bluuebunny/crossref_metadata_2025_split huggingface dataset:
Acute Fatty Liver of Pregnancy: The Challenging Obstetrical Emergency to Overcome [21G]
Authors: Siwatch Sujata , Singh Virendra , Suri Vanita , Jain Vanita , Kalra Jasvinder , Sikka Pooja 
Published: May 2019

INTRODUCTION:
Acute fatty liver of pregnancy (AFLP) is a rare entity with high morbidity and mortality. We aim to review the 5 years data of patients with AFLP, presenting to a tertiary care hospital.

METHODS:
The Swansea criteria were used to diagnose AFLP. We collected data and analyzed it for demographic profile, clinical presentation, complications, obstetrical outcome and mortality.

RESULTS:
Twenty eight women attending the obstetrical emergency services were diagnosed with AFLP from 2014 to 2018. The mean age was 25.7+/- 4.1 years. Most women were multigravidas and the median gestational age was 35 weeks (range 31-40 weeks). Of the women who delivered, 19/28 (67%) had male fetuses. The commonest initial presenting symptoms included jaundice and vomiting. The average median Swansea score was 7 (range 6-9). The median duration of illness before admission was 4 days. Most women underwent a torment course of disease. There were fifteen deaths. The commonest causes of death were sepsis, acute kidney injury and multiorgan dysfunction. Other contributory factors of mortality were coagulopathy, liver failure, encephalopathy, acidosis, acute respiratory distress syndrome and pancreatitis. Hypertension was observed in half (14/28) of the patients. All patients required transfusion of blood products and ICU care. Nineteen women had vaginal delivery while seven underwent caesarean section. Hemorrhage was noted in 20 (71%) as postpartum bleeding, vaginal and abdominal hematomas and urinary tract bleed.

CONCLUSION:
AFLP is a rare obstetrical cause of acute liver failure with high maternal morbidity and mortality. Sepsis, acute kidney injury and hemorrhage are the important contributory causes of death.
Antibiotic Use During Obstetric Anal Sphincter Injury: a Quality Improvement Initiative [30G]
Authors: Kieserman-Shmokler Caroline Ann , Bugosh Meghan Donald , Fenner Dee E. , Swenson Carolyn Weaver 
Published: May 2019

INTRODUCTION:
ACOG Practice Bulletin #165 recommends a single dose of broad-spectrum antibiotics be given at the time of obstetric anal sphincter injury (OASIS) repair. Our primary aim of this study is to assess antibiotic compliance at the time of OASIS repair after our institution launched a Quality Improvement (QI) initiative regarding best practices for OASIS management.

METHODS:
We conducted a retrospective chart review comparing the prevalence of antibiotic use with OASIS repair pre-initiative (1/1/2014-12/14/2017) and post-initiative (12/15/2017-9/23/2018). Best practice recommendations were presented during Grand Rounds and disseminated with posters and cards on L&D carts with recommended antibiotics and suture material. Cefazolin plus metronidazole or clindamycin plus gentamycin were the recommended antibiotics. Demographics, delivery characteristics, and postpartum complications were also compared between groups using Student t-test and Chi-square tests.

RESULTS:
Recommended antibiotic use increased from 0.27% (1/372) pre-initiative to 67.44% (58/86) post-initiative (P<.0001), and any antibiotic use increased from 3.49% (13/372) to 76.74% (66/86) (P<.0001). The rate of OASIS repaired in the OR increased from 3.5% to 18.6% (P<.0001). There were no differences in perineal wound complications (2.2% before versus 2.3% after, P>.99). Delivery characteristics including operative delivery, infant weight, length of second stage, and episiotomy were similar.

CONCLUSION:
After a QI initiative, antibiotic use at the time of OASIS repair significantly increased. This study demonstrates that a QI initiative targeted at wide spread dissemination of information to the OB/GYN department can lead to improved clinical care for our patients with OASIS.
Are Longer Periods of Latency After the Diagnosis of Preeclampsia Associated With Readmission? [31G]
Authors: Mussarat Naiha , Aziz Michael , Patterson Melinda Michelle , Duncan Jose R. , Meyer Norman L. 
Published: May 2019

INTRODUCTION:
To determine if longer periods of latency after the diagnosis of preeclampsia with severe features is associated with postpartum readmission or complications.

