bluuebunny/crossref_metadata_2025_split huggingface dataset:
Comparison of Characteristics and Outcomes of Morbidly Adherent Placenta in Twin Versus Singleton Pregnancies [24L]
Authors: Bateni Zhoobin , Erfani Hadi , Belfort Michael , Shamshirsaz Alireza A. 
Published: May 2017

INTRODUCTION:
To compare the characteristics and outcomes of patients with morbidly adherent placenta (MAP) in twin pregnancies versus singleton pregnancies.

METHODS:
All patients with pathology confirmed MAP (placenta accreta, increta or percreta) from January 2000 to June 2016, were included in this retrospective study. Data were reported using descriptive statistics and appropriate statistical methods were used based on the normality of the data.

RESULTS:
Total of 189 cases of pathologically confirmed MAP were identified over the study period, 13 of which were twin gestations. Median gestational age at delivery, gravidity and parity were lower in twin patients (P < 0.05). Regarding the severity of the adherence, 76.9% of the twins versus 51.5% of the singletons were placenta accreta and the remainder were either placenta increta or percreta (P = 0.04). Although not statistically significant, median blood loss during the surgery was 1000 cc higher in twin pregnancies which is clinically significant. Also the median hospital stay after surgery was 2 days longer in twin gestations (P = 0.03). Moreover, the rate of unsuspected subjects in twins was higher than the singletons; 69.2% versus 27.3% (P < 0.01).

CONCLUSION:
As the first report comparing MAP in twin versus singleton pregnancies, our study showed higher rate of MAP in Assisted Reproductive technology and lower rate of deep invasion (i.e. placenta increta or percreta) in twins, similar to findings by others in case reports resulting from IVF. Estimated blood loss was not significantly higher, however clinically may be important.
Longitudinal Patterns of Anti-Mullerian Hormone Across Normal Gestation [37L]
Authors: Roy Amrita , Whitcomb Brian , Healy Andrew 
Published: May 2017

INTRODUCTION:
Anti-Mullerian hormone (AMH) is a protein produced by granulosa cells of developing follicles and has demonstrated utility as an age-independent marker of ovarian reserve. Recent studies have suggested that AMH levels in pregnancy may serve as predictors of adverse pregnancy outcomes such as hypertensive disorders of pregnancy or preterm birth. These studies highlight the importance of characterizing AMH longitudinally throughout uncomplicated pregnancy. This study assessed the longitudinal pattern and associated variability of AMH throughout normal pregnancies.

METHODS:
We performed a prospective cohort study of 30 low risk pregnancies at our institution. Plasma levels of AMH were determined by sensitive ELISA in samples collected at five prenatal visits, at mean gestational ages of 11, 17, 25, 31 and 36 weeks. The longitudinal patterns of AMH were analyzed by repeated measures ANOVA using linear mixed models. Smoothed plots of AMH over gestation in PING were generated with cubic spline models using PROC LOESS. The interclass correlation coefficients (ICC) were estimated comparing variation among women (between subject) and during pregnancy (within subject).

RESULTS:
Mean AMH varied significantly by gestational age at sample collection, decreasing substantially in the first trimester and continuing throughout pregnancy. Though AMH varied substantially between women, variation over gestation was high and an ICC of 0.67 (95% confidence interval: 0.52, 0.79) observed.

CONCLUSION:
This pilot study demonstrates new information to establish normal AMH levels in uncomplicated pregnancies. Further studies are needed to assess the significance of longitudinal patterns of AMH in pregnancies complicated by adverse pregnancy outcomes compared to levels in uncomplicated pregnancies.
Then and Now: Experts Insights on Understanding the Women's Health Initiative Hormone Therapy Trials [4M]
Authors: Pinkerton JoAnn V. , Kaunitz Andrew , Lalonde Andre 
Published: May 2017

INTRODUCTION:
More than a decade following publication of the Women's Health Initiative (WHI) clinical trials for hormone therapy (HT), perception in the medical community remains that HT is unsafe for postmenopausal women. The evidence suggests otherwise for the majority of symptomatic menopausal women under 60 years and within 10 years of menopause.

