Association between interpregnancy interval and the labor curve.

BACKGROUND: Both short and long interpregnancy intervals are associated with adverse pregnancy outcomes; however, the impact of interpregnancy intervals on labor progression is unknown. OBJECTIVE: We examined the impact of interpregnancy intervals on the labor curve, hypothesizing that those with a longer interpregnancy intervals would have slower labor progression. STUDY DESIGN: This is a retrospective cohort study of patients with a history of one prior vaginal delivery admitted for induction of labor or spontaneous labor with a singleton gestation ≥37 weeks at an academic medical center between 2004 and 2015. Repeated measures regression was used to construct labor curves, which were compared between patients with short interpregnancy intervals, defined as <3 years since the last delivery, and long interpregnancy intervals, defined as >3 years since the last delivery. We chose this interval as it approximates the median birth interval in the United States. Interval-censored regression was used to estimate the median duration of labor after 4 centimeters of dilation, stratified by type of labor (spontaneous vs induced). Multivariate analysis was used to adjust for potential confounders. RESULTS: Of the 1331 patients who were included in the analysis, 544 (41%) had a long interpregnancy interval. Among the entire cohort, there were no significant differences in first or second-stage progression between short and long interpregnancy interval groups. In the stratified analysis, first-stage progression varied between groups on the basis of labor type: long interpregnancy interval was associated with a slower active phase among those being induced and a quicker active phase among those in spontaneous labor. The second-stage duration was similar between cohorts regardless of labor type. CONCLUSION: Multiparas with an interpregnancy interval >3 years may have a slower active phase than those with a shorter interpregnancy interval when undergoing induction of labor. Interpregnancy interval does not demonstrate an effect on the length of the second stage.

Peripartum Prediction of Fetal Weight in Gravidas With Obesity.

OBJECTIVES: Estimated fetal weight (EFW) is an important metric at delivery as neonates with abnormal birthweight and their mothers are at higher risk of birth complications. Data regarding optimal EFW assessment in gravidas with obesity is inconsistent, and with the increasing incidence of obesity, clarification of this question is crucial. We aimed to compare accuracy of ultrasound (US)-derived EFW and clinical assessments of EFW in predicting neonatal birthweight among gravidas with obesity. METHODS: This prospective cohort study enrolled gravidas with obesity and a singleton pregnancy admitted for delivery at term. EFW was determined using either US biometry or clinical assessment (Leopold's maneuvers, Johnson's formula, and Insler's formula) at time of admission. Our primary outcome was accurate EFW, defined as EFW within 500 g of birthweight. Secondary outcomes included ability to predict small-for-gestational age (SGA) and large-for-gestational age (LGA) birthweights. These outcomes were compared between all EFW methods. RESULTS: A total of 250 gravidas with a median body mass index of 36.4 kg/m2 were enrolled. Admission US outperformed Leopold's maneuvers in obtaining accurate EFW (81.6% versus 74.5%, P = .03). When comparing all methods, Johnson's and Insler's formulae performed the worst, accurately predicting EFW in only 27.4% and 14.3% of cases, respectively. Likewise, US-derived EFW outperformed Leopold's maneuvers and fundal height in the prediction of SGA and LGA neonates. CONCLUSIONS: US is more accurate than clinical assessment of EFW in gravidas with obesity both for estimation of actual birthweight and prediction of abnormal birthweight. Universal late third-trimester or peripartum US for EFW should be considered in gravidas with obesity.

Individual-Level and Community-Level Predictors of Healthy Pregnancy Outcomes in Multigravid Black Women.

