Adjusting models to better predict obstetric anal sphincter injury (OASIS) in forceps-assisted vaginal deliveries: A retrospective cross-sectional trial.

OBJECTIVE: Obesity and maternal age are increasing among pregnant patients. The understood effect of body mass index (BMI), advanced maternal age (AMA), and second stage of labor on obstetric anal sphincter injury (OASIS) at delivery is varied. The objective of this study was to assess whether incorporating BMI, second stage of labor length, and AMA into a model for predicting OASIS among forceps-assisted vaginal deliveries (FAVD) had a higher predictivity value compared to models without these additions. METHOD: This was an IRB-approved retrospective cohort study of singleton gestations who underwent a FAVD between 2017 and 2021. The primary outcome was prediction of OASIS via established models versus models including the addition of new predictive factors. RESULTS: A total of 979 patients met inclusionary criteria and were included in the final analysis. 20.4% of patients had an OASIS laceration, 11.3% of neonates had NICU admissions, 23.7% had a composite all neonatal outcome, and 8% had a composite subgaleal/cephalohematoma outcome. Comparisons of known factors that predict OASIS (nulliparity, race, episiotomy status) to known factors with additional predictors (BMI, AMA, and length of second stage in labor) were explored. After comparing each model's AUC to one another (a total of 3 comparisons made), there was no statistically significant difference between the models (all P > 0.62). CONCLUSION: Including BMI, AMA, and second stage of labor length does not improve the predictivity of OASIS in patients with successful FAVD. These factors should not impact a provider's decision to perform a FAVD when solely considering increased odds of OASIS.

Mitigating disparity?: Treatment patterns, survival, and recurrence rates by race, ethnicity, and hospital site across a large urban health system.

Objective: National data have shown worse endometrial cancer (EC) outcomes among racial and ethnic minorities. We aimed to analyze EC patient outcomes within a large urban academic health system, with a focus on patterns of care and recurrence rates. Methods: This was a retrospective chart review of EC patients at three system hospitals from 1/1/07-12/31/17. Demographic and clinical factors, including time from EMB to surgery, rate of chemotherapy completion, persistent or recurrent disease, and palliative care referrals were extracted. Descriptive statistics and survival curves were generated. Analysis was done using SAS version 9.4. Results: Black patients had lower overall survival compared to all others on univariate analysis only (p < 0.0001). Hospital site was associated with OS, with the academic anchor and satellite 1 having higher rates of all-cause mortality compared to satellite 2 (HR 4.68 academic anchor, 95 % CI 1.72-12.76, HR 5.36 satellite 1, 95 % CI 1.85-15.52). Time from EMB to surgery and rates of persistent disease following primary treatment were higher in Black patients. After adjusting for stage and grade, chemotherapy completion rate was significantly associated with race. Palliative care was utilized more for Black than White patients after adjusting for stage and grade (p = 0.005). Conclusions: Racial disparities in EC are caused by a complex web of interconnected factors that ultimately lead to worse outcomes in Black women. While precision medicine has helped to close the gap, social determinants of health should be addressed, and models focusing on the complex interactions between biologic, genetic, and social factors should be utilized.

Neonatal Birth Weight With Daily Compared With Every-Other-Day Glucose Monitoring in Gestational Diabetes Mellitus: A Randomized Controlled Trial.

