Decision and economic evaluation of abortion availability in the United States military.

BACKGROUND: Active-duty service women rely on the civilian sector for most abortion care due to limits on federal funding for abortion. Abortion is now banned in many states with large military presences. The Department of Defense has implemented policies to assist active-duty service women in accessing abortion, but there is debate to reverse this support. OBJECTIVE: Our goal was to compare the cost-effectiveness and incidence of adverse maternal and neonatal outcomes of a hypothetical cohort of active-duty service women living in abortion-restricted states comparing restricted abortion access (abortion not available cohort) to abortion available with Department of Defense travel support (abortion available cohort). STUDY DESIGN: We developed a decision tree model to compare abortion not available and abortion available cohorts for active-duty service women living in abortion-restricted states. Our cohorts were subdivided into normal pregnancies and those with a major fetal anomaly. Cost estimates, probabilities, and disability weights of various health conditions associated with abortion and pregnancy were obtained and derived from the literature. Effectiveness was expressed in disability-adjusted life years and the willingness-to-pay threshold was set to $100,000 per disability-adjusted life year gained or averted. We completed probabilistic sensitivity analyses with 10,000 simulations to test the robustness of our results. Secondary outcomes included numbers of stillbirths, neonatal deaths, neonatal intensive care unit admissions, maternal deaths, severe maternal morbidities, and first and second trimester abortions. RESULTS: The abortion not available cohort had a higher annual cost to the military ($299.1 million, 95% confidence interval 239.2-386.6, vs $226.0 million, 95% confidence interval 181.9-288.5) and was associated with 203 more disability-adjusted life years compared to the abortion available cohort. The incremental cost-effectiveness ratio was dominant for abortion available. Abortion not available resulted in an annual additional 7 stillbirths, 1 neonatal death, 112 neonatal intensive care unit admissions, 0.016 maternal deaths, 24 severe maternal morbidities, 27 less second trimester abortions, and 602 less first trimester abortions. Probabilistic sensitivity analysis revealed that the chance of the abortion available cohort being the more cost-effective strategy was greater than 95%. CONCLUSION: Limiting active-duty service women's access to abortion care increases costs to the military, even with costs of travel support, and increases adverse maternal and neonatal outcomes. This analysis provides important information for policymakers about economic and health burdens associated with barriers to abortion care in the military.

Prediction of metabolic syndrome following a first pregnancy.

BACKGROUND: The prevalence of metabolic syndrome is rapidly increasing in the United States. We hypothesized that prediction models using data obtained during pregnancy can accurately predict the future development of metabolic syndrome. OBJECTIVE: This study aimed to develop machine learning models to predict the development of metabolic syndrome using factors ascertained in nulliparous pregnant individuals. STUDY DESIGN: This was a secondary analysis of a prospective cohort study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study [nuMoM2b-HHS]). Data were collected from October 2010 to October 2020, and analyzed from July 2023 to October 2023. Participants had in-person visits 2 to 7 years after their first delivery. The primary outcome was metabolic syndrome, defined by the National Cholesterol Education Program Adult Treatment Panel III criteria, which was measured within 2 to 7 years after delivery. A total of 127 variables that were obtained during pregnancy were evaluated. The data set was randomly split into a training set (70%) and a test set (30%). We developed a random forest model and a lasso regression model using variables obtained during pregnancy. We compared the area under the receiver operating characteristic curve for both models. Using the model with the better area under the receiver operating characteristic curve, we developed models that included fewer variables based on SHAP (SHapley Additive exPlanations) values and compared them with the original model. The final model chosen would have fewer variables and noninferior areas under the receiver operating characteristic curve. RESULTS: A total of 4225 individuals met the inclusion criteria; the mean (standard deviation) age was 27.0 (5.6) years. Of these, 754 (17.8%) developed metabolic syndrome. The area under the receiver operating characteristic curve of the random forest model was 0.878 (95% confidence interval, 0.846-0.909), which was higher than the 0.850 of the lasso model (95% confidence interval, 0.811-0.888; P<.001). Therefore, random forest models using fewer variables were developed. The random forest model with the top 3 variables (high-density lipoprotein, insulin, and high-sensitivity C-reactive protein) was chosen as the final model because it had the area under the receiver operating characteristic curve of 0.867 (95% confidence interval, 0.839-0.895), which was not inferior to the original model (P=.08). The area under the receiver operating characteristic curve of the final model in the test set was 0.847 (95% confidence interval, 0.821-0.873). An online application of the final model was developed (https://kawakita.shinyapps.io/metabolic/). CONCLUSION: We developed a model that can accurately predict the development of metabolic syndrome in 2 to 7 years after delivery.

Point-of-Care Ultrasound in Critical Care Obstetrics: A Scoping Review of the Current Evidence.

