Mean Arterial Pressure and Neonatal Outcomes in Pregnancies Complicated by Mild Chronic Hypertension.

OBJECTIVE: To estimate the association between mean arterial pressure during pregnancy and neonatal outcomes in participants with chronic hypertension using data from the CHAP (Chronic Hypertension and Pregnancy) trial. METHODS: A secondary analysis of the CHAP trial, an open-label, multicenter randomized trial of antihypertensive treatment in pregnancy, was conducted. The CHAP trial enrolled participants with mild chronic hypertension (blood pressure [BP] 140-159/90-104 mm Hg) and singleton pregnancies less than 23 weeks of gestation, randomizing them to active treatment (maintained on antihypertensive therapy with a goal BP below 140/90 mm Hg) or standard treatment (control; antihypertensives withheld unless BP reached 160 mm Hg systolic BP or higher or 105 mm Hg diastolic BP or higher). We used logistic regression to measure the strength of association between mean arterial pressure (average and highest across study visits) and to select neonatal outcomes. Unadjusted and adjusted odds ratios (per 1-unit increase in millimeters of mercury) of the primary neonatal composite outcome (bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, or intraventricular hemorrhage grade 3 or 4) and individual secondary outcomes (neonatal intensive care unit admission [NICU], low birth weight [LBW] below 2,500 g, and small for gestational age [SGA]) were calculated. RESULTS: A total of 2,284 participants were included: 1,155 active and 1,129 control. Adjusted models controlling for randomization group demonstrated that increasing average mean arterial pressure per millimeter of mercury was associated with an increase in each neonatal outcome examined except NEC, specifically neonatal composite (adjusted odds ratio [aOR] 1.12, 95% CI, 1.09-1.16), NICU admission (aOR 1.07, 95% CI, 1.06-1.08), LBW (aOR 1.12, 95% CI, 1.11-1.14), SGA below the fifth percentile (aOR 1.03, 95% CI, 1.01-1.06), and SGA below the 10th percentile (aOR 1.02, 95% CI, 1.01-1.04). Models using the highest mean arterial pressure as opposed to average mean arterial pressure also demonstrated consistent associations. CONCLUSION: Increasing mean arterial pressure was positively associated with most adverse neonatal outcomes except NEC. Given that the relationship between mean arterial pressure and adverse pregnancy outcomes may not be consistent at all mean arterial pressure levels, future work should attempt to further elucidate whether there is an absolute threshold or relative change in mean arterial pressure at which fetal benefits are optimized along with maternal benefits. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT02299414.

Tranexamic acid to reduce blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery-a randomized controlled trial.

BACKGROUND: Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. Tranexamic acid has proven to be useful in treating hemorrhage from acute blood loss. However, its role in preventing blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery is not well studied. OBJECTIVE: This study aimed to assess the role of tranexamic acid in reducing blood loss during elective and unscheduled cesarean deliveries in women at high risk of postpartum hemorrhage. STUDY DESIGN: This was a prospective, placebo-controlled, randomized controlled trial from March 2021 to February 2022 at the Karnatak Lingayat Education Society Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India. Women at a high risk of postpartum hemorrhage undergoing cesarean delivery were recruited and randomized to receive either tranexamic acid or placebo (1:1) at least 10 minutes before skin incision. High-risk factors for postpartum hemorrhage included obesity, hypertension, multiparity, previous cesarean delivery, multiple pregnancy, abnormally implanted placenta, placenta previa, abruption, uterine leiomyomas, polyhydramnios, and fetal macrosomia. The primary outcome was blood loss, calculated by a formula using pre- and postoperative hematocrit levels. In addition, gravimetrically measured blood loss was measured and compared between the 2 groups. RESULTS: A total of 212 women met the inclusion criteria and were randomized (tranexamic acid [n=106] and placebo [n=106]). The mean blood loss estimates were 400.9 mL in the tranexamic acid group and 597.9 mL in the placebo group (P<.001). The mean gravimetrically measured blood loss estimates were 379.2 mL in the tranexamic acid group and 431.1 mL in the placebo group (P<.001). In addition, there was a significant difference in the fall in hemoglobin levels (1.04 vs 1.61 g/dL) and change in hematocrit levels (3.20% vs 4.95%) from the pre- to postoperative period between the 2 groups (P<.001). No difference in the need for additional uterotonics (P=.26) or the need for postoperative parental iron (P=.18) was noted. No woman was transfused in either group. CONCLUSION: High-risk women receiving tranexamic acid had significantly less blood loss than women receiving placebo during cesarean delivery.

