bluuebunny/crossref_metadata_2025_split huggingface dataset:
Geographic Variation of Hospital Costs and Volume of Female Pelvic Reconstructive Procedures [39S]
Authors: Wang Rui 
Published: May 2019

INTRODUCTION:
Studies have shown that there are vast differences in cost of care for the same type of procedure due to geographic differences in medical practice across the United States. The goal of this study is to evaluate how cost and volume of cases differ by the geographic region where female pelvic reconstructive procedures are performed.

METHODS:
The 2016 Medicare Inpatient Utilization and Payment Data includes information on utilization, payment, hospital-specific charges for U.S. hospitals across the country. Diagnosis Related Group codes were used to identify hospital charges for patients who underwent female pelvic reconstructive procedures and were admitted. The total inpatient hospital charges were converted to total cost using the Medicare cost-to-charge ratios.

RESULTS:
A total of 2,133 inpatients carrying the diagnosis of female pelvic reconstructive procedures were identified. The Northeast region had the lowest average cost ($10,888) and the West region was associated with the highest average cost ($13,766) (Table 1). Two states, Missouri and Virginia, are outliers in the average hospital costs for female pelvic reconstructive procedures (both >$20,000) compared to the median cost ($11,473) (Figure 1). Several states, Kansas, Mississippi, and Oklahoma are outliers in the volume of procedures performed per 100,000 Medicare beneficiaries (>9 compared to median of 4.06 procedures per 100,000 Medicare beneficiaries).

CONCLUSION:
The cost of inpatient care for female pelvic reconstructive surgeries differs across geographic region within the U.S. There are several outlier states with much higher average cost per patient or higher volume of inpatient admissions following these surgeries adjusted for size of Medicare population.
Pregnancy-Induced Atypical Hemolytic Uremic Syndrome: Case Report and Review of the Literature [1T]
Authors: Alex Maya , Collazo-Maldonado Roberto , Stovall Dale W. , Lytvak Irina 
Published: May 2019

INTRODUCTION:
Pregnancy-induced atypical hemolytic uremic syndrome (p-aHUS), a disease caused by hyperactivation of the alternative complement pathway, can lead to renal ischemia and ESRD. We present two cases of p-aHUS and discuss both the disease process and treatment options.

METHODS:
The first case, a 31 yo female, underwent a cesarean delivery at 29 weeks due to preterm labor with breech presentation. She developed elevated BP, thrombocytopenia, and elevated serum creatinine postpartum. A nephrology consult confirmed the diagnosis of p-aHUS with elevated LDH and normal ADAMST13 levels. The second case is a 32 yo who underwent a suction D&C due to retained placenta after delivery of an IUFD. Laboratory values revealed thrombocytopenia and acute kidney injury (AKI). Again, Nephrology diagnosed p-aHUS. Both patients underwent plasmapheresis and Eculizumab therapy as soon as p-aHUS was diagnosed. Literature review for p-aHUS revealed the following conclusions: 1) risk factors include postpartum period, history of a cesarean delivery, and a genetic mutation in the CFH gene; 2) other causes of thrombocytopenia, AKI, and hemolytic anemia in pregnancy include pre-E and TTP 3) TTP can be ruled out with a normal ADAMST13 and pre-E can be ruled out by an LDH <1000; and 4) immediate diagnosis and treatment helps to prevent kidney injury.

CONCLUSION:
Given the rarity of the disease, there is little research involved in p-aHUS. However it is it is important for clinicians to have a strong suspicion for p-aHUS and to initiate treatment immediately to decrease morbidity including ESRD.
Primary Cesarean Birth Rates Among Women With Obesity at Urban and Rural Hospitals in the [6T]
Authors: Antony Kathleen M. , Hsiang-Hui Daphne Kuo , Greene Madelyne , Shrider Emily , Hartenbach Ellen , Ehrenthal Deborah 
Published: May 2019

INTRODUCTION:
Studies have demonstrated that the rate of Cesarean birth (CB) is increased among women with obesity. 14% of births among women with class III obesity occur in rural areas. We aimed to investigate whether the relative risk of CB for women with obesity varied by location of birth (rural versus urban).

