Infections After Adoption of Antibiogram-directed Prophylaxis and Intracorporeal Urinary Diversion for Robot-assisted Radical Cystectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) has significantly decreased the morbidity associated with radical cystectomy. However, infectious complications including sepsis, urinary tract (UTIs), wound (WIs), and intra-abdominal (AIs) infections remain common. OBJECTIVE: To assess whether intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis would decrease infections after robotic-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed of a prospectively maintained database of patients undergoing RARC between 2014 and 2022 at a tertiary care institution, identifying two groups based on adherence to a prospectively implemented modified ERAS protocol for RARC: modified-ERAS-ICUD and antibiogram-directed ampicillin-sulbactam, gentamicin, and fluconazole prophylaxis were utilized (from January 2019 to present time), and unmodified-ERAS-extracorporeal urinary diversion (UD) and guideline-recommended cephalosporin-based prophylaxis regimen were utilized (from November 2014 to June 2018). Patients receiving other prophylaxis regimens were excluded. INTERVENTION: ICUD and antibiogram-directed infectious prophylaxis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was UTIs within 30 and 90 d postoperatively. The secondary outcomes were WIs, AIs, and sepsis within 30 and 90 d postoperatively, and Clostridioides difficile infection (CDI) within 90 d postoperatively. RESULTS AND LIMITATIONS: A total of 396 patients were studied (modified-ERAS: 258 [65.2%], unmodified-ERAS: 138 [34.8%]). UD via a neobladder was more common in the modified-ERAS cohort; all other intercohort demographic differences were not statistically different. Comparing cohorts, modified-ERAS had significantly reduced rates of 30-d (7.8% vs 15.9%, p = 0.027) and 90-d UTIs (11.2% vs 25.4%, p = 0.001), and 30-d WIs (1.2% vs. 8.7%, p < 0.001); neither group had a WI after 30 d. Rates of AIs, sepsis, and CDI did not differ between groups. On multivariate regression, the modified-ERAS protocol correlated with a reduced risk of UTIs and WIs (all p < 0.01). The primary limitation is the retrospective study design. CONCLUSIONS: Utilization of ICUD and antibiogram-based prophylaxis correlates with significantly decreased UTIs and WIs after RARC. PATIENT SUMMARY: In this study of infections after robotic radical cystectomy for bladder cancer, we found that intracorporeal (performed entirely inside the body) urinary diversion and an institution-specific antibiogram-directed antibiotic prophylaxis regimen led to fewer urinary tract infections and wound infections at our institution.

Trends in the Incidence of Cardiogenic Shock, and Utilization of Mechanical Circulatory Support in Myocarditis: Insights from the National Inpatient Sample 2016 to 2019.

A subset of patients with myocarditis present with cardiogenic shock. There is a lack of contemporary data assessing the use of mechanical circulatory support (MCS) in these patients. Myocarditis hospitalizations were analyzed using the National Inpatient Sample between 2016 and 2019. Characteristics of patients with and without cardiogenic shock were assessed. Trends in mortality, MCS, right-sided cardiac catheterization (RHC) and endomyocardial biopsy were evaluated. The impact of RHC on consequent MCS and mortality was studied. A total of 38,300 hospitalizations for myocarditis were included in the study, of which 3,490 hospitalizations (9.1%) had cardiogenic shock. Patients with cardiogenic shock were older (p <0.001) and had more chronic kidney disease and atrial fibrillation. Between 2016 and 2019, there was an increase in myocarditis admissions but no difference in rates of cardiogenic shock and mortality and the use of extracorporeal membrane oxygenation, percutaneous ventricular assist devices, intra-aortic balloon pumps, left ventricular assist devices, and cardiac transplant. The most common form of MCS used in myocarditis was extracorporeal membrane oxygenation. The rates of RHC (p = 0.02) and endomyocardial biopsy (p = 0.03) increased over time. Patients who underwent RHC were more likely to receive mechanical support, and in patients with shock, RHC was associated with lower mortality (adjusted odds ratio 0.34, p <0.01). Myocarditis admissions increased over time but with no increase in the rates of cardiogenic shock and MCS. In patients with cardiogenic shock, RHC resulted in lower mortality.

Maternal Morbidity with Repeated Cesarean Deliveries.

