bluuebunny/crossref_metadata_2025_split huggingface dataset:
Hyperreactio Luteinalis: Possible Cause of Intrahepatic Cholestasis and Disseminated Intravascular Coagulation [22B]
Authors: Luellwitz Ryan , Hawkins Jennifer , Hamber Elizabeth 
Published: May 2017

INTRODUCTION:
Hyperreactio luteinalis (HL) is a rare finding in pregnancy consisting of enlarged multicystic ovaries capable of producing excess human chorionic gonadotropin (hCG) and androgens. We present a patient with HL and twin gestation complicated by intrahepatic cholestasis of pregnancy (ICP) who presented to our institution with disseminated intravascular coagulation (DIC).

METHODS:
Case Report.

RESULTS:
A 31-year-old gravida 1 para 0 at 35 weeks 5 days gestation with dichorionic/diamniotic twins, presented to our institution for evaluation due to elevated liver enzymes. On presentation, the patient was jaundiced but asymptomatic with normal vital signs. Fetal assessment revealed category three fetal heart tracing for both fetuses. The patient underwent emergent cesarean delivery. During surgery, bilateral enlarged multicystic ovaries were noted and lab values were consistent with disseminated intravascular coagulation. The patient was treated with fresh frozen plasma and cryoprecipitate then transferred to the intensive care unit. Postoperatively, the patient was noted to have elevated bile acids, bilirubin, androstenedione and aldosterone.

CONCLUSION:
Studies demonstrate that estrogens play a role in development of ICP and can impair bile acid secretion. HL produces high levels of androgens that are converted to estrogens by precursors from the fetal adrenal gland and placental aromatase. We propose estrogens produced by HL lead to the development of ICP. Excess estrogen production throughout pregnancy may lead to chronic bile acid accumulation and contribute to development of DIC.
Medical Students, Mid-Level Providers, and Physician Attitudes Towards Yoga Practice During Pregnancy [25B]
Authors: Bell Sarah , Kobernik Emily , Hammoud Maya 
Published: May 2017

INTRODUCTION:
Yoga is a widely practiced form of exercise in the United States. We examined the attitudes of medical students, mid-level providers, and physicians regarding the role of yoga in obstetric patient care.

METHODS:
A 21-question survey was distributed from June 2016 to July 2016 to all second, third, and fourth year medical students, mid-level providers, (nurse practitioners, physician assistants, midwives), and Obstetrics and Gynecology and Family Medicine physicians at the University of Michigan. Bivariate analyses comparing participants who indicated they would recommend yoga to obstetric patients and those who did not was performed.

RESULTS:
The response rate among physicians/mid-level providers was 39% (114/294) and 33% (190/581) among medical students. Among 299 surveys eligible for analysis, 75.9% had ever practiced yoga, and 40.3% were current practitioners of yoga. Nearly two-thirds (61.4%) of participants indicated they would recommend yoga to their obstetric patients. Recommending yoga to obstetric patients was significantly associated with agreeing yoga is “a good form of exercise” (82.6% versus 42.6%, p < .0001), “safe” (89.1% versus 48.9%, p < .0001), recommending it to non-pregnant patients (82.6% versus 27.7%, p < .0001), and gender (58.4% males versus 74.9% females, p < 0.003). Among males, lifting weights was negatively associated with recommending yoga (37.0% versus 61.7%, p=0.02), and among females, running was negatively associated with recommending yoga (56.2% versus 77.3%, p=0.004).

CONCLUSION:
The majority of medical students, mid-level providers, and physicians would recommend yoga to their obstetric patients. Further research is needed to identify the specific predictors of recommending yoga to obstetrics patients.
Current Status of State-Level Maternal Mortality Review Legislation in the United States [26B]
Authors: Adesomo Adebayo , McDonald Amanda , Oben Ayamo G. , Rodriguez Emma , Ireland Kayla , Ramsey Patrick S. 
Published: May 2017

INTRODUCTION:
Over the past 20 years the United States’ the maternal mortality rate has doubled. Significant racial disparities and discrepancies in reporting highlight the need for standardized case definition, uniform reporting, and comprehensive review of maternal mortality cases. Our objective was to assess the presence of state-specific legislation requiring maternal mortality reporting and review in the United States.

METHODS:
We surveyed all 50 states for existing laws, or pending legislation, requiring maternal mortality reporting by searching state government and other legislative websites for keywords and phrases “maternal mortality, maternal death, pregnancy-related death.” Additionally, state health department officials were contacted directly to confirm the presence or absence of pertinent legislation.

