bluuebunny/crossref_metadata_2025 huggingface dataset:
Difference in Time to Delivery Between Dilation and Evacuation (D&E) Versus Induction of Labor for Medical Indications [ID: 1380391]
Authors: Navarrete Emily , Goldsmith Crystal , Guzik Claudia , Stephens Joncel , Wei Julia , Wei Julia , Weintraub Miranda
Published: May 2023

INTRODUCTION:

Pregnancy termination may be the safest management option among pregnancies with medical conditions that arise during the second trimester and are associated with elevated risk of maternal morbidity and mortality. Termination can be done by dilation and evacuation (D&E) or induction. Each method carries different risk and benefit profiles; however, variations in time to delivery have not been established. We assess the difference in time from diagnosis to delivery between D&E and induction for medically indicated second-trimester terminations.

METHODS:

Electronic medical records of 85 adult patients who underwent a D&E and 19 who underwent an induction between July 1, 2020, and December 31, 2020, within Kaiser Permanente Northern California were retrospectively surveyed for patient demographics and clinical characteristics, including indication for and method of termination, time of diagnosis and delivery, cervical preparation method, and perioperative complications.

RESULTS:

Patient demographic and clinical characteristics were similar across groups. The median time from diagnosis to delivery was 74 hours (interquartile range [IQR]: 18–141 hours) in the D&E cohort and 9 hours (IQR: 4–45 hours) in the induction cohort (P<.01). In the induction cohort, there were 21.1% (n=4) complications versus 4.7% (n=4) in the D&E cohort (P=.04). In the induction group, 10.5% (n=2) of patients required an additional procedure to complete the termination.

CONCLUSION:

The median time from diagnosis to delivery was 65 hours shorter in the induction group compared to D&E. This difference may be deemed clinically significant for patients who weigh time to delivery in their decision-making.
Comparison of Bony Pelvic Dimensions and Demographic Risk Factors in Individuals With and Without Pelvic Organ Prolapse [ID: 1377653]
Authors: DeRosa Alexandra , Ablove Tova , Doyle Scott , Lewis Steven
Published: May 2023

INTRODUCTION:

Previous studies have noted a correlation between bony pelvic measurements and the diagnosis of prolapse via musculofascial insertion points on magnetic resonance imaging. We investigated the importance of bony measurements of the lumbar spine and pelvis as risk factors in the development of prolapse via routine computed tomography (CT) imaging.

METHODS:

We sampled 171 UBMD obstetrics and gynecology clinic patients who were at least 40 years of age and had an abdominal/pelvic CT scan. Demographic and medical history was reviewed and collected. Participants were then divided into those with and without prolapse. CT images were uploaded to 3D Slicer 5.10. Each study was analyzed by a trained annotator blinded to prolapse status. The area of the anterior pelvis, interspinous diameter, pelvic outlet, ischial spine to pubic symphysis, sacrococcygeal junction to ischial spine, and lumbar and sacrococcygeal curvature were annotated. Demographic characteristics and measured annotations were compared using χ2 test.

RESULTS:

Women with prolapse were more likely to be older (P<.05) and of lower weight (mean 71.6 kg, P<.05) than controls. Patients with prolapse had a significantly larger area of their anterior pelvis (P<.05) and a significantly longer interspinous diameter (P<.05). Distance from ischial spine to pubic symphysis was significantly longer (P<.05), and pelvic outlet in women with prolapse was significantly longer than in controls (P<.05).

CONCLUSION:

In addition to known risk factors, bony measurements of the pelvis are significantly different in those with and without pelvic organ prolapse, which may be observed on routine CT imaging.
Increased Vaginal Cuff Dehiscence Among Gender-Diverse People on Testosterone [ID: 1377373]
Authors: Wong Jennifer , Ramm Olga , Vega Shayna , Weintraub Miranda , Xu Richie Houhong , Zaritsky Eve
Published: May 2023

INTRODUCTION:

Testosterone-induced vaginal atrophy is hypothesized to increase the risk of vaginal cuff dehiscence (VCD); however, current studies are limited and conflicting. This study compares risk of VCD among gender-diverse people on testosterone (GDT) and ciswomen (CW) and evaluates factors associated with VCD.

METHODS:

An IRB-approved retrospective cohort study was conducted among adults who underwent total hysterectomy (June 1, 2014 to December 31, 2019) for benign indications at Kaiser Permanente Northern California. Patients had 6 months postoperative follow-up, and GDT had greater than 6 months testosterone use prior to hysterectomy. Differences between GDT and CW were evaluated using Wald χ2, Fisher’s exact, Student’s t test, or Kruskal–Wallis tests. Unadjusted logistic regression was conducted to estimate odds ratios (OR) for VCD.

RESULTS:

The cohort (n=22,109) included 154 (0.7%) GDT and 21,995 (99.3%) CW. GDT were younger (median 27 [interquartile range (IQR) 22–36] versus 47 [IQR 42–52] years, P<.001) and had lower proportion with Charlson Comorbidity Index (CCI) greater than or equal to 1 (18.2% versus 27.1%, P=.013) than CW. A greater proportion of GDT experienced VCD (5.8% versus 2.5%, P<.016; OR 2.42, 95% CI 1.23–4.77, P=.011). Patients with CCI greater than or equal to 1 or had hypertension were associated with 25% (95% CI 4–50%, P=.015) and 41% (95% CI 18–68%, P<.001) higher odds of VCD, respectively.