OBJECTIVES: To synthesize the current evidence of maternal point-of-care ultrasound (POCUS) in obstetrics. A scoping review was conducted using PubMed, Clinicaltrials.gov, and the Cochrane library from inception through October 2023. METHODS: Studies were eligible for inclusion if they described the use of POCUS among obstetric or postpartum patients. Two authors independently screened all abstracts. Quantitative, qualitative, and mixed-methods studies were eligible for inclusion. Case reports of single cases, review articles, and expert opinion articles were excluded. Studies describing detailed maternal nonobstetric sonograms or maternal first trimester sonograms to confirm viability and rule out ectopic pregnancy were also excluded. Data were tabulated using Microsoft Excel and summarized using a narrative review and descriptive statistics. RESULTS: A total of 689 publications were identified through the search strategy and 12 studies met the inclusion criteria. Nine studies evaluated the use of lung POCUS in obstetrics in different clinical scenarios. Lung ultrasound (LUS) findings in preeclampsia showed an excellent ability to detect pulmonary edema (area under the receiver operating characteristic 0.961) and findings were correlated with clinical evidence of respiratory distress (21 of 57 [37%] versus 14 of 109 [13%]; P = .001). Three studies evaluated abdominal POCUS, two of the inferior vena cava (IVC) to predict postspinal anesthesia hypotension (PSAH) and fluid receptivity and one to assess the rate of ascites in patients with preeclampsia. Patients with PSAH had higher IVC collapsibility (area under the curve = 0.950, P < .001) and, in patients with severe preeclampsia, there is a high rate of ascites (52%) associated with increased risk of adverse outcomes. There were no studies on the use of subjective cardiac POCUS. CONCLUSION: POCUS use in the management of high-risk obstetrics has increased. LUS has been the most studied modality and appears to have a potential role in the setting of preeclampsia complicated by pulmonary edema. Cardiac and abdominal POCUS have not been well studied. Trials are needed to evaluate its clinical applicability, reliability, and technique standardization before widespread use.

Impact of Attempted Mode of Delivery on Neonatal Outcomes in Nulliparous Individuals According to Body Mass Index.

Objective To compare neonatal and maternal outcomes based on the attempted mode of delivery, stratified by prepregnancy body mass index (BMI kg/m2) in nulliparous individuals. Study Design This was a repeated cross-sectional analysis of US vital statistics Live Birth and Infant Death linked data from 2011 to 2020. The analysis was restricted to nulliparas with singleton pregnancies and cephalic presentation who delivered at term. Our primary outcome was a composite neonatal outcome. We also examined a composite maternal outcome. We compared outcomes between individuals who attempted labor and those who opted for non-labor cesarean delivery, categorized by BMI (< 18.5, 18.5-24.9, 25-29.9, 30-39.9, ≥ 40). To account for significant differences in baseline characteristics between groups, Coarsened Exact Matching was applied using a k-to-k solution. We employed modified Poisson regression and calculated a difference-in-difference (DID) to compare differences in predicted proportions across BMI categories. Results Out of 9,709,958 individuals, 1,083,332 were included in the matched analysis. Compared to attempted vaginal delivery, non-labor cesarean delivery was associated with an increased risk of the composite neonatal outcome across all BMI categories. However, the increase in risk was less pronounced in higher BMI categories compared to the reference group (BMI 18.5-24.9). For maternal outcomes, non-labor cesarean delivery was associated with an increased risk of the composite maternal outcome in the BMI 18.5-24.9 and 25-29.9 categories. In contrast, the risk of adverse maternal outcomes associated with non-labor cesarean delivery was lower in higher BMI groups compared to the reference group, with DID values ranging from -0.12 in the BMI 30-39.9 group to -0.16 in the BMI ≥ 40 group. Conclusion Non-labor cesarean delivery, as compared to attempted vaginal delivery, was associated with adverse neonatal outcomes across all BMI categories, though the relative increase in risk was diminished in higher BMI groups.

Impact of the ARRIVE Trial on Stillbirth Rates in Nulliparous Individuals.

OBJECTIVE: We aim to examine the population-level rates of induction, stillbirth, perinatal mortality, and neonatal death before and after the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial. STUDY DESIGN: This study was a cross-sectional analysis of publicly available U.S. Live Birth data linked with Infant Death and Fetal Death certificate data from National Vital Statistics Online. We limited analyses to nulliparous individuals with singleton pregnancy and cephalic presentation who delivered at 39 weeks or greater. The pre- and post-ARRIVE periods spanned from August 2016 to July 2018, and from January 2019 to December 2020, respectively. Our primary outcome was a stillbirth. Secondary outcomes included induction of labor, perinatal mortality, and neonatal death. Outcomes were compared between the pre- and post-ARRIVE periods. Modified Poisson regression was used to calculate adjusted relative risks (aRRs). RESULTS: Of 2,817,071 births, there were 1,454,346 births in the pre-ARRIVE period and 1,362,725 in the post-ARRIVE period; there were 1,196 and 1,062 stillbirths in the pre- and post-ARRIVE periods, respectively. Compared to the pre-ARRIVE period, the post-ARRIVE period was not associated with a significant decrease in the risk of stillbirth at 39 weeks or greater (aRR 0.92 [95% confidence interval {95% CI} 0.85-1.00]) and stillbirth at 40 weeks or greater (aRR 0.92 [95% CI 0.82-1.04]). Compared to the pre-ARRIVE trial period, the post-ARRIVE trial was associated with increased rates of induction of labor at 39 weeks (aRR 1.37 [95% CI 1.37-1.38]) and 40 weeks (aRR 1.24 [95% CI 1.24-1.25]. Similar to stillbirth, there was no significant decrease in the risk of perinatal mortality at 39 weeks or greater or 40 weeks or greater. There was also no statistically significant change in neonatal death rates at 39 weeks or greater or at 40 weeks or greater. CONCLUSION: The increase in induction of labor at 39 weeks was not large enough to impact the stillbirth rate at 39 weeks or greater. KEY POINTS: · Post-ARRIVE trial, rate of induction of labor increased at 39 and 40 weeks.. · Post-ARRIVE trial, stillbirth and perinatal mortality rates remained unchanged.. · Induction rate rise post-ARRIVE trial did not impact neonatal death rates..

