Antenatal steroids and neonatal outcomes in late preterm births with pregestational diabetes.

OBJECTIVE: To evaluate if antenatal steroid use was associated with a lower rate of respiratory complications in neonates born late preterm to patients with pregestational diabetes mellitus (PGDM). METHODS: This was a retrospective cohort study of live, singleton, non-anomalous, late preterm births complicated by PGDM using data from the Centers for Disease Control and National Vital Statistics System from 2017 to 2021. The primary (assisted ventilation use >6 h) and secondary neonatal outcomes (immediate assisted ventilation, Apgar score, neonatal intensive care unit [NICU] admission, and surfactant use) were compared between births that received steroids and those that did not. Multivariable analyses were performed to adjust for differences in demographic and clinical characteristics. RESULTS: There were 24 323 late preterm births with PGDM, of which 4613 received antenatal steroids and 19 710 did not receive steroids. After adjusting for the differences among the two groups, the need for assisted neonatal ventilation for more than 6 h (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI] 1.53-1.86), immediate assisted neonatal ventilation (aOR 1.67, 95% CI 1.55-1.80), NICU admission (aOR 1.95, 95% CI 1.81-2.10), and surfactant use (aOR 1.68, 95% CI 1.40-2.02) were higher in the births that received steroids compared with those that did not. These findings did not differ when examining outcomes at each gestational week of delivery between 34 weeks 0 days and 36 weeks 6 days. CONCLUSIONS: Antenatal steroid use in late preterm births complicated with PGDM was associated with worse immediate respiratory neonatal outcomes. Our findings support current recommendations against the use of steroids in the late preterm period in pregnancies with PGDM.

Incarcerated Gravid Uterus Liberated by Placement of a Vaginal Balloon.

BACKGROUND: Incarceration of the gravid uterus is an infrequent obstetric complication that can cause severe complications. CASE: A 37-year-old woman, G3P2002, at 14 weeks of gestation presented with vomiting, back pain, and urinary retention. She was noted to be in acute renal failure, with a creatinine level of 9.24 mg/dL, and results of her physical examination were concerning for uterine incarceration. Passive maneuvers and manual pressure failed to resolve the incarceration. Under spinal anesthesia, a Bakri balloon was inflated in the posterior vagina, elevating the fundus and relieving the incarcerated uterus. CONCLUSION: An intravaginal balloon may aid in the alleviation of uterine incarceration.

Outcomes among participants vs nonparticipants of randomized trials during pregnancy: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to evaluate the outcomes among individuals who were eligible and approached for participation in a randomized controlled trial during pregnancy, comparing those who enrolled with those who declined participation. DATA SOURCES: MEDLINE, Scopus, CINAHL, the Cochrane Library, and Ovid were searched from study inception to May 2022. STUDY ELIGIBILITY CRITERIA: This study included all obstetrical randomized controlled trials that reported clinical outcomes for both participants and nonparticipants. METHODS: The primary outcome captured the presence of morbidity. It was a composite of the primary outcome of each study comparing the participant arm with the nonparticipant arm. If a primary outcome was not clearly defined, a surrogate was developed on the basis of the core outcomes for the clinical condition studied. The risk of bias was assessed with the Newcastle-Ottawa Scale. Subgroup analyses for relevant obstetrical and neonatal outcomes were performed. The summary comparisons were reported as odds ratios with 95% confidence intervals computed using random-effects meta-analysis with heterogeneity evaluated using the I2 statistic. A funnel plot was used to examine publication bias, and there was no asymmetry. RESULTS: After reviewing more than 1100 abstracts, 17 obstetrical randomized controlled trials (103,610, with 26,293 participants and 77,317 nonparticipants) met our inclusion criteria and were analyzed. Of note, 9 studies were not rated as high quality, primarily for failing to control for confounding factors. Trial interventions were categorized as antepartum (n=11), intrapartum (n=5), or postpartum (n=1). Overall, participants in obstetrical randomized controlled trials had no difference in outcomes compared with nonparticipants (n=17: odds ratio, 0.88; 95% confidence interval, 0.52-1.49; I2=90%). Moreover, there was no difference seen when only randomized controlled trials that reported a primary outcome were included (n=12: odds ratio, 0.76; 95% confidence interval, 0.38-0.1.49; I2=93%). In addition, there was no difference noted in the subgroup where the randomized controlled trial intervention was not available to nonparticipants (n=7: odds ratio, 0.91; 95% confidence interval, 0.45-1.85; I2=68%). CONCLUSION: Pregnant individuals who agreed to participate in randomized controlled trials had no difference in outcomes compared with those who decline participation. Pregnant individuals should be provided with this reassuring information when offered to participate in a randomized controlled trial. Moreover, this information may improve patient recruitment into randomized controlled trials.