OBJECTIVE: To identify individual- and community-level factors that predict the odds of multigravid Black women having consecutive pregnancies without adverse pregnancy outcomes. METHODS: We conducted a secondary analysis of 515 multigravid Black women from a longitudinal observational study (2017-2019). We assessed the presence of adverse pregnancy outcomes (hypertensive disorders, gestational diabetes, preterm birth, fetal growth restriction, placental abruption, and pregnancy loss) for the index and prior pregnancies. We examined U.S. Census data, medical records, and surveys across multiple socioecologic domains: personal, behavioral, socioeconomic, and policy. We estimated adjusted odds ratios (aORs) and 95% CIs for the association between individual- and community-level factors and consecutive healthy pregnancies using hierarchical logistic regression models adjusted for maternal age, body mass index (BMI), gravidity, interpregnancy interval, and median household income. RESULTS: Among 515 multigravid Black women (age 27±5 years, BMI 31.4±8.9, gravidity 4±2), 38.4% had consecutive healthy pregnancies without adverse pregnancy outcomes. Individual-level factors associated with consecutive healthy pregnancies included normal glucose tolerance (aOR 3.9, 95% CI, 1.2-12.1); employment (aOR 1.9, 95% CI, 1.2-2.9); living in communities with favorable health indicators for diabetes, hypertension, and physical activity; and household income of $50,000 per year or more (aOR 3.5, 95% CI, 1.4-8.7). When individual and community factors were modeled together, only income and employment at the individual and community levels remained significant. CONCLUSION: Individual and community income and employment are associated with consecutive healthy pregnancies in a cohort of Black patients, emphasizing the need for comprehensive, multilevel systems interventions to reduce adverse pregnancy outcomes for Black women.

Brexanolone Treatment in a Real-World Patient Population: A Case Series and Pilot Feasibility Study of Precision Neuroimaging.

PURPOSE/BACKGROUND: Brexanolone is approved for postpartum depression (PPD) by the United States Food and Drug Administration. Brexanolone has outperformed placebo in clinical trials, but less is known about the efficacy in real-world patients with complex social and medical histories. Furthermore, the impact of brexanolone on large-scale brain systems such as changes in functional connectivity (FC) is unknown. METHODS/PROCEDURES: We tracked changes in depressive symptoms across a diverse group of patients who received brexanolone at a large medical center. Edinburgh Postnatal Depression Scale (EPDS) scores were collected through chart review for 17 patients immediately prior to infusion through approximately 1 year postinfusion. In 2 participants, we performed precision functional neuroimaging (pfMRI), including before and after treatment in 1 patient. pfMRI collects many hours of data in individuals for precision medicine applications and was performed to assess the feasibility of investigating changes in FC with brexanolone. FINDINGS/RESULTS: The mean EPDS score immediately postinfusion was significantly lower than the mean preinfusion score (mean change [95% CI]: 10.76 [7.11-14.40], t (15) = 6.29, P < 0.0001). The mean EPDS score stayed significantly lower at 1 week (mean difference [95% CI]: 9.50 [5.23-13.76], t (11) = 4.90, P = 0.0005) and 3 months (mean difference [95% CI]: 9.99 [4.71-15.27], t (6) = 4.63, P = 0.0036) postinfusion. Widespread changes in FC followed infusion, which correlated with EPDS scores. IMPLICATIONS/CONCLUSIONS: Brexanolone is a successful treatment for PPD in the clinical setting. In conjunction with routine clinical care, brexanolone was linked to a reduction in symptoms lasting at least 3 months. pfMRI is feasible in postpartum patients receiving brexanolone and has the potential to elucidate individual-specific mechanisms of action.

Dietary risk factors for hypertensive disorders of pregnancy.

OBJECTIVE: To assess whether diet quality and specific dietary components are associated with hypertensive disorders of pregnancy (HDP). STUDY DESIGN: Nested case control study in a prospectively collected cohort of 450 participants with singleton pregnancies who completed the National Institutes of Health Diet Health Questionnaire II (DHQ-II) in the third trimester or within 3 months of delivery. Patients with fetal anomalies, conception by in-vitro fertilization, and deliveries at outside hospitals were excluded from the original prospective cohort study. Cases were patients diagnosed with HDP and controls were patients without HDP. Cases and controls were matched by BMI class in a 1:2 ratio. Exposures of interest were HEI-2015 score components and other DHQ-II dietary components including minerals, caffeine, and water. These dietary components were compared between cohorts using univariate analyses. MAIN OUTCOME MEASURES: HEI-2015 total scores representing diet quality, component scores, and objective background data between patients with HDP and patients without HDP. RESULTS: 150 patients with HDP were matched to 300 controls without HDP. Baseline demographics were similar between groups, including BMI. Patients with HDP were less likely to have high quality diets (HEI ≥ 70) than controls (7.3 % v 15.7 %, P = 0.02). HDP were associated with significantly higher dairy, saturated fat, and sodium intake compared to controls. Other components were similar between groups. CONCLUSION: Patients with HDP are more likely to have lower diet quality and higher consumption of sodium, dairy, and saturated fats. These results can be used to study antenatal diet modification in patients at high risk of HDP.

