Clinical and Physician Factors Associated With Failed Operative Vaginal Delivery.

OBJECTIVE: To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births. METHODS: This was a retrospective cohort study of individuals with NTSV live births with an attempted operative vaginal delivery by a physician between 2016 and 2020 in California. The primary outcome was cesarean birth after failed operative vaginal delivery, identified using linked diagnosis codes, birth certificates, and physician licensing board data stratified by device type (vacuum or forceps). Clinical and physician-level exposures were selected a priori, defined using validated indices, and compared between successful and failed operative vaginal delivery attempts. Physician experience with operative vaginal delivery was estimated by calculating the number of operative vaginal delivery attempts made per physician during the study period. Multivariable mixed effects Poisson regression models with robust standard errors were used to estimate risk ratios of failed operative vaginal delivery for each exposure, adjusted for potential confounders. RESULTS: Of 47,973 eligible operative vaginal delivery attempts, 93.2% used vacuum and 6.8% used forceps. Of all operative vaginal delivery attempts, 1,820 (3.8%) failed; the success rate was 97.3% for vacuum attempts and 82.4% for forceps attempts. Failed operative vaginal deliveries were more likely with older patient age, higher body mass index, obstructed labor, and neonatal birth weight more than 4,000 g. Between 2016 and 2020, physicians who attempted more operative vaginal deliveries were less likely to fail. When vacuum attempts were successful, physicians who conducted them had a median of 45 vacuum attempts during the study period, compared with 27 attempts when vacuum attempts were unsuccessful (adjusted risk ratio [aRR] 0.95, 95% CI 0.93-0.96). When forceps attempts were successful, physicians who conducted them had a median of 19 forceps attempts, compared with 11 attempts when forceps attempts were unsuccessful (aRR 0.76, 95% CI 0.64-0.91). CONCLUSION: In this large, contemporary cohort with NTSV births, several clinical factors were associated with operative vaginal delivery failure. Physician experience was associated with operative vaginal delivery success, more notably for forceps attempts. These results may provide guidance for physician training in maintenance of operative vaginal delivery skills.

Aspirin in pregnancy: a review of indications, timing, dosing and efficacy.

PURPOSE OF REVIEW: The aim of this study was to evaluate the recent literature examining the utility of low-dose daily aspirin (LDA) in the prevention of preeclampsia and other potential adverse perinatal sequelae. The evidence supporting various aspirin doses and timing of initiation of treatment for this purpose will be examined. The potential benefits of LDA therapy in pregnancy will be discussed weighing against any potential associated harm. RECENT FINDINGS: Findings from several recent meta-analyses of randomized controlled trials are consistent with prior studies in showing a reduction in risk for preeclampsia with LDA use in individuals at an increased risk for this complication. Some studies suggest aspirin at a dose greater than the current recommended 81 mg is associated with the highest reduction in preterm PE.Several studies have demonstrated a reduction in risk for preterm birth, small for gestational age (SGA) infant or intrauterine growth restriction (IUGR), and a reduction in the risk of perinatal mortality associated with aspirin use. The findings of reduced preterm birth (PTB) and IUGR were also demonstrated among low-risk patients.Identifying patients at risk was re-evaluated, with resulting changes to existing United States Preventive Services Task Force (USPSTF) guidelines. SUMMARY: This review of recent evidence suggests a decreased rate of preeclampsia at aspirin doses higher than the standardly used 81 mg when treatment is initiated prior to 16 weeks of gestation. Although LDA use seems promising for other outcomes such as preterm delivery and IUGR, further studies to strengthen recommendations are warranted.

Early postpartum readmissions: identifying risk factors at birth hospitalization.

