bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Retrospective Look at Clusters of Maternal Mortality [ID 2683584]
Authors: Solomon Lindsey , DeCesare Ana , Amin Raid W. , Taylor Sarah A. , Decesare Julie 
Published: May 2024

INTRODUCTION:
The objective of this study was to identify clusters in the United States with the highest and lowest rates of maternal mortality, to pinpoint changes in maternal mortality rates, and to forecast maternal deaths by demographic variables.

METHODS:
A retrospective cohort study was used to report maternal deaths in the United States. The maternal mortality counts (as defined by ICD-10 codes) from 2010 to 2020 at the county level for the 48 contiguous states were obtained from the Centers for Disease Control and Prevention (CDC) via their Wonder application. Variables such as population density, environmental conditions, race, ethnicity, and physical and mental health conditions for each county were identified. A regression analysis and spatial cluster analysis of these variables generated a heat map to identify areas in the United States with high and low rates of maternal mortality.

RESULTS:
Spatial clusters in the 48 contiguous states averaged across all years were identified. There are discrete areas with higher maternal mortality, some broad, such as the Southeast region, and some specified to cities, such as New York. A regression model used multiple factors to predict maternal deaths from demographic variables. The four best predictors were high population density, air pollution, and Hispanic and African American ethnicities. Clusters were also identified with the lowest maternal mortality.

CONCLUSION:
The United States has the highest maternal mortality rate (MMR) among all high-income countries. Historically, MMR has steadily increased since 2016. This study found that the best predictors for maternal mortality were high population density, air pollution, and Hispanic and African American subpopulations. Such a study can be used by health agencies and beyond to delve into possible causes of elevated maternal mortality in certain geographic regions of the United States. More studies are indicated to determine causality and unearth strategies to improve maternal outcomes.
The Effect of Preeclampsia on Adverse Maternal Outcomes in Women With Placental Abruption at a Large Urban Hospital in Tennessee From 2019 to 2022 [ID 2683655]
Authors: Swayze Emma J. , Swailes Alexa L. , Weber Caiden 
Published: May 2024

INTRODUCTION:
Placental abruption is associated with increased pregnancy-related morbidity and mortality. Few studies have explored the effect of individual risk factors for placental abruption on outcomes. Our study evaluates the association of preeclampsia and maternal morbidity in patients with placental abruption.

METHODS:
We conducted a retrospective case–control study to evaluate the association of preeclampsia with adverse maternal outcomes in the setting of placental abruption. Univariate analyses were used to determine the relationship between preeclampsia and known adverse maternal outcomes of placental abruption. Multivariate logistic regression was then used to evaluate the relationship between preeclampsia and each significantly associated outcome, adjusting for factors including body mass index, gestational age, mode of delivery, race, trauma, diabetes, placental location, cocaine and tobacco use, prior cesarean sections, year of delivery, and parity. Significance was assessed at an alpha of 0.05.

RESULTS:
Of 147 singleton pregnancies complicated by placental abruption from 2019 to 2022, 37 (25.2%) were complicated by preeclampsia. No significant differences were found between groups in incidence of acute kidney injury, disseminated intracellular coagulation, cesarean delivery, fetal demise, preterm birth, or low birth weight. On adjusted multivariable regression, we found preeclampsia increased the odds of maternal transfusion requirement (adjusted odds ratio [aOR] 3.55; 95% CI: 1.2, 10.4) and postoperative hospital stay greater than 2 days (aOR 4.05; 95% CI: 1.5, 11.2).

CONCLUSION:
Preeclampsia was an independent predictor of need for blood transfusion and increased duration of hospital stay in patients with placental abruption. Recognition of preeclampsia as an independent risk factor for these outcomes may allow medical optimization, increased preparedness, and lead to decreased pregnancy-related morbidity.
Multidisciplinary Simulation Improves Resident Comfort With Perinatal Bereavement Care [ID 2683378]
Authors: Santos Roca Antonio J. , Rodriguez Normaliz , Poehacker Stefanie , Hays Jacinda , Chase Tess 
Published: May 2024

INTRODUCTION:
Physicians have difficulty delivering bad news because of discomfort and lack of appropriate education. We introduce an initiative to enhance trainee comfort in delivering the diagnosis of intrauterine fetal demise (IUFD) through multidisciplinary simulation training.