Treatment of metastatic rectal squamous cell carcinoma in a pregnant patient.

Rectal squamous cell carcinoma is an exceedingly rare form of rectal cancer, with limited data available regarding its presentation and effective treatment. Rectal cancer occurring during pregnancy is uncommon as well. This is a case of metastatic rectal squamous cell carcinoma presenting in a 22-week pregnant, female patient in her early 30s. The patient was treated with 5-fluorouracil and cisplatin and delivered a healthy male child born via uncomplicated vaginal delivery at 35 weeks. This article demonstrates that despite the rare nature of this cancer, in the already rare context of pregnancy, effective and safe treatment is possible with a multidisciplinary team.

County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri.

Background: Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates. Methods: In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates). Results: Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates. Conclusions: The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.

Pharmacotherapy for opioid use disorder in pregnancy.

PURPOSE OF REVIEW: Opioid use disorder (OUD) in pregnancy has significantly increased in the last decade, impacting 8.2 per 1000 deliveries. OUD carries significant risk of morbidity and mortality for both the birthing person and neonate, but outcomes for both are improved with opioid agonist treatment (OAT). Here, we describe the recommended forms of OAT in pregnancy, updates to the literature, and alternate OAT strategies, and share practical peripartum considerations for patients on OAT. RECENT FINDINGS: Recent studies comparing buprenorphine and methadone have reaffirmed previous findings that buprenorphine is associated with superior outcomes for the neonate, without clear differences in morbidity or mortality for the birthing person. Optimal initiation and dosing of OAT remains unclear, with several recent studies evaluating methods of initiation, as well as a potential role for higher and more rapid dosing in the fentanyl era. Alternative products such as buprenorphine-naloxone and extended-release buprenorphine are of significant research interest, though randomized prospective data are not yet available. SUMMARY: Buprenorphine and methadone are standard of care for treatment of OUD during pregnancy, and multiple patient factors impact the optimal choice. Insufficient data exist to recommend alternative agents as a primary strategy currently. All patients with OUD in pregnancy should be counseled regarding OAT. VIDEO: http://links.lww.com/COOG/A94.

Hepatitis C and obstetrical morbidity in a substance use disorder clinic: a role for telemedicine?

BACKGROUND: Hepatitis C infection often co-occurs with substance use disorders in pregnancy. Accessing hepatitis C treatment is challenging because of loss to follow-up in the postpartum period, attributable to social and financial barriers to care. Telemedicine has been explored as a means of increasing routine postpartum care, but the potential impact on retention in and completion of care for postpartum hepatitis C has not been assessed. OBJECTIVE: This study aimed to evaluate the impact of hepatitis C on obstetrical morbidity in a substance use disorder-specific prenatal clinic, and the effect of Infectious Disease telemedicine consultation on subsequent treatment delivery. STUDY DESIGN: We performed a retrospective cohort study of all patients in our substance use disorder prenatal clinic from June 2018 to February 2023. Telemedicine consults for hepatitis C diagnoses began in March 2020 and included electronic chart review by Infectious Disease when patients were unable to be seen. Our primary outcome was composite obstetrical morbidity (preterm birth, preeclampsia, fetal growth restriction, fetal anomaly, abruption, postpartum hemorrhage, or chorioamnionitis) compared between patients with and without active hepatitis C. We additionally evaluated rates of completed referral and initiation of hepatitis C treatment before and after implementation of telemedicine consult. RESULTS: A total of 224 patients were included. Of the 222 patients who underwent screening, 71 (32%) were positive for active hepatitis C. Compared with patients without hepatitis C, a higher proportion of patients with hepatitis C were White (80% vs 58%; P=.02), had a history of amphetamine use (61% vs 32%; P<.01), injection drug use (72% vs 38%; P<.01), or overdose (56% vs 29%; P<.01), and were on methadone (37% vs 18%; P<.01). There was no difference in the primary outcome of composite obstetrical morbidity. The rate of hepatitis C diagnosis was not statistically significantly different between the pre- and posttelemedicine cohorts (N=29 [41%], N=42 [27%]), and demographics of hepatitis C virus-positive patients were similar, with most being unemployed, single, and publicly insured. A lower proportion of patients in the posttelemedicine group reported heroin use compared with the pretelemedicine cohort (62% vs 90%; P=.013). After implementation of telemedicine, patients were more likely to attend the visit (19% vs 44%; P=.03), and positive patients were much more likely to receive treatment (14% vs 57%; P<.01); 100% of visits in the posttelemedicine group occurred via telemedicine. There were 7 patients who were prescribed treatment by their obstetrician after chart review by Infectious Disease. CONCLUSION: Patients with and without hepatitis C had similar maternal and neonatal outcomes, with multiple indicators of social and financial vulnerability. Telemedicine Infectious Disease consult was associated with increased follow-up and hepatitis C treatment, and obstetricians were able to directly prescribe. Because patients with substance use disorders and hepatitis C may have increased barriers to care, telemedicine may represent an opportunity for intervention.