OBJECTIVE: To assess whether universal use of every-other-day glucose monitoring in patients with gestational diabetes mellitus (GDM) resulted in similar birth weights and medication use and was preferred by the patient compared with traditional daily glucose monitoring. METHODS: This was a noninferiority randomized controlled trial conducted at a single New York City hospital between April 2021 and May 2022. Patients with singleton pregnancies who were diagnosed with GDM after 20 weeks of gestation and had a minimum of 7 days of previous daily blood glucose testing were randomly assigned to test blood glucose values daily or every other day. The primary outcome was neonatal birth weight. We calculated a total sample size of 196 participants needed for noninferiority to be tested, assuming the mean birth weight in the every-other-day group, compared with the daily group, was no higher than the predefined noninferiority margin of 200 g (80% power and one-sided alpha of 0.05). Postrandomization characteristics, including blood glucose values and medication initiation and timing, were recorded. Satisfaction with treatment group was assessed using the validated Oxford Maternity Diabetes Treatment Satisfaction Questionnaire. RESULTS: A total of 197 patients were randomized: 98 in the daily group and 99 in the every-other-day group. Baseline characteristics were similar between groups. The mean neonatal birth weight was similar between groups (mean±SD 3,090±418 g among newborns in the daily group compared with 3,181±482 g among newborns in the every-other-day group). For the primary outcome, the every-other-day group was found to be noninferior to the daily group with an upper confidence limit for the mean difference in mean birth weight of 197 g, which was below the noninferiority margin of 200 g (P=.046). Postrandomization, there were no significant differences in the number of patients who required medication, the gestational age at which medication was started, or the type of medication used. Average fasting and postprandial glucose values were similar between groups. There was an increase in adherence to treatment group in those randomized to every-other-day blood sugars, but no difference in patient satisfaction. CONCLUSION: In patients with GDM, testing blood glucose values every other day was as effective as testing daily, without apparent effects on birth weight, medication initiation, or glucose control. Reduced frequency of blood glucose monitoring might help decrease the emotional, physical, and financial burden experienced by patients with GDM. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04857073.

Adjuvant misoprostol or mifepristone for cervical preparation with osmotic dilators before dilation and evacuation.

OBJECTIVES: This study aimed to compare effectiveness and safety of cervical preparation with osmotic dilators plus same-day misoprostol or overnight mifepristone prior to dilation and evacuation (D&E). STUDY DESIGN: We conducted a retrospective cohort analysis of 664 patients initiating abortion between 18 and 22 weeks at an ambulatory health center. We abstracted medical record data from two consecutive 12-month periods in 2017 to 2019. All patients received overnight dilators plus: 600 mcg buccal misoprostol 90 minutes before D&E (period 1); 200 mg oral mifepristone at time of dilators (period 2). Our primary outcome was procedure time. We report frequency of patients experiencing any acute complication, defined as unplanned procedure (i.e., reaspiration, cervical laceration repair, uterine balloon tamponade) or hospital transfer and bleeding complications. RESULTS: We observed higher mean procedure time in the mifepristone group (9.7 ± 5.3 minutes vs 7.9 ± 4.4, p = 0.004). After adjusting for race, ethnicity, insurance, body mass index, parity, prior cesarean, prior uterine surgery, gestational age, provider, trainee participation, and long-acting reversible contraception initiation, the difference remained statistically significant (relative change 1.09, 95% CI 1.01, 1.17) but failed to reach our threshold for clinical significance. The use of additional misoprostol was more common in the mifepristone group, but the use of an additional set of dilators was not different between groups. Acute complications occurred at a frequency of 4.1% in misoprostol group and 4.3% in mifepristone group (p = 0.90). CONCLUSIONS: We found procedure time to be longer with adjunctive mifepristone compared to misoprostol; however, this difference is unlikely to be clinically meaningful. Furthermore, the frequency of acute complications was similar between groups. IMPLICATIONS: Overnight mifepristone at the time of cervical dilator placement is a safe and effective alternative to adjuvant same-day misoprostol for cervical preparation prior to D&E and may offer benefits for clinic flow and patient experience.

Characteristics of the post-surgical decrease in platelet counts in orthopedic surgery patients, observations and insights.

INTRODUCTION: A reduced platelet count (PLT) is a frequent post-operative finding in orthopedic surgery patients. Despite its prevalence, the characteristics of post-surgical thrombocytopenia have not been well described. METHODS: A retrospective chart review was conducted on patients who underwent a knee or hip replacement from 2012 to 2015. Patients who received heparin were excluded. RESULTS: A total of 56 patients were analyzed on post-operative days 0 to 4. By day 1, 90.9% of the patients experienced a reduction in their platelet counts. The lowest mean platelet count (nadir) occurred on day 2 (201.3 × 109/L). The average decrease in the platelet count from the baseline was 24% (95%CI: 20.6 - 27.2). The change in the platelet count from the baseline ranged from a 49.6% drop to a 14.2% increase. A substantial portion of patients experienced thrombocytopenia, with 28% occurring on day 2. Platelet counts less than 100 × 109/L occurred only once. The percent decrease in the platelet count from the baseline to any other time point was significantly larger in patients aged > 65 years, compared to patients aged ≤ 65 years (p = 0.007). Specifically, the average drop in the platelet count at the nadir (day 2) relative to the baseline was 27.8% in patients aged > 65 years, compared to 19.5% in patients aged ≤ 65 years. CONCLUSIONS: A reduction in the platelet count is a frequent post-operative finding in orthopedic surgery patients, even after removing confounding factors, such as heparin exposure, but clinical thrombocytopenia is uncommon. Alternative etiologies should be considered when the platelet count is less than 100 × 109/L. Vigilance should also be considered regarding elderly patients.

