bluuebunny/crossref_metadata_2025 huggingface dataset:
Early Feasibility Lessons: A Pilot Randomized Trial of Amnioinfusion as a Novel Indication for Intrapartum Neuroprotection [ID: 1374128]
Authors: Polnaszek Brock , Hamel Maureen , Lewkowitz Adam , Murphy Lauren , Rossen Julia , Whelan Anna
Published: May 2023

INTRODUCTION:

Developing evidence-based management strategies to decrease maternal/neonatal morbidity in labor is essential. However, the barriers/facilitators to executing these trials are underreported. Our objective is to present early feasibility lessons learned after the rollout of a pilot randomized control trial examining amnioinfusion as a novel indication for intrapartum neuroprotection.

METHODS:

Our pilot randomized control trial began recruiting patients in July of 2022. In the first 3 months of our pilot, we followed the Plan, Do, Check, Act (PDCA) cycle to identify barriers and facilitators as a part of our feasibility aim. The PDCA cycle was executed by the primary research team and began with the first patient to be successfully consented and randomized. The barriers and facilitator were tracked by key study personnel and addressed at the weekly research meetings. Using this cycle, we developed the study protocol before widespread recruitment was initiated.

RESULTS:

We identified several barriers including 1) challenging acute and emergent clinical situations inherent to intrapartum care; 2) lack of provider/patient acceptability for novel indication of amnioinfusion; 3) monitoring for the development of intrapartum risk factors, and 4) unanticipated hospital system processes. We implemented several facilitators in direct response to these barriers for the pilot feasibility trial including 1) identification and presence of a research champion on labor and delivery to build rapport with staff and participants; 2) continuous education of the novel therapy; 3) incentivization of care team and participants; and 4) engagement of key stakeholders.

CONCLUSION:

Using a PDCA was invaluable. We identified several barriers and facilitators to be considered when designing/implementing future randomized trials intrapartum, particularly when studying novel indications of therapy.
Understanding the Effect of Expectant Versus Expedited Delivery in the Periviable Period [ID: 1376738]
Authors: Griffin Laurie , Gimovsky Alexis , Gould Alexander , Passarelli Natalie
Published: May 2023

INTRODUCTION:

Periviable birth accounts for only 0.5% of births but contributes to a majority of neonatal deaths. There is no clear recommendation regarding expediting delivery in periviable patients with advanced cervical dilation (ACD). The objective of this study was to assess whether expectant management versus expedited delivery in patients with ACD affects perinatal outcomes.

METHODS:

This is a single-institution retrospective cohort study of singleton gestations at 20.0–25.6 weeks with ACD (4–6 cm) on admission from 2016 to 2018. Individuals were stratified into two groups: 1) those who progressed spontaneously to delivery (expectant management) and 2) those who underwent augmentation of labor or cesarean delivery at the time of ACD diagnosis (expedited delivery). The primary outcome was neonatal mortality. Secondary outcomes included differences in postpartum hemorrhage and infection rates.

RESULTS:

Forty-three of 199 preterm deliveries met eligibility criteria: 21 were expectantly managed and 22 underwent expedited delivery. There was no difference in demographic characteristics or gestational age between the expectant management and expedited delivery groups (23′1 [SD 1.65] versus 24′4 [SD 3.05] weeks, [P=.9]). There was no difference in neonatal mortality (n=13 [61.9%] versus n=10 [45.5%], P=.3), maternal infection (n=1 [4.76%] versus n=4 [18.2%], P=.3) or postpartum hemorrhage (n=2 [9.5%] versus n=1 [4.5%], P=1.0) between the expectant management and expedited delivery groups, respectively.

CONCLUSION:

In this cohort, there were no differences in neonatal mortality, maternal infection, or postpartum hemorrhage between expectant management and expedited delivery in singletons with ACD in the periviable period. Larger studies are needed to inform guidelines for management of these complex cases.
Antepartum and Postpartum Monocyte Distribution Width Values in Patients With Histopathologic Chorioamnionitis [ID: 1376799]
Authors: Vircks Julie , Dahlke Julia , Henricks Christine , Karmarkar Tanvi , Kaufman Eva , O’Brien Devon
Published: May 2023

INTRODUCTION:

In nonpregnant adults presenting to the emergency department, monocyte distribution width (MDW) progressively increases with infection severity. While studies have shown that chorioamnionitis alters monocyte response, MDW has not been well studied in pregnancy. The primary aim of the study was to examine MDW values antepartum and postpartum in patients with histopathologic chorioamnionitis.

METHODS:

A retrospective electronic chart review was performed from an urban safety net hospital. Patients with an MDW value on admission and postpartum day number 1 (PPD1), in addition to postpartum placental histopathologic examination, were included in the study. Institutional review board approval was obtained (UMKC #2093657). The Mann-Whitney U test was utilized for statistical analyses.

RESULTS:

Of the 419 obstetric patient encounters reviewed, 89 encounters met inclusion criteria, of which 32% were diagnosed with histopathologic chorioamnionitis. There was no difference (P>.05) in median MDW at the time of admission between those with and without chorioamnionitis on histopathology (18.78 U versus 18.53 U, P=.602). However, the median MDW was significantly higher on PPD1 in patients diagnosed with chorioamnionitis compared to those without chorioamnionitis on postpartum histopathology (21.48 U versus 19.56 U, P=.001).