OBJECTIVE: This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice. STUDY DESIGN: Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used. RESULTS: A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001). CONCLUSION: Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population. KEY POINTS: · Maternal morbidity increase with each CD.. · Absolute adverse outcomes remains low in highest order CDs.. · In women without placenta previa, there is no added morbidity with additional CDs..

Arcuate Uterus as an Independent Risk Factor for Adverse Pregnancy Outcomes.

OBJECTIVE: The aim of the study is to estimate the association between arcuate uterus and pregnancy outcomes using controls selected from a similarly high-risk cohort. STUDY DESIGN: This is a retrospective cohort study of women with an arcuate uterus cared for by a single maternal-fetal medicine practice from 2005 to 2020. We included all women with a singleton pregnancy ≥20 weeks and diagnosis of arcuate uterus and randomly selected (3:1) patients with a singleton pregnancy and no uterine anomaly from the same practice as controls. Baseline characteristics and pregnancy outcomes were compared between the two groups. Chi-square, Fisher's exact, and independent samples t-test were used for data analysis, as indicated. RESULTS: A total of 37 women with an arcuate uterus (55 independent singleton pregnancies) and 165 controls were included. There were no differences in baseline characteristics. Women with an arcuate uterus had a significantly higher rate of spontaneous preterm birth less than 37 weeks (10.9 vs. 3.0%, p = 0.031) and were more likely to require vaginal progesterone (5.5 vs. 0.6%, p = 0.049) and administration of antenatal corticosteroids (16.4 vs. 5.5%, p = 0.020). Arcuate uterus was also associated with lower birthweight (3,028.1 ± 528.0 vs. 3257.2 ± 579.9 g, p = 0.010) and higher incidence of intrauterine fetal growth restriction (20.0 vs. 7.3%, p = 0.008), despite similar starting body mass index (BMI) and weight gain throughout pregnancy. There were no differences in preeclampsia, malpresentation, cesarean delivery, blood transfusion, retained placenta, or morbidly adherent placenta. CONCLUSION: Arcuate uterus is associated with a significantly increased risk of spontaneous preterm birth (<37 weeks), need for vaginal progesterone for short cervix and antenatal corticosteroids, fetal growth restriction, and lower mean birthweight. These findings suggest that arcuate uterus is not just a normal variant of uterine anatomy but rather a risk factor for poor fetal growth, short cervix, and a higher risk pregnancy. KEY POINTS: · Arcuate uterus is associated with increased risk of preterm birth and fetal growth restriction.. · Women with arcuate uteri had higher rates of vaginal progesterone use during pregnancy.. · Arcuate uterus should be treated as a true finding rather than a normal anatomical variant..

The association between high-normal blood pressure and the development of preeclampsia in twin pregnancies.

Objective: We sought to determine if women with twin pregnancies and blood pressure (BP) above the 95th percentile but within normal ranges (i.e. less than 140 systolic and 90 diastolic) are at increased risk of hypertensive disorders of pregnancy.Methods: Retrospective cohort study of all women with twin pregnancies being cared for by a single Maternal Fetal Medicine practice between 2012 and 2018. We identified all women who had a systolic blood pressure (SBP) or diastolic blood pressure (DBP) above the 95th percentile but less than 140 systolic and 90 diastolic at any point during pregnancy. Based on prior publications, the 95th percentile was defined as: a SBP 121-139 mmHg up to 30 weeks or 131-139 mmHg after 30 weeks, a DBP 81-89 mmHg up to 34 weeks or 85-89 mmHg after 34 weeks. We excluded women diagnosed with chronic hypertension either before or during pregnancy. The primary outcome was the development of preeclampsia. Chi-square and logistic regression were used.Results: A total of 457 patients met the inclusion criteria, of whom 109 (23.9%) had either a systolic or diastolic BP above the 95th percentile (but normal) at any time during pregnancy. These women were significantly more likely to develop preeclampsia (30.3 versus 12.6%, p < .001, aOR 2.32 (1.31, 4.09)) and gestational hypertension without preeclampsia (16.5 versus 4.6%, p < .001, aOR 4.27 (2.01, 9.07)).Conclusions: In women with twin pregnancies, a high-normal systolic or diastolic BP (above 120 systolic or 80 diastolic prior to 30 weeks, or above 130 systolic or 84 diastolic after 30 weeks) is associated with a significantly increased risk of gestational hypertension and preeclampsia.

