Cesarean hysterectomy for placenta accreta spectrum: 3-2-1 approach.

Given the high risk of complications associated with cesarean hysterectomy for placenta accreta spectrum (PAS), any surgical approach and technique can yield utility in reducing the surgical morbidity. Here, we propose the 3-2-1 approach as a schema to be implemented in the proper setting for the surgical management of a PAS cesarean hysterectomy. The 3-2-1 approach begins with the surgical dissection of three anatomical landmarks that ultimately facilitate a safe surgical site for the ligation and transection of the uterine vessels. First-step is identification of the three anatomical landmarks which are (i) posterior lower uterine segment peritoneum de-serosalization, (ii) identification of the ureters laterally, and (iii) anterior bladder dissection. Posterior-to-anterior progression avoids encountering dense adhesions and hypervascularity in the anterior lower uterine segment early in the surgery. Further, allows better mobilization of the uterus to identify the anatomical landmarks laterally and anteriorly. Second-step is to deploy the 2-hand technique where the surgeon places one hand anteriorly and the other hand posteriorly in the lower uterine segment below the placental bed. The surgeon brings both hands together with flexed fingers perpendicular to the uterine tissue and gently elevates the uterus and placenta out of the pelvis and ensures safe anatomical distance to surrounding structures. Third-step is the consideration of a supracervical hysterectomy. In summary, this 3-2-1 approach to reflect the anatomy of enlarged lower uterine segment in PAS is a stepwise schema that can aid surgeons in the completion of a cesarean hysterectomy, with the goal to improve surgical outcomes.

Pregnant patients undergoing cholecystectomy: nationwide assessment of clinical characteristics and outcomes.

BACKGROUND: Gallstone disease in pregnancy is one of the most common indications for nonobstetrical surgery during pregnancy. National-level data on contemporary surgical practice and outcomes are limited. OBJECTIVE: This study aimed to assess the clinical characteristics and outcomes of patients undergoing cholecystectomy during pregnancy. STUDY DESIGN: This cross-sectional study examined the Healthcare Cost and Utilization Project's 2 nationwide databases in the United States: the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample. The study population included 18,630 patients who had cholecystectomy during pregnancy from January 2016 to December 2020. The exposure was gestational age, grouped sequentially into the following 5 groups: first trimester (<14 weeks), early second trimester (14-20 weeks), late second trimester (21-27 weeks), early third trimester (28-36 weeks), and late third trimester (≥37 weeks). The main outcomes were clinical demographics, medical comorbidities, surgical information, and pregnancy characteristics and outcomes, assessed by gestational age. RESULTS: Cholecystectomy was most common in the early second trimester (32.1%), followed by the first trimester (25.2%), late second trimester (23.1%), early third trimester (12.4%), and late third trimester (7.2%). Patients in the first-trimester group were more likely to be aged ≥35 years, to smoke, and to have acute cholecystitis, severe hyperemesis gravidarum including metabolic disturbance, pregestational diabetes, multifetal gestation, and sepsis/shock (P<.001). Patients in the early-third-trimester group were more likely to be obese and have gestational diabetes, Charlson Comorbidity Index of ≥1, premature rupture of membranes, and intrauterine growth restriction, whereas those in the late-third-trimester group were more likely to have gallstone pancreatitis, biliary colic, chorioamnionitis, gestational hypertension, preeclampsia, and severe maternal morbidity including sepsis (P<.001). At the cohort level, a laparoscopic approach was used in most cholecystectomy procedures (97.5%), and bile duct injury was uncommon (<0.1%). Delivery during the admission occurred in 0.3%, 0%, 0.6%, 17.8%, and 60.6% in the 5 gestational age groups, respectively (P<.001). Among the cases that had delivery in the early- and late-third-trimester groups, the delivery event preceded cholecystectomy in 61.4% and 86.2%, respectively, whereas both delivery and cholecystectomy occurred on the same day in 34.3% and 13.8%, respectively. CONCLUSION: This nationwide analysis suggests that clinical and pregnancy characteristics and outcomes of patients undergoing cholecystectomy differ by pregnancy stage with a bimodal distribution. Although patients in the first and third trimesters have distinct medical conditions, more clinically significant pregnancy and maternal outcomes were found in both groups compared with patients in the second trimester.