Uterine Weight and Perioperative Morbidity in Robotic-Assisted versus Conventional Laparoscopic Hysterectomy.

Background and Objectives: Minimally invasive approaches to benign hysterectomy are the current standard of care when feasible. Use of robotic-assisted laparoscopic hysterectomy (RA-LH) has been increasing; however, direct comparative data that accounts for uterine weight in conventional laparoscopic hysterectomy (CLH) and RA-LH is limited. We sought to examine the impact of uterine weight on immediate perioperative morbidity in CLH versus RA-LH. The primary outcome was a composite of complications including visceral injuries, conversions to abdominal procedures, and transfusions. Methods: A retrospective cohort study of patients who underwent a minimally invasive laparoscopic hysterectomy (CLH and RA-LH) in a single hospital system between January 1, 2014 and December 31, 2017 as identified by Current Procedural Terminology codes. The primary exposure was CLH or RA-LH. Uterine weight was categorized into four groups: <150 g, 150 to < 250 g, 250 to < 450 g, and ≥ 450 g. Results: A total of 1506 patients were included; 539 underwent CLH and 967 underwent RA-LH. Median uterine weight was higher in patients who underwent CLH (161.0 g) compared to RA-LH (147.0 g), P = .001. The odds of the composite of complications in CLH was 4.43 (2.84 - 6.92) higher than the odds of the composite in RA-LH. When stratified by the uterine weight, the odds of complications was significantly higher in CLH in the following categories: <150 g, 250 to < 450 g, and ≥ 450 g (OR: 4.41, 3.28, and 7.81, respectively). Conclusion: Surgical morbidity was lower in RA-LH across the spectrum of uterine weights compared to CLH. Patients may particularly benefit from RA-LH at higher uterine weights.

Cervical Pessary for Prevention of Preterm Birth in Individuals With a Short Cervix: The TOPS Randomized Clinical Trial.

Importance: A short cervix as assessed by transvaginal ultrasound is an established risk factor for preterm birth. Study findings for a cervical pessary to prevent preterm delivery in singleton pregnancies with transvaginal ultrasound evidence of a short cervix have been conflicting. Objective: To determine if cervical pessary placement decreases the risk of preterm birth or fetal death prior to 37 weeks among individuals with a short cervix. Design, Setting, and Participants: We performed a multicenter, randomized, unmasked trial comparing a cervical pessary vs usual care from February 2017 through November 5, 2021, at 12 centers in the US. Study participants were nonlaboring individuals with a singleton pregnancy and a transvaginal ultrasound cervical length of 20 mm or less at gestations of 16 weeks 0 days through 23 weeks 6 days. Individuals with a prior spontaneous preterm birth were excluded. Interventions: Participants were randomized 1:1 to receive either a cervical pessary placed by a trained clinician (n = 280) or usual care (n = 264). Use of vaginal progesterone was at the discretion of treating clinicians. Main Outcome and Measures: The primary outcome was delivery or fetal death prior to 37 weeks. Results: A total of 544 participants (64%) of a planned sample size of 850 were enrolled in the study (mean age, 29.5 years [SD, 6 years]). Following the third interim analysis, study recruitment was stopped due to concern for fetal or neonatal/infant death as well as for futility. Baseline characteristics were balanced between participants randomized to pessary and those randomized to usual care; 98.9% received vaginal progesterone. In an as-randomized analysis, the primary outcome occurred in 127 participants (45.5%) randomized to pessary and 127 (45.6%) randomized to usual care (relative risk, 1.00; 95% CI, 0.83-1.20). Fetal or neonatal/infant death occurred in 13.3% of those randomized to receive a pessary and in 6.8% of those randomized to receive usual care (relative risk, 1.94; 95% CI, 1.13-3.32). Conclusions and Relevance: Cervical pessary in nonlaboring individuals with a singleton gestation and with a cervical length of 20 mm or less did not decrease the risk of preterm birth and was associated with a higher rate of fetal or neonatal/infant mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT02901626.

Serum Cotinine and Adverse Cardiovascular Outcomes: A Cross-sectional Secondary Analysis of the nuMoM2b Heart Health Study.

