bluuebunny/crossref_metadata_2025_split huggingface dataset:
Reproductive Outcomes After Laser Surgery for Twin-Twin Transfusion Syndrome [28H]
Authors: French Ashley , DeFranco Emily , Habli Mounira , Lim Foong-Yen , McKinney David , Tabbah Sammy 
Published: April 2018

INTRODUCTION:
There is a paucity of evidence describing future reproductive outcomes in women who have had selective fetoscopic laser photocoagulation (SFLP) for twin-twin transfusion syndrome (TTTS). Our study aims to compare these outcomes following exposure to SFLP to outcomes following a monochorionic multiple gestation with no SFLP.

METHODS:
This is a retrospective cohort study which analyzed records of patients who were evaluated at the Cincinnati Fetal Center (2007-2014) for monochorionic multiple gestations. A questionnaire regarding reproductive and gynecologic outcomes following the index pregnancy was administered to participants by electronic distribution or by mail. Subsequent pregnancy and gynecologic outcome data was compared between pregnancies with prior SFLP vs no prior SFLP.

RESULTS:
There was a higher response rate in the SFLP group (150/355, 42.3%) vs the referent group (60/187, 32.1%). Approximately 38% of women in both groups attempted conception after the index pregnancy with a greater than 90% pregnancy success rate. Use of ART was highly prevalent in both the index and subsequent pregnancies with no significant difference between groups. The median interpregnancy interval for the entire cohort was between 1-2 years. Over 60% of women in each group did not attempt future pregnancy. Roughly 1 in 3 women cited the outcome of the index pregnancy as the primary reason for not pursuing future conception. There were no significant differences in selected maternal-fetal complications and new onset gynecologic problems.

CONCLUSION:
SFLP for TTTS does not appear to be associated with adverse reproductive outcomes. Our data will help facilitate evidence-based counseling for this patient population.
Predicting Postpartum Hypertension: A Study of High Risk Women Discharged Without Antihypertensive Therapy [37H]
Authors: Wiese Sarah , Leftwich Heidi , Chung Charles , Birchall Courtney , Yu Camilla , Leung Katherine 
Published: April 2018

INTRODUCTION:
Hypertensive disease of pregnancy is a leading cause of maternal mortality. The primary objective of our study was to identify associations between demographics and persistent postpartum hypertension, and secondary outcome to identify postpartum blood pressures predicting persistent hypertension.

METHODS:
We performed a retrospective electronic chart review of women with hypertensive disorders of pregnancy, delivered from 7/1/09-7/1/16. Exclusion criteria were anti-hypertensive medication upon discharge and no recorded blood pressure within 12 weeks postpartum. Study variables included maternal demographics, the three highest systolic and diastolic values <24 and 24-72 hours postpartum, and postpartum outpatient values. Chi-square and student’s T-test were used for analysis of patient demographics. A receiver operating characteristic analysis was performed to identify blood pressure values which would predict persistent hypertension.

RESULTS:
591 women met study criteria. Women with persistent hypertension were significantly more likely to be multiparous (p= 0.008) and obese (p=0.016) with a trend towards increased maternal age (p=0.05). Systolic and diastolic pressures 24-72 hours after delivery were significantly associated with continued postpartum hypertension (p<0.001). No specific systolic or diastolic value within 72 hours postpartum could reliably predict persistent hypertension.

CONCLUSION:
Persistent postpartum hypertensive disease is more likely in multiparous, obese women, with a trend towards increasing age. Although elevated blood pressures 24 to 72 hours postpartum are significantly associated with persistent hypertension, there is no specific systolic or diastolic value above which persistence can be accurately predicted from our study. This stresses the importance of close follow up for women with hypertensive disorders of pregnancy.
Assessing Documentation of Procedure Prerequisites in Women Undergoing Vacuum-Assisted Vaginal Delivery (VAVD) [3I]
Authors: Doulaveris Georgios , Moni Saila , Stone Joanne , Frieden Faith , Atallah Fouad , Bernstein Peter 
Published: April 2018

INTRODUCTION:
There are specific prerequisites that need to be met prior to VAVD and documented afterwards to demonstrate standard of care was met. Our objective was to examine the presence of adequate documentation in patients undergoing VAVD.