METHODS:
Twelve obstetrics and gynecology residents participated in perinatal bereavement training with a palliative care specialist utilizing the SPIKES framework, followed by an immersive simulation of an IUFD case and debrief with multidisciplinary physicians. Pre- and post-training surveys were administered. This study was approved by the IRB.

RESULTS:
Participants were equally distributed in training year (58% female, 33% male). 92% had previously delivered the diagnosis of IUFD, yet 50% had no previous bereavement training, and of those with training, most (84%) had less than 2 hours. Wilcoxon signed-ranks tests showed statistically significant increase in comfort level of delivering bad news (Z=66; P=.003), delivering a diagnosis of fetal demise (Z=64; P=.005), and having the skills and foundation to deliver the news of a fetal demise (Z=28; P=.017). Qualitative responses identified acquisition of verbal and nonverbal skills such as direct patient communication, using the word death, and sitting down at the patient’s eye level prior to delivering the news. Most described the experience as real, immersive, and a safe learning environment. One hundred percent would recommend the course to others.

CONCLUSION:
Perinatal bereavement education in obstetrics and gynecology residency training is lacking. Multidisciplinary, immersive simulation training significantly increased residents’ comfort and perceived preparedness in delivering the diagnosis of fetal demise.
The Necessity of Type and Screen Result Prior to Proceeding to Operating Room for Scheduled Cesarean Delivery in a Low Hemorrhage Risk Population [ID 2683392]
Authors: Hoffmann Eva , Druyan Brian Z. , Fletcher Michelle M. , Ridore Michelande , Paidas Michael J. , Toledo Paloma 
Published: May 2024

INTRODUCTION:
Delays in the operating room (OR) on labor and delivery are common. This leads to inefficiency, patient, and physician dissatisfaction and financial ramifications. One root cause of OR delays involves waiting for type and screen results prior to wheels into the OR. Our objective was to determine whether a type and screen result is necessary prior to wheeling into the OR.

METHODS:
This was an IRB-approved retrospective cohort study conducted at a single state sponsored academic institution. Chart review was performed identifying all patients who had a scheduled cesarean delivery (CD) from August 1, 2022, through September 31, 2022. We identified all patients who received a blood transfusion intra-op or postoperatively. We excluded all patients who had a medium-risk hemorrhage score or greater. We then calculated timing of blood transfusion from wheels into the OR.

RESULTS:
We identified a total of 85 patients scheduled for CD. Of these, 7 patients required a blood transfusion, and 4/7 patients received a blood transfusion within 60 minutes of wheels into the OR. There were no patients with a low-risk hemorrhage score on admission who received a blood transfusion within 60 minutes of wheels into the OR.

CONCLUSION:
There were no patients with a low-risk hemorrhage score scheduled for CD required a blood transfusion within 60 minutes of wheels into the OR. This supports elimination of mandatory type and screen result prior to wheels in for patient scheduled for CD with a low-risk hemorrhage score.
Intimate Partner Violence Screening in a Pregnant Military Population: Implementation of the E-HITS Protocol [ID 2683442]
Authors: Gregg Rebecca W. , Teneyuque Nicholas , Griffis Jeffrey 
Published: May 2024

INTRODUCTION:
The military population has higher rates of intimate partner violence (IPV) compared to the civilian population. This is further exacerbated in obstetrics patients, with an estimated rate of 4–29% of pregnant women affected. The American College of Obstetricians and Gynecologists and 2018 Department of Defense Clinical Practice Guidelines for Management of Pregnancy recommend routine screening for IPV at obstetric visits, although a preferred screening modality has not been identified.

METHODS:
The prevalence of IPV in pregnancy before and after implementation of the validated Extended-Hurt, Insult, Threaten, Scream (E-HITS) questionnaire at a single military treatment facility was compared. Retrospective chart review was conducted between January and December 2019 of patients who had been screened using a single question (“Do you feel safe at home?”). E-HITS was implemented in the obstetrics clinic in February 2022, and data were collected prospectively for 12 months. The difference between the two IPV screening modalities was analyzed using Fisher’s exact test.

