The association between uterine fibroid number and size and risk of preterm birth.

BACKGROUND: While the association between uterine fibroids and preterm birth is well known, data regarding whether fibroid characteristics such as number and size modify such risk are limited. OBJECTIVE: To evaluate the association between fibroid number and size and risk of preterm birth and determine whether these characteristics impact the severity of preterm birth. STUDY DESIGN: Multicenter retrospective cross-sectional study including all patients with singleton gestations who had at least one prenatal ultrasound at 18 0/7 weeks of gestation or later and delivered within a large university health system from January 1, 2019 to December 31, 2022. When fibroids were identified on ultrasound, their characteristics (i.e., number, size, and location) were documented. Patients with more than one delivery during the study period had only their first included for analysis. The primary outcome of preterm birth, stratified by gestational age (<37, <34, <32, and <28 weeks), was assessed based on fibroid number (1, 2, ≥3) and size (largest dimension <5 cm, 5-10 cm, >10 cm) separately in patients who had prenatally detected fibroids compared to those with no fibroids. Multivariate logistic regression was performed to adjust for potential confounders. Data were presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Among the 65,950 patients studied, 4,421 (6.7%) had at least one fibroid. The prevalence of preterm birth <37 weeks was 8.6%. The presence of any fibroid, regardless of number, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (1 fibroid: 12.8% vs. 8.2%, aOR 1.26, 95% CI 1.10-1.44; 2 fibroids: 12.7% vs. 8.2%, aOR 1.27, 95% CI 1.01-1.58; ≥3 fibroids: 18.5% vs. 8.2%, aOR 1.60, 95% CI 1.29-1.99). Patients with 2 fibroids were at increased risk of preterm birth <34, <32, and <28 weeks compared to those without fibroids, while patients with ≥3 fibroids were at increased risk of preterm birth <34 and <28 weeks compared to those without fibroids. The presence of at least one fibroid, regardless of the size of their largest dimension, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (<5 cm: 12.4% vs. 8.2%, aOR 1.19, 95% CI 1.04-1.36; 5-10 cm: 15.5% vs. 8.2%, aOR 1.47, 95% CI 1.23-1.75; >10 cm: 21.4% vs. 8.2%, aOR 2.26, 95% CI 1.55-3.28). Increasing fibroid size by largest dimension was associated with an increased risk of preterm birth <34 weeks. Patients with fibroids >10 cm by largest dimension were at increased risk of preterm birth <28 weeks compared to those without fibroids. There was no association between increasing fibroid size by largest dimension and preterm birth <32 weeks. CONCLUSIONS: Data from this large cohort suggest that fibroid characteristics such as number and size are associated with preterm birth and impact the severity of preterm birth. Increasing fibroid number and size is associated with a higher risk of earlier preterm birth compared to those without fibroids.

SAGES guidelines for the use of laparoscopy during pregnancy.

BACKGROUND: When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD). METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient. RESULTS: The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy. CONCLUSIONS: Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

Concurrent progestogen and cerclage to reduce preterm birth: a multicenter international retrospective cohort.

BACKGROUND: Both progestogens and cerclage are individually effective in preterm birth prevention in high risk pregnancies. However, national and international guidelines cite a lack of data available to comment on the potential benefit of concurrent progestogen therapy after cerclage has been placed. Studies to date have been small with mixed results regarding benefit of concurrent progestogen with cerclage leaving uncertainty regarding best clinical practice. OBJECTIVE: This study aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth in singleton pregnancies. METHODS: This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016 to June 2020. Exclusion criteria were lack of documentation regarding whether progestogen was prescribed, unavailable delivery outcome, and pregnancy termination (spontaneous or induced) before 16 weeks' gestation. The exposure of interest was progestogen use with cerclage placement, which included those who continued to use progestogen or who started progestogen after cerclage. The comparison group consisted of those without progestogen use after cerclage placement, which included those who had no progestogen use during the entire pregnancy or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. The primary outcome was spontaneous preterm birth at <37 weeks. The secondary outcomes were spontaneous preterm birth at <34 weeks, gestational age at delivery, and a composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia. There were planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate), preterm birth history, and site. Continuous variables were compared in adjusted analyses with analysis of covariance, and categorical variables were compared with multivariable logistic regression, adjusting for potential confounders with adjusted odds ratio. A Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. RESULTS: During the study period, a total of 699 singletons met the inclusion criteria: 561 in the progestogen with cerclage group and 138 with cerclage alone. Baseline characteristics were similar, except the higher likelihood of previous spontaneous preterm birth in the progestogen group (61% vs 41%; P<.001). Within the progestogen group, 52% were on 17-hydroxyprogesterone caproate weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of spontaneous preterm birth <37 weeks (31% vs 39%; adjusted odds ratio, 0.59 [0.39-0.89]; P=.01) and <34 weeks (19% vs 27%; adjusted odds ratio, 0.55 [0.35-0.87]; P=.01), increased latency to spontaneous delivery (hazard ratio for spontaneous preterm birth <37 weeks, 0.66 [0.49-0.90]; P=.009), and lower frequency of perinatal death (7% vs 16%; adjusted odds ratio, 0.37 [0.20-0.67]; P=.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a previous preterm birth, those with ultrasound- or examination-indicated cerclage, those who started progestogen therapy before cerclage, and in sites restricted to the United States. CONCLUSION: Use of progestogen with cerclage was associated with reduced rates of spontaneous preterm birth and early spontaneous preterm birth compared with cerclage alone. Although this study was not sufficiently powered for subgroup analysis, the strength of evidence for benefit appeared greatest for those with ultrasound- or examination-indicated cerclage, and with vaginal progesterone. El resumen está disponible en Español al final del artículo.

