bluuebunny/crossref_metadata_2025_split huggingface dataset:
Outcomes of Both Complex and Isolated Cases of Infants With Large Stomach on Fetal Ultrasound [33D]
Authors: McCormick Bridgette M. , Blakemore Karin J. , Johnson Clark , Bishop Juliet Chhay , Jelin Eric , Jelin Angie C. 
Published: May 2019

INTRODUCTION:
A sonographically large fetal stomach has resulted in gastrointestinal obstruction, per case reports, and is often followed with serial ultrasounds. We hypothesize that a LS is predictive of neonatal bowel obstruction.

METHODS:
We performed retrospective cohort study of all prenatal sonographic cases with a large stomach visualized between 1/1/02-6/1/16. Inclusion criteria required a liveborn delivery within the Johns Hopkins health system. We excluded pregnancy loss/termination cases and cases delivered outside JHHS. We defined a large stomach as an increased measurement in 2 or greater dimensions based on a normogram. Cases were classified as isolated or complex based on additional US findings at initial presentation. We collected demographics, sonographic findings and postnatal outcomes. Approval was obtained by the Johns Hopkins IRB.

RESULTS:
We identified 340 fetuses with large stomach. Two hundred thirty three met inclusion criteria, including 160 isolated and 73 complex. Of the 160 isolated cases, none resulted in gastrointestinal obstruction. Those with isolated findings were significantly less likely to deliver preterm (n=24, 15.0% vs n=31, 42.5%, p<0.001). Isolated cases were less likely to be complicated by polyhydramnios (n=13, 8.1% vs. n=18, 24.7%, p<0.001), NICU admittance (n=30, 18.8% vs n=70, 95.9%, P<0.001) or neonatal procedure (n=1, 0.63% vs. n=60, 82.2, p<0.001).

CONCLUSION:
While a sonographically large fetal stomach has been reported to result in gastrointestinal obstruction, the rate may be lower than previously hypothesized. We found that <1% of large fetal stomachs resulted in obstruction. When isolated, a large stomach is not a sole indication for ultrasounds and postnatal imaging.
Changes in Fetal Doppler Parameters Following Ablation of Placental Anastomoses in Twin-Twin Transfusion Syndrome [34D]
Authors: Chepa-Lotrea Xenia , Belfort Michael A. , Shamshirsaz Alireza A. , Nassr Ahmed , Sanz-Cortes Magdalena , Dorado Jimmy Espinoza 
Published: May 2019

INTRODUCTION:
Unequal placental sharing and unbalanced blood volume distribution contribute to TTTS in monochorionic pregnancies. This study describes changes in fetal Dopplers following laser photocoagulation of placental anastomoses.

METHODS:
230 women undergoing surgery for TTTS between 01/2012 and 05/2018 were included. Laser surgery was performed for Quintero stages II and greater, or stage I with symptomatic polyhydramnios, short cervix, or preterm labor. Pre and post-laser differences in impedance to blood flow in the umbilical artery (UA) and ductus venosus (DV) using pulsatility index (PI), as well as the middle cerebral artery peak systolic velocity [MCA PSV, as multiple of the median (MoM)] were calculated.

RESULTS:
TTTS Quintero stages I, II, III, and IV were present in 10%, 31.3%, 50.9% and 7.8% of cases. Median interval between scans before and after surgery was 2 days [interquartile range (IQR) 1-3 days]. Among donors, there was a significant reduction in UA PI [median prior: 1.313, IQR: 1.12-1.48 vs. median post PI: 1.186, IQR: 1.00-1.33, p<0.001). A similar trend among recipients did not reach significance. Among recipients, a significant elevation in MCA PSV was noted following surgery (median pre: 0.993 MoM, IQR: 0.82 to 1.12 vs. median post PSV: 1.077 MoM, IQR: 0.86-1.26; p=0.003. No significant differences were noted in DV PI changes in either donor or recipient twins.

