bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Association of Latent Labor and Classical Cesarean Delivery [2P]
Authors: Cockrum Richard , Winter Michelle , Young Danielle , Mueller Ariel , Rana Sarosh , Siddiqui Maryam 
Published: April 2018

INTRODUCTION:
Labor prior to cesarean delivery is thought to be a protective factor against classical incision at <28 weeks gestation, ostensibly from development of the lower uterine segment. This study aims to determine if latent labor has a similar secondary benefit to reduce classical cesarean deliveries at an early gestational age.

METHODS:
In this retrospective cohort study, patients with a singleton pregnancy between 24 and 31 weeks gestational age undergoing cesarean delivery at a single, tertiary academic medical center were enrolled between January 2011 and December 2015. Stages of labor were defined as none, latent phase (final dilation <6cm), and active phase (final dilation >/= 6cm). The primary outcome was type of uterine incision.

RESULTS:
For 263 eligible patients, the rate of classical cesarean delivery was 53%. This varied significantly by gestational age (77% at 24-27 weeks vs 32% at 28-31 weeks; p<0.0001). Other significant factors associated with classical incision included smaller birthweight, chorioamnionitis, and fetal malpresentation (p<0.05). Labor was not significantly associated with a reduction in the odds of classical incision (OR 0.79, 95% CI 0.49-1.29). Stratification by stage of labor also did not show a significant difference in rate of classical incision for none, latent, and active labor for all patients (55%, 50%, and 49%, respectively) or for 24-27 weeks (78%, 79%, and 71%, respectively). No difference was observed between spontaneous and induced labor or by provider specialty and experience.

CONCLUSION:
In this preliminary analysis, labor, regardless of stage, was not associated with reduction in the odds of classical cesarean delivery.
Clinical Presentation and Outcome of 10 Cases of Mirror Syndrome [3P]
Authors: Mogharbel Hussain , Hunt Jennifer C. 
Published: April 2018

INTRODUCTION:
Mirror syndrome, or Ballantyne’s syndrome, is a rare diagnosis with only 113 cases described in the literature. It is mainly characterised by maternal symptoms similar to preeclampsia in the setting of fetal hydrops. We identify 10 additional cases and provide a review of the maternal presentation, biochemical findings and perinatal outcome.

METHODS:
We performed a retrospective chart review of all cases of fetal hydrops from two tertiary centers in Winnipeg, Canada between 2000 and 2016. There were 276 cases of fetal hydrops during this period, of which 10 cases satisfied the criteria for Mirror syndrome.

RESULTS:
We report 10 cases of Mirror syndrome. The majority (80%) of women were multiparous. The mean gestational age at diagnosis was 23 weeks 4 days +/- 4 days and the mean gestational age at delivery was 25 weeks +/- 5 days. The most common clinical findings included hypertension, edema and placentomegaly. The most common laboratory findings included hypoalbuminemia (mean 20 7 gm/L), elevated uric acid level (mean 375 µmol/L) and anemia (mean hemoglobin 10g/dL). Half of the fetuses were stillborn and 40% of pregnancies resulted in neonatal deaths. Congenital anomalies were diagnosed in half of the pregnancies.

CONCLUSION:
Mirror Syndrome is likely under-diagnosed. Acute hemodilution, hypoalbuminemia and hyperuricemia might be early indicators for the diagnosis. Delivery is the treatment of choice and maternal symptoms usually resolve within few days after delivery. Fetal outcome is poor but early recognition may potentially avoid maternal morbidity.
Clinical Experience of Expanded Carrier Testing for Routine Preconception and Prenatal Care [10P]
Authors: Tschirgi Matt , Swope Betsy , Terhaar Catherine , Dohany Lindsay , Settler Christina 
Published: April 2018

INTRODUCTION:
Expanded carrier testing is recognized by ACOG as an acceptable testing strategy in women’s healthcare. We report a large OB/GYN practice’s experience with expanded carrier testing including partner testing uptake and reproductive risk.

METHODS:
A retrospective analysis of expanded carrier testing ordered at a multi-provider clinic was performed. Data analyzed included patient demographics, testing outcomes, and reproductive risks.