One-step vs 2-step gestational diabetes mellitus screening and pregnancy outcomes: an updated systematic review and meta-analysis.

OBJECTIVE: This was a systematic review and meta-analysis comparing maternal and neonatal outcomes of patients screened with the 1-step or 2-step screening method for gestational diabetes mellitus. DATA SOURCES: PubMed, Scopus, Cochrane, ClinicalTrials.gov, and LILACS were searched from inception up to September 2022. STUDY ELIGIBILITY CRITERIA: Only randomized controlled trials were included. Studies that had overlapping populations were excluded (International Prospective Register of Systematic Review registration number: CRD42022358903). METHODS: Risk ratios were computed with 95% confidence intervals by 2 authors. Unpublished data were requested. Large for gestational age was the primary outcome. RESULTS: The search yielded 394 citations. Moreover, 7 randomized controlled trials met the inclusion criteria. A total of 54,650 participants were screened for gestational diabetes mellitus by either the 1-step screening method (n=27,163) or the 2-step screening method (n=27,487). For large for gestational age, there was no significant difference found between the groups (risk ratio, 0.99; 95% confidence interval, 0.93-1.05; I2=0%). Newborns of patients who underwent 1-step screening had higher rates of neonatal hypoglycemia (risk ratio, 1.24; 95% confidence interval, 1.14-1.34; I2=0%) and neonatal intensive care unit admissions (risk ratio, 1.13; 95% confidence interval, 1.04-1.21; I2=0%) than newborns of patients who underwent 2-step screening. Patients in the 1-step screening method group were more likely to be diagnosed with gestational diabetes mellitus (risk ratio, 1.73; 95% confidence interval, 1.44-2.09; I2=80%) than patients in the 2-step screening method group. In addition, among trials that tested all patients before randomization and excluded patients with pregestational diabetes mellitus, newborns were more likely to have macrosomia (risk ratio, 1.27; 95% confidence interval, 1.21-1.34; I2=0%). Overall risk of bias assessment was of low concern. CONCLUSION: Large for gestational age did not differ between patients screened using the 1-step screening method and those screened using the 2-step screening method. However, patients randomized to the 1-step screening method had higher rates of neonatal hypoglycemia and neonatal intensive care unit admission and maternal gestational diabetes mellitus diagnosis than the patients randomized to the 2-step screening method.

Contractions of the lower uterine segment during transvaginal ultrasound cervical length: incidence, significance, proper measurement, and management.

An accurate transvaginal ultrasound cervical length is paramount to obtain the best prediction for preterm birth. Transvaginal ultrasound cervical length should be optimally obtained when a lower uterine segment contraction is not seen. For universal transvaginal ultrasound cervical length screening at approximately 20 weeks of gestation, the options are to do the transvaginal ultrasound soon after bladder void (lower uterine segment contractions present in 16%-43% of this approach) or to wait until the end of the anatomy scan (ideally within 30 minutes after bladder voiding) to decrease the chance of a lower uterine segment contraction. If the lower uterine segment contraction persists even after waiting up to 20 minutes or more, only the true transvaginal ultrasound cervical length should be reported. In particular, in patients with a previous spontaneous preterm birth, if the lower uterine segment contraction persists, the transvaginal ultrasound cervical length can be repeated in ≤7 days even in the presence of a normal (>25 mm) cervical length. Similar to a blood pressure cuff that must be of the right size for proper blood pressure measurement and a glucometer that must be properly calibrated, screening with transvaginal ultrasound cervical length should only be performed following a proper and standardized technique, including avoiding as much as feasible the presence of lower uterine segment contractions.