METHODS:
A 30-minute expert interview CME program discussed the accurate interpretation of data from the WHI trials. Correct answers were compared between immediate pre- and post-tests, including case-based scenarios.

RESULTS:
15,236 participants have engaged with the program to date (July 1–August 31, 2016) with 355 completions. Participants included physicians, 50%, and nurses, 21%, with 31% in women's health, 30% in primary care and the rest distributed among other specialties. Correct responses improved from pre- to post-test for all questions, including outcomes from the WHI trials (22%-52% to 49%-88%), attributes of new menopausal medications (43% to 67%) and appropriate application of clinical guidelines (64% to 90%). For most case-based questions, responses improved from 58%-83% in the pre-test to 78%-96% in the post-test, with one question in older postmenopausal women (aged 62) only improving from 42% to 48%.

CONCLUSION:
Results demonstrate the negative impact of inappropriate data interpretation, its effect on clinical care and guideline application. Continued uncertainty remains regarding HT risks, interpretation of follow-up studies, and the benefits/risks of newer medications. Future educational efforts must reinforce the need to treat symptomatic menopausal women according to the best available evidence, and how benefits exceed risks for many women with existing/new HT medications.
Universal Chlamydia Screening for Women With Threatened Preterm Labor: A Cost-Effectiveness Analysis [14M]
Authors: Gimovsky Alexis , Berghella Vincenzo , Werner Erika 
Published: May 2017

INTRODUCTION:
To estimate the cost and effect of universal chlamydia (CT) screening compared to no CT screening for women presenting with threatened preterm labor in the United States.

METHODS:
We created a decision model comparing universal screening for CT versus no CT screening for women presenting with threatened preterm labor. Assumed probabilities included incidence of CT in women with preterm labor of 12% and a conditional probability of congenital CT of 60%. Primary outcome was the cost to prevent one case of neonatal chlamydia. A strategy was considered cost-effective if cost was < $100,000 to prevent one case of congenital chlamydia. One way sensitivity analyses and Monte-Carlo simulations assessed the robustness of the model.

RESULTS:
Screening for CT at the time of threatened preterm labor was cost saving, saving $17,202,570 and preventing 6,624 cases of neonatal chlamydia and 1,268 cases of preterm birth/100,000 women screened. One way sensitivity analysis revealed that the model was sensitive to incidence of maternal CT and cost of CT screening and treatment. CT screening remained cost saving when the incidence of maternal CT was >1%. Monte Carlo analyses revealed that screening was cost-saving in 87.3% of simulations, cost effective, but not cost-saving in an additional 3.5% of simulations, and not cost-effective 9.1% of the time.

CONCLUSION:
Screening for CT at time of presentation for threatened preterm labor in the United States is cost saving in the majority of conditions. Only in populations at extremely low risk for Chlamydia does it decrease health care costs to defer CT testing.
Zika Screening Beyond Brazil: Zika Madness and Cost of Reassurance? [15M]
Authors: Al-Ibraheemi Zainab , Ashmead Graham , Porat Natalie , Taylor Dyese , Sinha Anila 
Published: May 2017

INTRODUCTION:
Zika infection during pregnancy can cause severe birth defects. We investigated patients concerns evaluated for Zika exposure in a perinatal center.

METHODS:
Following outbreak of Zika, patients presented to our fetal evaluation unit were prompted to provide information regarding exposure to the Zika Feb-July 2016. Information recorded included: travel to Zika areas, symptoms, mosquito bites, tests, ultrasound findings, partner exposure and use of barrier protection. Zika related visits and results were reviewed.

RESULTS:
A total of 13,769 ultrasounds were performed. Seventy two patients expressed concern regarding Zika exposure. One third of patients came solely for Zika screening for a total of 77 visits. Fifty four percent reported a mosquito bite, 10 % had Zika related symptom. Two patients had a fetal head circumference (HC) < 3%: one had craniosynostosis on MRI and the other was normal at birth. Fifty two patients had lab testing were negative. Two thirds of the patients' partners reported travel history only 1 had Zika testing. Thirty eight percent patients reported sexual activity after suspected exposure to Zika only 10% used a barrier method.