Infant Mortality Categorized by Birth Weight Percentiles for Deliveries between 22 and 28 Weeks of Gestation.

OBJECTIVE: Our objective was to describe infant mortality within 1 year of life according to gestational age and birth weight percentile in infants delivered between 22 and 28 weeks of gestation. STUDY DESIGN: This study was a retrospective cohort study based on publicly available U.S. birth certificate data linked to infant death data between 2014 and 2020. Maternal-neonate pairs of singleton live births between 220/7 and 286/7 weeks' gestation (vaginal or cesarean) were evaluated. We excluded infants with major fetal anomalies, chromosomal disorders, and birth weight outliers. Our primary outcome was infant mortality within 1 year of life. Individuals were categorized into eight sex-specific birth weight percentiles categories: less than the 3rd, 3rd-less than the 10th, 10th-less than the 25th, 25th-to less than the 50th, 50th-less than the 75th, 75th-to less than the 90th, 90th-less than the 97th, and 97th or higher. RESULTS: Of 27,014,444 individuals with live births from January 2014 to December 2020, 151,677 individuals who gave birth at 22 to 28 weeks of gestation were included in the study population. The mortality rate ranged from 4.2% for the 50th-less than the 75th percentiles at 28 weeks to 80.3% for the 3rd-less than the 10th percentile at 22 weeks. Using the 50th-less than the 75th birth weight percentile at each gestational age as a reference group, birth weight less than the 50th percentile was associated with increased mortality at all gestational ages in a dose-dependent manner. From 22 to 25 weeks of gestation, higher birth weight percentiles were associated with lower mortality, while the 97th or higher birth weight percentile was associated with increased mortality compared with the 50th-less than the 75th birth weight percentile at 26 to 28 weeks of gestation. CONCLUSION: The lower birth weight percentiles were associated with higher mortality across all gestational ages, but the association between higher birth weight percentiles and infant mortality exhibited an opposite pattern at 22 to 25 weeks as compared to later gestational age. KEY POINTS: · Birth weight ≥97th percentile was associated with increased infant mortality at 26 to 28 weeks.. · Higher birth weight percentiles were associated with a lower risk of mortality at 22 to 25 weeks.. · Lower birth weight percentiles were associated with a higher risk of mortality at 22 to 28 weeks..

Neonatal and Maternal Outcomes in Nulliparous Individuals according to Prepregnancy Body Mass Index.

OBJECTIVE: This study aimed to examine the effect of incremental changes in body mass index (BMI, kg/m2) on the association with adverse pregnancy outcomes. STUDY DESIGN: This was a retrospective cohort study of U.S. vital statistics Live Birth and Infant Death linked data from 2011 to 2020. We limited analyses to nulliparas with singleton pregnancies who delivered at 20 weeks or greater. Outcomes were compared according to the prepregnancy BMI category using 5 kg/m2 increments, with each of the other BMI categories sequentially as the referent. The composite neonatal outcome was defined as any neonatal death, neonatal intensive care unit (ICU), surfactant use, ventilation use, or seizure. Severe maternal morbidity was defined as any maternal ICU, transfusion, uterine rupture, and hysterectomy. Adjusted relative risks were calculated for each BMI category as a referent group, using modified Poisson regression and adjusting for confounders. RESULTS: A total of 11,174,890 nulliparous individuals were included. From 2011 to 2020, the proportions of individuals with BMI 40 or greater, BMI 50 or greater, and BMI 60 or greater increased significantly (from 3.1 to 4.9%, from 0.4 to 0.6%, from 0.03 to 0.06%, respectively; all trend p-values < 0.001). As BMI deviated from normal BMI, risks of neonatal and maternal adverse outcomes increased progressively. For example, as BMI deviated from normal BMI (18.5-24.9), the risk of composite neonatal outcome increased by 2% in individuals with BMI < 18.5 and up to 2.11-fold in individuals with BMI 65-69.9. When compared with BMI 40 to 44.9, BMI 35 to 39.9 was associated with an 8% decreased risk of composite neonatal outcome, whereas BMI 45 to 49.9 was associated with an 8% increased risk of composite neonatal outcome. CONCLUSION: Incremental increases in prepregnancy BMI are linked to higher risks of adverse pregnancy outcomes, highlighting the need for effective weight management before conception. KEY POINTS: · Incremental BMI increases raise pregnancy risks.. · Higher BMI linked to adverse neonatal outcomes.. · Elevated BMI heightens severe maternal morbidity..

Impact of the ARRIVE Trial in Nulliparous Individuals with Morbid Obesity: Interrupted Time Series Analysis.

