Faculty Bibliography

BACKGROUND:Early initiation of prenatal care is widely accepted to improve the health outcomes of pregnancy for both mothers and their infants. Identification of the various barriers to entry into care that patients experience may inform and improve health care provision and, in turn, improve the patient's ability to receive necessary care. AIM/OBJECTIVE:This study implements a mixed-methods approach to establish methods and procedures for identifying barriers to early entry to prenatal care in a medically-vulnerable patient population and areas for future quality improvement initiatives. METHODS:An initial chart review was conducted on obstetrics patients that initiated prenatal care after their first trimester at a large federally qualified health center in Brooklyn, NY, to determine patient-specified reasons for delay. A thematic analysis of these data was implemented in combination with both parametric and non-parametric analyses to characterize the population of interest, and to identify the primary determinants of delayed entry. RESULTS:The age of patients in the population of interest (n = 169) was bimodal, with a range of 15 - 43 years and a mean of 28 years. The mean gestational age of entry into prenatal care was 19 weeks. The chart review revealed that 8% recently moved to Brooklyn from outside of NYC or the USA. Nine percent had difficulty scheduling an initial prenatal visit within their first trimester. Teenage pregnancy accounted for 7%. Provider challenges with documentation (21%) were noted. The most common themes identified (n = 155) were the patient being in transition (21%), the pregnancy being unplanned (17%), and issues with linkage to care (15%), including no shows or patient cancellations. Patients who were late to prenatal care also differed from their peers dramatically, as they were more likely to be Spanish-speaking, to be young, and to experience a relatively long delay between pregnancy confirmation and entry into care. Moreover, the greatest determinant of delayed entry into care was patient age. CONCLUSION/CONCLUSIONS:Our study provides a process for other like clinics to identify patients who are at risk for delayed entry to prenatal care and highlight common barriers to entry. Future initiatives include the introduction of a smart data element to document reasons for delay and use of community health workers for dedicated outreach after no show appointments or patient cancellations.

Objective: Social determinants of health (SDOH) contribute to health inequities in pregnancy. The availability, convenience, and timeliness of access to care affects healthcare utilization. The COVID-19 pandemic exposed the need for efficient and widespread implementation of telehealth services. However, expanding telehealth services has changed adherence to maternal fetal medicine (MFM) at a large, urban, Federally Qualified Health Center (FQHC). We describe the utilization of these services and its effect on adherence to MFM visits.
Study Design: This is a retrospective, quality improvement project comparing non-adherence to scheduled visits looking at two time frames: 1) Pre-COVID (8/1/2018-2/29/2020) in-person only 2) Post-COVID 1/1/2021-7/31/2022 in-person or virtual. All encounters in MFM at FQHC were included during these periods. In the Post-COVID period, patients had the option for either in-person or virtual visit at the time of scheduling, while in pre-COVID period, in-person visit was the only option. Chi-square was used to compare differences between groups, with p< 0.05 defined as significant.
Result(s): A total of 1,607 encounters were included, n=609 in the pre-COVID and n=998 in the post-COVID group. Encounter completion rates differed between the pre-COVID and post-COVID groups (80% vs. 86%, p= 0.001), Table. In the post-COVID group, when telehealth was an alternative option, non-adherence rates were significantly lower in comparison to when telehealth was not an option in the pre-COVID group. However, in the post-COVID group, the non-adherence rate between virtual only or in-person only visits were not significantly different (p=0.178).
Conclusion(s): The availability of either in-person or virtual visits improved compliance and access to MFM care in a FQHC. While the option of telehealth services can improve patient compliance with visits, this may exacerbate other disparities due to limited internet services, access to remote devices, or language barriers. Further research is needed to understand how telehealth can be an ongoing solution to overcome the SDOH that create inequity. [Formula presented] [Formula presented]
Copyright