CONCLUSION:

The odds of VCD was 2.4 times higher in GDT despite being younger and healthier than CW. Charlson Comorbidity Index of 1 or higher and hypertension were also associated with higher risk of VCD. These findings support the theory of testosterone-induced vaginal atrophy as a risk factor for VCD. Additional studies are needed to better understand the pathophysiology of VCD among GDT and prevent this morbid complication.
Examining Antenatal Corticosteroid Administration at a Single Center via a New Proposed Quality Metric [ID: 1375947]
Authors: Anwer Tooba , Little Sarah , Reddy Rajesh , Reiff Emily
Published: May 2023

INTRODUCTION:

The Society for Maternal-Fetal Medicine (SMFM) proposed a new quality metric in 2022 to increase the rate of antenatal corticosteroid (ACS) provision for early preterm deliveries and minimize ACS for pregnancies ending in term deliveries. This study evaluates compliance with this quality metric and examines which delivery indications are associated with suboptimal ACS timing.

METHODS:

This is a single-center retrospective cohort of patients receiving ACS from January 2017 to September 2022. The primary outcome, measuring compliance with the SMFM ACS quality metric, is the proportion of all early preterm deliveries that received optimally timed ACS (one dose of ACS within 6 hours–7 days before birth). The secondary outcome is the proportion of term deliveries that had previously received ACS compared to all patients who received ACS. A sample of convenience of 500 patients was investigated to determine the indication for ACS.

RESULTS:

Of the 36,080 deliveries between 2017 and 2022, 2,022 patients received ACS (initial or rescue) and delivered at this center. There were 3,720 early preterm deliveries. Of early preterm deliveries, 14.67% received ACS in the optimal window. Of all the patients that received ACS, 20.9% delivered at term. ACS were more optimally dosed for hypertension relative risk (RR) 1.71 (95% CI 1.36–2.14) and preterm prelabor rupture of membranes RR 2.08 (95% CI 1.67–2.59).

CONCLUSION:

Based on the SMFM quality metric, rates of optimal ACS administration remain lower than minimum realistic benchmarks. Continuing efforts are needed to optimize ACS administration for preterm deliveries. In order to meet these goals, institutions may examine which clinical situations lead to suboptimal ACS.
Pregnancy Outcomes Before and After the Emergence of the SARS-CoV-2 B.1.1.529 (Omicron) Variant [ID: 1365953]
Authors: Seif Karl , Desai Andrea , Mangione Mary , Tadbiri Hooman , Turan Shifa , Wolfe Alexa
Published: May 2023

INTRODUCTION:

Starting December 15, 2021, the SARS-CoV-2 B.1.1.529 (Omicron) variant became the predominant strain in the United States. Preliminary data suggest that the Omicron variant causes less severe COVID-19 than earlier variants. We hypothesize that adverse maternal and neonatal outcomes are less likely if infection occurred during the Omicron epoch compared to pre-Omicron.

METHODS:

This IRB-approved retrospective cohort study was conducted at a major university health system in Maryland from March 2020 to May 2022. We identified patients who were SARS-CoV-2 positive before and after December 15, 2021. Demographics and maternal, obstetric, and neonatal outcomes were collected and compared. Wilcoxon rank-sum and Fisher’s exact tests were used to compare continuous and categorical data, respectively. Adjusted odds ratios (aORs) were calculated using vaccination status.

RESULTS:

A total of 742 SARS-CoV-2–positive pregnant patients were identified. Of those, 548 (74%) tested positive pre-Omicron and 194 (26%) tested positive during the Omicron wave. Tobacco and illicit drug use were higher among patients in the Omicron epoch. Patients were also older and more likely to have received at least one vaccine dose (3% versus 35%, P<.001). Omicron epoch patients had less severe disease as evidenced by higher rates of asymptomatic infection (72% versus 44%) as well as lower rates of hospital admission due to COVID-19, supplemental oxygenation, and intensive care unit (ICU) admission. However, the odds of ICU admission were not significantly decreased in Omicron epoch patients after adjusting for vaccination (aOR 0.15, 95% CI 0.02–1.14). The odds of preeclampsia and preterm birth less than 34 weeks were lower in Omicron epoch patients after adjusting for vaccination (aOR, 0.61 and 0.38, respectively). Neonatal outcomes were not statistically different between the two groups.

CONCLUSION:

Pregnant patients infected with SARS-CoV-2 during the Omicron epoch have a less severe disease course than those infected pre-Omicron. Lower ICU admissions during the Omicron epoch may be due to higher vaccination rates.
Disproportionate Fetal Abdominal Growth in Patients With Diabetes Does Not Increase the Risk of Neonatal Hypoglycemia [ID: 1369330]
Authors: Soehl John , Esposito Matthew , Lord Megan , Murphy Lauren , Whelan Anna
Published: May 2023

INTRODUCTION:

Neonates of pregnant persons with diabetes are at increased risk of hypoglycemia. The Fetal Abdominal Adiposity Score (FAAS) is a measure of disproportionate fetal abdominal growth theorized to serve as a proxy for fetal exposure to excess glucose in utero. We sought to characterize the relationship between FAAS and neonatal hypoglycemia in this population.

METHODS:

Pregnancies complicated by gestational diabetes (GDM), or preexisting diabetes type 1 (T1DM) or type 2 (T2DM), resulting in delivery of a live singleton nonanomalous fetus were identified within an existing NIH-funded database. Corresponding third-trimester ultrasounds (US) were identified. The FAAS was calculated as follows for each pregnancy, using measurements from the last US prior to delivery: fetal biparietal diameter minus fetal abdominal diameter (calculated as abdominal circumference/π). Results were expressed as a percentile for the gestational age at measurement relative to a reference population. Clinically significant neonatal hypoglycemia was defined as a hypoglycemia that either required treatment or resulted in a blood glucose level of 25 mg/dL or lower in the first 24 hours of life.