RESULTS:
Twenty-four of the 50 states (48%) currently have active or pending legislation regarding maternal mortality reporting. Twenty-nine of the 50 states (58%) have committees specifically designated to review maternal mortality. In states with legislation compared to states without legislation or committees there were no statistically significant differences in maternal mortality ratio (18.4 vs. 22.2), minority birth rate/1000 births (3.0 vs. 2.7) or overall birth rate/1000 births (12.3 vs. 12.1). 53% of states with a maternal mortality ratio greater than 25/100,000 have active or pending legislation.

CONCLUSION:
Less than half of states have active legislation requiring maternal mortality review. Review of maternal mortality cases in the United States needs to be standardized and universal to further elucidate the causes of the rising maternal mortality rate in the United States.
Use of Delayed Cord Clamping in Preterm Dichorionic Twin Gestations [27B]
Authors: Liu Lilly , Grobman William , Yee Lynn 
Published: May 2017

INTRODUCTION:
Delayed cord clamping (DCC) for premature neonates has become standard of care in singleton gestations, but the outcomes after DCC in twin gestations are unclear. The aim of this study was to examine feasibility and outcomes associated with DCC in twins.

METHODS:
This is a retrospective cohort study of women delivering dichorionic-diamniotic twin gestations between 23-32 weeks gestation at a single center (2013-2015). In 6/2013, this institution introduced a DCC protocol for singleton neonates delivering < 32 weeks, with some dichorionic twins who also received DCC. Clinical characteristics and neonatal outcomes of twins receiving DCC were compared to those who did not. Bivariable assessments and fixed effects multivariable logistic and linear regression were utilized.

RESULTS:
Of 58 women delivering dichorionic twins < 32 weeks, 8 (13.8%) had both neonates receive DCC, resulting in 16 neonates who received DCC. DCC occurred both among those who were delivered vaginally (n=7), and by cesarean section (n=9). Neonates who received DCC, compared to those who did not, had similar umbilical artery pH, initial temperature, 5-minute Apgar score, and peak bilirubin. Additionally, there were no differences in neonatal intensive care unit length of stay, birth hematocrit, total number of blood transfusions or transfusions received in the first week, mechanical ventilation, need for pressors, death, or other adverse outcomes.

CONCLUSION:
Performance of DCC in dichorionic twin gestations born < 32 weeks is feasible and not associated with worse neonatal outcomes in this small cohort. Further investigation of expansion of DCC protocols to dichorionic twin gestations appears worthy of exploration.
Current Practice and Knowledge of Aneuploidy Screening, a Nationwide Survey [28B]
Authors: Hunter-Greaves Tiffany , Cunningham Orlando , Harriott John , Lewis Gregory , Rattray Carole 
Published: May 2017

INTRODUCTION:
Aneuploidy screening is appropriate for all pregnant women as there is variable risk among all pregnancies. This study sought to determine the current approach and knowledge of aneuploidy screening among obstetricians and gynecologists in Jamaica.

METHODS:
A list of all practicing obstetricians and gynecologists was obtained from the medical council. A questionnaire was sent by mail or hand-delivered to all obstetricians and gynecologists across the country. The questions pertained to demographics, knowledge of screening and diagnostic tests available. Doctors with subspecialist training in maternal fetal medicine were excluded. The data obtained was kept anonymous.

RESULTS:
67 out of 100 (67%) doctors responded to the questionnaire. 63/67 (94.0%) reported that less than 25% of their patients had aneuploidy screening (95% confidence interval [CI], 88.3–99.7). 20.9% (95% CI, 11.2–30.6%) of respondents offered screening to all their patients while 35% offered to women 35 years or older. The frequency of screening tests was 37.3%, 16.4%, 11.9%, 6.0%, 6.0% and 3.0% for the QUAD screen, Triple screen, Second trimester ultrasound, First trimester screen, Free fetal DNA and Nuchal translucency respectively. Of the 6 knowledge questions asked, 4 questions had greater than 70% (95% CI, 59.0–81.0%) answered correctly.

CONCLUSION:
Obstetricians and gynecologists are aware of the risks of aneuploidy and screening tests available, however, only a small fraction of their patients received these tests. This suggests the need for further physician education on available tests, increased affordability of tests, patient education and studies on patient views on screening.
Does Timing of Administration of Vaginal Misoprostol for Cervical Ripening Affect Cesarean Delivery Rate? [32B]
Authors: Reisner Jenny , Pachtman Sarah , Rochelson Burt 
Published: May 2017

INTRODUCTION:
To determine whether the timing of initiation of vaginal misoprostol induction has an effect on delivery mode in nulliparous women.

