bluuebunny/crossref_metadata_2025_split huggingface dataset:
Intra-amniotic Instillation of Indocyanine Green in Uncertain Cases of Preterm Prelabor Rupture of Membranes [A185]
Authors: VanHise Katherine , Dellapiana Gabriela , Silverman Neil S. 
Published: June 2022

INTRODUCTION:
Amniocentesis with intra-amniotic dye instillation can be used to determine membrane status in clinically equivocal cases of preterm prelabor rupture of membranes (PPROM). Indigo carmine dye has been traditionally utilized for this purpose, with leakage of blue fluid from the vagina considered diagnostic of PPROM. However, with recent national shortages of this agent, alternates such as indocyanine green need to be considered.

METHODS:
This is a case series of four patients with suspected PPROM who underwent intra-amniotic dye instillation of indocyanine green dye during the years 2019–2021. Patients ranged between 31 0/7 and 32 4/7 weeks of gestation at time of dye instillation. Three milliliters of a 2.5 mg/mL solution of indocyanine green were instilled; following the procedure, patients were observed for leakage of green fluid from the vagina. Written consent was obtained from each patient for publication. Institutional review board approval for a case series consisting of less than five cases is not required at our institution.

RESULTS:
In all four cases, membranes were found to be intact, and all patients went on to have uncomplicated deliveries at or near term. We observed transient fetal premature atrial contractions following indocyanine green instillation in one patient that resolved spontaneously within 12 hours. No other maternal, fetal, or neonatal adverse events were identified in our patients either following the intra-amniotic dye instillation or at the time of delivery.

CONCLUSION:
Indocyanine green should be considered as a safe alternative to indigo carmine for use in intra-amniotic dye instillation to establish or exclude a diagnosis of PPROM.
Trial of Labor and Vaginal Birth After Cesarean Delivery: Racial Disparities Modified by Payment Source [A187]
Authors: Vila Irigoyen Ana I. , Hollinger Ruby C. , Schreiber Marina , Rodriguez Pura , Cherry Sheldon H. , Pelaez Juan Ruiz 
Published: June 2022

INTRODUCTION:
The cesarean delivery rate in the United States is three times that recommended by the World Health Organization and contributes excessively to maternal morbidity and mortality, especially in Black women. Vaginal birth after cesarean delivery (VBAC) is a proposed solution, given that the primary indication for cesarean delivery is a previous cesarean delivery. Barriers to VBAC not only include medical contraindications, but also race/ethnicity and social factors, such as payment source. This study explored the associations between maternal race/ethnicity, attempt of trial of labor after cesarean delivery (TOLAC), and successful VBAC.

METHODS:
A retrospective cohort study examined 262,946 deliveries in the U.S. in 2019 after prior cesarean delivery; 68,912 underwent TOLAC. Multiple logistic regression assessed associations between maternal race/ethnicity and outcomes adjusting for confounders and effect modification from payment source.

RESULTS:
Among women with Medicaid, Black women had the highest odds of TOLAC (OR, 1.52; 95% CI, 1.46–1.58), but lower odds of VBAC (OR, 0.72; 95% CI, 0.67–0.77). White women with Medicaid had the lowest odds of TOLAC (reference group), but the highest odds of VBAC. With private insurance, Black women had the highest odds of TOLAC (OR, 1.22; 95% CI, 1.16–1.27), but the lowest odds of VBAC (OR, 0.60; 95% CI, 0.55–0.65). White women with private insurance had the highest odds of VBAC.

CONCLUSION:
Racial/ethnic disparities exist in whether TOLAC is attempted and VBAC is successful. Further, these disparities are modified by payment source. Future directions should examine these associations in the context of location, resources, patient education, and provider attitudes to elucidate the source of this difference and address inequality in VBACs.
Food Desert Residence and the Effect on Breastfeeding Initiation [A199]
Authors: Smith Mary Ann , Tanner Jean Paul , Campos Adriana , Wilson Ronee , Fryer Kimberly , Jacques Adetola Louis 
Published: June 2022

INTRODUCTION:
A myriad of social determinants of health (SDH) impact breastfeeding initiation (BFI). Prior research by this group using ecological data demonstrated that food desert residence (FDR) is associated with lower rates of BFI. This study uses individual level data to examine the effect of FDR on BFI.

METHODS:
Florida Department of Health birth data from 2019 were linked to the 2019 United States Department of Agriculture (USDA) Food Access Research Atlas. Food desert census tracts were defined per the USDA definition. Adjusted risk ratios (aRR) and 95% CIs were calculated using modified Poisson regression models. Models were adjusted for known SDH.