RESULTS:

Clinically significant hypoglycemia occurred in 58/1,299 neonates (4.5%), including 0/39 (0%) with FAAS at the 10th centile and 11/229 (4.8%) with FAAS at the 90th centile. There was no statistically significant difference in risk of hypoglycemia between various FAAS categories (P=.133). FAAS was weakly associated with the lowest postnatal blood sugar (R=0.098).

CONCLUSION:

Among pregnancies complicated by diabetes, FAAS was not associated with risk of neonatal hypoglycemia even for those at the extremes of abdominal growth.
Progesterone After Cerclage Does Not Improve the Preterm Birth Rate [ID: 1372160]
Authors: Sayres Lauren , Lijewski Virginia , Reeves Shane , Sheeder Jeanelle , Taylor Natalie
Published: May 2023

INTRODUCTION:

Preterm birth represents a leading cause of neonatal morbidity and mortality. Cerclage and progesterone supplementation are the two most frequently employed interventions to reduce the risk of prematurity. Guidelines for cerclage and progesterone have evolved as conflicting evidence for their use mounts, and combination therapy remains poorly understood. Our objective is to determine whether there is benefit to adjunct progesterone supplementation after cerclage placement.

METHODS:

This is a retrospective cohort review of all individuals who underwent transvaginal cerclage placement at a tertiary medical center between 2005 and 2021. The rate of delivery prior to 37 weeks was compared between participants with and without progesterone supplementation after cerclage. Several secondary maternal and neonatal outcomes were evaluated. Multivariate regression analysis accounted for cerclage indication, use of progesterone prior to cerclage, and other factors that affect prematurity risk.

RESULTS:

Of 451 participants, there were 160 history-indicated, 134 ultrasound-indicated, and 157 examination-indicated cerclages. Overall, 285 (63.2%) received postcerclage progesterone. Progesterone after cerclage did not decrease the rate of preterm delivery (adjusted odds ratio 1.1, 95% CI 0.4–2.6) for any indication of cerclage. Moreover, adjunct progesterone was associated with decreased latency between cerclage placement and delivery (P=<.01).

CONCLUSION:

Prescribing patterns for progesterone after cerclage suggest clinical equipoise. We have found that adjunct progesterone does not decrease the preterm delivery rate and may in fact cause harm by decreasing latency from cerclage to delivery. These data do not support the use of progesterone after cerclage for any indication.
Early Treatment of Gestational Diabetes Mellitus and Prediabetes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials [ID: 1377137]
Authors: Hessami Kamran , Harper Lorie M. , Shamshirsaz Alireza A. , Werner Erika F.
Published: May 2023

INTRODUCTION:

This meta-analysis aims to determine whether early treatment of hyperglycemia in gestational diabetes mellitus (GDM) and prediabetic pregnancies improve perinatal outcomes.

METHODS:

PubMed/Medline, EMBASE, ClinicalTrials.gov and Web of Science were systematically searched up to June 30, 2022. Randomized clinical trials (RCTs) of early treatment for gestational diabetes mellitus (International Association of the Diabetes and Pregnancy Study Groups [IADPSG] or Carpenter and Coustan [C&C] criteria) and prediabetes (HbA1c 5.7–6.4%) before 20 weeks of gestation were considered eligible. Random-effects model meta-analysis was used to pool the odds ratios (OR) and/or mean differences (MD) with 95% CI. Furthermore, subgroup analysis was performed stratifying by indication for intervention (GDM versus prediabetic).

RESULTS:

Seven RCTs including 2,757 pregnant individuals, of whom 647 had positive screening before 20 weeks of gestation, were included. Of 647 individuals, 346 were allocated to early treatment and 301 to the routine treatment. There was no significant difference in terms of gestational age at delivery (MD –0.21 [95% CI: −0.44, 0.02], P=.089), rate of cesarean delivery (OR 0.93 [95% CI: 0.64, 1.34], P=.394), hypertensive disorder of pregnancy (OR 1.19 [95% CI: 0.59, 2.39], P=.341), any diabetic medication use (OR 1.31 [95% CI: 0.89, 1.93], P=.177), and neonatal hypoglycemia (OR 1.02 [95% CI: 0.50, 2.08], P=.952). However, there was a decreased risk of macrosomia (OR 0.42 [95% CI: 0.19, 0.92], P=.031) and increased need for insulin use (OR 2.23 [95% CI: 1.30, 3.84], P=.004) for early treatment group. After separate analyses on GDM and prediabetics as distinct groups, the risk of macrosomia was not decreased for GDM and prediabetic subgroups after early treatment.

CONCLUSION:

Treatment in early pregnancy for GDM or prediabetes does not appear to improve the maternal or neonatal outcomes.
Late-Onset Severe Fetal Growth Restriction and Isolated Severely Small Abdominal Circumference: Do Neonatal Outcomes Differ? [ID: 1377666]
Authors: Hirsch Anna , Ha Laura , Naqvi Mariam
Published: May 2023

INTRODUCTION:

Updated guidelines from the Society for Maternal-Fetal Medicine (SMFM) define severe fetal growth restriction (sFGR), or an estimated fetal weight (EFW) less than 3rd percentile, as a distinct entity due to higher perinatal morbidity in this group. Whether an isolated abdominal circumference (AC) less than 3rd percentile similarly portends adverse outcomes remains unclear.