OBJECTIVE: We aimed to examine rates of induction of labor at 39 weeks and cesarean delivery before and after the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial stratified by body mass index (BMI; kg/m2) category. STUDY DESIGN: This was a repeated cross-sectional analysis of publicly available U.S. birth certificate data from 2015 to 2021. We limited analyses to nulliparous individuals with a singleton pregnancy, cephalic presentation, without chronic hypertension, diabetes (gestational or pregestational), and fetal anomaly who delivered between 39 and 42 weeks' gestation. The pre-ARRIVE period spanned from August 2016 to July 2018 and the post-ARRIVE period spanned from January 2019 to December 2020. The dissemination period of the ARRIVE trial was from August 2018 to December 2018. Our co-primary outcomes were induction at 39 weeks and cesarean delivery. Our secondary outcomes were overall induction of labor and preeclampsia. We conducted an interrupted time series analysis after stratifying by prepregnancy BMI (<40 or ≥40). Negative binomial regression was used to calculate adjusted incident rate ratios with 95% confidence intervals. RESULTS: Of 2,122,267 individuals that were included, 2,051,050 had BMI <40 and 71,217 had BMI ≥40. In individuals with BMI <40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, a decreased rate of cesarean delivery, and an increased rate of overall induction of labor. In individuals with BMI ≥40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, an increased rate of overall induction of labor and a decreased rate of preeclampsia; however, the decrease in the rate of cesarean delivery was not significant. CONCLUSION: An increase in induction of labor at 39 weeks' gestation in individuals with BMI ≥40 was not associated with a decrease in the cesarean delivery rate. KEY POINTS: · The ARRIVE trial increased 39-week labor inductions in BMI <40 and ≥40.. · BMI <40 had fewer cesareans; BMI ≥40 showed no significant decrease.. · Offering labor induction is reasonable as cesarean rates didn't increase..

Trial of Labor versus Repeat Cesarean Delivery in Individuals with Morbid Obesity after Previous Cesarean Delivery.

OBJECTIVE: This study aimed to compare adverse neonatal outcomes associated with the trial of labor after cesarean (TOLAC) at term in pregnancies according to maternal prepregnancy body mass index (BMI; kg/m2) and the presence of previous vaginal delivery (VD). STUDY DESIGN: This was a repeated cross-sectional analysis of individuals with singleton, cephalic, and term deliveries with a history of one or two cesarean deliveries in the Linked Birth/Infant Death data from 2011 to 2020. Outcomes were examined according to the BMI category including BMI <30, 30 to 39.9, and 40 to 69.9 kg/m2. The primary outcome was a composite neonatal outcome, defined as any presence of neonatal death, neonatal intensive care unit admission, assisted ventilation, surfactant therapy, or seizures. Outcomes were compared between TOLAC and elective repeat cesarean delivery (eRCD) after stratifying by BMI category and previous VD. Log-binomial regression was performed to obtain adjusted relative risk (aRR) with 99% confidence intervals, controlling for covariates. RESULTS: Of 4,055,440 individuals, 2,627,131 had BMI <30 kg/m2, 1,108,278 had BMI 30 to 39.9 kg/m2, and 320,031 had BMI 40 to 69.9 kg/m2. In individuals with no previous VD, VD rates after TOLAC were 66.7, 57.2, and 48.1%, respectively. In individuals with previous VD, VD rates after TOLAC were 81.4, 74.7, and 67.3%, respectively. In individuals without previous VD, compared with those who had an eRCD, those who had TOLAC were more likely to experience composite neonatal outcomes in individuals with BMI < 30 kg/m2 (5.0 vs. 6.5%; aRR = 1.33 [1.30-1.36]), BMI 30 to 39.9 kg/m2 (6.1 vs. 7.8%; aRR = 1.29 [1.24-1.34]), and BMI 40 to 69.9 kg/m2 (8.2 vs. 9.0%; aRR = 1.15 [1.07-1.23]). In individuals with previous VD, there was no difference in the composite neonatal outcomes in BMI < 30 kg/m2 (6.2 vs. 5.8%; aRR = 0.98 [0.96-1.00]), BMI 30 to 39.9 kg/m2 (7.4 vs. 7.1%; aRR = 0.99 [0.95-1.02]), and BMI 40 to 69.9 kg/m2 (9.4 vs. 8.7%; aRR = 0.96 [0.91-1.02]). CONCLUSION: TOLAC among obese individuals could be offered in selected cases. KEY POINTS: · TOLAC among obese individuals could be offered selectively, despite their reduced likelihood of attempting or succeeding at it.. · Higher BMI individuals show decreased rates of both attempting and achieving successful TOLAC.. · Despite these trends, attempting TOLAC after a previous vaginal delivery does not heighten neonatal complications..

Outcomes of Ultrasound or Physical Examination-Indicated Cerclage according to the Degree of Cervical Dilation.

