bluuebunny/crossref_metadata_2025_split huggingface dataset:
Analysis of Characteristics Associated With Pregnancy Duration After Cervical Cerclage Placement in Singleton Gestations [ID: 1378088]
Authors: Hong Leah , Hasty Miranda , Jolly Sonia , Powel Jennifer , Tomlinson Tracy , Zantow Emily 
Published: May 2023

INTRODUCTION:
Cervical cerclage technique and perioperative interventions vary widely among providers because of lack of evidence to inform management. Our aim was to identify factors independently associated with pregnancy duration in singleton gestations after cerclage placement.

METHODS:
This was a retrospective cohort analysis from 2008 to 2020 at an academic tertiary care center. Because of the inclusion of one or more pregnancies for ∼37% of the cohort, a linear mixed-effects model was utilized to evaluate the association between various factors and pregnancy duration. Variables with P<.2 on unadjusted analysis were considered for incorporation into a multivariable model. Model fit was assessed using Akaike’s information criterion (AIC).

RESULTS:
Out of 762 pregnancies, 42% underwent history-indicated, 22% ultrasound-indicated, and 36% physical exam-indicated cerclage placement. Mean gestational age (GA) at delivery was 35.0±5.8 weeks. 22% occurred less than 32 weeks and 7% resulted in previable delivery. Mean duration of pregnancy after cerclage placement was 17.1±7.0 weeks. An 8-covariate multivariable analysis revealed adjusted differences (β) in weeks of GA at delivery (95% CI): nulliparity +1.61 (0.57, 2.64), multiparity with most recent delivery 34 weeks or greater +1.31 (0.53, 2.10), married +0.94 (0.18, 1.70), concomitant progesterone use +1.06 (0.35, 1.76), preoperative cervical dilation 0.5 cm or higher −1.26 (−2.10, −0.41), utilization of Foley balloon for membrane elevation −2.27 (−3.53, −1.01), postoperative cervical length less than 20 mm −6.34, (−7.37, −5.32), and requiring cerclage revision −3.79 (−5.40, −2.18).

CONCLUSION:
Apart from use of a Foley balloon for membrane elevation and concomitant progesterone, we did not find any modifiable factors associated with pregnancy duration after cervical cerclage placement. However, this information may inform counseling as well as management for those with a postoperative cervical length less than 20 mm.
Factors Associated With Pregnancy Duration up to 32 Weeks in Patients With Twin Gestations Who Underwent Cerclage Placement [ID: 1378167]
Authors: Hong Leah , Hasty Miranda , Jolly Sonia , Powel Jennifer , Tomlinson Tracy , Zantow Emily 
Published: May 2023

INTRODUCTION:
Historically, cerclages were not recommended in multiple-gestation pregnancies because of uncertain efficacy and concern for harm. However, a meta-analysis of twin pregnancies found cerclage was associated with reduction in preterm birth (PTB) less than 32 weeks with cervical length (CL) of 15 mm or lower.

METHODS:
We conducted a retrospective analysis of women who underwent cervical cerclage placement at a single tertiary academic center from 2008 to 2020. Data pertaining to maternal demographics, obstetric course, sonographic CL, and cerclage operative technique were abstracted for women with twin gestations. Factors with P value of .2 or lower on univariate analysis of spontaneous PTB (sPTB) less than 32 weeks were considered for incorporation along with history of sPTB into a Cox proportional-hazards model to assess factors associated with pregnancy duration up to 32 weeks.

RESULTS:
Seventy-five twin gestations were analyzed. On univariate analysis, neuraxial anesthesia during cerclage placement, preoperative cervical dilation, use of Foley catheter for membrane elevation, shorter postoperative CL, and twin B male sex were found to be significantly associated with sPTB less than 32 weeks. Cox proportional-hazards analysis demonstrated that use of Foley catheter for membrane elevation, neuraxial anesthesia, postoperative CL less than 25 mm recorded 24 weeks or earlier, and history of sPTB greater than 16 weeks had significantly higher adjusted hazard ratios. The bias-corrected bootstrapped (1,000 repetitions) AUROC for a logistic regression model with these four covariates predictive of sPTB less than 32 weeks was 0.83 (95% CI 0.69–0.89).