METHODS:

This is a single-institution, retrospective cohort study of singleton gestations with late-onset FGR and normal Doppler studies from 2012 to 2022. Pregnancies affected by AC less than 3rd percentile (but EFW≥3rd percentile) and EFW less than 3rd percentile were compared using univariable analysis and multivariable logistic regression. The primary outcome was neonatal intensive care unit (NICU) admission.

RESULTS:

Among eligible participants, 78 (63%) had an isolated AC less than 3rd percentile and 45 (37%) had sFGR. Neonates prenatally diagnosed with sFGR were more likely to be admitted to the NICU than those with isolated AC less than 3rd percentile (68.9% versus 23.1%, P<.001). After adjusting for gestational age, birth weight, race, maternal age, and medical comorbidities, sFGR was still associated with an increased odds of NICU admission (adjusted odds ratio 4.9, 95% CI 1.37–17.48, P=.014). Rates of cesarean delivery (46.7% versus 26.9%; P=.03), small for gestational age (86.7% versus 67.9%, P=.02), and 5-minute Apgar score less than 7 (6.7% versus 0.0%, P=.02) were also higher in the sFGR group. There were no significant differences in NICU length of stay or perinatal death between groups.

CONCLUSION:

Adverse neonatal outcomes were more prevalent in pregnancies affected by sFGR compared with isolated AC less than 3rd percentile, providing support for the updated SMFM guidelines.
Risk of Adverse Perinatal Outcomes in Hispanic Women With Pregestational Type 1 Diabetes Mellitus [ID: 1379155]
Authors: Echeverria Milady Banegas , Arce Lidia , Robles Claudia Flores , Cruz Nayeli Martínez , Muñoz Enrique Reyes
Published: May 2023

INTRODUCTION:

Type 1 diabetes mellitus (T1DM) during pregnancy is associated with increased risk of maternal and fetal complications. We aimed to compare the risk of adverse perinatal outcomes in women with pregestational T1DM to those of background population.

METHODS:

In this historical cohort study, we included Mexican pregnant women who attended from 2016 to 2021 a tertiary-level hospital in Mexico City. Group 1: Pregnant women with T1DM; group 2: pregnant women without diabetes, matched 1:2 by maternal age, pregestational body mass index (BMI), gestational age at admission and parity with women of group 1. Relative risk (RR) with a 95% CI was calculated using logistic regression. We had IRB approval.

RESULTS:

Group 1, n=203; group 2, n=406; there were no differences in maternal age, pregestational BMI, gestational age, and parity. The mean glycated hemoglobin A1C and gestational age at admission to prenatal care in T1DM women were 8.0±2.0 and 19.1±6.6, respectively. The risk of adverse perinatal outcomes was increased in women with T1DM and were expressed as RR (95% IC); preterm birth, 4.03 (3.0–5.3); preeclampsia, 5.2 (3.3–8.3); cesarean birth, 1.5 (1.3–1.7); miscarriage, 34 (4.5–253); congenital malformations, 8.5 (3.8–19.1); neonatal hypoglycemia, 15 (3.4–64); hyperbilirubinemia, 2.8 (1.6–4.9); respiratory distress syndrome, 8.6 (3.6–20); and large for gestational age, 6.8 (3.7–12.4).

CONCLUSION:

The risk of adverse perinatal outcomes was increased in Hispanic women with T1DM compared with general population. These adverse outcomes show the critical importance to prioritize education to patients and resources for glucose control to improve outcomes before and during pregnancy.
Combatting Food Insecurity Through Implementing Food Pantry Amenities in Clinical Settings [ID: 1375662]
Authors: Neal Amber , Frazier La-Tisha , Hawthorne Jenci , Miller Edward , Root Emily
Published: May 2023

INTRODUCTION:

The SARS-CoV-2 pandemic has brought renewed public attention to food insecurity and other social determinants of health. According to the United States Department of Agriculture (USDA), food insecurity affects 10.5% of households nationwide. Our study sought to determine the prevalence of food insecurity at the University of Louisville and the effect that implementing food pantry amenities within the clinic has on pregnancy outcomes.

METHODS:

Institutional review board approval was obtained. We screened pregnant women presenting to our outpatient clinic for prenatal care each trimester. Food security was determined using a modified version of the USDA Adult Food Security Survey over the past 12 months. Women that were determined to be food insecure were provided access to food pantry amenities at each prenatal visit. Screening data were entered in REDCap, then exported into Stata for statistical analysis.

RESULTS:

Survey data demonstrated that 38% of our patients screened positive for food insecurity. As a result, a total of 5,829 lb of food have been distributed. Secondary outcomes including prenatal care adherence rates, weight gain during pregnancy, pregnancy complications, and birth outcomes will be displayed graphically.

CONCLUSION:

Rates of food insecurity in our clinic population were three times higher compared to the national average. Formal screening allows providers to better identify families experiencing food insecurity and connect them to food pantry amenities. Importantly, our initiative can serve as a guide for other institutions considering food security interventions. Implementing food pantries in academic institutions nationwide will enhance and inform these innovations to target at-risk populations and provide health equity.
Effect of Race on Obstetric Ultrasound Keepsakes [ID: 1376924]
Authors: Stoddard Rachel , Duffy Cassandra , Kim Hyunseo , Modest Anna , Quesnelle Georgia , Wylie Blair
Published: May 2023

INTRODUCTION:

Differences in treatment and health outcomes by race are well-documented. Ultrasound photos represent important keepsakes and may affect patient experience and care. We examined whether race and other factors affected the number of keepsakes given during obstetric ultrasound. A secondary outcome was patient satisfaction.