Outcomes for patients with high-risk endometrial cancer undergoing sentinel lymph node assessment versus full lymphadenectomy.

OBJECTIVE: The objective of this study was to determine the progression free survival (PFS) and overall survival (OS) among patients with high-risk endometrial cancer (EC) who underwent sentinel lymph node (SLN) mapping and dissection compared to patients who underwent pelvic +/- para-aortic lymphadenectomy (LND). METHODS: Patients with newly diagnosed high-risk EC were identified. Inclusion criteria included patients who underwent primary surgical management from January 1, 2014 to September 1, 2020 at our institution. Patients were categorized into either the SLN or LND group based on their method of planned lymph node assessment. Patients in the SLN group had dye injected followed by successful bilateral lymph node mapping, retrieval, and processing per our institutional protocol. Clinicopathological and follow-up data were extracted from patient's medical records. The t-test or Mann-Whitney test was used to compare continuous variables and Chi-squared or Fisher's exact test were used for categorical variables. Progression-free survival (PFS) was calculated from the date of initial surgery to the date of progression, death, or last follow-up. Overall survival (OS) was calculated from the date of surgical staging to the date of death or last follow-up. Three-year PFS and OS were calculated using the Kaplan-Meier method, and the log-rank test was used to compare cohorts. Multivariable Cox regression models were used to assess the relationship between nodal assessment cohort and OS/PFS while adjusting for age, adjuvant therapy, and surgical approach. A result was considered statistically significant at the p < 0.05 level of significance and all statistical analysis was done using SAS version 9.4 (SAS Institute, Cary, NC). RESULTS: Out of 674 patients diagnosed with EC during the study period, 189 were diagnosed with high-risk EC based on our criteria. Forty-six (23.7%) patients underwent SLN assessment and 143 (73.7%) underwent LND. No difference was observed between the two groups in regards to age, histology, stage, body mass index, tumors myometrial invasion, lymphovascular space invasion, or peritoneal washing positivity. Patients in the SLN group underwent robotic-assisted procedures more frequently than those in the LND group (p < 0.0001). The three-year PFS rate was 71.1% (95% CI 51.3-84.0%) in the SLN group and 71.3% (95% CI 62.0-78.6%) in the LND group (p = 0.91). The unadjusted hazard ratio (HR) for recurrence in the SLN versus LND group was 1.11 (95% CI 0.56-2.18; p = 0.77), and after adjusting for age, adjuvant therapy, and surgical approach, the HR for recurrence was 1.04 (95% CI 0.47-2.30, p = 0.91). The three-year OS rate was 81.1% (95% CI 51.1-93.7%) in the SLN group and 95.1% (95% CI 89.4-97.8%) in the LND group (p = 0.009). Although the unadjusted HR for death was 3.74 in the SLN vs LND group (95% CI 1.39-10.09; p = 0.009), when adjusted for age, adjuvant therapy, and surgical approach, it was no longer significant with a HR of 2.90 (95% CI 0.94-8.95, p = 0.06). CONCLUSIONS: There was no difference in three-year PFS in patients diagnosed with high-risk EC who underwent SLN evaluation compared to those who underwent full LND in our cohort. The SLN group did experience shorter unadjusted OS; however, when adjusting for age, adjuvant therapy and surgical approach, there was no difference OS in patients who underwent SLN compared to LND.

Intra-Sonographer Correlation Between Transabdominal and Transvaginal Cervical Length Measurements and Associated Patient Demographics.