OBJECTIVE: Pregnancy outcomes of individuals receiving cervical cerclage when the cervix is dilated are not well known. We sought to examine preterm birth rates after ultrasound or physical examination-indicated cerclage placement according to the degree of cervical dilation. STUDY DESIGN: This was a retrospective cohort study of individuals with singleton pregnancies undergoing ultrasound or physical examination-indicated cerclage before 240/7 weeks of gestation from 2004 to 2018. Individuals were categorized based on the degree of cervical dilation at the time of cerclage. Our primary outcome was preterm delivery at less than 37 weeks of gestation. Multivariable logistic regression was performed to calculate adjusted odds ratios (aOR) with 95th confidence intervals (95% CI), controlling for predefined covariates. RESULTS: Of 147 individuals undergoing ultrasound or physical examination-indicated cerclage, 90/147 (61%) had a closed or 0.5 cm dilated cervix at the time of cerclage placement, 45/147 (31%) had a cervical dilation of 1 to 2.5 cm, and 12/147 (8%) had a cervical dilation of 3 to 4 cm at the time of placement. Individuals with a cervical dilation of 1 to 2.5 cm compared with those who had a closed cervix did not have increased odds of preterm delivery (58 vs. 42%; aOR: 1.95; 95% CI: 0.93-4.07). However, individuals with a cervical dilation of 3 to 4 cm compared with individuals who had a closed cervix had significantly increased odds of preterm delivery (75 vs. 42%; aOR: 4.33; 95% CI: 1.05-17.77). CONCLUSION: The rate of preterm birth increases with increasing cervical dilation at the time of cerclage placement. However, individuals who have a cerclage placed when the cervix is 1 to 2.5 cm can achieve an outcome that is not significantly different from those who had a cerclage placed when the cervix is closed. KEY POINTS: · Time from cerclage placement to delivery decreases as cervical dilation increases.. · Individuals 1 to 2.5 cm dilated at the time of cerclage can achieve a favorable outcome.. · A cervical dilation of ≥3 cm at cerclage placement was associated with extreme prematurity..

A Validated Calculator to Estimate Risk of Chorioamnionitis in Laboring and Induced Patients at Term.

OBJECTIVE: Chorioamnionitis is associated with neonatal morbidity and infection-related mortality, but our ability to predict intrapartum infection is limited. We sought to derive and validate a prediction model for chorioamnionitis among patients presenting to labor and delivery at term. STUDY DESIGN: This was a planned secondary analysis of a large cohort study from 2014 through 2018 at an academic tertiary care center. To derive a prediction model for chorioamnionitis, we limited our analysis to full-term (≥37 weeks) patients with a singleton gestation undergoing labor induction and presenting in labor. Both nulliparous and multiparous patients were included. Patients with a planned cesarean delivery, fever on admission, or missing data were excluded. The model was derived using multivariable logistic regression. Refinement of the prediction model with internal calibration was performed. External validation was performed utilizing a publicly available database (Consortium on Safe Labor) and applying the same inclusion and exclusion criteria. The discriminative power of each model was assessed using a bootstrap, bias-corrected area under the curve. RESULTS: The chorioamnionitis rates in the derivation and external validation groups were 5% (1,005/19,966) and 5.8% (n = 3,005/52,171), respectively. In multivariable modeling, maternal age, nulliparity, gestational age, smoking status, group B Streptococcus colonization, hours ruptured, number of cervical exams, length of labor, epidural use, internal monitoring, and meconium were significantly associated with infection. A calculator was created and externally validated with an area under the curve of 0.82 (95% confidence interval, 0.81-0.82). External validity was further confirmed with a calibration intercept of 0.81. CONCLUSION: This is the first infection calculator created and validated for the prediction of developing chorioamnionitis in patients undergoing induction of labor at term. This calculator can be used to augment patient counseling and guide intrapartum infection surveillance in laboring patients. KEY POINTS: · This calculator was created and validated for the prediction of developing chorioamnionitis.. · This calculator can be used to augment patient counseling.. · Predictive factors were identified and significantly associated with infection..

Temporal Trend in Maternal Morbidity and Comorbidity.

OBJECTIVE: This study aimed to examine the temporal trends of severe maternal morbidity (SMM) in the U.S. population in relation to trends in maternal comorbidity. STUDY DESIGN: We performed a repeated cross-sectional analysis of data from individuals at 20 weeks' gestation or greater using U.S. birth certificate data from 2011 to 2021. Our primary outcome was SMM defined as the occurrence of intensive care unit admission, eclampsia, hysterectomy, uterine rupture, and blood product transfusion. We also examined the proportions of maternal comorbidity. Outcomes of the adjusted incidence rate ratio (IRR) with 99% confidence intervals (99% CIs) for 2021 m12 compared with 2011 m1 were calculated using negative binomial regression, controlling for predefined confounders. RESULTS: There were 42,504,125 births included in the analysis. From 2011 m1 to 2021 m12, there was a significant increase in the prevalence of advanced maternal age (35-39 [45%], 40-44 [29%], and ≥45 [43%] years), morbid obesity (body mass index 40-49.9 [66%], 50-59.9 [91%], and 60-69.9 [98%]), previous cesarean delivery (14%), chronic hypertension (104%), pregestational diabetes (64%), pregnancy-associated hypertension (240%), gestational diabetes (74%), and preterm delivery at 34 to 36 weeks (12%). There was a significant decrease in the incidence of multiple gestation (9%), preterm delivery at 22 to 27 weeks (9%), and preterm delivery at 20 to 21 weeks (22%). From 2011 m1 to 2021 m12, the incidence of SMM increased from 0.7 to 1.0% (crude IRR 1.60 [99% CI 1.54-1.66]). However, the trend was no longer statistically significant after controlling for confounders (adjusted IRR 1.01 [95% CI 0.81-1.27]). The main comorbidity that was associated with the increase in SMM was pregnancy-associated hypertension. CONCLUSION: The rise in the prevalence of comorbidity in pregnancy seems to fuel the rise in SMM. Interventions to prevent SMM should include the management and prevention of pregnancy-associated hypertension. KEY POINTS: · The rise in maternal mortality is related to morbidity.. · Pregnancy-associated hypertension increases morbidity.. · There were increasing trends in age, body mass index, and medical conditions..