METHODS:
The Natality Data Set of live births in the United States between 2014 and 2015 was queried for nulliparous, vertex, term births. BMI was classified into eight groups defined by WHO criteria with sub-stratification of class III every 5 kg/m2 up to BMI ≥50 kg/m2. Rates of CB were assessed according to the National Center for Health Statistics' county-level urban-rural classification scheme.

RESULTS:
The rate of CB per 1000 live births increased with BMI across all geographic categories (highest RR 3.89 (95%CI 2.20-6.90) for BMI 50+). The rate of CB among women with BMI between 40 and 44.9, 45 and 49.9 and ≥50 kg/m2 was proportionally higher than expected (due to BMI alone) for rural hospitals (RR 1.21 (95% CI 1.17-1.25), RR 1.33 (95% CI 1.27-1.39), and RR 1.30 (95% CI 1.23-1.37), respectively). A higher proportion of all deliveries at rural hospitals occurred among women with obesity compared to urban hospitals.

CONCLUSION:
The relative risk of CB for women with BMI ≥-40 kg/m2 was higher than expected in rural hospitals. Rural hospitals proportionally deliver more women with obesity of all strata. This indicates that rural facilities require operative equipment to accommodate obesity and may indicate rural-urban disparities that warrant further investigation.
Racial Differences in Hypertensive Disorders of Pregnancy: The Role of Sleep-Disordered Breathing [8T]
Authors: Greco Patricia , Pitts D'Angela , O'Brien Louise 
Published: May 2019

INTRODUCTION:
Hypertensive disorders of pregnancy vary by race. Pregnancy-onset sleep disordered breathing (SDB), has emerged as an independent risk factor for hypertensive disorders of pregnancy. We examined whether the contribution of SDB to hypertensive disorders of pregnancy differed by race.

METHODS:
Pregnant women were recruited from a tertiary medical center and queried about the presence of SDB, defined as snoring at least 3 nights per week. Only African American and Caucasian women were in the analysis as there was insufficient numbers of other racial groups. Logistic regression analyses were conducted to determine the contribution of SDB to pre-eclampsia after adjusting for history of gestational hypertension/pre-eclampsia, chronic hypertension, type II diabetes mellitus, maternal age, body mass index, parity, and smoking.

RESULTS:
The sample size was 1563 (81.5% Caucasian, 18.5% African American). In unadjusted analyses, pregnancy-onset, but not chronic SDB was associated with development of pre-eclampsia in Caucasian women, OR 2.1 (95%CI 1.4-3.0). Conversely, chronic SDB, but not pregnancy-onset SDB was associated with development of pre-eclampsia in African American women, OR 2.8 (95%CI 1.3-5.9). In adjusted analyses, while chronic hypertension, history of gestational hypertension/pre-eclampsia, and smoking were significantly related to the development of pre-eclampsia, pregnancy-onset SDB remained independently associated with pre-eclampsia in Caucasian women (aOR 1.6, 95%CI 1-1-2.6). In African American women the association with chronic SDB and pre-eclampsia was no longer significant after adjustment.

CONCLUSION:
Pregnancy-onset SDB is an independent predictor of pre-eclampsia in Caucasian women but SDB does not appear to be independently associated with the development of pre-eclampsia in African American women.
Patient Portal Use for Secure Messaging During Pregnancy [9T]
Authors: Ukoha Erinma , Feinglass Joseph , Yee Lynn 
Published: May 2019

INTRODUCTION:
Use of electronic patient portals and in particular secure messaging during pregnancy is rapidly expanding. Our objective was to qualitatively examine secure messaging between pregnant women and providers and explore how these differed based on which party initiated the message.

METHODS:
This is a retrospective cohort study of women who received prenatal care at an academic medical center and were enrolled in the EMR patient portal. Women were included if they exchanged at least one message with an obstetrics-affiliated medical provider during pregnancy or immediately postpartum. Messages were organized into threads, defined as a group of messages related to an original message by successive replies. We performed a qualitative analysis of the threads, eliciting themes and comparing threads based on the initiating party.

RESULTS:
This cohort of 384 women participated in 1349 message threads. Of these message threads, 884 (65.5%) were patient-initiated. Threads were categorized into six themes: results, medications, administrative, patient education, symptoms, and social/emotional support. The majority (73%) of provider-initiated threads involved results, compared to only 17.3% of those initiated by patient. Additionally, 2.4% of provider-initiated messages were regarding symptoms as opposed to 24% of patient messages involving this theme.

