Diana Garretto

Obesity May Be Protective against Severe Perineal Lacerations.

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.

Interstitial twin pregnancy: A unique case presentation

Early recognition and timely treatment of an interstitial pregnancy is imperative to avoid the high morbidity and mortality of this type of ectopic pregnancy. We report a case of twin interstitial pregnancy that was initially missed on initial sonogram and was subsequently recognized at our institution by transvaginal sonography. The patient underwent open laparoscopic surgery with cornual wedge resection but suffered infundibulopelvic ligament hemorrhage and subsequently required ipsilateral salpingo‐oophorectomy. She did well and was discharged home a day later.

Antenatal Diagnosis of Velamentous Cord Insertion and Vasa Previa: Preparing for a Good Outcome When the Cervix Is Shortened

Undiagnosed vasa previa is a condition associated with high perinatal mortality due to fetal exsanguination. Early diagnosis using transvaginal sonography, hospitalization, and early elective cesarean delivery may reduce poor perinatal outcomes. A 28-year-old primigravida at a gestational age of 28 weeks 6 days was admitted to the obstetric service for management of preterm labor and vasa previa. A fetal anatomic survey done at 20 weeks in our American Institute of Ultrasound in Medicine–accredited obstetric ultrasound facility had revealed an anteriorly implanted placenta with a velamentous cord insertion (Figure 1A) and vasa previa. Vasa previa was visualized again on follow-up sonography at 24 weeks’ gestation, confirming the fixed, membranous location of the cord in the region of the internal cervical os. Follow-up transvaginal sonography at 28 weeks 6 days revealed a cervical length of 9 mm with funneling and confirmed vasa previa (Figure 1B). On admission, she was given magnesium sulfate for tocolysis and a course of betamethasone for acceleration of fetal lung maturity. She responded well and was kept hospitalized in the antepartum unit, with continuous intravenous access and in-house obstetric and obstetric anesthesiology coverage 24 hours a day. Because of the risks associated with vasa previa and a shortened cervix, the patient was counseled regarding the option of cesarean delivery at 34 weeks or earlier, but she strongly desired to wait until 35 to 36 weeks. The neona-

Does Buprenorphine Decrease the Risk of Neonatal Abstinence Syndrome in Mothers with Opioid use Disorder? [26N]

INTRODUCTION:The objective of this study is to determine if buprenorphine opioid maintenance therapy is associated with a decrease risk of neonatal abstinence syndrome in mothers with opioid use disorder.METHODS:A retrospective cohort study of pregnant women with opioid use disorder was performed at

Does Opioid Maintenance Therapy Decrease the Risk of Neonatal Withdrawal in Mothers with Opioid Use Disorder? [28N]

INTRODUCTION:The objective of the study is to determine if opioid maintenance therapy decreases the risk of neonatal abstinence syndrome in pregnant women with opioid use disorder.METHODS:A retrospective cohort study of pregnant women with opioid use disorder was performed at a tertiary care hospita

Do Psychiatric Medications Exacerbate Neonatal Withdrawal in Pregnant Women Using Opioid Maintenance Therapy? [27N]

INTRODUCTION:The objective is to determine if opioid maintenance therapy (OMT) in conjunction with psychiatric medications increases the risk of neonatal abstinence syndrome and adverse neonatal outcomes.METHODS:A retrospective cohort study of pregnant women with opioid use disorder was performed at

Vitamin A and β-carotene in pregnant and breastfeeding post-bariatric women in an urban population

Abstract Background As breastfeeding awareness and social acceptance are increased, maternal nutritional deficiency requires more investigation. Methods A prospective cohort study was conducted to determine if vitamin A deficiency is more common in pregnant, lactating post-bariatric surgery women in an inner city population. Antepartum, women after bariatric surgery and controls with no history of malabsorption were recruited. Third trimester, postpartum maternal blood and cord blood were collected as well as three breast milk samples: colostrum, transitional and mature milk. A nutritional survey of diet was completed. Each serum sample was analyzed for total retinol and β-carotene; breast milk samples were analyzed for retinol and retinyl esters, total retinol and β-carotene. Results Fifty-three women after bariatric surgery and 66 controls were recruited. Postpartum serum retinol was significantly higher in women after bariatric surgery in the univariate analysis (P<0.0001) and confirmed in the multiple linear mixed model (P=0.0001). Breast milk colostrum retinol and transitional milk total retinol were significantly greater in the bariatric surgery group in the univariate analysis (P=0.03 and P=0.02, respectively), but not after adjusting for confounders. Serum β-carotene in the third trimester and postpartum were lower (P<0.0001 and P=0.003, respectively) in the bariatric surgery group but not after adjusting for confounders. Vitamin A deficiency was high in both groups in serum and breast milk samples. Conclusion Nutritional deficiencies in breastfeeding women after bariatric surgeries may in fact be less common than in control women in an inner city.