BACKGROUND: The high maternal mortality and severe morbidity rates in the United States compared with other high-income countries have received national attention. Characterization of postpartum hospital readmissions within the first days after delivery hospitalization discharge could help to identify patients who need additional preparedness for discharge. OBJECTIVE: This study aimed to investigate conditions at birth associated with postpartum readmissions occurring within 0 to 6 days and at 7 to 29 days after discharge from the delivery hospitalization. STUDY DESIGN: We analyzed linked vital statistics and hospital discharge records of patients who gave birth in California during 2007 to 2018. We investigated hospital readmissions within 30 days after birth hospitalization discharge. We used multivariable logistic regression to investigate factors associated with early readmission (0-6 days) and later readmission (7-29 days) compared with no readmission within 30 days (reference). The risk factors assessed included maternal medical or obstetrical conditions before and at birth, birth hospitalization length of stay, and mode of delivery. Severe maternal morbidity was defined as the presence of any of the 21 indicators recommended by the Centers for Disease Control and Prevention. RESULTS: Among 5,248,746 pregnant patients, 23,636 (0.45%) had an early postpartum readmission, whereas 24,712 (0.47%) had a later postpartum readmission. After adjustments, early readmission was most strongly associated with sepsis (adjusted odds ratio, 4.63; 95% confidence interval, 3.87-5.53), severe maternal morbidity (adjusted odds ratio, 3.46; 95% confidence interval, 3.28-3.65) at birth hospitalization, or preeclampsia before birth hospitalization (adjusted odds ratio, 3.67; 95% confidence interval, 3.54-3.81). The associations between later readmission and sepsis and severe maternal morbidity were similar, whereas the association between preeclampsia and later readmission was less strong (adjusted odds ratio, 1.65; 95% confidence interval, 1.57-1.73). CONCLUSION: Pregnant patients with sepsis or severe maternal morbidity during delivery hospitalization or preeclampsia before birth hospitalization were at the highest risk for readmission within 6 days of discharge. These findings may be informative for efforts to improve postpartum care.

Individualized growth assessment in pregnancies complicated by fetal gastroschisis.

OBJECTIVE: Prenatal ultrasound (US) has been shown to overestimate the incidence of suspected fetal growth restriction (FGR) in gastroschisis cases. This is largely because of altered sonographic abdominal circumference (AC) measurements when comparing gastroschisis cases with population nomograms. Individualized Growth Assessment (IGA) evaluates fetal growth using serial US measurements that allow consideration of the growth potential for a given case. Our goal was to assess the utility of IGA for distinguishing normal and pathological fetal growth in gastroschisis cases. STUDY DESIGN: Pregnancies with prenatally diagnosed fetal gastroschisis were managed and delivered at a single academic medical center. US fetal biometry including head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FDL), and neonatal measurements including birthweight and HC were collected and analyzed for 32 consecutive fetal gastroschisis cases with at least two 2nd and two 3rd trimester measurements. Second trimester growth velocities were compared to a group of 118 non-anomalous fetuses with normal neonatal growth outcomes. Gastroschisis cases were classified into groups based on fetal growth pathology score (FGPS9) patterns. Agreement between IGA (FGPS9) and serial conventional estimated fetal weight (EFW) measurements for determining growth pathology was evaluated. Neonatal size outcomes were compared between conventional birthweight classifications for determining small for gestational age (SGA) and IGA Growth Potential Realization Index (GPRI) for weight and head circumference measurements. RESULTS: Fetal growth pathology score (FGPS9) measurements identified three in-utero growth patterns: no growth pathology, growth restriction and recovery, and progressive growth restriction. In the no growth pathology group (n = 19), there was 84% agreement between IGA and conventional methods in determining pathological growth in both the 3rd trimester and at birth. In the growth restriction and recovery group (n = 7), there was 71% agreement both in the 3rd trimester and at birth between IGA and conventional methods. In the progressive growth restriction group (n = 5), there was 100% agreement in the 3rd trimester and 60% agreement at birth between IGA and conventional methods. CONCLUSION: We present the first study using IGA to evaluate normal and pathological fetal growth in prenatally diagnosed gastroschisis cases. IGA was able to delineate two 3rd trimester growth pathology patterns - one with persistent growth restriction and another with in-utero growth recovery. Further validation of these initial findings with larger cohorts is warranted.

Adnexal torsion in a pediatric population: Acute presentation with question of chronicity.

OBJECTIVES: To establish the frequency of torsion with multiple twists of the adnexa in girls 19 years old and younger surgically diagnosed with torsion. STUDY DESIGN: A retrospective chart review using an institutional tool to review charts of female patients 19 years old or younger who presented with acute abdominal pain leading to a surgical diagnosis of adnexal torsion. RESULTS: Of 141 pediatric patients with torsion, 61 (43%) had documentation of multiple twists, with 2 to 12 rotations present. 33% reported acute pain (<24 hrs) whereas most (67%) had pain > 24 h up to 4 weeks without abatement (23%) or experienced discrete episodes with pain resolution between episodes (44%). Even when vascular flow was demonstrated, multiple twists were frequently found (14/36 = 39%). When multiple twists were documented, more patients had an extirpative procedure due to a nonviable appearing ovary than when a single or unstated number of twists twist was found, although the results were not statistically significant (53.5% vs 42.9%, p = 0.098). CONCLUSIONS: Forty-three percent of girls presenting with symptoms of torsion had multiple twists in the adnexa. Many had provided a history of previous similar episodes of pain and presentation to emergency departments, suggesting possible previous undiagnosed episodes of torsion. Earlier diagnosis may provide a better opportunity for ovarian conservation prior to a recurrent torsion. Further study may reveal whether multiple twists are more likely to result in a nonviable ovary and need for oophorectomy.