CONCLUSION:
Women commonly use secure messaging via patient portals during pregnancy. The content and frequency of messaging vary widely. Emerging research suggests portal use may be associated with improved outcomes. As patient portals become more prevalent in pregnancy, it is imperative for providers to understand how we can best harness this application as a resource to empower women and improve outcomes.
Racial Disparities in Obstetric Outcomes Within Traditional Prenatal Care Versus CenteringPregnancy [10T]
Authors: Leung Andrea , Paoletti Andrew , Goldberg Jay 
Published: May 2019

INTRODUCTION:
CenteringPregnancy is an innovative model of group prenatal care that aims to improve outcomes among high-risk women. The purpose of this study was to determine if discrepancies in obstetrical outcomes among non-Hispanic black (NHB) and non-Hispanic white (NHW) women are reduced with CenteringPregnancy, as compared to traditional care (TC).

METHODS:
A retrospective chart review was performed of patients who delivered at Einstein Medical Center Philadelphia from 1/1/2014 to 9/1/2018. The primary outcome was preterm birth (<37 weeks). The secondary outcome was breastfeeding rates. A Pearson Chi-square test was used to compare the outcomes of interest between NHW women receiving TC (n=409), NHB women receiving TC (n=1,972), and NHB women in CenteringPregnancy (n=266). NHW women in CenteringPregnancy were not included due to an insufficient sample (n=30).

RESULTS:
Data was analyzed from 2,647 pregnancies. A non-significant increase in preterm birth was observed among NHB women receiving TC as compared to NHW women receiving TC (15.2% vs 11.5%, p = 0.055). No significant difference in incidence of preterm birth was observed among NHB women in Centering as compared to NHW women receiving TC (12.8% vs. 11.5%, p = 0.614). No significant difference in incidence of breastfeeding was observed among NHW and NHB women receiving TC (56.3% vs. 52.9%, p = 0.197), or among NHW women receiving TC and NHB women in CenteringPregnancy (56.3% vs. 60.1%, p = 0.321).

CONCLUSION:
No statistically significant difference in incidence of preterm delivery or breast feeding was observed between NHB and NHW women receiving either traditional prenatal care or Centering Pregnancy.
Relationship Between Buprenorphine Dose, Timing of Dosing to Delivery and Neonatal Opioid Withdrawal Syndrome [13T]
Authors: Srinivasan Aarthi , Bauer John , Shook Lori , Qi Ya , Critchfield Agatha 
Published: May 2019

INTRODUCTION:
To determine a relationship between the timing of buprenorphine dosing to delivery and subsequent Neonatal Opioid Withdrawal Syndrome (NOWS).

METHODS:
This was a pilot retrospective cohort study. Pregnant women with opioid use disorder (OUD) on opioid maintenance therapy (OMT) through a perinatal OUD treatment program (PATHways) were enrolled. Prior PATHways data revealed improved neonatal outcomes in women on a mean buprenorphine dosing of 12 mg/day.12 mg was utilized as a cut point for high vs low dose. High dose cases on 16 mg/day were compared with low dose controls (0.5 - 12 mg/day). Timing of last dose of medication received was evaluated. Primary outcome was the presence of medication requiring NOWS post-delivery

RESULTS:
Twenty-three high dose cases and 30 low dose controls were included. There was no significant difference in the incidence of treatment requiring NOWS (30% vs 40%, P=0.45). The duration between buprenorphine dose and delivery was not significantly different (6.4± 2.6 hours vs.11.5± 6 hours, P=0.06). However, within the high dose OMT group, the time interval between buprenorphine dose and delivery in women with infants treated for NOWS was significantly shorter than those where infants were not treated for NOWS (10± 3.8 hours vs. 6.4± 2.6 hours, P= 0.038). Peak Finnegan scores (15 ± 4 vs. 9± 4, P= 0.025) and hospital stay (21± 12 days vs. 5± 0.7 days, P=0.01) were significantly higher when patients received buprenorphine close to delivery.

CONCLUSION:
These findings suggest a relationship between the timing of buprenorphine and NOWS at higher doses and serves as a pilot data for a future prospective trial.
Relationship Between Maternal BMI and Labor Induction Outcomes [14T]
Authors: Teal Elizabeth Nicole , Lewkowitz Adam , Koser Sarah , Tran Carol , Gaw Stephanie 
Published: May 2019

INTRODUCTION:
Nearly 25% of US pregnancies result in an induction of labor (IOL). The US population is increasingly obese. This study aims to assess the relationship between obesity and IOL outcomes.

