bluuebunny/crossref_metadata_2025_split huggingface dataset:
Hypertensive Disorders of Pregnancy Increase Neonatal Intensive Care Unit Admission in Growth Restricted Fetuses [27K]
Authors: Nwabuobi Chinedu , Kuznicki Michelle , Pargas Anaisy , Sinkey Rachel G. , Odibo Anthony O. 
Published: May 2019

INTRODUCTION:
The vast majority of pregnancies with fetal growth restriction (FGR) are in normotensive women. We aimed to determine whether hypertensive disorders of pregnancy (HDP) result in worse perinatal outcomes in pregnancies complicated by FGR.

METHODS:
This is a retrospective cohort study of non-anomalous, singleton, growth restricted fetuses - defined as estimated fetal weight (EFW) < 10th% - delivered in a single tertiary referral center from 01/2011 to 12/2016. Institutional Review Board approval was obtained. HDP included chronic hypertension, gestational hypertension, and all forms of preeclampsia. Perinatal outcomes examined include: cesarean delivery, neonatal intensive care unit (NICU) admission, and composite adverse neonatal outcomes (5 min Apgar < 7, respiratory distress syndrome, necrotizing enterocolitis, hypoglycemia, intraventricular hemorrhage grade 3, periventricular leukomalacia, and neonatal death). Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) for each outcome between the groups.

RESULTS:
594 pregnancies with FGR met inclusion criteria of which 137 (23.1%) were complicated by HDP. The rates of cesarean delivery, NICU admission, and the composite adverse neonatal outcomes were: 40.9%, 34.3% and 24.8%, respectively. HDP was independently associated with increased risk of NICU admission (aOR 2.37, 95% Confidence Interval 1.51-3.72) even after adjusting for gestational age at delivery. In contrast, HDP was not associated with increased risk of cesarean delivery or composite adverse neonatal outcomes.

CONCLUSION:
Women with HDP and FGR are at a significantly increased risk of NICU admission. This information can be useful for counseling patients and helpful in anticipating the need for additional neonatal support at the time of delivery.
Impact of a Standardized Clinical Assessment and Management Plan on Labor Induction Outcomes [29K]
Authors: Boardman Lori A. , Peach Daniel , Lanier Shelley 
Published: May 2019

INTRODUCTION:
Induction of labor (IOL) occurs in more than one in five births in the U.S. Choice of induction method depends on national guidelines, local protocols, clinical factors, and provider practice. Because of the potential for marked variation in care, we used SCAMP methodology to develop a clinician-designed algorithm to promote care standardization. The purpose of this study was to evaluate the impact of the algorithm on clinical outcomes and resource utilization.

METHODS:
A decision-tree algorithm was developed by a multidisciplinary committee; at each decision node, a preferred choice was indicated. If an alternative option was selected, providers were to indicate their rationale. Prior to piloting the algorithm, the Care Transformation team oriented clinicians and nurses to the project and use of data collection forms. Outcomes included the vaginal birth rate, length of stay, and choice of pharmacologic cervical ripening agent.

RESULTS:
SCAMP forms were completed for 37.9% (320/845) of patients undergoing induction. Using combined data from the two hospitals and comparing the same period (11/27-4/16) in 2017-2018 to 2016-2017, we realized a 12% (10.6 hour) decrease in ALOS, an increase in the vaginal birth rate from 73% to 80%, and a shift favoring use of misoprostol over dinoprostone (52% to 70%). With extended follow-up through 7/10/18, improvements seen in the pilot were maintained or surpassed (e.g., misoprostol use rose to 74%).

CONCLUSION:
Significant improvements in clinical outcomes and provider practice were seen with use of an internally created IOL algorithm. Cost analyses and expansion to two other hospitals are underway.
Women's Healthcare Providers' Experiences and Perceptions of Discussing Obesity: A Needs Assessment Survey [34K]
Authors: Schmuhl Nicholas B. , Antony Kathleen M. , Braun Emilie J. , Brown Heidi W. , Guan Wen , Williams Makeba L. 
Published: May 2019

INTRODUCTION:
Obesity is the most common co-morbidity occurring in women across their lifespans, associated with reproductive health problems, gynecologic and breast cancers, and numerous chronic conditions. Maternal obesity is associated with pregnancy complications, infant mortality, and childhood obesity. The goals of this study were to assess obstetrics and gynecology (Ob-Gyn) providers' experiences, attitudes, and practices pertaining to obesity counseling and to identify target areas for further training.

