bluuebunny/crossref_metadata_2025_split huggingface dataset:
Von Willebrand's Disease and Pregnancy: A Single Center Experience [10K]
Authors: Beck Stacy M. , Samuels Philip , Huang Ying , Kraut Eric , Wang Tzu-Fei 
Published: May 2017

INTRODUCTION:
Von Willebrand's disease (VWD) is a common inherited bleeding disorder. Studies show increased risk of postpartum hemorrhage (PPH) in women with VWD. Guidelines recommend pre-delivery treatment when third trimester Von Willebrand factor (VWF) antigen (Ag) or activity levels are less than 50%, but practice remains variable regarding treatment threshold. Our aim was to evaluate peripartum management and outcomes of VWD patients including primary PPH and association between third trimester VWF levels and estimated blood loss (EBL) at delivery.

METHODS:
We performed a retrospective review to assess the management and pregnancy outcomes of women with VWD who gave birth at the Ohio State Wexner Medical Center between January 1, 2006 and April 30, 2016. We included singleton pregnancies with documented VWD and recorded third trimester VWF levels. We excluded women with an unclear diagnosis, lack of third trimester VWF levels, and women with other diagnoses or use of medications that increase risk of bleeding.

RESULTS:
There were 24 pregnancies from 20 women with median third trimester VWF Ag of 118. Seven of 20 patients with median VWF Ag of 54 received pre-delivery treatment, and their EBL was not significantly different from those who received no pre-delivery treatment (p=0.1). In our cohort, there were no primary PPH. There was no correlation between any third trimester levels and EBL, regardless of mode of delivery (p= 0.53, 0.63, 0.74 respectively).

CONCLUSION:
Our limited cohort showed good outcomes. Optimal peripartum management VWD remains unclear. Prospective studies of VWD in pregnancy are needed to elucidate optimal therapy.
Vasa Previa: Maternal and Early Neonatal Outcomes in the New Era of Obstetrical Care [13K]
Authors: Dunn Timothy , Nassr Ahmed A. , Moaddab Amirhossein , Eppes Catherine , Shamshirsaz Alireza A. 
Published: May 2017

INTRODUCTION:
Report on one institution's experience with diagnosis, management, and outcomes in vasa previa cases.

METHODS:
Retrospective study of all pregnancies referred to two tertiary hospitals from 2010 to 2016 for suspicion or high risk for vasa previa. Medical records and imaging were reviewed by multiple authors to confirm diagnosis and assess outcomes.

RESULTS:
408 pregnant women were referred for evaluation of suspected vasa previa. 380 (93%) were not diagnosed with vasa previa after ultrasonography. Of the 28 confirmed cases, 20 (71%) and 8 (29%) were diagnosed as Type 1 and Type 2 vasa previa respectively. In 9 (32%) women, vasa previa resolved spontaneously after a mean 5.8 plus or minus 3.9 weeks. Unresolved cases were diagnosed on average at 25.9 plus or minus 5.2 weeks. Delivery occurred at 33.4 plus or minus 2.9 weeks on average. 13 (68%) neonates from unresolved vasa previa cases required NICU admission. Neonates had an average 5 minute Apgar score of 9. Only 1 fetus expired, but death was attributable to complications from a pericardial teratoma prior to delivery. One Type 2 case received antepartum laser obliteration of fetal vessels that successfully prolonged pregnancy. Average maternal blood loss was 860 plus or minus 56 cc with no ICU admissions or maternal deaths.

CONCLUSION:
In this large series, we display the continued improved maternal and neonatal outcomes in vasa previa. In equipped centers, physicians are able to successfully manage and deliver fetuses with careful antepartum attention. Furthermore, one case's treatment with laser ablation suggests a possible intervention in some presentations.
A Different Model of Care: High-Risk Obstetrical Services in a Rural Midwestern State [14K]
Authors: Jacobson Lisette , Farley Darren , Peterson Casey , Lu Kelsey , Collins Tracie 
Published: May 2017

INTRODUCTION:
Rural obstetrical patients are more likely to experience adverse pregnancy and birth outcomes compared to their urban counterparts. Serving an underserved population in a Midwestern state, a rural hospital with 300 deliveries per year experienced a high rate of pregnancies complicated by gestational diabetes. The purpose of this study was to assess women's perceptions of obstetrical services in this area.