Management for Acute Uncomplicated Appendicitis During Pregnancy: National Trends and Patient Outcomes.

OBJECTIVE: This study analyzes national trends in the management of uncomplicated appendicitis during pregnancy, comparing outcomes for nonoperative management (NOM) and appendectomy. BACKGROUND: In the nonpregnant population, several randomized controlled trials demonstrated noninferiority of NOM compared with appendectomy for acute uncomplicated appendicitis. However, it remains unclear whether these findings are generalizable to pregnant patients. METHODS: The National Inpatient Sample was queried for pregnant women diagnosed with acute uncomplicated appendicitis from January 2003 to September 2015. Patients were categorized by treatment: NOM, laparoscopic appendectomy (LA), and open appendectomy. A quasi-experimental analysis with interrupted time series examined the relationship between the year of admission and the likelihood of receiving NOM. Multivariable logistic regression analyses were used to evaluate the association between treatment strategy and patient outcomes. RESULTS: A total of 33,120 women satisfied the inclusion criteria. Respectively, 1070 (3.2%), 18,736 (56.6%), and 13,314 (40.2%) underwent NOM, LA, and open appendectomy. The NOM rate significantly increased between 2006 and 2015, with an annual increase of 13.9% (95% CI, 8.5-19.4, P <0.001). Compared with LA, NOM was significantly associated with higher rates of preterm abortion (odds ratio [OR]: 3.057, 95% CI, 2.210-4.229, P <0.001) and preterm labor/delivery (OR: 3.186, 95% CI, 2.326-4.365, P <0.001). Each day of delay to appendectomy was associated with significantly greater rates of preterm abortion (OR: 1.210, 95% CI, 1.123-1.303, P <0.001). CONCLUSIONS: Although NOM has been increasing as a treatment for pregnant patients with uncomplicated appendicitis, compared with LA, it is associated with worse clinical outcomes.

Postpartum Glucose Tolerance Testing Among Patients With Gestational Diabetes During the Coronavirus Disease 2019 Pandemic.

Introduction The impact of the coronavirus disease (COVID-19) COVID-19 pandemic on the care of pregnant patients with gestational diabetes (GDM) is largely unreported. The objective of this study was to compare the completion of postpartum oral glucose tolerance testing (GTT) prior to and during the COVID-19 pandemic among patients with GDM. Methods This was a retrospective review of patients diagnosed with GDM between April 2019 and March 2021. Medical records of patients diagnosed with GDM prior to and during the pandemic were compared. The primary outcome was the difference in the completion of postpartum GTT prior to and during the COVID-19 pandemic. Completion was defined as testing between four weeks to six months postpartum. Secondary objectives were: 1) to compare maternal and neonatal outcomes prior to and during the pandemic among patients with GDM, and 2) to compare pregnancy characteristics and outcomes by compliance with postpartum GTT. Results There were 185 patients included in the study, of whom 83 (44.9%) delivered prior to the pandemic and 102 (55.1%) delivered during the pandemic. There was no difference in completion of postpartum diabetes testing prior, compared to during the pandemic (27.7% vs 33.3%, p=0.47). Postpartum diagnosis of pre-diabetes and type two diabetes mellitus (T2DM) did not differ between groups (p=0.36 and p=1.00, respectively). Patients who completed postpartum testing were less likely to have preeclampsia with severe features compared to patients who did not (OR 0.08, 95% CI 0.01-0.96, p=0.02). Conclusion Completion of postpartum testing for T2DM remained poor prior to and during the COVID-19 pandemic. These findings underscore the need for the adoption of more accessible methods of postpartum testing for T2DM among patients with GDM.

Unsuspected placenta accreta spectrum at vaginal delivery: assessment of incidence, characteristics, and maternal morbidity.