CONCLUSION:

In the setting of histopathologic chorioamnionitis, a significant elevation in postpartum MDW values compared to admission values suggests intrapartum MDW values increase as the infection develops. Additional longitudinal and prospective analysis of intrapartum MDW values may help characterize this rise and establish its potential role as a predictor of adverse pregnancy outcomes.
BMI Had a Negative Effect on Decision-to-Incision Times for Urgent Cesarean Deliveries [ID: 1377147]
Authors: Deal Laura , Gad Mary , Goldberg Jay , Jaspan David , White Chase
Published: May 2023

INTRODUCTION:

Greater maternal body mass index (BMI) is associated with worse maternal and fetal outcomes. Intrapartum care of patients may be more difficult with higher BMIs. We studied the effect of BMI on decision-to-incision times less than 30 minutes for urgent cesarean sections.

METHODS:

After IRB approval, a retrospective chart review of 186 consecutive urgent cesarean deliveries during 2020 at an academic medical center were examined. Data were abstracted from patient and neonate charts. Statistical analysis was performed using χ2, t test, and Pearson’s r test.

RESULTS:

Seventy-one percent of patients with BMI greater than 30 had decision-to-incision times of more than 30 minutes, compared to 46% with BMI less than 30 (P=.03). The mean time from decision-to-incision with BMI greater than 30 was 44 minutes, and 36 minutes with BMI less than 30 (P=.005). When BMI was greater than 40, the mean time was 50 minutes (P=.03). 16% of patients with BMI greater than 30 had decision-to-incision times of more than 60 minutes, compared to 2% with BMI less than 30 (P=.007). BMIs greater than 30 had longer decision-to-operating room (OR) entry (22 versus 17 minutes, P=.02) and OR entry-to-incision times (22 versus 19 minutes, P=.053). Body mass indexes of greater than 40 had both longer decision-to-OR entry (24 versus 19 minutes) and OR entry-to-incision times (25 versus 19 minutes, P=.005). Mothers with BMI greater than 50 had the longest times from OR entry-to-incision and had babies most likely to go to the neonatal intensive care unit (NICU) (50% versus 16%).

CONCLUSION:

Greater maternal BMIs had longer times for urgent cesarean sections for decision to incision, decision to OR entry, and OR entry to incision. There was a lengthening of decision-to-incision times with increasing BMI. The highest maternal BMIs were most likely to result in NICU admissions. Decision-to-incision time of greater than 30 minutes did not affect umbilical cord arterial pH or NICU admission.
The Majority of Urgent Cesarean Sections Had a Decision-to-Incision Time of Greater Than 30 Minutes [ID: 1377172]
Authors: Deal Laura , Gad Mary , Goldberg Jay , Jaspan David , White Chase
Published: May 2023

INTRODUCTION:

The American College of Obstetricians and Gynecologists has recommended that hospitals providing obstetrical care should have the capability to begin cesarean deliveries within 30 minutes. This has been taken out of context in that failure to meet a 30-minute decision-to-incision time for urgent cesarean sections may be criticized litigiously if a poor neonatal outcome occurs.

METHODS:

After IRB approval, a retrospective chart review of 186 consecutive urgent cesarean deliveries during 2020 at an urban academic medical center was performed. Data were abstracted from patient and neonate charts. Statistical analysis was performed using χ2, t test, and Pearson’s r test.

RESULTS:

Sixty-seven percent of urgent cesarean section had a decision-to-incision time greater than 30 minutes. Mean time was 42 minutes and median time was 36 minutes (8–194 minutes). Seventy-one percent of patients with body mass index (BMI) greater than 30 had decision-to-incision times greater than 30 minutes, compared to 46% with BMI less than 30 (P=.03). Seventy-eight percent of patients without an epidural took more than 30 minutes, compared to 64% with an epidural (P=.09). Sixty-four percent of urgent cesarean sections occurring between 7 am and 5 pm had decision-to-incision times of greater than 30 minutes, compared to 69% between 5 pm and 7 am (P=.54).

CONCLUSION:

Sixty-seven percent of urgent cesarean sections had a decision-to-incision time greater than 30 minutes at an academic medical center. Deliveries with BMI greater than 30 were associated with failure to meet a 30-minute threshold. Not having an epidural trended towards failure to meet a 30-minute threshold. Whether delivering during the daytime or nighttime, race, and insurance status did not affect decision-to-incision times. Decision-to-incision time greater than 30 minutes did not affect umbilical cord arterial pH or neonatal intensive care unit admission.
External Validation of Second-Stage Vaginal Delivery Prediction Model [ID: 1377356]
Authors: Herz-Roiphe Rachel , Little Sarah , Reiff Emily
Published: May 2023

INTRODUCTION:

We sought to externally validate Gimovsky et al.’s prediction model for spontaneous vaginal delivery (SVD) in the second stage (https://www.pushprescriber.com [PUSH MODEL]) prior to using it for a quality improvement (QI) intervention at our hospital.

METHODS:

This was a retrospective cohort of 2,296 birthing persons delivering at a single hospital over 1 year. Inclusion criteria were similar to the PUSH MODEL: nulliparous, term, without planned cesarean, singleton, vertex, nonanomalous, epidural anesthesia. We calculated the predicted probability of SVD at every hour from the PUSH MODEL to generate receiver–operator curves and analyzed factors associated with second stage duration in our cohort.

RESULTS:

Overall, 1,735 (77%) delivered by SVD, similar to 74% in the PUSH MODEL. Head position had the strongest association with SVD (83% OA versus 39% OP, P<.01). The area under the curve from the PUSH MODEL at the start of the second stage was 0.64 (95% CI 0.62–0.77), as compared to 0.73 in the original population. The model had similar performance at hours 1 (n=1,513), 2 (n=917), 3 (n=522), and 4 or more (n=255). Using a cutoff of 77% (baseline rate of SVD in our population), those who “Screen Positive” at the start of the second stage had an 78.5% rate of SVD as compared to 39.3% for those who “Screen Negative” (P<.01).