OBJECTIVE: We aimed to (1) compare serum cotinine with self-report for ascertaining smoking status among reproductive-aged women; (2) estimate the relative odds of adverse cardiovascular (CV) outcomes among women by smoking status; (3) assess whether the association between adverse pregnancy outcomes (APOs) and CV outcomes varies by smoking status. STUDY DESIGN: We conducted a cross-sectional study of the nuMoM2b Heart Health Study. Women attended a study visit 2 to 7 years after their first pregnancy. The exposure was smoking status, determined by self-report and by serum cotinine. Outcomes included incident chronic hypertension (HTN), metabolic syndrome (MetS), and dyslipidemia. Multivariable logistic regression estimated odds ratios (ORs) for each outcome by smoking status. RESULTS: Of 4,392 women with serum cotinine measured, 3,610 were categorized as nonsmokers, 62 as secondhand smoke exposure, and 720 as smokers. Of 3,144 women who denied tobacco smoke exposure, serum cotinine was consistent with secondhand smoke exposure in 48 (1.5%) and current smoking in 131 (4.2%) After adjustment for APOs, smoking defined by serum cotinine was associated with MetS (adjusted OR [aOR] = 1.52, 95% confidence interval [CI]: 1.21, 1.91) and dyslipidemia (aOR = 1.28, 95% CI: 1.01, 1.62). When stratified by nicotine exposure, nonsmokers with an APO in their index pregnancy had higher odds of stage 1 (aOR = 1.64, 95% CI: 1.32, 2.03) and stage 2 HTN (aOR = 2.92, 95% CI: 2.17, 3.93), MetS (aOR = 1.76, 95% CI: 1.42, 2.18), and dyslipidemia (aOR = 1.55, 95% CI: 1.25, 1.91) relative to women with no APO. Results were similar when smoking exposure was defined by self-report. CONCLUSION: Whether determined by serum cotinine or self-report, smoking is associated with subsequent CV outcomes in reproductive-aged women. APOs are also independently associated with CV outcomes in women. KEY POINTS: · Cotinine was detected in 5.7% of reported nonsmokers.. · Smoking and APOs were independently associated with CV health.. · Smoking was associated with MetS and dyslipidemia..

Risk factors for postoperative ileus after cesarean delivery.

BACKGROUND: Despite extensive data regarding risk factors for postoperative ileus in the general and colorectal surgery literature, few studies have identified risk factors specific to the obstetrical population. OBJECTIVE: This study aimed to identify factors associated with postoperative ileus following cesarean delivery. STUDY DESIGN: This retrospective case-control study identified women who underwent cesarean delivery at a single hospital between January 2000 and January 2020 and subsequently developed postoperative ileus. Cases were matched in a 1:2 ratio with controls who underwent cesarean delivery and did not develop postoperative ileus. They were matched by age (±1 year) and body mass index (±1 kg/m2). Demographics, common comorbidities, obstetrical history, and delivery characteristics were analyzed. RESULTS: A total of 147 cases and 294 controls were identified. Cases and controls were similar in terms of parity, number of previous cesarean deliveries, labor preceding their cesarean delivery, incidence of chorioamnionitis, and presurgical diagnosis of hypothyroidism or chronic hypertension. Cases tended to have a diagnosis of preeclampsia (cases 23.1% vs controls 10.5%; P<.001) and were more likely to have been exposed to magnesium sulfate (cases 34.0% vs controls 15.0%; P<.001). Surgical considerations that were common in cases were exposure to general anesthesia (cases 37.4% vs controls 4.1%; P<.001), midline vertical skin incisions (cases 13.6% vs controls 1.4%; P<.001), classical hysterotomy (cases 8.8% vs controls 1.7%; P=.001), estimated blood loss >1000 mL (cases 44.4% vs controls 11.6%; P<.001), transfusion of blood products (cases 25.8% vs controls 2.0%; P<.001), and hysterectomy at the time of cesarean delivery (cases 6.1% vs controls 0.7%; P=.001). After a multivariable modeling using stepwise logistic regression of all variables found to be statistically significant, transfusion of blood products, estimated blood loss >1000 mL, and exposure to general anesthesia were the remaining surgical factors associated with the development of ileus. These variables reflect both the complexity and most likely the duration of surgery that was required, although we note that we did not have operative time as a variable to explore. Preeclampsia was also identified as a comorbidity linked to the development of ileus. CONCLUSION: A diagnosis of preeclampsia, exposure to general anesthesia, estimated blood loss >1 L, and transfusion of blood products were identified as potential risk factors for postcesarean ileus.