OBJECTIVES: To assess transvaginal (TV) and transabdominal (TA) cervical length (CL) measurements' variability and patient factors associated with TA CL accuracy. We hypothesized that patient factors would affect the accuracy of TA CL. METHODS: This was a prospective cohort study. During anatomy ultrasound, TA and TV CL measurements were obtained, distance from placental edge to internal cervical os assessed, and demographic questionnaires completed. Patients between 18 to 22 weeks and 6 days were included and those <18 year old or with a twin gestation were excluded. TA CL >0.5 cm different from TV length was considered inaccurate. RESULTS: A total of 530 patients were included. Exactly 18.7% had a prior cesarean, 9.8% a preterm birth, and 2.2% a cervical procedure. Mean age and BMI were 31.1 years and 27.8 kg/m2 . Median number of living children was one. Median TA and TV CL were 3.42 and 3.53 cm. Exactly 36% (95% CI: 32-40%) of TA CL measurements were inaccurate. CL of 3.4 cm corresponded to a mean difference of zero between TA and TV CL. TA ultrasound had a sensitivity of 25% and a specificity of 98.5% to detect TV CL <2.5 cm. On multivariable analyses, Hispanic ethnicity was associated with inaccurate TA measurement (OR 0.48, 95% CI: 0.24-0.96, P = .04). CONCLUSIONS: On average, TA CL underestimates TV CL when TV CL >3.40 cm and overestimates TV CL when TV CL <3.40 cm. Additional co-variates did not impact accuracy. TA ultrasound has low sensitivity to predict short cervix. Relying solely on TA CL to identify those who need intervention may miss diagnoses. It may be reasonable to develop protocols in which TV CL is used for TA CL <3.4 cm.

Barriers to completion of expanded carrier screening in an inner city population.

PURPOSE: The American College of Medical Genetics and Genomics emphasizes a "consistent and equitable approach for offering carrier screening." At our academic center, publicly insured prenatal patients underwent universal expanded carrier screening (ECS) to promote equitable care. The aim of the study was to evaluate rates, time, and barriers to complete ECS. This was defined as post-test counseling and partner testing after a patient was found heterozygous for a pathogenic variant. METHODS: In this descriptive retrospective cohort study from 2018 to 2021, patients were offered ECS, consisting of 283 recessive and X-linked genes. Heterozygotes were contacted by genetic counselors (≤5 attempts) for education and partner testing. Rates of counseling, partner testing, diagnostic procedures, follow-up times, and barriers to completion were assessed. RESULTS: During this time, 643 women underwent ECS. Of these 643 women, 462 were heterozygotes and 326 of 462 had undergone counseling. Two hundred twenty-two of 462 partners obtained testing, with a median of 32 days from patient to partner result. Approximately 21 couples were heterozygous for the same pathogenic variant. One patient pursued diagnostic testing. CONCLUSION: ECS offers useful information; however, this study highlights significant barriers to completion. There was suboptimal patient follow-up and low partner screening, perhaps from insufficient time to educate and counsel. Future directions include implementing quality measures to ensure optimal completion.

Outcomes of Elective Compared to Non-Elective Fetal Reduction by Radiofrequency Ablation in Monochorionic Multifetal Pregnancies.

INTRODUCTION: Higher order fetal gestation is associated with adverse pregnancy outcomes, and monochorionic (MC) pregnancies have unique complications. Multifetal pregnancy reduction (MPR) by radiofrequency ablation (RFA) may be used to optimize the outcomes of a single fetus. The purpose of this study was to determine whether pregnancy outcomes differ for elective reduction compared to reduction for medically complicated MC multifetal pregnancies. METHODS: This was a retrospective cohort of patients with MC twins and higher order multiples who underwent MPR via RFA at a single institution between 2008 and 2021. Patients undergoing elective reduction were compared to patients undergoing reduction due to a complication of MC pregnancy. Pregnancy outcomes were evaluated. RESULTS: Forty-eight patients who underwent RFA reduction between 2008 and 2021 were included in the analysis. Sixteen patients (33.3%) underwent elective RFA for MPR, and 32 (66.7%) underwent an RFA procedure for a complicated pregnancy. All pregnancies with RFA performed for elective indication had a continuing pregnancy (live birth rate 100%). There were no reported pregnancy losses within 4 weeks of the procedure when performed for a solely elective indication (n = 0) compared to 6.3% of complicated multifetal pregnancy (n = 2; 6.3%) (p = 0.001). CONCLUSION: In this retrospective cohort study, elective reduction of MC twins using RFA was associated with no cases of fetal loss or PPROM within 4 weeks of the procedure and a 100% live birth rate.