CONCLUSION:

The PUSH MODEL performed well on external validation; we similarly found that head position and second-stage duration were strongly associated with the probability of SVD in our cohort, supporting incorporation of this tool in QI work at our hospital.
Outpatient Cervical Ripening Program Evaluation: A Comparison of Osmotic Cervical Dilators and Foley Balloon [ID: 1377400]
Authors: Sidebottom Abbey , Colicchia Laura , Drake Kelly , Goering Mary , Vacquier Marc , Wunderlich Whitney
Published: May 2023

INTRODUCTION:

With increased demand for elective and medically indicated inductions of labor, outpatient cervical ripening programs have the potential to increase clinical efficiency, decrease costs, and promote patient satisfaction. This study describes patient characteristics, process, and outcome measures for an outpatient cervical ripening program.

METHODS:

This retrospective cohort study examined low-risk women (39–40 6/7 weeks) undergoing outpatient cervical ripening with osmotic cervical dilators (Dilapan-S) or Foley balloon from March 2020 to March 2022. Outcomes included mode of delivery, obstetric complications, and changes in cervical dilation and simplified Bishop score (SBS) (a 0- to 9-point scoring system based on dilatation, effacement, and station).

RESULTS:

One hundred twenty patients completed outpatient cervical ripening (80 osmotic dilators, 40 Foley). Foley patients were less likely to be White and had higher SBS at insertion. 16.7% (n=20) of patients returned before scheduled induction, primarily because of contractions. Device expulsion prior to admission was more common among Foley patients (27.5%) than osmotic dilators (6.3%). Mean time from insertion to admission was 17.5 hours for osmotic dilators and 13.6 hours for Foley. The mean SBS change was 1.78, and mean dilation change was 1.83 cm with no differences by device type. Mean time from admission to delivery was 20.96 (15.36) hours, and 74.2% of patients delivered vaginally, with no difference by device type in adjusted models. Rates of infection (4.2%), and postpartum hemorrhage (2.3% vaginal, 32% cesarean) did not differ by device.

CONCLUSION:

Outpatient cervical ripening with osmotic cervical dilators or Foley improves SBS on admission with low complications and no significant differences in outcomes by device.
Inpatient Versus Outpatient Induction of Labor in Low-Risk Pregnancies: A Retrospective Cohort Study [ID: 1377456]
Authors: Dong Zi Yang (Susan) , Alavifard Sepand , Ashraf Rizwana , D’Souza Rohan , Huszti Ella
Published: May 2023

INTRODUCTION:

To determine whether outpatient induction of labor (OP-IOL) using balloon catheters improved outcomes and resource utilization when compared with inpatient (IP)-IOL.

METHODS:

Outcomes in low-risk singleton pregnancies from April 2016 to December 2018 after introduction of an OP-IOL protocol were compared with those that underwent IP-IOL between April and December 2016 at the same institution.

RESULTS:

We included 225 IP- and 850 OP-IOL cases. Prostaglandin was more commonly employed in operator-determined IP-IOL (78.7%), while balloon catheters were almost exclusively used in OP-IOL (95.4%), consequent to a unit policy. There was no difference in caesarean deliveries (CDs) (adjusted odds ratio [aOR], 1.25 [95% CI, 0.76, 2.08]), neonatal intensive care unit admission, 5-minute Apgar scores less than 7, or maternal adverse events after onset of labor. Those undergoing OP-IOL were less likely to need a second induction agent (aOR 0.19 [95% CI 0.11, 0.33]) but experienced more maternal adverse events related to the induction (aOR 3.72 [95% CI 1.24, 11.75]), a longer median IOL-to-delivery interval (19.13 versus 30.14 hours [7.28, 11.80]), although a median of 13.83 of these 30.14 hours were spent outside the hospital. There were no differences in the admission-to-delivery (−1.45 hours [–3.29, 0.38]) and total hospitalization time (0.66 hours [–3.93, 5.25]).

CONCLUSION:

Although IP- and OP-IOL had comparable CD and neonatal outcomes, operator-determined IP-IOL had significantly shorter IOL-to-delivery. A universal policy of OP balloon catheters did not shorten duration of hospitalization, but increased IOL-to-delivery and maternal adverse events. Whether an individualized approach to OP-IOL could reduce resource utilization needs to be explored.
Diabetes and Hypertensive Disorders of Pregnancy and the Risk of Third- and Fourth-Degree Perineal Lacerations: A Large United States Cohort 2016–2020 [ID: 1377605]
Authors: Gobioff Samantha , Bar-El Liron , Bornstein Eran , Chervenak Frank , Grunebaum Amos , Lenchner Erez
Published: May 2023

INTRODUCTION:

The objective of this study was to assess the effect diabetes and hypertensive disorders of pregnancy have on the rate of third- and fourth-degree perineal laceration (3/4 PL).

METHODS:

This represents a retrospective cohort based on the Centers for Disease Control and Prevention Natality Live Birth database (2016–2020). We compared the rates of 3/4 PL in term, singleton vaginal births across the United States based on maternal gestational hypertension, preeclampsia, pregestational diabetes, and gestational diabetes. We used Pearson χ2 and multivariate logistic regression to control for confounding variables. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios (aORs) with 95% CI.

RESULTS:

Of the 11,677,671 who met inclusion criteria, 139,174 (1.2%) women experienced 3/4 PL. Gestational hypertension and preeclampsia were associated with increased rates of 3/4 PL (1.53% with aOR 1.28, 95% CI 1.25–1.30, and 1.61% with aOR 1.31, 95% CI 1.06–1.17, respectively). Additionally, both pregestational diabetes and gestational diabetes were associated with higher rates (1.44% with aOR 1.45, 95% CI 1.35–1.56, and 1.44% with aOR 1.27, 95% CI 1.25–1.30, respectively).