RESULTS:
A total of 1,627 IPV screenings were reviewed. Of the 783 IPV screenings using the single question, there were 2 positive screens (0.26%). Using greater than 7 as the positive screening cutoff, there were 24 positives (2.84%) out of the 844 E-HITS screenings. Using greater than 6 as the cutoff for E-HITS, there were 54 positive screens (6.4%). There was a statistically significant difference in the detection rate between the two modalities at both cutoff levels (P<.0001).

CONCLUSION:
E-HITS is a more sensitive screening tool for IPV in this population, more closely mirroring previously published rates.
Discharges Against Medical Advice in Pregnant Patients at a Canadian Tertiary Care Center: Does Lack of Access to Childcare Play a Role? [ID 2683591]
Authors: Litalien Ariane , Aubrey Christa L. , Merali Sabrina 
Published: May 2024

INTRODUCTION:
Discharges against medical advice (AMA) during pregnancy have been associated with poor maternal and fetal outcomes. Moreover, one of the documented reasons why female patients might leave the hospital AMA is lack of access to childcare. In recent years, lack of access to childcare has been identified as a potential risk factor for discharge AMA and maternal mortality at a tertiary care center in Edmonton, Alberta, Canada. The goal of this chart review project is to study the characteristics of pregnant women who leave AMA from this center, and to determine what proportion of these discharges is due to difficulties securing childcare.

METHODS:
Ethics approval was obtained through the University of Alberta’s Health Research Ethics Board. All patients who were discharged AMA from the triage and antepartum units at the study site between May 28, 2021, and May 27, 2022, were identified. Patients were included in the chart review as long as they remained undelivered at the time of discharge. Reasons for admission and discharge AMA were extracted from each patient’s chart whenever available. Patients' age, gravidity, parity, and gestational age at the time of discharge were also collected.

RESULTS:
During the study period, approximately 9.3% of recorded discharges from the triage and antepartum units were for patients who left AMA. In total, we included 89 individual patient visits that ended with a discharge AMA. For these patients, the most frequent reason for admission was threatened preterm labor (including short cervix). Although the reason motivating discharges AMA was not documented in the majority of charts reviewed (49/89), lack of access to childcare was the most frequently documented reason provided by patients for leaving AMA (15/40).

CONCLUSION:
Improving access to childcare for pregnant patients who are admitted to the study site might help to decrease discharges AMA, and therefore help reduce perinatal complications.
Reduction of the NTSV (Nulliparous, Term, Singleton, Vertex) Cesarean Section Rate and Evaluation of Balancing Measures [ID 2683626]
Authors: Counts Rachael 
Published: May 2024

INTRODUCTION:
To decrease the nulliparous, term, singleton, vertex (NTSV) cesarean section (CS) rate at a single tertiary care center. We hypothesized the NTSV CS rate due to labor dystocia would decrease after the intervention.

METHODS:
Quality improvement interventions were instituted over 7 months, including education on labor dystocia, recognition of NTSV patients, implementation of necessary skills, guidelines to support labor progression, and improvements in team communication. A retrospective chart review was performed over the 6 months prior and 6 months after intervention period. Primary outcomes included NTSV CS rates and indication for CS. Secondary outcomes included adverse maternal and neonatal outcomes.

RESULTS:
There were 1,079 NTSV patients during the pre-intervention (n=421) and post-intervention (n=658) timeframes. The NTSV CS rate downtrended but was not statistically different between the pre- and post-intervention timeframes. The NTSV CS rate due to labor dystocia down-trended but was not statistically different. There were no differences in the neonatal adverse outcomes pre- and post-intervention. Rates of chorioamnionitis/endometritis (4.1% pre- versus 9.9% post-intervention; P=<.01) and hospital readmission rates (0.3% pre- versus 2.7% post-intervention; P=.01) were both significantly increased in the vaginal delivery cohort after the intervention. Differences in other maternal adverse outcomes pre- and post-intervention were not statistically different in the vaginal delivery nor CS cohort.