Food Allergy Management Practices Utilizing Individual Patient Thresholds: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee.

The paradigm for food allergy management has been strict avoidance of the food allergen. There is literature supporting a "high-threshold" phenotype, those who tolerate a small-to-modest amount of allergen but react to larger amounts. There is no consensus for best practice for these "high-threshold" individuals. We sought to understand management practices of "high-threshold" reactors using a survey that was distributed to a random sample of fellows and members of the American Academy of Allergy, Asthma, and Immunology. There were 89 respondents from the United States and Canada (11% response rate), with 64 (72%) answering all questions. Participants worked in private (52%) and academic practice (38%) and saw a median of 30 food allergic patients monthly. Eighty-one percent of respondents reported management strategies other than strict avoidance. When threshold was known, strategies ranged from allowing ingestion up to a specified amount (57%), proactively advising ingestion to a certain amount (56%), or oral immunotherapy (47%). Participants were more likely to choose a permissive approach for a mild reaction in a high-threshold milk-allergic patient compared with a peanut-allergic patient (83% vs 71%, p=.01). Important factors that influenced the approach included severity of reaction (52%), comfort with family/patient using emergency medications (42%), and family/patient preferences (41%). These survey results suggest that food allergy management recommendations are no longer binary in nature, with clinicians solely recommending avoidance for those who are allergic and ingestion for those who may not be.

Increase in Rate of Hospitalizations for Pediatric Intentional Acetaminophen Ingestion at a Single Center During the COVID-19 Pandemic.

OBJECTIVES: Social disruption due to COVID-19 has detrimentally affected American adolescents' emotional well-being. Within our system, pediatric acetaminophen ingestions increased in 2020, compared with previous years. We sought to evaluate the rate of hospitalizations for acetaminophen self-harm ingestions and self-harm of adolescents during the COVID-19 pandemic. STUDY DESIGN: We identified patients (aged 0-23) from billing data with diagnosis of acetaminophen ingestion with self-harm intent (ICD-10 code T391X2A), from a multicenter urban, quaternary health care system. We performed retrospective chart review from 2016 to 2020 and performed statistics using a generalized estimating equation (GEE) logistic regression model. RESULTS: From 2016 to 2020, there were 25 790 discharges of adolescents with 65 acetaminophen self-harm ingestion and 148 self-harm discharges. Of the 65 acetaminophen patients, 75% identified as female and 54% identified as non-white; 71% with Medicaid insurance. The proportion of acetaminophen ingestion and self-harm admissions increased from 0.13% in 2016 to 0.46% by 2020 and 0.42% in 2016 to 0.73% by 2020, respectively. The odds of acetaminophen ingestion admission increased by 28% each additional year (odds ratio = 1.28; 95% confidence interval: 1.08, 1.53; P = .006). There was not enough evidence to conclude that the log-odds of a self-harm ingestion were linearly related to time (P = .06). CONCLUSIONS: Acetaminophen ingestion for self-harm has significantly increased, while overall self-harm has increased to a lesser, nonsignificant degree. Primarily females of color and those with Medicaid insurance are affected. It is important to note this growing, disturbing trend, and to continue to screen for depression in our adolescent community and ensure access to mental health resources.

Pregnancy during a Pandemic: A Cohort Study Comparing Adverse Outcomes during and before the COVID-19 Pandemic.