CONCLUSION:
Reductions in the resistance to donor twin umbilical artery blood flow and improvements in recipient middle cerebral artery peak systolic velocity may represent early sonographic signs of TTTS resolution following laser surgery.
Current Experience With the Vaginal Breech Initiative at the George Washington University Hospital [1E]
Authors: Marko Kathryn I. , Gimovsky Alexis C. , Madkour Amr , Daines Dina , Abbasi Annam Hafeez , Soloff Michelle Aileen 
Published: May 2019

INTRODUCTION:
We have established a Vaginal Breech Initiative (VBI) to increase access to, and training in, the process of vaginal breech delivery. The VBI is a collaborative care team composed of physicians and nurse-midwives that leads care of participating women. Components of the VBI are: thorough antenatal screening, strict inclusion and exclusion criteria, rigorous informed consent, established delivery guidelines, and frequent simulation training.

METHODS:
This is a retrospective analysis of the VBI from 8/2011 to 11/2017. Inclusion criteria were: gestational age 34-42 weeks, singleton pregnancy, estimated fetal weight 2000-3800g, frank or complete breech, flexed head, adequate clinical pelvimetry, head and abdominal circumference within normal range and concordant, spontaneous labor and presence of a Vaginal Breech Team member. The primary outcome was incidence of vaginal breech delivery. Maternal and neonatal outcomes were examined secondarily.

RESULTS:
In total, 47 patients underwent a vaginal breech trial of labor, of which 72.3% had a successful vaginal breech delivery (n=34/47). Piper forceps were utilized in 11.8% of deliveries (n=4/34). The incidence of postpartum hemorrhage was 2.1% (n=1/47). There was one 3rd degree laceration (2.1%; n=1/47). Neonatal outcomes included an 8.5% incidence of neonatal intensive care unit admission (n=4/47) and a 2.1% frequency of head entrapment (n=1/47).

CONCLUSION:
The majority of patients undergoing breech vaginal delivery through our VBI had a successful vaginal breech delivery. Perinatal morbidity outcomes were rare. Through careful patient selection, counseling, and collaboration, breech vaginal deliveries performed in the context of a VBI are feasible in an academic medical center.
Delivery Outcomes in Women with Body Mass Index ≥40: A Systematic Review and Meta-analysis [2E]
Authors: D'Souza Rohan D. , Horyn Ivan , Jacob Claude-Emilie , Zaffar Nusrat , Maxwell Cynthia 
Published: May 2019

INTRODUCTION:
To compare delivery outcomes in pregnant women with a body mass index (BMI) ≥40based on the planned and actual mode of delivery.

METHODS:
Five databases were searched until July 2017 to identify studies that reported on delivery outcomes in women with BMI ≥40. Outcomes were presented as proportions. Relative risks (RR) and 95% confidence intervals were calculated using random-effects meta-analysis.

RESULTS:
Eight observational studies with low risk-of-bias (Newcastle-Ottawa Scale) were included. Based on 1597 pregnancies, planned vaginal birth (VB) vs. planned caesarean delivery (CD) was associated with higher risk for postpartum hemorrhage (PPH) [7.27% vs. 3.44%, RR 2.116 (1.02-4.40)] and low five-minute Apgars [4.51% vs. 1.53%, RR 2.955 (1.01-8.63)]. Based on 4144 pregnancies, planned trial of scar after caesarean vs. repeat CD was associated with higher risk for endometritis [4.97% vs. 2.19%, RR 2.22 (1.60-3.09)], low five-minute Apgars [4.94% vs. 1.68%, RR 2.98 (2.03, 4.28)], birth trauma [1.06% vs. 0.21% RR 4.61 (1.77-12.03)] and prolonged hospitalization [30.3% vs. 26% RR 1.163 (1.05-1.29)]. Based on 3625 pregnancies, successful VB vs. intrapartum CD was associated with lower risk of PPH [15.06% vs 69.96%, RR 0.21 (0.19-0.23)], wound disruption [0% vs. 4.44%, RR 0.05 (0.003-0.88)], prolonged hospitalization [1.9% vs. 6.67%, RR 0.28 (0.08-0.98)] and low five-minute Apgars (0.95% vs. 5.56%, RR 0.17 (0.03-0.86)], but more birth trauma [5.91% vs. 0.56% RR 6.56 (1.26-34.10)]. Compared groups had dissimilar demographic characteristics.