CONCLUSION:

Based on this current U.S. database, we identified several medical complications of pregnancy that are associated with an increased risk for 3/4 PL. Specifically, hypertensive disorders of pregnancy (gestational hypertension and preeclampsia), pregestational as well as gestational diabetes were all associated with significantly increased risks. Understanding these associations may contribute to reduction in the rates of 3/4 PL in gravidas with these conditions.
Chorioamnionitis Is an Independent Risk Factor for Third- and Fourth-Degree Perineal Lacerations in the United States [ID: 1377609]
Authors: Gobioff Samantha , Bar-El Liron , Bornstein Eran , Chervenak Frank , Grunebaum Amos , Lenchner Erez
Published: May 2023

INTRODUCTION:

The objective was to determine the effect chorioamnionitis has on the risk of third- and fourth-degree perineal lacerations (3/4 PL).

METHODS:

This represents a retrospective cohort based on the Centers for Disease Control and Prevention Natality Live Birth database (2016–2020). We compared the rates of 3/4 PL in term, singleton vaginal births across the United States based on diagnosed intrapartum chorioamnionitis. We used Pearson chi-square and multivariate logistic regression to control for confounding variables. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios (aORs) with 95% CI.

RESULTS:

Of the 11,677,671 who met inclusion criteria, 139,174 (1.2%) women experienced 3/4 PL. Intrapartum chorioamnionitis was associated with a staggering 3.96% rate of 3/4 PL compared to a 1.15% rate in women without chorioamnionitis (aOR 1.85, 95% CI 1.80–1.90).

CONCLUSION:

Based on this current U.S. database we identified chorioamnionitis as a major risk factor for 3/4 PL. The potential explanation may be due to dysfunctional labor, increased perineal edema secondary to protracted labor, or increased friability of tissue. Understanding this association may assist in better counseling and potentially reduce the rates of 3/4 PL in gravidas with chorioamnionitis.
Risk Factors for Worsening Placental Invasion Within a Cohort of Placenta Accreta Spectrum Patients [ID: 1380333]
Authors: Hussein Nada , Harrison Rachel , Holmgren Calla , Phelps Alexandra , Steinberg Guy , Steinberg Guy
Published: May 2023

INTRODUCTION:

Risk factors for placenta accreta spectrum (PAS) are overall well understood. We sought to evaluate whether those with more severe disease (increta/percreta) have a subset of patient-specific risk factors that could assist in preoperative planning.

METHODS:

Institutional review board-approved case–control study of patients diagnosed with PAS who underwent cesarean hysterectomy with pathology confirmed findings. Those with final pathology of placenta increta or percreta were compared to those whose final pathology demonstrated placenta accreta. Baseline characteristics and pregnancy histories were compared between groups via Student’s t tests and χ2 analysis, and a backwards logistic regression was performed to evaluate individual factors associated with more severe PAS invasion.

RESULTS:

A total of 83 participants met criteria with 51 (61.4%) diagnosed on pathology with increta/percreta. Those with increta/percreta had higher body mass index (34.3±7.0 versus 30.8±8.0) and higher number of prior cesarean births (2.2±1.0 versus 1.7±0.9), and were less likely to have undergone in vitro fertilization (3.9% versus 21.9%) or have a previous cesarean birth with two-layer closure compared to single-layer closure (25.0% versus 63.6%) (all P<.05). After controlling for confounders, there was a trend for more prior cesarean births to increase the risk of increta/percreta and for prior cesarean birth with two-layer closure to decrease the risk, but these were not statistically significant (adjusted odds ratio [aOR] 1.18, 95% CI 0.43–3.23, and aOR 0.51, 95% CI 0.18–1.46, respectively).

CONCLUSION:

Our study did not identify patient-specific factors that increased the risk for more severe PAS invasion; however, there was a trend for multiple prior cesarean births and previous cesarean birth with single-layer closure to be associated with increased risk.
Recent Trends in Tranexamic Acid Use During Postpartum Hemorrhage in the United States [ID: 1380480]
Authors: Litman Ethan , Ahmadzia Homa , Ma Phillip , Nelson Stuart
Published: May 2023

INTRODUCTION:

The United States has one of the highest rates of maternal mortality among developed regions, and postpartum hemorrhage (PPH) accounted for 14% of all pregnancy-related deaths between 2017 and 2019. Several large studies have demonstrated decreased PPH rates with the use of tranexamic acid (TXA). Consensus has not yet been reached on the when to administer use of TXA. Little data exist regarding the prevalence of TXA use in obstetric patients with and without PPH.

METHODS:

Using a national database, we identified over 1.2 million pregnancies between January 1, 2015, and June 30, 2021. Pregnancy and delivery information was abstracted using ICD-10 codes. The GW Institutional Review Board approved the study protocol and waived the requirement for patient informed consent.

RESULTS:

Overall, TXA was used 1% of the time (12,394/1,262,574), and there was a fivefold increase in TXA use (0.5–2.5%) during the study period. Patients had similar demographic characteristics. Tranexamic acid use differed by geographic region. The use of TXA increased in both patients with PPH and those without. There was a greater increase in the number of patients who received TXA for prophylaxis of PPH than those who received it as treatment of PPH.

CONCLUSION:

This is the largest U.S. observational study to examine patterns of TXA use in obstetrics. Tranexamic acid was only administered in approximately 10% (4,586/43,928) of cases of PPH. This represents an opportunity to increase awareness for the role of TXA in management and prevention of PPH.
Effect of Body Mass Index on Adverse Neonatal Outcomes in Patients With Emergency Cesarean Deliveries [ID: 1381091]
Authors: Doshi Uma , Caughey Aaron , Chaiken Sarina , Garg Bharti
Published: May 2023

INTRODUCTION:

The objective of this study was to evaluate the association of body mass index (BMI) with adverse neonatal outcomes in pregnant patients with emergency cesarean delivery (CD).