OBJECTIVE: This study was aimed to evaluate how the novel coronavirus disease 2019 (COVID-19) pandemic may have negatively impacted birth outcomes in patients who tested negative for the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus. STUDY DESIGN: We conducted a retrospective cohort study using electronic health records of pregnant women admitted to a tertiary medical center in New York City, an epicenter of the pandemic. Women with a singleton gestation admitted for delivery from March 27 to May 31, 2019, and March 27 to May 31, 2020, were included. Women less than 18 years of age, those with a positive SARS-CoV-2 polymerize chain reaction (PCR) test on admission, fetal anomaly, or multiple gestation were excluded. Adverse pregnancy outcomes were compared between groups. Univariable and multivariable logistic regression analyses were used to assess outcomes. The primary outcome was preterm birth. RESULTS: Women who delivered during the 2020 study interval had a significantly higher rate of hypertensive disorders of pregnancy (gestational hypertension [GHTN] or preeclampsia; odds ratio [OR] = 1.40, 95% confidence interval [CI]: 1.05-1.85; p = 0.02), postpartum hemorrhage (PPH; OR = 1.77, 95% CI: 1.14-2.73; p = 0.01), and preterm birth (OR = 1.49, 95% CI: 1.10-2.02; p = 0.01). Gestational age at delivery was significantly lower in the 2020 cohort compared with the 2019 cohort (39.3 versus 39.4 weeks, p = 0.03). After adjusting for confounding variables, multivariate analysis confirmed a persistent increase in hypertensive disorders of pregnancy (OR = 1.56, 95% CI: 1.10-2.20, p = 0.01), PPH (OR = 1.74, 95% CI: 1.06-2.86, p = 0.03), and preterm birth (OR = 1.72, 95% CI: 1.20-2.47, p = 0.003) in patients who delivered in 2020 compared with the same period in 2019. Specifically, medically indicated preterm births increased during the pandemic (OR = 3.17, 95% CI: 1.77-5.67, p < 0.0001). CONCLUSION: Those who delivered during the COVID-19 pandemic study interval were more likely to experience hypertensive disorders of pregnancy, medically indicated preterm birth, and PPH even in the absence of SARS-CoV2 infection. KEY POINTS: · Stressful life events can lead to adverse pregnancy outcomes.. · Even patients negative for COVID-19 experienced GHTN, preeclampsia, PPH and preterm birth during the pandemic.. · Pandemic-related stress may adversely affect perinatal outcomes..

Pattern Electroretinogram Parameters and their Associations with Optical Coherence Tomography in Glaucoma Suspects.

Aim: To investigate whether steady state pattern electroretinogram (ssPERG) could identify retinal ganglion cell (RGC) dysfunction, and to assess the relationship between ssPERG with optical coherence tomography (OCT) measurements in glaucoma suspects (GS). Materials and methods: This was a prospective cohort study of GS, identified based on suspicious optic disk appearance and glaucoma risk factors. Complete eye exam, Standard automated perimetry, OCT, and ssPERG were performed. Magnitude (Mag), Magnitude D (MagD), and MagD/Mag ratio were subsequently used in the correlation and linear regression analyses between ssPERG parameters and the RNFL, GCL/IPL, and macular thicknesses measurements. Results: Forty-nine eyes of 26 patients were included. Mag and MagD were significantly correlated with the superior, inferior, and average RNFL thicknesses (avRNFLT). All ssPERG parameters were significantly correlated with the average and minimum GCL/IPL thicknesses and the inner macular sector thicknesses. Mag and MagD significantly predicted the superior, inferior, and avRNFLT in the regression analysis. All ssPERG parameters were predictive of GCL/IPL thickness in all sectors as well as the average and minimum GCL/IPL thicknesses. All ssPERG parameters were predictive of all inner macular sector thicknesses and MagD was also predictive of some outer macular sector thicknesses as well. Conclusion: ssPERG has significant correlations with and is predictive of RNFL, GCL/IPL, and macular thicknesses in glaucoma suspects. Clinical significance: ssPERG may serve as a useful objective functional tool for identifying and following the progression of disease in glaucoma suspects. How to cite this article: Tirsi A, Wong A, Zhu D, et al. Pattern Electroretinogram Parameters and their Associations with Optical Coherence Tomography in Glaucoma Suspects. J Curr Glaucoma Pract 2022;16(2):96-104.

Same-Day Compared With Overnight Cervical Preparation Before Dilation and Evacuation Between 16 and 19 6/7 Weeks of Gestation: A Randomized Controlled Trial.