INTRODUCTION/BACKGROUND:Simulation-based training to manage surgical postpartum hemorrhage allows for improved preparation for these rarely needed life-saving procedures. Our objectives were to design a low-tech simulation model for use in training and evaluation of surgical techniques for the management of postpartum hemorrhage and to present evidence of its validity in assessment and training. METHODS:Fifty-two obstetrics and gynecology residents and 25 attending physicians from an academic hospital were video recorded while performing the O'Leary and B-Lynch techniques on the low-tech model. Performance was evaluated using a Technical Skills Checklist, for B-Lynch and O'Leary techniques, and the Reznick's Global Rating Scale. Interrater reliability was computed to assess the consistency of the ratings between 2 raters. Average scores were determined and compared between incoming residents, junior residents, senior residents, and attending physicians to show construct validity. RESULTS:For the B-Lynch, Technical Skills Checklist scores (maximum 17 points) of attendings (15.04) and senior residents (15.12) were higher than those of junior residents (5.63) and new residents (3.38). Global Rating Scale scores (maximum 25 points) on the B-Lynch reflected the same increase (22.38, 19.35 vs. 8.85, 6.75, respectively). For the O'Leary stitch, the scores of attendings, senior, junior, and incoming residents were as follows: 15.20, 13.65, 11.54, and 2.83, respectively (maximum 19 points). This supports the construct validity of the model. The model was considered realistic and useful for improving surgical skills in 71.4% of participants. CONCLUSIONS:This low-cost, easily constructed model is a useful tool for training these surgical skills.

Background/UNASSIGNED:infection resulting in uterine is one such rare clinical circumstance where there is minimal information in the literature to guide its treatment and management. Case/UNASSIGNED:infection was noted intraoperatively. After three weeks of antibiotic therapy, she had resolution of her infection. Conclusion/UNASSIGNED:is a highly pathogenic organism that can cause endomyometritis, persistent bacteremia, and uterine necrosis, which necessitates definitive surgical management with hysterectomy to achieve resolution of the infection.

BACKGROUND Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are causes of rare but life-threatening emergencies characterized by desquamation of the skin and mucosa. As SJS most commonly presents with skin rash followed by mucosal involvement, we present a case of vulvovaginal lesions as the initial presentation with progression to SJS after re-exposure to the culprit drug. CASE REPORT A 27-year-old female with acute cystitis was given trimethoprim-sulfamethoxazole. After 2 days, she reported vaginal pain. Three days later, she was hospitalized with vulvovaginal ulcerations and restarted on trimethoprim-sulfamethoxazole, leading to worsening vaginal lesions with rapid desquamation of conjunctival and oropharyngeal involvement. Biopsies of arm lesions revealed SJS. CONCLUSIONS It is important to recognize SJS as a rare but life-threatening cause of vulvovaginal ulceration, as early diagnosis is vital for successful treatment.

Background/UNASSIGNED:Heterotopic pregnancy involving the implantation of an ectopic pregnancy into a prior cesarean scar with a concurrent intrauterine pregnancy is a rare and potentially life-threatening condition with minimal information in the literature to guide treatment and management options. Case/UNASSIGNED:A 40-year-old G5P3103 at 12 weeks and 3 days with a history of two cesarean deliveries was diagnosed with a live heterotopic pregnancy containing a cesarean scar ectopic and an intrauterine pregnancy. After selective reduction of the cesarean scar gestation with potassium chloride (KCl), the patient presented ten days later to the emergency department with septic abortion and sepsis. The patient underwent bilateral uterine artery embolization followed by ultrasound guided uterine evacuation with dilation and curettage, which was complicated by intraoperative hemorrhage and persistent bacteremia. The patient had resolution of her bacteremia after total abdominal hysterectomy. Conclusion/UNASSIGNED:Conservative management of uterine infection resulting from selective reduction of a heterotopic pregnancy cesarean scar pregnancy may be considered; however, severe septicemia and persistent bacteremia may necessitate definitive surgical management.

PURPOSE/OBJECTIVE:to evaluate whether the duration of gonadotropin stimulation predicts the likelihood of live birth after ART. METHODS:all IVF or ICSI cycles using fresh autologous oocytes at our institution between January 2004 and December 2007 were analyzed. RESULTS:out of 699 cycles resulting in oocyte retrieval, 193 produced a live birth (27.6%). Women who achieved a live birth had a significantly shorter stimulation phase (11.1 vs. 11.5 days, respectively). Multivariable analysis suggested that 13 days or longer of stimulation decreased the likelihood of a live birth by 53% as compared to cycles that were 10-12 days long (odds ratio [OR] 0.47; 95% confidence interval [CI]: 0.30-0.75) after adjustment for female age, maximum historical FSH, total dose of gonadotropin received, oocytes retrieved, embryos transferred, antagonist suppression and PCOS diagnosis. CONCLUSIONS:prolonged duration of gonadotropin stimulation is an independent negative predictor of ART success in our cohort.