METHODS:

This was a retrospective cohort study of singleton nonanomalous pregnancies between 23 and 42 weeks from 2007 to 2012 in California. Pregnancies resulting in an emergency CD were stratified based by ICD-9 codes for cord prolapse, or uterine rupture. Outcomes included neonatal intensive care unit (NICU) admission, Apgar scores less than 3 at 5 minutes, infant death, respiratory distress syndrome (RDS), neonatal seizures, and hypoglycemia. After stratifying by cause of emergency CD, multivariable logistic regression models were used to evaluate associations of BMI at delivery with adverse neonatal outcomes. Models were adjusted for maternal race and ethnicity, age, education level, insurance, parity, smoking status, and prenatal care.

RESULTS:

Of this cohort, 1,368 had an emergent CD in the setting of cord prolapse, and 992 had an emergent CD in the setting of a uterine rupture. Of individuals with cord prolapse, patients whose BMI was classified as obesity class II had decreased odds of NICU admission, and those whose BMI was classified as obesity class III had decreased odds of NICU admission and RDS. Of individuals with a uterine rupture, patients whose BMI was classified as overweight had decreased odds of all neonatal outcomes analyzed. Those with a BMI classified as obesity class I had decreased odds of all neonatal outcomes except for neonatal seizures. Those with a BMI classified as obesity class II had decreased odds of lower Apgar scores, NICU admission, infant death, and RDS. Those with a BMI greater than 50 had increased odds of RDS and hypoglycemia.

CONCLUSION:

Higher BMI was associated with decreased risk of many adverse neonatal outcomes in the setting of patients delivering emergently with cord prolapse or uterine rupture. These findings may be useful in appropriately managing patients presenting with emergent CD.
Newborn Outcomes After Maternal COVID-19 Infection in Pregnancy and the Potential Role of Infection Severity [ID: 1373946]
Authors: Elsayed Yosra , Bailey Beth , Oatey Elena
Published: May 2023

INTRODUCTION:

COVID-19 poses health risks in pregnancy including increased rates of cesarean sections, preeclampsia, and miscarriage. However, less is known about newborn effects and the effect of severity of infection. We evaluated the link between pregnancy COVID-19 infection status and severity, and newborn outcomes.

METHODS:

Participants in this IRB-approved retrospective chart review study were identified via medical records from a single university-affiliated obstetric practice and grouped as COVID-19 positive during pregnancy (n=69), or COVID-19 negative delivering pre-COVID (n=59). Severity of infection was based on emergency department visit, hospitalization, oxygen treatment, steroids, antibodies, or ventilation. Information on socioeconomic factors, medical history, and birth outcomes was also abstracted.

RESULTS:

Compared to controls, and after adjustment for background differences, those with COVID-19 infection during pregnancy had newborns 242 g lighter and were 4.3 times more likely to deliver preterm, 2.6 times more likely to have a newborn with a 1-minute Apgar score less than 8, and 2.9 times more likely to remain hospitalized a week or more. Differences were largely driven by earlier delivery. Finally, severe COVID-19 infection (which occurred for 41% of participants with COVID-19) was a strong predictor of preterm delivery, low birth weight, receipt of oxygen, neonatal intensive care unit admission, and longer hospital stay.

CONCLUSION:

COVID-19 infection during pregnancy predicts adverse newborn outcomes, especially as a result of reduced gestational duration. Additionally, severity of infection may predict worse outcomes. A larger, more diverse sample is needed to confirm findings, and to examine potential effect of vaccination in reducing the effect of COVID-19 infection during pregnancy.
Postpartum Readmission in Maryland by Race and Ethnicity [ID: 1358223]
Authors: Hamilton Sonia , Lawson Shari , Olson Sarah , Voegtline Kristin
Published: May 2023

INTRODUCTION:

In Maryland, 81% of pregnancy-related deaths occurred in the postpartum period. We sought to compare postpartum readmission by race and ethnicity to better understand disparities in maternal mortality.

METHODS:

In this retrospective study (2016–2019), childbirth hospitalizations from the Maryland State Inpatient Database for childbearing age patients were analyzed. Indication for readmission was described. Multivariable logistic regression models were employed to determine race and ethnicity differences in postpartum readmissions, adjusting for maternal and obstetric characteristics (Johns Hopkins IRB00320807).

RESULTS:

Among total deliveries (n=260,778), 3,914 patients (1.5%) were readmitted within 60 days of delivery. The most common primary diagnoses at readmission were hypertension and infection. The prevalence of readmission was 1.2% for White patients, 2.3% for Black patients, and 1.2% for Hispanic patients (P<.0001). Black patients had the highest rates of readmission for hypertensive disorders (37%, P<.0001). In adjusted models, Black patients were more likely to be readmitted than White patients (odds ratio 1.64, CI 1.52–1.77). The majority of readmissions occurred in the first week after delivery; however, Black patients had higher rates of readmission in the second week relative to all other groups (P<.0001).

CONCLUSION:

Hypertension is a leading factor for postpartum readmission in Maryland. Black patients were more likely to be readmitted for hypertensive disorders of pregnancy and to have delayed readmission relative to other race/ethnic groups. Maryland public health officials should address disparities with interventions targeting racial and ethnic minorities, patients at risk for hypertensive disorders, and barriers to timely care.
Maternal Outcomes in Placenta Accreta Spectrum Disorders Managed With REBOA [ID: 1370002]
Authors: Muller Benjamin , Chang Eugene , Finneran Matthew , McElwee Eliza , Peneva Ralitza , Sullivan Scott
Published: May 2023

INTRODUCTION:

Pregnancies complicated by placenta accreta spectrum (PAS) are increasing. In PAS, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control life-threatening hemorrhage, although supporting data are conflicting. The aim of this study was to determine the outcomes in pregnancies complicated by PAS managed with REBOA.