RESULTS:
Of 209,087 live singleton births, 16% resided in a food desert. FDR birthers had decreased BFI compared to non-FDR birthers (aRR, 1.23). Risk of decreased BFI was highest among Black birthers (aRR, 1.26) and lowest among Hispanic (aRR, 0.58) and Asian/Pacific Islander birthers (aRR, 0.74). Lower education level was associated with decreased BFI compared to college-educated birthers (aRR, middle school, 5.42; high school, 3.46; some college education, 1.95). History of diabetes and preterm or low-birth-weight infants (aRR, 1.14, 1.47, and 1.38, respectively) were also associated with reduced BFI.

CONCLUSION:
After adjustment for known SDH impacting BFI, FDR remains an important risk factor for decreased BFI. Level of education was the SDH most strongly associated with decreased BFI. Understanding how FDR impacts BFI allows better tailoring of interventions to increase BFI.
Does Preferred Spoken Language Affect Time to Epidural for Nulliparous Patients? [A203]
Authors: Bonilla Kevin , Kouba Insaf , Nguyen Anthony , Blitz Matthew J. 
Published: June 2022

INTRODUCTION:
Some studies have observed sociodemographic disparities in administration of intrapartum epidural anesthesia. Our objective was to determine whether preferred spoken language was associated with time to epidural administration.

METHODS:
This was a retrospective cohort study of all nulliparous patients admitted for labor or induction at one academic hospital in New York who received intrapartum epidural analgesia prior to delivery from January to December 2019. The outcome was time to epidural, which was evaluated for English-speaking and non-English-speaking patients. For patients undergoing scheduled induction, time to epidural was defined as the interval from induction agent to epidural administration. For patients admitted in spontaneous labor, time to epidural was defined as the time interval from hospital presentation to epidural administration. Demographic and clinical data were collected. Patients in the induction and spontaneous labor groups were analyzed separately.

RESULTS:
A total of 417 patients were included: 215 (52%) inductions and 202 (48%) presenting in spontaneous labor. Overall, 264 (63%) patients preferred English and 153 (47%) preferred another language (primarily Spanish). In the spontaneous labor group, there was no difference in time to epidural between English-speaking and non-English-speaking patients (307 versus 272 minutes, respectively). Among scheduled inductions, time to epidural was lower for English speakers than non-English speakers (869 versus 1,100 minutes, respectively; P<.01). English-speaking patients were more likely to be induced (56% versus 43%, P<.01). Sociodemographic factors such as age, race/ethnicity, and marital status were not associated with time to epidural.

CONCLUSION:
Preferred language was not associated with time to epidural in the spontaneous labor group, but a significant difference was noted for patients undergoing induction. Non-English-speakers may experience delayed analgesic interventions.
Initial Screening Results for Gonorrhea and Chlamydia in Pregnancy and the Association With Subsequent Test Results [A216]
Authors: Kairis Kelsey , Holbert Michael , Von Hoene Amanda , Mitchell Ashley 
Published: June 2022

INTRODUCTION:
Gonorrhea and chlamydia infections during pregnancy are associated with adverse perinatal outcomes. The Centers for Disease Control and Prevention recommends screening for gonorrhea and chlamydia at the first prenatal visit and again in the third trimester for high-risk patients. The objective of this study is to determine rates of subsequent positive gonorrhea/chlamydia tests in pregnant patients based on their initial screening results.

METHODS:
This is an institutional review board‒approved multicenter observational study including patients who delivered from January 1, 2014, to December 31, 2020, with more than one gonorrhea/chlamydia test during pregnancy. Patients whose initial tests were negative were compared with patients whose initial tests were positive. Fisher’s test and multiple logistic regression were performed.

RESULTS:
There were 8,163 pregnancies with multiple gonorrhea tests and 8,213 pregnancies with multiple chlamydia tests. There was a significant difference in subsequent gonorrhea-positives in pregnancies with an initial positive test (33/194, 17.0%) compared to an initial negative test (10/7,969, 0.1%); odds ratio (OR), 163.2; 95% CI, 76.5–378.2; P<.001. Likewise, there was a significant difference in subsequent chlamydia-positives in pregnancies with an initial positive test (266/1,003, 26.5%) compared to an initial negative test (37/7,210, 0.5%); OR, 69.9; 95% CI, 48.9–102.3; P<.001. These associations remained significant following logistic regression to control for confounders.