Evidence-based labor management: postpartum care after vaginal delivery (part 6).

In the setting of postpartum care after vaginal delivery, rooming-in is associated with a higher rate of exclusive breastfeeding rate at hospital discharge, but there is insufficient evidence to support or refute rooming-in to increase breastfeeding at 6 months. Education and support for breastfeeding are valuable interventions to promote initiation of breastfeeding whether it is offered by a healthcare professional, nonhealthcare professional, or peer. A combined intervention, a professional provider-led intervention, having a protocol available for the provider training program, and implementation during both the prenatal and postnatal periods increased the rate of exclusive breastfeeding for 6 months. There is no single effective treatment for breast engorgement. Breast massage, continuing breastfeeding, and pain relief are recommended by national guidelines. Nonsteroidal anti-inflammatory drugs and acetaminophen are better than placebo for relief of pain caused by uterine cramping and perineal trauma; acetaminophen is effective in breastfeeding individuals who underwent episiotomy; and local cooling pain relievers have been shown to reduce perineal pain for 24 to 72 hours, compared with no treatment. There is insufficient evidence to assess the safety and efficacy of postpartum routine universal thromboprophylaxis after vaginal delivery. Anti-D immune globulin administration is recommended in Rhesus-negative individuals who have given birth to a Rhesus-positive infant. There is very low-quality evidence that a universal complete blood count is useful in reducing the risk of receiving blood products. In the absence of any postpartum complication, there is insufficient evidence to recommend a routine postpartum ultrasound. Measles, mumps, and rubella combination; varicella; human papillomavirus; and tetanus, diphtheria, and pertussis vaccines should be administered in nonimmune individuals in the postpartum period. Smallpox and yellow fever vaccines should be avoided. Individuals undergoing postplacental placement are more likely to use an intrauterine device at 6 months than those advised to follow-up for placement during outpatient postpartum care. An implant is safe and effective for immediate postpartum contraception. There is insufficient evidence to support or refute the routine administration of micronutrient supplements in breastfeeding women. Placentophagia does not provide any benefits and exposes mothers and offspring to infectious risks. Therefore, it should be discouraged. Because of the low level of evidence, there is insufficient data to assess the efficacy of home visits in the postpartum period. There is insufficient evidence to recommend when to resume daily activities, and individuals should be counseled to return to prepregnancy level of activity or exercise when comfortable. Sexual activity, housework exercise, driving, climbing stairs, and lifting weights should be resumed as soon as postpartum individuals want. A behavioral educational intervention reduces depression symptoms and increases breastfeeding duration. Physical activity after delivery is protective against postpartum mood disorders. There is no strong evidence that supports early discharge after vaginal delivery compared with standard discharge (ie, ≥48 hours).

Vaginal progesterone compared with intramuscular 17-alpha-hydroxyprogesterone caproate for prevention of recurrent preterm birth in singleton gestations: a systematic review and meta-analysis.