METHODS:

This was an IRB-exempt retrospective cohort study of pregnancies complicated by PAS at a single institution. The primary outcome was arterial thrombus. Secondary outcomes were estimated blood loss, operative room time, transfusion risk, and hospital and intensive care unit stays. Demographics and outcomes were compared by univariate analysis. Multivariable logistic regression with a mixed effects model was used to control for confounders.

RESULTS:

Ninety-one pregnancies (16 REBOA and 75 non-REBOA) were included. REBOA was associated with an increased risk of arterial thrombus, adjusted odds ratio of 1.33 (95% CI 1.05–1.77, P<.001). Patients with an arterial thrombus had longer hospital (P<.003) and intensive care unit stays (P<.001). REBOA use was associated with increased total operative time (249 versus 171 minutes, P=.001). REBOA was not associated with lower total estimated blood loss (EBL, 2,699 versus 3,455 mL, P=.28).

CONCLUSION:

The use of REBOA in PAS is associated with an increased risk of arterial thrombus compared to management without. This risk remains elevated after controlling for demographic and clinical variables. REBOA use was not associated with clinical benefits such as decreased EBL or operative time.
Nonobstetric Maternal Mortality Trends by Race in the United States From 2000 to 2019 [ID: 1376551]
Authors: Huang Ryan , Abenhaim Haim Arie
Published: May 2023

INTRODUCTION:

Public health interventions to reduce maternal mortality have focused on direct and indirect obstetric causes, while neglecting nonobstetric causes of death. The study objective was to examine recent trends in maternal deaths from nonobstetric causes in the United States.

METHODS:

A population-based cross-sectional study was conducted in the United States using data from the “Birth Data” and “Mortality Multiple Cause” files compiled by the Centers for Disease Control and Prevention from 2000 to 2019. The annual incidence of maternal deaths attributed to nonobstetric causes per 100,00 live births were calculated across racial groups using official death certificates, while the effects of race on the risk of nonobstetric maternal mortality and temporal changes over the study period were examined using logistic regression models.

RESULTS:

From 2000 to 2019, a total of 7,334 women died during pregnancy and childbirth from nonobstetric causes, where 31.3% of these deaths were caused by transport accidents and 27.3% by accidental poisoning. American Indian women were found to be at the highest risk of nonobstetric maternal mortality (odds ratio 2.20, 95% CI 1.90–2.56), and 46.1% of all deaths among pregnant American Indian women were caused by nonobstetric complications. The risk of nonobstetric maternal mortality increased overall during the study period, with a greater increase among Black (1.15, 1.13–1.17) and American Indian women (1.17, 1.13–1.21).

CONCLUSION:

Nonobstetric causes of death have become increasingly prevalent in the United States, overall and especially in American Indian women. Novel interventions to address these nonobstetric factors should especially target American Indian women to improve maternal outcomes.
The Effect of Transverse Skin Incision Location on Wound Morbidity After Cesarean Delivery for Patients With Morbid Obesity [ID: 1377795]
Authors: Baranco Nicholas , Mastrogiannis Dimitrios , Zhang Junchao
Published: May 2023

INTRODUCTION:

The objective of this study was to assess whether placement of transverse skin incision below or above the panniculus for cesarean delivery in patients with morbid obesity is associated with postoperative wound complications.

METHODS:

We identified a cohort of all women with body mass index (BMI) higher than 40 who delivered by cesarean at our institution from 2016 to 2020, had complete postpartum records, singleton gestation, and transverse skin incision. Medical records were abstracted after IRB exemption. The primary outcome was composite wound morbidity (infection, disruption, or dehiscence). Secondary outcomes included operative time, neonatal outcome, and blood transfusion. Analysis was performed with χ2 and logistic regression including BMI percentile, diabetes, smoking, unscheduled surgery, and prior cesarean.

RESULTS:

Two hundred sixty-three patients had a low transverse incision and 65 had a high transverse incision. 14.6% of patients had wound morbidity. There were two reoperations and no fascial dehiscences or deep site infections. Patients with a high transverse incision had higher mean BMI (53.0 versus 45.9, P<.001) and were less likely to be in labor (relative risk 0.52, 0.28–0.96) but were otherwise similar to patients with a low incision. High transverse incision was associated with composite wound morbidity (adjusted odds ratio 5.12, 2.36–11.09) and increased operative time (61 versus 54 minutes, P=.02) but not other secondary outcomes. Results did not significantly differ when analysis was restricted to patients with BMI greater than 50.

CONCLUSION:

Wound morbidity was more frequent after high transverse skin incision for cesarean delivery. Prospective studies are needed to determine whether incision location or other factors caused this increase.
Analysis of Characteristics Associated With Pregnancy Duration After Cervical Cerclage Placement in Singleton Gestations [ID: 1378088]
Authors: Hong Leah , Hasty Miranda , Jolly Sonia , Powel Jennifer , Tomlinson Tracy , Zantow Emily
Published: May 2023

INTRODUCTION:

Cervical cerclage technique and perioperative interventions vary widely among providers because of lack of evidence to inform management. Our aim was to identify factors independently associated with pregnancy duration in singleton gestations after cerclage placement.