CONCLUSION:
Despite not being statistically significant, there was a notable clinical difference in the NTSV CS rate following this quality improvement initiative. However, the potential associated increases in chorioamnionitis/endometritis and postpartum readmission rates should be considered.
Obstetric Anal Sphincter Injury Management at a Tertiary Academic Birthing Center: A Quality Improvement Initiative [ID 2683441]
Authors: Zdroik Anna , Greene Andrew , VanderMeersch Courtney M. , Stamilio David M. , Matthews Catherine A. 
Published: May 2024

INTRODUCTION:
As a quality improvement project, we implemented an evidence-based management protocol to optimize outcomes after obstetric anal sphincter injuries (OASIS). The aim was to evaluate compliance with practice guidelines for antibiotic use, standardized surgical technique and documentation, utilization of a bowel regimen, and short-term outpatient follow-up after a resident educational OASIS program.

METHODS:
An OASIS practice guideline was implemented via a curriculum utilizing didactics and simulation with porcine sphincter models to demonstrate primary prevention, proper diagnosis, repair technique, documentation, and post-procedure OASIS management. Pre (August 2018 to July 2022) and post-intervention (August 2022 to July 2023) cohorts were compared for characteristics and provider adherence to guidelines. We used control charts, chi-squared, and Student's t-tests to estimate the effect of the intervention.

RESULTS:
Among 226 OASIS cases, 168 were pre-intervention and 58 were post-intervention. Proper documentation of OASIS repair increased from 13 (7.7%) pre-intervention to 24 (41.4%) post-intervention (risk ratio [RR] 7.57; 95% CI, 4.3–13.1); proper antibiotic use increased from 79 (47.0%) pre-intervention to 39 (67.2%) post-intervention (RR 1.42; CI, 1.12–1.18); and utilization of bowel regimen increased from 147 (87.5%) to 56 (96.6%) post-intervention (RR 1.1; CI, 1.02–1.18). There was no change in close follow-up appointment attendance (81.0% for both groups; P=.98). Control charts showed a process change in bowel regimen use and OASIS documentation, but no significant change in antibiotic use or close follow-up appointments.

CONCLUSION:
Implementation of an evidence-based management guideline was associated with increased compliance with evidence-based practices. Future improvement cycles are necessary to optimize outpatient follow-up after OASIS.
Patient and Provider Perspectives on Postpartum Pain Management in Individuals With Opioid Use Disorder and Chronic Pain [ID 2683542]
Authors: Azar Michelle , Sharif Limi , Moniz Michelle H. , Low Lisa Kane , Peahl Alex 
Published: May 2024

INTRODUCTION:
Birthing people with opioid use disorder (OUD) and chronic pain (CP) face significant barriers to effective postpartum pain management including medical complexity of analgesic decisions as well as stigma and bias towards individuals with these diagnoses. To date, clinical practice guidelines (CPGs) for patients with OUD and CP have lacked patients’ perspectives. We sought to capture voices of patients and their medical providers to inform effective, equitable pain management CPGs for birthing people with OUD and CP.

METHODS:
We performed a subgroup analysis of 31 patient and 22 provider interviews conducted to develop CPGs. Institional review board approval was obtained along with participant consent, and data were de-identified. We isolated quotes pertaining to OUD and CP from participants with and providers caring for individuals with these conditions. We then used inductive thematic analysis, allowing insights to emerge from the data.

RESULTS:
In total, 266 quotes were identified relating to OUD and CP. Five key themes emerged from the data: 1) the need to mitigate health care team bias to improve pain management access and experience; 2) the need for standardized sets of pain management options for all patients; 3) the importance of tailoring pain management plans to individuals’ unique needs; 4) the need to partner with patients in creating pain management plans to promote trust and autonomy; and 5) the importance of interprofessional teams in treating postpartum pain for individuals with OUD and CP.