OBJECTIVE: Randomized trials have found benefits of both vaginal progesterone and 17-alpha-hydroxyprogesterone caproate in the prevention of recurrent preterm birth. A previous meta-analysis directly comparing the two was limited by low-quality evidence, and national and international society guidelines remain conflicting regarding progestin formulation recommended for prevention of recurrent preterm birth. The aim of this updated systematic review with meta-analysis was to evaluate the efficacy of vaginal progesterone compared with 17-alpha-hydroxyprogesterone caproate in the prevention of spontaneous preterm birth in patients with singleton gestations and previous spontaneous preterm birth. DATA SOURCES: Searches were performed in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, the International Prospective Register of Systematic Reviews (PROSPERO), SciELO, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) with the use of a combination of keywords and text words related to "preterm birth," "preterm delivery," "singleton," "cervical length," "progesterone," "progestogens," "vaginal," "17-alpha-hydroxy-progesterone caproate," and "intramuscular" from inception of each database to September 2021. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials of asymptomatic singleton gestations with previous spontaneous preterm birth that were randomized to prophylactic treatment with either vaginal progesterone (ie, intervention group) or intramuscular 17-alpha-hydroxyprogesterone caproate (ie, comparison group). Post hoc sensitivity analysis was performed for studies with low risk of bias and studies with protocol registration. METHODS: The primary outcome was preterm birth <34 weeks' gestation. The summary measures were reported as relative risks with 95% confidence intervals. RESULTS: Seven randomized controlled trials including 1910 patients were included in the meta-analysis. Patients who received vaginal progesterone had a significantly lower rate of preterm birth at <34 weeks (14.7% vs 19.9%; relative risk, 0.74; 95% confidence interval, 0.57-0.96), preterm birth at <37 weeks (36.0% vs 46.6%; relative risk, 0.76; 95% confidence interval, 0.69-0.85), and preterm birth at <32 weeks of gestation (7.9% vs 13.6%; relative risk, 0.58; 95% confidence interval, 0.39-0.86), compared with women who received intramuscular 17-alpha-hydroxyprogesterone caproate. There were no significant differences in the rate of preterm birth at <28 weeks' gestation. Adverse drug reactions were significantly lower in the vaginal progesterone group than in the 17-alpha-hydroxyprogesterone caproate group (15.6% vs 22.2%; relative risk, 0.71; 95% confidence interval, 0.54-0.92). Perinatal mortality was lower in the vaginal progesterone group than in the 17-alpha-hydroxyprogesterone caproate group (2.2% vs 4.4%; relative risk, 0.51; 95% confidence interval, 0.25-1.01). In sensitivity analysis including trials rated with at least 4 Cochrane tools as of "low risk of bias," 4 trials were included (N=575), and there was no longer a significant difference in preterm birth at <34 weeks' gestation between vaginal progesterone and 17-alpha-hydroxyprogesterone caproate (12.2% vs 13.9%; relative risk, 0.87; 95% confidence interval, 0.57-1.32). CONCLUSION: Overall, vaginal progesterone was superior to 17-alpha-hydroxyprogesterone caproate in the prevention of preterm birth at <34 weeks' gestation in singleton pregnancies with previous spontaneous preterm birth. Although sensitivity analysis of high-fidelity studies showed the same trend, findings were no longer statistically significant.

First-trimester uterine rupture: a case report and systematic review of the literature.

OBJECTIVE: This study aimed to present a case of first-trimester uterine rupture and perform a systematic review to identify common presentations, risk factors, and management strategies. DATA SOURCES: Searches were performed in PubMed, Ovid, and Scopus using a combination of key words related to "uterine rupture," "first trimester," and "early pregnancy" from database inception to September 30, 2020. STUDY ELIGIBILITY CRITERIA: English language descriptions of uterine rupture at ≤14 weeks of gestation were included, and cases involving pregnancy termination and ectopic pregnancy were excluded. METHODS: Outcomes for the systematic review included maternal demographics, description of uterine rupture, and specifics of uterine rupture diagnosis and management. Data were extracted to custom-made reporting forms. Median values were calculated for continuous variables, and percentages were calculated for categorical variables. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for case reports and case series. RESULTS: Overall, 61 cases of first-trimester uterine rupture were identified, including our novel case. First-trimester uterine ruptures occurred at a median gestation of 11 weeks. Most patients (59/61 [97%]) had abdominal pain as a presenting symptom, and previous uterine surgery was prevalent (44/61 [62%]), usually low transverse cesarean delivery (32/61 [52%]). The diagnosis of uterine rupture was generally made after surgical exploration (37/61 [61%]), with rupture noted in the fundus in 26 of 61 cases (43%) and in the lower segment in 27 of 61 cases (44%). Primary repair of the defect was possible in 40 of 61 cases (66%), whereas hysterectomy was performed in 18 of 61 cases (30%). Continuing pregnancy was possible in 4 of 61 cases (7%). CONCLUSION: Uterine rupture is an uncommon occurrence but should be considered in patients with an acute abdomen in early pregnancy, especially in women with previous uterine surgery. Surgical exploration is typically needed to confirm the diagnosis and for management. Hysterectomy is not always necessary; primary uterine repair is sufficient in more than two-thirds of the cases to achieve hemostasis. Continuing pregnancy, although uncommon, is also possible.

Pelvic inflammatory disease in pregnancy: a systematic review focusing on perinatal outcomes.