RESULTS:
Out of 537 female patients tested, 265 (49.3%) were positive; of those, 201 (75.8%) had partner testing. Fourteen (7.0%) couples were at risk to have a child affected with an autosomal recessive disorder (8 hemochromatosis, 3 familial Mediterranean fever, 1 PKU, 1 primary congenital glaucoma, 1 GJB2 non-syndromic hearing loss). Thirty women were carriers of an X-linked disorder (22 G6PD, 7 Fragile X premutation, and 1 GJB1-related Charcot-Marie Tooth disease). Incidentally, 10 patients were found who may have symptoms of a genetic condition based on their genotype (5 G6PD, 4 hemochromatosis, 1 carnitine palmitoyltransferase II deficiency), which could impact patient and pregnancy management.

CONCLUSION:
Implementing an expanded carrier testing protocol including partner testing identifies carriers of many disorders and allows for reproductive risk identification. In this cohort, out of 537 patients who were tested, 43 (8.0%) were identified to have reproductive risk either due to an X-linked disorder or as carriers of the same autosomal recessive disorder. Risk identification empowers patients to make informed decisions with the guidance of their provider. This experience demonstrates the yield of expanded carrier testing when routine testing and partner follow-up is incorporated in a busy obstetrical practice.
Induction of Labour in Low-Risk Pregnancies before 40 Weeks of Gestation: A Systematic Review and Meta-Analysis [11P]
Authors: Bapoo Shakira , Shukla Minakshi , Abbasi Nimrah , D'Souza Rohan 
Published: April 2018

INTRODUCTION:
Retrospective data suggest that adverse outcomes in low-risk pregnancies are lowest at 39 weeks, and systematic reviews of randomized controlled trials (RCTs) suggests that induction of labour (IOL) after 37 weeks regardless of indication and cervical favourability is associated with lower rates of caesarean deliveries (CD) when compared with expectant management. Our objective was to determine whether IOL <40 weeks reduces CD rates and improves pregnancy outcomes.

METHODS:
We conducted a systematic review of RCTs comparing IOL to expectant management in low-risk women. We searched four databases until November 2016 using appropriate keywords and MeSH terms. Two authors independently completed title screening, data extraction and risk-of-bias (ROB) assessment using the Cochrane ROB tool. Meta-analysis was performed using RevMan 5.3 and results were reported as odds ratios and 95% confidence intervals (OR, 95%CI).

RESULTS:
We identified 2523 titles and included 14 eligible articles, most of which had low ROB. Outcomes for IOL (n=1268) vs. expectant management (n=1266) were as follows: CD 1.02 (0.81, 1.28), operative vaginal delivery 1.32 (1.06, 1.66), infective morbidity 1.26 (0.79, 1.99), perinatal mortality 0.72 (0.14, 3.71), postpartum 1.00 (0.73, 1.38), neonatal admissions 0.71 (0.33, 1.51), abnormal cord gases 0.69 (0.26, 1.87) and low 5-minute Apgar scores 0.94 (0.44, 2.03).

CONCLUSION:
There were no differences in rates of CD or other adverse pregnancy outcomes when IOL <40 weeks is compared with expectant management in low-risk pregnancies. A policy of IOL at 39 weeks to lower CD rates and improve pregnancy outcomes can only be recommended under the confines of RCTs.
Neonatal Hypoglycemia after Initiation of Late Preterm Antenatal Corticosteroids at a Single Center [13P]
Authors: Uquillas Kristen , Lee Richard , Chen Ellison , Ihenacho Ugonna , Cortessis Victoria , Barton Lorayne 
Published: April 2018

INTRODUCTION:
After the publication of the Antenatal Late Preterm Steroids (ALPS) trial in 2016, LAC+USC Medical Center began to offer antenatal corticosteroids to patients at risk of late preterm birth. The ALPS trial found an association between late preterm corticosteroids and neonatal hypoglycemia, however this was not fully described.

METHODS:
We retrospectively examined data from all neonates born in the late preterm period between 2/1/15-7/31/17. Patients were excluded according to the ALPS study criteria. Hypoglycemia was defined as glucose <40 mg/dl within 72 hours of birth. Neonatal outcomes were compared between pregnancies treated with and without corticosteroids. Student’s T-test and Pearson’s chi-squared test were used as appropriate with a p-value <0.05 considered significant.

RESULTS:
During the study period, 67 (34.5%) received corticosteroids and 127 (65.5%) did not. There was no significant association between neonatal hypoglycemia and corticosteroids [OR 1.86 (95% CI 0.95-3.59), p = 0.05]. The mean glucose nadir (40.4±15.4 vs. 45.5±13.6, p = 0.02) and mean initial glucose (45.7±21.3 vs. 51.9±17.7, p = 0.03) were significantly lower in the neonates who received corticosteroids.