METHODS:

From October 2021 to September 2022, we distributed a survey after outpatient obstetric ultrasounds at a tertiary care hospital, including questions on demographics, number of photos received, and overall satisfaction. Exclusion criteria included inability to complete the survey in one of four available languages or carrying a multifetal gestation. Ultrasound staff and faculty were blinded to the research question. This study was approved by the Beth Israel Deaconess Medical Center IRB.

RESULTS:

Of 405 individuals approached, 251 completed the survey (response rate of 62.0%). Of these, 53.4% identified as White, 16.3% Asian, 10.4% Black, 7.2% as multiple races, 6.8% other race, and 6.0% preferred not to say. In total, 81.3% of patients received photos (median, 4; interquartile range [IQR], 3–6), with no difference in number by race, ethnicity, primary language, or body mass index. Most patients expected to receive photos, with no appreciable differences by race. Ratings for visits were high (IQR, 8–10/10) with no difference between patients who did or did not receive photos or by number of photos.

CONCLUSION:

We found no difference in number of photos patients received by race. Overall ratings of ultrasound visits were high and not associated with number of keepsakes received. While reassuring, further research is needed into equitable treatment in obstetric ultrasound.
Socioeconomic Disadvantage Is Associated With Risk and Severity of Anemia [ID: 1377641]
Authors: Phillips Jaclyn , Hacker Francis , Lemon Lara , Simhan Hyagriv , Simhan Jayanthi , Simhan Uma
Published: May 2023

INTRODUCTION:

Anemia on admission for delivery is a significant contributor to peripartum transfusion. Risk of maternal morbidity including transfusion has been linked to neighborhood deprivation. We sought to explore the relationship between a composite measure of neighborhood-level deprivation and frequency and severity of anemia on admission for delivery.

METHODS:

We performed an IRB-approved retrospective cohort analysis of delivery admissions in a single health care network from 2015 to 2020. Area deprivation index (ADI) was used to represent neighborhood socioeconomic disadvantage and is a composite index of neighborhood that spans income, education, household characteristics, and housing. The index ranges from 1 to 100 with higher values indicating higher disadvantage. Anemia was defined as hemoglobin less than 11.0 mg/dL and severe anemia less than 9.0 mg/dL. Multivariable binomial regression models assessed the relationship between ADI and anemia.

RESULTS:

Eighty-five thousand five hundred fifty-three delivery admissions were included. A monotonic linear positive relationship was observed between ADI and anemia. Individuals who reside in the most disadvantaged neighborhoods (ADI>95) had 2.2 times the odds (95% CI 2.1–2.3) of anemia on admission for delivery. For example, individuals who live in a less disadvantaged neighborhood (ADI of 5) had a 11% predicted probability of anemia compared to 23% in individuals who lived in a more disadvantaged neighborhood (ADI of 95). Individuals who lived in the most disadvantaged neighborhoods had a higher rate of severe anemia (1% versus 3%, P<.001).

CONCLUSION:

Anemia is more likely and more severe in individuals living in disadvantaged neighborhoods. Neighborhood-level interventions could be used to target populations at high risk for anemia and potentially affect maternal outcomes.
The Effect of the ARRIVE Trial and the COVID-19 Pandemic on Obstetric Practice and Racial Disparities [ID: 1380285]
Authors: Wheeler Malena , Hong Hwanhee , Swamy Geeta , Truong Tracy , Unnithan Shakthi
Published: May 2023

INTRODUCTION:

Black birthing people are at increased risk for cesarean delivery (CD) and gestational hypertension (gHTN), compared to their White counterparts. In the ARRIVE trial, labor induction at 39 weeks decreased CD and gHTN in low-risk nulliparous patients. Our aim was to determine whether racial differences in labor induction, CD or gHTN changed after ARRIVE and the COVID-19 pandemic.

METHODS:

We conducted an IRB-approved, retrospective cohort study using publicly available birth certificate data from three time periods: pre-ARRIVE (January 1, 2015 to August 31, 2018), post-ARRIVE (September 1, 2018 to February 29, 2020), and post-COVID (March 1, 2020 to December 31, 2020). All non-Hispanic Black (NHB) or White (NHW) nulliparous patients with a singleton gestation who delivered at more than 39 weeks of gestation with no documented high-risk conditions were included. Odds of labor induction, gHTN, and CD were compared by time period and race and ethnicity using an interrupted time series analysis adjusted for seasonality and covariates.

RESULTS:

There were 471,351 NHB and 2,265,018 NHW birth records included in the analysis. Post ARRIVE, the rate of labor induction increased among NHB and NHW birthing people. Non-Hispanic Black patients were less likely to be induced than their White counterparts before and after the publication of ARRIVE and COVID-19. In the adjusted ITS analysis, the odds of induction of labor (IOL) were lower while the odds of gestational hypertension and cesarean birth were higher for NHB compared to NHW in all three time periods.

CONCLUSION:

It is plausible that the racial difference in 39-week IOL may contribute to racial disparities in gestational hypertension and cesarean delivery. The results of the ARRIVE trial suggest that ensuring equitable access to IOL in the 39th week may be one strategy to reduce obstetric racial disparities.
Understanding Afghan Refugee Experiences With Obstetrical Care: A Qualitative Study [ID: 1381425]
Authors: Sekhon Subhjit , Morales Pedro , Smith Lucy
Published: May 2023

INTRODUCTION:

Providing equitable maternal care to refugees is a challenging task for hosting countries because of differences in personal experiences and health care systems. It is important to understand these unique needs because of the increased risk of poor pregnancy and birth outcomes for refugee patients. The aim of this study was to explore the experiences of obstetrical care among Afghan refugees in their native countries to mitigate that risk.