CONCLUSION:
A survival analysis approach offers valuable clinical insight into predictors of shorter pregnancy duration up to 32 weeks in twin gestations undergoing cervical cerclage placement.
Single-Layer Versus Double-Layer Uterine Closure at the Time of Cesarean and Subsequent Risks in Those With Placenta Accreta Spectrum [ID: 1381003]
Authors: Phelps Alexandra , Harrison Rachel , Holmgren Calla , Hussein Nada , Steinberg Guy 
Published: May 2023

INTRODUCTION:
Benefits of single- versus double-layer uterine closure at the time of cesarean delivery are unclear. We sought to evaluate the effect of single- versus double-layer closure in prior cesarean delivery at the time of cesarean hysterectomy for placenta accreta spectrum (PAS).

METHODS:
Retrospective study of patients with PAS and available prior cesarean delivery operative report were included in this IRB-approved cohort study. Those with history of single-layer closure were compared to those with history of double-layer closure, and the effect on maternal outcomes at the time of cesarean hysterectomy for PAS was evaluated. The primary outcome was surgical pathology diagnosis of percreta or increta versus accreta. Secondary outcomes included blood loss, intensive care unit admission, length of stay, and surgical time. Groups were compared via chi-square, Fisher’s exact, and t tests with logistic regression to evaluate for confounders.

RESULTS:
There were 36 participants available for review, 20 of whom (55.6%) had prior single-layer closure. Those with single-layer closure had a higher number of prior cesarean deliveries (2.5±1.1 versus 1.4±0.8, P=.003); otherwise, baseline characteristics were similar between groups. Diagnosis of percreta or increta at the time of cesarean delivery was more likely among those with single-layer closure (79.9% versus 41.7%, P=.056), although not statistically significant. Blood loss, operative time, and length of stay were higher as well, but these did not reach statistical significance (approximately 3,200 versus 1,900 mL, P=.138; 167 versus 140 minutes, P=.151; 4.8 versus 3.4 days, P=.059). In the regression analysis, after controlling for the number of prior cesarean deliveries and other potential confounders, the apparent increase in diagnosis of percreta or increta did not persist (adjusted odds ratio 0.55, 95% CI 0.20–1.53).

CONCLUSION:
No statistically significant benefit to prior single- versus double-layer closure was noted at the time of cesarean hysterectomy in those with PAS.
Racial Disparities in Cesarean Delivery Outcomes: Analysis of Native Hawaiians or Pacific Islanders and American Indians or Alaska Natives [ID: 1377727]
Authors: Sato Danielle , Abella Maveric , Collins Robert , Pawar Deepraj , Shirriff Ashley , Stafford Michelle 
Published: May 2023

INTRODUCTION:
Racial disparities in cesarean delivery (CD) are well documented, but Native Hawaiians or Pacific Islanders (NHPI) and American Indians or Alaska Natives (AIAN) are underrepresented in literature. We aim to elucidate racial disparities in CD outcomes, focusing on NHPI and AIAN populations.

METHODS:
The National Surgical Quality Improvement Program was queried to identify CD outcomes from 2019 to 2020 in the National Surgical Quality Improvement Project (n=25,649). Multivariable logistic regression models were used to investigate the association of race and ethnicity on major and minor postoperative complications and reoperation.

RESULTS:
Racial minority groups were compared to non-Hispanic White people and adjusted for confounders. The NHPI patients had the highest risk of complication, at 4.6% greater risk of any postoperative complication (adjusted odds ratio [AOR] 1.046 [1.001–1.093]) and 3.2% greater risk of major complication (AOR 1.032 [1.006–1.058]). This was compared to a 3.2%, 1.9%, and 1.8% greater risk for any postoperative complication in Asian, Black, and Hispanic/Latina patients, respectively. The AIAN patients had the highest risk of reoperation of all groups, at 2.6% greater risk of reoperation (AOR 1.026 [1.015–1.037]).

CONCLUSION:
Across all groups undergoing CD, NHPI patients had the greatest risk of any postoperative complication, and AIAN patients had the greatest risk of reoperation. Our findings emphasize the need to further investigate these underrepresented minority groups in future obstetric research.
Postpartum Emergency Department Visits and Risk Factors for Readmission [ID: 1363150]
Authors: Mei Jenny , Corry-Saavedra Kate , Murphy Aisling , Nguyen Tina 
Published: May 2023

INTRODUCTION:
Postpartum emergency department (ED) visits complicate 12% of births. We aimed to characterize trends in ED visits and risk factors for readmission.

