bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Cost-effectiveness of a Trial of Labor After Two Prior Cesareans: Impact on the Subsequent Pregnancy [29Q]
Authors: Sargent James , Worstell Teresa , Griffin Emily , Savitsky Leah , Caughey Aaron B. 
Published: May 2017

INTRODUCTION:
The benefits of a trial of labor (TOL) after a single cesarean are generally accepted; this is not true regarding a TOL following two cesareans. Since mode of delivery in the index pregnancy will affect the outcomes in the subsequent pregnancy, we designed a model to examine the cost-effectiveness of a TOL vs elective repeat cesarean (eRCD).

METHODS:
A decision-analytic model was built using TreeagePro and incorporated probabilities, costs, and utilities from the literature. This model was applied to a theoretical cohort of 100,000 women in order to assess the clinical outcomes of uterine rupture, maternal/perinatal death, and neonatal short/long-term disability in both the index and subsequent pregnancy (including future incidence of previa/accreta). A cost-effectiveness threshold was set to $100,000 per quality-adjusted life year, and the robustness of the model was assessed with sensitivity analyses.

RESULTS:
In our model, a TOL following 2 cesareans resulted in 46 fewer maternal demises, 65 additional perinatal demises, and 8 additional cases of cerebral palsy. eRCD resulted in 173 additional cases of placenta previa and 137 cases of placenta accreta. A TOL conferred a cost savings of $3,837 per pregnancy, and was the cost-effective strategy up to a rate of uterine rupture during TOL of 4.4% and down to a successful TOL rate of 20.2%.

CONCLUSION:
When including the outcomes of both the index and subsequent pregnancy, a TOL following two previous cesareans is the cost-effective delivery strategy. Careful counseling regarding the increased rates of neonatal complications (despite an overall low absolute risk) must be addressed.
Accuracy of a Limited vs Expanded cfDNA Platform for the Detection of Fetal Aneuploidy in a High Risk Population [30Q]
Authors: Westover Thomas , Spivack Lauren , Smolinsky Ciaran , Khandelwal Meena 
Published: May 2017

INTRODUCTION:
Two types of cell free DNA (cfDNA) platforms are available to screen for fetal chromosome abnormalities. The “limited” platform screens for a fixed number of chromosomal abnormalities while the “expanded” platform screens for abnormalities throughout the entire genome. We sought to compare the accuracy of these two platforms.

METHODS:
We performed a retrospective review of pregnancies undergoing cfDNA, invasive genetic testing, or both, between 2015-2016. Singleton high risk pregnancies were included. Maternal and newborn charts were reviewed to determine which cfDNA platform was performed and whether prenatal or postnatal genetic testing was performed. Appropriate statistical tests were performed for parametric and non-parametric data. Significant chromosome abnormalities were defined as whole chromosome aneuploidy, subchromosomal abnormalities >7 megabases and 22q deletion.

RESULTS:
790 cfDNA assays were performed: 384 limited, 406 expanded. 44 chromosomal abnormalities were found (34 prenatally, 10 postnatally). 75% were common trisomies or sex chromosome aneuploidies while 25% were uncommon chromosomal abnormalities (deletions, duplications, unbalanced translocations, triploidy, rare autosomal trisomy). The expanded platform could potentially have detected 94% of the total number of abnormalities while the limited platform could potentially have detected only 75% (p=.03).

CONCLUSION:
We found that that 25% of chromosomal abnormalities in a high risk population cannot be detected by a limited cfDNA platform. Clinicians should consider usage of an expanded genome wide cfDNA platform that screens for pathogenic, clinically relevant, actionable chromosome abnormalities in patients who prefer non-invasive screening as first line testing.
The “Double Pain” of Childbirth: Immigrant Women's Preference for Female Providers Intrapartum [33Q]
Authors: Aubrey Christa , Mumtaz Zubia , Chari Radha , Mitchell Peter (BF) 
Published: May 2017

INTRODUCTION:
Having a male obstetrical provider can be particularly problematic for some immigrant women whose religio-cultural ideals instill a strong preference for female providers. The objective of this study was to gain understanding of the importance and effect of provider gender for immigrant women accessing obstetrical care.

