Induction of labor in twin pregnancy in patients with a previous cesarean delivery.

BACKGROUND: Trial of labor after cesarean delivery (TOLAC) in twin gestations has been associated with decreased rates of successful vaginal delivery compared to singleton pregnancies, with mixed results regarding maternal and neonatal morbidity. However, induction of labor (IOL) in this unique population has not yet been fully evaluated. OBJECTIVE: To assess success rates and maternal and neonatal outcomes in women with a twin gestation and a previous cesarean delivery undergoing IOL. METHODS: A retrospective cohort study including women with a twin gestation and one previous cesarean delivery undergoing a trial of labor between the years 2009-2020. Patients requiring IOL were compared to those with a spontaneous onset of labor. RESULTS: There were 53 patients who met the inclusion criteria: 31 had a spontaneous onset of labor (58%) and 22 required an IOL. Baseline characteristics were comparable between the groups apart from a history of labor arrest which was more common in the IOL group (40.9% vs. 9.6%, P = 0.006). A successful vaginal delivery occurred in all (100%) women with a spontaneous labor compared to 81% in the IOL group (p = 0.02). Secondary outcomes were comparable. A history of no previous vaginal delivery, maternal obesity, and IOL were associated with TOLAC failure. CONCLUSIONS: IOL after cesarean delivery in twin gestation is associated with an increased risk of TOLAC failure compared to spontaneous onset of labor. However, no adverse neonatal or maternal outcomes were found. IOL in this high-risk population is feasible but patients should be counseled about the lower rate of success.

Trends in Pediatric Acute Otitis Media Burden During the First COVID-19 Year.

OBJECTIVE: To study the changes in acute otitis media (AOM) pediatric emergency department (PED) visits and pediatric admission before and during the first coronavirus disease 2019 (COVID-19) year. STUDY DESIGN: Retrospective case review. SETTING: Secondary care center. PATIENTS: Children younger than 18 years with all-cause and AOM-related PED visits and pediatric admissions for 3 years (March 1, 2018-January 28, 2021) were identified. Children were categorized according to age (0-2, 2-6, and 6-18 yr) and their date of presentation: pre-COVID-19 (yearly average of visits/admissions during the 2 prepandemic years: March 1, 2018-February 28, 2019 and March 1, 2019-February 29, 2020) or COVID-19 year (visits/admissions between March 1, 2020-February 28, 2021). INTERVENTION: Pre- and post-COVID-19 emergence, alternating lockdowns, kindergarten and school closures, and increased hygiene measures. MAIN OUTCOME MEASURE: Post- versus pre-COVID-19 AOM PED visit and pediatric admission incidence rate ratios (IRRs), using a generalized estimating equation model with a negative binomial regression calculation, while controlling for monthly fluctuations. RESULTS: Annual AOM visits/admissions during the pre-COVID-19 and COVID-19 years were 517 and 192 and 256 and 94, respectively (p < 0.05 for both). For children aged 0 to 2 years, AOM visits/admissions significantly decreased during the first COVID-19 year, compared with the pre-COVID years (ß = -1.11 [IRR, 0.33; 95% confidence interval [CI], 0.26-0.42; p < 0.005] and ß = -1.12 [IRR, 0.33; 95% CI, 0.25-0.42; p < 0.005]). Relatively to all-cause of children aged 0 to 2 years, AOM visits/admissions decreased during the first COVID-19 year versus the pre-COVID-19 years (ß = -2.14 [IRR, 0.12; 95% CI, 0.08-0.17; p < 0.005] and ß = -1.36 [IRR, 0.26; 95% CI, 0.23-0.29; p < 0.005]) and had monthly fluctuations coinciding with the lockdown/relaxation measures. For children aged 2 to 6 years, the reduction in AOM admissions was significant (ß = -1.70, IRR, 0.18; 95% CI, 0.09-0.37; p < 0.005). No significant differences were observed for children aged 6 to 18 years because of the small sample size. CONCLUSION: Pediatric AOM burden substantially decreased during the first COVID-19 year.