bluuebunny/crossref_metadata_2025_split huggingface dataset:
Outcomes in Trial of Labor after Cesarean Section in Twin Pregnancies [36Q]
Authors: Walker Allison R. , Skeith Ashley E. , Caughey Aaron B. 
Published: April 2018

INTRODUCTION:
We sought to compare delivery and neonatal outcomes in twin pregnancies undergoing a trial of labor after cesarean section (TOLAC).

METHODS:
This retrospective cohort included 2,013 pregnancies undergoing a TOLAC and compared outcomes of cesarean section (CS) versus vaginal birth after cesarean section (VBAC). Delivery outcomes included unplanned hysterectomy, Apgar score <7 at 5 minutes, NICU admission, transfusion, and assisted ventilation >6 hours. Multivariate regression analyses and chi-squared test were used for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance. Age, race, BMI, education, and insurance status were controlled for.

RESULTS:
VBACs were associated with Apgar scores <7 at 5 minutes (OR 3.21; 95% CI 2.31-4.47) and lower NICU admission rate (OR 0.75; 95% CI 0.62-0.90). Unplanned hysterectomy, transfusion, and assisted ventilation >6 hours were not statically significant.

CONCLUSION:
VBACs were associated with a lower Apgar scores and fewer NICU admissions than CS in twin pregnancies undergoing TOLAC.
Office versus Operating Room Hysteroscopy: A Comparison of Outcomes and Resource Utilization [3R]
Authors: Dilday Elizabeth A. , Shields Jessica K. , Kho Kimberly A. 
Published: April 2018

INTRODUCTION:
Parkland Hospital Gynecology Clinic initiated office hysteroscopy while continuing hysteroscopy in the operating room (OR). This study compares utilization of resources between office and OR cases.

METHODS:
Retrospective chart review of hysteroscopies from April 1, 2016 to March 31, 2017 in the OR, Ambulatory Surgery Center (ASC) and Gynecology Clinic. Data regarding preoperative evaluation, operative details and time spent the day of the procedure was collected.

RESULTS:-
Patients undergoing procedures in the office and OR were similar with median age 44 SD ±11.0 vs 46 SD ±11.1 years (p=0.92) and BMI of 30.7 SD ±7.6 vs BMI of 34.4 SD ±9.0 kg/m2 (p=0.82). -75 (24.6%) office and 230 (75.4%) OR hysteroscopies were performed -Indications for office procedures were: 33 (44%) suspected polyp, 23 (30.7%) IUD related, 7 (9.3%) postmenopausal bleeding, and 6 (8%) intracavitary mass. Indications for OR were: 65 (28.4%) suspected polyp, 36 (15.7%) hyperplasia, 29 (12.7%) abnormal uterine bleeding and 24 (10.5%) IUD related -34.6% of office procedures required OR hysteroscopy for: 9 (40.9%) large polyp, 5 (22.7%) pain, 9 (22.7%) cervical stenosis, and 3 (13.6%) fibroid found. There were 3 (1.11%) complications in the OR and 0 (0%) in the office (p=0.32). Patients undergoing office procedures spent 153 minutes (SD ±57 minutes) in clinic compared to 337 minutes (SD ±168 minutes) for OR (p=0.02). Prior to hysteroscopy, patients undergoing office hysteroscopy required 1.01±1.17 studies vs 3.12±6.12 studies (p=0.003).

CONCLUSION:
When comparing hysteroscopies in the office versus the OR, demographics and indications were similar. In-office cases involved significantly less time from patients and superior utilization of resources.
Case Report: Management in a 25-year-old with Severe Erosive Vulvovaginal Lichen Planus [6R]
Authors: Syed Fatima , Vyas Anuja 
Published: April 2018

INTRODUCTION:
Erosive lichen planus (ELP) is a rare inflammatory dermatologic condition characterized by scarring and adhesions. ELP can involve female genitalia causing vulvar anatomic distortion and vaginal stenosis. Topical corticosteroids or calcineurin inhibitors are the mainstay of medical therapy. Vaginal adhesions and scarring can be managed with intravaginal steroids, dilators and surgical release.

METHODS:
Chart review; Literature review

RESULTS:
We present a 25-year-old Caucasian G0 with oral-vulvo-vaginal ELP. At time of presentation she had severe vaginal adhesive disease and was unable to have intercourse. The patient underwent surgical genital lysis of adhesions after which she was able to conceive and deliver a term neonate. Patient maintained vaginal patency in the puerperal period with topical corticosteroids, intravaginal corticosteroids and dilators.