CONCLUSION:
Among a small population of late preterm neonates, there was no difference in the rate of hypoglycemia between those who did and did not receive corticosteroids. Although the hypoglycemia was more severe in the group who received corticosteroids, as evidenced by the significantly lower mean glucose nadir and mean initial glucose, there was no difference in the need for IV treatment or neonatal length of stay.
Characterization of Fetal Heart Rate Tracings During Eclamptic Seizures [15P]
Authors: Ambia Anne M. , Yule Casey S. , Wells C. Edward 
Published: April 2018

INTRODUCTION:
The well-known association of fetal bradycardia following maternal eclampsia has not been described in detail. We sought to characterize fetal heart rate tracing at the time of an intrapartum maternal eclamptic seizure and the changes in obstetric management that may result.

METHODS:
This was a retrospective study of fetal heart rate tracings recorded during an eclamptic seizure and the resultant obstetrical management of our institution from August 2009 to December 2016. Eclampsia was diagnosed according to criteria of the ACOG Executive Summary. Tracings were reviewed independently by three physicians based on the National Institute of Child Health and Human Development Criteria. Maternal and fetal outcomes were then analyzed.

RESULTS:
A total of 70 women were diagnosed with eclampsia during this time period. Nineteen women experienced a confirmed intrapartum seizure while on fetal heart rate monitors. Of those who experienced an intrapartum seizure, 16 of the 19 patients (84%) developed fetal heart rate decelerations with a mean duration of 6±4 minutes. For all women, the mean duration from the eclamptic seizure to delivery was 244±263 minutes. As a result of the fetal heart rate tracings, two patients underwent a change in obstetric management with a resultant emergent cesarean delivery due to profound bradycardia to the 50s without recovery. There were no neonatal deaths and three neonatal intensive care admissions.

CONCLUSION:
Management of fetal bradycardia during eclamptic seizures remains challenging. Despite a period of prolonged fetal bradycardia associated with intrapartum eclampsia, close observation resulted in a favorable neonatal outcome in the majority of cases.
Fetal Laceration Injury at Cesarean Delivery: Comparison between Low-Risk and High-Risk Intrapartum Care [17P]
Authors: Vander Haar Emilie L. , Miller Russell , Simpson Lynn L. 
Published: April 2018

INTRODUCTION:
Our objective was to determine the frequency, severity, and documentation of fetal laceration during cesarean delivery (CD) in patients receiving intrapartum low-risk (LRC) vs high-risk (HRC) care.

METHODS:
This is a retrospective cohort study of patients delivered at a single, academic medical center from January 2014 to December 2016. Medical records were reviewed for infants with a laceration after CD, and maternal, fetal, and obstetric variables were extracted. Lacerations were classified as mild, moderate, or severe. Patients assigned to LRC were compared to those assigned to HRC using appropriate bivariate analyses with an alpha of 0.05.

RESULTS:
Over the study period, there were 8,454 (62.7%) vaginal deliveries and 5,036 (37.3%) CDs. Of the CDs, 3,104 (61.6%) were performed on patients assigned to LRC and 1,932 (38.4%) to HRC. There were 14 total lacerations: 12 (85.7%) were classified as mild, 1 (7.1%) as moderate, and 1 (7.1%) as severe. There were more lacerations in patients assigned to HRC (71.4% vs 28.6%; p=0.01), with a fetal laceration rate of 1.3 per 1000 LRC CDs and 5.2 per 1000 HRC CDs. Of note, 42.9% of fetal injuries were associated with emergency CDs, and the risk of emergency delivery was higher in the HRC group, although this did not reach statistical significance (50.0% vs 25.0%, P=0.68). Documentation of fetal laceration was poor, recorded in only 42.8% of the maternal medical records.

CONCLUSION:
There was a four-fold increase in fetal injury associated with CD and HRC. Documentation of fetal injury at the time of CD needs improvement.
Postpartum Concerns after Discharge: Who has Them, and What are They? [19P]
Authors: Siegel Molly , Barrett Blair , Wheeler Margaret , Ustinov Alla , Li Ben , Rosenstein Melissa 
Published: April 2018

INTRODUCTION:
To identify the prevalence of concerns among postpartum women and the factors associated with them

METHODS:
All postpartum women from March to June 2017 were contacted after discharge via an automated call. A call was successful if the woman engaged with the automated system, and those with concerns were contacted by a nurse. We compared call success and presence of concerns by mode of delivery, insurance type (public or private), parity, pregnancy complication (diabetes, hypertension, hemorrhage), and neonatal intensive care (ICN) admission using univariate analyses and multivariable logistic regression.