METHODS:

A qualitative study was conducted of 10 Afghan women. Institutional review board approval was obtained (UMKC #2092624). Face-to-face, semistructured, and in-depth interviews were conducted with certified interpreters. Interviews were analyzed using a thematic analytical method.

RESULTS:

All study participants were recent migrants within the past 6 months with no prior care within the U.S. health care system. Patients were pregnant in their second (n=8) or third trimester (n=2). Two were nulliparous. Three major themes were identified: insufficient prenatal and postpartum care, inadequate information, and decreased social support. None of the participants had regular prenatal care, ultrasounds, or labs. Most of the women (n=8) had previously delivered in a hospital, although they noted several differences: lack of private delivery rooms, fetal monitoring, and support during the process. There was no consent process, and the women were unaware of indications for delivery or cesarean delivery.

CONCLUSION:

With better understanding of the background and experiences of Afghan refugee patients, we can develop strategies to improve obstetric care and outcomes. This includes educational efforts geared towards introducing these women to a new health care model that closes the gaps they previously experienced.
Young Birthing Age and Delivery and Neonatal Outcomes [ID: 1356517]
Authors: Jones Cresta , Bader Alexandra , Brumley Caroline , Considine Samantha , Tessier Katelyn , Wanberg Lindsey
Published: May 2023

INTRODUCTION:

The objective of this study is to examine differences in obstetric delivery and neonatal outcomes between young birthing patients (age 18 years or younger) and a standard risk birthing population (age 25–30 years).

METHODS:

This is a retrospective cohort study of patients delivering between 2012 and 2017 in a single urban academic health system. Outcomes were examined for a young birthing cohort (n=528) and compared with a standard risk cohort age 25–30 years (n=937). This study was identified as exempt by the local IRB.

RESULTS:

When examining delivery outcomes, young birthing age was associated with a lower risk of cesarean section, even after adjusting for a history of prior cesarean section (13.4% versus 30.7%, adjusted odds ratio [aOR] 0.41), and a lower risk of postpartum hemorrhage (8.5% versus 12.85, aOR 0.48), all with P<.05. However, young age was also associated with an increased risk of delivery at less than 37 weeks of gestation (15.2% versus 9.5%, OR 1.96). When examining neonatal outcomes, young birthing age was associated with a lower rate of congenital anomalies at birth (6.6% versus 14.4%, aOR 0.42). After adjusting for covariates, there was no difference in low birth weight or neonatal intensive care unit (NICU) admission.

CONCLUSION:

Young birthing patients have delivery outcomes that vary from those of a standard birthing cohort, with a lower risk of cesarean delivery and postpartum hemorrhage but an increased risk of preterm birth. In addition, younger birthing patients have a lower risk of anomalies identified at birth but no increased risk of lower birth weight or NICU admission. These data may help tailor birthing programs for younger patients to better address their specific delivery risks.
Effect of an Obstetric Enhanced Recovery After Surgery (ERAS) Protocol on Maternal and Neonatal Outcomes [ID: 1375461]
Authors: Powel Jennifer , Chavan Niraj , Childress Katherine , Huber Madeline , Kumanan Krithika Narayana , Peramsetty Nikita
Published: May 2023

INTRODUCTION:

Enhanced Recovery After Surgery (ERAS) is a protocol initiated in many specialties with the goal of reducing health care costs, postoperative complications, and patient morbidity.

METHODS:

We undertook a retrospective cohort study of pregnant women undergoing nonlaboring, nonurgent cesarean delivery between October 2020 and October 2021. Data pertaining to demographic characteristics, pregnancy comorbidities, and maternal and neonatal outcome measures pertaining to operative and postoperative complications, readmission, length of stay, breastfeeding, neonatal cord gases, and neonatal intensive care unit admission were abstracted from electronic health records and compared across two groups, preimplementation and postimplementation, using Student t-test, Pearson’s χ2, Mann-Whitney U, and/or Fisher’s exact test, as indicated. Statistical significance was set at P<.05. Institutional review board approval was obtained.

RESULTS:

Demographic characteristics and rates of pregnancy comorbidities, including chronic hypertension, hypertensive disorders of pregnancy, and pregestational/gestational diabetes, were similar across pregnant women undergoing cesarean delivery in the preimplementation (N=168) and postimplementation (N=123) groups. Cesarean procedure duration, overall intraoperative and/or postoperative complication rates, readmission, breastfeeding rates, and postoperative length of stay did not change after ERAS implementation and were comparable to the pre-ERAS cohort. Postoperative Foley catheter replacement was more common after ERAS implementation (P=.03). Neonatal outcomes were comparable across both study groups.

CONCLUSION:

Implementation of an ERAS protocol did not significantly alter maternal and neonatal clinical outcomes in our study cohort with the exception of a small increase in Foley catheter replacement rates, which may be attributable to the protocol workflow requiring Foley removal within 6 hours postoperatively.
Evaluating the Effect of Interdisciplinary Simulation Training on Provider Comfort in the Management of Postpartum Hemorrhage (PPH) in a Low-Resource Setting [ID: 1363496]
Authors: Voigt Paxton , Hernandez Sasha , Ramos Beralis , Shirazian Taraneh
Published: May 2023

INTRODUCTION:

Maternal mortality from postpartum hemorrhage (PPH) can be reduced through timely management. Interdisciplinary simulation-based training (SBT) has been shown to improve team response to PPH, but SBT is not widely available in low-resource settings. The purpose of this study is to assess the acceptability of SBT and its effect on interdisciplinary personnel’s self-efficacy in a low-resource setting.