CONCLUSION:
With aggressive surgical and medical management and continued close surveillance, patients with ELP affecting the vulva and vagina can have significantly improved quality of life and successfully deliver term pregnancies.
Demographic Factors Associated with Opioid Use Following Laparoscopic or Robotic Hysterectomy [8R]
Authors: Cohen Michael , Weston Erica , Raker Christina , Huang David , Mathews Cara 
Published: April 2018

INTRODUCTION:
The number of opioid-related deaths has quadrupled in the United States since 1999, and the opioid crisis is well-defined. The purpose of this study is to identify demographic predictors of increased inpatient and post-discharge opioid use in order to tailor postoperative opioid dispensation.

METHODS:
This study is a secondary analysis of a prospective cohort designed to correlate mindfulness with post-operative pain in patients undergoing laparoscopic or robotic hysterectomy by a gynecologic oncologist at a single institution. Inpatient opioid use was measured via chart review and outpatient use via surveys at 1-2 week and 4-6 week post-operative visits and via pharmacy records. Demographic information was measured via chart review and pre-operative surveys. Descriptive statistics and correlation were used to determine associations.

RESULTS:
Mean age (n=126) was 60.4 (SD 11.66) and mean BMI was 33.6 (SD 9.35). Additionally, 54% of subjects had private insurance, 20% had Medicaid products, and 25.6% had Medicare. 85% of subjects were referred from a private OBGYN office. Younger patients used significantly more opioids inpatient and outpatient based on total milligram morphine equivalents (MME) (p=0.0003 inpatient, p=0.045 outpatient) and total number of doses (p=0.001 inpatient; p=0.048 outpatient). Insurance source trended with post-discharge MMEs used, with Medicaid patients using more, but this correlation was not statistically significant (p=0.13). BMI, race, insurance status, referral source, and comorbidities did not predict post-operative opioid use.

CONCLUSION:
Older patient use fewer opioids and this population may be a target for smaller postoperative prescriptions to reduce unused opioids. This warrants further study in other populations.
Opioid Detoxification during Pregnancy: Systematic Review and Meta-Analysis of Maternal and Neonatal Outcomes [11R]
Authors: Wang Michelle , Kuper Spencer , Sims Brian , Paddock Cayce , Williams-Glass Terri , Harper Lorie 
Published: April 2018

INTRODUCTION:
While maintenance therapy for opioid use disorders is the standard of care, the expanding opioid epidemic has renewed interest in maternal detoxification. We aim to assess the efficacy and safety of detoxification from opioids compared to maintenance with methadone or buprenorphine to treat opioid-dependent pregnant women.

METHODS:
We searched PubMed, Embase, the Cochrane Library and ClinicalTrials.gov from inception to June 2017. We included randomized controlled trials or cohort studies that compared detoxification with maintenance for treating opioid-dependent pregnant women. We sought to find any studies with outcomes data for maternal abstinence at time of delivery, neonatal abstinence syndrome (NAS), stillbirth, and preterm birth (PTB). Pooled relative risks (RRs) were calculated using a random-effects model. Heterogeneity was assessed using the chi-squared test for heterogeneity and the I2 test. Publication bias was assessed using funnel plots and Harbord test.

RESULTS:
Three cohort studies met inclusion criteria; these studies compared an inpatient taper to inpatient or outpatient maintenance therapy. These eligible studies included a total of 235 women with opioid use disorder in pregnancy. Maternal detoxification was associated with increased risk of relapse (RRs 1.91, 95% confidence interval (CI) = 1.14-3.21). However, no treatment differences were observed for rates of NAS (RRs=0.99, 95% CI = 0.38-2.53) or PTB (RRs = 0.39, 95% CI = 0.10-1.60).

CONCLUSION:
Our findings suggest there is an increased risk of relapse with detoxification compared with maintenance; however, we found detoxification does not increase the risk of PTB or NAS. Further studies should confirm our findings and explore mechanisms to fight the opioid epidemic.
The Experience of Pregnant Women With a History of Addiction at a High Risk Clinic [16R]
Authors: Williams Eva , Strong Abigail , Finch Lindsey , Curry Christine 
Published: April 2018

INTRODUCTION:
5.0% of pregnant women use one or more addictive substances. Drug use during pregnancy significantly increases the risk of adverse maternal and fetal outcomes. The Prenatal Recovery Clinic (PRC) is a specialty clinic at Jackson Memorial Hospital that provides care for pregnant women with a history of addiction. The objective of our study is to gain a greater understanding of the patients, their drug habits, health care experiences, and health outcomes at the PRC.