METHODS:
A needs assessment survey was distributed to 85 Ob-Gyn providers at a mid-sized academic medical center. Participants included physicians, trainees, and advanced practice providers.

RESULTS:
One quarter (25.6%) of respondents had never been trained to communicate with patients about obesity while 43.6% had not received training beyond medical or professional school. Fewer than half (45.2%) said they were at least somewhat comfortable addressing the topic of obesity, and only 18% felt at least somewhat successful (0% felt very successful). Providers who were more comfortable talking about obesity were also more confident about their patients' success, as well as their own success in counseling patients. A majority of providers (52.1%) discuss obesity often or always with pregnant patients with obesity (PWOs), while only 27.0% discuss obesity often or always with non-pregnant PWOs. Comorbidities and severity of obesity were the two most influential factors in deciding whether to discuss obesity. Pregnancy status and upward trend in weight gain were also important factors.

CONCLUSION:
These findings were used to design department-wide educational and faculty development opportunities intended to improve provider comfort and efficacy in discussing obesity.
Estradiol-to-Gonadotropin Ratio as Predictor of In Vitro Fertilization Success [36K]
Authors: Beyer Christopher D. , Gounko Dmitry , Pan Stephanie , Joseph Lee , Copperman Alan , Stein Daniel 
Published: May 2019

INTRODUCTION:
There are currently no markers that effectively correlate with cycle-specific oocyte yield, euploid embryo yield, and ultimately, in vitro fertilization (IVF) success. We hypothesize that patients with a greater response to gonadotropin stimulation, as demonstrated by the ratio of peak estradiol (E2) level to total dose of gonadotropins (G), will have better odds of achieving a higher yield of euploid embryos than will poor responding patients.

METHODS:
Patients who underwent IVF and pre-implantation genetic testing for aneuploidy (PGT-A) from 6/25/2015 to 5/20/2017 were included in this retrospective study. 1,885 cycles were evaluated for peak E2 (pg/ml), total dose of gonadotropins (G, IU), E2/G ratio (pg/ml-IU), and confounders including age, anti-mullerian hormone level (AMH, ng/ml), and body mass index (BMI, kg/m2). The primary outcome was total number of euploid embryos; secondary outcomes were number of retrieved oocytes, mature oocytes, and fertilized oocytes. Odds of additional embryo or oocyte were modeled by multivariable logistic generalized estimating equations.

RESULTS:
Accounting for confounders, E2/G ratio was significantly and positively associated with all outcomes. A 0.5-unit increase in E2/G above the mean was associated with one additional euploid embryo (odds ratio [OR] 1.74, 95% CI 1.53-1.98, P<.001), higher counts of oocytes retrieved (OR 3.13, 95% CI 2.65-3.70, P<.001), mature oocytes (OR 2.92, 95% CI 2.43-3.49, P<.001) and fertilized oocytes (OR 1.92, 95% CI 1.65-2.24, P<0.001).

CONCLUSION:
Optimal stimulation is essential to achieving IVF success. The association between E2/G and yield of euploid embryos may serve as a novel marker and predictive tool for patients undergoing IVF with PGT-A.
Perinatal Characteristics of Women With Uncontrolled Pregestational Diabetes [38K]
Authors: Thayer Sydney Marie , Owens Sarah N. , Skeith Ashley , Valent Amy , Caughey Aaron B. 
Published: May 2019

INTRODUCTION:
Uncontrolled diabetes in pregnancy carries risk of adverse maternal and neonatal outcomes. Glycemic control is a modifiable perinatal risk factor. Identifying demographics that are at higher risk of having uncontrolled diabetes in pregnancy is vital for improving health outcome disparities. Our objective was to compare perinatal characteristics of pregnant women with controlled and uncontrolled pregestational diabetes in a large cohort in California state.

METHODS:
This is a retrospective cohort study of singleton gestations among women with pregestational diabetes between 2007 and 2011 using linked vital statistics and ICD-9 data. Chi-square tests were used to compare perinatal characteristics between patients with controlled and uncontrolled diabetes during pregnancy. Uncontrolled diabetes status was defined by the delivering clinician. Multivariable logistic regression was used to estimate adjusted odds ratio (aOR), controlling for maternal age, education, parity, previous diagnosis of chronic hypertension, race, insurance status and tobacco use.

