bluuebunny/crossref_metadata_2025_split huggingface dataset:
Surgical Site Infection Risk in Patients With Superobesity Undergoing Cesarean Delivery [ID: 1377550]
Authors: VanDillen Michael , Feltner Catherine , Gold Joann , Houser Molly , Lund Amanda 
Published: May 2023

INTRODUCTION:
Studies have reported increasing surgical site infection rates with increases in body mass index (BMI). Given a recent increase in the prevalence of BMI of 50 or higher across the United States, we sought to determine the association between incremental increases in BMI and the risk of surgical site infections.

METHODS:
This represents an IRB-approved single-institution retrospective cohort of patients with superobesity who underwent cesarean delivery from 2019 to 2022. The patient population is composed of predominantly underserved Black women receiving care at a safety net hospital serving a tri-state area in the mid-South. SPSS was utilized for data analysis to assess associations between variables. Covariate analysis was performed with logistic regressions.

RESULTS:
A total of 246 patients were included in the analysis. Patients were predominantly Black (84%, n=204) with public insurance (88.5%, n=201), and a median age of 30. Patients had a median BMI of 54. The median surgical site infection rate was found to be 11.8% (n=29). Surgical site infection rate in Pfannenstiel versus vertical was 7.4% (n=14) versus 16% (n=23.2) (odds ratio 2.29, P=.01). Surgical infection risk was 6.1% in BMI 40–49, 12.7% in patients with superobesity with BMI higher than 50, and 18.3% in patients with BMI higher than 60.

CONCLUSION:
Our study found that increasing increments of obesity are associated with increased morbidity. Regardless of incision type, surgical site infection rates are high in BMI greater than 60. A diagnosis of preeclampsia and reported allergy to antibiotics were found to exacerbate the risk for infection. This relationship warrants further investigation on interventions to mitigate these risks.
Efficacy of Transcervical Balloon Catheter Versus Hygroscopic Dilator for Outpatient Prelabor Cervical Ripening [ID: 1382587]
Authors: McCue Brigid , Demertzis Kristen , Lin Brenda , Lu Anjanique Mariquit , Muscat Jolene , Shahani Disha Prakash 
Published: May 2023

INTRODUCTION:
Outpatient preinduction cervical ripening with mechanical agents has been associated with reduced length of stay and cesarean delivery rates. This study aimed to demonstrate equivalence in efficacy and patient satisfaction between balloon catheter and hygroscopic dilators for outpatient cervical ripening.

METHODS:
This randomized control equivalence trial compared the 30-cc silicone Foley catheter (off-label) to Dilapan-S. Inclusion criteria were elective induction, low risk, group B streptococcus negative, and Bishop score of less than 6. The primary outcome was time from admission to delivery. Secondary outcomes included cesarean delivery rates, pain scores, and patient satisfaction. A power calculation determined 150 patients per arm were needed. Ochsner Health IRB approved CR00003326.

RESULTS:
Between March 1, 2019, and May 31, 2021, 8,150 deliveries occurred, with 1,605 patients meeting screening criteria and 175 completing the study. Time from admission to delivery for balloon was 17.7 hours versus 17.9 hours for dilators. The mean time difference was −0.1524 hours (90% CI –2.4617 to 2.1569), which was statistically significantly equivalent within the specified symmetrical 3-hour equivalence margin (P=.0215). Pain scores with insertion were 3.52 with balloon versus 3.87 with dilators. Satisfaction with outpatient cervical ripening was 91.7% with balloon versus 97.4% with dilators. Cesarean delivery rate of primiparous patients was 31% with balloon versus 25.3% with dilators.

CONCLUSION:
Although the enrollment goal was unmet, metrics suggested outpatient cervical ripening with balloon catheter and hygroscopic dilators were equivalent in time from admission to delivery and patient-reported pain scores. Further research is needed to assess a potential trend toward improved satisfaction and cesarean delivery rate with dilators.
Low-Dose Aspirin Prescription for Pregnant People at Risk for Preeclampsia [ID: 1356912]
Authors: Jaeke Elisha , Domeyer-Klenske Amy , Johnson Morgan , Palatnik Anna , Snowden Nina 
Published: May 2023

INTRODUCTION:
Low-dose aspirin (LDA) prescription during pregnancy is recommended for preeclampsia prevention for patients with one or more high-risk factors and two or more moderate-risk factors. Despite recognition that LDA is beneficial for at-risk patients, there appear to be gaps in the practice of prescribing LDA. Our objective was to measure prescriber adherence in a Midwestern health network.