Prophylactic negative pressure wound therapy on wound complications after cesarean delivery in women with obesity: a meta-analysis of randomized controlled trials.

OBJECTIVE: This systematic review and meta-analysis of randomized controlled trials aimed to assess whether negative pressure wound therapy affects the rate of wound complications when applied to women with obesity after cesarean delivery compared with standard postoperative dressings. DATA SOURCES: This research used PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials as electronic databases, from the inception of each database to January 2021, with randomized controlled trial as the publication type. There was no restriction applied for language or geographic location. STUDY ELIGIBILITY CRITERIA: The selection criteria included only randomized controlled trials comparing the effect of negative pressure wound therapy with that of standard dressings on wound complications in women with obesity undergoing cesarean delivery. METHODS: The primary outcome was a wound complication composite outcome (wound infection, separation or dehiscence, hematoma, seroma, or readmission secondary to a wound concern). The wound complication composite was analyzed by counting events once per patient. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals using the random-effects model of DerSimonian and Laird. An I-squared (Higgins I2) value of >0% was used to identify heterogeneity. RESULTS: Overall, 11 randomized controlled trials, which included 5746 participants with obesity undergoing cesarean delivery, were included. Of those participants, 2869 (49.9%) were randomized to the intervention group (negative pressure wound therapy), and 2877 (50.1%) were randomized to the control group (standard dressing). Prophylactic negative pressure wound therapy was not associated with a significant change in the rate of wound complications (relative risk, 1.00; 95% confidence interval, 0.81-1.23) compared with standard postoperative dressings. However, the use of negative pressure wound therapy decreased the rate of wound infections (relative risk, 0.79; 95% confidence interval, 0.66- 0.96) and increased the frequency of skin reactions (relative risk, 4.59; 95% confidence interval, 1.29-16.38). Negative pressure wound therapy did not result in a significant difference in the rate of dehiscence, hematoma, seroma, readmission, reoperation, and antibiotic use for wound infection. CONCLUSION: Compared with standard postoperative incision dressings, negative pressure wound therapy did not affect the rate of wound complications but decreased the frequency of wound infections when applied to women with obesity after cesarean delivery. However, results should be interpreted with caution, as wound infection outcome includes different definitions per the individual trials. CONDENSATION: Prophylactic negative pressure wound therapy has no effect on overall wound complications in women with obesity after cesarean delivery compared with standard dressings.

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.

Background: The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited. Objective: This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2. Study Design: This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results: Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission. Conclusion: In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.

Knowledge, Attitudes, and Acceptability of Pre-Exposure Prophylaxis among Individuals Living with HIV in an Urban HIV Clinic.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is an effective tool to reduce HIV transmission. The primary objective of this study was to assess awareness of PrEP by individuals living with HIV (HIV+) and acceptance of its use for their HIV negative (HIV-) partners. METHODS: A cross sectional survey was conducted among individuals living with HIV who received care at an urban HIV clinic between January 2013 and June 2013. The survey examined knowledge, attitudes, and acceptability of PrEP, and perception of transmission risk of HIV. Chi-Square test and Fisher's Exact test were used to compare proportions. RESULTS: Among 206 subjects living with HIV, 15.3% (32) had heard of PrEP. Men who have sex with men (MSM) were more likely to be aware of PrEP than all others (p = 0.003). Once educated about PrEP those who believed PrEP would reduce their partner's risk for HIV were more likely to recommend PrEP to their partner (p<0.001). 92% of all respondents said they would be "extremely likely/likely" to discuss PrEP use with their provider. Of 159 subjects whose main partner was HIV-, MSM (p = 0.007), male participants (p = 0.044), and those who were consistently taking meds (p = 0.049) were more likely to be aware of PrEP. Those who perceived they were at risk of transmitting HIV (p<0.001) and those who were consistently taking meds (0.049) were more likely to agree that PrEP could reduce the risk of HIV to their partners. CONCLUSION: This study illustrates a low awareness of PrEP but once educated the willingness of a cohort of individuals living with HIV to recommend PrEP to their partners. Our findings demonstrate the importance of providers informing their patients living with HIV about PrEP, as these persons are an underutilized link to support the uptake of PrEP by their HIV- partners.