Predicting primary cesarean delivery in pregnancies complicated by gestational diabetes mellitus.

BACKGROUND: Prediction models have shown promise in helping clinicians and patients engage in shared decision-making by providing quantitative estimates of individual risk of important clinical outcomes. Gestational diabetes mellitus is a common complication of pregnancy, which places patients at higher risk of primary CD. Suspected fetal macrosomia diagnosed on prenatal ultrasound is a well-known risk factor for primary CD in patients with gestational diabetes mellitus, but tools incorporating multiple risk factors to provide more accurate CD risk are lacking. Such tools could help facilitate shared decision-making and risk reduction by identifying patients with both high and low chances of intrapartum primary CD. OBJECTIVE: This study aimed to develop and internally validate a multivariable model to estimate the risk of intrapartum primary CD in pregnancies complicated by gestational diabetes mellitus undergoing a trial of labor. STUDY DESIGN: This study identified a cohort of patients with gestational diabetes mellitus derived from a large, National Institutes of Health-funded medical record abstraction study who delivered singleton live-born infants at ≥34 weeks of gestation at a large tertiary care center between January 2002 and March 2013. The exclusion criteria included previous CD, contraindications to vaginal delivery, scheduled primary CD, and known fetal anomalies. Candidate predictors were clinical variables routinely available to a practitioner in the third trimester of pregnancy found to be associated with an increased risk of CD in gestational diabetes mellitus. Stepwise backward elimination was used to build the logistic regression model. The Hosmer-Lemeshow test was used to demonstrate goodness of fit. Model discrimination was evaluated via the concordance index and displayed as the area under the receiver operating characteristic curve. Internal model validation was performed with bootstrapping of the original dataset. Random resampling with replacement was performed for 1000 replications to assess predictive ability. An additional analysis was performed in which the population was stratified by parity to evaluate the model's predictive ability among nulliparous and multiparous individuals. RESULTS: Of the 3570 pregnancies meeting the study criteria, 987 (28%) had a primary CD. Of note, 8 variables were included in the final model, all significantly associated with CD. They included large for gestational age, polyhydramnios, older maternal age, early pregnancy body mass index, first hemoglobin A1C recorded in pregnancy, nulliparity, insulin treatment, and preeclampsia. Model calibration and discrimination were satisfactory with the Hosmer-Lemeshow test (P=.862) and an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.74-0.77). Internal validation demonstrated similar discriminatory ability. Stratification by parity demonstrated that the model worked well among both nulliparous and multiparous patients. CONCLUSION: Using information routinely available in the third trimester of pregnancy, a clinically pragmatic model can predict intrapartum primary CD risk with reasonable reliability in pregnancies complicated by gestational diabetes mellitus and may provide quantitative data to guide patients in understanding their individual primary CD risk based on preexisting and acquired risk factors.

Frailty as a predictor of delayed initiation of adjuvant chemotherapy in patients with ovarian cancer.

OBJECTIVE: This study aimed to identify whether frailty is associated with the time between surgery and the initiation of chemotherapy for patients with ovarian cancer. METHODS: This retrospective cohort study included patients 18 years or older with stage II to IV ovarian cancer who underwent primary debulking surgery at a tertiary medical center between July 2006 and July 2015. Basic demographics and clinical information were obtained from a departmental database and the electronic medical record. The Modified Frailty Index (mFI) was calculated based on 10 comorbidities and functional status yielding 11 items total. Patients were categorized by a total score: 0-1=no frailty, 2=moderate frailty and 3+=high frailty. RESULTS: Among 451 patients, 359 had mFI scores of 0-1, 60 had a score of 2, and 32 had scores of 3+. Mean time from surgery to initiation of chemotherapy was 37 days. Mean number of days between surgery and initiation of chemotherapy increased with increasing frailty score: 36 days for the not frail group, 39 days for the moderate frailty group, and 54 days for the high frailty group (p<0.001). Time to initiation of chemotherapy of 42 days or more occurred in 23% of the no frailty group, 28% in the moderate frailty group, and 63% in the high frailty group (p<0.001). Overall survival decreased with increasing frailty scores. CONCLUSION: High mFI scores lead to a greater delay between surgery and chemotherapy initiation. Being able to predict delays in initiation of chemotherapy may allow oncologists to consider neoadjuvant chemotherapy, pre-habilitation before surgery, and improved preoperative counseling in high-risk patients.

Outcomes among Neonates after a Diagnosis of Persistent or Transient Fetal Growth Restriction Delivered at Term.