BACKGROUND: Placenta accreta spectrum refers to morbidly adherent trophoblastic tissue invading into the gravid uterus and is associated with significant maternal morbidity. Most cases of placenta accreta spectrum are suspected antenatally, and most patients undergo planned, late-preterm cesarean hysterectomy to reduce the risk of morbidity. Rarely, however, placenta accreta spectrum is incidentally diagnosed at vaginal delivery, but there is a scarcity of data regarding these events. OBJECTIVE: This study aimed to examine the incidence, characteristics, and outcomes of pregnant individuals with incidentally diagnosed placenta accreta spectrum at term vaginal delivery. STUDY DESIGN: This was a retrospective cohort study investigating the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population was 8,694,669 term vaginal deliveries from January 2016 to December 2019. Exclusion criteria included previous uterine scar, placenta previa, and preterm delivery. Exposure was assigned by the diagnosis of placenta accreta spectrum. The main outcomes were: (1) incidence rate, (2) clinical and pregnancy characteristics, and (3) maternal morbidity related to unsuspected placenta accreta spectrum at vaginal delivery. Multivariable binary logistic regression analysis and inverse probability of treatment weighting were fitted for statistical analysis. RESULTS: Unsuspected placenta accreta spectrum was reported in 1 in 3797 vaginal deliveries. In a multivariable analysis, the following were associated with increased likelihood of unsuspected placenta accreta spectrum (all, P<.05): (1) patient factor with older age, (2) uterine factors such as uterine anomaly and uterine myoma, (3) pregnancy factors including early-term delivery and previous recurrent pregnancy losses, and (4) fetal factors of in utero growth restriction and demise. Of those, uterine anomaly had the greatest association with unsuspected placenta accreta spectrum (adjusted odds ratio, 6.23; 95% confidence interval, 4.20-9.26). In a propensity score-weighted model, patients in the unsuspected placenta accreta spectrum group were more likely to have hemorrhage (65.2% vs 4.1%), blood product transfusion (21.3% vs 0.6%), hysterectomy (14.9% vs <0.1%), coagulopathy (2.9% vs 0.1%), and shock (2.9% vs <0.1%) compared with those without placenta accreta spectrum. Patients in the unsuspected placenta accreta spectrum group were also more likely to receive manual removal of the placenta compared with those in the non-placenta accreta spectrum group (25.1% vs 0.6%). CONCLUSION: This study suggests that although unsuspected placenta accreta spectrum among patients undergoing term vaginal delivery is rare, it is associated with significant morbidity. The observed association between uterine anomalies and placenta accreta spectrum warrants further investigation.

Incidence trends of shoulder dystocia and associated risk factors: A nationwide analysis in the United States.

OBJECTIVE: To examine recent incidence trends and characteristics of shoulder dystocia. METHODS: This is a retrospective cohort study querying the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population included 9 913 838 vaginal deliveries for national estimates from January 2016 to December 2019. The main outcome measure was the diagnosis of shoulder dystocia. A binary logistic regression model was used to identify characteristics of shoulder dystocia in multivariable analysis. RESULTS: Shoulder dystocia was reported in 228 120 deliveries (23.0 per 1000). The incidence of shoulder dystocia increased from 21.0 to 24.6 per 1000 deliveries during the 4-year study period (17.1% relative increase, P < 0.001). In a multivariable analysis, the recent year of delivery remained an independent factor for shoulder dystocia: adjusted odds ratio (aOR) compared with 2016, 1.09 (95% confidence interval [CI], 1.08-1.11), 1.13 (95% CI, 1.12-1.14), and 1.18 (95% CI, 1.16-1.19) for 2017, 2018, and 2019, respectively. Large for gestational age (aOR 4.33 [95% CI, 4.25-4.40]), diabetes mellitus (pregestational aOR, 4.78 [95% CI, 4.63-4.94], and gestational aOR, 1.69 [95% CI, 1.66-1.71]), and vacuum-assisted delivery (aOR, 2.18 [95% CI, 2.15-2.21]) exhibited the largest risks for shoulder dystocia. CONCLUSION: This national-level analysis identified various risk factors for shoulder dystocia and demonstrated that shouder dystocia cases are increasing gradually in the United States.