Association of N-Terminal Pro-Brain Natriuretic Peptide Concentration in Early Pregnancy With Development of Hypertensive Disorders of Pregnancy and Future Hypertension.

IMPORTANCE: Hypertensive disorders of pregnancy are associated with future cardiovascular disease, perhaps because of subclinical cardiac dysfunction before pregnancy leading to impaired adaptation to pregnancy. Natriuretic peptides are promising biomarkers for detecting subclinical cardiac dysfunction outside of pregnancy. OBJECTIVE: To investigate whether higher concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) in early pregnancy would be associated with hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study, a prospective multicenter observational study. A total of 4103 nulliparous women with complete data and no prepregnancy hypertension or diabetes who were treated at 8 clinical sites were included. Women were followed up with for 2 to 7 years after pregnancy. Data were collected from October 2010 to October 2017, and data were analyzed from August 2020 to November 2021. EXPOSURES: NT-proBNP concentration, measured using an electrochemiluminescence immunoassay from a first-trimester blood sample. MAIN OUTCOMES AND MEASURES: Hypertensive disorders of pregnancy and incident hypertension (systolic blood pressure of 130 mm Hg or diastolic blood pressure of 80 mm Hg or use of antihypertensive agents) at follow-up visit. RESULTS: A total of 4103 women met inclusion criteria; the mean (SD) age was 27.0 (5.6) years. Among these women, 909 (22.2%) had an adverse pregnancy outcome, and 817 (19.9%) had hypertension at the follow-up visit. Higher NT-proBNP concentrations were associated with a lower risk of hypertensive disorders of pregnancy (adjusted odds ratio per doubling, 0.81; 95% CI, 0.73-0.91), which persisted after adjustment for age, self-reported race and ethnicity, early-pregnancy body mass index, smoking, and aspirin use. Similarly, higher NT-proBNP concentration in early pregnancy was also associated with a lower risk of incident hypertension 2 to 7 years after delivery (adjusted odds ratio per doubling, 0.84; 95% CI, 0.77-0.93), an association that persisted after controlling for confounders, including hypertensive disorders of pregnancy. CONCLUSIONS AND RELEVANCE: In this cohort study, higher NT-proBNP concentrations in early pregnancy were associated with a lower risk of hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum. These findings suggest that normal early-pregnancy cardiovascular physiology, as assessed by NT-proBNP concentration, may provide biologic insights into both pregnancy outcome and cardiovascular disease risk.

Incremental risk of clinical chorioamnionitis associated with cervical examination.

BACKGROUND: Clinical chorioamnionitis is associated with significant maternal and neonatal morbidity, yet there is no clear evidence on the association between cervical examinations and infection. OBJECTIVE: We sought to assess the association between the number of cervical examinations performed during term labor management and the risk of clinical chorioamnionitis. STUDY DESIGN: This is a retrospective cohort study of term (≥37 weeks of gestation), singleton pregnancies who labored at our tertiary care center from 2014 to 2018. The primary outcome of clinical chorioamnionitis was defined as maternal intrapartum fever (single oral temperature of >39°C or 38°C-38.9°C for 30 minutes) and 1 or more of the following: maternal leukocytosis, purulent cervical drainage, or fetal tachycardia. The primary exposure was the number of digital cervical exams documented in the medical record. Log-binomial regression was used to model the effect of cervical examinations on the risk of clinical chorioamnionitis while adjusting for potential confounders. RESULTS: A total of 20,029 individuals met the inclusion criteria and 1028 (5%) patients experienced clinical chorioamnionitis. The number of cervical exams was associated with increased risk of developing infection after adjusting for potential confounders. Individuals with ≥8 cervical exams had 1.7 times the risk of developing clinical chorioamnionitis compared with those with 1 to 3 exams. Prolonged rupture time, nulliparity, Black race, Medicaid insurance, higher gestational age, and higher body mass index were associated with increased risk of clinical chorioamnionitis, whereas smoking and group B Streptococcus colonization were associated with a lower risk. CONCLUSION: Our study found that the number of cervical exams performed during labor is an independent risk factor for developing clinical chorioamnionitis. Unnecessary cervical exams should be avoided during labor management at term.

Obstetrical outcomes are unchanged after hysteroscopic myomectomy in women with submucosal fibroids.