The Association between Mode of Transportation Support and Research Study Visit Attendance among Pregnant Patients.

OBJECTIVE: This study aimed to examine the association between transportation assistance and study visits, and explore differences by transportation modality. STUDY DESIGN: This was a secondary analysis of prospective cohort study. We identified patients requesting transportation support for research ultrasound visits and identified controls (1:2 ratio) who did not request support matched for age, race, and insurance type. Conditional logistic regression examined the association between transportation support and mode of transportation with study visit attendance. RESULTS: Transportation support was requested by 57/1,184 (4.8%) participants. Participants that requested transportation support were three times more likely to attend visits than their matched controls (adjusted odds ratio [aOR] = 3.16, 95% confidence interval [CI]: 1.76-5.68). Among visits with transportation support, those supported by a ridesharing service had five-fold higher odds of attendance than visits supported with taxi service (aOR = 5.06, 95% CI: 1.50-16.98). CONCLUSION: Transportation support, especially a ridesharing service, is associated with improved attendance at research study visits in a sample of predominantly low-income, Black, pregnant participants. Implementing transportation support may be a promising strategy to improve engagement in research studies. KEY POINTS: · Participants utilizing transportation assistance were more likely to attend study appointments.. · Participants using ridesharing had higher likelihood of attendance than those using taxi service.. · Transportation assistance may improve research engagement for historically marginalized people..

Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care. DATA SOURCES: We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences. TABULATION, INTEGRATION, AND RESULTS: Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09). CONCLUSION: Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021279233.

Buprenorphine Extended-Release Treatment for Opioid Use Disorder in the Postpartum Period.

Buprenorphine extended-release (XR) is an extended-release monthly injection to treat opioid use disorder (OUD). This retrospective case series includes 15 postpartum patients who were treated with buprenorphine-XR at a single center and reports on their outcomes. The average total daily sublingual buprenorphine dose before initiation of buprenorphine-XR was 16.25 mg (SD±7.76, range 2-32 mg). Overall, 137 total doses of buprenorphine-XR were administered between May 17, 2021, and April 11, 2023. Urine toxicology test results were negative for opioids other than buprenorphine in the majority (80.0%) of patients once appropriate maintenance doses were achieved. Euphoria and intoxication were not reported. A minority of patients (20.0%) discontinued buprenorphine-XR. Although more extensive research is needed before widespread use, buprenorphine-XR may be a favorable treatment for OUD in this high-risk population.

Self-Identified Stage in Recovery and Substance-Use Behaviors among Pregnant and Postpartum Women and People with Opioid Use Disorder.