Transvaginal cervical tumor-concealing no-look no-touch technique in minimally invasive radical hysterectomy for early-stage cervical cancer: a novel operation technique.

The Laparoscopic Approach to Cervical Cancer (LACC) trial demonstrated that minimally invasive radical hysterectomy was inferior to the open approach [1]; this unexpected result could be attributed to the spillage of cancer cells [2]. Following the LACC trial, laparoscopic radical hysterectomy without an intrauterine manipulator upon completion of a vaginal cuff closure became the new standard treatment method [3]. However, the lack of intrauterine manipulator results in poor visualization and inadequate paracervical tissue resection. This study describes the no-look no-touch technique to address this difficulty. The core procedures in our no-look, no-touch laparoscopic radical hysterectomy are: (Step 1) Creation and closure of a vaginal cuff; (Step 2) Manipulation of the uterus without an intra-uterine manipulator; and (Step 3) Exposure of the paracervical tissues by the suspension technique. The patient eligibility for our procedure is as follows: 1) previously untreated cervical cancer (those who underwent diagnostic conization could be included); 2) clinical stage IA2, IB1, IB2, and IIA1 based on the 2018 International Federation of Gynecology and Obstetrics staging system; 3) histologically confirmed cervical cancer, including squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma. The important indication for this procedure is in cases where the tumor is less than 4 cm in diameter. We previously reported that our no-look no-touch technique enables smooth performance of laparoscopic radical hysterectomy without worsening oncologic outcomes [4]. According to a recent systematic review and meta-analysis [5], minimally invasive radical hysterectomy with vaginal cuff closure is a safe treatment option; however, it involves a steep learning curve, which has impeded its increased application. This video will hopefully make minimally invasive radical hysterectomy with protective maneuvers against cancer cell spillage more accessible. Based on our experiences, we propose that our transvaginal cervical tumor-concealing no-look no-touch technique will mitigate the risk of surgical spill of tumor cells during minimally invasive radical hysterectomy. The informed consent for use of this video was taken from the patient.

Pregnancy characteristics and outcomes after bariatric surgery: national-level analysis in the United States.

BACKGROUND: Bariatric surgery is an effective surgical treatment for weight reduction in individuals with obesity. Pregnancy outcomes related to prior bariatric surgery are currently under active investigation. OBJECTIVE: To assess national-level trends, characteristics, and outcomes of pregnancy after bariatric surgery in the United States. SETTING: Retrospective cohort study queried the National Inpatient Sample. METHODS: The study population was 14,648,135 patients who had vaginal or cesarean delivery from January 2016 to December 2019. Exposure allocation was based on the history of bariatric surgery. The main outcomes were (1) trends and characteristics related to bariatric surgery, assessed with multivariable binary logistic regression model; and (2) Centers for Disease Control and Prevention-defined severe maternal morbidity, assessed by propensity score matching and generalized estimating equation. RESULTS: A total of 53,950 (.4%) patients had prior bariatric surgery. The number of patients with prior bariatric surgery increased from .3% to .5%, and this trend remained independent in multivariable analysis (P < .001). Patients who had bariatric surgery were also more likely to be older and have obesity, medical co-morbidities, fetal growth restriction, preterm birth, and cesarean delivery compared with those without bariatric surgery (all, P < .05). In a propensity score matched model, patients who had bariatric surgery were more likely to receive blood product transfusion (2.3% versus 1.6%; odds ratio = 1.45; 95% confidence interval, 1.19-1.77), but severe maternal morbidity other than blood product transfusion was comparable to those without (1.1% versus 1.4%; odds ratio = .80; 95% confidence interval, .63-1.02). CONCLUSION: There is a gradual increase of pregnancy after bariatric surgery in recent years in the United States.

Prevalence of anxiety and depressive disorders in pregnant women with malignancy.