METHODS:
A retrospective cohort analysis was performed using data from the electronic health records (EHRs) of a Midwestern health network. Patients who began prenatal care prior to 28 weeks and gave birth between September 2021 and December 2021 were included. Risk factors for preeclampsia and LDA prescription were extracted from the EHRs, with public insurance serving as a proxy for low socioeconomic status. Patients were excluded if LDA was contraindicated or prescribed for a purpose other than preeclampsia prevention.

RESULTS:
A total of 360 patients qualified for LDA recommendation during the study period. Of the 120 patients with at least one high-risk factor, 86 (71.7%) were prescribed LDA. Of the 240 patients with at least two moderate-risk factors, 54 (22.5%) were prescribed LDA. Among the 34 patients with a high-risk factor who were not prescribed LDA, the most common missed indication was autoimmune disease. Among the 186 patients with two or more moderate-risk factors who were not prescribed LDA, the most common risk factors included sociodemographic risk, nulliparity, and obesity.

CONCLUSION:
Our data demonstrate the need for quality improvement interventions targeting patients with two or more moderate-risk factors or the high-risk factor of autoimmune disease.
The Conceptualization of Pregnancy-Associated Maternal Morbidity in Research Studies: A Scoping Review [ID: 1376717]
Authors: Feldman Sherry , D'Souza Rohan , Gupta Gauri 
Published: May 2023

INTRODUCTION:
This study aimed to review the clinical literature to understand how maternal morbidity has been conceptualized.

METHODS:
We conducted a scoping review wherein we searched four databases until May 2022 for studies on maternal morbidity. We screened abstracts in duplicate and extracted data on the study scope, terms used to describe maternal morbidity, and conditions included. Results were presented descriptively.

RESULTS:
We identified 8,178 titles, of which 589 studies from 1986 to 2022 were included in the final analysis. Included studies used 73 terms to describe maternal morbidity. While 217 (37%) studies described maternal morbidity in the context of the general pregnant population, others described more specific contexts, for example, hypertensive disorders of pregnancy (43 studies, 7%), obesity (38 studies, 6%), and gestational and pregestational diabetes (31 studies, 5%). In terms of component outcomes, 156 (26%) studies utilized the World Health Organization criteria for maternal near miss and potentially life-threatening conditions or the Centers for Disease Control and Prevention criteria for severe maternal morbidity, while others included between one and 45 outcomes, the most frequent of which were intensive care unit admission, preeclampsia, eclampsia, hemorrhage, uterine rupture, hysterectomy, and blood transfusion. Notably, 36 (6%) studies included fetal or neonatal outcomes when describing maternal morbidity.

CONCLUSION:
Although maternal morbidity is reported in a large number of pregnancy studies, there is no consistency in what outcomes are included in its definition. There is need for a standardized definition of maternal morbidity that embodies the perspectives of persons with lived experience of pregnancy.
Promoting Best Practice in Obstetrics: Findings From a State-Based Perinatal Quality Collaborative Implementing the Obstetric Hemorrhage Maternal Safety Bundle [ID: 1377611]
Authors: Kheyfets Anna , Conklin Claire , Iverson Ronald , Meadows Audra , Vitek Kali 
Published: May 2023

INTRODUCTION:
The Perinatal Neonatal Quality Improvement Network (PNQIN) of Massachusetts engaged hospital teams in a statewide improvement initiative to address maternal morbidity from obstetric hemorrhage (OB HEM) through support of implementation and adherence to best practices in screening for and diagnosis of OB HEM.

METHODS:
The Alliance for Innovation on Maternal Health (AIM) OB HEM bundle was adapted and implemented across hospitals in Massachusetts from June to December 2021. Each month, participating hospital teams joined educational webinars, learned quality improvement strategies, received access to resources for the intervention, and submitted data on six structure and five process measures. Severe maternal morbidity rates were provided using state hospital discharge data. Reliability of implementation was monitored by structure and process measure submission. Aggregate data were shared statewide.

RESULTS:
Fifty-three percent of birthing hospitals in the state (21 of 40) voluntarily participated. Baseline risk screening for OB HEM was 93% and quantitative blood loss measurement (QBL) was 60% in aggregate for all teams. Six participating hospitals reported all 11 measures monthly across the 6-month period. Half of these sites had all six structure measures in place at baseline and 83% reported completion of structure measures by the end of the study period. Among these six sites, the cumulative proportion QBL utilization increased 178% from 28% to 78% and documented OB HEM risk assessment during labor admission increased 8.4% from 83% to 90%.