METHODS:
This was a nested case control study of all patients with severe preeclampsia at an academic medical center from 2014 until 2017. The primary outcome was readmission within six weeks of discharge. The primary exposure was pregnancy latency after the diagnosis of preeclampsia with severe features until delivery. Secondary exposures were the differing severe features or complications of preeclampsia which the patients were diagnosed with during their antepartum admission. Controls were randomly selected from the patients who had been diagnosed with preeclampsia with severe features in a 2:1 ratio. Median latency, baseline characteristics, severe features, and complications of preeclampsia were compared between patients who were readmitted and those who were not.

RESULTS:
Of the 18,645 deliveries over this time period, 950 were complicated by preeclampsia with severe features. Of these deliveries, 39 were readmitted. The median gestational age on admission was 37 weeks and one day. Contrary to our hypothesis, readmission was more likely with shorter latencies (mean rank 65 vs 45, p<0.01). Pregestational diabetes was a risk factor for readmission (OR 3.2, p=0.04); Antepartum headache (OR 0.36, p=0.02), parenteral antihypertensives (OR .30, p<0.01), oral antihypertensives (OR 0.25, p<0.01), antepartum magnesium sulfate (OR 0.07, p<0.01) during the initial admission were protective.

CONCLUSION:
Analyzing the factors that contribute to readmission in preeclamptic patients allow us to be cognizant of factors that may lead to increased maternal morbidity and mortality.
Congenital Uterine Anomalies: Prevalence and Teratogen Exposure [33G]
Authors: Calhoun Byron , Schaible Burk , Seybold Dara , Frank Annie 
Published: May 2019

INTRODUCTION:
Other than diethylstilbestrol, there are no strong risk factors known to cause congenital uterine anomalies (CUA). Discrepancies in defining and diagnosing uterine anomalies also create difficulties in discerning the prevalence of CUA. The study objective was to explore prevalence and risk factors of CUA in a cohort of women from an area with a history of chemical and teratogen exposure.

METHODS:
This was a retrospective observational study of obstetric patients with uterine ultrasounds from 1 January 2006 to 31 December 2016 at a tertiary care center. An Optimized Hot Spot analysis and Ripley's K- Function was constructed to ascertain any association with environmental exposures.

RESULTS:
The study population consisted of 46.4% of women having an ultrasound for an anatomy scan and 22.6% due to abdominal pain. The mean age was 26.1 years. The prevalence of a CUA was 0.9% (118/13040), which is below the reported national average of 3%. The most common were septate (46; 39.8%) and bicornuate (47; 39.0%). A Ripley's K - Function showed a normal observable relationship between Environmental Protection Agency (EPA) facilities and cases of congenital uterine anomalies. However, the Optimized Hot Spot Analysis located several statistical significant zip-codes of CUA in relation to zip-codes that include EPA chemical sites with possible watershed exposure.

CONCLUSION:
While the rate of CUA may be below the national prevalence, this may be due to the discrepancies in diagnostic classification. There was a statistically significant association of cases of CUA and zip-codes with EPA dump sites with possible teratogenic chemical exposure effect.
Effect of Service-Branch on Contraception Use and Childbirth Rates Among United States Military Recruits [6H]
Authors: Roberts Timothy , Smalley Joshua , Weir Larissa F. , Adelman William 
Published: May 2019

INTRODUCTION:
Unintentional pregnancy is a common problem among US servicewomen, particularly junior enlisted, with negative effects on the mother, infant, and military readiness.

METHODS:
Secondary analysis of insurance records from 92,072 servicewomen, who attended basic training between 2013 and 2017, examining differences between service-branches in prescription contraception use after 6 months on active duty and childbirth in the first 24 months of active duty using Kaplan-Meier and Cox Regression Analyses. IRB approved.