METHODS:
Pregnant women 18-50 years old that used substance and were patients at the PRC between March 2016 and April 2017 were eligible to participate in the study. Surveys was administered at two different times; the first at a PRC prenatal visit and another postpartum. Birth outcome data was extracted from medical records manually.

RESULTS:
Twelve patients were enrolled in the study. Of these patients, 33% reported more than one drug as their drug of choice. Participants rated the PRC clinic experience overall more favorably than their experience at the hospital for delivery, although the two experiences were not found to be statistically significant. Averages of PRC patient birth outcomes, such as gestational age, birth weight, and APGAR scores fell within normal limits.

CONCLUSION:
Pregnant patients with addiction can benefit from specialized clinics like the PRC that provide specialized care and assistance for pregnant women with a history of substance use. The results from our study indicate a potential for establishing a model similar to the PRC, that can be replicated to other clinics to address addiction in pregnancy.
Severe Maternal Morbidity and Mortality in Women with Congenital Heart Disease [18R]
Authors: Platner Marissa , Lipkind Heather S. , Campbell Katherine 
Published: April 2018

INTRODUCTION:
Studies have demonstrated an increase in adverse pregnancy outcomes in women with congenital heart disease. We sought to examine the association of maternal congenital heart disease (CHD) with the risk of severe maternal morbidity and mortality (SMM) compared to women without congenital heart disease.

METHODS:
This retrospective cross-sectional study used 2008 through 2012 New York City (NYC) birth certificates linked to hospital discharge data to identify delivery hospitalizations. Cases of SMM were identified using ICD-9 diagnosis and procedure codes based on the Center for Disease Control and Prevention criteria. Data were limited to singleton, live births. CHD included women with any vascular, septal, or valvular abnormality of the heart at birth. Multivariable logistic regression was used to evaluate SMM in women with CHD adjusting for maternal demographics, socioeconomic status, and medical comorbidities.

RESULTS:
From 2008 through 2012 there were 578,840 live singleton births in NYC, 347 of these births were to women with CHD (6/10,000). Acute renal failure, adult respiratory distress syndrome, thrombotic embolism, cardiac arrest/ventricular fibrillation, pulmonary edema/heart failure, conversion of cardiac rhythm, and transfusion were all independently associated with CHD. Women who had CHD had higher adjusted odds of SMM(aOR 2.43; 95% CI 1.60-3.70) compared to women without CHD after adjusting for maternal socioeconomic status, demographics and medical comorbidities. There was one maternal death.

CONCLUSION:
SMM is increased in women with CHD, even after adjusting for co-morbid conditions. It is important that these women receive care from an identified multidisciplinary team from preconception to postpartum to optimize pregnancy outcomes.
Multidisciplinary Prenatal Care of the Patient with Opioid Use Disorder: A One Stop Shop [21R]
Authors: Peneva Ralitza , Holman Stacey , Heard Asha , Conrad Erich 
Published: April 2018

INTRODUCTION:
Opioid use has increased dramatically over the past two decades and affects pregnant women across racial, ethnic, and socioeconomic groups. Rates of neonatal drug withdrawal have increased in accordance. Pregnancy provides a unique opportunity to identify and treat opioid use disorders to optimize maternal and fetal health. Most studies focus on targeting this chronic issue with pharmacotherapy, but few have examined the benefits of streamlining care for prenatal patients. We propose combining the evidence-based practice of “SBIRT” (Screening, Brief Intervention, Referral to Treatment) and treatment itself into a multidisciplinary clinical experience.

METHODS:
This is a descriptive study of a collaboration between the Louisiana State University Departments of Obstetrics and Gynecology and Psychiatry in New Orleans, LA. Prenatal patients with opioid use disorders are referred to addiction psychiatry clinic . Prenatal care is given within the same clinic space to allow for collaboration between services. Inpatient pregnant patients undergoing opioid initiation or treatment are also referred to this specialized clinic upon discharge from the hospital.

RESULTS:
Since initiating this joint effort in July 2014, the perinatal psychiatry clinic has had approximately 2.5 scheduled patient encounters per week. A review of delivered patients over the past 5 years shows 3-5 patients/month with opioid use disorders. Of our pregnant patients, this constitutes about 3% of the delivery population.

CONCLUSION:
This collaboration has improved access to care for pregnant patients with opioid use disorders. Future work includes looking at patient compliance with visits and neonatal outcomes. Multidisciplinary care for this patient population is essential to optimize maternal and fetal outcomes.
What are the Perinatal Outcomes Associated with Expectant Management of PPROM Cases in the Periviable Period? [23R]
Authors: Moni Saila , Comfort Lizelle , Tropper Pamela , Bernstein Peter 
Published: April 2018

INTRODUCTION:
PPROM is estimated to complicate 3% of all births and is associated with up to 40% all preterm births. Recently ACOG has extended the appropriateness of the administration of latency antibiotics starting at 20 wks of gestation for patients who opt for expectant management in the periviable period. Our objective was to evaluate perinatal outcomes among PPROM patients in the periviable period (20-23+6 wks of gestation).