METHODS:
Retrospective cohort study evaluated nulliparas with singleton gestations who underwent cervical ripening with vaginal misoprostol. Exclusion criteria included multiple gestation, previous delivery, age less than 18 years, Bishop score greater than 7, or induction prior to 39 weeks. Induction for rupture of membranes, chorioamnionitis, oligohydramnios, diabetes, preeclampsia, or growth restriction were excluded. The primary outcome was delivery mode. Chi-squared test was performed to determine if the time of start of induction is associated with cesarean in 6-hour intervals.

RESULTS:
226 subjects met inclusion criteria and 107 (47.3%) had a cesarean delivery. 106 patients (46.9%) were scheduled between 6:00pm and 11:59pm, and 48.1% delivered via cesarean. 80 patients (35%) were scheduled between 12:00am and 5:59am, and 52.5% delivered via cesarean. 40 patients (17.6%) were scheduled between 6:00am and 5:59pm, and 37.5% delivered via cesarean. Results of Chi-Square test failed to show an association between time interval induction and delivery mode among 226 subjects (p=0.23). Subgroup analysis was performed on patients with Bishop score less than or equal to 4, and 57.7% delivered via cesarean. Chi-Squared test also failed to show an association between start time and delivery mode.

CONCLUSION:
Timing of cervical ripening with vaginal misoprostol is not associated with delivery mode in uncomplicated, nulliparas after 39 weeks. Scheduling of inductions at the discretion of patient or provider, or based on availability of institutional resources does not increase risk of cesarean delivery.
Immediate Postpartum Urinary Retention: A Chart Review [34B]
Authors: Christie Alexandra C. , Urbina Josephine , Valthaty Rebekah 
Published: May 2017

INTRODUCTION:
Postpartum urinary retention is an unexpected common complication. In previous studies about a 1.7 -17 percent incidence of urinary retention was reported. We defined urinary retention as absence of spontaneous micturition within six hours of vaginal delivery or within six hours of removal of catheter after cesarean delivery. Our hypothesis is that operative deliveries increase the incidence of urinary retention in the immediate postpartum period.

METHODS:
A retrospective chart review was conducted over two years in a hospital setting with a suburban population . The data collected included the method of delivery, anesthesia received during delivery, complications following delivery or prior to delivery such as indications for a cesarean-section, Foley required after patient was discharged and parity of patient. Women with recent urinary tract infection, pyelonephritis during pregnancy, diabetes and neuropathy were excluded from the study.

RESULTS:
Based on our 2 year chart review we found 65 % of patients with retention had cesarean delivery and 15 % had operative vaginal deliveries , 62.5 percent were primiparous, 12 % had birth weight of >4000 grams, 68 percent received an epidural for anesthesia , 9.3 % required Foley postpartum.

CONCLUSION:
Postpartum urinary retention is a relatively common condition. Some of the risk factors identified in our study include cesarean delivery, operative births, primiparous women and birth weight of > 4000 grams, epidural analgesia. This is an ongoing study and further multicenter study is required to confirm these risk factors.
Vaginal Length After Laparoscopic Hysterectomy: Laparoscopic Versus Vaginal Closure. Randomized Trial Update [39B]
Authors: Nezhat Camran , Main Jillian , Falik Rebecca , Di Francesco Lucia , Farrimond Frances , Nezhat Azadeh 
Published: May 2017

INTRODUCTION:
The purpose of our study is to observe the change in vaginal length after total laparoscopic hysterectomy with laparoscopic cuff closure (LC) versus vaginal approach to cuff closure (VC).

METHODS:
This is an update on our prospective, randomized study of women undergoing total laparoscopic hysterectomy. Vaginal length was measured pre-operatively and at 6-12 weeks, 6 months and then 12 months postoperatively.

RESULTS:
A total of 76 patients were included in the study (37 women in the vaginal group, 39 women in the laparoscopic group). The median preoperative vaginal lengths were not statistically significant: VC 10.7cm vs LC 11.8 cm; (P=.31). The difference in median vaginal lengths at 6-12 weeks were: VC 9.8cm versus LC 9.7 cm (P=.92). The median vaginal lengths at 6 months were 10.5cm in the VC and 10.2cm in the LC (P=.63). The median vaginal lengths at 12 months were 11.0 cm in the VC and 11.2 cm in the LC (P=.65). The cuff closure time was significantly longer in the LC group (15.6 min versus 7.9 minutes in the VC, P < .05). There were zero cases of vaginal cuff dehiscence. 13.5% of women in the VC group developed granulation tissue vs 2.5 % in the LC group (P < .05).