BACKGROUND: Pelvic inflammatory disease during pregnancy is a rare and an understudied occurrence with potential negative outcomes. OBJECTIVE: This study aimed to evaluate the outcomes of pregnant women with pelvic inflammatory disease with or without pelvic abscesses. DATA SOURCES: We performed a systematic review of the literature using Ovid MEDLINE, Scopus, CINAHL, and PubMed (including Cochrane) with no time limitations. STUDY ELIGIBILITY CRITERIA: Relevant studies on pelvic inflammatory disease during pregnancy were identified and considered eligible if they described at least 1 case of pelvic inflammatory disease after conception, defined as infection in one or more of the following: uterus, fallopian tubes, and ovaries; based on clinical findings, physical examination, and imaging with or without pelvic abscesses present. Only studies on pelvic inflammatory disease with or without tubo-ovarian abscesses during pregnancy that evaluated perinatal outcomes were included. Data on the risk factors, delivery methods, and maternal, fetal, and neonatal outcomes were collected. METHODS: Reviewers screened all relevant titles using the inclusion/exclusion criteria and selected relevant articles for appraisal. A total of 49 cases with reported pelvic inflammatory disease, pelvic abscesses, or both were included. RESULTS: After exclusion of articles that did not meet the inclusion criteria, 34 manuscripts describing the occurrence of pelvic inflammatory disease in 49 pregnancies were analyzed, focusing primarily on cases reported after 1971. The mean age of patients was 25±6.3 years, the mean gestational age at diagnosis was 19.0±10.3 weeks, and 67.6% of patients were multiparous. Of all included patients, 27 (62.8%) underwent exploratory laparotomies, 14 (32.6%) underwent unilateral salpingo-oophorectomies, and 11 (25.6%) underwent appendectomies. Of all the deliveries, 13 (50%) pregnancies were full term, 14 (53.8%) were cesarean deliveries, 10 (38.5%) were spontaneous vaginal deliveries, and 2 (7.7%) were cesarean hysterectomies. There were 26 (60.5%) cases of viable births (mean gestational age at delivery, 33.8±5.1 weeks) and 17 (39.5%) cases of nonviable births. Sepsis was a complication in 3 (7.0%) cases and caused 3 neonatal deaths. CONCLUSION: Although rare, pelvic inflammatory disease can have severe health consequences. Risk factors for pelvic inflammatory disease development include maternal pelvic structural anomalies, a history of sexually transmitted infections, recent pelvic surgery, and in vitro fertilization or oocyte retrieval. Pelvic inflammatory disease can coincide with pregnancy and can occur in the second trimester. Making a prompt diagnosis can help to improve the outcomes; therefore, if a high enough suspicion exists, treatment should not be delayed.

Enhanced Recovery after Surgery Protocol to Improve Racial and Ethnic Disparities in Postcesarean Pain Management.

OBJECTIVE: The objective of this study was to assess the efficacy of an enhanced recovery after surgery (ERAS) protocol and determine its effect on racial/ethnic disparities in postcesarean pain management. STUDY DESIGN: We performed an institutional review board-approved retrospective cohort study of scheduled cesarean deliveries before and after ERAS implementation at a single urban academic institution. Pre-ERAS, all analgesic medications were given postoperatively on patient request. The ERAS protocol included preoperative acetaminophen and celecoxib. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was available as needed, and opioid patient-controlled analgesia was eliminated from the standard order set. The primary outcome was total opioid use in the first 48 hours after cesarean, pre- and post-ERAS, reported in total milliequivalents of intravenous morphine (MME). A secondary analysis of opioid use and pain scores by racial groups was also performed. Chi-square, independent t-tests, analysis of variance, Mann-Whitney U, and Kruskal-Wallis tests were used depending on variable and data normality. RESULTS: Pre-ERAS and post-ERAS groups included 100 women each. Post-ERAS, total opioid use in 48 hours was less (40.8 vs. 8.6 MME, p < 0.001) and visual analog scale (VAS) pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 maximum at rest: 6.7 vs. 5.3, p < 0.001). Pre-ERAS pain scores differed by race with non-Hispanic Black (NHB) patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, maximum VAS at rest: NHB-7.4, non-Hispanic White-6.6, Hispanic-5.8, Asian-4.4, p = 0.006). Post-ERAS, there were no differences in postoperative pain scores between groups with movement on POD1 and POD2. CONCLUSION: A standardized ERAS protocol for postcesarean pain decreases opioid use and may improve some racial disparities in postcesarean pain control. KEY POINTS: · ERAS protocols improve postoperative pain control and lower postoperative opioid use.. · Studies show that there are racial and ethnic disparities in postpartum pain control.. · Protocols standardize care and may decrease the effects of provider implicit bias..

Vaginal progesterone vs intramuscular 17-hydroxyprogesterone caproate for prevention of recurrent preterm birth: a randomized controlled trial.