METHODS:
This is a case series of all cases of PPROM after 20 weeks of gestation delivered at our institution from January 2014-May 2017.

RESULTS:
We reviewed 14 cases of PPROM in the periviable period (20 wks and 2 days to 23 wks and 5 days) that were managed expectantly. 13 patients (93%) received latency antibiotics on admission, 9 patients (64%) received betamethasone at 23 wks or later in gestation, 6 patients (43%) received tocolytics and 6 patients (43%) received magnesium for neuroprotection. Seven7 patients (50%) delivered prior to reaching 24 wks of gestation and 11 patients (79%) delivered prior to reaching 25 wks of gestation. The furthest gestational age reached was 31wks and 2 days. The following maternal and fetal/neonatal morbidities were noted: 5 (36%) chorioamnionitis, 1 (7%) abruption, 1 (7%) cord prolapse, 6 (43%) IUFDs and 2 (14%) neonatal demises. 6 neonates (43%) survived to discharge from the hospital.

CONCLUSION:
Given the significant morbidity and mortality associated with expectant management of PPROM cases at less than 24 wks of gestation, appropriate and accurate counseling of maternal and neonatal outcomes is required.
Limiting Leftovers: Analysis of Usage and Storage Patterns of Opiate Medication after Cesarean Delivery [37R]
Authors: Grimes Meghan , Dangel Alissa , Iyer Vidya , Sadr Farnaz 
Published: April 2018

INTRODUCTION:
Limiting excess opiate medication in the community should be a focus of all physicians including Ob-Gyns. Patient’s pain medication usage and home storage patterns following Cesarean delivery may provide insight into limiting accessibility to leftover medication.

METHODS:
A single site, prospective cohort study was initiated to survey postpartum women regarding their post Cesarean pain control, medication usage and storage patterns. Patients were eligible if they underwent cesarean section at Tufts Medical Center, were >18 years old and had a valid email address. The automated survey was sent via the RedCap database at 2 weeks postpartum.

RESULTS:
The initial 100 survey responses from 177 recruited subjects were reviewed, 98 of which had usable data (response rate of 55.4%). Of responders, 63.3% underwent a primary cesarean section. Most patients (75.5%) indicated they only took opiate medication for 7 days or less. Opiate storage information was available on 95% of respondents as follows; 25.5% bathroom, 40.8% bedroom, 22.4% kitchen and 9.2% other. Specific location indicated 34.7% storing their medication in a closed space (cabinet or drawer), of which only 39% used any form of lock. Medication disposal plans included the following: 8% flushing medication, 11.2% return to a designated facility, 10.2% planned on keeping them and 28.6% were unsure.

CONCLUSION:
There are a significant amount of leftover opiate pills associated with cesarean delivery being stored in unsecured locations. Patient education regarding safe storage and subsequent disposal of opiate medication should be initiated.
FOXO3 Expression in the Human Ovary [6OP]
Authors: Swenson Helen Paige , Beachy Dawn E. , Barilovits Sarah J. , Nick Harry S. , Rush Demaretta S. , Rhoton-Vlasak Alice 
Published: April 2018

INTRODUCTION:
To assess FOXO3 gene expression levels and members of the KL-PI3K-AKT-FOXO3 pathway in pre- and postmenopausal human ovaries. To evaluate in a temporal manner protein localization of FOXO3 in pre- and postmenopausal human ovaries by immunohistochemistry (IHC).

METHODS:
Total RNA was isolated from human ovary collected from pre- and postmenopausal patients undergoing oophorectomy and used for real-time qPCR for members of the KL-PTEN-PI3K-FOXO3 pathway, as well as other genes. IHC was performed on archived paraffin embedded ovaries to visualize the presence and localization of FOXO3 in human ovaries ranging from fetal to menopausal.

RESULTS:
FOXO3 is expressed in premenopausal human ovary and to a significantly reduced level in postmenopausal ovary. Nine additional genes in the KL-PTEN-PI3K-FOXO3 pathway were also expressed in premenopausal ovaries but like FOXO3 displayed significantly decreased levels in the postmenopausal cohort. IHC analysis revealed strong nuclear FOXO3 staining in primordial follicles from pre-pubertal ovaries through menarche/post-pubertal. A dominant population of primordial follicles were identified in older post-pubertal ovaries and in the reproductive/premenopausal groups that displayed light to negative nuclear staining for FOXO3, with a second much less abundant population of primordial follicles retaining strong positive nuclear FOXO3 staining. Postmenopausal ovaries were devoid of follicles but had strong stromal FOXO3 staining.