RESULTS:
881 women were called and 730 (83%) successfully contacted; 224 (29%) reported a concern. Women with operative vaginal delivery were more likely to report an issue than spontaneous vaginal and cesarean delivery (42% vs 28% p=0.04). Women with public insurance were less likely to be successfully contacted (68% vs 84% p=0.003), but the frequency of concerns were equivalent (28% vs 29%). Nulliparous women were more likely to answer the call (86% vs 79% p=0.004) and to report an issue (32% vs 25% p=0.05). Women with neonates in the ICN were less likely to be successfully contacted. When controlling for confounders, nulliparity (OR 1.5, 95% CI 1.1- 2.2) and private insurance (OR 1.9, 95% CI 1.1 - 3.8) were independently associated with successful contact.

CONCLUSION:
The majority of postpartum women responded to a call, and one third had concerns. The system was less effective in contacting women with public insurance. Nulliparous women and women with operative vaginal deliveries may benefit from additional discharge support.
Efficacy of Quantitative Blood Loss Compared to Estimated Blood Loss for Predicting Severe Obstetric Hemorrhage [21P]
Authors: Le Nicole K. , Briceno Maria , Brown Alyssa , Leavitt Karla , Louis Judette 
Published: April 2018

INTRODUCTION:
Quantitative blood loss (QBL) has been proposed to be more accurate than estimated blood loss (EBL) for management of obstetric hemorrhage. We sought to evaluate the effectiveness of QBL in identifying women with severe obstetric hemorrhage.

METHODS:
We conducted a retrospective cohort study including all women who delivered at a tertiary center during 2/1/2013-1/31/2014. Medical charts were reviewed for relevant clinical data. Two methods were compared: quantitative blood loss and estimated blood loss. The data was analyzed using Spearman correlation and ROC curves where appropriate. P < 0.05 was considered significant.

RESULTS:
During the study period there were 9,890 deliveries and 2.9% were complicated by obstetric hemorrhage (N=287). Among women with postpartum hemorrhage, 47.5% had a cesarean delivery and 22.8% had a cesarean after labor. Overall, 26.8% of the women required a blood transfusion. Women who required a blood transfusion compared to those who did not need one, had a lower admission hemoglobin and took longer to stabilize. QBL (r= 0.33, p<.001) but not EBL (r= 0.2, p=.08) was correlated with a drop in hemoglobin. QBL estimation (sensitivity 87%, specificity 67%) showed a small improvement over estimated blood loss in the prediction (66% sensitivity, 85% specificity) of women who would require a blood transfusion [AUC=.84 (95%CI 0.810 to 0.908) vs. AUC=.77 (95% CI 0.698 to 0.882)], but no difference in blood transfusion (28 vs 22 %, p=.34).

CONCLUSION:
QBL has higher sensitivity in predicting severe obstetric hemorrhage but it was not associated with more frequent blood transfusions.
Isolated Echogenic Intracardiac Foci: A Comparison of Aneuploidy Screening Tests [28P]
Authors: Hacker Francis , Griffin Emily E. , Shaffer Brian L. , Caughey Aaron B. 
Published: April 2018

INTRODUCTION:
The 2014 Fetal Imaging Workshop endorses obtaining a quad screen or cell-free fetal DNA (cfDNA) test in fetuses identified to have an isolated echogenic intracardiac foci (EIF) without prior aneuploidy screening. Our goal was to compare estimated outcomes and costs of the recommendation. We additionally hoped to gain information to assist providers in offering patient specific recommendations.

METHODS:
A decision-analytic model was constructed using TreeAge software and probabilities derived from the literature. The model compared use of quad testing to cfDNA in women with an isolated EIF identified on screening ultrasound, with T21 sensitivities assumed at 81% and 99% respectively. Baseline risk of T21 was assumed at 1/400. Positive likelihood ratio for T21 with an isolated EIF, was assumed to be 1.5. Outcomes of interest included T21 diagnosis, procedure related loss, termination, spontaneous abortion, and T21 live births. Strategies were compared to generate an incremental cost-effectiveness ratio, with a $100,000/QALY threshold, and applied to a theoretical cohort of 100,000.