CONCLUSION:
Vaginal length at 6 and 12 months did not differ based on method of vaginal closure. Laparoscopic closure times are longer than vaginal cuff closures and neither method had cases of vaginal cuff dehiscence. Vaginal closure is associated with an increased risk of developing granulation tissue.
Risk Factors for Obstetric Anal Sphincter Injury in a Diverse Population [1C]
Authors: Woo Victoria G. , Hung Yun-Yi , Ramm Olga 
Published: May 2017

INTRODUCTION:
We evaluated risk factors for obstetric anal sphincter injuries (OASIS) and determined the effect of duration of second stage of labor (DSS) on OASIS risk.

METHODS:
We included term, singleton, cephalic vaginal deliveries within Kaiser Permanente Northern California over two years. Bivariate analysis identified OASIS risk factors. Multiple logistic regression helped eliminate confounding. Classification and Regression Tree (CART) recursive partitioning created decision nodes based on risk factors. DSS was grouped into 15-minute intervals to examine effect magnitude.

RESULTS:
Of 22,741 deliveries included, 93.8% were spontaneous and 6.2% were vacuum-assisted. The OASIS rate was 4.9%. Multiple logistic regression identified Asian race (OR 2.4, CI 2.1-2.8), vacuum delivery (OR 4.6, CI 3.9-5.4), DSS greater than 75 minutes (OR 2.4, CI 2.1-2.8), VBAC (OR 2.8, CI 2.1-3.8), and nulliparity (OR 1.7, CI 1.4-2.1) as independent risk factors for OASIS. DSS ranged from 0-680 minutes. Median length was 95 minutes for nulliparous and 27 minutes for multiparous women. The first CART decision node was DSS greater than 75 minutes. Each additional 15 minutes of pushing resulted in 1.07 (p < 0.001) increase in the odds of OASIS in nulliparous women and 1.14 (p < 0.001) in multiparous women. CART analysis identified Asian women delivered via vacuum after a greater than 75 minute second stage as the subpopulation with highest risk of OASIS at 43%.

CONCLUSION:
Risk factors for highest rates of OASIS were identified. Each incremental increase in DSS confers an increase in OASIS risk. Changing management based on our findings could improve outcomes for laboring women.
Tdap in Pregnancy: A Quality Improvement Project [2C]
Authors: Holdt Somer Sarah J. , Bruder Karen , Louis Judette 
Published: May 2017

INTRODUCTION:
Current recommendations are for Tdap vaccination during each pregnancy to induce immunity in the neonate. Administration rates were low at a prenatal clinic in Tampa, Florida and so a quality improvement project was undertaken to improve coverage. We sought to evaluate the effectiveness of a protocol to improve the rates of prenatal Tdap vaccine administration.

METHODS:
This project was implemented at a single publicly funded obstetric clinic and its affiliated academic hospital. Women receiving care at the clinic are predominately underserved minorities and working poor. The clinic's providers include physicians, nurses, midwives, and nurse practitioners. The intervention had several components: In February 2016, clinic providers received education about current recommendations regarding Tdap vaccination in pregnancy. Posters were placed throughout the clinic to motivate the patients. Finally, the hospital's administration agreed to redirect money previously used for inpatient postpartum vaccinations to instead cover the cost of vaccination for uninsured patients during prenatal visits, when the vaccine is most effective. Vaccination rates were then compared between the four months before and after implementation.

RESULTS:
In the four months preceding the project, a total of 273 prenatal Tdap vaccines were given at the clinic; in the four months after, 380 were given. When divided by the total number of clinic patients delivered during these time frames, rates of vaccination improved from 40% to 63% (p < 0.001), respectively.

CONCLUSION:
Education, awareness, and financial assistance resulted in a significant increase in the Tdap vaccination rate at the clinic. Further Plan-Do-Study-Act cycles are planned to further improve vaccination rates.
Risk Factors for Postpartum Hemorrhage Following Nulliparous Induction of Labor [3C]
Authors: Ainsworth Alessandra J. , Holman Michelle A. , McGree Michaela , Weaver Amy , Torbenson Vanessa , Tolcher Mary Catherine 
Published: May 2017

INTRODUCTION:
Postpartum hemorrhage is the leading cause of maternal mortality worldwide. There are multiple known risk factors, including induction of labor.

METHODS:
A retrospective cohort study was completed with review of nulliparous women undergoing labor induction at term, from July 2006 to May 2011. Baseline maternal variables and risk factors for postpartum hemorrhage were assessed. All combinations of methods of induction were sequential rather than concurrent. The need for additional uterotonics (beyond routine oxytocin) was used as a surrogate for postpartum hemorrhage. Variables were evaluated for an association with additional uterotonic use based on fitting logistic regression models.