CONCLUSION:
Among pregnancies with an initial negative gonorrhea/chlamydia screening result, subsequent positive results were unlikely. This may be a simple differentiator for the need for subsequent testing in pregnancy, leading to significant cost savings.
Head-to-Body Interval and Neonatal Outcomes After Shoulder Dystocia [A225]
Authors: Antelo Leonardo F. , Williams Shauna , Krishnamoorthy Kaila , Powell Kimone A. , Apuzzio Joseph , Gittens-Williams Lisa 
Published: June 2022

INTRODUCTION:
Shoulder dystocia (SD) is a potentially devastating emergency. Complications may result from maneuvers, yet delivery delay can result in hypoxic-related injury. Awaiting the next contraction is reported to assist in shoulder rotation. We hypothesized that shorter head-to-body delivery interval (HBI) is associated with an increase in neonatal injury without an increase in hypoxia-related sequelae.

METHODS:
This is a retrospective, institutional review board‒approved review of records of patients with singleton pregnancies at a tertiary-care hospital (January 1, 2015, to May 31, 2021). Patients were included if SD was documented in the delivery summary. Neonatal injury was defined as brachial plexus injury, clavicular fracture, or humerus fracture, and were compared based on HBI.

RESULTS:
A total of 9,044 deliveries occurred during the study period. Of these, 71 patients were identified with SD; one was excluded. Of patients with SD, 71% had HBI <3 minutes, 90% had HBI <4 minutes, and one had HBI >6 minutes. Cord pH was available for 67% of patients, none of whom had pH <7.0. Neonatal injury was documented in 22 deliveries and was similar between HBI ≤3 minutes and >3 minutes (30% versus 42%, P=.67). Cord pH was similar with and without neonatal injury (7.177 versus 7.223, P=.069). Two infants had hypoxic injury, both with HBI >4 minutes.

CONCLUSION:
HBI was not associated with neonatal injury. Hypoxic injury was rare and was only seen with HBI >4 minutes. These data support allowing for maternal effort during the subsequent contraction after delivery of the head when less than 4 minutes.
Initiation of Surveillance for Fetal Growth Restriction: At Time of Diagnosis or at 32 Weeks? [A230]
Authors: Vadlamudi Gayathri D. , Hinge Amita M. , Goyert Gregory , Shaman Majid 
Published: June 2022

INTRODUCTION:
Following the 2020 Society for Maternal–Fetal Medicine guideline on management of fetal growth restriction (FGR), our institution began initiating antenatal surveillance at time of FGR diagnosis instead of at 32 weeks of gestation.

METHODS:
This institutional review board‒approved retrospective cohort study included patients with FGR, without absent or reversed end diastolic velocity in umbilical artery Dopplers, from the 12-month periods preceding and following this change in surveillance. Previously, twice-weekly non-stress testing (NST) was initiated at 32 weeks of gestation. Subsequently, surveillance was initiated at time of FGR diagnosis, with weekly biophysical profile (BPP) starting at 26 weeks and additional weekly NST at 32 weeks. The primary outcome was a composite of neonatal intubation, respiratory distress syndrome, intraventricular hemorrhage, and perinatal death. Secondary outcomes were rates of neonatal intensive care unit (NICU) admission, preterm delivery, surveillance visit attendance, and referral for further monitoring.

RESULTS:
A total of 150 patients were studied: 73 with antenatal testing initiated after 32 weeks and 77 with testing starting at time of diagnosis. There was no difference in primary neonatal composite outcome (6.8% versus 9.1%, P=.766), rates of NICU admission (19.2% versus 18.2%, P=.876), preterm delivery (16.4% versus 16.9%, P=.942), surveillance visit attendance (91.7% versus 88.9%, P=.697), or overall referral rate for further monitoring (8.0% versus 8.2%, P=.894). With initiation of surveillance at time of diagnosis, 7.5% of referrals occurred prior to 32 weeks.

CONCLUSION:
In the setting of FGR with normal Dopplers, initiating antenatal surveillance at time of diagnosis led to increased referrals for further monitoring at earlier gestational ages without improvement in neonatal outcomes.
Mobile Integrated Health for Postpartum Blood Pressure Monitoring: Impact on Hospital Readmissions [A237]
Authors: Goebel Anna M. , Abam Cynthia , Dude Carolynn M. , Boulet Sheree , Stanhope Kaitlyn K. , Geary Franklyn H. 
Published: June 2022

INTRODUCTION:
Starting in December 2019, Grady Memorial Hospital, a public institution in Atlanta, Georgia, implemented a home visiting mobile integrated health (MIH) program to reduce risk for postpartum complications among women with hypertensive disorders of pregnancy (HDP). We aimed to assess the impact of the MIH intervention on readmission rates.