RESULTS:
Rates of prescription contraception use after 6-months on active duty varied significantly between branches [Army (18.1%), Air Force (27.4%), Navy (37.6%), and Marines (26.5%); (P<.001)] as did the proportion of women on prescription contraception using longer-acting methods (Depot-medroxyprogesterone, Implant, or Intrauterine) [Army (15.2%), Air Force (17.5%), Navy (54.7%), and Marines (49.8%); P<.001)]. There were significant (P<.001) differences in the rate of childbirth in the first 24 months on active duty between all of the services except the Air Force and Navy (P=.057) [(Army: 11.1% (95% Confidence Interval 10.7-11.5), Air Force 6.0% (5.6-6.4), Navy 6.7% (6.3-7.1), and Marines 8.4% (7.8-9.0)). In multivariable analysis accounting for age and contraception use, there were significant (P<.001) differences between services in the risk of childbirth. For example, the Navy (Hazard Ratio 1.24 (95% Confidence Interval 1.13-1.35)), Marines (1.48 (1.33-1.65)), and Army (1.86 (1.71-2.01)) all had a higher risk than the Air Force.

CONCLUSION:
Despite access to an identical medical benefit, including free contraception, contraceptive use and pregnancy rates among junior enlisted vary significantly across services. Further study is needed to determine the etiology of these differences.
A Protocol to Evaluate Low Risk Pregnancies of Unknown Location Reduces Emergency Department Length of Stay [17H]
Authors: Parker Pamela Brooke , Mercier Rebecca 
Published: May 2019

INTRODUCTION:
Women are frequently diagnosed with pregnancy of unknown location (PUL) in the emergency department (ED). These patients often receive a gynecology consult and then must be followed closely to finalize diagnosis. In 2017, our hospital implemented a protocol allowing low-risk patients diagnosed with PUL in the ED to have a telephone consult with gynecology rather than in-person evaluation. We investigated impact of this protocol on ED length of stay (LOS) for these patients.

METHODS:
Retrospective chart review of patients entered into the beta book from January 2017 to November 2017. All patients entered into the beta book after an ED visit were included, while those diagnosed outpatient were excluded. Primary outcome was ED LOS; secondary outcomes included provider adherence to the protocol and patients' completeness of follow up.

RESULTS:
120 subjects were included. LOS was significantly shorter in the telephone consult group (Median 270 min, IQR 223-346 min) than in the standard consult group (Median 345 min, IQR 276-434 min), P=.009. In-person gynecology consult was more likely when: a resident provided the initial evaluation (P=.017), patients presented with pain or nausea (P=.006), and ultrasound demonstrated free fluid (P=.007), adnexal mass (P=.001), or ectopic pregnancy (P<.001). Patient compliance with follow-up care was similar in both groups, and no adverse events were noted during study time frame.

CONCLUSION:
Patients with PUL not required to have an in-person gynecology consult have a significantly decreased ED LOS without compromising adherence to outpatient care. Such protocols may be safely adopted in tertiary care centers.
Cannabis for Treatment of Chronic Pelvic Pain: A Survey of Prevalence and Effectiveness [21H]
Authors: Johns Charity , Lachiewicz Mark 
Published: May 2019

INTRODUCTION:
Chronic pelvic pain (CPP) is a prevalent but difficult entity to treat. Cannabis has been shown to significantly improve pain in several populations. There have been no studies on cannabis use among women with CPP. We aim to examine the prevalence of cannabis use in patients with CPP and hypothesize that CPP patients report an improvement in their pain symptoms with cannabis use.

METHODS:
Patients were identified via a medical record query of commonly used CPT codes for pelvic pain. Patients were contacted via phone then emailed an anonymous online survey. Setting: Tertiary care academic medical center.

RESULTS:
114 patients who screened positive for CPP over the phone were emailed; 89 responded for a response rate of 78.1%. The prevalence of current use was 16.9% (14/83). Nine of fourteen (64.3%) current users reported using cannabis for CPP while 8/24 (33.3%) of previous users reported using cannabis for CPP; all 17 (100%) reported that it was helpful. The users who reported using cannabis for CPP reported an average reduction in pain by 5.9 points (P<.0001) and those who did not report using cannabis for CPP also reported a reduction in pain by 2.9 points (P=.0012). 71/82 (86.6%) respondents would consider being in a clinical trial of medical cannabis to treat CPP.

