65%. We did not see a change in satisfaction scores following implementation of the new postoperative pain management protocol.

CONCLUSION:
In conclusion, adoption of a new standard of inpatient opioid prescribing in the postoperative obstetrical patient coupled with education of prescribers and nursing staff was associated with a reduction of inpatient exposure to opioids with similar pain control.
Risk Factors for Progression to Severe Features in the Outpatient Management of Preeclampsia [17T]
Authors: Treloar Mackenzie S. , Finneran Matthew M. , Smith Devin D. , Gonzalez-Brown Veronica M. , Rood Kara M. 
Published: May 2019

INTRODUCTION:
Outpatient management is considered an acceptable surveillance method for women with preeclampsia (PE) without severe features (SF). While risk for disease progression has been studied in inpatient populations, outcome data for outpatient management is lacking. Our study aims to identify risk factors for disease progression in women with PE managed in the outpatient setting.

METHODS:
This was a retrospective cohort study of outpatients diagnosed with PE without SF at a large academic medical center from 2012-2017. The primary outcome was disease progression to SF. Demographic, diagnosis, and outcome data were compared between groups in univariate analysis. Backwards stepwise logistic regression was used to generate odds ratios (OR) adjusting for variables identified as risk factors for progression to SF.

RESULTS:
Of the 224 women who met inclusion criteria, 127 (56.7%) progressed to SF with a median latency from diagnosis of 7 days (IQR 1-12). Nulliparity was more common in the progression group (52% vs 35.1%; p=0.1), but no other demographic variables differed. Women with progression had an earlier gestational age (GA), greater rates of antihypertensive use, and higher systolic/diastolic blood pressure (BP), uric acid, and proteinuria at diagnosis. After stepwise regression, any systolic BP > 160 mmHg, uric acid > 4.65 mg/dL, GA < 32 weeks and nulliparity at diagnosis were independently associated with progression to SF (model AUC: 0.708; p<0.1).

CONCLUSION:
Over half of women with PE managed as outpatients progressed to SF. Nulliparity, GA, isolated severe-range systolic BP and uric acid levels were independently associated with progression to SF.
The NTSV Challenge; They Are Not All Created Equal [22T]
Authors: Mariona Federico G. 
Published: May 2019

INTRODUCTION:
Obesity represents the prototypical example of a non-contagious endemic population health care concern. We explored the possible influences of extreme maternal obesity defined as a body mass index (BMI) of ≥50 k/mÂ2 on the primary cesarean rate of nulliparous patients, at term pregnancy, with a single live fetus and vertex presentation (NTSV), also classified as Robson TGCS group 2

METHODS:
A retrospective secondary analysis of prospectively collected administrative and clinical data in a limited cohort of extremely obese pregnant women care for in a single tertiary care hospital. Twins, non-vertex, preterm < 37 weeks gestation and multiparous were excluded.

RESULTS:
Between 2008 and 2018 442 extremely obese pregnant women were included. 120 patients were NTSV (27.1%). The unadjusted primary cesarean rate was 78.7%, adjusted 55.5%. (OR=2.4). 55.4% of the patients were induced, with a diagnosed failed induction of 41%. The expected number of cesarean deliveries was 26; the observed number was 60, a clinical an statistical significant difference.

CONCLUSION:
Maternal obesity continues to present a major health concern in the United States. Extreme obesity presents a clinical challenge during prenatal care and at delivery time. Efforts are in place to safely reduced the primary cesarean in the so called low risk pregnant women represented by the NTSV population. We have shown that extreme obesity in the NTSV population continues to militate against efforts at safely reducing the primary cesarean rate. We encourage a multiinstitutional effort to define the role of extreme obesity in safely reducing the primary cesarean rate.
The Role of Digital Cervical Examination in the Setting of a Sonographically Short Cervix [23T]
Authors: Shahawy Sarrah , Henricks Andrea , Chow Kimberly , Saladi Nikita , Saade George Robert , Miller Emily Stinnett 
Published: May 2019

INTRODUCTION:
Many practices that have instituted universal cervical length (CL) screening have not included digital cervical examination in their process. Our objective was to investigate the incidence of cervical dilatation (CD) at various midtrimester CL thresholds as well as characteristics associated with CD that may inform who would benefit from digital examination in the setting of a short CL.

METHODS:
This retrospective IRB-approved cohort study included women with a singleton gestation with a midtrimester CL ≤ 2.5 cm who subsequently had a digital cervical examination within a week. The primary outcome was any CD on digital examination. Maternal sociodemographic, clinical, and sonographic characteristics were abstracted from the medical record. Bivariable and multivariable analyses were used to determine the relationship between these characteristics and CD. Receiver operating curves were developed to assess the predictive capacity of these characteristics to identify CD or CD ≥1 cm.