Opioid use among pregnant and postpartum women and people (PPWP) has significant health repercussions. This study explores how substance-use behaviors may vary by stage in recovery among PPWP with opioid use disorder (OUD). We recruited 29 PPWP with OUD. "High-risk" participants self-identified as "not being engaged in treatment" or "new or early in their recovery" (n = 11); "low-risk" participants self-identified as being "well-established" or "in long-term recovery" (n = 18). Participants were queried regarding sociodemographic, mental health, and drug-misuse factors; urine drug screens were collected at baseline. Univariate group comparisons between high-risk and low-risk PPWP were conducted. High-risk PPWP were more likely to self-identify as non-Hispanic African American and more likely to report current opioid use, other illicit drugs, and tobacco. High-risk PPWP had higher opioid cravings versus low-risk PPWP. High-risk PPWP were more likely to screen positive on urine tests for non-opioid drugs and on concurrent use of both non-opioid drugs and opioids versus low-risk participants. PPWP earlier in recovery are at higher-risk for opioid and other illicit drug misuse but are willing to disclose aspects of their recent use. PPWP early in recovery are an ideal population for interventions that can help facilitate recovery during the perinatal period and beyond.

Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA.

BACKGROUND: Associations between race/ethnicity and medications to treat OUD (MOUD), buprenorphine and methadone, in reproductive-age women have not been thoroughly studied in multi-state samples. OBJECTIVE: To evaluate racial/ethnic variation in buprenorphine and methadone receipt and retention in a multi-state U.S. sample of Medicaid-enrolled, reproductive-age women with opioid use disorder (OUD) at the beginning of OUD treatment. DESIGN: Retrospective cohort study. SUBJECTS: Reproductive-age (18-45 years) women with OUD, in the Merative™ MarketScan® Multi-State Medicaid Database (2011-2016). MAIN MEASURES: Differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, "other" race/ethnicity) in the likelihood of receiving buprenorphine and methadone during the start of OUD treatment (yes/no) were estimated using multivariable logistic regression. Differences in time to medication discontinuation (days) by race/ethnicity were evaluated using multivariable Cox regression. RESULTS: Of 66,550 reproductive-age Medicaid enrollees with OUD (84.1% non-Hispanic White, 5.9% non-Hispanic Black, 1.0% Hispanic, 5.3% "other"), 15,313 (23.0%) received buprenorphine and 6290 (9.5%) methadone. Non-Hispanic Black enrollees were less likely to receive buprenorphine (adjusted odds ratio, aOR = 0.76 [0.68-0.84]) and more likely to be referred to methadone clinics (aOR = 1.78 [1.60-2.00]) compared to non-Hispanic White participants. Across both buprenorphine and methadone in unadjusted analyses, the median discontinuation time for non-Hispanic Black enrollees was 123 days compared to 132 days and 141 days for non-Hispanic White and Hispanic enrollees respectively (χ2 = 10.6; P = .01). In adjusted analyses, non-Hispanic Black enrollees experienced greater discontinuation for buprenorphine and methadone (adjusted hazard ratio, aHR = 1.16 [1.08-1.24] and aHR = 1.16 [1.07-1.30] respectively) compared to non-Hispanic White peers. We did not observe differences in buprenorphine or methadone receipt or retention for Hispanic enrollees compared to the non-Hispanic White enrollees. CONCLUSIONS: Our data illustrate inequities between non-Hispanic Black and non-Hispanic White Medicaid enrollees with regard to buprenorphine and methadone utilization in the USA, consistent with literature on the racialized origins of methadone and buprenorphine treatment.

Intrapartum electronic fetal monitoring features associated with a clinical diagnosis of nonreassuring fetal status.