CONCLUSION:
Given the clinical equipoise, a randomized trial is needed to determine the optimal mode of delivery in women with BMI ≥40.
Impact of Rural Hospital Closures on Patient Outcomes in a Perinatal Region of Georgia [4E]
Authors: Stephens Angela Jessica , Nezafat Kiana , Poch Alexandra , Ghosh Santu , Street Linda , Ray Chadburn 
Published: May 2019

INTRODUCTION:
Rural hospital closures in the United States have left millions without access to healthcare. <50% of rural counties have hospital-based obstetrical services. Despite this, there are limited studies on the impact of obstetrical unit closures on patient outcomes. Augusta University Medical Center (AUMC) is the designated tertiary center for one of Georgia's six perinatal regions. We hypothesized that rural hospital closures directly impacted the outcomes of our patients.

METHODS:
The National Institute of Health's I2B2 software was used to identify charts of patients seen at AUMC for obstetrical services between January 1, 2010-December 31, 2011 and January 1, 2015-December 31, 2016. A retrospective chart review was performed to obtain and compare clinical outcomes between cohorts.

RESULTS:
6,096 charts were reviewed. 58.6% (3572/6096) of charts met inclusion criteria representing 74.6% (1501/2012) and 71.2% (2071/2910) of actual deliveries at AUMC for 2010-11 and 2015-16, respectively. Evaluated parameters included: obesity, birthweight, prematurity, APGARs, length of stay, insurance, psychiatric disease, hypertension, NICU admission, neonatal death, ICU admission, readmission, tobacco/substance use, cardiopulmonary disease, diabetes, VTE, transfusion/return to operating room. There we statistically significant increases in PTD and low APGARs/birth weight for those >76 miles away. Statistically significant decreases in normal birthweight infants for those >76 miles away. There were increased rates of substance abuse for all zip codes in 2015-16. There were no statistically significant differences in obesity, hypertension, neonatal death, ICU admissions, readmissions, VTE, or transfusions/return to the OR.

CONCLUSION:
Hospital closures within our perinatal region directly impacted aspects of patient outcomes at AUMC.
Development of a Venous Thromboembolism Prevention Tool in the Postpartum Period [5E]
Authors: Binstock Anna Berlyn , Larkin Jacob C. 
Published: May 2019

INTRODUCTION:
Venous thromboembolism (VTE) is a leading cause of pregnancy-related morbidity. Consensus is limited regarding optimal postpartum thromboprophylaxis strategies, with individual practices guided by expert opinion and extrapolation from non-obstetric data. RCOG has developed treatment guidelines for post-partum thromboprophylaxis with limited specificity. We aimed to develop a more specific predictive model that could decrease the number needed to treat (NNT) to prevent VTE following Cesarean delivery.

METHODS:
We performed a secondary analysis of the MFMU sponsored Observational Study of Cesarean Section and Vaginal Birth after Cesarean Section. Studying 29,763 women that underwent Cesarean delivery, we performed logistic regression to develop a predictive model of VTE. This predictive algorithm was then applied to an independent dataset of 2875 women that underwent Cesarean delivery at Magee-Womens Hospital in 2011. We then compared the sensitivity/specificity of our developed algorithm with RCOG guidelines.

RESULTS:
There were 11 postpartum VTEs in our cohort (incidence 0.38%). The sensitivity of our model was 100%, specificity 8%. The sensitivity of the RCOG system was 100%, specificity 6%.