METHODS:
Through collaboration of the hospital, medical school, and a regional healthcare system, a rural maternal-fetal medicine (MFM) clinic was established. Once a month, a MFM physician and his staff travel by plane to see high-risk pregnant patients. Self-reported surveys were administered to these patients. Questions focused on quality of care, communication, patient adherence, support services, barriers to care, health status, and demographic characteristics. Data were collected between January and April, 2016. Descriptive analyses were conducted.

RESULTS:
Of the 31 distributed surveys, 26 pregnant women completed the survey. The majority of respondents were non-Hispanic white (44%) or Hispanic (40%), a high school graduate (31%), WIC enrolled (58%), and earned less than $25,000/year (54%). Women's average age was 29 with an average body mass index of 29.7 three months prior to pregnancy. Overall, women reported being satisfied with the quality of care, identified un/underinsurance as barriers to care, and expressed a need for additional support services.

CONCLUSION:
This study is a first step toward enhancing the quality of care provided to underserved, rural women with high-risk pregnancies. Follow-up studies are needed to improve the delivery of specialized rural healthcare services.
Does Obesity Increase the Complication Rate During Trial of Labor After Cesarean? [15K]
Authors: Mei Jenny Y. , Havard Alexandra , Mularz Amanda , Maykin Melanie , Valderramos Stephanie 
Published: May 2017

INTRODUCTION:
Obesity has been shown to adversely affect success rates of trial and labor after cesarean (TOLAC), and has been associated with prolonged labor, increased cesarean rates, infection, and hemorrhage. We aimed to investigate the effect of obesity on risk of complications during TOLAC.

METHODS:
This is a retrospective cohort study of women electing for a TOLAC at a single institution from May 2007 to April 2016. Exclusion criteria included age < 18 years, fetal demise, lethal fetal anomalies, or incomplete medical records. Clinical data collected included maternal demographics and comorbidities, obstetric history, obstetric and perinatal outcomes, and BMI pre-pregnancy and at the time of delivery. Chi squared analysis was performed.

RESULTS:
614 patients met inclusion criteria. The overall TOLAC success rate was 72.31% (n=444) and average BMI at delivery was 30.7. Among women who were either obese prior to pregnancy (n=138), became obese during pregnancy (n=172), or were obese at time of delivery (n=311), there were no differences in augmentation rate, incidence of operative vaginal delivery, chorioamnionitis, postpartum hemorrhage, arrest of descent, or need for intrapartum magnesium. There was also no difference in composite maternal morbidity (P=.492). Moving up in obesity class during pregnancy was associated with an increased risk of augmentation of labor (47.8% no change vs 61.3% increase in class, P=.024).

CONCLUSION:
In contrast with prior studies, we found no adverse effects of obesity on maternal morbidity of TOLAC. An increase in weight class during pregnancy was associated with increased rate of augmentation.
Variation in Medicaid Managed Care Coverage Policies for Progesterone to Prevent Preterm Birth [18K]
Authors: Batra Priya , Hernandez Gray Ashley A. , Moore Jennifer E. 
Published: May 2017

INTRODUCTION:
Preterm birth (PTB) is the leading cause of U.S. infant morbidity and mortality; Medicaid enrollees disproportionately experience preterm deliveries. Data suggest that progesterone – an evidence-based therapy for preventing PTB – is not provided to all eligible Medicaid beneficiaries. This study aimed to identify variation in progesterone coverage guidelines among state Medicaid Managed Care Organizations (MCOs).

METHODS:
Using a cross-sectional design, participation in a national web-based survey was offered to executives at 20 Medicaid MCOs between November 11, 2015 and January 15, 2016. The survey inquired about coverage guidelines for progesterone and associated interventions to prevent PTB. MCOs identified key barriers in providing progesterone. Descriptive analyses were performed.