OBJECTIVE: This study aimed to evaluate whether transient fetal growth restriction (FGR) that resolves prior to delivery confers a similar risk of neonatal morbidity as uncomplicated FGR that persists at term. STUDY DESIGN: This is a secondary analysis of a medical record abstraction study of singleton live-born pregnancies delivered at a tertiary care center between 2002 and 2013. Patients with fetuses that had either persistent or transient FGR and delivered at 38 weeks or later were included. Patients with abnormal umbilical artery Doppler studies were excluded. Persistent FGR was defined as estimated fetal weight (EFW) <10th percentile by gestational age from diagnosis through delivery. Transient FGR was defined as EFW <10th percentile on at least one ultrasound, but not on the last ultrasound prior to delivery. The primary outcome was a composite of neonatal morbidity: neonatal intensive care unit admission, Apgar's score <7 at 5 minutes, neonatal resuscitation, arterial cord pH <7.1, respiratory distress syndrome, transient tachypnea of the newborn, hypoglycemia, sepsis, or death. Baseline characteristics and obstetric and neonatal outcomes were compared using Wilcoxon's rank-sum and Fisher's exact test. Log binomial regression was used to adjust for confounders. RESULTS: Of 777 patients studied, 686 (88%) had persistent FGR and 91 (12%) had transient FGR. Patients with transient FGR were more likely to have a higher body mass index, gestational diabetes, diagnosed with FGR earlier in pregnancy, have spontaneous labor, and deliver at later gestational ages. There was no difference in the composite neonatal outcome (relative risk = 1.03, 95% confidence interval [CI] 0.72, 1.47) for transient versus persistent FGR after adjusting for confounders (adjusted relative risk = 0.79, 95% CI 0.54, 1.17). There were no differences in cesarean delivery or delivery complications between groups. CONCLUSION: Neonates born at term after transient FGR do not appear to have differences in composite morbidity compared with those where uncomplicated FGR persists at term. KEY POINTS: · No differences in neonatal outcomes in uncomplicated persistent versus transient FGR at term.. · Transient FGR pregnancies more likely to deliver at later gestational ages.. · No differences in mode of delivery or obstetric complications in persistent versus transient FGR at term..

Risk Factors for Progression From Gestational Diabetes to Postpartum Type 2 Diabetes: A Review.

Gestational diabetes mellitus (GDM) complicates 6% to 8% of pregnancies and up to 50% of women with GDM progress to type 2 diabetes mellitus (DM) within 5 years postpartum. Clinicians have little guidance on which women are most at risk for DM progression or when evidence-based prevention strategies should be implemented in a woman's lifecycle. To help address this gap, the authors review identifiable determinants of progression from GDM to DM across the perinatal period, considering prepregnancy, pregnancy, and postpartum periods. The authors categorize evidence by pathways of risk including genetic, metabolic, and behavioral factors that influence progression to DM among women with GDM.

Systemic racism and Non-Hispanic Black to Non-Hispanic White disparities in infant mortality at the county level.

OBJECTIVE: To use a novel measure of systemic racism to examine its relationship with Non-Hispanic Black (NHB) to Non-Hispanic White (NHW) racial disparities in infant mortality across U.S. counties. STUDY DESIGN: In this cross-sectional study, a composite, multi-dimensional measure of systemic racism at the county level was developed using confirmatory factor analysis based on indicators across five dimensions of systemic racism. Using linear regression analysis, we examined the relationship between the systemic racism factor scores and the NHB to NHW racial disparities in county-level infant mortality rates. Additionally, we performed a multi-level analysis of infant mortality, with births nested within counties by running a random intercept model that controlled for factors at both the individual and county levels to take into account the clustered nature of the data. RESULTS: There were 325 counties that met inclusion criteria for the county level analysis and 1181 counties for the individual level analysis. Each one standard deviation increase in the Systemic Racism Index was associated with an increase of 10.4% in the Non-Hispanic Black to Non-Hispanic White infant mortality rate ratio at the county level (aOR 1.104, 95% CI [1.061-1.148]). After controlling for individual level clinical factors and county level factors, each one standard deviation increase in the systemic racism index score was associated with a decrease of 3.5% in the NHW infant mortality rate (aOR 0.965, 95% CI [0.943-0.988]). CONCLUSION: Systemic racism is significantly associated with differences between counties in the magnitude of their Non-Hispanic Black to Non-Hispanic White racial disparities in infant mortality rates.