BACKGROUND: Previous studies have demonstrated increased rates of poor obstetrical outcomes including preterm delivery, placental abruption, and intrauterine growth restriction in women with uterine leiomyomas. Currently, preconception myomectomy has not been reported to improve pregnancy rates or pregnancy outcomes in women with subserosal leiomyomas, and the data remain inconclusive for intramural fibroids. Pregnancy rates have been found to improve after the removal of submucosal fibroids. However, the effect of preconception myomectomy for submucosal fibroids on birth outcomes has yet to be examined. OBJECTIVE: This study aimed to determine whether hysteroscopic excision of submucosal leiomyomas affects the rate of preterm delivery, among other obstetrical outcomes. STUDY DESIGN: We performed a retrospective case-control study of women who underwent hysteroscopic resection of leiomyomas (cases) and controls of women who had submucosal fibroids at the time of their first-trimester ultrasounds. Women were included if they delivered a nonanomalous fetus beyond 20 weeks' gestation. A total of 73 cases were identified and matched with 219 controls (case-to-control ratio, 1:3). Subsequently, owing to multiple-gestation pregnancy, 11 patients were excluded from the case population and 4 patients from the control group. The final analysis included 277 women-62 cases and 215 controls. Our primary outcome was preterm delivery before 37 weeks' gestation. Prespecified secondary outcomes of interest were preterm delivery before 34 weeks' gestation, placental abruption, fetal malpresentation, intrauterine growth restriction, and rate of cesarean delivery. Data analysis was performed using univariate and multivariate statistics. RESULTS: Cases and controls were similar with respect to age, race, body mass index, and mode of delivery. Cases were more likely to be primiparous (66% cases [42 of 62] vs 37% controls [80 of 215]; P=.00) and use assisted reproductive technology to conceive (22.6% cases [14 of 62] vs 7.0% controls [15 of 215]; P<.001). No differences were found in the rate of preterm delivery at <37 weeks' gestation (12.9% cases [8 of 62] vs 13.5% controls [29 of 215]; P=.89), preterm delivery at <34 weeks' gestation (4.84% cases [3 of 62] vs 6.97% controls [15 of 215]; P=.77), or other obstetrical outcomes. CONCLUSION: Overall, women with submucosal uterine leiomyomas who undergo hysteroscopic removal have similar birth outcomes to those who do not.

Prescription and Other Medication Use in Pregnancy.

OBJECTIVE: To characterize prescription and other medication use in a geographically and ethnically diverse cohort of women in their first pregnancy. METHODS: In a prospective, longitudinal cohort study of nulliparous women followed through pregnancy from the first trimester, medication use was chronicled longitudinally throughout pregnancy. Structured questions and aids were used to capture all medications taken as well as reasons they were taken. Total counts of all medications taken including number in each category and class were captured. Additionally, reasons the medications were taken were recorded. Trends in medications taken across pregnancy and in the first trimester were determined. RESULTS: Of the 9,546 study participants, 9,272 (97.1%) women took at least one medication during pregnancy with 9,139 (95.7%) taking a medication in the first trimester. Polypharmacy, defined as taking at least five medications, occurred in 2,915 (30.5%) women. Excluding vitamins, supplements, and vaccines, 73.4% of women took a medication during pregnancy with 55.1% taking one in the first trimester. The categories of drugs taken in pregnancy and in the first trimester include the following: gastrointestinal or antiemetic agents (34.3%, 19.5%), antibiotics (25.5%, 12.6%), and analgesics (23.7%, 15.6%, which includes 3.6%; 1.4% taking an opioid pain medication). CONCLUSION: In this geographically and ethnically diverse cohort of nulliparous pregnant women, medication use was nearly universal and polypharmacy was common. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01322529.

Pain is an Independent Risk Factor for Failed Global Endometrial Ablation.