OBJECTIVE: To examine national-level prevalence of anxiety and depressive disorders among pregnant women with malignancy. METHODS: This is a pre-planned secondary analysis of a previous retrospective cohort study using the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 14 648 135 deliveries including 10 145 patients with malignancy from 2016 to 2019. A multivariable binary logistic regression model was fitted to assess the association of malignancy and anxiety or depressive disorder. RESULTS: Pregnant women with malignancy were 49% more likely to have the diagnosis of either anxiety or depressive disorder compared with those without malignancy (prevalence rate 114 vs. 61 per 1000 cases, adjusted odds ratio [aOR] 1.49, 95% confidence interval [CI] 1.40-1.58). The increase in the risk associated with malignancy on either anxiety or depressive disorder was more than two-fold among patients with brain and other nervous system tumors (aOR 2.69, 95% CI 2.01-3.60), bone and joint tumors (aOR 2.32, 95% CI 1.33-4.04), and leukemia (aOR 2.12, 95% CI 1.81-2.48). CONCLUSIONS: This national-level analysis suggests that pregnant women with malignancy experience increased rates of psychological distress more often than pregnant women without malignancy.

Prior vertical uterine incision: Effect on subsequent pregnancy characteristics and outcomes.

OBJECTIVE: To examine characteristics and outcomes of cesarean delivery (CD) in women with a history of vertical hysterotomy. METHOD: This is a comparative study that retrospectively queried the National Inpatient Sample from October 2016 to December 2018. Pregnancy characteristics and surgical outcomes of CD among 18 575 women with prior vertical uterine incision were compared to 1 072 949 women with prior low-transverse incision, assessed by multivariable generalized estimating equation model and propensity score weighting. RESULTS: In a multivariable analysis, women who had prior vertical uterine incision were more likely to have placenta percreta (odds ratio [OR] 3.41, 95% confidence interval [CI] 1.87-6.20), pre-labor uterine rupture (OR 2.70, 95% CI 1.52-4.80), in-labor uterine rupture (OR 2.33, 95% CI 1.55-3.51), and extreme preterm delivery <28 weeks (OR 17.8, 95% CI 15.2-20.7) in the current pregnancy, compared to those who had prior low-transverse uterine incision. In a weighted model, prior vertical hysterotomy was associated with increased surgical morbidity in current CD compared to prior low-transverse hysterotomy (10.6% vs. 4.8%, OR 2.02, 95% CI 1.81-2.26), including hemorrhage (OR 1.99, 95% CI 1.74-2.27) and hysterectomy (OR 3.67, 95% CI 2.97-4.53). CONCLUSION: Prior vertical uterine incision at CD was associated with increased risk of placenta percreta, uterine rupture, particularly before labor, and adverse outcomes in the subsequent pregnancy.

Patient characteristics of contraception and sterilization selection at vaginal delivery.

Objective: To examine patient characteristics among those who selected the long-acting reversible contraception (LARC) and surgical sterilization methods at vaginal delivery. Design: Retrospective cohort study. Setting: The National Inpatient Sample. Patients: A total of 8,013,785 vaginal deliveries from October 2016 to December 2019. Interventions: Exposure assignment per LARC (subdermal contraceptive implant [implants] or intrauterine device [IUD]) or surgical sterilization (bilateral salpingectomy [BS] or bilateral tubal ligation [BTL]) type. Main Outcome Measures: Utilization trends of LARC or surgical sterilization, assessed with linear segmented regression with log-transformation, and differences in patient characteristics per the exposure strata (implants vs. IUD in the LARC group and BS or BTL in the surgical sterilization group), assessed using the multivariate binary logistic regression model. Results: In a comparison between LARC and surgical sterilization, surgical sterilization use decreased from 1.90% to 1.55% (18.4% relative decrease), whereas LARC use increased from 0.35% to 1.02% (191% relative increase). In the LARC group, implant use (from 0.12% to 0.50%) increased more compared with IUD use (from 0.22% to 0.52%): relative increase, 317% vs. 136%. In the surgical sterilization group, BTL use decreased from 0.66% to 0.18% (72.7% relative decrease), whereas BS use was statistically unchanged (from 1.24% to 1.37%). In a multivariate analysis, recent year remained an independent characteristic for implant use in the LARC group and BS use in the surgical sterilization group. Moreover, in both LARC and surgical sterilization strata, procedure choices significantly differed on the basis of patient, pregnancy, hospital, and delivery factors. Conclusions: Immediate postpartum contraception choice has evolved in recent years in the United States with an increasing demand for the LARC methods with implants at the time of vaginal delivery.

Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism.

Importance: Amniotic fluid embolism (AFE) is an uncommon pregnancy complication but is associated with high maternal mortality. Because of the rarity of AFE, associated risks factors and maternal outcomes have been relatively understudied. Objective: To examine the clinical, pregnancy, and delivery characteristics and the maternal outcomes related to AFE in a recent period in the US. Design, Setting, and Participants: This retrospective cohort study examined hospital deliveries from January 1, 2016, to December 31, 2019, from the Healthcare Cost and Utilization Project's National Inpatient Sample. Main Outcomes and Measures: The primary outcome was clinical, pregnancy, and delivery characteristics of AFE, assessed with a multivariable binary logistic regression model. The coprimary outcome was failure to rescue, defined as maternal mortality after AFE. Associations with other severe maternal morbidity indicators and failure to rescue per clinical and pregnancy characteristics were also assessed. Results: A total of 14 684 135 deliveries were examined, with AFE diagnosed in 880 women, corresponding to an incidence rate of 6.0 per 100 000 deliveries. The cohort-level median patient age was 29 years (IQR, 25-33 years). In a multivariable analysis, (1) patient factors of older age, Asian and Black race, Western US region, pregestational hypertension, asthma, illicit substance use, and grand multiparity; (2) pregnancy factors of placental accreta spectrum (PAS), placental abruption, uterine rupture, polyhydramnios, chorioamnionitis, preeclampsia, fetal growth restriction, and fetal demise; and (3) delivery factors of early gestational age, cervical ripening, cesarean delivery, operative delivery, and manual removal were associated with AFE. Among these characteristics, PAS had the largest association with AFE (adjusted odds ratio [aOR], 10.01; 95% CI, 7.03-14.24). When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE (aOR for increta and percreta, 17.35; 95% CI, 10.21-28.48; and aOR for accreta, 7.62; 95% CI, 4.83-12.01). Patients who had AFE were more likely to have coagulopathy (aOR, 24.68; 95% CI, 19.38-31.44), cardiac arrest (aOR, 24.56; 95% CI, 17.84-33.81), and adult respiratory distress syndrome (aOR, 10.72; 95% CI, 8.09-14.20). The failure-to-rescue rate after AFE was 17.0% overall. However, the failure-to-rescue rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators: 45.8% for AFE, cardiac arrest, and coagulopathy; 43.2% for AFE, shock, and cardiac rhythm conversion; and 38.6% for AFE, cardiac arrest, coagulopathy, and shock. The failure-to-rescue rate after AFE also exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and PAS and 31.3% for AFE and placental abruption. Conclusions and Relevance: This contemporaneous, national-level analysis validated previously known risk factors for AFE and confirmed the dismal outcomes of pregnancy complicated by AFE. The association between PAS and AFE, which was not previously reported, warrants further investigation.

Temporal trends of cesarean delivery on maternal request in the United States, 2016-2019.