Buccal versus Vaginal Misoprostol Combined with a Foley Catheter among Individuals with Obesity Undergoing Induction.

OBJECTIVE: Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied. Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population. STUDY DESIGN: This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 µg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m2) was stratified. The primary outcome was time to delivery. RESULTS: A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m2 (vaginal misoprostol-FC: 21.3 hours vs. buccal misoprostol-FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1-1.7). There were no significant differences in maternal and neonatal outcomes. CONCLUSION: We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population. KEY POINTS: · Vaginal misoprostol was superior to buccal route among patients with obesity.. · There was no difference in the cesarean delivery rate between the two groups.. · Vaginal misoprostol should be the preferred route of administration among patients with obesity..

Neonatal Outcomes among Fetuses with an Abdominal Circumference <3rd %ile and Estimated Fetal Weight 3rd to 9th %ile Compared to Fetuses with an EFW <3rd %ile.

OBJECTIVE: Fetal growth restriction (FGR) is defined as an estimated fetal weight (EFW) or abdominal circumference (AC) <10th percentile (%ile) for gestational age (GA). An EFW <3rd %ile for GA is considered severe FGR (sFGR). It remains unknown if fetuses with isolated AC <3rd %ile should be considered sFGR. Our primary objective was to assess composite neonatal outcomes in fetuses with an AC <3rd %ile and overall EFW 3rd to 9th %ile compared with those with an EFW <3rd %ile. STUDY DESIGN: This retrospective cohort study was undertaken at a tertiary academic center from January 2016 to December 2021. Inclusion criteria were singleton fetuses with an EFW <3rd %ile (Group 1) or AC <3rd %ile with EFW 3rd to 9th %ile (Group 2) at 28 weeks' gestation or greater. Exclusion criteria were multiple gestations, presence of a major fetal anomaly, resolution of FGR, genetic syndrome, or infection. Composite neonatal outcome was defined by any of the following: neonatal intensive care unit admission >48 hours, necrotizing enterocolitis, sepsis, respiratory distress syndrome, mechanical ventilation, retinopathy of prematurity, seizures, intraventricular hemorrhage, stillbirth, or death before discharge. Small for gestational age (SGA) was defined as birth weight <10th %ile for GA. RESULTS: A total of 743 patients fulfilled our study criteria, with 489 in Group 1 and 254 in Group 2. The composite neonatal outcome occurred in 281 (57.5%) neonates in Group 1 and 53 (20.9%) in Group 2 (p < 0.01). The rates of SGA at birth were 94.9 and 75.6% for Group 1 and Group 2, respectively (OR 5.99, 95% confidence interval 3.65-9.82). CONCLUSION: Although AC <3rd %ile with EFW 3rd to 9th %ile is associated with a lower frequency of SGA and neonatal morbidity than EFW <3 %ile, fetuses with AC <3 %ile still exhibited moderate rates of these adverse perinatal outcomes. Consideration should be given to inclusion of an AC <3rd %ile with EFW 3rd to 9th %ile as a criterion for sFGR. However, prospective studies comparing delivery at 37 versus 38 to 39 weeks' gestation are needed to ensure improved outcomes before widespread adaptation in clinical practice. KEY POINTS: · The composite neonatal outcome occurred in 57.5% of fetuses with an overall EFW <3rd %ile and 20.9% of fetuses with an AC <3rd %ile but EFW 3rd to 9th %ile.. · Both groups demonstrated a high positive predictive value for SGA birth weight.. · Consideration should be given to inclusion of an AC <3rd %ile as a criterion for sFGR..

External Validation of the fullPIERS Risk Prediction Model in a U.S. Cohort of Individuals with Preeclampsia.

OBJECTIVE: To externally validate the fullPIERS risk prediction model in a cohort of pregnant individuals with preeclampsia in the United States. STUDY DESIGN: This was a retrospective study of individuals with preeclampsia who delivered at 22 weeks or greater from January 1, 2010, to December 31, 2020. The primary outcome was a composite of maternal mortality or other serious complications of preeclampsia occurring within 48 hours of admission. We calculated the probability of the composite outcome using the fullPIERS prediction model based on data available within 12 hours of admission including, gestational age, chest pain or dyspnea, serum creatinine levels, platelet count, aspartate transaminase levels, and oxygen saturation. We assessed the model performance using the area under the curve (AUC) of the receiver operating characteristic curve. The optimal cutoff point was determined using Liu's method. A calibration plot was used to evaluate the model's goodness-of-fit. RESULTS: Among 1,510 individuals with preeclampsia, 82 (5.4%) experienced the composite outcome within 48 hours. The fullPIERS model achieved an AUC of 0.80 (95% confidence interval: 0.75-0.86). The predicted probability for individuals with the composite outcome (median: 18.8%; interquartile range: 2.9-59.1) was significantly higher than those without the outcome (median: 0.9%; interquartile range: 0.4-2.7). The optimal cutoff point of 5.5% yielded a sensitivity of 70.7% (95% CI: 59.6-80.3), a specificity of 85% (95% CI: 82.7-86.5), a positive likelihood ratio of 4.6 (95% CI: 3.8-5.5), and an odds ratio of 13.3 (95% CI: 8.1-21.8). The calibration plot indicated that the model underestimated risk when the predicted probability was below 1% and overestimated risk when the predicted probability exceeded 5%. CONCLUSION: The fullPIERS model demonstrated good discrimination in this U.S. cohort of individuals with preeclampsia, suggesting it may be a useful tool for healthcare providers to identify individuals at risk for severe complications.