RESULTS:
In a cohort of 18,198 pregnant women consisting of 785 uncontrolled diabetics and 17,413 controlled diabetics, we found that pregnant women with uncontrolled diabetes were more likely to be black women, less than 20 years of age, hold a diagnosis of chronic hypertension, or have attended less than 5 prenatal visits. The other examined characteristics of interest did not show statistical significance.

CONCLUSION:
Teenage pregnancy, black race, chronic hypertension, and limited prenatal care are associated with uncontrolled pregestational diabetes. To improve health outcome disparities, these populations should be specifically targeted with planned resource allocation for the treatment of diabetes in pregnancy.
A Mature Cystic Teratoma on the Ovary Does Not Alter in Vitro Fertilization Success Rate [39K]
Authors: Hernandez-Nieto Carlos , Alkon Tamar , Lee Joseph , Gonzalez Katherine , Copperman Alan B. , Sandler Benjamin 
Published: May 2019

INTRODUCTION:
Patients who undergo surgical excision of a dermoid-cyst prior to in vitro fertilization may be at risk of resection of healthy ovarian tissue. Our objective was to analyze ovarian reserve, response to stimulation, and IVF success rates in patients with a dermoid-cyst versus those who underwent a cyst removal prior to undergoing IVF.

METHODS:
The retrospective cohort analysis included patients who underwent IVF with fresh blastocyst transfer from 2005 to 2018. Patients with a history of oophorectomy and/or donated oocytes were excluded. Patients were segregated in to 3 cohorts: (group 1: Resected dermoid-cyst, group 2: Present dermoid-cysts, and group 3: a matched control group). Comparative statistics and an adjusted multivariable logistic regression were used to analyze collected data. Study was approved by the Western Institution Review Board.

RESULTS:
119 patients were included, 54.6% (n=65) had an active dermoid-cyst during IVF cycle(s) while 45.4% (n=54) underwent cystectomy prior to treatment. 352 patients were included as a control. Demographic characteristics, ovarian reserve, stimulation parameters and pregnancy rates were comparable among cohorts. After controlling for age, BMI, AMH, endometrial thickness, blastocysts transferred and cyst size, no association was found with the odds of implantation (OR 1.56, P 0.58), clinical pregnancy (OR 2.52, P 0.63) ongoing pregnancy (OR 1.3, P 0.84) pregnancy loss (OR 0.76, P 0.84) or multiple pregnancy rates (OR 0.6, P 0.84) among patients with a dermoid-cyst.

CONCLUSION:
The presence or removal of an ovarian dermoid cyst did not adversely influence ovarian reserve or IVF success. Clinicians can be reassured that the presence of a dermoid cyst is not a barrier to assisted reproduction treatment success.
Impact of Type of Opioid Use on Methadone Dose at Delivery in Pregnant Women [13L]
Authors: Rosenthal Emily , Cruz Yury , Reyes Andres , Roman Amanda , Hand Dennis 
Published: May 2019

INTRODUCTION:
In our institution, the methadone initiation protocol for treatment of opioid use disorder (OUD) in pregnancy does not differentiate between heroin use and use of prescribed or diverted prescription opioids. We sought to determine whether there is a difference in methadone dose at delivery when comparing these two groups.

METHODS:
This is a retrospective cohort study of pregnant women with OUD treated with methadone at our institution from 2012-2017. The primary outcome was methadone dose at delivery. We compared women with prior heroin use to women with prior prescribed or diverted prescription opioid use alone.

RESULTS:
There were 335 patients identified. Of these, 254 reported heroin use, and 81 reported prescription opioid use alone. There were differences in baseline characteristics. A higher proportion of patients with prior heroin use were white (87 vs. 63%, p<.0001). A lower proportion were multiparous. Patients with prior heroin use had a lower mean initial BMI (25.70 vs. 27.15, p=.039). Prior to adjustment, there was a significant difference in methadone dose at delivery between the two groups (144.4 mg vs. 123.2 mg, p=0.013). After adjustment for covariates, this was no longer significant. In the adjusted model, only race was significant, with non-white women receiving significantly lower doses (107.59 mg vs. 145.75 mg, p<0.001).

CONCLUSION:
After adjusting for race, parity and initial BMI, there is no significant difference in methadone dose at delivery between women with prior heroin use vs. prescription opioid use. Women of non-white race have significantly lower methadone dose at delivery compared to white women.
Impact of Uterine Closure Technique at Time of Cesarean Section on Development of Abnormally-Invasive Placentation [14L]
Authors: Leovic Michael Phillip , Perlow Jordan Hugh 
Published: May 2019

INTRODUCTION:
Uterine closure technique at time of cesarean section has been extensively studied with regard to risk of operative bleeding, infectious morbidity, development of wedge defects, and risk of uterine rupture in subsequent pregnancy. Only one study has evaluated subsequent risk of abnormally-invasive placentation (AIP). We seek to describe AIP risk based on hysterotomy closure characteristics at the time of prior cesarean delivery.