CONCLUSION:
While both our prediction models identified all postpartum VTEs, use of either predictive model would result in thromboprophylaxis of >90% of patients undergoing Cesarean section. The inability to distinguish between patients that will and will not develop VTE indicates a limited utility to predictive models. Universal thromboprophylaxis may be a more effective strategy.
Does 1st Trimester Hemoglobin A1c Predict Adverse Pregnancy Outcomes? [9E]
Authors: Davis Jay , Heiselman Cassandra , Hoffmann Eva , Dinglas Cheryl , Vintzileos Anthony M. , Heo Hye Jung 
Published: May 2019

INTRODUCTION:
Recent prospective study demonstrates a correlation between 1st trimester HgA1c with development of gestational diabetes (GDM) in low risk populations. We sought to determine if 1st trimester HbA1c is predictive of GDM, abnormal ultrasound (U/S) parameters, and adverse pregnancy outcomes (APO) in high-risk pregnant populations and define the optimal HbA1c cut-off value.

METHODS:
IRB-committee approved retrospective cohort study performed on 156 singleton, non-pregestational diabetic pregnancies (HbA1c<6.5%), screened with 1st trimester HbA1c for increased risk of GDM, in an academic center between August 2016 to June 2018. HbA1c was correlated to the development of GDM, U/S parameters (femur length/abdominal circumference, head circumference/abdominal circumference, and observed/expected weight ratios, and amniotic fluid indices) at ∼20weeks, ∼30weeks, and ∼36weeks, birth weight parameters, and other APO using Receiver Operating Characteristic curves (ROC) and corresponding areas under the curves (AUC). Spearman correlation coefficients assessed the relationship between 1st trimester HbA1c values and observed/expected EFW, birth weight, and ponderal index.

RESULTS:
Among these 156 patients, prevalence of GDM was 16.0%. There was statistically significant correlation between 1st trimester HbA1c values and development of GDM (AUC=.728, P<.0003) at an optimal HbA1c cutoff value of 5.4%. There was no correlation between 1st trimester HbA1c and U/S parameters, birth weight parameters, or other APO.

CONCLUSION:
1st trimester HbA1c is predictive of GDM development in high-risk populations at values above 5.4%, a value much lower than the current AGOG guideline (HgA1c<5.7) for early GDM screening. In women without pregestational diabetes (HgA1c<6.5), HbA1c does not predict abnormal fetal U/S parameters or APO.
Outcomes of Water Immersion During The Second Stage of Labor [11E]
Authors: Valarezo Vanessa , Powel Jennifer E. , Benito Carlos , Yates Joann 
Published: May 2019

INTRODUCTION:
Water immersion during labor and delivery has become popularized, resulting in questions regarding outcomes, safety, and efficacy. Our study analyzed neonatal and maternal outcomes of water immersion during the first and second stage of labor and delivery, and compared outcomes to land births as controls.

METHODS:
Retrospective cohort study of singleton, cephalic presentation term pregnancies between January 2013-March 2017. This study was IRB approved. Comparison groups included: labor and land birth, water immersion exposure, and all deliveries in the study period. Obstetrical and neonatal outcomes were reviewed and analyzed. Student t-test, Mann Whitney test, Test of Proportion and Chi square tests were utilized for analysis. Significance was set at P=<0.05.

RESULTS:
Vaginal delivery (P<.001) and vaginal birth after cesarean section (VBAC) (P<.001) rates were higher in the water immersion exposure group compared to land births. The cesarean (P<.001) and operative delivery (P<.001) rates were lower. The uterine rupture rate was not significant (P=.94) between water immersion exposure and land birth groups. NICU admission rates were not significantly different between the immersion exposure and land birth groups (P=.99).