BACKGROUND: Preterm birth is the leading cause of neonatal morbidity and mortality, and previous preterm birth is one of the strongest risk factors for preterm birth. National and international obstetrical societies have different recommendations regarding progesterone formulation for the prevention of recurrent preterm birth. OBJECTIVE: This study aimed to determine whether vaginal progesterone is superior to 17-hydroxyprogesterone caproate in the prevention of recurrent preterm birth in patients with singleton pregnancies who had a previous spontaneous preterm birth. STUDY DESIGN: This was an open-label multicenter pragmatic randomized controlled trial at 5 US centers of patients with singleton pregnancies at <24 weeks of gestation who had a previous spontaneous preterm birth randomized 1:1 to either 200 mg vaginal progesterone suppository nightly or 250 mg intramuscular 17-hydroxyprogesterone caproate weekly from 16 to 36 weeks of gestation. Based on the estimated recurrent preterm birth rate of 36% with 17-hydroxyprogesterone caproate, 95 participants were needed in each arm to detect a 50% reduction in preterm birth rate with vaginal progesterone, with 80% power and 2-sided alpha of 0.05. The primary outcome was preterm birth at <37 weeks of gestation. Prespecified secondary outcomes included preterm birth at <34 and <28 weeks of gestation, mean gestational age at delivery, neonatal morbidity and mortality, and measures of adherence. Analysis was by intention to treat. The chi-square test and Student t test were used as appropriate. P<.05 was considered significant. RESULTS: Overall, 205 participants were randomized; 94 participants in the vaginal progesterone group and 94 participants in 17-hydroxyprogesterone caproate group were included. Although gestational age at enrollment was similar, those assigned to vaginal progesterone initiated therapy earlier (16.9±1.4 vs 17.8±2.5 weeks; P=.001). Overall continuation of assigned formulation until delivery was similar (73% vs 69%; P=.61). There was no significant difference in preterm birth at <37 (31% vs 38%; P=.28; relative risk, 0.81 [95% confidence interval, 0.54-1.20]), <34 (9.6% vs 14.9%; P=.26; relative risk, 0.64 [95% confidence interval, 0.29-1.41]), or <28 (1.1% vs 4.3%; P=.37; relative risk, 0.25 [95% confidence interval, 0.03-2.20]) weeks of gestation. Participants in the vaginal progesterone group had a later mean gestational age at delivery than participants in the 17-hydroxyprogesterone caproate group (37.36±2.72 vs 36.34±4.10 weeks; mean difference, 1.02 [95% confidence interval, 0.01-2.01]; P=.047). CONCLUSION: Vaginal progesterone did not reduce the risk of recurrent preterm birth by 50% compared with 17-OHPC; however, vaginal progesterone may lead to increased latency to delivery. This trial was underpowered to detect a smaller, but still clinically significant, difference in the efficacy of preterm birth prevention. Patient factors that impact adherence and ability to obtain medication in a timely fashion should be included in counseling on progesterone selection.

A reminder system for postpartum diabetes screening after gestational diabetes: a randomized clinical trial.

OBJECTIVE: To evaluate if a reminder postpartum screening system, providing patients with laboratory requisition on the postpartum ward followed by a telephone reminder one week prior to their 6 weeks appointment, would increase the diabetes mellitus screening rate. METHODS: Parallel group, open label, multicenter randomized trial. Patients were recruited between July 2015 and March 2016. All women with gestational diabetes mellitus in their index pregnancy with access to a mobile or landline phone were eligible for participation. Gestational diabetes mellitus diagnosis was made with a one-hour 50 g OGTT ≥135 mg/dl, and a subsequent 3 h OGTT with ≥2 values above fasting 95 mg/dl, 1 h 180 mg/dl, 2 h 155 mg/dl, and 3 h 140 mg/dl. Participants were assigned in a 1:1 ratio to "reminder system" (intervention group) or to "routine care (control group)." Those assigned to the reminder system were provided with two reminders. The first was a laboratory requisition slip given to them while on the postpartum ward. The second was a telephone reminder on the fifth week postpartum, consisting of a standardized script to encourage contacted participants to complete the screening test during the sixth week postpartum. The primary outcome was completion of the two-hour 75 g OGTT 6-12 weeks postpartum. RESULTS: A total of 75 patients were included in the study. Thirty-eight patients were randomized to the reminder system, and 37 patients were randomized to routine care. A total of 22 women (29.3%) completed the test. In the "reminder" group, 31.6% completed the test, and in the "routine care" group 27% of patients completed the test. This increase in screening uptake in the reminder group was not noted to be statistically significant (p=.8). When evaluating whether perinatal or sociodemographic factors influenced the effect of reminder systems on screening uptake, only insurance type was noted to have a statistically significant influence. Screening uptake was significantly increased in patients with public insurance assigned to "reminder group" (13.5%) compared to those assigned to "routine care" (0%). Of those women who completed the test, seven patients (31.8 %) were diagnosed with prediabetes and none with diabetes. CONCLUSIONS: Telephone reminders were not found to have a significant impact on increasing postpartum screening for diabetes. The exception was among the publicly insured population. These findings suggest a targeted role for reminder systems, particularly among those with socioeconomic disadvantage.