METHODS:
This was a retrospective cohort study on postpartum ED visits within 42 days of delivery at a tertiary care center over 1 year. Readmitted patients were compared to those who remained outpatient as appropriate. IRB #14-001098.

RESULTS:
Of 3,084 deliveries, 138 (4.5%) patients presented to the ED for total 157 encounters. 17 (12.3%) patients presented more than once. 55 (35%) ED visits resulted in readmission, with 4 patients readmitted twice. Public insurance rates in the cohort were significantly higher than baseline (16.7% versus 8.5%, P=.001). Postpartum hypertension (HTN) was the most common reason for ED visits (40%) and had four times higher likelihood of being readmitted (adjusted odds ratio [aOR] 4.076, 95% CI 2.04–8.15, P<.001). Black women were six times more likely to be readmitted compared to other groups (aOR 6.53, 95% CI 1.26–33.88, P=.026). Coexistent psychiatric disease had lower likelihood of readmission (aOR 0.43, 95% CI 0.19–0.95, P=.037). Having more than one ED visit led to fivefold higher odds of readmission (aOR 5.05, 95% CI 1.66–15.32, P=.004). Median days from delivery to ED visit were 8 (interquartile range [IQR]: 5, 15).

CONCLUSION:
Seventy-three percent of presentations to the ED were within 2 weeks of delivery, and postpartum HTN was the leading cause. Black patients were more likely to be readmitted. Further studies are needed to evaluate whether earlier postpartum visits for high-risk groups may reduce ED visits and readmissions.
Expanded Clinician Offering of Expectant Management of PPROM 34 Weeks 0 Days–36 Weeks 6 Days After Introduction of Shared Decision-Making Aid [ID: 1364841]
Authors: Thayer Sydney , Frolova Antonina , Huysman Bridget , Kelly Jeannie , Kernberg Annessa , Zofkie Amanda 
Published: May 2023

INTRODUCTION:
In March 2020, the American College of Obstetricians and Gynecologists updated recommendations for prelabor preterm rupture of membranes (PPROM) at 34 weeks 0 days–36 weeks 6 days to include shared decision-making (SDM) for expectant management (EM) versus immediate delivery (ID). We sought to compare the patient populations offered EM before and after a SDM aid.

METHODS:
This is a retrospective cohort study from March 2020 to February 2022 of patients presenting with PPROM 34 weeks 0 days–36 weeks 6 days. On October 25, 2022, a SDM aid was introduced to help clinicians discuss the benefits and risks to EM versus ID of PPROM. Patients offered EM were compared before and after the SDM aid using Fisher exact, χ2, and t tests.

RESULTS:
Eighty-six patients presented with PPROM during the study period, 26 before the SDM aid and 60 afterwards. Populations were similar, with the exception of more publicly insured patients post-SDM aid. Significantly more patients were offered EM of PPROM post-SDM aid than pre-SDM aid (48% versus 11%, P=.001). The proportion of Caucasian and privately insured patients offered EM significantly increased after the SDM aid; more African American and publicly insured patients were offered EM as well, but this was not statistically significant. No patients accepted EM prior to the SDM aid compared to 41% who chose EM after the SDM aid.

CONCLUSION:
A SDM aid significantly increased the number of patients offered EM of PPROM. Still, while more patients elected for EM after the SDM aid, the majority elected for ID. A standardized approach to SDM may improve provider awareness of management options and provide patients with necessary information to make informed decisions.
Reduction of Cesarean Delivery Rates in South Florida: The MSMC Experience [ID: 1370319]
Authors: Kostolias Alessandra , Husnain Zia , James Jane , Lauture Adolphia , Mayrink Maximiliano , Perez Jorge 
Published: May 2023

INTRODUCTION:
Mount Sinai Medical Center (MSMC) in Miami Beach, Florida, is home to a diverse and international obstetric population. In 2017, the state of Florida had a cesarean delivery (CD) rate for nulliparous, term, singleton, vertex (NTSV) of 31.1%, the highest in the nation. Mount Sinai Medical Center had a NTSV CD rate of 38.3%. The national rate of NTSV CD in 2017 was 26%. Mount Sinai Medical Center joined PROVIDE (Promoting Primary Vaginal Deliveries), a statewide initiative by the Florida Perinatal Quality Collaborative with the goal of improving maternal and newborn outcomes by applying evidence-based interventions and reducing NTSV CD rates.