CONCLUSION:
Interviews with patients and the people who care for them reveal important considerations for CPGs that improve rather than exacerbate existing disparities for birthing people with OUD and CP. Implementation of CPGs informed by patients’ lived experiences is a crucial step in ensuring equitable options for postpartum pain management in patients who face significant biases and barriers to effective care.
Factors Associated With Postpartum Readmission for Hypertension in Women With Hypertensive Disorders of Pregnancy [ID 2683562]
Authors: Chen Grace , Jones Jody , Mowers Erika 
Published: May 2024

INTRODUCTION:
Hypertensive disorders of pregnancy (HDP) are a common indication for postpartum readmissions. Our study aims to identify demographic and clinical variables associated with hypertension-related postpartum readmissions in patients with known HDP.

METHODS:
We conducted a retrospective cohort study at a single institution of patients who delivered between March 1, 2020, and March 31, 2022. We included patients with a HDP during their delivery admission but excluded those with chronic hypertension. Bivariate analysis was performed to identify if readmission rates were associated with maternal age, race, ethnicity, delivery route, severe disease, blood pressure before discharge, discharge timing, antihypertensive regimen inpatient and at discharge, or attendance at an outpatient blood pressure check. These variables were further stratified by race.

RESULTS:
Of 1,744 included patients, 68 (3.9%) were readmitted for hypertension. Odds of readmission increased if patients were greater than 35 years old (odds ratio [OR] 1.96; 95% CI, 1.13–3.41), had average blood pressure within 12 hours of discharge 140–149/90–99 (OR 1.95; 95% CI, 1.06–3.58), or if last blood pressure before discharge was 140–149/90–99 (OR 2.14; 95% CI, 1.22–3.74), and decreased if patients had severe disease (OR 0.41; 95% CI, 0.20–0.83) or received magnesium sulfate (OR 0.36; 95% CI, 0.18–0.71) during their delivery admission. Stratification by race did not elucidate any differences in risk factors.

CONCLUSION:
Blood pressure range in 140s/90s compared with normotension prior to discharge and advanced maternal age was associated with increased odds of postpartum readmission for hypertension. Future research and quality improvement interventions are needed regarding ideal blood pressure range prior to discharge.
Association Between Mode of Delivery and Postpartum Assessment of High-Grade Cervical Dysplasia Diagnosed in Pregnancy [ID 2683564]
Authors: Mulder Isabelle , Nambiar Anjali , Holloway Steven Blaine , Pruszynski Jessica , Lea Jayanthi , Martin Robert B. 
Published: May 2024

INTRODUCTION:
Approximately 5% of pregnancies are complicated by cervical dysplasia. It is hypothesized that cervical remodeling during vaginal delivery may confer higher rates of postpartum regression when compared to cesarean. We sought to evaluate the relationship between mode of delivery and postpartum dysplasia outcomes.

METHODS:
This is a retrospective cohort study of patients with biopsy-proven high-grade dysplasia diagnosed during pregnancy from January 2013 to December 2022. Demographics, obstetric outcomes, and antepartum and postpartum cervical pathology were collected and IRB approval obtained. Only immunocompetent patients with postpartum pathology obtained within 1 year of delivery were included. Definitions based on postpartum pathology were as follows: regression as low-grade or resolved dysplasia, persistence as high-grade dysplasia, and progression as cervical cancer. Rates were stratified by mode of delivery and data analyzed using the chi-squared test.

RESULTS:
Among our cohort (N=286), 101 (35%) were diagnosed with CIN2, 181 (63%) with CIN3/CIS, and 4 (1%) with HSIL (not otherwise specified) on antepartum cervical biopsy. 228 (80%) delivered via vaginal delivery and 58 (20%) delivered via cesarean. Rate of postpartum regression was similar in both delivery groups (37% versus 38%; P=.927), as was persistence (62% versus 60%; P=.786). Rate of apparent progression to invasive cancer was low in both groups (<1% versus 2%; P=.365).

CONCLUSION:
High rates of persistence and low rates of apparent progression were observed subsequent to both vaginal and cesarean deliveries. Our data indicate that the natural history of high-grade dysplasia diagnosed during pregnancy is not affected by route of delivery in a way that should influence postpartum management.