CONCLUSION:
This study demonstrates that patients with CPP are self-treating with cannabis and finding this to be an effective intervention. Cannabis may serve as a future treatment option for females with CPP if found to be safe and effective. Clinical trials are needed.
Chronic Endometritis: A Prevalent Yet Poorly Understood Entity [23H]
Authors: Margulies Samantha Lee , Flores Valerie Alysse , Parkash Vinita , Pal Lubna 
Published: May 2019

INTRODUCTION:
Chronic endometritis (CE) remains poorly understood by both pathologists and obstetrician/gynecologists (OB/GYNs). The purpose of this study was to: 1) assess uniformity in histological criteria utilized by pathologists for diagnosing CE, and 2) evaluate for clarity in OB/GYN provider understanding of the pathophysiology and patterns in management approaches to CE.

METHODS:
In a prospective observational study, members of national and international professional OB/GYN (including ACOG) and Pathology societies were surveyed utilizing two anonymous electronic surveys designed to respectively examine diagnostic criteria, pathophysiology, clinical implications and treatment.

RESULTS:
262 OB/GYNs and 336 pathologists responded. Inconsistencies in histological criteria utilized by pathologists for diagnosing CE, as well as lack of clarity in understanding the pathophysiology and management of CE were apparent. While respondents agreed on an infectious etiology, consensus on nature of infectious agent for CE was lacking (p < 0.001). Obvious discrepancies in understanding of clinical presentation and diagnostic methodology were apparent, and lack of consensus on treatment was noted, both in terms of whether to treat or not and on choice and duration of antimicrobial treatment. Differences in provider understanding of subject matter by experience and location were examined.

CONCLUSION:
Despite its prevalence, there are inconsistencies and deficiencies in practitioners' understanding of CE, which likely affects patient care. We propose consideration for establishment of a task force to examine the literature on CE to provide a standard of care for the diagnosis and management of this gynecologic condition.
Benefits and Challenges of Linking Electronic Medical Record and Claims Data for Perinatal Research [28H]
Authors: Stuebe Alison M. , Tucker Christine , Ferrari Renee , Verbiest Sarah , Pate Virginia , Jonsson-Funk Michele 
Published: May 2019

INTRODUCTION:
To improve understanding of the postpartum health services received in the 90 days following delivery for mothers of medically fragile infants (MMFI) we linked electronic medical record (EMR) data to commercial insurance claims.

METHODS:
We conducted a retrospective cohort study of mothers delivering liveborn infants at North Carolina Women's Hospital between 7/1/2014 and 6/30/2016 (n=6849). We linked data from the UNC Health System Epic EMR to member encounters from a commercial insurance provider to measure prevalent conditions, health care utilization, and receipt of recommended services among MMFI compared with mothers of well babies. A list of mothers names with the payor on their delivery account (n=1687), birthdate, delivery date, procedure code for delivery, delivery location, subscriber ID, and billed provider was provided to an honest broker for matching.

RESULTS:
The honest broker identified members with enrollment and a childbirth-related procedure code during the study period (n=90,490) and applied context-based blocking and fuzzy matching on combinations of first and last name for a 97% match rate (n=1642). Having a finite time-period (a childbirth-related encounter date within 1-2 days of that mother's EMR delivery date) and adding anesthesia procedure codes contributed to a successful linkage. Changes in the mother's medical record number made it challenging to query EMR data on the same woman longitudinally.

CONCLUSION:
Linking claims to EMR data can elucidate women's health utilization in the early postpartum period by allowing ascertainment of encounters outside of the hospital. Additionally our findings have contributed to improved data quality initiatives in the hospital's EMR system.
Characteristics of Category II Tracings During Last Hour of Second Stage Labor in Predicting Fetal Acidosis [37H]
Authors: Hoskins Iffath Abbasi , Berg Robert E. 
Published: May 2019

INTRODUCTION:
Intrapartum fetal heart rate (FHR) monitoring although sensitive, lacks specificity for predicting fetal acidosis. Category II tracings, within the last hour of labor, occur in >/=96% of uncomplicated, term, laboring patients. Most result in delivery of well oxygenated neonates. Neonatal acidosis occurs in <3% of term neonates and may result in neonatal encephalopathy. Currently, there is no standard approach to management of Category II tracings.

METHODS:
We retrospectively reviewed Category II tracings in singleton, uncomplicated, term patients, during the last hour prior to delivery, in women who delivered neonates with cord blood pH /=8 (Group 1) and pH ≥ 7.20, base excess.