Factors Associated with Refractory Severe Hypertension in Patients with Preeclampsia.

OBJECTIVE: This study aimed to identify factors associated with refractory severe hypertension that does not resolve after an initial dose of antihypertensive medication in patients with preeclampsia. STUDY DESIGN: This was a retrospective study of all pregnant and postpartum individuals with a diagnosis of preeclampsia, superimposed preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome, or eclampsia who delivered at 22 weeks or greater at a single academic institution from 2010 to 2020. Inclusion criteria were patients with preeclampsia who developed severe hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥110 mm Hg) and received antihypertensive medications for acute severe hypertension. We defined refractory severe hypertension as a systolic blood pressure of ≥160 mm Hg or a diastolic blood pressure of ≥110 mm Hg that did not improve after receiving the initial treatment. To evaluate for factors associated with refractory severe hypertension, we developed multivariable modified Poisson regression using all variables with p-value <0.1 on bivariable analysis and calculated adjusted relative risks (aRRs) with 95% confidence intervals (95% CIs). RESULTS: Of 850, 386 (45.4%) had refractory severe hypertension and 464 (54.6%) responded to the initial antihypertensive medications. Factors associated with refractory severe hypertension included higher body mass index (BMI), chronic hypertension, and higher systolic pressure. Every 5 kg/m2 increase in BMI was associated with a 7% increased risk of refractory severe hypertension (aRR = 1.07; 95% CI: 1.02-1.12). Every 10 mm Hg increase in systolic blood pressure was associated with a 10% increased risk of refractory severe hypertension (aRR = 1.10; 95% CI: 1.04-1.17). Chronic hypertension was associated with a 25% increased risk of refractory severe hypertension (aRR = 1.25; 95% CI: 1.01-1.56) in the diastolic pressure model. CONCLUSION: Refractory severe hypertension was associated with elevated BMI, chronic hypertension, and higher systolic blood pressure. KEY POINTS: · Risk factors for refractory severe hypertension are not well-known.. · Almost half of the patients had refractory severe hypertension.. · Higher BMI, chronic hypertension, and higher systolic pressure were the risk factors.. · These patients would require closer follow-up and prompt response to vital signs..

Cost-effectiveness of history-indicated cerclage vs cervical length assessment for prevention of preterm birth.

BACKGROUND: Preterm birth is one of the major causes of neonatal morbidity and mortality. Preterm delivery is a large burden to our health care system, and a history of preterm birth is one of the most common risk factors for subsequent preterm birth. OBJECTIVE: We sought to examine the cost-effectiveness of the history-indicated cerclage strategy compared with the transvaginal ultrasound cervical length assessment strategy in individuals with a history of preterm birth. STUDY DESIGN: We developed a decision analysis model to compare history-indicated cerclage and cervical length assessment. The primary outcome was the net monetary benefit from a maternal and neonatal perspective of both strategies, defined as the value of an intervention with a known willingness to pay threshold for a unit of benefit. The time horizon was set to be a lifetime. Costs (in 2022 USD) included those for the cerclage, serial transvaginal ultrasounds, maternal care for admission, neonatal care, and severe disability. Probabilities, utilities, and costs were derived from the literature. A cost-effectiveness threshold was set at $100,000 per QALY (quality-adjusted life year). We first conducted 1-way sensitivity analyses with associated variables as sensitivity analyses. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation with 1000 trials to test the robustness of the results in the setting of simultaneous changes in probabilities, costs, and utilities. RESULTS: In our base-case analysis, the history-indicated cerclage strategy compared to transvaginal ultrasound cervical length assessment was associated with more cost ($85,038 vs $70,155), with slightly less effectiveness from the maternal perspective (26.74 QALY vs 26.78 QALY) and from the neonatal perspective (28.91 QALY vs 29.06 QALY), and with less maternal and neonatal net monetary benefit. Therefore, the history-indicated cerclage strategy was dominated. With the 1000 trials of Monte Carlo simulation, transvaginal ultrasound cervical length assessment was the preferred strategy 84% and 88% of the time from the maternal and neonatal perspectives, respectively. CONCLUSION: The history-indicated cerclage strategy was more expensive and slightly less effective than the transvaginal ultrasound cervical length assessment strategy with a lower net monetary benefit.

Longitudinal Ultrasound Evaluation of Dilapan-S During Cervical Ripening.

OBJECTIVE: To assess the diameter change of hygroscopic rod dilation during 12 hours of cervical ripening. METHODS: This was an observational, prospective study of term women undergoing labor induction with a bishop score ≤ 6. Women were allocated into two groups (soaked gauze or no gauze) stratified by parity. Using transvaginal ultrasound, maximal rod diameters were obtained in a longitudinal plane. Measurements were taken at four pre-specified time points (3, 6, 8, and 12 hours). All rods were removed at 12 hours from insertion. Patient satisfaction scores between the groups were assessed. To evaluate if measures were significantly different among the four time points, a generalized linear model was used. Independent t-tests were used to compare mean rod diameter values and pain measures between the two groups. Fisher Exact tests were used to evaluate categorical satisfaction measures. RESULTS: Forty-four women were recruited with a total of 178 hygroscopic rods placed. Mean rod diameters (mm) were significantly different among the four time periods (3 hour: 7.9 mm [SD 0.9]; 6 hour: 9.4 mm [SD 0.9]; 8 hour: 10.0 mm [SD 0.9]; 12 hour: 10.9 mm [SD 0.8]; P-value <.001). After stratifying by the use of gauze, there was no difference in rod diameters at 3, 6, 8, and 12 hours respectively. There was no difference in patient satisfaction scores between the two groups. CONCLUSION: The majority of hygroscopic rod dilation occurs within the first 8 hours of cervical ripening. Placement of saturated gauze does not accelerate rod dilation.