METHODS:
This was a retrospective cohort analysis of patients undergoing VAVD in seven academic NY hospitals over two years derived from a quality improvement database. Singletons in cephalic presentation beyond 34 weeks of gestation were included. Data was reviewed for documentation of fetal station and position, cervical dilation, pelvic adequacy, fetal heart tracing, estimated fetal weight, empty bladder, and indication. Standard univariate analyses were performed.

RESULTS:
698 VAVDs were reviewed. 654 (93.7%) patients had a successful VAVD and 44 (6.3%) had a failed VAVD. In 246 cases (35.2%) at least one component was not documented; cervical dilation was most commonly omitted (74 cases, 10.6%) and indication least commonly (12 cases, 1.7%). Failed procedures had a significantly higher percentage of missing documentation for indication (6.8% vs. 1.4%, p=0.03), number of pop-offs (22.7 vs. 6.6%, p=0.0009), fetal station (27.3% vs. 3.8%, p<0.0001) and head position (36.4 vs. 4%, p<0.0001) compared to successful VAVD. Only 50% of patients with failed VAVD had adequate documentation compared to 68.5% after successful VAVD (p=0.01).

CONCLUSION:
VAVD is an operative procedure with significant risks. Failed procedures that require urgent cesarean present additional risk and require accurate and complete documentation. We observed that documentation was often suboptimal, particularly in unsuccessful procedures. Consideration should be given to utilizing functionality in electronic medical records to improve documentation.
Concordance Between Maternal Recollection Versus Documented Date of Vaccinations in Pregnancy [11I]
Authors: Gelvin Brady J. , Morrow Ardythe L. , Staat Mary A. , DeFranco Emily 
Published: April 2018

INTRODUCTION:
To assess the concordance between patient reporting time and documented date of vaccine administration of influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) immunizations in pregnant women.

METHODS:
Pregnant women >34 weeks were offered enrollment in a prospective cohort study, Pediatric Respiratory & Enteric Virus Acquisition and Immunogenesis Longitudinal Cohort (PREVAIL, www.cdc.gov/surveillance/nvsn/prevail.html). The difference between maternal report and medical record documented date of vaccine receipt were calculated (vaccine recall error, VRE). Multivariate logistic regression estimated the association between a large VRE (≥30 days) and maternal characteristics.

RESULTS:
Of 58 enrolled mothers, 38 (65.5%) reported influenza and 44 (75.9%) reported Tdap vaccine receipt during pregnancy. Medical record confirmed administration for 31 (81.6%) for influenza and 41 (93.2%) for those self-reporting Tdap vaccine. The mean VRE was 34.7 (±31.7, range 0-127 days) and 21.4 (±30.6, range 0-170 days) days for influenza and Tdap vaccinations, respectively, p-value = 0.0653. No factors were significantly associated with a high VRE of ≥30 days, which may be influenced by small sample size. For influenza vaccine, multiparity adjusted RR 2.09 (95% CI 0.22-19.53), public insurance 3.61 (0.18-71.40), black race 1.72 (0.08-34.93), and income <$25,000 2.41 (0.31-18.52). Factors associated with a high VRE for Tdap were no college education 7.37 (0.56-97.12), public insurance 6.31 (0.19-207.71), black race 0.80 (0.04-14.90), income <$25,000 1.12 (0.09-14.09), and smoking 1.00 (0.09-11.30).

CONCLUSION:
Our preliminary analysis has demonstrated that reporting times for recommended maternal vaccinations varies greatly and this time difference needs to be taken into consideration in future research utilizing survey data.
Is Self-Reported Insulin Adherence Associated With Maternal and Neonatal Outcomes? [23I]
Authors: Sheng Jessica , Wernimont Sarah A. , Fleener Diedre , Traore Fanta , Syrop Craig , Andrews Janet 
Published: April 2018

INTRODUCTION:
Diabetes in pregnancy carries significant maternal and fetal risks. Medication adherence is critical to optimize glucose control and neonatal outcomes. Outside of pregnancy, high self-reported adherence is associated with lower glycosylated hemoglobin (HbA1c) values. We hypothesized that self-reported poor medication adherence at the first prenatal visit would be associated with worse maternal glucose control and neonatal outcomes.