Adult Granulosa Cell Tumor in Pregnancy: A New Case and a Review of the Literature.

Granulosa cell tumors are rare ovarian tumors that can arise during pregnancy. We present a new case of recurrent adult granulosa cell tumor (AGCT) in pregnancy and a systematic review of the literature. The new case described is a 41-year-old woman G5P1122 with a prior history of AGCT that was referred to our center at 29 weeks because of a symptomatic abdominal mass, compatible with a possible recurrence of AGCT. At 36 + 3 weeks, she underwent a cesarean delivery for preterm labor and a total hysterectomy with a radical surgical staging. A healthy female infant was delivered. The patient received a platinum-based chemotherapy, with a 26-month follow-up negative for recurrence. Analyzing our case with the four identified by the literature review, three were recurrent and two were primary AGCT. Only one required surgery for AGCT at 15 weeks, while another underwent chemotherapy in pregnancy. In the other three cases, surgery for AGCT was done at the time of cesarean delivery. There were three cases of preterm delivery. All five pregnancies resulted in the birth of live babies with weight adequate for gestational age. In conclusion, AGCT diagnosed in pregnancy is rare, reported in only five cases. All gave birth to live babies in the third trimester, and maternal outcome at up to 18 months showed no recurrence.

OBGYN practice patterns regarding combination therapy for prevention of preterm birth: A national survey.

OBJECTIVE: Our objective was to examine if US obstetrician-gynecologists (OBGYNs) practice outside of evidenced-based guidelines and use a combination of interventions to prevent spontaneous preterm birth (sPTB). STUDY DESIGN: An electronic survey was distributed to members of the Pregnancy-Related Care Research Network (PRCRN), and also to members of the Society of Maternal-Fetal Medicine (SMFM). The survey consisted of questions regarding physician demographics, and the use of interventions to prevent sPTB in women with 1) a prior sPTB, 2) an incidental short cervix (no prior sPTB), and 3) a history of cervical insufficiency. RESULTS: The PRCRN response rate was 58.6% (283/483) with an additional 143 responses from SMFM members. Among PRCRN responders, 82.7% were general OBGYNs and 17.3% were Maternal-Fetal Medicine subspecialists. Respondents were from all geographic regions of the country; most practiced in a group private practice (42.6%) or academic institution (31.4%). In women with prior sPTB, 45.2% of respondents would consider combination therapy, most commonly weekly intramuscular progesterone (IM-P) and serial cervical length (CL) measurements. If the patient then develops a short cervix, 33.7% would consider adding an ultrasound-indicated cerclage. In women with an incidental short cervix, 66.8% of respondents were likely to recommend single therapy with daily vaginal progesterone (VP). If a patient developed an incidentally dilated cervix, 40.8% of PRCRN respondents would recommend dual therapy, most commonly cerclage + VP, whereas 64.3% of SMFM respondents were likely to continue with VP only. In women with a history of cervical insufficiency, 47% of PRCRN respondents indicated they would consider a combination of IM-P, history-indicated cerclage and serial CL measurements. CONCLUSION: Although not currently supported by evidence-based medicine, combination therapy is commonly being used by U.S. OBGYNs to prevent sPTB in women with risk factors such as prior sPTB, short or dilated cervix or more than one of these risks.

Role of progesterone, cerclage and pessary in preventing preterm birth in twin pregnancies: A systematic review and network meta-analysis.