BACKGROUND: Nonreassuring fetal status detected by continuous electronic fetal monitoring accounts for almost 1 in 4 primary cesarean deliveries. However, given the subjective nature of the diagnosis, there is a need to identify the electronic fetal monitoring patterns that are clinically considered nonreassuring. OBJECTIVE: This study aimed to describe which electronic fetal monitoring features are most commonly associated with first-stage cesarean delivery for nonreassuring fetal status, and to evaluate the risk of neonatal acidemia following cesarean delivery for nonreassuring fetal status. STUDY DESIGN: This was a nested case-control study in a prospectively collected cohort of patients with singleton pregnancies at ≥37 weeks' gestation, admitted in spontaneous labor or for induction of labor from 2010 to 2014 at a single tertiary care center. Patients with preterm pregnancies, multiple gestations, planned cesarean delivery, or nonreassuring fetal status in the second stage of labor were excluded. Cases were identified as having nonreassuring fetal status on the basis of what was documented in the operative note by the delivering physician. Controls were patients without nonreassuring fetal status within 1 hour of delivery. Cases were matched to controls in a 1:2 ratio by parity, obesity, and history of cesarean delivery. Electronic fetal monitoring data were abstracted by credentialed obstetrical research nurses for the 60 minutes before delivery. The primary exposure of interest was the incidence of high-risk category II electronic fetal monitoring features in the 60 minutes before delivery; in particular, the incidence of minimal variability, recurrent late decelerations, recurrent variable decelerations, tachycardia, and >1 prolonged deceleration were compared between groups. We also compared neonatal outcomes between cases and controls, including fetal acidemia (umbilical artery pH <7.1), other umbilical artery gas analytes, and neonatal and maternal outcomes. RESULTS: Of the 8580 patients in the parent study, 714 (8.3%) underwent cesarean delivery for nonreassuring fetal status in the first stage of labor. Patients diagnosed with nonreassuring fetal status requiring cesarean delivery were more likely to have recurrent late decelerations, >1 prolonged deceleration, and recurrent variable decelerations compared with controls. More than 1 prolonged deceleration was associated with 6 times increased rate of nonreassuring fetal status diagnosis resulting in cesarean delivery (adjusted odds ratio, 6.73 [95% confidence interval, 2.47-8.33]). Rates of fetal tachycardia were similar between groups. Minimal variability was less common in the nonreassuring fetal status group compared with controls (adjusted odds ratio, 0.36 [95% confidence interval, 0.25-0.54]). Compared with control deliveries, cesarean delivery for nonreassuring fetal status was associated with nearly 7 times higher risk of neonatal acidemia (7.2% vs 1.1%; adjusted odds ratio, 6.93 [95% confidence interval, 3.83-12.54]). Composite neonatal morbidity and composite maternal morbidity were more likely among patients delivered for nonreassuring fetal status in the first stage (3.9% vs 1.1%; adjusted odds ratio, 5.70 [2.60-12.49]; and 13.3% vs 8.0%; adjusted odds ratio, 1.99 [1.41-2.80]). CONCLUSION: Although multiple category II electronic fetal monitoring features have been traditionally linked to acidemia, the presence of recurrent late decelerations, recurrent variable decelerations, and prolonged decelerations seemed to concern obstetricians enough to surgically intervene for nonreassuring fetal status. A clinical intrapartum diagnosis of nonreassuring fetal status in the setting of these electronic fetal monitoring features is also associated with increased risk of acidemia, suggesting clinical validity to the diagnosis of nonreassuring fetal status.

The Impact of Cervical Effacement at Time of Amniotomy in Patients Undergoing Induction of Labor.

OBJECTIVE: There is evidence to suggest that early amniotomy during induction of labor is advantageous. However, following cervical ripening balloon removal, the cervix remains less effaced and the utility of amniotomy in this setting is less clear. We investigated whether cervical effacement at the time of amniotomy impacts outcomes among nulliparas undergoing induction of labor. STUDY DESIGN: This was a secondary analysis of a prospective cohort of singleton, term, nulliparous patients at a tertiary care center undergoing induction of labor and amniotomy. The primary outcome was completion of the first stage of labor. Secondary outcomes were vaginal delivery and postpartum hemorrhage. Outcomes were compared between patients with cervical effacement ≤50% (low effacement) and >50% (high effacement) at time of amniotomy. Multivariable logistic regression was used calculate risk ratios (RR) to adjust for confounders including cervical dilation. Stratified analysis was performed in patients with cervical ripening balloon use. A post hoc sensitivity analysis was performed to further control for cervical dilation. RESULTS: Of 1,256 patients, 365 (29%) underwent amniotomy at low effacement. Amniotomy at low effacement was associated with reduced likelihood of completing the first stage (aRR: 0.87 [95% confidence interval, CI: 0.78-0.95]) and vaginal delivery (aRR: 0.87 [95% CI: 0.77-0.96]). Although amniotomy at low effacement was associated with lower likelihood of completing the first stage in all-comers, those who had amniotomy performed at low effacement following cervical ripening balloon expulsion were at the highest risk (aRR: 0.84 [95% CI: 0.69-0.98], p for interaction = 0.04) In the post hoc sensitivity analysis, including patients who underwent amniotomy at 3- or 4-cm dilation, low cervical effacement remained associated with a lower likelihood of completing the first stage of labor. CONCLUSION: Low cervical effacement at time of amniotomy, particularly following cervical ripening balloon expulsion, is associated with a lower likelihood of successful induction. KEY POINTS: · Low cervical effacement at amniotomy was associated with lower rates of complete dilation.. · Effacement at amniotomy is especially important for patients who had a cervical ripening balloon.. · Providers should consider cervical effacement when timing amniotomy for nulliparous term patients..