CONCLUSION:
Patient concerns regarding Zika exposure declined precipitously after peaking early in 2016 likely due to avoiding travel to Zika affected areas. Less than 1% of visits were solely for Zika concerns, none of which had a positive sonographic evidence of infection. The minimal cost of Zika screening appeared to provide reassurance with negligible impact on the flow of care. As Zika spreads to Florida and other states, the clinical burden of screening may increase.
Compliance With Guidelines on Group B Streptococcal Sepsis Prophylaxis During Unscheduled Cesareans [22M]
Authors: Schwenk Evan E. , Campbell Blaine , Duong Jennifer , Harkins Kristin 
Published: May 2017

INTRODUCTION:
In 2013, compliance with the American College of Obstetrics and Gynecology (the College) guidelines for Group B streptococcus (GBS) prophylaxis was 69.6% at our institution. In non-compliant cases, 80% were due to lack of antibiotics. Afterward, improving GBS prophylaxis was emphasized during an Obstetrics and Gynecology Section meeting, but no formal education was provided. The objective of this project was to assess whether there has been an improvement in compliance with prophylaxis for GBS.

METHODS:
Retrospective review of GBS positive women confirmed at term gestation, who delivered via unscheduled cesarean from October 2014 to March 2015 was performed. Women were included if gestational age at delivery was 37-39 weeks, and spontaneous rupture of membranes or active labor was documented prior to delivery. Compliance was determined based on evidence of appropriate antibiotics for GBS according to the College guidelines.

RESULTS:
Of 43 patients reviewed, 31 met inclusion criteria. The majority of women 38 weeks gestation (45.2%, n=14). Rectovaginal swab confirmed GBS positive status in 24 (77.4%) cases. The majority of women delivered via primary cesarean (54.8%, n=17). Out of 31 cases, 26 (83.9%) were compliant with the College guidelines on GBS prophylaxis. Of the non-compliant cases, 4 of the 5 (80%) were due to no evidence of antibiotics being administered for GBS. There were 3 (9.7%) cases in which antibiotics were not given for surgical prophylaxis.

CONCLUSION:
Adherence to GBS prophylaxis guidelines improved since 2013, but failing to administer any antibiotics continues to be the primary reason for non-compliance.
Improving Physician Behavior With an Obstetric Dashboard [30M]
Authors: Xiong Katherine , Boehrer Robyn Horsager 
Published: May 2017

INTRODUCTION:
The American College of Obstetricians and Gynecologists no longer recommends routine use of episiotomy. However, high variation in provider practice continues to exist. The objective of this study was to determine if a physician dashboard reporting individual and group episiotomy rates could reduce usage to below the national benchmark of 5.5%.

METHODS:
Baseline data extracted from records of patients delivering between 1/1/2015 and 7/15/2015 were entered into a dashboard that listed all obstetricians at our hospital. Identities were blinded and physicians were provided individual and group rates. Data were then collected prospectively following dashboard implementation.

RESULTS:
The institutional baseline rate for episiotomy performance was 9.9%, with individual rates ranging from 0.0% to 55.6%. Following dashboard implementation, there was a significant reduction in the institutional rate (9.9% pre-intervention vs 2.7% post-intervention, P value less than .001). Our analysis also validated the increased risk of severe, third and fourth degree perineal lacerations with the performance of episiotomy [OR 4.1 (1.2, 14.0)]. Despite the reduction in episiotomy utilization, we were unable to demonstrate a reduction in the frequency of severe perineal lacerations (2.42% pre- vs 1.31% post-intervention, P value equal to 0.1), suggesting that multiple factors contribute to these events.

CONCLUSION:
When variation in physician performance exists, utilizing a physician dashboard comparing providers' behaviors can result in significant improvements in provider and institutional performance on specific metrics. We plan to evaluate whether this intervention can significantly reduce our rates of cesarean delivery in nulliparous, term, singleton, vertex gestations.
Perinatal Depression and Anxiety — Implementing Screening and Response Protocols [6N]
Authors: Keats John , Kendig Sue , Simas Tiffany Moore , Byatt Nancy , Hoffman Camille , Kay Lisa 
Published: May 2017

INTRODUCTION:
Perinatal mood and anxiety disorders are the most common pregnancy complications, and are associated with adverse maternal, infant and child outcomes. Recognizing this, the Council on Patient Safety in Women's Healthcare developed an evidence-based safety bundle to establish a standard of care for these disorders that is relevant to every woman in every clinical setting. Its objective was to outline how to implement current recommendations at the practice level.