Postpartum headaches after epidural or spinal anesthesia.

PURPOSE OF REVIEW: Postpartum headache is a common occurrence with various obstetric, neurologic, and anesthetic etiologies. Post dural puncture headache (PDPH) after neuraxial anesthesia is a culprit that may be less familiar to obstetricians. In this review, authors will discuss the differential diagnosis and management of postpartum headache, review PDPH, and explore evidence suggesting that PDPH may have greater implications than previously considered. RECENT FINDINGS: Emerging evidence suggests that PDPH, previously believed to be benign and self-limited, is associated with significant acute and chronic sequelae. A recent large database study links PDPH to subdural hematoma and cerebral venous sinus thrombosis. The authors also identified associations between PDPH and bacterial meningitis, depression, and back pain. A growing body of literature also links PDPH or unintentional dural puncture with an epidural needle (UDP) with development of chronic headaches. SUMMARY: Patients who experience UDP or PDPH should be counseled to return for evaluation for new or worsening headache. In the immediate postpartum setting, clinicians assessing these patients should have a low threshold to obtain brain imaging. In addition, obstetricians should be alerted that patients who suffer UDP may be prone to develop chronic headache disorders and consider referral to pain specialists.

Severe maternal and neonatal morbidity after attempted operative vaginal delivery.

BACKGROUND: Operative vaginal delivery is a critical tool in reducing primary cesarean delivery, but declining operative vaginal delivery rates and concerns about provider skill necessitate a clear understanding of risks. These risks are ambiguous because most studies compare outcomes of operative vaginal delivery with that of spontaneous vaginal delivery rather than outcomes of cesarean delivery in the second stage of labor, which is usually the realistic alternative. OBJECTIVE: This study aimed to compare severe maternal and neonatal morbidity by mode of delivery of patients with a prolonged second stage of labor who had a successful operative vaginal delivery, a cesarean delivery after failed operative vaginal delivery, or a cesarean delivery without an operative vaginal delivery attempt. STUDY DESIGN: We used a population-based database to evaluate nulliparous, term, singleton, vertex live births in California between 2007 and 2012 of patients with prolonged second stage of labor. Birth certificates and the International Classification of Diseases, Ninth Revision, Clinical Modification coded diagnoses and procedures were used for ascertainment of exposure, outcome, and demographics. Exposure was mode of delivery of patients who had any operative vaginal delivery attempt vs cesarean delivery without operative vaginal delivery attempt. The outcomes were severe maternal morbidity and severe unexpected newborn morbidity, defined using established indices. Anticipating that the code for prolonged second stage of labor would represent only a fraction of true operative vaginal delivery candidates, a secondary analysis was conducted removing this restriction to explore granular outcomes in a larger cohort with unsuccessful labor. Multivariable logistic regression was used to compare outcomes by mode of delivery adjusted for measured confounders. Sensitivity analyses were done excluding patients with combined vacuum-forceps-assisted delivery and birthweight of >4000 g. RESULTS: A total of 9239 births after prolonged second stage of labor were included, where 6851 (74.1%) were successful operative vaginal deliveries, 301 (3.3%) were failed operative vaginal deliveries, and 2087 (22.6%) were cesarean deliveries without operative vaginal delivery attempts. Of successful operative vaginal deliveries, 6195 (90.4%) were vacuum assisted and 656 (10.6%) were forceps-assisted. Of failed operative vaginal deliveries where operative vaginal delivery type was specified, 83 (47.4%) were vacuum assisted, 38 (21.7%) were forceps-assisted, and 54 (30.9%) were combined vacuum-forceps-assisted. Of note, all 54 combined vacuum-forceps-assisted operative vaginal delivery attempts that we identified failed. The outcomes of patients with failed operative vaginal delivery differed from those with successful operative vaginal delivery, such as higher rates of comorbidities, use of combined operative vaginal delivery, and birthweight of >4000 g. Successful operative vaginal delivery was associated with reduced severe maternal morbidity (adjusted odds ratio, 0.55; 95% confidence interval, 0.39-0.78) without a difference in severe unexpected neonatal morbidity (adjusted odds ratio, 0.99; 95% confidence interval, 0.78-1.26). In contrast, failed operative vaginal delivery was associated with increased severe maternal morbidity (adjusted odds ratio, 2.14; 95% confidence interval, 1.20-3.82) and severe unexpected neonatal morbidity (adjusted odds ratio, 1.78; 95% confidence interval, 1.09-2.86). In addition, findings were similar in the secondary analysis of 260,585 patients with unsuccessful labor. CONCLUSION: In this large cohort of nulliparous, term, singleton, vertex births, successful operative vaginal delivery was associated with a 45% reduction in severe maternal morbidity without differences in severe unexpected neonatal morbidity compared with cesarean delivery after prolonged second stage of labor. Operative vaginal delivery infrequently failed and was associated with a 214% increase in severe maternal morbidity and a 78% increase in severe unexpected neonatal morbidity; furthermore, combined operative vaginal deliveries were major contributors to this, as all combined operative vaginal deliveries failed. Optimization of operative vaginal delivery success rates through means such as improved patient selection, enhanced provider skill, and discussions against combined operative vaginal delivery could reduce maternal and neonatal complications.