RESULTS:
Analyses included data from 18 plans providing coverage in 31 of the 39 states with Medicaid MCOs (response rate 90%). Responding MCOs were diverse: 55.6% were multistate, 33.3% were nonprofit, and 31.2% covered more than 1,000,000 lives. Most respondents (87.5%) covered branded progesterone, and 81.3% covered the compounded progesterone (C17P). Prior authorization was not universal for branded progesterone (86.7%) or C17P (75.0%). MCO gestational age restrictions for initiating progesterone varied from 22 to 37 weeks of gestation, even within the same state. Barriers to providing progesterone included: cost, lack of provider knowledge of indications and coverage, and variation in billing procedures.

CONCLUSION:
Significant variation in Medicaid MCO policies regarding progesterone exists both between and within states. This non-standardized approach may be a significant barrier to accessing this evidence-based intervention to prevent PTB.
Factors Affecting Obstetric Patient Participation in Research [26K]
Authors: Monson Martha , Einerson Brett D. , Esplin Sean , Varner Michael 
Published: May 2017

INTRODUCTION:
To assess factors that may contribute to obstetric patients' willingness to participate in clinical research.

METHODS:
Pilot study survey of obstetric patients greater than 17 years of age at a University and community tertiary care institution in the same community. A convenience sample of patients completed a Likert Scale survey about factors that may impact their willingness to participate in research. Survey questions were divided into 3 overarching categories (caregiver influence, altruism and convenience/personal-benefit). We report descriptive statistics and compared demographic characteristics in the groups willing to participate in research.

RESULTS:
171 consecutive patients agreed to the survey out of 177 patients approached. Patients report being positively influenced toward participation in research when considering provider enthusiasm for research as well as convenience/personal-benefit factors. College educated patients are more likely than non-college educated patients to respond positively to all question categories (P < .05). Married patients were more likely react positively to altruism and convenience/personal benefit factors (P < .05). Patients greater than 30 years old were more likely to cite convenience/personal benefit factors for influencing research participation (P < .05). Additionally, patients who have previously participated in research or who attend University-based practice are more likely to respond positively to questions appealing to altruism (P < .05).

CONCLUSION:
Caregiver influence, altruism, and convenience/perceived personal-benefit factors all impact obstetric patients' decision to participate in research. Demographics appear to influence a patient's response to matters of altruism and convenience. Clinical study recruitment efforts should focus on these factors to expand enrollment.
Does Antenatal Surveillance Improve Neonatal Outcomes in Women With Morbid Obesity? [34K]
Authors: Bedell James , Hosey Kathryn , Malhotra Tani , Van Wyck Laura , Hole James 
Published: May 2017

INTRODUCTION:
Obesity has reached epidemic status and its effects on women of reproductive age and pregnancy cannot be overlooked. It is our hypothesis that antenatal surveillance beginning at 36 weeks' has made an effect of adverse pregnancy outcome in our practice since its implementation.

METHODS:
This is a retrospective cohort study where we compared women who presented for care prior to October 20, 2013, when antenatal surveillance was enacted at our institution, and those who underwent such surveillance. In total, 229 women met criteria for entry into the study, 120 patients in the study group and 107 patients in the control group.

RESULTS:
There were no observed demographic differences between the study and control groups. There were no differences in outcomes in either groups. Although cesarean sections occurred in 55.14% of the control group, while only comprising 44.17% of the study group, they were not statistically significant [P=.099; OR 0.6 (95% CI 0.38 – 1.09)]. Similarly, there were no differences in neonatal outcome in either group. NICU admissions were 5.61% of the control group and 8.3% of the study group, and were not statistically significant [P=0.423; OR 0.7 (95% CI 0.23 – 1.86)].

CONCLUSION:
Obesity will likely remain a major health concern for the world's population for the foreseeable future. Although our study did not find any statistically significant differences, further research is needed to determine if surveillance can lower the rate of stillbirths in this population, and, possibly, lead to statistically significant decrease in cesarean section rates.
Does a Strict Requirement of Quintero Stage Greater Than Two Matter When Performing Laser Therapy for TTTS? [35K]
Authors: Kennedy Devin , Sutton Whitney , Pandey Vishal , Lee Gene 
Published: May 2017

INTRODUCTION:
We sought to see if perinatal mortality in Twin Twin Transfusion Syndrome (TTTS) differs if strict adherence to the Quintero stage greater than two is used as a uniform criteria to perform laser ablation.