STUDY OBJECTIVE: To determine whether pain, as part of an indication for global endometrial ablation, is an independent risk factor for failure. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Academic-affiliated community hospital. PATIENTS: Women undergoing global endometrial ablation with radiofrequency ablation (RFA), hydrothermablation (HTA), or uterine balloon ablation (UBA) between January 2003 and December 2015. INTERVENTIONS: Procedure failure was defined as subsequent hysterectomy after the index ablation. MEASUREMENTS AND MAIN RESULTS: A total of 5818 women who underwent an endometrial ablation were identified, including 3706 with RFA (63.7%), 1786 with HTA (30.7%), and 326 with UBA (5.6%). Of the 5818 ablations, 437 (7.5%) involved pain (i.e., pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, or adenomyosis) before ablation, along with abnormal uterine bleeding. Pain as part of the preoperative diagnoses before endometrial ablation was a significant risk factor for subsequent hysterectomy compared with all other diagnoses (19.2% vs 13.5%; p = .001). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which held true even when one of the indications for ablation was related to pain (odds ratio, 0.96/year; 95% confidence interval, 0.95-0.97). When the pathology reports of women who underwent a hysterectomy were examined, women in the pain group had lower rates of adenomyosis than women without pain (38.1% vs 50.1%; p = .04). However, there was a trend toward a higher rate of endometriosis on pathology reports (14.3% vs 8.7%; p = .09) and even higher rates of visualized endometriosis identified by operative reports in women who had pain before their ablation (42.9% vs 15.8%; p < .001). Patients who had pain before their ablation were less likely to have myomas/polyps (p = .01). CONCLUSION: Pelvic pain before global endometrial ablation is an independent risk factor for failure.

Incidence and predictors of failed second-generation endometrial ablation.

BACKGROUND: The need for any treatment following an endometrial ablation is frequently cited as "failed therapy," with the two most common secondary interventions being repeat ablation and hysterectomy. Since second-generation devices have become standard of care, no large cohort study has assessed treatment outcomes with regard to only these newer devices. We sought to determine the incidence and predictors of failed second-generation endometrial ablation, defined as the need for surgical re-intervention.We performed a retrospective cohort study at a single academic-affiliated community hospital. Subjects included women undergoing second-generation endometrial ablation for benign indications between October 2003 and March 2016. Second-generation devices utilized during the study period included the radiofrequency ablation device (RFA), hydrothermal ablation device (HTA), and the uterine balloon ablation system (UBA). RESULTS: Five thousand nine hundred thirty-six women underwent endometrial ablation at a single institution (3757 RFA (63.3%), 1848 HTA (31.1%), and 331 UBA (5.6%)). The primary outcome assessed was surgical re-intervention, defined as hysterectomy or repeat endometrial ablation. Of the total 927 (15.6%) women who required re-intervention, 822 (13.9%) underwent hysterectomy and 105 (1.8%) underwent repeat endometrial ablation. Women who underwent re-intervention were younger (41.6 versus 42.9 years, p < .001), were more often African-American (21.8% versus 16.2%, p < .001), and were more likely to have had a primary radiofrequency ablation procedure (hazard ratio 1.37; 95%CI 1.01 to 1.86). Older age was associated with decreased risk for treatment failure with women older than 45 years of age having the lowest risk for failure (p < .001). Age between 35 and 40 years conferred the highest risk of treatment failure (HR 1.59, 95% CI 1.32-1.92). Indications for re-intervention following ablation included menorrhagia (81.8%), abnormal uterine bleeding (27.8%), polyps/fibroids (18.7%), and pain (9.5%). CONCLUSION: Surgical re-intervention was required in 15.6% of women who underwent second-generation endometrial ablation. Age, ethnicity, and radiofrequency ablation were significant risk factors for failed endometrial ablation, and menorrhagia was the leading indication for re-intervention.

Postpartum Emergency Department Visits and Inpatient Readmissions in a Medicaid Population of Mothers.

BACKGROUND: Little comprehensive literature exists to broadly examine risk factors for emergency department (ED) utilization or inpatient admission after obstetrical delivery. MATERIALS AND METHODS: We conducted a retrospective cohort study of Medicaid-insured women from 2009 to 2012 who delivered at a regional perinatal center in the Mid-Atlantic. Women were included if Medicaid was the primary payer of record for the delivery and there was continuous 9-month predelivery Medicaid eligibility. Electronic obstetrical data were linked to Medicaid claims for 9-month prenatal and 6-month postpartum care following delivery. Negative binomial regression was used to examine factors associated with an ED visit; multivariable logistic regression was used to examine factors associated with hospital admission. RESULTS: Following 4484 births, 1564 (34.9%) mothers had an ED visit, and 298 (6.6%) a hospital admission, within 6 months of delivery. Mother's race was significantly associated with both ED visits and inpatient admissions, whereas age and marital status were associated with ED use. Medical comorbidities, tobacco and substance use, cesarean delivery, and severe obstetrical morbidity were associated with both ED visits and hospital admission. In addition, both prenatal opioid use and bipolar disorder increased the odds of ED use and hospital admission. CONCLUSIONS: Medical, social, and behavioral characteristics of women, as well as cesarean delivery, were associated with increased medical utilization in the postpartum.