CONCLUSION:
Implementation of the OB HEM bundle was effective in increasing adherence to evidence-based care among participating birth hospitals through a collaborative, quality improvement approach.
Placental Pathology After Low-Impact Maternal Trauma [ID: 1380074]
Authors: Sridhar Shobha , Chornock Rebecca , Kumnick Allison , Lotke Pamela 
Published: May 2023

INTRODUCTION:
Placental abruption is the most common cause of fetal death in cases of blunt trauma, and the majority of abruptions occur within 24 hours of the injury. Because of this potential complication, the observation time after trauma remains controversial. Our study aims to demonstrate the incidence of placental abruption and abnormal placental pathology at the time of delivery in women who have experienced low-impact trauma.

METHODS:
This was a retrospective cohort study of pregnant patients between the years of 2014 and 2020 at MedStar Washington Hospital Center who presented to triage for low-impact trauma identified by “trauma,” “IPV,” “fall,” or “MVA.” MedStar Health Research Institute IRB approved this study. Data from their evaluation during triage visit, mode of delivery, and placental pathology were assessed. Patients were de-identified and analyses included χ2 tests, linear regression, and multinomial logistic regression analyses, as appropriate (α=0.05).

RESULTS:
Of 184 patients identified, delivery data were available for 144 (79%). The mean time from trauma to delivery was 9 weeks. After delivery, the placental pathology was grossly assessed or sent to pathology, and 76.6% were intact with 7.6% noting an infarct when sent to pathology. Observation time did not predict placental infarction or calcification. The type of trauma did not correlate with mode of delivery (P=.629), prelabor preterm rupture of membranes (P=.746), placental infarct (P=.358), intact placenta (P=.834), or placental calcification (P=.288).

CONCLUSION:
Although a small percentage of patients who experienced low-impact trauma had infarction identified on placental pathology, no patients experienced clinical or pathologic placental abruption in 24 hours after trauma.
Predicting Patients Requiring Treatment for Depression in the Postpartum Period From Common Electronic Medical Record Data Antepartum Using Machine Learning [ID: 1365796]
Authors: Wakefield Colin , Frasch Martin 
Published: May 2023

INTRODUCTION:
Depression requiring treatment in the postpartum period significantly affects maternal and neonatal health. While preventive management of depression in pregnancy has been shown to decrease the negative effects, current methods for identifying at-risk patients are insufficient. Given the complexity of the diagnosis and interplay of clinical/demographic factors, we tested whether machine learning (ML) techniques can accurately identify patients at risk of depression requiring treatment in the postpartum period (PPD).

METHODS:
This is a retrospective cohort study of the NIH Nulliparous Pregnancy Outcomes Study (nuMoM2b), which enrolled 10,038 nulliparous people. The primary outcome was PPD. We constructed and optimized four ML models using distributed random forest modeling based on the nuMoM2b dataset. Model 1 utilized only readily obtainable sociodemographic data. Model 2 added maternal prepregnancy mental health data. Model 3 utilized recursive feature elimination to construct a parsimonious model. Model 4 further titrated the input data to exclude prepregnancy mental health variables.

RESULTS:
Of 8,454 births, 338 (4%) were complicated by PPD. Model 3 was the highest performing, demonstrating the area under the receiver operating characteristics curve (AUC) of 0.91 (±0.02). Models 1–3 identified the nine variables most predictive of depression hierarchically ranging from body mass index (highest), prior depression, age, income, medications, education, past medical history, race, and prior anxiety (lowest). In model 4, the AUC remained at 0.80 (±0.04).

CONCLUSION:
Counterintuitively, the presence of prepregnancy mental health conditions is not the most predictive factor of PPD. Furthermore, PPD can be predicted with high accuracy for individual patients using antepartum information commonly found in the electronic medical record.
Defined Protocol Including Quantitative Blood Loss Obviates the Need for Postpartum Day 1 Complete Blood Count in Uncomplicated Vaginal Deliveries [ID: 1371414]
Authors: Stansbury Nicholas , Creedon Douglas , Palacios Diana 
Published: May 2023

INTRODUCTION:
A postpartum day 1 (PPD1) complete blood count (CBC) is a common postpartum practice. The purpose of PPD1 CBCs is to identify patients with anemia that may benefit from a blood transfusion (BT). However, after the introduction of quantitative blood loss (QBL), we questioned the benefit of PPD1 CBC collection. This study aimed to determine whether PPD1 CBCs provided clinical utility in objectively defined uncomplicated vaginal deliveries.