METHODS:
The implementation of an obstetrics and gynecology residency program and monthly grand rounds contributed to an effort of evidence-based medicine. The interventions implemented were nurse education of labor positioning from Bundle Births and Spinning Babies, nursing recognition as “Vaginal Queen of the Month,” Bishop score documentation added to H&P, obstetric physicians assigned “Badge Buddies” next to their hospital ID cards disclosing their personal NTSV CD rate, and a pre-cesarean checklist for labor dystocia or failed induction.

RESULTS:
After 2 years of multifaceted interventions, MSMC had decreased its cesarean delivery rate for NTSV patients from 38.3% in 2017 to 27.7% in 2019. The average rate in Florida overall was 29.7% in 2019 and the national rate of CD in NTSV patients was 25.6% in 2019 (data source: FPQC Perinatal Indicator System).

CONCLUSION:
With continued interventions, we hypothesize that we will meet the healthy people 2030 target CD for NTSV rate of 23.6% as the initiative enters its sustainability phase.
Effect of Single-Unit Transfusion Guideline on Red Blood Cell Transfusion for Obstetric Patients [ID: 1375663]
Authors: Triebwasser Jourdan , Bailey Joanne , Carver Alissa , Hyatt David , Logan-Sitko Ashley , Smith Roger 
Published: May 2023

INTRODUCTION:
The American Red Cross recently declared a national blood crisis. We aimed to evaluate the effect of a single-unit transfusion guideline on the transfusion rate.

METHODS:
An interdisciplinary quality improvement initiative to reduce blood transfusion for postpartum hemorrhage (PPH) was conducted in a tertiary obstetric hospital with approximately 5,000 births annually. Opportunities for improvement were prioritized including antepartum anemia treatment, early recognition and treatment of PPH, and blood stewardship. The baseline period was January 2019 to December 2020. The intervention period was July 2021 to April 2022. We recommended transfusions begin with an order for a single unit of blood (“Start with One”). Plan-do-check-act cycles were initiated. The clinical outcome was units of blood transfused per 1,000 deliveries. Relative risks, t tests, and control charts were used for analysis. The quality improvement project was IRB exempt (HUM00213652).

RESULTS:
Incidence of PPH decreased between baseline and intervention periods (relative risk 0.83, 95% CI 0.77–0.90). The baseline transfusion rate was 79.3 units of blood per 1,000 births. During the intervention period, this decreased by 32.8% to 53.2 units per 1,000 births (P=.004). Special cause variation was found after introduction of the “Start with One” campaign: 8 consecutive months in the intervention period have been above the mean proportion for single-unit transfusions.

CONCLUSION:
A single-unit transfusion guideline, as part of a multimodal strategy to reduce PPH, was associated with a significant decrease in red cell transfusion. The current national blood shortage should be a call to action for all obstetric providers to safely reduce the volume of blood transfusions.
Adapting Obstetric-Capacity Assessments to a Rural Context to Drive System Improvements [ID: 1375979]
Authors: Glover Annie , Brown Diane , Fertaly Kaitlin , Holman Carly , McCracken Clayton , Nelson Megan 
Published: May 2023

INTRODUCTION:
As part of its Health Resources and Services Administration Maternal Health Innovation, Centers for Disease Control and Prevention (CDC) ERASE MM, and the American College of Obstetricians and Gynecologists Alliance for Innovation on Maternal Health (AIM) awards, Montana assessed capacity to provide risk-appropriate care in Montana's hospitals with labor and delivery (L&D) units as well as critical access hospitals (CAHs) without L&D units that serve remote communities in maternity care deserts.

METHODS:
Montana conducted the CDC LOCATe assessment in 96% (N=25) of hospitals with an L&D and adapted an assessment used internationally by the World Health Organization to assess emergency obstetric capacity in 94% of CAHs without an L&D. Surveys were conducted in REDCap, and the research team provided facilities with technical support in their completion of the assessments.