Development and validation of a spontaneous preterm delivery predictor in asymptomatic women.

BACKGROUND: Preterm delivery remains the leading cause of perinatal mortality. Risk factors and biomarkers have traditionally failed to identify the majority of preterm deliveries. OBJECTIVE: To develop and validate a mass spectrometry-based serum test to predict spontaneous preterm delivery in asymptomatic pregnant women. STUDY DESIGN: A total of 5501 pregnant women were enrolled between 17(0/7) and 28(6/7) weeks gestational age in the prospective Proteomic Assessment of Preterm Risk study at 11 sites in the United States between 2011 and 2013. Maternal blood was collected at enrollment and outcomes collected following delivery. Maternal serum was processed by a proteomic workflow, and proteins were quantified by multiple reaction monitoring mass spectrometry. The discovery and verification process identified 2 serum proteins, insulin-like growth factor-binding protein 4 (IBP4) and sex hormone-binding globulin (SHBG), as predictors of spontaneous preterm delivery. We evaluated a predictor using the log ratio of the measures of IBP4 and SHBG (IBP4/SHBG) in a clinical validation study to classify spontaneous preterm delivery cases (<37(0/7) weeks gestational age) in a nested case-control cohort different from subjects used in discovery and verification. Strict blinding and independent statistical analyses were employed. RESULTS: The predictor had an area under the receiver operating characteristic curve value of 0.75 and sensitivity and specificity of 0.75 and 0.74, respectively. The IBP4/SHBG predictor at this sensitivity and specificity had an odds ratio of 5.04 for spontaneous preterm delivery. Accuracy of the IBP4/SHBG predictor increased using earlier case-vs-control gestational age cutoffs (eg, <35(0/7) vs ≥35(0/7) weeks gestational age). Importantly, higher-risk subjects defined by the IBP4/SHBG predictor score generally gave birth earlier than lower-risk subjects. CONCLUSION: A serum-based molecular predictor identifies asymptomatic pregnant women at risk of spontaneous preterm delivery, which may provide utility in identifying women at risk at an early stage of pregnancy to allow for clinical intervention. This early detection would guide enhanced levels of care and accelerate development of clinical strategies to prevent preterm delivery.

Morcellation and the Incidence of Occult Uterine Malignancy: A Dual-Institution Review.

OBJECTIVES: To determine the incidence of unsuspected uterine sarcoma (UtSarc), other uterine malignancies, and potential malignancies at the time of hysterectomy or myomectomy using power morcellation. METHODS: We performed a retrospective cohort study of all women undergoing myomectomy or hysterectomy using power morcellation at 2 institutions between January 1, 2004, and May 31, 2015. The primary outcome was the incidence of uterine malignancy (UM). The predefined secondary outcome was the occurrence of other conditions associated with malignant behavior. For analysis, any UtSarc or endometrial cancer was categorized as a "uterine malignancy," whereas other pathologies with cytologic atypia were categorized as "uterine premalignant disease" (UPM). All other pathological results were classified as "nonmalignant." RESULTS: A total of 1004 women underwent hysterectomy or myomectomy using power morcellation during the studied period. Two women (1/502; 95% confidence interval [CI], 1/4144-1/139) were found to have UM pathology, 2 endometrial carcinomas and none with UtSarc (97.5% CI, 0-1/273). Six (1/167; 95% CI, 1/455-1/77) women were found to have UPM on final pathology: 2 atypical leiomyomas, 1 STUMP (smooth muscle tumors of uncertain malignant potential), and 3 endometrial atypical hyperplasias. Women with UM had uteri that weighed more than those with NM pathology (840 g vs 217.7 g, P = 0.028), and this trend was also seen with UM and UPM (435.0 g vs 217.2 g, P = 0.081). Women with UM and UPM were more likely to have a preoperative surgical indication of "uterine leiomyoma" compared with other benign etiologies (P < 0.001). CONCLUSIONS: Among this cohort, all cases of unsuspected UM at the time of myomectomy or hysterectomy using power morcellation were found to be endometrial carcinoma. Unsuspected UM pathology had an incidence of 1 of 502. Factors associated with increased likelihood of UM or UPM were greater uterine weight and leiomyoma as the surgical indication.