METHODS:
A retrospective chart review was performed on all vaginal deliveries from January 1, 2021 to January 31, 2022, at a single-site level IV maternity facility. Exclusion criteria were as follows: intraamniotic infections, QBL of 1,000 mL or more, starting hematocrit less than 35, or no documented QBL. Patients were divided into three groups based on QBL: less than 500 mL, 501–749 mL, and 750–999 mL.

RESULTS:
The total number of deliveries was 2,427. One thousand two hundred fifty-three met inclusion criteria: QBL less than 500 mL: 922; 501–749 mL: 240; and QBL 750–999 mL: 91. Among all included deliveries, one patient, in the QBL 750- to 999-mL group, received a BT due to symptomatic anemia but had hemoglobin and hematocrit greater than 7/21. The total cost of PPD1 CBCs for included deliveries was $87,710.

CONCLUSION:
None of the patients in this study who met the inclusion criteria received a BT based on the PPD1 CBC result. This indicates that a PPD1 CBC is of limited clinical utility when uncomplicated vaginal deliveries are defined using this purely objective protocol in the setting of QBL. Therefore, elimination of a PPD1 CBC is consistent with best practice and results in postpartum care cost reduction.
Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People With Gestational Diabetes [ID: 1375592]
Authors: Ayala Nina , Fain Audra , Hamel Maureen , Schlichting Lauren , Smith Megan , Werner Erika 
Published: May 2023

INTRODUCTION:
The 2-hour glucose tolerance test (GTT) performed during delivery hospitalization is as predictive of postpartum dysglycemia as the 4- to 12-week test. Our objective was to assess test uptake as part of routine care rather than a research protocol.

METHODS:
This is a retrospective cohort study of patients with gestational diabetes mellitus (GDM) at a high volume center. The in-hospital (“early”) GTT began being offered in early 2021 as postpartum glucose screening option, and we collected 6 months of postimplementation data. Adherence to the GTT was compared between those who elected an early GTT versus those who deferred testing. Descriptive characteristics including demographics, care team characteristics, and postpartum testing/visit attendance were compared between those who received an early GTT and those who did not. Institutional review board approval was waived.

RESULTS:
Six hundred eighty-one patients with GDM delivered during the study period, and 340 (50%) received the early GTT. Of those who had an early GTT ordered (n=408), 83.3% completed the test. Among those who did not receive an early GTT, only 104 (30.5%) completed any postpartum glucose testing. There were significant differences in demographic characteristics among those who completed the early GTT compared to those who did not. When postpartum visit attendance was assessed, those who completed an early GTT had a lower rate of attendance compared to those who deferred (75.6% versus 91.5%, P<.01).

CONCLUSION:
When an early GTT is offered in clinical practice, adherence rates are still significantly higher than when the test is deferred until the postpartum visit.
Differences in Rural and Urban Treatment of Postpartum Depression and Anxiety in the United States [ID: 1377353]
Authors: Gimbel Lauren , Bruno Ann , Horns Joshua , Paudel Niraj , Silver Robert , Smid Marcela 
Published: May 2023

INTRODUCTION:
The objective of this study was to evaluate pharmacologic and psychotherapy treatment among individuals with postpartum depression or anxiety living in urban versus rural areas of the United States.

METHODS:
We performed a retrospective cohort study of individuals diagnosed with postpartum depression or anxiety within 12 months of delivery from 2011 to 2020 in the MarketScan Commercial Research Database. Individuals with postpartum depression and anxiety were identified using International Classification of Diseases codes. Individuals previously receiving treatment were excluded. The exposure, urban residence, was determined by residence in a metropolitan statistical area. The primary outcome was a composite of pharmacologic and psychotherapy treatment. Secondary outcomes included components of the primary outcome and time from delivery to first prescription fill. Multivariable modeling adjusted for clinically relevant confounders including history of depression or anxiety. Sensitivity analysis included individuals with prior treatment.

RESULTS:
Of 1,602,058 individuals included, 1,415,793 (88%) had urban residence. Individuals with postpartum depression or anxiety residing in urban areas were less likely to receive treatment (adjusted hazard ratio [aHR] 0.86, 95% CI 0.85–0.88) than those residing in rural areas, including pharmacologic (aHR 0.75, 95% CI 0.73–0.77), and psychotherapy (aHR 0.94, 95% CI 0.92–0.96). Fifty percent of individuals filled a prescription by 107 days from delivery in urban compared to 100 days in rural areas. Results were similar in sensitivity analysis.