METHODS:
This is a retrospective cohort study including nulliparous women with non-anomalous, singleton, vertex pregnancies who underwent IOL at an academic hospital from January 2015 to April 2017. Patients were divided by body mass index (BMI): underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9), class I obesity (30.0-34.9), and class II and III obesity (≥35). The primary outcome was IOL duration. Secondary outcomes were vaginal delivery (VD) rate, maternal morbidity (hemorrhage, transfusion, infection), and neonatal morbidity (NICU admission). The data were analyzed using the Kruskal-Wallis test and logistic regression.

RESULTS:
Of 955 patients, 673 (70.5%) delivered vaginally. Compared with normal weight women, those with BMI ≥35 had decreased odds of VD (OR 0.5, CI 0.3 - 0.9). Increasing BMI was associated with increasing IOL duration (p=.0001) with the longest median duration 37.9 hours in the BMI ≥35 group. After adjusting for potential confounders (maternal age, race, gestational age, and IOL indication), there was no association between BMI and hemorrhage, transfusion, infection, or NICU admission.

CONCLUSION:
In this cohort, increasing BMI was associated with longer IOL and BMI 35 or greater was associated with decreased odds of VD. There was no association between BMI and maternal or neonatal morbidity. This data suggests that although higher class obesity is associated with a decreased chance of VD, obese women can safely be allowed more time for IOL.
Respectful Maternity Care in the US [15T]
Authors: Patel Suha J. , Schantz-Dunn Julianna 
Published: May 2019

INTRODUCTION:
To understand the status of respectful maternity care (RMC) in the U.S.

METHODS:
A cross-sectional survey of U.S. women age 18-50 in April 2018. SurveyMonkey Audience distributed this anonymous survey online. Women were eligible if they gave birth in the U.S. in the last 5 years. Participants were those who answered at least one question about RMC from their most recent birth. Quantitative survey data consisted of demographics and responses about RMC indicators and comments about their birth experience.

RESULTS:
Of 1081 eligible, 1036 women (95.8%) participated. The locations of births from this group spanned the entire U.S. Most births (95%) occurred in hospitals. 36.7% of births were cesarean deliveries. The median maternal age was 32. 19.5% of respondents felt neglected at some point during their birth experience; more than half in the postpartum phase of care only. 333 left decipherable comments. When women reported issues, they were almost always one of the following: clinical staff performance or competency, neglect, interpersonal communication issues, lack of respect for wishes, negative experience with breastfeeding services, peri-partum complications, or perceived discrimination.

CONCLUSION:
This is the first study on RMC from women who have delivered in the U.S. Overall, the women surveyed were treated with dignity during their birth experiences. However, this data suggests that care for women during their birth experiences can be more respectful and that women feel more neglected during the postpartum period. Strategies to improve quality of maternal health care in the U.S. should include attention to the provision of RMC.
The Effects of Infiltration of Liposomal Bupivacaine for Pain Control After Cesarean Delivery: A Randomized Trial [19T]
Authors: Ton Raquel , Stovall Dale W. , Rhoades-Lazenby Courtney 
Published: May 2019

INTRODUCTION:
In response to the growing opioid epidemic, we determine whether the addition of liposomal bupivacaine infiltration administered above and below the fascial layer and within the subcutaneous tissue at the time of closure post cesarean delivery would reduce pain scores compared to the use of intra-thecal morphine alone.

METHODS:
Randomized, placebo-controlled, single-blinded study. Eligible women over 17 years of age and at least 34 weeks gestation, non-emergent cesarean delivery under spinal anesthesia. Random assignment to receive either intrathecal Astramorph® and saline wound infiltration or intrathecal Astramorph® and wound infiltration with liposomal bupivacaine (Exparel®). Primary outcome was post-operative pain scores measured via visual analog scale until discharge. Secondary outcomes included side effects and patient satisfaction. A t-test was used to assess differences between groups for continuous variables, and a chi-square test was used to assess differences for categorical variables. Informed consent and IRB approval obtained.