Frequency of spontaneous resolution of vasa previa with advancing gestational age.

BACKGROUND: Vasa previa is a serious obstetric complication that can result in fetal hemorrhage and death on spontaneous labor. Suggested management for vasa previa is elective hospitalization and cesarean delivery before spontaneous labor. There is little reported evidence of the rate of vasa previa resolution over the course of gestation. Identification of the resolution rate and of factors predictive of resolution potentially could improve clinical management and patient counseling. OBJECTIVE: The purpose of this study was to identify the resolution rate of vasa previa across gestation and to determine clinical and sonographic factors that are associated with vasa previa resolution. STUDY DESIGN: We conducted a retrospective cohort study of all women who were diagnosed with vasa previa in a single ultrasound unit between 2005 and 2018. Vasa previa was defined as a fetal vessel within 2 cm of the internal cervical os on transvaginal sonography. The primary outcome was vasa previa resolution, defined as migration of the vasa previa to >2 cm away from the internal os. RESULTS: One hundred women with vasa previa that had been diagnosed at a mean gestational age of 22.8±4.9 weeks were included. Thirty-nine women (39.0%; 95% confidence interval, 30-49%) had resolution of vasa previa at a mean gestational age of 28.6-4.7 weeks. Factors that were associated with vasa previa resolution were an earlier gestational age at diagnosis (adjusted odds ratio, 6.10; 95% confidence interval,1.92-19.40), vasa previa did not cover the internal os at diagnosis (adjusted odds ratio, 8.29; 95% confidence interval, 2.79-24.62), and vasa previa was not the result of a resolved placenta previa (adjusted odds ratio, 2.85; 95% confidence interval, 1.01--8.03). One woman with a dichorionic twin pregnancy and vasa previa resolution (at 31 weeks gestation; fetal vessels located 2.8 cm from the internal os) presented at 33 weeks with massive bleeding and fetal death of twin A. It was unclear whether the death was related to vasa previa or placental abruption. CONCLUSION: Thirty-nine percent of vasa previas in our population resolved over the course of pregnancy. Earlier gestational age at diagnosis, vasa previa not covering the internal os, and not having a resolved placenta previa all are associated independently with an increased likelihood of vasa previa resolution. Women with vasa previa should be observed serially to assess for vasa previa resolution, because many will resolve in the third trimester.

Pregnancy outcomes in viable pregnancies with a septate uterus compared with viable pregnancies after hysteroscopic uterine septum resection.

BACKGROUND: Septate uterus is one of the more common Müllerian anomalies and is the anomaly most amenable to surgical correction. It is currently uncertain if hysteroscopic septum resection reduces the incidence of adverse pregnancy outcomes. OBJECTIVE: The purpose of this study was to compare pregnancy outcomes in women who had reached at least 20 weeks gestation with those women with a uterine septum and those women who had undergone septum resection before pregnancy. STUDY DESIGN: Retrospective cohort study of women with a history of uterine septum who were cared for by a large maternal-fetal medicine practice from 2005-2018. We included women with singleton pregnancies at >20 weeks gestation. Baseline characteristics and pregnancy outcomes were compared between women with a history of a hysteroscopic uterine septum resection and women with an unresected septum. Regression analysis was performed to control for differences in baseline characteristics. The analysis was repeated in nulliparous women only. RESULTS: A total of 109 women (163 pregnancies) were included. In the entire population, pregnancy outcomes did not differ between the groups, aside from a higher rate of cesarean delivery in the resected septum group. In the 63 nulliparous women, septum resection was associated with later gestational ages at delivery (39.1 vs 37 weeks; P=.030), decreased preterm birth <37 weeks gestation (4.5% vs 31.6%; adjusted odds ratio, 0.154; 95% confidence interval, 0.027-0.877), and an increased incidence of cesarean delivery in women who attempted vaginal delivery (30.6% vs 0%; P=.012). There was no difference in the rates of small for gestational age, preeclampsia, blood transfusion, retained placenta, or morbidly adherent placenta. CONCLUSION: In nulliparous women with viable pregnancies, hysteroscopic resection of a uterine septum is associated with a decreased incidence of preterm birth and an increased incidence of cesarean delivery. These findings need to be confirmed in a well-designed randomized trial before uterine septum resection is recommended routinely.