METHODS:
To promote safety bundle dissemination, the American College of Obstetricians and Gynecologists invited 20 nationally representative obstetric and behavioral health providers to engage in a journey mapping process. The journey map followed the safety bundle format and addressed implementation steps needed to screen for and respond to perinatal mood and anxiety disorders. Opportunities to ease implementation were also assessed.

RESULTS:
The journey map focused on the process of addressing these disorders and identified multiple potential barriers. Each step of implementation must consider an ever changing obstetric practice environment, and the absence of related direct reimbursement. It is critical to focus on implementation until consensus is reached regarding outcomes measures to assess screening and treatment.

CONCLUSION:
As the implications of untreated perinatal mood and anxiety disorders are better understood, it is critical to develop and disseminate implementation processes to help obstetric practices screen for and address this issue. Implementation protocols need to be customized to each unique care setting. Further efforts are required to establish meaningful outcome measures.
Placenta Accreta: Descriptive Study of Risk Factors and Maternal Outcomes in a Tertiary Hospital in Puerto Rico [7N]
Authors: Gonzalez Cristina , Mendez Kemari , Rivera Nelly 
Published: May 2017

INTRODUCTION:
Cesarean section is one of the most important risk factors for abnormal placentation and in 2012 the CDC reported a C-section rate of 48.5% in Puerto Rico, one of the highest in the world. Placenta Accreta has been implicated to increase morbidity/mortality with detrimental outcomes to the patient as well as to the fetus. The objective of the current study is to describe the population and outcomes of Puerto Rican women diagnosed with abnormal placentation in a tertiary hospital.

METHODS:
We performed a retrospective descriptive study of medical records identified with a diagnosis of abnormal placentation from 2009-2015 from the University District Hospital in PR. Data regarding patient demographics, risk factors, maternal and fetal outcomes were obtained and recorded in an electronic database using EPI INFO.

RESULTS:
20 medical records were analyzed. Mean maternal age was 31 years, BMI:28 and mean gestational age at delivery was 28 weeks. All but one had previous cesarean sections. Mean neonatal weight was 2417 g. 11 patients had an EBL of more than 2 L and 10 received post op blood transfusions. 2 patients had to be admitted to the ICU, 1 received ACLS and died. 11 bladder injuries were reported. 17 cesarean hysterectomies performed to control hemorrhage.

CONCLUSION:
The most prevalent risk factor was previous cesarean sections. Increased blood loss, prematurity and bladder injuries were the most common complications. Our results demonstrate the importance of identifying risk factors and managing suspected cases in a setting where immediate access to blood transfusions and subspecialist are available.
Placental Pathology Findings Associated With Adverse Outcomes Among Women With Sickle Cell Hemoglobinopathies [8N]
Authors: Brown Jewel , Sinkey Rachel , Steffensen Thora , Louis-Jacques Adetola , Louis Judette 
Published: May 2017

INTRODUCTION:
The objective of this study is to investigate the relationship between placental pathology findings among women with sickle cell hemoglobinopathies (SCH) and adverse perinatal outcomes (APO).

METHODS:
This is a retrospective cohort study of non-anomalous, singleton infants born to mothers with laboratory confirmed SCH and placental pathology results. Medical charts were reviewed for maternal and neonatal outcomes as we sought to identify histologic findings associated with APOs. APOs included fetal death, small for gestational age neonates, umbilical cord pH < 7.2, 5 minute Apgar < 7, and neonatal death.