Impact of a robotic surgical system on hysterectomy trends.

OBJECTIVE: To determine the impact of introduction of a robotic surgical system on hysterectomy trends. METHODS: A retrospective, cohort study using longitudinal medical records from a tertiary care community hospital was used to determine the surgical approach to hysterectomy. For the purposes of analysis, surgical approaches were categorized as robotically assisted, laparoscopic, laparotomy, vaginal, or laparoscopically assisted vaginal. RESULTS: A total of 4,440 women underwent a hysterectomy between January 2007 and December 2012 (benign gynecology N = 3,127, gynecologic oncology N = 1,001, urogynecology N = 312). Amongst benign gynecologists, during the five years following introduction of the robotic system, the rate of hysterectomy performed via laparotomy decreased from 62.2 percent to 39.1 percent, p-value < 0.001. The rate of robotically assisted hysterectomy increased from 0.0 percent to 26.4 percent, p-value < 0.001. When subspecialties were examined, the rate of hysterectomy performed by a gynecologic oncologist via laparotomy decreased from 89.7 percent to 20.0 percent, p-value < 0.001. The rate of robotically assisted hysterectomy increased from 0.0 percent to 78.3 percent, p-value < 0.001. Amongst urogynecologists, the rate of hysterectomy performed vaginally decreased from 80.0 percent to 33.6 percent, p-value < 0.001, while the rate of robotically assisted hysterectomy increased from 0.0 percent to 54.2 percent, p-value < 0.001. CONCLUSIONS: The percentage of robotically assisted hysterectomies has dramatically increased and is now the primary modality for performing hysterectomy amongst subspecialists.

Clopidogrel use throughout pregnancy in a patient with a drug-eluting coronary stent.

BACKGROUND: Little information regarding the potential implications of drug-eluting stents and clopidogrel on pregnancy exists. CASE: We report a case of a 27-year-old woman who received a drug-eluting coronary stent for an acute myocardial infarction and was started on clopidogrel as treatment. She was on clopidogrel when she conceived and delivered a child by cesarean. Her postpartum course was complicated by postoperative bleeding requiring transfusion. CONCLUSION: This case highlights the perinatal and peripartum concerns of these interventions in women of childbearing age. It suggests that cesarean delivery is associated with an elevated risk of perioperative bleeding and may best be approached like other surgical procedures, with the optimal timing of surgery, when feasible, being 5 or more days after the discontinuation of clopidogrel.

Necrotizing cervical and uterine infection in the postpartum period caused by group A streptococcus.

BACKGROUND: Group A Streptococcus, once the most common causes of puerperal sepsis, is now a rare cause of postpartum fever. CASE: A term 27-year-old woman presented after spontaneous membrane rupture. After an uncomplicated vaginal delivery, she became febrile without a source of infection. Despite two different antibiotic regimens, she remained febrile for 3 days. A computed tomography scan showed a wedge-shaped discontinuity in the anterior uterus suggesting uterine infection with early abscess formation. The patient underwent exploratory laparotomy and hysterectomy, with an uneventful postoperative course. Uterine pathology revealed a necrotizing infection within the uterus and cervix from Group A Streptococcus. CONCLUSION: Puerperal sepsis from Group A Streptococcus can be a cause of necrotizing infection following delivery. Physicians should be aware of the resurgence of this potentially fatal pathogen.

Placenta accreta and intrauterine fetal death in a woman with prior endometrial ablation: a case report.

BACKGROUND: Few cases of pregnancy following endometrial ablation have been reported. Placenta accreta and poor perinatal outcome are potential risks due to underlying endometrial destruction and uterine scarring. CASE: A 41-year-old, white woman presented for initial prenatal care at 12 weeks, 3 years after endometrial ablation with resection of a leiomyoma. The patient's prenatal care was unremarkable until 20 weeks, when she presented with intrauterine fetal death. Labor was induced with misoprostol, and a stillborn fetus resulted. The placenta failed to deliver spontaneously after 6 hours and continuing doses of misoprostol. An attempt at manual extraction failed to demonstrate a clear cleavage plane between the placenta and endometrium. The patient underwent a hysterectomy for placenta accreta, which was confirmed on pathology. CONCLUSION: Endometrial ablation may predispose the patient to abnormal placentation and intrauterine fetal death. Physicians should counsel their patients appropriately about the likelihood of this outcome.