RESULTS:
While half of CAHs without L&D reported an emergency delivery in the last 2 years, just one reported capacity to perform all services necessary to safely manage emergency deliveries. Two-thirds of facilities without L&D units did not have a written transport protocol. In hospitals with L&D who conducted the LOCATe assessment, nearly half (48%) overestimated the level of maternal health care that they were able to provide. Ultrasound and maternal-fetal medicine were the most common capacity insufficiencies.

CONCLUSION:
The system assessments revealed specific interventions that can expand capacity for quality obstetric care in a rural state like Montana, such as simulation training, adoption of AIM safety bundles through the perinatal quality collaborative, and enhanced access to ultrasound and maternal-fetal medicine services through telemedicine. National assessments like LOCATe should be adapted for the rural context to facilitate targeted resource investments.
A Simulation Model of the Effects of Tailored Prenatal Care Delivery on Care Access [ID: 1377136]
Authors: Kandiraju Meghana , Bryan Timothy , Cohn Amy , Ghrayeb Leena , Kingston Cole , Peahl Alex 
Published: May 2023

INTRODUCTION:
The Michigan Plan for Appropriate Tailored Healthcare in pregnancy (PATH) recommends tailoring prenatal care delivery to patients’ risk factors for visit number (for low risk: 8–9 visits; for high-risk patients: 12–14 visits) and preferences for care modality (in-person only or hybrid with virtual visits). We used simulation to explore how tailored prenatal care recommendations affect care access.

METHODS:
A discrete event simulation was created in C++ to assess the operational effects of tailored recommendations in comparison to standard care. Patients enter the system and are divided into low-risk and high-risk categories based on medical conditions. The simulation models dynamic patient arrivals, varied patient classifications, tailored pathways, heterogeneous durations of total care, and patient flow until each patient's pathway ends (eg, childbirth). Metrics captured include patient delays, overbooked appointments, and unused capacity. The model was run with 1,000 replications during a 52-week period with a 10-year warm-up period to reach steady-state equilibrium within the simulation. The IRB designated this analysis of de-identified data exempt.

RESULTS:
Transitioning to the new prenatal care model reduced mean care delays per patient in all care modalities by 3.5 weeks for low-risk patients (9.79 weeks–6.37 weeks) and 0.4 weeks for high-risk patients (9.8 weeks–9.4 weeks). Tailoring care reduced the percentage of overbooked appointments by an average of 9.4% and the average unused capacity by 7.4%.

CONCLUSION:
Tailored prenatal care models including telemedicine result in improved operational efficiencies.
The Feasibility of Establishing a Canadian Obstetric Survey System (CanOSS) for Severe Maternal Morbidity: Interim Results [ID: 1377349]
Authors: D'Souza Rohan , Ashraf Rizwana , Malhamé Isabelle , Seymour Rebecca 
Published: May 2023

INTRODUCTION:
Obtaining granular data on events and circumstances leading to severe maternal morbidity (SMM) could complement large epidemiologic studies and enable targeted interventions to improve maternal health. This study aims to assess the feasibility of gathering such data from maternity units across Canada through a Canadian Obstetric Survey System (CanOSS).

METHODS:
The study is a sequential explanatory mixed-methods study, the first step of which is a nationwide survey of maternity unit leads. Semistructured qualitative interviews are being conducted with unit leads that expressed interest in response to the survey. Responses are reported using proportions and percentages. Interviews are being thematically analyzed. This study was approved by the Hamilton Integrated Research Ethics Board (HiREB) #14002.

RESULTS:
As of October 18, 2022, we have identified 306 maternity units nationally, and sent 218 surveys, with 59 maternity units across 8 provinces completing. Among these, 34 (83%) report having a system in place for reviewing SMM, conducted on an as-needed basis in 61% of units, and most commonly involving a multidisciplinary panel of experts with representation from nursing (85%), maternity unit leadership (79%), and hospital management (74%). A written report is prepared following 76% of meetings. Findings are shared with health care professionals involved in the event and formulated into recommendations in 79% and 82% of units, respectively. Importantly, 78% of respondents would be willing to contribute anonymized data on SMM within a centralized reporting system. Interviews have taken place with 14 unit leads. Interviewed participants unanimously agree that an obstetric survey system is needed. Concerns raised include privacy, resources, funding, and having a clear definition of SMM.

CONCLUSION:
This feasibility study will facilitate future planning, clarify barriers to be addressed, and resource implications for gathering data on SMM at a national level, and lay the foundations for a future CanOSS.