METHODS:

This was a retrospective cohort analysis from 2008 to 2020 at an academic tertiary care center. Because of the inclusion of one or more pregnancies for ∼37% of the cohort, a linear mixed-effects model was utilized to evaluate the association between various factors and pregnancy duration. Variables with P<.2 on unadjusted analysis were considered for incorporation into a multivariable model. Model fit was assessed using Akaike’s information criterion (AIC).

RESULTS:

Out of 762 pregnancies, 42% underwent history-indicated, 22% ultrasound-indicated, and 36% physical exam-indicated cerclage placement. Mean gestational age (GA) at delivery was 35.0±5.8 weeks. 22% occurred less than 32 weeks and 7% resulted in previable delivery. Mean duration of pregnancy after cerclage placement was 17.1±7.0 weeks. An 8-covariate multivariable analysis revealed adjusted differences (β) in weeks of GA at delivery (95% CI): nulliparity +1.61 (0.57, 2.64), multiparity with most recent delivery 34 weeks or greater +1.31 (0.53, 2.10), married +0.94 (0.18, 1.70), concomitant progesterone use +1.06 (0.35, 1.76), preoperative cervical dilation 0.5 cm or higher −1.26 (−2.10, −0.41), utilization of Foley balloon for membrane elevation −2.27 (−3.53, −1.01), postoperative cervical length less than 20 mm −6.34, (−7.37, −5.32), and requiring cerclage revision −3.79 (−5.40, −2.18).

CONCLUSION:

Apart from use of a Foley balloon for membrane elevation and concomitant progesterone, we did not find any modifiable factors associated with pregnancy duration after cervical cerclage placement. However, this information may inform counseling as well as management for those with a postoperative cervical length less than 20 mm.
Factors Associated With Pregnancy Duration up to 32 Weeks in Patients With Twin Gestations Who Underwent Cerclage Placement [ID: 1378167]
Authors: Hong Leah , Hasty Miranda , Jolly Sonia , Powel Jennifer , Tomlinson Tracy , Zantow Emily
Published: May 2023

INTRODUCTION:

Historically, cerclages were not recommended in multiple-gestation pregnancies because of uncertain efficacy and concern for harm. However, a meta-analysis of twin pregnancies found cerclage was associated with reduction in preterm birth (PTB) less than 32 weeks with cervical length (CL) of 15 mm or lower.

METHODS:

We conducted a retrospective analysis of women who underwent cervical cerclage placement at a single tertiary academic center from 2008 to 2020. Data pertaining to maternal demographics, obstetric course, sonographic CL, and cerclage operative technique were abstracted for women with twin gestations. Factors with P value of .2 or lower on univariate analysis of spontaneous PTB (sPTB) less than 32 weeks were considered for incorporation along with history of sPTB into a Cox proportional-hazards model to assess factors associated with pregnancy duration up to 32 weeks.

RESULTS:

Seventy-five twin gestations were analyzed. On univariate analysis, neuraxial anesthesia during cerclage placement, preoperative cervical dilation, use of Foley catheter for membrane elevation, shorter postoperative CL, and twin B male sex were found to be significantly associated with sPTB less than 32 weeks. Cox proportional-hazards analysis demonstrated that use of Foley catheter for membrane elevation, neuraxial anesthesia, postoperative CL less than 25 mm recorded 24 weeks or earlier, and history of sPTB greater than 16 weeks had significantly higher adjusted hazard ratios. The bias-corrected bootstrapped (1,000 repetitions) AUROC for a logistic regression model with these four covariates predictive of sPTB less than 32 weeks was 0.83 (95% CI 0.69–0.89).

CONCLUSION:

A survival analysis approach offers valuable clinical insight into predictors of shorter pregnancy duration up to 32 weeks in twin gestations undergoing cervical cerclage placement.
Single-Layer Versus Double-Layer Uterine Closure at the Time of Cesarean and Subsequent Risks in Those With Placenta Accreta Spectrum [ID: 1381003]
Authors: Phelps Alexandra , Harrison Rachel , Holmgren Calla , Hussein Nada , Steinberg Guy
Published: May 2023

INTRODUCTION:

Benefits of single- versus double-layer uterine closure at the time of cesarean delivery are unclear. We sought to evaluate the effect of single- versus double-layer closure in prior cesarean delivery at the time of cesarean hysterectomy for placenta accreta spectrum (PAS).

METHODS:

Retrospective study of patients with PAS and available prior cesarean delivery operative report were included in this IRB-approved cohort study. Those with history of single-layer closure were compared to those with history of double-layer closure, and the effect on maternal outcomes at the time of cesarean hysterectomy for PAS was evaluated. The primary outcome was surgical pathology diagnosis of percreta or increta versus accreta. Secondary outcomes included blood loss, intensive care unit admission, length of stay, and surgical time. Groups were compared via chi-square, Fisher’s exact, and t tests with logistic regression to evaluate for confounders.

RESULTS:

There were 36 participants available for review, 20 of whom (55.6%) had prior single-layer closure. Those with single-layer closure had a higher number of prior cesarean deliveries (2.5±1.1 versus 1.4±0.8, P=.003); otherwise, baseline characteristics were similar between groups. Diagnosis of percreta or increta at the time of cesarean delivery was more likely among those with single-layer closure (79.9% versus 41.7%, P=.056), although not statistically significant. Blood loss, operative time, and length of stay were higher as well, but these did not reach statistical significance (approximately 3,200 versus 1,900 mL, P=.138; 167 versus 140 minutes, P=.151; 4.8 versus 3.4 days, P=.059). In the regression analysis, after controlling for the number of prior cesarean deliveries and other potential confounders, the apparent increase in diagnosis of percreta or increta did not persist (adjusted odds ratio 0.55, 95% CI 0.20–1.53).