METHODS:
This is a prospective cohort study of insulin requiring pregnant women enrolled in a team-based perinatal diabetes program. The validated Morisky Medication Adherence Survey was administered to women at their initial prenatal visit. “Good” and “poor” self-reported adherence was defined as a score of 0 or 1 and between 2 and 8 respectively. The primary outcomes evaluated were HbA1c and a neonatal composite of hypoglycemia, large for gestational age, preterm birth and hyperbilirubinemia requiring phototherapy.

RESULTS:
Both groups had a similar proportion of women with type 1 and type 2 diabetes with younger women noted to have poor adherence. Women with good adherence had significantly better glucose control at time of delivery (HbA1c 5.68 vs 6.29, p=0.03). However, change in HbA1c from initial visit to delivery was similar between groups (-1.87 vs -1.88, p=0.98). There were no statistically significant differences in neonatal outcomes.

CONCLUSION:
Pregnant women with insulin requiring diabetes who report good medication adherence demonstrate improved glucose control at delivery compared to women who report poor adherence, although neonatal outcomes were similar. Regardless of reported adherence at initial visit, a team-based perinatal diabetes program achieves improved glucose control during pregnancy.
Sequential Compression Device Compliance During Inpatient Antepartum Management [26I]
Authors: Chen Meinuo , Palatnik Anna 
Published: April 2018

INTRODUCTION:
Recently, we implemented a quality improvement protocol where each antepartum admission order set included a pre-checked order for sequential compression device (SCD). The purpose of this study was to evaluate whether this change has led to increased compliance with SCD use during antepartum admission.

METHODS:
This was a prospective observational study including all pregnant women admitted for inpatient management in a single tertiary care center. The study was conducted between May 2017 and September 2017, a year after implementation of pre-checked order for SCD in the electronic antepartum admission order set. Prior to this implementation the rate of SCD order was 46.0%. Women receiving pharmacologic thromboprophylaxis were excluded. During daily morning rounds the study investigators assessed whether SCD was ordered, was in the room and whether it was in use. Woman was considered to be compliant if she was ambulating or in bed with SCD in use.

RESULTS:
During the study period a total of 356 rounding encounters were documented for 61 women. Mean length of stay was 6.51 days ± 7.6. 73.8% of admissions had a documented SCD order with 75.6% of these orders being placed on hospital day 1. Among women who had SCD ordered, 73.9% had the machine in the room and 33.3% were compliant with its use. Non-compliance increased with repeat rounding encounters (odds ratio of 1.35 per each rounding day, 95% CI 1.15 -1.54).

CONCLUSION:
Although pre-checked order set for SCD increased physician compliance with ordering SCD, patient compliance with SCD during antepartum admission was still low.
ZIP Code Matters: An Ecological Study of Preterm Birth in Rochester, New York [28I]
Authors: Toscano Marika A. , Olson-Chen Courtney 
Published: April 2018

INTRODUCTION:
Preterm birth (PTB) is not homogeneously distributed among populations. Risk factors can accumulate in discrete locations. We sought to investigate the geographical relationships between PTB and sociodemographic factors as denoted by ZIP code.

METHODS:
We conducted an ecological analysis of data from 2012 to 2014 in each Rochester ZIP code using vital statistics, hospital records and the American Community Survey. Pearson correlation coefficients (r) assessed the relationship between PTB rates and sociodemographic variables by ZIP code. Geographic information system (GIS) mapping explored the spatial relationships of PTB rates.

RESULTS:
17,876 deliveries occurred with a PTB rate of 11.3%. The PTB rate ranged from 6.8% to 15.6% across 22 ZIP codes. GIS mapping demonstrated clustering of ZIP codes with the highest PTB rates in the urban center which overlapped with high levels of poverty and crime. Increased PTB rates significantly correlated with ZIP codes containing the largest percentage of minorities (r=0.836, P<0.001). PTB rates positively correlated with inadequate prenatal care (r=0.864, P<0.001), unmarried status (r=0.857, P<.001), state-funded insurance (r=0.848, P<0.001), poverty (r=0.855, P<0.001) and teen pregnancy rates (r=0.709, P<0.001) by ZIP code. Areas with the highest PTB rates had the lowest number of obstetric providers (r = -0.385, p=0.077).