METHODS:
Using electronic medical record for all deliveries between March 2018 and June 2021 at Grady Memorial Hospital, we calculated monthly rates of all-cause readmissions within 42 days of delivery discharge. We used a controlled interrupted time series design to compare readmission rates before (March 1, 2018, to November 30, 2019) and after (December 1, 2019, to June 30, 2021) the implementation of the MIH program for deliveries with and without HDP, assuming a level and slope change. Deliveries without HDP were not eligible for the MIH intervention and were used as controls. Emory’s institutional review board approved this study.

RESULTS:
There were 3,455 deliveries with HDP and 4,479 deliveries without HDP. Overall rates of readmission for deliveries with and without HDP were 3.7% (95% CI, 2.9–4.7%) and 1.8% (95% CI, 1.3–2.4%) in the pre-MIH period and 3.9% (95% CI, 3.0–5.1%) and 1.9% (95% CI, 1.4–2.6%) in the post-MIH period, respectively. We found no evidence of a sudden change in readmission rates (β, 0.029; P=.96) or a linear trend in readmissions (β, –0.069; P=.17) following the implementation of the MIH intervention among deliveries with HDP compared with deliveries without HDP.

CONCLUSION:
A MIH intervention for women with HDP was not associated with decreased rates of postpartum readmissions in our population.
Obstetrics and Gynecology Resident and Physician Experience With Management of Cesarean Wound Complications [A238]
Authors: Olig Emily M. , Reddy Madhuri 
Published: June 2022

INTRODUCTION:
With the increasing BMI of the pregnant population putting women at higher risk for cesarean delivery and subsequent wound complications, it is important to identify where our specialty stands in our ability to manage these complications independently. This study was designed to elicit the general knowledge and comfort level of residents and practicing physicians with respect to managing complex postoperative wound infections after cesarean.

METHODS:
This descriptive study was performed as an anonymous online survey using REDCap database tools. Institutional review board approval was obtained. Links to the online study were sent electronically to program coordinators at U.S. residency programs in obstetrics and gynecology for distribution to their residents and faculty.

RESULTS:
Of the 65 respondents, 65% were trainees and 35% were practicing physicians. Of those with community or combined community/academic training, 65% felt they did not have enough hands-on training in residency. This was true of 33% of those who trained in a predominantly academic setting. Overall, only 10% of respondents either identified wound care as something they did not desire to participate in or as something that was out of their scope of practice. Over half (55%) of respondents in each training group identified continued education in wound care as an essential part of being able to manage these complications independently.

CONCLUSION:
This preliminary study suggests that training in postoperative wound care is often insufficient in residency, and that a significant portion of obstetrician–gynecologists would provide this care to their postoperative patients independently with access to enhanced educational opportunities.
Perspectives of Postpartum Pain Management Among Patients With Prenatal Opioid Exposure [A252]
Authors: Townsel Courtney , Keer Emma , Irani Sanaya , Nguyen Buu-Hac , Hallway Alex , Peahl Alex F. 
Published: June 2022

INTRODUCTION:
Opioid-sparing protocols can reduce postpartum opioid prescribing in opioid-naïve patients; however, patients with a history of opioid use disorder (OUD) and chronic pain are typically excluded from evaluations. We assessed the postpartum pain experience in patients who were not opioid-naïve before delivery.

METHODS:
We conducted a phone survey assessing maternal postpartum pain experiences for all patients with OUD and chronic pain on opioids prenatally who delivered between January 2020 and August 2021 at a single hospital. In this IRB exempt study, verbal informed consent was obtained for all participants. Analyses included simple descriptive statistics.

RESULTS:
Of 24 patients successfully contacted, 17 (71%) participated. Patients were predominantly White (100%, 17/17), publicly insured (76%, 13/17), multiparous (82%, 14/17), had a vaginal delivery (53%, 9/17), and had an average age of 32. Patients were most commonly identified as having OUD (88%, 15/17) followed by chronic pain (12%, 2/17). About a quarter (4/17, 24%) reported poor pain control (7/10 or greater) in the hospital and one week after discharge. Among patients with vaginal deliveries, 11% (1/9) used opioids postpartum, 78% (7/9) used acetaminophen, and 67% (6/9) used ibuprofen. Among cesarean births, 50% (4/8) used opioids postpartum, 100% (8/8) used acetaminophen, and 75% (6/8) used ibuprofen. Of the 69% (11/16) who reported breastfeeding, 45% (5/11) reported some pain interference.