Evidence-based surgery for cesarean hysterectomy secondary to placenta accreta spectrum: A systematic review.

OBJECTIVE: In this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity. DATA SOURCES: We conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy. STUDY ELIGIBILITY CRITERIA: We included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria. STUDY APPRAISAL AND SYNTHESIS METHODS: Articles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations. RESULTS: Based on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria). CONCLUSIONS: Development of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted.

Prediction Model for Vaginal Birth After Induction of Labor in Women With Hypertensive Disorders of Pregnancy.

OBJECTIVE: To identify characteristics associated with vaginal delivery compared with cesarean delivery after labor induction among women with hypertensive disorders of pregnancy and to develop and validate a prediction model to assist in clinical care. METHODS: We studied a retrospective cohort of women with singleton pregnancies who had hypertensive disorders of pregnancy and who underwent induction of labor at 34 weeks of gestation or more from January 1, 2002, to March 31, 2013. Exclusion criteria included spontaneous labor, prelabor cesarean delivery, and known fetal anomalies. The study cohort was randomly divided into two groups; 70% of pregnancies were used to identify characteristics associated with vaginal delivery and develop a prediction model, and 30% were used to internally validate the model. Candidate predictors were limited to those associated with cesarean delivery and were available to a practitioner at time of induction. Stepwise backward logistic regression was used to build the most parsimonious model predicting cesarean delivery. Hosmer-Lemeshow test was used to assess goodness-of-fit. Model discrimination was evaluated using the concordance index and displayed through the area under the receiver operating characteristic curve (AUC). RESULTS: Of the 1,357 women meeting study criteria, 974 (71.8%) had a vaginal delivery. The final model consisted of eight variables: maternal age, body mass index, gestational age, intrapartum magnesium sulfate for seizure prophylaxis, need for cervical ripening, prior cesarean delivery and cervical dilation, and effacement. Model calibration and discrimination were satisfactory with Hosmer-Lemeshow test P=.35 and with a 95% CI, an AUC of 0.76 (0.73-0.79). Among those with predicted probability of cesarean delivery of 20% or less, 89.5% had a vaginal delivery. Internal validation demonstrated similar discriminatory ability. CONCLUSION: Using information available before labor induction, and contingent on future external validation, our model can help women better understand their likelihood of vaginal delivery success when undergoing induction of labor for hypertensive disorders of pregnancy.

Attempted and Successful Vacuum-Assisted Vaginal Delivery by Prepregnancy Body Mass Index.

OBJECTIVE: To examine rates of attempted and successful vacuum-assisted vaginal delivery by prepregnancy body mass index (BMI). METHODS: We conducted a retrospective cohort study of 2,084 women with singleton gestations needing operative delivery assistance and vacuum-eligible (fully dilated, +2 station or greater, 34 weeks of gestation or greater) using 2006-2014 inpatient records. Prepregnancy BMI was categorized as underweight (less than 18.5), normal weight (18.5 to less than 25), overweight (25 to less than 30), or obese (30 or greater). Logistic regression models estimated odds ratios (ORs) and 95% confidence intervals (CIs) of attempted and successful vacuum-assisted vaginal delivery by prepregnancy BMI adjusted for age, race, marital status, parity, diabetes, labor induction-augmentation, episiotomy, gestational age, and neonatal birth weight. RESULTS: Thirty-nine percent of women requiring delivery assistance and eligible for a vacuum were overweight or obese, 79% had vacuum attempts, and 95.3% of attempted vacuum-assisted vaginal deliveries were successful. Compared with women who were normal weight prepregnancy (82.8%), women who were overweight or obese were less likely to have vacuum attempted (75.8%, OR 0.71, 95% CI 0.53-0.96 and 71.2%, OR 0.53, 95% CI 0.39-0.74, respectively). Among women with attempted vacuum-assisted vaginal delivery, successful delivery did not differ by prepregnancy BMI (92.6%, OR 0.54, 95% CI 0.21-1.37 for underweight; 94.5%, OR 1.07, 95% CI 0.57-2.00 for overweight; 96.3%, OR 1.09, 95% CI 0.51-2.33 for obese compared with 95.6% among normal-weight women). CONCLUSION: Among women in need of operative delivery assistance, prepregnancy obesity was associated with lower likelihood of attempted vacuum-assisted vaginal delivery but, if attempted, success rates were similar to rates among normal-weight women. With significant morbidity of second-stage cesarean delivery in obese women, research should examine whether vacuum-assisted vaginal delivery may be appropriate for additional obese patients.