METHODS:
A retrospective chart review from 2009-2015 was performed at our institution. All twin gestations with diagnosed TTTS were reviewed. Patients with fetal anomalies or lack of follow up after diagnosis were excluded. Ultrasound parameters, clinical data, and neonatal outcomes were abstracted from each patient's medical record. Strict Quintero staging and survival was determined. Outcomes were then compared to the reference group with Chi-square good of fit tests.

RESULTS:
After exclusions there were 26 patients identified with TTTS who underwent laser ablation. 19 of those patients were Quintero stage greater than two. The remaining gestations did not fit into a strict stage criteria. Among the seven remaining gestations, there was a notable absence of single twin survival and also higher dual twin death. This trend was statistically significant. However, the inclusion of these surgical cases did not alter the overall perinatal mortality when compared to a theoretical rate derived from our 19 member reference group.

CONCLUSION:
A strict indication of Quintero stage greater than two for laser ablation in TTTS would not have produced improved perinatal survival. There is a trend for increased dual twin death in TTTS cases which are not clearly stage greater than two. Further study for criteria for laser photocoagulation in TTTS is warranted when a larger pool of data is available.
Fetal Anomalies and Labor Complications [36K]
Authors: McCormick Anna , Simpson Pippa , Pan Amy , McIntosh Jennifer , Hibbard Judith 
Published: May 2017

INTRODUCTION:
The purpose of this study was to evaluate labor complications and obstetric outcomes in patients diagnosed with fetal anomalies.

METHODS:
Using the Safe Labor Consortium, a retrospective dataset including labor information from 19 United States hospitals collected from 2002-2008, we compared patients diagnosed with a viable infant with a fetal anomaly to low risk singleton pregnancies. The primary outcome was need for operative vaginal delivery or cesarean delivery. Secondary outcomes include: maternal outcomes–bleeding (administration of blood products, abruption, postpartum hemorrhage, uterine rupture, hysterectomy), malpresentation, maternal ICU admission or death, chorioamnionitis/endometritis, lacerations (third- or fourth-degree), shoulder dystocia and birth injury. Chi-Square or Fisher's exact test was used to examine the association between anomaly and secondary outcomes. Odds ratios and confidence intervals were calculated.

RESULTS:
We evaluated 5360 patients with a fetal anomalies and compared them to 93,129 patients with low risk singleton pregnancies. There was no significant difference in need for operative vaginal delivery between groups (OR 0.98 95% CI 0.88, 1.10). There was a significant increase risk of cesarean delivery in the patients with anomalies (OR 1.5 95% CI 1.39, 1.62), as well as incidence of malpresentation (OR 1.27 CI 1.11,1.45) and breech presentation (OR 1.7 CI 1.41, 2.18), intrapartum fetal distress (OR 1.30 CI 1.15, 1.48) and birth injury (OR 1.88 CI 1.53, 2.30).

CONCLUSION:
Patients diagnosed with a fetal anomaly are at increased risk of cesarean delivery, malpresentation and birth injury. These increased risks should be taken into consideration in management of these patients.
Iron Deficiency Anemia in Pregnancy and Treatment Options: A Patient-Preference Study [1L]
Authors: Nguyen Vanessa , Wuebbolt Danielle , Thomas Hannah , Murphy Kellie , D'Souza Rohan 
Published: May 2017

INTRODUCTION:
As many as 17% of Canadian women suffer from iron deficiency anemia (IDA) in pregnancy. Treatment options include oral ferrous salts, haem iron, intravenous (IV) iron and blood transfusions. Trade-offs pregnant women are willing to make to alleviate symptoms of IDA have not been determined. This study elicits preferences of pregnant women for health-states arising from IDA and the use of various treatment options.

METHODS:
A cross-sectional study was conducted on pregnant women with and without IDA. Participants were presented with five vignettes representing maternal health-states arising from IDA in pregnancy. They were asked to rank these states and assign them values on a visual analogue scale, by the standard gamble, and by time trade-off methods. Utility values (preferences) of women with and without IDA, obtained from these methods were presented on a scale of 0-100 where 0 represented death and 100 represented perfect health.