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor

OBJECTIVE The aim of this study was to improve patient handoffs on the labor floor. METHODS A prospective cohort study of obstetrics residents at Montefiore Medical Center was performed between 2012 and 2014. Labor-floor handoffs were recorded before and after didactic sessions as well as after installation of whiteboards formatted with the mnemonic SWIFT (Subject, Why?, Issues, Fetus, Tasks). Handoff transcripts were evaluated by obstetricians blinded to timing and speaker identity. An intraclass correlation coefficient accounted for evaluator differences. Data analysis was by ordinal logistic regression, the generalized estimating equations method (correlated data), and Bonferroni adjustment (multiple comparisons). RESULTS Forty-five handoffs were evaluated (15 each predidactics, postdidactics, and postwhiteboard revision). Higher completeness scores over time were noted for admission reason, labor concerns, and task list (not statistically significant). Comprehensive score increases prelecture to postwhiteboard were seen in handoff clarity (2.81 versus 2.91) and overall quality (2.77 versus 2.81) (not statistically significant). A subanalysis of four residents who gave multiple handoffs over different periods revealed few significant changes over time. Greater interevaluator consistency was noted with more objective elements. CONCLUSIONS The mnemonic SWIFT, with formalized curricula for obstetrical resident training focusing on new learners and increased faculty involvement and reinforcement, may result in improvement of handoffs on the labor floor.

Bariatric Surgeries in Pregnancy—As Different as One May Think? [17R]

INTRODUCTION: Bariatric surgery pregnant patients are at risk for nutrient deficiencies. The objective is to identify specific nutritional deficiencies, monitor the degree of deficiency, the pre-pregnancy BMI, gestational weight gain, and pregnancy outcomes among different bariatric surgeries. METHODS: Over a three year period, bariatric pregnant patients were identified. Data included: type of bariatric surgery, interval between surgery and pregnancy, pre and last visit BMI, gestational weight gain, diagnosis of diabetes, nutritional deficiencies in the beginning and end of pregnancy, supplements, birthweight, and mode of delivery. Logistic regression analysis assessed associations between each type of bariatric surgery and above data points. RESULTS: 125 patients with a history of bariatric surgery were identified. 41% Roux-en-Y, 28% gastric sleeve, 8% gastric band, 2% biliopancreatic diversion, and 21% unsure of the type. Postpartum hemoglobin was significant (P=.006). All other nutrients did not differ significantly. Pre-pregnancy BMIs did not differ significantly but 100% of gastric band patients were obese, 66% of Roux-en-Y, and 52% of gastric sleeve. Women gained too much weight in all groups. The last visit BMI was significant among the groups (P=.04). As the years post surgery increases, so does the last visit weight (P=.03). At delivery, no difference was noted in primary cesarean rate or birth weight. CONCLUSION: No significant difference in nutrition among different bariatric surgeries exists. Supplementation is needed in each type and nutritional screening is essential. Most women remain obese and gain too much weight. Delivery risks are no different among the surgeries.

Vitamin A Status in Breast Milk and Serum After Bariatric Surgery in an Urban Population [5K]

INTRODUCTION: Bariatric surgery increases the risk of nutritional deficiencies especially fat soluble vitamins including vitamin A. Levels in the mother influence fetal stores in the liver leading newborns to rely on maternal breast milk for their supply. We sought to determine the risk for maternal serum, cord blood, and breast milk vitamin A deficiency of post-bariatric surgery breastfeeding women compared to non-surgical controls. METHODS: A prospective cohort study was conducted. Antepartum women with bariatric surgery, singleton pregnancies planning to breastfeed were recruited. Controls with singleton pregnancies, no history of malabsorption, planning to breastfeed were recruited randomly. Background information and pregnancy outcomes were collected. Third trimester serum and cord blood samples were obtained. Postpartum, participants completed a nutritional survey. Postpartum maternal serum was collected on day 1. Three milk samples were collected: colostrum (PPD1-5), transitional (PPD7-14), and mature milk (PP 6 weeks). Each sample was analyzed for retinol, retinyl esters, and total retinol by HPLC. Power analysis estimated a total of 66 patients. RESULTS: 53 bariatric women and 61 controls were recruited. Breastfeeding rates were significantly different between groups (51% bariatric women vs 23% in controls). Colostrum and transitional milk retinol was significantly higher in bariatric women vs controls (P=.01 and P=.02, respectively). Postpartum serum retinol was significantly higher in women with bariatric surgery compared to controls (P<.0001). CONCLUSION: Vitamin A deficiency exists in the United States in the general urban population more than bariatric women. Consideration for monitoring levels in all breastfeeding women and supplementing is needed for maternal and newborn health.