An Externally Validated Model to Predict Prolonged Induction of Labor with an Unfavorable Cervix.

OBJECTIVE: To develop and externally validate a prediction model to calculate the likelihood of prolonged induction of labor (induction start to delivery time > 36 hours). STUDY DESIGN: This was a retrospective cohort study of all nulliparous women with singleton pregnancies and vertex presentation at term who underwent induction of labor and had a vaginal delivery at a single academic center. Women with contraindications for vaginal delivery were excluded. Analyses were limited to women with unfavorable cervix (both simplified Bishop score [dilation, station, and effacement: range 0-9] <6 and cervical dilation <3 cm). Prolonged induction of labor was defined as the duration of induction (induction start time to delivery) longer than 36 hours. A backward stepwise logistic regression analysis was used to identify the factors associated with prolonged induction of labor by considering maternal characteristics and comorbidities as well as fetal conditions. The final model was validated using an external dataset of the Consortium on Safe Labor after applying the same inclusion and exclusion criteria. We developed a receiver observer characteristic curve with area under the curve (AUC) in validation cohorts. RESULTS: Of 2,118 women, 364 (17%) had prolonged induction of labor. Factors associated with prolonged induction of labor included body mass index at admission, hypertension, fetal conditions, and epidural. Factors including younger maternal age, prelabor rupture of membranes, and a more favorable simplified Bishop score were associated with a decreased likelihood of prolonged induction of labor. In the external validation cohort, 4,418 women were analyzed, of whom 188 (4%) had prolonged induction of labor. The AUC of the final model was 0.76 (95% confidence interval: 0.73-0.80) for the external validation cohort. The online calculator was created and is available at: https://medstarapps.org/obstetricriskcalculator. CONCLUSION: Our externally validated model was efficient in predicting prolonged induction of labor with an unfavorable cervix. KEY POINTS: · The number of inductions of labor at 39 weeks' gestation and beyond has been increasing.. · Our model had a good prediction of prolonged induction of labor.. · An online calculator has been created and available..

The Association between Fetal Growth Restriction and Maternal Morbidity.

OBJECTIVE: This study aimed to compare adverse maternal outcomes between pregnancies complicated by fetal growth restriction (FGR) and those without FGR. STUDY DESIGN: This was a secondary analysis of the data from the Consortium on Safe Labor, which was conducted from 2002 to 2008 in 12 clinical centers with 19 hospitals across 9 American College of Obstetricians and Gynecologists districts. We included singleton pregnancies without any maternal comorbidities or placenta abnormalities. We compared the outcomes of individuals with FGR with individuals without FGR. Our primary outcome was severe maternal morbidity. Our secondary outcome included various adverse maternal and neonatal outcomes. Multivariable logistic regression was performed to obtain adjusted odds ratios (aOR) and 95% confidence intervals (95% CI), adjusting for confounders. Missing values for maternal age and body mass index were imputed. RESULTS: Of 199,611 individuals, 4,554 (2.3%) had FGR and 195,057 (97.7%) did not have FGR. Compared with the individuals without FGR, individuals with FGR had increased odds of severe maternal morbidity (0.6 vs. 1.3%; aOR: 1.97 [95% CI: 1.51-2.57]), cesarean delivery (27.7 vs. 41.2%; aOR: 2.31 [95% CI: 2.16-2.48]), pregnancy-associated hypertension (8.3 vs. 19.2%; aOR: 2.76 [95% CI: 2.55-2.99]), preeclampsia without severe features (3.2 vs. 4.7%; aOR: 1.45 [95% CI: 1.26-1.68]), preeclampsia with severe features (1.4 vs. 8.6%; aOR: 6.04 [95% CI: 5.39-6.76]), superimposed preeclampsia (18.3 vs. 30.2%; aOR: 1.99 [95% CI: 1.53-2.59]), neonatal intensive care unit admission (9.7 vs. 28.4%; aOR: 3.53 [95% CI: 3.28-3.8]), respiratory distress syndrome (2.2 vs. 7.7%; aOR: 3.57 [95% CI: 3.15-4.04]), transient tachypnea of the newborn (3.3 vs. 5.4%; aOR: 1.62 [95% CI: 1.40-1.87]), and neonatal sepsis (2.1 vs. 5.5%; aOR: 2.43 [95% CI: 2.10-2.80]). CONCLUSION: FGR was associated with increased odds of severe maternal outcomes in addition to adverse neonatal outcomes. KEY POINTS: · FGR is associated with cesarean section.. · FGR is not associated with severe maternal morbidity.. · FGR is related to pregnancy-associated hypertension.. · FGR is associated with neonatal morbidity..