METHODS:

A pilot low-fidelity PPH SBT program using PRONTOPack was conducted from November 2021 to September 2022 after an initial audit revealed inadequate training at a public teaching hospital with the highest national maternal mortality rate in the Dominican Republic. Thirty interdisciplinary providers were trained in two cohorts. Self-efficacy was assessed via anonymous, postsimulation surveys.

RESULTS:

One hundred percent of providers reported that the SBT was an effective form of training that will help them manage PPH in the future. In the first cohort (n=7), providers reported high comfort with their teamwork (4.57/5 S 0.49) and communication skills (4.29/5 S 0.45) after SBT. In the second cohort (n=23), 100% of trainees agreed that SBT improved their ability to communicate effectively, work in teams, and manage PPH.

CONCLUSION:

Low-fidelity interdisciplinary SBT was found to be useful in improving trainees’ self-perceived nontechnical skills in the management of PPH. Most notably, communication skills were improved between providers that routinely manage real-time PPHs in clinical practice. Next steps are to integrate and standardize SBT into the obstetric department’s workflow to train all personnel managing PPHs.
Identifying Racial Inequities in Respect and Autonomy During Delivery Care [ID: 1378253]
Authors: Amutah-Onukagha Ndidiamaka , Declercq Eugene , Larson Elysia , Macharia AnnLiz , Meadows Audra , Schneider Lily
Published: May 2023

INTRODUCTION:

Measuring patient experience is core to understanding and addressing inequities in obstetric care quality.

METHODS:

People who gave birth at one of five hospitals in Massachusetts and identified as non-Hispanic Black (NHB) or non-Hispanic White (NHW) were invited to complete a structured survey 7–16 weeks postpartum, from February to September 2022. The survey included two validated patient experience instruments: the Mothers on Respect index, dichotomized as “very respectful” or not and the Mothers Autonomy in Decision Making scale, dichotomized as “high patient autonomy” or not. We report risk ratios of associations between patient characteristics and respectful or autonomous care, adjusting for hospital cluster using Stata v.17. Institutional review board approval was received from the Social and Behavioral Research IRB at Tufts University.

RESULTS:

Of 417 respondents (response rate: 25%), 245 (59%) were NHW and 172 (41%) were NHB. Most had a bachelor’s degree (62%). 241 (60%) of births were vaginal. Very respectful treatment was reported by 78% of respondents, whereas high patient autonomy was only reported by 64%. Non-Hispanic White people were 1.2 times as likely to report high respect compared to NHB (95% CI: 1.1, 1.4). Respect was also significantly lower for those with lower education and those with vaginal birth compared to those with cesarean birth. Differences in respect by race remained significant in multivariable models (1.2, 95% CI: 1.0, 1.4). Autonomy did not differ by any of the assessed demographic or delivery characteristics.

CONCLUSION:

Examining patient experience revealed inequities. To identify opportunities for improvement and monitor change, brief, validated, patient reported experience measures need to be incorporated into routine data collection.
Perceptions of Maternal Mortality in the Missouri Birthing Population [ID: 1380060]
Authors: Johnson Traci , Florio Karen , Kendig Susan , Quay Daniel , Rideout Reggi , Williams Alison
Published: May 2023

INTRODUCTION:

Missouri ranks ninth worst for pregnancy-related deaths (PRDs). Black women die at a rate threefold that of White women. The etiologies are multifactorial, including lack of awareness. We therefore sought to understand perceptions of PRD among the birthing population in Missouri.

METHODS:

The Perinatal Quality Collaborative (PQC) of Missouri developed a questionnaire assessing baseline knowledge surrounding risk factors, causes, and perceived underlying contribution of discrimination to maternal mortality (MM). A mailing list racially representative of the birthing population was purchased (Dynata) with grant support. Thirty-nine questions were distributed from March to August 2022 to birthing persons aged 18 years or older. Those without a Missouri ZIP code or who identified as male were excluded.

RESULTS:

One thousand seven hundred thirty-eight people met inclusion criteria with a response rate of 89%. Of those, 74.5% identified at White, 14% Black, 3.5% Hispanic, 3.6% Native American, 2.5% Asian, 0.3% as Hawaiian Native or Pacific Islander, and 1.6% as other/unknown. Over 78% reported awareness of MM with 58.2% believing those numbers to be high. Twenty-two percent reported a family member succumbing to MM. When asked about etiologies, 78.8% identified high blood pressure, 30.21% identified heart disease, and 79.63% reported health disorders as contributors. Fifty-seven percent of the cohort believed discrimination or bias have a role to play in MM in Missouri.

CONCLUSION:

The birthing population in Missouri is aware not only of the current maternal mortality crisis but astute to the underlying causes, including discrimination or bias. Our PQC will utilize this information to guide implementation of preventative measures for maternal mortality.
Hand Forceps for Delivery of Floating Fetal Head at Cesarean Section: A Randomized Pilot Study [ID: 1375984]
Authors: Jiang Xuezhi , Rodger Jonathan , Tegos George , Wu Rebecca
Published: May 2023

INTRODUCTION:

On occasion, obstetricians encounter difficulty delivering the floating fetal head at cesarean section; additional techniques may need to be employed beyond the traditional one-handed delivery technique. We propose a modified two-handed manual delivery method or “hand forceps,” with surgeon’s both hands shaped like a pair of forceps, as an alternative technique for fetal head delivery. The purpose of this study is to compare the efficacy and safety of two-handed technique by comparing with the traditional one-handed technique.