CONCLUSION:
As predicted from mouse genetic models, FOXO3 mRNA and protein is present in premenopausal human ovary as are nine members of the KL- PI3K-AKT-FOXO3 pathway. FOXO3 localization in the human ovary undergoes an age-dependent transition from strongly positive nuclei in young ovaries to predominantly light to negative staining in reproductive/premenopausal. Given FOXO3's importance to genome stability, primordial follicles with high nuclear FOXO3 levels may define high quality oocytes lacking detrimental levels of DNA damage, so that the ratio of FOXO3 positive to negative oocytes may explain the consequences of decreasing ovarian reserve.
Expanding the Cervical Cancer Screening Guidelines in Resource Limited Settings [9OP]
Authors: Hari Anjali Y. , Brabender Danielle E. , Temko Jamie E. , Shen Aricia 
Published: April 2018

INTRODUCTION:
The World Health Organization (WHO) guidelines for cervical cancer prevention in low resource countries recommend Visual Inspection with Acetic Acid (VIA) and cryotherapy to screen and treat women ages 30–50. Our study examined the clinical benefit of extending the screening to include patients aged 18 to 75.

METHODS:
841 women were screened at two sites during different campaigns in Tanzania. VIA+ women, regardless of age, were treated with cryotherapy. Women with cervical cancer were referred for gynecologic oncology consults.

RESULTS:
The combined VIA+ rate was 13.32% overall (112 out of 841), 14.94% for women under 30 (39 out of 261), and 7.32% for women over 50 (6 out of 82). 34.82% of VIA+ results were in women ages 18 to 29 (39 out of 112). Severe dysplasia and cervical cancer was detected in 15 patients overall, 6 of whom fall outside the 30–50 age limit.

CONCLUSION:
Despite WHO guidelines, we found a high rate of VIA+ results in patients under 30, consistent with studies assessing VIA+ prevalence in resource limited areas. VIA has established specificity and sensitivity (∼79% and 85%, respectively) in identifying CIN2+ lesions, which guidelines advise to treat in younger patients. Given the low rates of pelvic exams in this population and low cryotherapy complication rates, women over 50 should also be screened. We propose reassessing the WHO guidelines to reflect the need for screening and appropriate treatment for women aged 18–75, especially in resource-limited countries like Tanzania.
Assisted Reproductive Technology and Stillbirth Risk: Selected States, 2006–2011 [15OP]
Authors: Chang Jeani , Zhang Yujia , Boulet Sheree L. , Crawford Sara B. , Kissin Dmitry M. 
Published: April 2018

INTRODUCTION:
To examine trends and characteristics of stillbirths among pregnancies (live births and stillbirths) following assisted reproductive technology (ART) and to evaluate the association between ART and risk of stillbirth using linked ART surveillance and vital records from Connecticut, Florida, Massachusetts, and Michigan.

METHODS:
We examined trends of stillbirth rate (number of stillbirths/1,000 live births and stillbirths) and estimated the adjusted risk ratios (aRR) for associations between ART and stillbirth (adjusting for maternal characteristics, pregnancy history, and pre-pregnancy medical conditions), stratified by plurality and gestational age (<28 and >28 weeks). We also used ICD-10 to examine causes of stillbirth.

RESULTS:
During 2006–2011, 282 ART stillbirths and 15,540 non-ART stillbirths were identified. ART stillbirth rates were lower than the non-ART stillbirth rates for both singleton (3.1 versus 6.0) and multifetal pregnancies (9.4 versus 18.3). At <28 weeks, the risk of stillbirth among ART-pregnancies was significantly lower than for non-ART pregnancies, aRR 0.38, 95% confidence interval (CI) 0.22–0.65 among singletons and aRR 0.63, 95% CI 0.42–0.94 among multiples. The leading causes of stillbirth were similar for both ART and non-ART pregnancies; maternal conditions (16.6%) (eg, hypertensive disorders, infections, respiratory diseases, periodontal diseases, incompetent cervix, etc), followed by placental abnormalities (9.8%), umbilical cord conditions (9.2%), chorioamnionitis (3.8%), and low birth weight (2.7%).

CONCLUSION:
ART was associated with a decreased stillbirth risk prior to 28 weeks of gestation. Earlier detection and management of fetal and maternal conditions among ART-conceived pregnancies may explain the lower rates of early fetal death observed in this study.