OBJECTIVE: Cesarean delivery on maternal request (elective-CD) increased between 1999 and 2015 in the United States, but multiple studies have reported the association between elective-CD and adverse maternal and neonatal outcomes. More contemporary trends and outcomes are currently unknown. The objective of the current study was to examine contemporaneous trends and outcomes of patients who had elective-CD in the United States. METHODS: This is a retrospective cohort study querying the Healthcare Cost and Utilization Project's National Inpatient Sample from January 2016 to December 2019. A three-step exclusion approach was used to identify the surrogate for elective-CD (prior uterine scar, maternal / fetal indications for CD, and labor). The primary outcome was temporal trend of elective-CD. The secondary outcomes included severe maternal morbidity in low-risk vaginal delivery candidates, assessed with inverse probability of treatment weighting propensity score. RESULTS: Among 14,648,135 all deliveries for national estimates, 184,945 (1.26 %) patients had elective-CD. The number of patients undergoing elective-CD decreased from 1.35 % to 1.13 % among all deliveries (16.3 % relative-decrease; P-trend < 0.001) and from 4.14 % to 3.51 % among all CD cases (15.2 % relative-decrease, P-trend = 0.002) between QT1/2016 and QT4/2019. The decreasing trend of elective-CD remained independent in multivariable analysis: odds ratio (OR) compared to 2016, 0.96 (95 % confidence interval [CI] 0.95-0.97) for 2017, 0.94 (95 %CI 0.93-0.95) for 2018, and 0.87 (95 %CI 0.86-0.89) for 2019. In a propensity score weighted model among low-risk vaginal delivery candidates, patients in the elective-CD group were more likely to have severe maternal morbidity compared to those in the non-elective-CD group (OR 2.01, 95 %CI 1.87-2.15). CONCLUSIONS: This national-level analysis suggests that the number of elective-CD is gradually decreasing in recent years in the United States.

Association of severe maternal morbidity and post-traumatic stress disorder.

BACKGROUND: Severe maternal morbidity refers to the most serious complications of pregnancy. Whether severe maternal morbidity is associated with post-traumatic stress disorder is currently under active investigation. OBJECTIVE: This study aimed to examine the association between severe maternal morbidity and post-traumatic stress disorder at delivery. STUDY DESIGN: This was a retrospective cohort study querying the Healthcare Cost and Utilization Project's National Inpatient Sample, which included 12,857,721 patients for national estimates who had vaginal or cesarean deliveries between January 2016 and December 2019. Patients with mental health conditions other than post-traumatic stress disorder and substance use disorder were excluded. Severe maternal morbidity was defined according to the Centers for Disease Control and Prevention definition (a total of 21 indicators). Main outcomes were trends and characteristics related to post-traumatic stress disorder, assessed with a multivariable binary logistic regression model. Sensitivity analysis included subcohort assessment restricted to patients per clinical and obstetrical demographics. RESULTS: A total of 8880 patients had a diagnosis of post-traumatic stress disorder during the hospital admission for delivery (prevalence rate, 6.9 per 10,000). The prevalence rate of post-traumatic stress disorder increased from 5.0 to 8.8 per 10,000 deliveries between 2016 and 2019. This increasing trend remained independent in multivariable analysis. The adjusted odds ratio, compared with 2016, was 1.26 (95% confidence interval, 1.19-1.35) for 2017, 1.50 (95% confidence interval, 1.41-1.60) for 2018, and 1.73 (95% confidence interval, 1.63-1.84) for 2019. Severe maternal morbidity occurred in 210,605 (1.6%) patients. Patients who had severe maternal morbidity were more likely to have a diagnosis of post-traumatic stress disorder than those without severe maternal morbidity (12.8 vs 6.8 per 10,000 deliveries; adjusted odds ratio, 1.57; 95% confidence interval, 1.39-1.78) in multivariable analysis. This association remained robust in several subcohort analyses including (1) participants aged ≤35 years (adjusted odds ratio, 1.62; 95% confidence interval, 1.41-1.86), (2) those aged ≤35 years without medical comorbidity (adjusted odds ratio, 2.01; 95% confidence interval, 1.70-2.37), and (3) those aged <35 years without medical comorbidity, cesarean delivery, and preterm delivery (adjusted odds ratio, 4.52; 95% confidence interval, 3.56-5.74). CONCLUSION: There has been a gradual increase in the number of patients with a diagnosis of post-traumatic stress disorder at delivery in recent years among those without other mental health or substance use conditions. These data suggest that there is a possible association between severe maternal morbidity and post-traumatic stress disorder.