Heterogeneity in management of category II fetal tracings: data from a multihospital healthcare system.

BACKGROUND: Electronic fetal monitoring is widely used to identify and intervene in suspected fetal hypoxia and/or acidemia. Category II fetal heart rate tracings are the most common class of fetal monitoring in labor, and intrauterine resuscitation is recommended given the association of category II fetal heart rate tracings with fetal acidemia. However, limited published data are available to guide intrauterine resuscitation technique selection, leading to heterogeneity in the response to category II fetal heart rate tracings. OBJECTIVE: This study aimed to characterize approaches to intrauterine resuscitation in response to category II fetal heart rate tracings. STUDY DESIGN: This was a survey study administered to labor unit nurses and delivering clinicians (physicians and midwives) across 7 hospitals in a Midwestern healthcare system spanning 2 states. The survey posed 3 category II fetal heart rate tracing scenarios (recurrent late decelerations, minimal variability, and recurrent variable decelerations) and asked participants to select first- and second-line intrauterine resuscitation management strategies. The participants were asked to quantify the level of influence certain factors have on their choice using a scale from 1 to 5. Intrauterine resuscitation strategy selection was compared by clinical role and hospital type (nurses vs delivering clinicians and university-affiliated hospital vs non-university-affiliated hospital). RESULTS: Of 610 providers invited to take the survey, 163 participated (response rate of 27%): 37% of participants from university-affiliated hospitals, 62% of nurses, and 37% of physicians. Maternal repositioning was the most selected first-line strategy, regardless of the type of category II fetal heart rate tracing. First-line management varied by clinical role and hospital affiliation for each fetal heart rate tracing scenario, particularly for minimal variability, which was associated with the most heterogeneity in the first-line approach. Previous experience and recommendations from professional societies were the most influential factors in intrauterine resuscitation selection overall. Of note, 16.5% of participants reported that published evidence did not influence their choice at all. Participants from a university-affiliated hospital were more likely than participants from a non-university-affiliated hospital to consider patient preference when selecting an intrauterine resuscitation technique. Nurses and delivering clinicians differed significantly in the rationale for management choices: nurses were more often influenced by advice from other healthcare providers on the team (P<.001), whereas delivering clinicians were more influenced by literature (P=.02) and ease of technique (P=.02). CONCLUSION: There was significant heterogeneity in the management of category II fetal heart rate tracing. In addition, motivations for choice in intrauterine resuscitation technique varied by hospital type and clinical role. These factors should be considered when creating fetal monitoring and intrauterine resuscitation protocols.

Initiation and Treatment Discontinuation of Medications for Opioid Use Disorder in Pregnant People Compared With Nonpregnant People.