METHODS:
A review of participants delivered at a single, large, tertiary care center from 12/15/2011-08/22/2017 was performed. Records were reviewed and data was abstracted pertaining to demographics, pregnancy characteristics, obstetric history, suture use, and tissue pathology. Data was summarized using SAS software, version 9.4.

RESULTS:
Of the 169 cases of AIP, 154 (91.1%) had a history of cesarean section. Information detailing prior hysterotomy closure was available for 48 (31.2%) patients, 9 (39.6%) with single-layer closure and 29 (60.4%) were closed in two layers. There was a statistically-significant difference observed in incidence of AIP among patients with double-layer closures (93.1% vs 41.4%, p 0.035). Closures were performed with Vicryl (n = 32, 20.8%), Monocryl (n = 5, 3.2%), PDS (n = 6, 3.9%), and chromic (n = 4, 2.6%) suture. The incidence of AIP for each group was 81.3%, 100%, 83.3%, and 50%, respectively (p 0.97). Larger suture caliber was associated with an increased incidence of AIP (p 0.032).

CONCLUSION:
Our data suggests that risk of AIP may be influenced by double- vs single-layer hysterotomy closure. Future large, randomized trials are warranted to adequately assess this relationship.
Implementation of a Preterm Labor Evaluation Algorithm in a Multi-State Health System [15L]
Authors: Girardi Gerald J. , Garpiel Susan , Mancuso Sarah , Frame Elizabeth A. , Ruma Michael S. 
Published: May 2019

INTRODUCTION:
To determine the effect of implementing a standardized preterm labor (PTL) algorithm in a multiple hospital health system.

METHODS:
We performed a prospective evaluation of patients presenting with PTL at 34 hospitals within the Trinity Health System. Prior to implementation of a PTL algorithm, patients presenting with PTL symptoms were assessed in a manner determined by the clinician. After training, a PTL evaluation algorithm was implemented system-wide as a quality improvement project. The algorithm detailed the use of sterile speculum examination (SSE), fetal fibronectin (fFN) collection and transvaginal ultrasound cervical length (TVCL). Pre- and post-implementation data were compared using Chi-Square tests. Negative predictive value (NPV) was calculated for fFN and/or TVCL testing.

RESULTS:
1,826 women (557 pre- and 1,269 post-implementation) were included in the quality improvement project. The rate of SSE (pre: 51%, post: 68%; P<.0001) and fFN performance (pre: 23%, post: 36%; P<.0001) increased after utilization of the algorithm, while the rate of TVCL remained unchanged (pre: 13%, post: 14%; P>.05). Maternal admission rates decreased with algorithm utilization (pre: 21%, post: 15%; P<.01). Women presenting with PTL symptoms who were not evaluated by fFN or TVCL delivered within 2 weeks at a rate of 24%, while those who received either fFN, TVCL, or both had a rate of 6% (P<.0001). NPV for fFN and/or TVCL diagnostic testing for delivery within 2 weeks is 96.8%.

CONCLUSION:
Use of the PTL algorithm improved the clinical evaluation of patients in our health system and decreased the maternal admission rate.
Increasing Convalescent Leave Duration Has No Effect on Postpartum Physical Fitness [24L]
Authors: Sitler Collin A. , DeGroot David , Langan Kelly L. , Penberthy Sean , Hauret Keith , Gehrich Alan P. 
Published: May 2019

INTRODUCTION:
Army Directive 2016-09, effective 2 Feb 2016, increased postpartum convalescent leave from 6 to 12 weeks. While this change is beneficial for Army families, the impact on the mother's ability to meet physical fitness standards postpartum is unknown. Therefore the purpose of this study was to determine the changes in Army Physical Fitness Test (APFT) performance before and after the implementation of the new policy.

METHODS:
Primigravid active duty Army women who delivered at Tripler Army Medical Center between 1 Jan 2011 and 31 March 2017 were eligible for inclusion in the study. APFT data were obtained from the Digital Training Management System; the last test prior to and the first test after pregnancy were used for analysis. Data were analyzed with repeated measures ANOVA and Fisher exact test.