RESULTS:
In Group 1 (n=414), 91% of tracings exhibited good/moderate variability, 17.5% demonstrated minimal/absent variability, 13% had accelerations (≥15 bpm, lasting ≥15 secs). In Group 2 (n = 913), 97% showed moderate/good variability, 9% minimal/absent variability, 92% demonstrated accelerations (P<0.05). Duration of second stage labor was comparable in both Groups, (Group 1 = 3.5 hours, Group 2 = 3.1 hours), as were rates of chorioamnionitis, Pitocin use. Apgar scores and rates of NICU interventions were also similar in the two Groups.

CONCLUSION:
Minimal/decreased variability and the absence of accelerations, in Category II tracings, reliably predict fetal acidosis. Thus, expedited delivery should be considered in this clinical setting.
Encouraging Obstetrics and Gynecology Residents to Deliver Cost-Conscious Care: A Randomised Controlled Trial [4I]
Authors: Rawji Fahrin , Edwards Allison , Yaskina Maryna , Ross Sue 
Published: May 2019

INTRODUCTION:
Residents have a professional obligation to the stewardship of healthcare resources yet there is a paucity of research on how to improve their cost-awareness. Rising health care expenditure has highlighted a critical need to improve education in this competency. This study aims to test if an educational module can teach residents to make cost-conscious management plans and reduce health care spending.

METHODS:
All Canadian Obstetrics and Gynecology residents in 2017 were eligible for this randomised controlled trial. Institutional ethics board approval was obtained. The study was administered online via REDCap. Interested residents were enrolled, stratified by level of training and block randomised. Residents completed a survey to determine their management of four obstetrical scenarios. The intervention group reviewed an educational module on cost-effective ordering prior to completing the survey; the control group had the option to review it after. The primary outcome was mean total expenditure as calculated from the survey. Student t-test was used to compare the mean total expenditure between the two groups.

RESULTS:
85 residents were enrolled, 63 residents completed study requirements (30 intervention and 33 control). Mean total expenditure was $291.03 CAD (95% confidence interval [CI] 259.38-322.68) versus $192.98 CAD (95% CI 170.67-215.29) in the control and intervention groups respectively, corresponding to a 33.69% or $98.05 CAD (P=.0001) reduction in total expenditure.

CONCLUSION:
This educational module decreased expenditure by Canadian Obstetrics and Gynecology residents in the management of hypothetical obstetrical cases. This introduces a potential curriculum innovation to improve resident education in judicious use of healthcare resources.
Maternal Fetal Medicine Resources—Variations Across the Military Health Care System [14I]
Authors: Lutgendorf Monica Ann , Thagard Andrew Sloane , Foglia Lisa M. , Staat Barton C. 
Published: May 2019

INTRODUCTION:
Maintaining high quality, efficient obstetric care is augmented by integration of maternal fetal medicine (MFM) resources to care for high risk pregnancies. Changes in the MFM workforce and staffing could affect pregnancy care in the Military Healthcare System (MHS). We sought to assess the current state of MFM resources within the MHS to identify variations and opportunities for improvement.

METHODS:
We identified military treatment facilities with MFM physicians in both the continental US and overseas. This was an IRB approved QI project. Sites were sent a data collection sheet for staffing information including MFM physicians, genetic counselors and ultrasound techs and delivery volume. MFM sites were also asked about residency & medical student training and research activities and presentations.

RESULTS:
We identified 11 centers with MFM physicians, 3 Navy sites, 4 Army sites, 3 combined sites and 1 Air Force site. Nine MFM sites responded to our request with a response rate of 82%. Centers with MFMs had delivery volumes of 800 to 3,000 deliveries per year, and were level 2-3 maternity hospitals. Number of deliveries per MFM ranged from 500 to 2,000, and encounters per MFM ranged from 1,400 to 3,000 per year. Of MFM centers, 4 (44%) had genetic counselors, while only 1 (11%) had genetic counselors outside the MFM division. Of the 5 sites with ongoing research, all but one had access to a research nurse.

CONCLUSION:
We noted a wide range of practice staffing and volume across the MHS. Future studies should evaluate the optimum staffing to maximize efficiency.