OBJECTIVE: To examine the association between pregnancy and medications for opioid use disorder (MOUD) initiation and discontinuation among reproductive-aged people receiving treatment for opioid use disorder (OUD) in the United States. METHODS: We conducted a retrospective cohort study of people with gender recorded as female, aged 18-45 years, in the Merative TM MarketScan ® Commercial and Multi-State Medicaid Databases (2006-2016). Opioid use disorder and pregnancy status were identified based on inpatient or outpatient claims for established International Classification of Diseases, Ninth and Tenth Revision diagnosis and procedure codes. The main outcomes were buprenorphine and methadone initiation and discontinuation, determined by using pharmacy and outpatient procedure claims. Analyses were conducted at the treatment episode level. Adjusting for insurance status, age, and co-occurring psychiatric and substance use disorders, we used logistic regression to estimate MOUD initiation and used Cox regression to estimate MOUD discontinuation. RESULTS: Our sample included 101,772 reproductive-aged people with OUD, encompassing 155,771 treatment episodes (mean age 30.8 years, 64.4% Medicaid insurance, 84.1% White), of whom 2,687 (3.2%, encompassing 3,325 episodes) were pregnant. In the pregnant group, 51.2% of treatment episodes (1,703/3,325) involved psychosocial treatment without MOUD, in comparison with 61.1% (93,156/152,446) in the nonpregnant comparator group. In adjusted analyses assessing likelihood of initiation for individual MOUD, pregnancy status was associated with an increase in buprenorphine (adjusted odds ratio [aOR] 1.57, 95% CI 1.44-1.70) and methadone initiation (aOR 2.04, 95% CI 1.82-2.27). Discontinuation rates of MOUD at 270 days were high for both buprenorphine (72.4% for nonpregnant episodes vs 59.9% for pregnant episodes) and methadone (65.7% for nonpregnant episodes vs 54.1% for pregnant episodes). Pregnancy was associated with a decreased likelihood of discontinuation at 270 days for both buprenorphine (adjusted hazard ratio [aHR] 0.71, 95% CI 0.67-0.76) and methadone (aHR 0.68, 95% CI 0.61-0.75), in comparison with nonpregnant status. CONCLUSION: Although a minority of reproductive-aged people with OUD in the United States are initiated on MOUD, pregnancy is associated with a significant increase in treatment initiation and a reduced risk of medication discontinuation.

Video Instruction for Pushing in the Second Stage: a randomized controlled trial.

BACKGROUND: The second stage of labor requires active patient engagement. Previous studies suggest that coaching can influence the second stage of labor duration. However, a standardized education tool has not been established, and patients face many barriers to accessing childbirth education before delivery. OBJECTIVE: This study aimed to investigate the effect of an intrapartum video pushing education tool on the second stage of labor duration. STUDY DESIGN: This was a randomized controlled trial of nulliparous patients with singleton pregnancies ≥37 weeks of gestation admitted for induction of labor or spontaneous labor with neuraxial anesthesia. Patients were consented on admission and block randomized in active labor to 1 of 2 arms in a 1:1 ratio. The study arm viewed a 4-minute video before the second stage of labor on what to anticipate in the second stage of labor and pushing techniques. The control arm received the standard of care: bedside coaching at 10 cm dilation from a nurse or physician. The primary outcome was second stage of labor duration. The secondary outcomes were birth satisfaction (using the Modified Mackey Childbirth Satisfaction Rating Scale), mode of delivery, postpartum hemorrhage, clinical chorioamnionitis, neonatal intensive care unit admission, and umbilical artery gases. Of note, 156 patients were needed to detect a 20% decrease in the second stage of labor duration with 80% power, 2-sided alpha level of .05, and 10% loss after randomization. Funding was provided by the Lucy Anarcha Betsy award from the division of clinical research at Washington University. RESULTS: Of 161 patients, 81 were randomized to standard of care, and 80 were randomized to intrapartum video education. Among these patients, 149 progressed to the second stage of labor and were included in the intention-to-treat analysis: 69 in the video group and 78 in the control group. Maternal demographics and labor characteristics were similar between groups. The second stage of labor duration was statistically similar between the video arm (61 minutes [interquartile range, 20-140]) and the control arm (49 minutes [interquartile range, 27-131]) (P=.77). There was no difference in mode of delivery, postpartum hemorrhage, clinical chorioamnionitis, neonatal intensive care unit admission, or umbilical artery gases between groups. Although the overall birth satisfaction score on the Modified Mackey Childbirth Satisfaction Rating Scale was similar between groups, patients in the video group rated their "level of comfort during birth" and "attitude of the doctors in birth" significantly higher or more positively than patients in the control group (P<.05 for both). CONCLUSION: Intrapartum video education was not associated with a shorter second stage of labor duration. However, patients who received video education reported a higher level of comfort and a more favorable perception of their physician, suggesting that video education may be a helpful tool to improve the birth experience.