Faculty Bibliography

INTRODUCTION: Women who present to the emergency department (ED) for gynecologic issues at our institution undergo multiple evaluative steps. We sought to understand how these steps delay indicated operative management. Time spent at each stage of an ED visit for an acute surgical presentation was investigated as part of a quality improvement project for NYU Langone Health.
METHOD(S): This retrospective, observational study quantifies time spent by patients at each evaluative stage from presentation to operating room incision time. We included females 18 years or older, presenting to the NYU Tisch Hospital ED with acute gynecologic complaints requiring surgery. Gynecology consult records from 9/1/16 to 8/29/17 were reviewed and surgical cases were identified. We defined five relevant time points for each patient: 1--initial presentation, 2--ED provider evaluation, 3--Gynecology consult, 4--time of imaging, and 5--surgical start time. We recorded time in hours, between the above evaluations.
RESULT(S): Of 1194 consults reviewed, 79 patients required urgent surgery for benign etiologies (eg, adnexal torsion, ruptured ectopic pregnancy or heavy vaginal bleeding). The median time spent from presentation to incision was 6.1 (IQR: 4.12-8.53) hours. The median time from presentation to finalization of imaging and from gynecology evaluation to incision were 0.78 (IQR: 0.35-14) and 3.3 (IQR: 1.6-54) hours, respectively.
CONCLUSION(S): This information implies that throughout an evaluation for urgent gynecologic surgery, more than 50% of the time is spent after the decision has been made to operate. Further study of this time frame may ultimately improve bed utilization and reduce delays

Cardiovascular disease complicating pregnancy is rising in prevalence secondary to advanced maternal age, cardiovascular risk factors, and the successful management of congenital heart disease conditions. The physiological changes of pregnancy may alter drug properties affecting both mother and fetus. Familiarity with both physiological and pharmacological attributes is key for the successful management of pregnant women with cardiac disease. This review summarizes the published data, available guidelines, and recommendations for use of cardiovascular medications during pregnancy. Care of the pregnant woman with cardiovascular disease requires a multidisciplinary team approach with members from cardiology, maternal fetal medicine, anesthesia, and nursing.

Objective: While the incidence of cervical cancer has declined in the United States, cervical cancer continues to be a significant source of morbidity and mortality among specific subsets of women. In a recent study published in Cancer, black women over the age of 85[1] were found to have the greatest mortality from cervical cancer. Importantly, cervical cancer screening guidelines do not extend to this age group, highlighting the importance of gaining a comprehensive understanding of these at risk populations. The objective of this study was to define the characteristics, risk factors and clinical course of patients treated for cervical cancer at a large urban public hospital. [1] Beavis, AL, Gravitt, P Rositch, A, Hysterectomy Corrected Cervical Cancer Mortality Rates;Cancer:2017:-1044-50. Design: A review of patients treated for cervical cancer by gynecologic oncologists at Bellevue Hospital between 2007- 2015. Results: One-hundred and fifty-nine patients were treated for cervical cancer by gynecologic oncologists at an urban academic institution during the specified time period. The median age at diagnosis was 51 years (range 28- 80), with 26 (16.4%) patients over 65 years. Sixty-nine (43.4%) patients identified as Hispanic or Latina, 36 (22.6%) as Black or African-American, 25 (15.7%) as Asian, 17 (10.7%) as Caucasian, and 12 (7.5%) were unknown. Seventy-six (47.8%) patients originated from the United States, while 57 (36%) patients reported their region of origin elsewhere - 24 (15.1%) from Asia, 16 (10.1%) South America, 5 (3.1%) Africa, 12 (7.5%) Europe, and 26 (16.4%) were unknown. The vast majority of patients had public insurance (71.1%), or were uninsured (20.8%). One hundred and seven (67%) patients presented with stage IB2 or higher disease, and the predominant stage at diagnosis was IIB (40, 24.2%). Only 34 (21.4%) patients had a known history of dysplasia, with HSIL being the most common cervical cytology prior to diagnosis. Forty-two (26.4%) patients were smokers, only 1 (0.6%) patient was HIV positive on antiretroviral therapy, and 5 (3.1%) had a history of radiation or chemotherapy from a prior cancer diagnosis. One hundred and eighteen (74.2%) underwent chemotherapy and radiation, while 55 (34.6%) were treated surgically, and 3 (1.9%) did not undergo treatment. At the most recent encounter, 85 (53.5%) patients had no evidence of disease, 67 (42.1%) were alive with disease, and 6 (3.8%) had died of their disease. Conclusion: Despite advances in detection and treatment, cervical cancer remains a significant women's health care issue among at-risk patient populations in the United States. These findings draw attention to how the new screening guidelines may affect the care of women over 65 years of age

Objective Preterm birth is a leading cause of perinatal morbidity and mortality. Prevention strategies rarely focus on preconception care. We sought to create a preconception nomogram that identifies nonpregnant women at highest risk for preterm birth using the Pregnancy Risk Assessment Monitoring System (PRAMS) surveillance data. Methods We used PRAMS data from 2004 to 2009. The odds ratios (ORs) of preterm birth for each preconception variable was estimated and adjusted analyses were conducted. We created a validated nomogram predicting the probability of preterm birth using multivariate logistic regression coefficients. Results 192,208 cases met inclusion criteria. Demographic/maternal health characteristics and associations with preterm birth and ORs are reported. After validation, we identified the following significant predictors of preterm birth: prior history of preterm birth or low birth weight baby, prior spontaneous or elective abortion, maternal diabetes prior to conception, maternal race (e.g., non-Hispanic black), intention to get pregnant prior to conception (i.e., did not want or wanted it sooner), and smoking prior to conception (p < 0.05). Overall, our preconception preterm risk model correctly classified 76.1 % of preterm cases with a negative predictive value (NPV) of 76.7 %. A nomogram using a 0-100 scale illustrates our final preconception model for predicting preterm birth. Conclusion This preconception nomogram can be used by clinicians in multiple settings as a tool to help predict a woman's individual preterm birth risk and to triage high-risk non-pregnant women to preconception care. Future studies are needed to validate the nomogram in a clinical setting.