RESULTS:
When compared to aneuploidy screening using quad testing, the strategy that utilized cfDNA after detection of an isolated EIF resulted in 47 fewer live T21 births and 85 additional QALYs with cost savings of $525,964 per 100,000 pregnancies; a dominant strategy in cost-effectiveness analysis.

CONCLUSION:
In a population with an isolated EIF identified on screening US without prior aneuploidy screening it is cost effective to offer cfDNA as compared to a quad screening test. Despite the higher cost of cfDNA, these results likely stem from the increased sensitivity and decreased false positive rate.
Perinatal Outcome of Fetal Umbilical Vein Varix: A Multicenter Cohort Study [29P]
Authors: Novoa Y Novoa Victoria Arruga , Tonni Gabriele , Prefumo Federico , Ruano Rodrigo 
Published: April 2018

INTRODUCTION:
Umbilical vein varix (UVV) is a focal dilation of the fetal umbilical vein. Clinical significance is not clearly established but it has been associated with adverse outcomes. This study investigates the clinical outcomes of UVV diagnosed during pregnancy.

METHODS:
We performed a multicenter retrospective (USA, Chile, Italy and Brazil) study by reviewing 19 fetuses diagnosed with UVV between 2012 and 2017. We investigated gestational age at diagnosis and at delivery, UVV maximum diameter, fetal gender, associated anatomical anomalies, intrauterine growth restriction, fetal demise, type of delivery, birth weight, Apgar scores.

RESULTS:
UVV was diagnosed at 26.4+/- 4.4 weeks of gestation. Maximum diameter of the defect at diagnosis typically was 13.1+/- 5mm. The majority of fetuses were male (n=12, 63%). Growth restriction was diagnosed in 26% (n=5) of the fetuses. Seventeen (89%) infants survived. Fetal demise occurred in 2 (11%) patients; one was associated with structural anomalies, and the other fetus did not have any other associated anomaly. Vaginal delivery was performed in 10 (53%) patients; median weight at birth was 2870 g (270-4960 g). Median Apgar scores were 8 and 9 on 1st and 5th minutes consecutively (ranging from 0 to 10). Genetic and anatomical anomalies were present in 21% (n=4) of the fetuses and included: karyotype 47,XY+13, cleft lip and palate, cerebellar hypoplasia, aortic hypoplasia, cardiomegaly, Blake's pouch cyst, ambiguous genitalia, campomelic dysplasia with SOX9 mutation.

CONCLUSION:
UVV is a rare congenital condition that is usually associated with low frequency of other structural/genetic anomalies and with good prognosis.

ACKNOWLEDGEMENTS:
Waldo Sepulveda, Edward Araujo Junior, Mari Charisse Trinidad, and Heron Werner
Maternal Assessment With Sonography for Hemorrhage (MASH): A Prospective Cohort Study [33P]
Authors: Spiegel Tirtza , Yukhayev Anar , Fleischer Adiel , Meirowitz Natalie 
Published: April 2018

INTRODUCTION:
Intra-abdominal hemorrhage must be diagnosed and managed expeditiously in women with hemodynamic instability after Cesarean delivery. Our objective was to determine the amount of free intra-abdominal fluid normally present on ultrasound after Cesarean delivery, and whether intra-operative blood loss influences this measurement.

METHODS:
Transabdominal ultrasound examinations were performed in the supine position 1 to 3 hours after Cesarean delivery. Free intra-abdominal fluid was measured using a 5-1 MHz phased array transducer. Vertical fluid pockets were combined for each subject using a 4-quadrant technique. Cases with intraoperative irrigation were excluded. Demographic and delivery data, including intra-operative blood loss, were collected and analyzed.

RESULTS:
None of the 85 participants had intra-abdominal bleeding within 12 hours after Cesarean delivery. One woman had an intra-abdominal hematoma and hemodynamic instability one day after delivery. Nineteen women (22.4%) had free fluid on ultrasound, with a median combined fluid pocket of 1.4 cm (range between 0.5 and 3.4 cm). Twenty women (23.5%) had intra-operative blood loss more than 1,000 ml. Intra-operative blood loss did not differ between women with and without free fluid on ultrasound (968 ml vs. 900 ml).

CONCLUSION:
Sonographic assessment for free fluid may be useful after cesarean delivery when intra-abdominal bleeding is suspected. Although a small amount of free fluid may be visualized in a minority of patients, a combined fluid pocket of more than 3 cm is uncommon, and requires further evaluation. This ongoing study will assess the inter-observer variability, and the diagnostic accuracy of this sonographic technique.