RESULTS:
There were 167 women in the old leave policy cohort and 64 in the new policy cohort. Push-up and sit-up repetitions decreased and run time increased postpartum (33.9±11.2 vs 39.3±11.5 reps, 60.9±14.4 vs 68.1±11.3 reps, 17.8±2.9 vs 16.9±2.2 min, P<.01 for all). There were no significant differences in APFT performance between convalescent leave groups, pre- or postpartum. The proportion of passed APFTs decreased postpartum (pre-pregnancy group 1: 96.3%, group 2: 98.4%; postpartum group 1: 86.2%, group 2: 84.4%) however there was no difference between groups that failed the post-partum APFT, P=0.62.

CONCLUSION:
Our data indicate that the new Army postpartum convalescent leave policy does not adversely affect performance on the APFT, however poorer postpartum APFT performance remains.
Induction Compared to Expectant Management for Women With Gestational Diabetes at Term [26L]
Authors: Nau Christopher Thomas , Has Phinnara , Kole Martha Brown , Rouse Dwight J. , Russo Melissa Lauren , Werner Erika F. 
Published: May 2019

INTRODUCTION:
To evaluate the risk of cesarean delivery by gestational week of induction versus expectant management in women with gestational diabetes mellitus (GDM).

METHODS:
We conducted a retrospective cohort study of term women with a singleton gestation and GDM who underwent a trial of labor and delivered between January 2016 and July 2018 at a tertiary care center. Outcomes were compared between women who underwent induction versus expectant management during a given gestational week. The primary outcome was mode of delivery. Maternal and pregnancy characteristics were compared between women in each group.

RESULTS:
Of 401 women with GDM, women induced during the 37th, 38th, and 39th weeks had greater body mass index than those who were expectantly managed and women induced during the 37th and 38th weeks were more likely to have hypertensive disorders of pregnancy. At all gestational ages, women who were induced were less likely to be diet-controlled. Overall, induction during the 39th week was associated with a lower rate of cesarean delivery, 14% compared to 28% with expectant management (P<0.01). This remained statistically significant when women with diet controlled GDM (n=216) were examined separately (11% vs 27%, P=0.02). Induction during the 39th week continued to be associated with a reduced risk of cesarean after adjusting for differences between each group; aOR 0.4 (95% CI 0.2-0.8) for all women with GDM and aOR 0.3 (95% CI 0.1-0.8) for women with diet-controlled GDM.

CONCLUSION:
For women with GDM, labor induction at 39 weeks is associated with a lower rate of cesarean delivery than expectant management.
Influence of Hypertensive Disorders of Pregnancy on Phenotype and Recovery in Peripartum Cardiomyopathy [27L]
Authors: Sangtani Ajleeta , Alrahmani Layan , Parikh Pavan 
Published: May 2019

INTRODUCTION:
Peripartum cardiomyopathy (PPCM) and cardiomyopathy secondary to hypertensive disorders of pregnancy (HDP) are considered to represent distinct cardiac entities (i.e. dilated vs hypertrophic cardiomyopathy). The goal of this systematic review and meta-analysis was to determine if HDP alters the odds of recovery and if baseline left ventricle characteristics are significantly different.

METHODS:
Ovid Medline, EMBASE, CENTRAL and Scopus were searched for combinations of the following: hypertension, preeclampsia, cardiomyopathy, peripartum, postpartum or puerperium. Articles describing initial left ventricular ejection fraction (LVEF), odds of recovery (EF >50%) or end diastolic diameter (EDD) amongst those with PPCM were included. Two raters analyzed abstracts and full text to determine eligibility and risk of bias. Risk of bias was determined using the Newcastle-Ottawa scale and the DerSimonian-Laird method was used to combine odds ratios.

RESULTS:
1838 articles were identified and 148 full text articles were reviewed for eligibility, with 11 observational studies meeting criteria. There was substantial agreement for selection (K: 0.817) and for risk of bias (K: 0.633) between raters. There was no significant difference (mean: 1.837%, 95% CI-4.882, 1.282) in baseline LVEF or EDD (1.837 cm, 95% CI-1.104, 4.778) between patients who developed PPCM +/- HDP. Further, recovery rates between groups were similar with OR of 1.870 (95% CI 0.854, 4.094) and a moderate degree of heterogeneity.

CONCLUSION:
Counseling regarding eventual recovery of LVEF after PPCM should not be altered due to the presence of HDP; it is unlikely that a phenotypic difference exists in the cardiomyopathy induced by HDP compared to idiopathic PPCM.