RESULTS:
Of the 256 women who met eligibility criteria, 103 (40.2%) were found to have any CD; 87 (34.0%) were at least 1 cm dilated and 8 (3.1%) were at least 2 cm dilated. While race/ethnicity, insurance status, nulliparity, a prior cervical excisional procedure, funneling on ultrasound, and the sonographic CL were each associated with CD, including all of these variables into a regression yielded a model with only fair predictive capacity to identify CD or CD ≥ 1 cm [AUC = 0.77 (95% CI 0.71-0.83) and 0.76 (0.70-0.82), respectively].

CONCLUSION:
As prediction of CD is limited, consideration should be given to performing a digital cervical exam in the setting of a sonographically short cervix.
What is the Optimal Cutoff for Maternal Serum Vitamin D Level to Predict Chorioamnionitis? [26T]
Authors: Persad Malini D. , Staszewski Cara , Khan Farzana , Perseleni Tatyana , Herrera Kimberly , Garretto Diana 
Published: May 2019

INTRODUCTION:
To determine the optimal Vitamin D (25(OH)D) cutoff to predict of maternal intrapartum infection.

METHODS:
A cutoff for the optimal 25(OH)D level for the prediction of chorioamnionitis was derived from data collected from a trial on Vitamin D3 use from October 2016 and May 2018. Women not utilizing Vitamin D3 in the pregnancy were included in the analysis. Per the trial women with an intrauterine pregnancy, between 12-16 weeks gestation were included. Women taking Vitamin D3 supplements prior to enrollment, diagnosed with a malabsorption disorder, or carrying an anomalous fetus were excluded. Maternal demographics, baseline Vitamin D status, and the whether the participant development of intrapartum infection was collected from the electronic medical record. Clinical chorioamnionitis was defined as presence of an elevated temperature of 39C or greater or 38C, twice, 30 minutes apart with fetal tachycardia, maternal tachycardia, purulent vaginal discharge or uterine tenderness. Descriptive analyses were performed on baseline characteristics. The optimal Vitamin 25(OH)D cutoff was derived from a ROC curve.

RESULTS:
A total of 107 women were included in the analysis. Based on available data, the incidence of maternal infection was 3.8% (4/103) among participants. Women were approximately 30 years old, primarily Caucasian, parous, and overweight. The optimal cutoff for the maternal serum Vitamin D level in predicting chorioamnionitis was 20 ng/mL (sensitivity 70%, specificity of 100%; AUC 0.813; 95% CI 0.716-0.910).

CONCLUSION:
To predict chorioamnionitis, the optimal cutoff for maternal serum Vitamin 25(OH)D level is 20 ng/mL. Preconception optimization to this value should be considered to prevent intrapartum infection.
Urine Protein/Creatine Ratio at Term: Does It Change Management? [29T]
Authors: Zuber Matthew J. , Carlson Sandra Kathleen , Dudley Donald , Cortez Briana , Cotton-Caballero Amaya 
Published: May 2019

INTRODUCTION:
We hypothesized that women with labor or rupture of membranes (ROM) commonly have proteinuria at term without preeclampsia as defined by urine protein/creatinine ratio (UPCR).

METHODS:
Women in this IRB-approved single-center, prospective cohort study were recruited at 35w0d-36w6d and provided a clean-catch urine for UPCR. With labor onset or ROM, a second urine specimen was collected. To detect a 10% difference in proteinuria between those with and without preeclampsia, we calculated a power of 82.3% and alpha of 0.05 for 84 patients.

RESULTS:
Baseline characteristics were similar between those with and without proteinuria. Race affected the risk of proteinuria, with 46.7% of Hispanic women, 27.3% African American, 7.1% Caucasian, and 0% of Asian patients having an elevated UPCR (>0.30) in labor or with ROM (P=.04). Only 3 patients in a cohort of 84 had UPCR > 0.30 between 35w0d and 36w6d. At admission, 13 of 84 patients (15.6%) had elevated UPCR. Five were diagnosed with preeclampsia without severe features (incidence 6%), and the diagnosis of preeclampsia did not correlate with the presence of proteinuria (P<.00). There was a trend toward elevated UPCR with ROM (26.7% vs 13.2%, P=.18). UPCR > 0.30 did not correlate with elevated blood pressure (>140/90) on admission (P=.48). Composite outcomes of maternal and neonatal morbidity were unchanged by proteinuria.

CONCLUSION:
Elevated UPCR is common independent of hypertension, with poor predictive value for preeclampsia at term. Proteinuria was more common in Hispanic and African American women. We question the clinical utility of UPCR in managing term hypertension.
Progesterone for Prior Late Preterm Birth: Is it Worth it? [34T]
Authors: Taliani Catherine A. , Hade Erinn , Finneran Matthew M. , Waickman Colleen , Frey Heather A. 
Published: May 2019

INTRODUCTION:
To examine the use of any progesterone therapy versus none in the prevention of recurrent preterm birth (PTB) in women with only a history of late (340 - 366 weeks) prior spontaneous PTB.