Firearm injuries due to legal intervention in children and adolescents: a national analysis.

BACKGROUND: Firearm injuries related to legal intervention have come under scrutiny because of recent events. METHODS: The Kids' Inpatient Database (1997-2012) was searched for firearm injuries due to legal interventions (International Classification of Diseases, ninth revision, Clinical Modification E970) requiring inpatient admission in children aged <20 y. Cases were weighted to provide national estimates. The Brady Campaign criteria were used to identify lenient versus strict gun law states. RESULTS: Overall, 275 cases were identified, with a 7.5% mortality rate. Incidence peaked at 1.0 per 100,000 admissions in 2006, significantly increased from a low 0.2 per 100,000 admissions in 1997, P < 0.001. Patients were predominantly male (97%). African Americans (44%) represented the largest racial group, followed by Hispanics (30%) and Caucasians (20%). Mean age was 17.5 ± 2.08 y. Patients were insured by Medicaid (33%) or a private payer (24%); the remainder (43%) was uninsured. Admissions most frequently occurred at urban teaching hospitals (81%). Cases occurred most frequently in the Southern United States (44%), followed by the Western United States (35%). Most patients presented to non-children's hospitals (97%). Mean hospital admission cost was 27,507 ± 40,197 USD, whereas mean charges amounted to 75,905 ± 116,622 USD. Cases mostly occurred in lenient (56%) gun law states, whereas the remainder occurred in strict (41%) and neutral (3%) states. When analyzed by race, Caucasians (16%) had a significantly higher mortality rate when compared with African Americans (5%), P = 0.03. CONCLUSIONS: An analysis of this very specific injury mechanism demonstrates important findings, which are difficult to collect from conventional data sources. Future research will contribute to the objective analysis of this politically charged subject.

Three-dimensional MRI assessments of patchy and large myocardial infarction in beating and nonbeating swine hearts: validation with microscopy.

RATIONALE AND OBJECTIVES: To measure and validate patchy and large myocardial infarction (MI) at 3 days and 5 weeks in beating and nonbeating hearts using contrast-enhanced three-dimensional (3D) inversion-recovery gradient echo (IR-GRE) magnetic resonance imaging (MRI) and microscopy. MATERIALS AND METHODS: Pigs (n = 28) were subjected to 1) patchy MI (group I), 2) large MI (group II), or 3) combined (patchy and large) MI (groups III and IV) using microemboli and/or 90-minute left anterior descending (LAD) occlusion and imaged at 3 days and 5 weeks after interventions. Gadolinium diethylenetriamine penta-acetic acid (Gd-DTPA)-enhanced 3D and two-dimensional (2D) IR-GRE were performed for comparison in beating and nonbeating hearts. Macroscopic histochemical and microscopic histopathologic measurements were used for validation. RESULTS: Three-dimensional images demonstrated hyperenhanced patchy microinfarction, large MI, hypoenhanced/hyperenhanced microvascular obstruction, and infarct resorption. Acute and chronic combined MI on 3D was underestimated compared to microscopy (bias: -1.8 ± 3.8%) but overestimated acute large infarction. In beating and nonbeating hearts, close correlations/agreements were found between 3D/2D acquisitions in all groups (beating hearts: r = 0.70-0.99; bias: group I 0.47 ± 2.0%, II 0.33 ± 1.2%, III 0.54 ± 1.5%, and IV 0.28 ± 1.0%). CONCLUSIONS: The 3D IR-GRE underestimated the extent of acute and chronic combined MI compared to microscopic measurements. This sequence may have the potential to differentiate patchy from large MI and demonstrate MI healing after coronary interventions.