CONCLUSION:
Water immersion has positive outcomes in terms of increased rates of vaginal delivery and successful VBAC, and decreased rates of cesarean section. Water immersion for the second stage of labor and delivery is similar, if not better, than land birth in terms of maternal outcomes. Neonatal outcomes after water immersion exposure were similar to land births.
Patients With Diabetes Mellitus Managed With Insulin Detemir: Hospital Outcomes [18E]
Authors: Christman Lauren , Piszczek Jaclyn , Magee Maxwell , Ferris Letisha , Duong Jennifer , Farley Darren 
Published: May 2019

INTRODUCTION:
Approximately 7% of pregnancies are complicated by diabetes mellitus. Due to a greater prevalence of obesity and sedentary lifestyle, the prevalence of diabetes is increasing globally. The aim of this study is to evaluate hospital outcomes of patients with diabetes mellitus managed with insulin detemir during pregnancy.

METHODS:
We retrospectively reviewed all patients managed with insulin detemir at a single maternal fetal medicine clinic. Patients included in the study delivered between January 1, 2007 and August 31, 2016 at a single institution. Patients were excluded if pregnant with a neonate not expected to survive, or if hospital stay was beyond 21 days. IRB committee approval was obtained for this study.

RESULTS:
Of 161 patients, 154 were included in the final analysis. The majority of patients had gestational diabetes (75.3%, n=116) and were white (73.4%, 113/150). Average maternal age at delivery was 31.0±5.4 years old (range: 19-43). Sixty-six were obese at the initial appointment (42.9%). Average hospital stay was 2.6±1.2 days (range: 1-8). Half of patients delivered via cesarean (51.3%, n=79). Average neonatal weight was 3.3±0.6 kilograms (range: 1.3-5.0). APGAR scores were 8 at 1 minute (54.4%, 74/136), and 9 at 5 minutes (78.5%, 117/136). Average neonatal glucose was 62.3±14.0 mg/dL (range: 37-107). Average maternal glucose during the hospital stay was 109.2±22.6 mg/dL (range: 67.3-184). Six (3.9%) patients received regular insulin treatment during their hospital stay.

CONCLUSION:
Among patients treated with insulin detemir during pregnancy, few patients required supplemental insulin treatment during the hospital stay for delivery. Neonatal outcomes were satisfactory.
Peripartum Chest Pain Should Prompt Cardiac Evaluation [23E]
Authors: Hasan Abida , Hill Michael , Massad Malek , Shroff Adhir , DiGiovanni Laura M. , Briller Joan 
Published: May 2019

INTRODUCTION:
Cardiovascular disease is a leading cause of maternal morbidity and mortality. Women are at 3 to 4 fold higher risk acute myocardial infarction (AMI) during pregnancy and post-partum (PP). Spontaneous coronary artery dissection (SCAD) is the most common cause of AMI typically presenting within 6 weeks PP. Diagnosis can be missed given low suspicion for ischemic etiologies in young women with chest discomfort.

METHODS:
A 29-year-old G2P2002 without cardiac risk factors, who provided consent for presentation, underwent uncomplicated vaginal birth after cesarean at 39 weeks. Delivery and immediate PP course were uncomplicated. She was discharged PP day 2. On PP day 22, she self-presented to ED with substernal chest pain (CP) reporting that she had called EMS with prior CP episodes days 5 and 15 PP and was told CP was due to anxiety. EKG suggested ischemia and troponins were elevated. She received sublingual nitroglycerin, aspirin, beta-blocker, and heparin. Coronary angiography demonstrated 60-70% left main coronary artery stenosis, 90% distal left anterior descending artery stenosis, and 100% occlusion of left circumflex artery raising concern for underlying SCAD. While SCAD can often be managed conservatively, she continued to have symptoms with rising biomarkers despite medical therapy, and underwent coronary bypass surgery on PP day 25. Diagnosis of SCAD was confirmed intraoperatively.