We performed a double-blind, placebo-controlled, randomized noninferiority trial to compare same-day osmotic dilators plus misoprostol with overnight osmotic dilators alone for cervical preparation before dilation and evacuation (D&E) between 16 0/7 and 19 6/7 weeks of gestation. The primary outcome was procedure time. The study was halted early owing to poor accrual. However, the median procedure time was 5.7 minutes in the same-day group compared with 4.2 minutes in the overnight group. The median absolute difference in procedure time was 1.5 minutes, which corresponded to a 35% increase in procedure time (relative difference 35%, one-sided 95% CI -Inf to 52%). Same-day cervical preparation with osmotic dilators plus buccal misoprostol before D&E may be a timely option. Clinical Trial Registration: ClinicalTrials.gov, NCT03002441.

The role of the first trimester screen in the face of normal cell free DNA.

OBJECTIVE: There is no consensus for the method of aneuploidy screening in pregnancy. Cell free DNA (cfDNA) is the most sensitive screen for trisomies 21, 13, and 18, however the first trimester screen (FTS) is a marker for other adverse outcomes, such as structural anomalies, growth restriction, and preeclampsia. In 2019, we offered FTS (nuchal translucency (NT) and analytes) with or without cfDNA. The purpose of this study was to assess clinical relevance of abnormal FTS in women with normal cfDNA. METHODS: We retrospectively reviewed women undergoing screening in our Fetal Evaluation Unit in 2019. Women included had normal cfDNA and abnormal FTS; consisting of NT >95%, PAPP-A < 0.4 MoM, beta-HCG >2.5 MoM, or overall increased risk of trisomies. RESULTS: 195 patients had abnormal FTS and normal cfDNA. 41 (21%) had adverse maternal outcomes including hypertension, abnormal placentation, and placental abruption. 34 (17%) had adverse fetal outcomes including growth restriction, structural anomalies, fetal demise, polyhydramnios, previable PPROM, necrotizing enterocolitis after a preterm birth, and a balanced translocation. CONCLUSION: Abnormal FTS predicts adverse outcomes in 33% of women with normal cfDNA. Our data suggests that offering universal FTS with cfDNA may have clinical benefit.

Racial and Ethnic Disparities Among Women Undergoing a Trial of Labor After Cesarean Delivery: Performance of the VBAC Calculator with and without Patients' Race/Ethnicity.

The Maternal Fetal Medicine Units Network (MFMU) vaginal birth after cesarean (VBAC) calculator is a clinical tool designed to predict trial of labor after cesarean delivery (TOLAC) success. The calculator has come under scrutiny for its inclusion of race and ethnicity, which systematically predicts a lower likelihood of success for patients who identify as African American or Hispanic. We hypothesized that the calculator would predict VBAC more accurately without the use of race or ethnicity. A retrospective chart review including all patients undergoing TOLAC from 2016 to 2019 was conducted. A multivariate logistic regression was used to compare one model that utilizes the original variables in predicting VBAC (model 1) and another that uses the same variables except for race and ethnicity (model 2). In model 1, race and ethnicity were the only variables not associated with the probability of successful TOLAC (p = 0.065). The area under the curve (AUC) for models 1 and 2 were 0.77 and 0.78, respectively. There was not a statistically significant difference between the predictive abilities of the two models (p = 0.40). Rates of PPH (p = 0.001), abruption (p = 0.04), intra-amniotic infection (p < 0.0001), and other postpartum complications (p = 0.005) differed significantly by race and ethnicity. The use of race and ethnicity did not contribute to the accuracy of VBAC prediction. The use of race and ethnicity in this predictive model should be omitted to prevent inherent bias and discrimination. There were also significant racial and ethnic differences in overall postpartum complication rates.

Outcomes of Children with Inflammatory Bowel Disease who Develop Anti-tumour Necrosis Factor-induced Skin Reactions.