RESULTS:
A total of 785 women were included in the study. Additional uterotonics were required for 84/785 (11%) of women. Based on univariate analysis, only birth weight and presence of meconium were significantly (p < 0.05) associated with additional uterotonic use, while method of induction approached statistical significance (p=0.06). The mean (SD) birth weight was 3668 (584) vs. 3463 (500) grams in those with and without additional uterotonic use. Multivariate analysis showed an increased risk of additional uterotonics with higher birth weight (adjusted odds ratio (aOR) 1.44 per 500 gram increase in birth weight; 95% CI 1.15, 1.82) and use of Foley plus oxytocin (aOR 4.40; 95% CI 1.36, 14.23).

CONCLUSION:
In our model, higher birth weight and induction method of Foley followed by oxytocin were associated with increased need for additional uterotonics. This data adds detail to previous studies that have broadly identified induction of labor as a risk factor for postpartum hemorrhage.
Risk of Primary Cesarean Delivery in Women With Pregnancy-Associated Hypertension [7C]
Authors: Penfield Christina A. , Wing Deborah A. 
Published: May 2017

INTRODUCTION:
Despite the lack of evidence supporting cesarean delivery (CD) in the setting of pregnancy-associated hypertension (PAH), women with this diagnosis continue to have high CD rates. The aim of this study is to determine whether the higher rate of primary CD among women with PAH can be explained by the presence of other known CD risk factors.

METHODS:
A retrospective cohort study of singleton, vertex, nulliparous women delivering between 34 and 42 weeks using the 2013 US National Vital Statistics Report dataset. Rates of primary CD in women with and without PAH were compared. Multivariate logistic regression predicted CD after controlling for known risk factors, including advanced maternal age (AMA), race/ethnicity, gestational age, pre-pregnancy BMI, US residency, insurance type, prenatal care, diabetes, and eclampsia.

RESULTS:
We analyzed 1,103,999 women, including 94,332 women diagnosed with PAH. The unadjusted CD rate in women with PAH was 41.3% compared to 26.9% in those without PAH (p < 0.01). Each analyzed risk factor was significantly associated with CD (Table). However, even after controlling for these risk factors, the predicted probability of CD in a woman with PAH would be 37.2% vs 26.5% without PAH (p < 0.01). PAH remained an independent predictor for CD (aOR 1.68 [95% CI 1.65-1.71]).

CONCLUSION:
After controlling for other risk factors, diagnosis of PAH alone is a significant risk factor for CD, likely reflecting a widespread practice that is not supported by the most recent clinical evidence. Women with PAH may therefore represent an important target population for efforts that aim to reduce primary CD rates.
TAC It Up? The Impact of Taping the Abdomen at Cesarean on Wound Complications in the Morbidly Obese Patient [8C]
Authors: Fitzgerald Garrett , Crimmins Sarah , Bharadwaj Shobana , Malinow Andrew , Turan Ozhan 
Published: May 2017

INTRODUCTION:
Cesarean delivery (CD) in the extremely obese patient presents significant surgical and postsurgical challenges. Available data guiding proper surgical technique are limited. Our aim is to investigate the impact of taping the abdomen at cesarean (TAC), with respect to wound complication (WC). We hypothesize that TAC will not increase risk of WC.

METHODS:
Retrospective cohort study of singleton pregnancies with morbid obesity (BMI greater than 40 kg/m2) between 37 and 42 weeks gestation delivered via non-urgent CD. Maternal demographics, comorbidities, operative data, and postpartum follow up were reviewed. Skin incision was divided in to 3 main groups; vertical (VSI), transverse (TSI) and TSI with TAC. WC were defined as surgical site infections or wound separation. The relationship between skin incision type and WC was evaluated using descriptive statistics. Adjusted odds ratio was calculated for WC controlling for confounders, BMI and incision type.

RESULTS:
A total of 174 complete records were reviewed. Median BMI was 49.2 kg/m2, 48 (27.5%) patients had intrapartum CD and 43 (24.5%) were diabetic. Skin incision incidence: 38(21.8%) were VSI, 98(56.4%) were TSI and 38 (21.8%) were TSI-TAC. Postoperatively, WC were diagnosed in 25 (14.2%) patients. After controlling for incision type and BMI, VSI showed aOR of 2.2 [1.2-4.0,P=.01] for WC. The risk of WC was similar between TSI and TSI-TAC (P=.8).

CONCLUSION:
In a cohort known for high risk of WC, TSI demonstrates lower risk. TAC does NOT significantly alter WC risk when TSI is chosen.