CONCLUSION:
Peripartum women with SCAD may be missed because of young age and few risk factors for atherosclerosis. This case illustrates the imperative of maintaining a high index of suspicion for ischemic disease when women present with CP during pregnancy or PP.
Placenta Accreta: Does Antenatal Diagnosis Improve Maternal and Neonatal Outcomes? [25E]
Authors: Kim Angela , Stohl Hindi E. 
Published: May 2019

INTRODUCTION:
The incidence of placenta accreta has been increasing in the US. Accretas can be diagnosed antenatally (via prenatal imaging) or at time of delivery. The primary benefit of antenatal diagnosis is multidisciplinary delivery planning. However, data is limited on whether antenatal diagnosis of accreta improves pregnancy outcomes. The objective of this study is to compare maternal and neonatal outcomes in patients with versus without an antenatal diagnosis of accreta.

METHODS:
This is an IRB-approved, retrospective chart review of patients delivering at Harbor UCLA from January 2005 to January 2016 with a pathology-confirmed diagnosis of accreta. Statistical analysis was performed using Chi-square and T-test with SPSS software.

RESULTS:
Of the 16 patients with pathology-confirmed accreta, 10 patients had antepartum diagnosis and 6 patients were diagnosed at delivery. Compared to unsuspected cases, suspected cases had a non-significantly lower mean gestational age at delivery (35+6 vs. 36+6 weeks, p=0.488), maternal length of stay (5.6 vs. 8 days, p=0.117) and estimated blood loss (3200 vs. 3666 ml, p=0.645) and a non-significantly higher number of NICU admissions (60% vs. 30%, p=0.696). Significantly more midline incisions were performed in suspected accreta group versus unsuspected accreta groups (70% vs. 12.5%, respectively, p=0.001). All 16 cases of accreta resulted in peripartum hysterectomy.

CONCLUSION:
We found few differences in maternal and neonatal outcomes between suspected and unsuspected accreta cases. Our findings may be limited by sample size or may highlight the overall importance of delivery of accreta at a tertiary center, where complications are relatively low.
A Systematic Review of Telehealth on Clinical Outcomes in Obstetrics & Gynecology [27E]
Authors: DeNicola Nathaniel G. , Lowery Curtis L. , Marko Kathryn I. , Grossman Daniel Aaron 
Published: May 2019

INTRODUCTION:
Telehealth is an emerging trend that has applications for obstetrics, gynecology, and Ob/Gyn specialties. These novel developments warrant robust scientific evaluation and clinical guidance.

METHODS:
A literature search was conducted by a team of medical librarians. Telehealth interventions included virtual visits with audio/visual, mobile health, wearable devices, and SMS; interventions were excluded if it only involved telephone calls or websites. Outcomes were organized by Low-Risk Obstetrics, High-Risk Obstetrics, Family Planning, and Specialty. The PRISMA method was followed, an evidence distilling system was used which included dual review of studies for quality rating and risk of bias assessment. To quality rate the studies we used the Cochrane Collaboration's tool for assessing the risk of bias for RCTs and the ROBINS-I tool for assessing risk of bias in non-randomized studies.

RESULTS:
Low-Risk Obstetrics yielded 1781 references, 19 met inclusion. An effect of telehealth intervention was found on smoking cessation, pregnancy wellness, influenza vaccination, and breastfeeding. High-Risk Obstetrics yielded 1271 references, 14 met inclusion. An effect was found on diabetic management, preterm labor, prenatal visit reduction, and asthma control. Family Planning yielded 527 references, 13 met inclusion. An effect was found on contraceptive continuation and on access to medical abortion. Specialty yielded 1387 references, 8 met inclusion. An effect was found on sexually transmitted illness, menopause management, stress urinary incontinence, weight loss, and gynecology post-operative management.

CONCLUSION:
Telehealth has interventions with effect on clinical outcomes in obstetrics, gynecology, and specialty fields. Women's health providers can gain guidance on these new opportunities through continued research.