CONCLUSION:
Rochester ZIP codes have a high correlation between PTB rate and sociodemographic factors, highlighting the abundance of risk factors that concentrate in geographic areas. The high risk areas seem to lack obstetric care providers. Policies and interventions should target these ZIP codes in order to improve PTB rates and access to care.
Fetal Heart Changes Following Neuraxial Analgesia in Uteroplacental Insufficiency Pregnancies [30I]
Authors: Maetzold Erin , Lambers Donna , Devaiah Ganga , Habli Mounira 
Published: April 2018

INTRODUCTION:
Epidural analgesia (EA) and combined spinal epidural (CSE) can cause fetal heart rate changes due to maternal hypotension and uterine tachysystole. Previous studies have focused on CSE or EA in “healthy” pregnancies, excluding uteroplacental insufficiency (UPI) conditions. No studies have discussed the impact of EA and CSE on fetal heart rate in laboring UPI pregnancies. Our objective was to compare the impact of EA versus CSE during labor on fetal heart rate in pregnancies complicated with UPI.

METHODS:
We conducted a retrospective study of singleton pregnancies complicated with UPI that received EA (n=110) or CSE (n=127) for intrapartum pain relief in a single center from 2012-2015. UPI was defined as pregnancies with chronic hypertension, preeclampsia, and/or fetal growth restriction (IUGR) as per ACOG criteria definitions. Primary outcome was fetal heart rate abnormalities classified as normal, suspicious or pathologic as well as the NICHD criteria. Data collected included maternal demographics, blood pressure, uterine tachysystole, mode of delivery, interventions for FHR abnormalities and neonatal outcomes. Data was analyzed using Student’s t-test, Mann-Whitney U test and Chi-squared or Fisher’s exact test.

RESULTS:
There was no significant difference among groups in baseline characteristics, rate of maternal hypotension, uterine tachysystole, pregnancy outcome and fetal heart rate categories/abnormalities. When compared to the EA group, CSE had a higher rate of NICU admission (28.3% vs. 16.4%, p-value = 0.031).

CONCLUSION:
Pregnancies complicated with UPI are neither at higher risk of abnormal fetal heart pattern nor increased rate of fetal intervention.
Systematic Improvements Aimed at Improving Exclusive Breastfeeding Rates in Los Angeles County [31I]
Authors: Eskander Ramy N. , Bender Nicole , Buzad Paul , Jackson Ashaki , Saleeby Erin 
Published: April 2018

INTRODUCTION:
Disparities in exclusive breastfeeding rates vary widely between institutions, with communities of low resources often demonstrating lower rates of exclusively breastfed infants. We evaluated how, in a tertiary care academic setting, systematic changes to an electronic health record system can impact the rates of exclusively breastfed, term infants, not admitted to the Neonatal ICU.

METHODS:
We collected baseline data on exclusive breastfeeding rates through discharge on women who delivered within the Los Angeles County Department of Health Services system from July 2015 through June 2016 (Group 1). Beginning July 2016, a campaign was deployed aimed at educating patients & staff on the benefits of exclusive breastfeeding (Group 2). In December 2016, in addition to education, we modified our newborn feeding protocol within the Electronic Health Record System (Group 3). We then compared baseline exclusive breastfeeding rates, to the following 6 and 12 months.

RESULTS:
While no statistical difference existed in monthly exclusive breastfeeding rates between Group 1 and Group 2, following removal of formula from system options, a summary t-test analysis revealed a notable difference in rates between Group 2 and Group 3. Group 3 had a higher rate of exclusively breastfeeding women (M=53.90, SD=5.64) than Group 2 (M=40.57, SD=3.09); t(10)=-7.41, P<.001. Exclusive breastfeeding rates rose to 54%.

CONCLUSION:
Making small, systematic changes to an electronic health record can have a significant impact on provider behavior, ultimately leading to significant increases in the rate of exclusive breastfeeding through hospital discharge.
Enhanced Recovery Program Reduces Length of Stay & Improves Value for Patients Undergoing Elective Cesarean Section [33I]
Authors: Kett Atilla , Cherot Elizabeth 
Published: April 2018

INTRODUCTION:
Multiple obstetrical units in the United Kingdom introduced Enhanced Recovery Programs and demonstrated improved quality of care and significant savings with superior patient satisfaction. Our participation in the Perioperative Surgical Learning Collaborative and partnership with leading experts from the UK provides us with the unique opportunity to pioneer this pathway in the United States.