METHODS:
Women with a singleton gestation and a history of late spontaneous PTB who received prenatal care at a single tertiary medical center between 2011-2016 were included in this IRB approved retrospective cohort study. Pregnancies were considered exposed to progesterone if it was initiated prior to 24 weeks; those with a fetus with a major congenital anomaly were excluded. The primary outcome was PTB <37 weeks. In order to control for treatment selection bias, adjusted risk differences (aRD) in PTB proportions and 95% two-sided confidence intervals were estimated via inverse probability weighted (IPW) regression with adjustment for multiple pregnancies per patient through robust sandwich standard errors. Secondary outcomes included: PTB <34 weeks, spontaneous PTB, neonatal intensive care unit admission, and gestational age at delivery.

RESULTS:
Of the 478 pregnancies included, 56% (n=270) received progesterone. After adjustment for treatment selection bias, pregnancies which received progesterone therapy had an increased risk of late PTB (<37 weeks: aRD: 11.5% (2.9, 20.0)). Similarly a significant increase in late spontaneous PTB (<37 weeks: 9.6% (3.2, 16.1)) and NICU admission (11.7% (5.2, 18.2)) was identified. No substantial difference in PTB <34 weeks was identified between exposure groups.

CONCLUSION:
This study suggests that progesterone supplementation may not be effective at preventing recurrent PTB in women with a prior spontaneous PTB between 340 - 366 weeks gestation.
Timing of Pregnancy After Ovarian Hyperstimulation Syndrome and Pregnancy-Related Outcomes [35T]
Authors: Sangtani Ajleeta , Ismail Maryama , Khan Zaraq 
Published: May 2019

INTRODUCTION:
The incidence of ovarian hyperstimulation syndrome (OHSS) after assisted reproduction is approximately 3%. The outcomes of pregnancy in immediate versus delayed pregnancy has not been previously studied.

METHODS:
A retrospective cohort study was conducted using the Rochester Epidemiology Project Database. Residents of Olmsted County and the surrounding 9 counties with OHSS were identified between 1995 and 2017. Patients were included if they had a pregnancy lasting ≥20 weeks gestation after the diagnosis of OHSS. Background data and pregnancy outcomes were collected. Data were then analyzed using a combination of t-test and Chi squared test. Women with OHSS and same cycle pregnancy were compared to those with subsequent cycle pregnancy.

RESULTS:
85 women with OHSS were analyzed, 47 with same-cycle pregnancies and 38 with subsequent cycle pregnancies. Background data did not differ between the two groups for infertility cause, body mass index, gestational age, parity, or number of embryos transferred. OHSS treatment modalities (paracentesis, thoracentesis, hospitalization and medical treatment) did not differ between groups. Patients with same-cycle pregnancies had neonates delivered at 35.6 weeks compared to 38.3 weeks with delayed pregnancies (p=0.0006). Patients with same cycle pregnancies also had lower birth weights compared to patients with delayed pregnancies (3201 g v 2628 g, p=0.003). Incidence of hypertensive disorders, diabetes, placental abruption, thromboembolism, intrauterine fetal death, intrauterine growth restriction, and 1 and 5 minute Apgar scores did not differ between the two groups.

CONCLUSION:
The data gives new insight into the risk of same-cycle pregnancies in patients with OHSS. Larger studies are needed to confirm the data.
The Use of Minimal Ovarian Stimulation to Achieve Autologous Pregnancy in Extremely Poor Prognosis Patients [36T]
Authors: Prokai David , Li-Jon Wu John , Babayev Samir , Carr Bruce R. , Bukulmez Orhan 
Published: May 2019

INTRODUCTION:
Patients with extreme advanced reproductive age and/or markedly diminished ovarian reserve are often recommended to undergo oocyte donation following failure to obtain embryos or achieve pregnancy with conventional high dose ovarian stimulation protocols. We present a cohort of patients who were recommended to use oocyte donation who underwent minimal stimulation for the purposes of embryo banking subsequently achieving ongoing pregnancy.

METHODS:
Retrospective cohort.

RESULTS:
A total of 20 self-referred patients after only being offered donor oocyte at an outside fertility clinic. Characteristics of this cohort included mean age 40.1 ± 0.74 years, Anti-Müllerian hormone 0.89 ng/mL ± 0.19, and the average number of conventional high dose cycles prior to referral was 2.2 ± 0.3 cycles. Of the patients undergoing minimal ovarian stimulation protocols, 90% (18/20) were able to have embryos frozen after undergoing 3.8 (+/- 0.41) cycles. Of these patients, 61.1% (11/18) progressed to embryo transfer (ET). For those who underwent ET, a total of 5 ongoing pregnancies (45% pregnancy rate) were achieved with an average time to pregnancy of 1.3 ± 0.24 years. Two spontaneous pregnancies (1 ongoing and 1 miscarriage) occurred during the course of treatment.

CONCLUSION:
Repetitive minimal simulation protocols with embryo banking allow the opportunity for autologous pregnancy in patients who previously failed conventional stimulation protocols and were recommended donor oocytes.