BACKGROUND AND AIMS: Anti-tumour necrosis factor [anti-TNF] induced skin reactions are common adverse events in paediatric inflammatory bowel disease [IBD]. We aimed to report on outcomes of children with anti-TNF induced skin reactions who switched to ustekinumab [UST] vs. continued anti-TNF therapy. METHODS: Charts were reviewed for paediatric IBD patients with anti-TNF induced skin reactions. Skin reactions, including psoriasiform dermatitis [PD], were classified as mild or severe based on a severity score. Primary outcome was frequency of skin resolution at 6 months. Secondary outcomes were combined clinical remission and skin resolution at 6 months and skin resolution at latest follow-up. RESULTS: A total of 111/638 [17%] children ([85, 21%] infliximab [IFX]; [26, 11%] adalimumab [ADA]) developed skin reactions. Eighty [72%] had PD, 25 [23%] infections, and four [4%] alopecia areata; 71 [64%] continued anti-TNF; and 40 [36%] switched to UST. In all, 73 [66%] had severe reactions and were more likely to switch to UST than if mild (37 [51%] vs. 3 [8%]; p <0.0001). Switching to UST had a higher rate and odds of resolution (29 [73%] vs. 24 [34%]; p <0.0001; odds ratio [OR] = 19.7, 95% confidence interval [CI]: 5.6, 69.5; p <0.0001) and combined remission (21 [52%] vs. 22 [31%]; p = 0.03; OR = 8.5, 95% CI: 2.5, 28.4; p = 0.0005] vs. continuing anti-TNF at 6 months. CONCLUSIONS: Children who switched to UST after anti-TNF induced skin reactions were more likely to have improved outcomes than those who continued anti-TNF therapy. Future studies are needed to determine immune mechanisms of anti-TNF induced skin reactions and treatment response.

Scheduled versus as-needed postpartum analgesia and oxycodone utilization.

BACKGROUND: An optimal approach for providing sufficient postpartum analgesia while minimizing the risk of opioid misuse or diversion has yet to be elucidated. Moreover, there is scant literature on the efficacy of around-the-clock (ATC) scheduled dosing of opioid analgesia compared to pro re nata (PRN; as-needed) dosing for postpartum pain management. Here we evaluate a quality improvement intervention that aimed to proactively provide pain relief with a multimodal analgesic regimen that includes oxycodone at scheduled time intervals. This new protocol stands in stark contrast to many contemporary postpartum pain management regimens in which oral opioid medications are reserved for treating breakthrough pain. OBJECTIVE: Our aim was to determine how inpatient oxycodone use is affected by as-needed compared to ATC scheduled dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications. We also sought to determine the effect of each modality on patient satisfaction with pain control. METHODS: Retrospective cohort study of singleton deliveries at ≥37 weeks of gestation at a tertiary hospital from 2013 to 2016. In month 21 of the 48-month study period, a new institutional protocol for postpartum pain management was implemented which consisted of scheduled dosing of a multimodal analgesic regimen. Prior to this, patients received pain relief only as needed, by reporting elevated pain scores to nursing staff. Patients were excluded for the following: NSAID or opioid allergies, protocol deviations, transition month deliveries, history of drug abuse, positive urine toxicology, delivery with general anesthesia, prolonged hospitalization, postpartum hemorrhage, hypertensive disorders of pregnancy, incomplete records. Outcomes evaluated were the percentage of patients receiving oxycodone and mean oxycodone use per inpatient day (milligrams). Segmented regression analysis of interrupted time series was performed to estimate linear time trends of oxycodone consumption pre- and post-protocol implementation. Results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) standardized survey were also compared before and after implementation. RESULTS: A total of 19,192 deliveries were included. After adjusting for confounders, a significant downward trend in the percentage of patients receiving oxycodone was noted among both cesarean (0.004% decrease per month; p < .006) and vaginal deliveries (0.005% decrease per month; p < .0001) before implementation of the scheduled pain management protocol. Among cesarean deliveries, there was no shift at the time of implementation, and no change in the slope of the trend after implementation. Among vaginal deliveries, there was an upward shift at implementation (+7.4%, p < .0001) but no change in the slope of the trend after implementation. Regardless of mode of delivery, no trend in monthly mean oxycodone consumption per day existed before or after implementation of the new protocol, and there was no shift at the time of implementation. Scheduled multimodal analgesia was associated with an improvement in HCAHPS scores for patient reported pain control after cesarean section (63 versus 71% reporting "Always" well controlled; p < .001) but had no effect after vaginal delivery. CONCLUSION: After cesarean delivery, scheduled multimodal analgesia that includes ATC dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications, does not increase the percentage of women who receive oxycodone or mean oxycodone consumption per inpatient day compared to as-needed analgesia. After vaginal delivery, scheduled multimodal analgesia is associated with an increase in the percentage of women who receive oxycodone but no change in mean oxycodone consumption per inpatient day.