RESULTS:
60 pregnant women (30 with IDA and 30 without) completed the interviews. With all three methods, utility values were lowest for blood transfusion and highest for oral iron. Regardless of the evaluation method, there was no difference in utility values for treatment with oral ferrous salts vs. haem iron or between women with or without IDA.

CONCLUSION:
Women acknowledge that symptoms of IDA in pregnancy reduce quality of life. Despite side effects and frequency of administration, oral iron is preferred over IV iron and blood transfusion. Confirmation of these findings in larger studies would directly inform clinical practice and research.
Low Back Pain in Pregnancy–Investigations, Management, and the Role of Neuraxial Analgesia: A Narrative Review [2L]
Authors: Sehmbi Herman , D'Souza Rohan , Murphy Kellie , Bhatia Anuj 
Published: May 2017

INTRODUCTION:
Low back pain (LBP) is common in pregnancy affecting approximately 50% of pregnant women. Yet, there is much ambiguity with regard to the diagnostic work-up and management of pregnant women with LBP. This narrative review summarizes evidence surrounding investigations, management strategies and the considerations around performing neuraxial blocks for pregnant women with LBP to inform clinical practice.

METHODS:
MEDLINE, MEDLINE In-Process and Embase were searched from inception to November 2015. The search was limited to humans and restricted to the English language. All studies from case reports to randomized controlled trials describing diagnostic modalities, management strategies and use of neuraxial techniques during labor and delivery in pregnant women with LBP were identified.

RESULTS:
A total of 6803 records were identified through database-searching and 60 through citation-tracking, of which 77 studies were included. Of these, 32 described the use of diagnostic modalities, 56 described management strategies, and three reported the use of neuraxial techniques for labor and delivery. Magnetic resonance imaging is the safest diagnostic modality for LBP in pregnancy. Antenatal educational programs, exercise and steroid injections into the epidural space or sacroiliac joints may help with pain management. Worsening neurological deficits, vertebral fractures, and tumors may need surgical management. There is limited evidence on challenges of performing neuraxial blocks in the peripartum period but there is a potential for increased risk of neurological complications in parturients with pre-existing neurological deficits.

CONCLUSION:
This review summarizes the available evidence and provides a clinical algorithm for the diagnosis and management of pregnant women with LBP.
Management of Severe Range Blood Pressures During Obstetrical Care: A Quality Improvement Project [3L]
Authors: Piazza Adriana , Sienas Laura , Wolfe Kristen , Stricklin Melaney , Creinin Mitchell 
Published: May 2017

INTRODUCTION:
Hypertensive disorders of pregnancy are a leading cause of maternal and neonatal morbidity and mortality. Timeliness of treatment improves maternal and neonatal outcomes. This study assesses the impact of implementing a program for severe range blood pressure (SRBP) management during inpatient obstetrical care.

METHODS:
We prospectively collected data from a single academic center during 2015-2016 comparing outcomes before and after a system change. The changes included 1) an algorithm to improve blood pressure (BP) recheck times (for validating SRBP) and time to intravenous medication when indicated; 2) improved medication access making all medications equally available; and 3) multidisciplinary training including simulation sessions. All patients with ICD-10 codes of pregnancy-related hypertensive disorders who had SRBP were evaluated over a three-month period before and after program implementation. SRBP treatment included intravenous labetalol or hydralazine or oral nifedipine. Primary endpoints compared time to BP recheck, time to medication when indicated and type of medication.

RESULTS:
More women had a BP recheck within one hour post-implementation (330/344, 95.9%) vs. pre-implementation (390/425, 91.7%) (P=.0025). A similar improvement occurred when evaluating BP recheck within 10 minutes (60.5% vs. 40.0%, respectively, P=.0001). For the 113 post-implementation and 89 pre-implementation SRBP events requiring treatment, time to medication did not improve (median 13 and 14 minutes, respectively, P=.40). Use of labetalol vs. hydralazine post-implementation increased from 13.3% to 38.1% (P=.0001); nifedipine was rarely used (1 and 3 patients, respectively).

CONCLUSION:
Implementation of an algorithm to treat SRBP can improve BP recheck rates and impact choice of intravenous medications.