METHODS:
A focused ethnography was conducted using purposive and convenience sampling of 38 immigrant women from one hospital in Edmonton, Alberta, Canada. Data collection comprised of semi-structured interviews antenatally (38) and postpartum (21), and observation intrapartum (17). Interviews were audio-recorded and transcribed verbatim. Data was managed by a qualitative data analysis software, and analyzed by thematic analysis.

RESULTS:
Women came from various educational and ethnic backgrounds, but the majority were Muslim (30) and married (36), with a mean age of 27.7 years. All women stated that although they preferred a female, they would accept care from a male provider, as provider competency and desire for a safe birth were most important. A culture of modesty, often interwoven with Islam, informed this preference. Nonetheless, women experienced varying degrees of psychological stress from having received care from a male provider intrapartum, which for a small minority led to considerable, potentially serious consequences.

CONCLUSION:
As a whole, women are accepting of care from a male provider. However, for a small minority of women, it can be quite detrimental. There is a need to identify those women for whom this is a substantial barrier, so that optimal support can be determined.
Adherence to Rh Immune Globulin Prophylaxis Guidelines: An Audit of a Modern Obstetric Cohort [34Q]
Authors: Peterson Ashley , Folker Christin , Bond Brian 
Published: May 2017

INTRODUCTION:
There is excellent evidence for postpartum Rh immune globulin (RhIG) prophylaxis efficacy and effectiveness. Continued adherence to RhIG prophylaxis guidelines is essential in preventing Rh alloimmunization and hemolytic disease of the newborn. This study aimed to perform an audit of RhIG prophylaxis practice in a modern obstetric cohort.

METHODS:
A retrospective chart review of 451 consecutive deliveries of Rh-negative women at a single-site tertiary medical center was performed. Fisher exact test was used for statistical analysis.

RESULTS:
The prevalence of Rh negativity was 8.9%. Of the Rh-negative women eligible to receive postpartum RhIG, 97.7% received RhIG and 98.9% were screened for fetomaternal hemorrhage (FMH). Of the Rh-negative women ineligible for RhIG administration, 4.6% inappropriately received RhIG and 91.9% were incorrectly screened for FMH. Evidence of FMH was demonstrated in 26.6% of Rh-negative women. Additionally, 1.7% of Rh-negative women had evidence of excessive FMH requiring additional administration of RhIG. Patients with FMH were more likely to have evidence of maternal acute blood loss anemia (47.8% versus 32.9%, P < .05). Mode of delivery was not associated with increased likelihood of FMH (P=.4).

CONCLUSION:
This audit revealed two key areas for improvement. First, the widespread practice of ordering an unnecessary laboratory test was identified. Second, the rates of failure to order RhIG and FMH screening were determined. Though multiple factors likely contribute to imperfect adherence to guidelines, RhIG prophylaxis has historically been physician-driven at our institution. Implementing a protocol-driven approach may improve adherence; however, further study will be necessary to determine a superior approach.
Maternal and Neonatal Morbidity Among Women With Sickle Cell Anemia and Sickle Cell Trait [4R]
Authors: Brown Jewel , Sinkey Rachel , Steffensen Thora , Louis-Jacques Adetola , Louis Judette 
Published: May 2017

INTRODUCTION:
The objective of this study is to investigate maternal and neonatal morbidities among a contemporary cohort of women with sickle cell anemia (SCA) and sickle cell trait (SCT).

METHODS:
This is a retrospective cohort study among women with laboratory confirmed SCA and SCT with placental pathology results. We sought to compare maternal and neonatal morbidity among a contemporary cohort of women with SCT and SCA.

RESULTS:
One hundred thirty-two patients met inclusion criteria: 16 (12%) with SCA and 116 (88%) with SCT. Baseline characteristics including age, gravidity, parity, race, funding source and smoking status were similar between groups. Co-morbidities were similar with the exception of a higher incidence of chronic infectious diseases among patients with SCA (38% vs. 9%, p=0.002). With respect to maternal morbidity, the following were significantly more likely to occur among patients with SCA as compared to SCT: antepartum hospital admission (81% vs. 19%, p < 0.001), antepartum (69% vs. 4%, p < 0.001) and postpartum blood transfusions (38% vs. 5%, p < 0.001), postpartum readmission (19% vs. 3%, p=0.004) and endometritis (6% vs. 0%, p=0.01) (Table 1). With respect to neonatal morbidity, 25% of infants born to mothers with SCA were small for gestational age as compared 6% of infants born to SCT mothers (p=0.02). No other short-term neonatal morbidities were identified among infants born to mothers with SCA as compared to infants born to mothers with SCT.