METHODS:
We enrolled low risk patients with the diagnosis of repeat Cesarean Section. Our team partnered with SeamlessMD, a leading provider of a clinical intelligence platform to develop the smartphone application to engage and empower our patients. Our solution has a wide range of capabilities, including a cross-platform application which accommodates patient education, reminders and the ability to perform remote monitoring and measure performance through an analytics dashboard including patient satisfaction and opioid use.

RESULTS:
We enrolled 110 patients in our first year. The average length of stay reduced from 3.7 to 2.45 days. We developed a financial model projecting the net direct variable costs and savings associated with the adoption of our program. Based on the implementation cost and daily direct variable cost savings, our Enhanced Recovery Program yielded a 296 % ROI during the first year and a projected 451% in subsequent years.

CONCLUSION:
Implementation of a Enhanced Recovery Program for patients undergoing elective Cesarean Sections can improve the value of care without forcing hospitals to incur a large expense. Cost savings associated with reduction in length of stay and improvement in patient outcomes and satisfaction can justify the cost associated with the implementation of the program.
Should a Private Obstetric Practice Switch Hospitals within a Tiered Hospital Payment System? [34I]
Authors: Siddiqui Zishan , Cherot Elizabeth 
Published: April 2018

INTRODUCTION:
As hospitals align themselves in tiered payment systems, patients are faced with financial implications of continuing their existing relationship with their obstetrical practice. Patients may switch to a new obstetrical group and hospital. Obstetric practices are assessing if changing hospital affiliation will minimize patient attrition. Not much is understood about patient loyalty and barriers to switching providers. We conducted a patient survey to asses switch cost, loyalty and likelihood of attrition.

METHODS:
555 patients from a single obstetrical practice were surveyed. Student t-test was used to assess the relation between self-reported likelihood for attrition (outcome) and self-reported switch cost and loyalty

RESULTS:
Only 43.5% of the patients chose the practice because they wanted a doctor at the practice, others chose to be able to deliver at the affiliated hospital. 22.8% of the patients would certainly chose hospital over the practice. Patients were likely to choose the OB practice over the hospital if they chose to join the practice for its doctors, if they extensively researched physicians, or were worried about developing a relationship with a new doctor or the logistic hassle related to switching providers.

CONCLUSION:
A large number of patients chose an obstetrics practice because of the hospital they deliver in rather than because of the physicians. This factor is an important predictor of attrition if the OB practice switch their hospital affiliation. A deep understanding of patient-mix regarding their loyalty, motivation and perceived switch cost may help a practice asses the financial implications of switching hospital affiliation.
Cesarean Wound Risk Assessment and Management: A Quality Improvement Study [35I]
Authors: Griffiths Kara M. , Nguyen Xuan-Loc , Maxwell Rose , Polenakovik Hari , Shahin Maryam , Galloway Michael 
Published: April 2018

INTRODUCTION:
Surgical site infections (SSIs) represent approximately 17% of all hospital-acquired infections with an estimated 500,000 SSIs per year. Cesarean delivery is the primary contributor to SSIs, resulting in patient morbidity and increasing length of hospital stay and medical costs. Studies have shown a benefit to pre-operative antibiotics, but no studies have been done to determine the benefits of stratifying patients into risks categories to tailor management with the goal of preventing infection.

METHODS:
This is a prospective two-phase quality improvement study in which women undergoing cesarean delivery were categorized according to a risk stratification checklist into high and low-risk groups for developing SSIs. Management for the low risk group consisted of standard pre-operative intravenous antibiotics and a standard pressure dressing. Management for the high risk group consisted of 24 hours of intravenous antibiotics and a specialized Mepilex dressing. SPSS software was used for data analysis.

RESULTS:
The overall occurrence of SSIs in the low and high risk groups were 7.1% and 3.3% respectively, p-value <0.23. 20% of patients with SSIs had insulin-controlled diabetes, p-value <0.06. Logistic regression demonstrated that both diabetes and BMI were strong predictors of SSIs, p-value <0.01. The incidence of complex SSIs decreased 40% after initiation of the protocol.

CONCLUSION:
Our data suggest an overall decrease in SSIs after stratifying patients into high and low risk groups with the assigned antibiotics/dressing. Obesity and diabetes are the greatest predictors of SSIs. These risk factors should prompt consideration of use of prolonged antibiotics and a specialized dressing.