RESULTS:
One hundred thirty-five patients met inclusion criteria. Eighty-six percent had sickle cell trait, 12% had sickle cell disease, and 2% had hemoglobin SC disease. Twenty-seven pregnancies (20%) were complicated by APOs. There was no difference in presence of the following placental findings among the APO group as compared to the group without APOs: delayed villous maturation (p=0.59), perivillous fibrin deposition (p=0.58), placental infarction (p=0.62), chorioamnionitis (p=0.63), funisitis (p=0.24), villous congestion (p=0.39), and increased syncytial knots (p=0.10). When placental pathology findings among patients with sickle cell anemia were compared to patients with other types of SCH, there was a difference among groups with respect to increased syncytial knots (p < 0.01).

CONCLUSION:
There was no difference in placental pathology findings among patients with SCH with and without APOs. Severity of maternal disease was associated with a higher rate of increased syncytial knots; which are associated with reduced uteroplacental perfusion and may be induced by exposure of the placenta to hypoxia or oxidative stress as seen in SCH.
Predicting Term Induction to Delivery Intervals Utilizing Machine Learning [14N]
Authors: Clifford Corey , Namaky Devin , Holbert Michael 
Published: May 2017

INTRODUCTION:
Machine learning methodologies, such as artificial neural networks, are increasingly being used to improve clinical decision making. They can be used to discover complex relationships in clinical data. The goal of this study was to evaluate their ability to predict term induction to delivery intervals.

METHODS:
A retrospective cohort of 439 term inductions that resulted in an unassisted vaginal delivery was used to develop a predictive artificial neural network. This model utilized factors known at the time of induction, such as maternal demographics, pregnancy history, cervical examination, and current pregnancy complications. A separate cohort of 233 patients was then used to evaluate the efficiency of the model.

RESULTS:
On the cohort of 233 patients, the model exhibited a predictive odds ratio for delivery within 12 hours of 5.76 (95% CI 3.17-10.43, P < .001). Furthermore, it exhibited a sensitivity, specificity, positive predictive value, and negative predictive value of 78%, 62%, 80%, and 59% respectively. The five elements that contributed the greatest were Bishop score-position, maternal race, parity, presence of diabetes in the current pregnancy, and presence of hypertensive disease in the current pregnancy. Of the remaining factors; gestational age, cervical dilation, gravidity, and maternal BMI demonstrated moderate weighting. The remainder were less important.

CONCLUSION:
A machine learning approach is moderately successful in predicting induction to delivery intervals in term patients. This technique could be used to guide the timing of the initiation of induction in these patients to maximize staffing availability and improve outcomes.
Predictors of a Positive Illicit Drugs Screens for Pregnant Women in Colorado [15N]
Authors: Son Shannon L. , Heyborne Kent , Sheeder Jeanelle , Guiahi Maryam 
Published: May 2017

INTRODUCTION:
There are no clear guidelines to determine when illicit drug screening in pregnant women is warranted. We investigated which testing indications reliably predict a positive screen.

METHODS:
We performed a historical cohort study of all pregnant women who underwent drug screening on labor and delivery in 2014 at a safety-net hospital in Denver, Colorado. Testing was performed at provider discretion and with patient consent. Illicit drugs were included in the urine toxicology screen; tetrahydrocannabinol was not. Chart abstraction included testing indications, demographic, reproductive, social, and substance use characteristics. We performed descriptive frequencies and used Fisher's exact tests to compare testing results.

RESULTS:
In 2014, 166 urine toxicology tests were performed; 14 (8.4%) were positive. Women with positive tests were more likely to have had a prior STI (83.3% vs 39.7%, p>0.01), previous child protective services case (35.7% vs 8.6% p=0.009), child removed from custody (60.0% vs 7.3%, p < 0.001), prior drug use (92.9% vs 34.2%, p < 0.001) or treatment (64.3% vs 11.2%, p < 0.001), self-reported current drug use (71.4% vs. 27.6%, p < 0.01), current tobacco use (71.4% vs 19.7%, p < 0.001), less than 5 prenatal visits (58.3% vs 28.0%, p=0.05), or outborn delivery (28.6% vs. 0.7%, p < 001). No obstetrical indications were associated. A composite variable including history of child protective services case, child removed from custody, history of drug use or treatment, and/or self-reported drug use had a PPV=100% and NPV=65%.

CONCLUSION:
Using a composite variable based on historical factors to determine performance of drug screening may be a strong predictor of positive tests and reduce over-testing.