CONCLUSION:
Maternal morbidity among patients with SCA is significantly greater as compared to mothers with SCT; infants born to SCA mothers also have higher rates of SGA.
Maternal Risk Factors in a Cohort Study of Mexican Americans Living Near the U.S.-Mexico Border [10R]
Authors: Patel Divya , Salahuddin Meliha , Gowen Rose , Fisher-Hoch Susan , McCormick Joseph 
Published: May 2017

INTRODUCTION:
Preterm and early term births are higher in border versus non-border regions of Texas, though the prevalence of maternal risk factors contributing to negative birth outcomes in this region is not well understood.

METHODS:
Weighted descriptive analyses were conducted on self-reported medical history and information on first pregnancy collected from 384 women ages 19-49 at enrollment into the Cameron County Hispanic Cohort, a prospective study of Mexican Americans residing in South Texas near the U.S.-Mexico border.

RESULTS:
Women in the sample were predominantly Hispanic (89.8%), married (69.5%), and born outside the U.S. (57.5%), with average age of 36.7 years. Nearly one-quarter (23.1%) smoked 100 cigarettes or more in their lifetime. A majority (83.3%) of participants were obese or overweight, and sizeable proportions reported having high blood pressure (22.4%) or high cholesterol (11.1%). During their first pregnancy, most participants (79.0%) reported attending at least 6 prenatal visits. Prevalence of high blood pressure, diabetes, and preeclampsia during pregnancy was 7.6%, 3.2%, and 7.1%, respectively. Approximately 27% had cesarean delivery for the first pregnancy. Self-reported outcomes of the first pregnancy included preterm delivery (11.3%), miscarriage (9.7%), abortion (3.9%), and infant death (3.0%).

CONCLUSION:
Findings from this study indicate a higher burden of overweight/obesity and hypertensive disorders, as well as cesarean and preterm delivery, among Mexican American women of reproductive age in the South Texas border region compared to state averages. Interventions aimed at mitigating maternal risk factors may help improve birth outcomes and the long term health of women in this population.
Meconium Stained Amniotic Fluid: 10 Years After [12R]
Authors: Tilstra Matthew , Guzman Angela , Peart Mishka , Carlan Steve , McWhorter Jeannie 
Published: May 2017

INTRODUCTION:
Meconium stained amniotic fluid (MSAF) occurs in 10-20% of deliveries, and, in the past, was considered a reason to alter obstetric and newborn management. Over the past decade, however, otherwise uncomplicated pregnancies characterized by MSAF have been managed regardless of the presence of MSAF. Whether the changes in hospital protocol regarding MSAF have resulted in poorer pregnancy outcomes have not been studied. The purpose of this study was to compare the outcomes of MSAF versus no MSAF pregnancies since hospital protocol removed MSAF as a risk factor for modifying management.

METHODS:
This was a retrospective study of all 45,961 singleton deliveries from 12/2009 to 12/2013. MSAF occurred in N=4,917.

RESULTS:
Newborn weight and gestational age at delivery were higher in the MSAF group (3344 ± 539 versus 3185 ± 645 grams, and 39 ± 1.8 versus 38 ± 2.5 weeks, respectively, P less than .05. The incidence of Cesarean delivery, and NICU admission were higher and Apgars lower in the MSAF, but umbilical cord pH was similar.

CONCLUSION:
This study suggests that MSAF influences subjectively assigned Apgar scores, but umbilical cord pH, an objective measure of fetal wellbeing is not different. Abandoning hospital protocols that included obstetric management changes when MSAF was present did not influence umbilical cord pH.
Mitochondrial Myopathy, Encephalomyopathy, Lactic Acidosis, Stroke-like Episodes Syndrome: Pregnancy Outcomes [14R]
Authors: Kfouri Julia , Gundy Serena , Faghfoury Hannah , D'Souza Rohan 
Published: May 2017

INTRODUCTION:
The purpose of this study was to systematically review the literature on pregnancy outcomes in women with MELAS syndrome, one of the commonest mitochondrial disorders, and summarize strategies for their preconceptional, antepartum and intrapartum care.