OBJECTIVE: To determine the role of progesterone, pessary and cervical cerclage in reducing the risk of (preterm birth) PTB in twin pregnancies and compare these interventions using pairwise and network meta-analysis. STUDY DESIGN: Medline, Embase, CINAHL and Cochrane databases were explored. The inclusion criteria were studies in which twin pregnancies were randomized to an intervention for the prevention of PTB (any type of progesterone, cervical cerclage, cervical pessary, or any combination of these) or to a control group (e.g. placebo or treatment as usual). Interventions of interest were either progesterone [vaginal or oral natural progesterone or intramuscular 17a-hydroxyprogesterone caproate (17-OHPC)], cerclage (McDonald or Shirodkar), or cervical pessary. The primary outcome was PTB < 34 weeks of gestation. Both primary and secondary outcomes were explored in an unselected population of twin pregnancies and in women at higher risk of PTB (defined as those with cervical length <25 mm). Random-effect head-to-head and a multiple-treatment meta-analyses were used to analyze the data and results expressed as risk ratios. RESULTS: 26 studies were included in the meta-analysis. When considering an unselected population of twin pregnancies, vaginal progesterone, intra-muscular17-OHPC or pessary did not reduce the risk of PTB < 34 weeks of gestation (all p > 0.05). When stratifying the analysis for spontaneous PTB, neither pessary, vaginal or intramuscular 17-OHPC were associated with a significant reduction in the risk of PTB compared to controls (all p > 0.05), while there was no study on cerclage which explored this outcome in an unselected population of twin pregnancies. When considering twin pregnancies with short cervical length (≤25 mm), there was no contribution of either pessary, vaginal progesterone, intra-muscular 17-OHPC or cerclage in reducing the risk of overall PTB < 34 weeks of gestation. CONCLUSIONS: Cervical pessary, progesterone and cerclage do not show a significant effect in reducing the rate of PTB or perinatal morbidity in twins, either when these interventions are applied to an unselected population of twins or in pregnancies with a short cervix.

FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction.

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled "LRS" in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

Utility of follow-up cervical length screening in low-risk women with a cervical length of 26 to 29 mm.

BACKGROUND: In women with a previous preterm birth, a protocol for serial cervical length screening has been studied and recommended for the identification and treatment of a short cervix. Cervical length screening along with vaginal progesterone has been suggested for low-risk women with singleton pregnancies to treat a short cervix and reduce preterm birth. However, specific protocols for single vs serial ultrasound measuring cervical length in this population are not established. Cost-effectiveness of universal cervical length screening depends on the cost of screening; follow-up of borderline measurements can contribute to increased costs with uncertain benefit. OBJECTIVE: This study aimed to determine the utility of follow-up cervical length screening in otherwise low-risk women with singleton pregnancies with a midtrimester cervical length measurement of 26 to 29 mm through the assessment of the rate of short cervix (≤25 mm) on follow-up ultrasound and subsequent delivery outcomes. STUDY DESIGN: This was a 2-year retrospective cohort study at a single urban institution of women with singleton pregnancies with no previous spontaneous preterm birth and an initial transvaginal ultrasound cervical length measurement of 26 to 29 mm identified during universal cervical length screening at time of anatomy ultrasound (18 0/7 to 22 6/7 weeks' gestation). The primary outcome was the rate of short cervix (defined as ≤25 mm on transvaginal ultrasound) on follow-up ultrasound at <24 weeks' gestation. Secondary outcomes included the rate of spontaneous preterm birth (<37 and <34 weeks' gestation). RESULTS: During the study period, there were 2801 women with singleton pregnancies at 18 0/7 to 22 6/7 weeks' gestation with transvaginal ultrasound cervical length screening at time of anatomy scan. Among those women, 201 had a cervical length of 26 of 29 mm, and 184 (7%) had no previous spontaneous preterm birth and were included in the study. Furthermore, 144 women (78%) had a follow-up cervical length completed before 24 weeks' gestation. The mean follow-up interval was 1.5±0.6 weeks. Overall, the percentage of short cervix (≤25 mm) on follow-up was 15% (n=21). Baseline characteristics were similar, but the initial cervical length measurement was shorter in women who subsequently developed a short cervix (26.7±0.8 vs 27.8±1.0; P<.01). Delivery outcomes were available for 126 patients. The rate of spontaneous preterm birth at <37 weeks' gestation in women with an initial cervical length 26 to 29 mm and subsequent short cervix was significantly higher than the rate of spontaneous preterm birth in a historical cohort of low risk women with an initial cervical length >25 mm (16% vs 3%; P=.03). The rate of spontaneous preterm birth at <34 weeks' gestation in women with a subsequent short cervix was 11% (2 of 19). CONCLUSION: Here, approximately 15% of low-risk women with singleton pregnancies with a midtrimester cervical length measurement of 26 to 29 mm will experience cervical shortening of ≤25 mm before 24 weeks' gestation. Compared to women with singleton pregnancies without a history of preterm birth, the rate of spontaneous preterm birth (16%) in women with an initial cervical length of 26 to 29 mm and a subsequent cervical shortening of ≤25 mm is significantly higher. A total of 111 follow-up ultrasounds measuring cervical length would be required to prevent 1 early preterm birth at <34 weeks' gestation.