CONCLUSION:

No statistically significant benefit to prior single- versus double-layer closure was noted at the time of cesarean hysterectomy in those with PAS.
Racial Disparities in Cesarean Delivery Outcomes: Analysis of Native Hawaiians or Pacific Islanders and American Indians or Alaska Natives [ID: 1377727]
Authors: Sato Danielle , Abella Maveric , Collins Robert , Pawar Deepraj , Shirriff Ashley , Stafford Michelle
Published: May 2023

INTRODUCTION:

Racial disparities in cesarean delivery (CD) are well documented, but Native Hawaiians or Pacific Islanders (NHPI) and American Indians or Alaska Natives (AIAN) are underrepresented in literature. We aim to elucidate racial disparities in CD outcomes, focusing on NHPI and AIAN populations.

METHODS:

The National Surgical Quality Improvement Program was queried to identify CD outcomes from 2019 to 2020 in the National Surgical Quality Improvement Project (n=25,649). Multivariable logistic regression models were used to investigate the association of race and ethnicity on major and minor postoperative complications and reoperation.

RESULTS:

Racial minority groups were compared to non-Hispanic White people and adjusted for confounders. The NHPI patients had the highest risk of complication, at 4.6% greater risk of any postoperative complication (adjusted odds ratio [AOR] 1.046 [1.001–1.093]) and 3.2% greater risk of major complication (AOR 1.032 [1.006–1.058]). This was compared to a 3.2%, 1.9%, and 1.8% greater risk for any postoperative complication in Asian, Black, and Hispanic/Latina patients, respectively. The AIAN patients had the highest risk of reoperation of all groups, at 2.6% greater risk of reoperation (AOR 1.026 [1.015–1.037]).

CONCLUSION:

Across all groups undergoing CD, NHPI patients had the greatest risk of any postoperative complication, and AIAN patients had the greatest risk of reoperation. Our findings emphasize the need to further investigate these underrepresented minority groups in future obstetric research.
Postpartum Emergency Department Visits and Risk Factors for Readmission [ID: 1363150]
Authors: Mei Jenny , Corry-Saavedra Kate , Murphy Aisling , Nguyen Tina
Published: May 2023

INTRODUCTION:

Postpartum emergency department (ED) visits complicate 12% of births. We aimed to characterize trends in ED visits and risk factors for readmission.

METHODS:

This was a retrospective cohort study on postpartum ED visits within 42 days of delivery at a tertiary care center over 1 year. Readmitted patients were compared to those who remained outpatient as appropriate. IRB #14-001098.

RESULTS:

Of 3,084 deliveries, 138 (4.5%) patients presented to the ED for total 157 encounters. 17 (12.3%) patients presented more than once. 55 (35%) ED visits resulted in readmission, with 4 patients readmitted twice. Public insurance rates in the cohort were significantly higher than baseline (16.7% versus 8.5%, P=.001). Postpartum hypertension (HTN) was the most common reason for ED visits (40%) and had four times higher likelihood of being readmitted (adjusted odds ratio [aOR] 4.076, 95% CI 2.04–8.15, P<.001). Black women were six times more likely to be readmitted compared to other groups (aOR 6.53, 95% CI 1.26–33.88, P=.026). Coexistent psychiatric disease had lower likelihood of readmission (aOR 0.43, 95% CI 0.19–0.95, P=.037). Having more than one ED visit led to fivefold higher odds of readmission (aOR 5.05, 95% CI 1.66–15.32, P=.004). Median days from delivery to ED visit were 8 (interquartile range [IQR]: 5, 15).

CONCLUSION:

Seventy-three percent of presentations to the ED were within 2 weeks of delivery, and postpartum HTN was the leading cause. Black patients were more likely to be readmitted. Further studies are needed to evaluate whether earlier postpartum visits for high-risk groups may reduce ED visits and readmissions.
Expanded Clinician Offering of Expectant Management of PPROM 34 Weeks 0 Days–36 Weeks 6 Days After Introduction of Shared Decision-Making Aid [ID: 1364841]
Authors: Thayer Sydney , Frolova Antonina , Huysman Bridget , Kelly Jeannie , Kernberg Annessa , Zofkie Amanda
Published: May 2023

INTRODUCTION:

In March 2020, the American College of Obstetricians and Gynecologists updated recommendations for prelabor preterm rupture of membranes (PPROM) at 34 weeks 0 days–36 weeks 6 days to include shared decision-making (SDM) for expectant management (EM) versus immediate delivery (ID). We sought to compare the patient populations offered EM before and after a SDM aid.

METHODS:

This is a retrospective cohort study from March 2020 to February 2022 of patients presenting with PPROM 34 weeks 0 days–36 weeks 6 days. On October 25, 2022, a SDM aid was introduced to help clinicians discuss the benefits and risks to EM versus ID of PPROM. Patients offered EM were compared before and after the SDM aid using Fisher exact, χ2, and t tests.

RESULTS:

Eighty-six patients presented with PPROM during the study period, 26 before the SDM aid and 60 afterwards. Populations were similar, with the exception of more publicly insured patients post-SDM aid. Significantly more patients were offered EM of PPROM post-SDM aid than pre-SDM aid (48% versus 11%, P=.001). The proportion of Caucasian and privately insured patients offered EM significantly increased after the SDM aid; more African American and publicly insured patients were offered EM as well, but this was not statistically significant. No patients accepted EM prior to the SDM aid compared to 41% who chose EM after the SDM aid.

CONCLUSION:

A SDM aid significantly increased the number of patients offered EM of PPROM. Still, while more patients elected for EM after the SDM aid, the majority elected for ID. A standardized approach to SDM may improve provider awareness of management options and provide patients with necessary information to make informed decisions.