METHODS:
MEDLINE, EMBASE, Web of Science, and PubMed were searched from inception to January 2016 for publications describing pregnancies with MELAS syndrome. Studies were only restricted to humans. The grey literature and references of relevant articles were hand-searched. Authors were contacted for missing data or eligibility inquiries. Article selection, data extraction and risk of bias assessment were performed in duplicate with discrepancies resolved by a third reviewer. Articles were excluded if MELAS syndrome was not confirmed or pregnancy outcomes were not described.

RESULTS:
Of 1412 identified titles and abstracts, 53 full texts were retrieved; 12 case reports were retained for final analysis, including one from our institution. In 2/12 (17%) cases, MELAS syndrome was diagnosed in pregnancy. Up to 11/12 (91%) women experienced severe maternal or obstetric complications such as admission to the intensive care unit, stroke-like episodes, or hypertensive disorders of pregnancy. Adverse fetal or neonatal outcomes, such as pregnancy loss or intrauterine growth restriction, were seen in 8/16 (50%) and 4/11 (36%) pregnancies respectively. Adverse outcomes occurred even when women were in complete remission pre-pregnancy. There were no maternal or neonatal deaths.

CONCLUSION:
MELAS syndrome is a multi-organ disorder associated with significant adverse medical and obstetric outcomes. Patients with this diagnosis should have preconception counseling and multidisciplinary pregnancy management in a tertiary center to optimize outcomes.
Neonatal Hypoglycemia in Women Controlled Intrapartum With Insulin Pump as Compared to Subcutaneous Insulin & Drip [18R]
Authors: Soni Shelly , Shah Nikita , Rochelson Burt , Simmonds Lisa 
Published: May 2017

INTRODUCTION:
To evaluate the incidence of neonatal hypoglycemia in women with diabetes whose intrapartum insulin management is controlled with continuous insulin pump as compared with those managed with subcutaneous insulin as well as drip.

METHODS:
Retrospective review of patients with pregestational Type 1 and 2 diabetes. Primary outcome was neonatal hypoglycemia, defined as neonatal blood glucose levels of < than 40 mg/dl in the first 24 hrs. Patients were categorized into groups — those receiving intrapartum subcutaneous insulin as well as drip and those with intrapartum insulin pumps. Elective cesarean sections were excluded.

RESULTS:
102 patients were included. 71 had type 2 diabetes and 30.4% had type 1 diabetes. There was a greater rate of neonatal hypoglycemia in patients receiving subcutaneous/insulin drip, the difference was not statistically significant (28.6% vs 15.6%, p=0.2). There was no difference in the other perinatal outcomes; cesarean deliveries, birth weights, NICU admissions and the need of neonatal intravenous glucose. There were more patients with Type 1 diabetes in the pump group. Periconception HbA1C was similar. Though birth weights were higher in the pump group, the rate of hypoglycemia as well as the need of intravenous glucose was lower. Our data may have been biased because of more Type 1 diabetics in the pump group.

CONCLUSION:
We found no statistical difference in neonatal outcomes of patients receiving intrapartum continuous subcutaneous insulin infusion pump and those on subcutaneous insulin or drip. Continuing these patients on pump is a reasonable option, especially with lower rates of neonatal hypoglycemia and need of intravenous glucose.
Neonatal Outcomes of Infants at the Threshold of Viability in a Tertiary Care Center [20R]
Authors: Tonismae Tiffany , Lord Megan , Durica Allison 
Published: May 2017

INTRODUCTION:
The goal of this study is to analyze outcomes of periviable deliveries at a tertiary care center in Southwest Virginia from January 2010 to 2016 of those infants delivered from 22 to 25 weeks.

METHODS:
This is a retrospective case series of 76 infants delivered between 22 0/7 and 24 6/7 weeks from 2010-2015. Infant and maternal charts were reviewed for data from admission until NICU discharge or in hospital death. Outcomes included death prior to discharge and major morbidities associated with prematurity.