RESULTS:
Of the 22 eligible subjects identified during the study interval, 18 were randomized and completed the study. The groups were similar in regards to demographic parameters. As compared to the placebo group, the mean daily pain scores were significantly lower in the Exparel® group on post-operative days 1 and 2 (P < 0.05) and required less opioids. No significant differences between groups in satisfaction scores or the presence of side effects. No patients required additional opioid analgesia after discharge.

CONCLUSION:
Wound infiltration with liposomal bupivacaine during cesarean delivery reduced post-operative pain scores without increasing side effects. Supports the effectiveness of this multimodal approach to post cesarean delivery analgesia.
Visualizing Delivery Catchment Area for Severe Maternal Morbidity in Harris County, Texas, 2016 [25T]
Authors: Salahuddin Meliha , Eisenhart Amelia , O'Neil Molly , Byrd-Williams Courtney , Lakey David , Patel Divya A. 
Published: May 2019

INTRODUCTION:
Severe maternal morbidity (SMM) reflects complex, multi-level factors. In Texas, the SMM rate was 17.0 per 1,000 deliveries in 2016. In this exploratory case study, we describe SMM by ZIP Code for select hospitals in the Texas county with the highest delivery volume, to highlight differences in SMM at a granular level.

METHODS:
Using Texas all-payer inpatient hospitalization data for 2011-2016, delivery-related hospitalizations were classified as SMM based on 21 ICD-10-CM diagnosis and procedure codes. Using ArcGIS Desktop, SMM was mapped at (1) maternal residence ZIP Code for Harris County, and (2) maternal residence ZIP Code and hospital level for two hospitals with the lowest and two hospitals with the highest SMM rates.

RESULTS:
SMM remained consistent during 2011-2016 in Harris County (15.4-23.4 per 1,000 deliveries, P>.05). Among the 125 ZIP Codes with at least 100 deliveries in 2016, over one-third had SMM higher than the state rate. In the four hospitals included in this study, the SMM rate ranged from 1.9 to 33.8 per 1,000 deliveries. The hospital with the highest SMM rate included deliveries from a wide catchment area, while the other three hospitals had a relatively concentrated delivery catchment area.

CONCLUSION:
In this exploratory study, we observed differences in SMM across hospital and community settings, which reflects complex factors, including patient preexisting conditions, hospital quality of care and community characteristics. Our findings can help generate additional research to gain in-depth understanding of the relative contribution of these multi-level factors to SMM and inform development of risk adjustment approaches for SMM.
Why Do We Deliver? A Closer Look at Indicated Deliveries Scheduled Less Than 39 Weeks [28T]
Authors: Jackson David N. , Kirgan Marsha Matsunaga , Patil Pooja , Brar Bobby , Parr Ashley , Belilovets Anastasia 
Published: May 2019

INTRODUCTION:
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires practice guidelines to eliminate elective near term deliveries. Our primary goal was to determine why practitioners continue to schedule non-elective (indicated) deliveries at less than 39 weeks.

METHODS:
A retrospective case series examined the incidence, indications, and outcomes for deliveries requested through our labor and delivery approval process from February 2013 thru July 2018. We analyzed these deliveries for indications, maternal demographics and neonatal outcomes between private and resident delivery services.

RESULTS:
Scheduled deliveries requested less than 39 weeks occurred for 450 viable pregnancies within 13,512 births (3.3%). Of these, 54% were by private obstetricians and 46% were by the resident service. The mean gestational age was 37.1 +/- 1.2 weeks (range 28.6 to 38.9 weeks). Frequency of key indications for delivery were intrauterine growth restriction 24.7% (n=111), hypertension related 14.9% (n=67), uncontrolled diabetes 13.3% (n=60), cholestasis 11.3% (n=51), multiple gestation 10.7% (n=48), other medical disorder 6.2% (n=28) and placenta previa 4.0% (n=18). NICU admissions occurred in 20.9% (94/450). Cesarean section occurred in 46%. There were no significant differences in demographics, indications, or frequency of NICU care in the private versus resident services.

CONCLUSION:
In an era of avoiding elective deliveries at less than 39 weeks, we found that approved, non-elective deliveries account for 3.3% of all births. Despite a mean gestational age of 37.1 weeks, NICU utilization is high at 20.9%. This series identifies opportunities for prospective studies to modify and reduce the neonatal risks within scheduled near term deliveries.