CONCLUSION:
Many patients on maintenance opioids prenatally reported poor postpartum pain control. Non-opioid medications were not optimized in patients undergoing cesarean delivery, suggesting an opportunity for better opioid-sparing pain management strategies.
Estimating In Vivo Levonorgestrel Release Rate and Exposure Over Eight Years With Levonorgestrel Releasing Intrauterine System 52 mg Use With Population Pharmacokinetic Approach [A03]
Authors: Jensen Jeffrey T. , Reinecke Isabel , Lukkari-Lax Eeva , Hofmann Birte M. 
Published: June 2022

INTRODUCTION:
To characterize performance of the levonorgestrel releasing intrauterine system (LNG-IUS) 52 mg (Mirena) for 8 years of use (currently approved for 7 years) and facilitate comparisons with LNG-IUS 19.5 mg and LNG-IUS 13.5 mg, we estimated in vivo LNG release rates and LNG plasma/serum concentrations using a population pharmacokinetic (popPK) approach with data from the Mirena Extension Trial (MET) and earlier clinical trials.

METHODS:
Previously, we developed a popPK model based on measured plasma/serum LNG concentrations and residual LNG content from removed 52 mg, 19.5 mg, and 13.5 mg LNG-IUS devices in clinical studies for up to 5 years of use, estimating in vivo LNG release and describing LNG exposure. To estimate release and exposure for years 6–8 of use, we applied the model to data for 6, 7, and finally 8 years from the MET.

RESULTS:
As expected, LNG release rates for LNG-IUS 52 mg were higher than for 19.5 mg and 13.5 mg devices. After 8 years, LNG-IUS 52 mg release rate (7.04 µg/day) was similar to LNG-IUS 19.5 mg after 5 years (7.6 µg/day) and higher than LNG-IUS 13.5 mg after 3 years (5.5 µg/day). Model-based estimated and measured LNG concentrations showed good agreement, with average plasma LNG concentrations after 8 years LNG-IUS 52 mg (100ng/L [CV%: 39.9%]) similar to after 5 years LNG-IUS 19.5 mg (84.8ng/L [39.9%]) and higher than after 3 years LNG-IUS 13.5 mg (58.1ng/L [40.8%]) use.

CONCLUSION:
LNG release rates from LNG-IUS 52 mg at 8 years are similar to 19.5 mg at 5 years and higher than 13.5 mg at 3 years. The 8-year popPK model provides in vivo LNG release rate and concentration estimates, facilitating more direct comparisons between the three LNG-IUSs.
Medical Student-Led Implementation of Preclinical Abortion Didactics [A09]
Authors: Cardall Anna K. , Barker Margot , Rosecrance Katherine G. , Masini Irene , Patibandla Yamini , Patel Jasmine 
Published: June 2022

INTRODUCTION:
Although all physicians encounter patients who have had abortions, formal abortion education in medical school is often limited to individual interest. Given that less than 50% of US medical schools formally discuss abortion care, we evaluated a preclinical session for our fellow medical students teaching about abortion care.

METHODS:
We created and presented a didactic session reviewing non-biased pregnancy options counseling and outlining abortion epidemiology, techniques, and safety with an interactive small group case-based discussion. We anonymously obtained pre- and post-intervention surveys which collected demographics and views on the necessity and impact of the session as well as evaluated changes in participants’ knowledge of and attitudes towards abortion. We compared matched results using McNemar’s test for discordant pairs.

RESULTS:
Ninety-two first- and second-year medical students participated in both surveys, for a 76.7% response rate. An overwhelming majority (94.6%) of participants agreed that basic abortion knowledge is necessary for all physicians. In addition, 88% affirmed that the session would affect their future practice. We observed a significant increase in knowledge of abortion epidemiology (OR 13.3, P<.001) and techniques (OR 48, P<.001). Participants felt more comfortable discussing pregnancy options (OR 39, P<.001) and 30.4% cited changes in their attitudes towards abortion after the session. Qualitative feedback demonstrated appreciation of our focus on the medical aspects of abortion care and emphasized the appropriateness of the session.

CONCLUSION:
Abortion education for preclinical medical students is valuable for them and their future patients. Additionally, it can be implemented effectively by a medical student cohort with institutional support.