RESULTS:
Seventy-six patients were identified, with none less than 23 0/7 weeks. Three patients were excluded due to life-limiting genetic or anatomic abnormalities diagnosed antenatally. Mean gestational age at delivery was 24 0/7 weeks (22 6/7-24 6/7 weeks) with mean birth weight 610 g (342-907 g). Demographic information was obtained including maternal age/race, receipt of betamethasone and magnesium sulfate, and causes for delivery. Placental pathology reports were also reviewed. Overall survival was 63% (57% at 23 weeks, 70% at 24 weeks), with a mean length of stay of 159 days (77-167 days). Seventy-four percent of survivors were diagnosed with major morbidity including: stage 3-4 retinopathy of prematurity (15%); late onset sepsis (28%); necrotizing enterocolitis (20%); grade 3-4 intraventricular hemorrhage (15%); periventricular leukomalacia (9%); and spontaneous bowel perforation (22%). 70% of survivors were discharged with home oxygen requirements.

CONCLUSION:
Our survival rate is above national benchmark data for this gestational age. However, the majority of survivors experienced significant morbidity, which should be considered when making decisions regarding resuscitation at the threshold of viability.
Obstetric Delivery Practices and Malpractice Claims: Is There a Correlation? [26R]
Authors: Baja Angela , Miller Lauren , Mills Emily , Clarke Bayley , Zarlengo Gerald 
Published: May 2017

INTRODUCTION:
This study assesses the correlation in trends between obstetric delivery practices and liability claims over 30 years.

METHODS:
A retrospective chart review was performed at a single Colorado hospital, averaging 4,690 deliveries per year, from alternating years between 1978 and 2012. The number of cesarean sections (CS), operative vaginal deliveries (OVD) and vaginal lacerations (3rd and 4th degree) were recorded. A database of obstetrics liability claims, provided by COPIC Insurance, was tabulated and correlated with delivery data. All liability data was occurrence based and aggregated per year. Analysis was performed with Pearson correlation coefficients.

RESULTS:
The CS rate for singletons increased from 13% to 25% from 1978 to 2012. OVDs decreased from 14% to 2.5%. Lacerations decreased from 10.2% to 1.5%. The number of obstetric claims increased steadily until 2006 and then decreased. There was a significant positive correlation between CS rates and obstetrics claims (P =.006). No significant correlation was found between OVD rates and liability claims (P =.073) or lacerations and liability claims (P = .052).

CONCLUSION:
A positive correlation between CS rates and liability claims was noted, while no correlation in OVD or laceration rates to liability claims was found. Together, these trends suggest that abandonment of OVD has not been protective from a liability perspective. The decreasing rates of CS and malpractice claims starting in 2006 are likely explained by Colorado's medical tort reform in 2003. Undoubtedly fear of malpractice affects obstetricians' management, however abandoning OVD in favor of CS has not proven to be a protective solution.
Outcomes in Women With Chronic Hypertension but Normal Blood Pressures in Pregnancy [29R]
Authors: Youngstrom Mallory , Tang Ying , Gardner Meg , Biggio Joseph , Tita Alan , Harper Lori 
Published: May 2017

INTRODUCTION:
Many women with chronic hypertension (HTN) have normal blood pressure (BP) without medication during pregnancy. We sought to assess outcomes in this group compared to women with no hypertension diagnosis, and those who require antihypertensives.

METHODS:
Retrospective cohort of singletons with HTN at UAB from 2000-2014. Exclusions were fetal anomalies, medical problems other than HTN and diabetes. For the same time period, a random group without HTN was chosen. Outcomes were compared between normotensive women with HTN with no medications (noMeds), normotensive women on medications (Meds), and those without HTN (NML). Primary outcome was a neonatal composite of stillbirth, neonatal death, respiratory support, seizures, cord pH less than 7, 5-minute Apgar less than 3. Secondary outcomes were preeclampsia (PE), preterm birth (PTB), and small for gestational age (SGA). Groups were compared using Student's t-test and χ2 test for trend. Logistic regression was used to adjust for confounders.

RESULTS:
Of 830 women with HTN, 212 (25%) were noMeds, and 618 (75%) were Meds. These groups were compared to 476 NML. Women with HTN were older, had a higher BMI, PIH in a prior pregnancy, renal disease, and diabetes compared to NML. The composite was more common in both HTN groups (AOR 2.9, 95% CI 1.21-6.85 NoMeds; AOR 5.0, 95% CI 2.38-10.54 Meds). The risk of PE, PTB, and SGA was not increased in NoMeds compared to NML.

CONCLUSION:
In spite of normal BP without medications, women with HTN have an increased risk of adverse neonatal outcomes compared to NML. Further research is needed to elucidate whether this is related to baseline characteristics of HTN or the HTN process.