METHODS:

We conducted a randomized pilot study of women undergoing cesarean section (NCT04159857, ClinicalTrials.gov). Inclusion criteria included a singleton in cephalic presentation, at gestational age of 37 weeks or greater, with planned low transverse uterine incision, cervical dilation of 6 cm or lower and station less than −3. Patients were randomized to either the one-handed or two-handed delivery group. The primary outcome was “U-D interval,” defined as the time from entry of the hands into the uterus to the delivery of the fetal head. The secondary outcome was incidence of hysterotomy extension. Neonatal safety data were also collected.

RESULTS:

A total of 40 patients participated in the study; 16 randomized to the one-handed group, 19 randomized to the two-handed group, and 5 patients excluded because of protocol deviation. U-D interval (mean±SD) was significantly shorter in the two-handed group (6.0±7.4 seconds) than in the one-handed group (14.3±9.9 seconds), P<.001. There was no significant difference in incidence of hysterotomy extension, maternal and neonatal outcomes between the two groups.

CONCLUSION:

The two-handed method for fetal head delivery has a significantly decreased U-D interval compared to the one-handed method, without increasing the incidence of hysterotomy extension. A large-scale multicenter randomized controlled study is needed to further determine whether the “hand forceps” can be considered a safe alternative technique for delivery of the floating fetal head in cesarean sections.
The Use of Virtual Reality During Extraamniotic Balloon Insertion for Pain and Anxiety Relief: A Randomized Controlled Trial [ID: 1376399]
Authors: Kleiner Ilia , Bar Jakob , Barda Giulia , Cartun Zachary , Mor Liat , Weiner Eran
Published: May 2023

INTRODUCTION:

Induction of labor (IOL) with extraamniotic balloon (EAB) catheter is a procedure commonly associated with maternal discomfort, pain, and anxiety. We aimed to investigate the distractive effect of virtual reality (VR) technology on pain and anxiety in pregnant women who undergo IOL with EAB.

METHODS:

In this randomized controlled trial, pregnant women intended for IOL with EAB at term, were recruited, signed a consent form, and randomized into two groups. The control group received the institutional standard care for EAB insertion, while women in the VR group were exposed to a VR clip during the procedure. Pain scores (expressed by Visual Analog Scale [VAS]) were obtained before, during, and after EAB insertion. Anxiety levels (expressed by validated State-Trait-Anxiety Inventory Scale [STAI-S]) were obtained before and after the procedure. Maternal satisfaction was also recorded. The primary outcome was the VAS score during EAB insertion.

RESULTS:

Total of 145 women were recruited 1:1 ratio. There were no differences between groups in terms of age, body mass index, gestational age at enrollment, indication for IOL, or preprocedural VAS score and anxiety levels. VAS score during the procedure was significantly lower in the VR group compared to the control group (4.62±2.89 versus 5.95±3.18, P=.04). In addition, the VR group benefited from a higher rate of anxiety relief expressed by the difference between preprocedure and postprocedure STAI score (7.09±10.45 versus 2.84±8.65, P=.039). Women in the VR group reported an overall very high (93%) satisfaction score.

CONCLUSION:

In this randomized controlled trial, we demonstrated that the use of VR technology in women undergoing IOL with EAB was associated with lower VAS scores during the procedure, with significant anxiety reduction, and a higher satisfaction score, compared to women who received standard care.
Risk of Cesarean Delivery Varies by Race and Ethnicity Among Pregnancies Complicated by Fetal Growth Restriction [ID: 1377645]
Authors: Nilsen Nichole , Esposito Matthew , Lord Megan
Published: May 2023

INTRODUCTION:

Cesarean delivery (CD) rates differ between non-Hispanic White (NHW) and Hispanic/non-White (H/NW) patients, although the relationship varies by indication. We examined CD rates among NHW and H/NW patients in pregnancies complicated by fetal growth restriction (FGR).

METHODS:

This was an IRB-approved secondary analysis of a retrospective cohort of singleton live births 2003–2012 with an estimated fetal weight (EFW) less than 10th centile for gestational age on the last ultrasound prior to delivery.

RESULTS:

Of 563 pregnancies, 270 (46.88%) were to NHW patients and 306 (53.12%) to H/NW patients. NHW were older (27.92 versus 26.04 years), taller (160.42 versus 158.58 cm), and more likely to have private insurance (51.30% versus 20.26%) and be admitted to a private practice (70.00% versus 44.41%) (P<.01 for all). There was no difference in umbilical artery Doppler findings, EFW, proportion of CD performed because of nonreassuring fetal status, maternal body mass index, gestational age at FGR diagnosis or delivery, or maternal comorbidities. Apgar scores, arterial cord pH, neonatal intensive care unit admission, hypoglycemia, need for respiratory support, and neonatal death were similar (P>.05 for all). However, NHW patients were more likely to undergo CD (35.71% versus 22.90%, P<.01) including prelabor cesarean (21.48% versus 13.75%, P<.01). After adjusting for maternal age, height, insurance status, and delivering team, risk of CD remained higher among NHW patients (relative risk 1.56, 95% CI 1.20–2.03; adjusted relative risk 1.48, 95% CI 1.12–1.96).

CONCLUSION:

Despite similar neonatal outcomes, NHW are more likely than H/NW patients to deliver by CD, particularly prelabor CD, when the EFW is below the 10th centile.