CONCLUSION:
Urban-residing individuals with postpartum depression or anxiety were less likely to receive pharmacologic or psychotherapy treatment than rural-residing individuals in this U.S. cohort. Future studies evaluating reasons for treatment differences are warranted.
Postpartum Insurance Discontinuity and Use of Prescription Contraceptive Methods [ID: 1377734]
Authors: Schaefer Kimberly , Hacker Michele , Hawkins Summer , Molina Rose 
Published: May 2023

INTRODUCTION:
Medicaid eligibility income thresholds increase during pregnancy and historically ended 60 days postpartum. Thus, this postpartum period is especially vulnerable to insurance discontinuity, which may decrease access to contraception.

METHODS:
We used Pregnancy Risk Assessment Monitoring System survey data (2012–2020) in 42 states. Exposure, assessed 2 or more months after childbirth, was categorized as continuous insurance, insurance loss, discontinuous Medicaid-to-private, and discontinuous private-to-Medicaid. We used modified Poisson regression to estimate risk ratios (RRs) with 95% CIs for using contraception methods requiring prescriptions compared to nonprescription methods/none, adjusted for race and ethnicity, language, education, age, marital status, federal poverty level, and year. We then stratified by Medicaid expansion status at time of delivery.

RESULTS:
Of 246,088 respondents, 76.4% held continuous insurance from childbirth to 2 or more months postpartum, 11.9% lost insurance, 7.6% experienced discontinuity from Medicaid-to-private insurance, and 4.1% from private-to-Medicaid. Compared to continuous insurance, the adjusted RR for prescription postpartum contraception was 0.88 (CI 0.86–0.89) for loss of insurance, 0.99 (0.97–1.01) for discontinuous Medicaid-to-private, and 0.96 (0.93–0.98) for discontinuous private-to-Medicaid. Stratification by Medicaid expansion status yielded similar results. Of respondents in states or time periods without Medicaid expansion, 16.2% experienced insurance loss compared to 7.9% of those with Medicaid expansion.

CONCLUSION:
Insurance loss 2 or more months after childbirth was associated with decreased likelihood of prescription postpartum contraception, with a higher proportion of respondents without Medicaid expansion vulnerable to such insurance loss. Increased state adoption of the federal 12-month postpartum Medicaid extension option could improve access to prescription postpartum contraception.
Remote Patient Monitoring for Postpartum Hypertensive Disorders of Pregnancy [ID: 1378058]
Authors: Spiro Leah , Bairey Merz C. Noel , Bello Natalie , Kilpatrick Sarah , Minissian Margo , Wei Janet 
Published: May 2023

INTRODUCTION:
Hypertensive disorders of pregnancy (HDP) account for 2.5–4.6% of readmissions within 6 weeks postpartum (PP); 60% occur in the first 7 days. A standardized approach to HDP management can improve outcomes through optimized PP blood pressure (BP) management. Remote patient monitoring (RPM) has established safety, outcomes, financial benefit, and increased compliance. The primary outcome of this study was to determine the feasibility of a standardized RPM program for PP patients with HDP.

METHODS:
Participants (n=30) received a phone application and BP monitor that automatically uploaded data to a nurse practitioner (NP)-monitored dashboard. Participants were asked to record a single BP twice daily (6 am–11 am and 6 pm–11 pm) until 10 days PP. Telehealth visits with an NP occurred at 48 hours postdischarge. Feasibility was measured using a one-sided t test of the proportion of participants with satisfaction (via validated Likert-style post-participation surveys) and adherence of 80% or higher (recorded BPs/expected BPs). Secondary outcomes included readmissions, elevated BPs (mild, 140–159/90–109 mm Hg; severe, ≥160/110 mm Hg), and antihypertensive medication up-titration.

RESULTS:
One hundred percent of participants completed the program. Overall adherence rate was 91%, and overall satisfaction rate was 92%. Of 450 recorded BP measurements, 88 (19.6%) were mild and 2 (0.4%) were severe, with 0 hospital readmissions. Medication up-titration occurred seven times in six participants (20%). We demonstrated feasibility with a proportion of 0.767 participants (P=.0027; CI: 0.577, 0.885).

CONCLUSION:
A standardized RPM program for PP HDP utilizing early telemedicine visits with an NP successfully demonstrated feasibility in a pilot sample of PP patients. Compliance with PP follow-up recommendations was high. Future work to improve systems innovation for BP optimization in PP patients is needed.