Gynecologic oncologists in surgery for placenta accreta spectrum: a survey for practice, experience, and interest.

OBJECTIVE: Surgery for placenta accreta spectrum is associated with significant maternal morbidity and mortality. The role of gynecologic oncologists in the surgical management of placenta accreta spectrum is currently under investigation. This study examined the practices, experiences, and interests of gynecologic oncologists in placenta accreta spectrum surgeries. METHODS: The intervention was an anonymous, cross-sectional, 20-question survey sent to 1084 members of the Society of Gynecologic Oncology in the USA. RESULTS: A total of 184 gynecologic oncologists responded to the survey (response rate 17.0%). Most participating gynecologic oncologists have been practicing for >10 years after fellowship (53.2%), practice in urban-teaching hospitals (84.8%) with delivery volumes ≥3000/year (54.3%), and have a multidisciplinary approach (82.5%). Three-quarters (78.7%) feel that the rate of placenta accreta spectrum is increasing over time. One-third (35.5%) perform ≥6 hysterectomies for placenta accreta spectrum yearly. Less than half (45.5%) practice conservative management. Approximately half are involved from the beginning of the case (49.7%) and perform the surgery in the main operating room (59.4%). Almost three-quarters (71.6%) have experienced surgical blood loss >5 L and one-third (36.6%) have experienced cases with blood loss >10 L. About half (50.3%) of participants are interested in placenta accreta spectrum surgery for future practice. Gynecologic oncologists engaging in a multidisciplinary approach are more likely to practice in an urban-teaching hospital, have higher surgical volume, be involved from the beginning of the case, and be interested in placenta accreta spectrum surgery. Those >10 years post-training and in the Southern US region are more likely to practice conservative management or delayed hysterectomy. CONCLUSION: This society-based cross-sectional survey suggests that gynecologic oncologists are actively involved in the surgical management of placenta accreta spectrum in the USA. Nearly half of gynecologic oncologists who responded to the survey expressed interest in surgery for placenta accreta spectrum.

Association between sentinel lymph node biopsy and micrometastasis in endometrial cancer.

OBJECTIVE: Sentinel lymph node (SLN) biopsy is increasingly utilized at surgical staging for early endometrial cancer. This study examined the association between SLN biopsy and micrometastasis in endometrial cancer. METHODS: This is a retrospective cohort study examining the National Cancer Institute's Surveillance, Epidemiology, and End Result Program. The study population was 6,414 women with T1-2 endometrial cancer who underwent primary hysterectomy and surgical nodal evaluation. Exclusion criteria included cases with isolated tumor cells. Exposure assignment was surgical nodal evaluation (SLN biopsy or lymphadenectomy). Main outcome measure was micrometastasis, assessed by inverse probability of treatment weighting propensity score in a stage-specific fashion. RESULTS: In T1a disease (n = 4,608), SLN biopsy was performed in 1,164 (25.3%) cases. SLN biopsy was associated with a 90% increased likeliness of identifying micrometastasis compared to lymphadenectomy (1.3% versus 0.7%, odds ratio 1.90, 95% confidence interval 1.02-3.55, P = 0.040). In T1b disease (n = 1,369), 270 (19.7%) cases had SLN biopsy. The incidence of micrometastasis was significantly higher in the SLN biopsy group compared to the lymphadenectomy group (8.4% versus 5.0%, odds ratio 1.74, 95% confidence interval 1.06-2.86, P = 0.028). In T2 disease (SLN biopsy in 57 [13.0%] of 437 cases), the incidence of micrometastasis was similar between the two groups (7.9% versus 7.0%, odds ratio 0.88, 95% confidence interval 0.30-2.60, P = 0.818). CONCLUSION: This study suggests that SLN biopsy protocol may identify more micrometastasis in the regional lymph nodes of T1 endometrial cancer. Whether national-level increase in the utilization of SLN biopsy for early endometrial cancer results in a stage-shifting to advanced disease on a population-basis warrants further investigation.