Obstetric outcomes in women with vulvodynia or vaginismus.

PURPOSE: Vulvodynia and vaginismus are common chronic vulvar pain disorders for which there is a paucity of literature on pregnancy outcomes of affected women. The study objective was to evaluate the associations between vulvodynia and vaginismus and obstetric outcomes. METHODS: We performed a retrospective cohort study including all birth-related admissions from 1999 to October 2015 extracted from the Healthcare Cost and Utilization Project-National Inpatient Sample from the United States. Women with vulvodynia or vaginismus were identified using the appropriate ICD-9 codes. Multivariate logistic regression models, adjusted for baseline maternal characteristics, were performed to evaluate the effect of vulvodynia and vaginismus on obstetrical and neonatal outcomes. RESULTS: A total of 879 obstetrical patients with vulvodynia or vaginismus were identified in our cohort of 13,792,544 patients admitted for delivery in US hospitals between 1999 and 2015, leading to an overall prevalence of 6 cases per 100,000 births. Between 1999 and 2015, the annual prevalence of vulvodynia or vaginismus rose from 2 to 16 cases per 100,000. Vulvodynia and vaginismus were associated with increased risks of eclampsia, chorioamnionitis, post-term pregnancy, cesarean delivery, instrumental vaginal delivery, blood transfusions, prolonged hospital stays, congenital anomalies and intrauterine growth restriction. CONCLUSION: Vulvodynia and vaginismus in pregnancy appears underreported in pregnancy compared to reported population rates. Prevalence of reporting seems to have increased in the last decades and is associated with increased risks of maternal and newborn morbidities. Obstetrical caregivers should be aware of the underreporting of these conditions and the associated adverse effects when counseling obstetrical patients.

Maternal and neonatal outcomes in women with a history of chemotherapy exposure: a population-based study of 8 million obstetric admissions.

PURPOSE: With improvement in cancer care and fertility preservation, increasing numbers of cancer survivors are requiring obstetrical care. The objective of our study was to evaluate the effect of history of chemotherapy exposure on maternal and neonatal outcomes. METHODS: A retrospective population-based cohort study was conducted using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) to obtain data on maternal and newborn outcomes in a cohort of births occurring between the years 2006 and 2015. The annual and overall prevalence of chemotherapy exposure was calculated among pregnant women, and multivariate logistic regression models were used to estimate the effect of history of exposure to chemotherapy on the risk of adverse maternal and newborn outcomes. RESULTS: Of 7,907,139 birth admissions, 613 had a history of chemotherapy exposure for an overall incidence of 7.75 per 100,000 admissions. The prevalence of chemotherapy exposure in pregnancy increased during the study period (P < 0.001). Women with a history of chemotherapy were more likely to suffer from obstetric and medical complications including pre-eclampsia, chorioamnionitis, postpartum hemorrhage, and venous thromboembolism as well as an increased risk in overall mortality (OR 9.39, 95% CI 1.31-67.32). No differences were observed in the incidence of adverse neonatal outcomes, including stillbirth, intra-uterine growth restriction, or preterm birth. CONCLUSION: Women with history of chemotherapy have higher incidence of pregnancy complications and maternal death, with no differences in fetal or newborn outcomes.

Hospital antenatal admissions for threatened preterm labor: how long should we be "observing"?

PURPOSE: We sought to describe temporal trends in hospital admissions for threatened preterm labor (TPTL) and to examine hospital admission duration among women delivered or discharged undelivered. METHODS: We carried out a cohort study on all TPTL admissions among pregnancies with a live singleton fetus and intact membranes between 1999 and 2015 using the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. ICD-9 codes were used to identify women with TPTL. Duration of antenatal admission length of stay was calculated in days following admission to hospital until delivery ("Delivery Admission") or undelivered discharge ("Observation Admission"). Analyses included evaluating trends of birth admissions over total admissions, identifying predictors of delivery using logistic regression, and measuring risk for delivery with increasing duration of antepartum hospitalization. RESULTS: Of 15,335,288 pregnancy admissions, 1,089,987 admissions were for TPTL, with 61.8% being 'Delivery Admissions". During the 16-year study period, overall rates of TPTL admissions declined with a rising proportion of admissions being "Delivery Admissions". "Delivery Admissions" were more common among patients who were older, non-Caucasian, obese, or who had placental abruption. "Observation Admissions" were more common among admissions for antepartum hemorrhage or antepartum spotting. Among all "Delivery Admissions" for TPTL, 89% had delivered within 2 days, 7% delivered within 3-6 days, and 5% delivered beyond 6 days. CONCLUSION: Overall admissions for TPTL declined over the study period with increasing proportions being "Delivery Admissions". Protocols taking into consideration declining risk of preterm birth among patients undelivered after 2 days may be helpful in reducing unnecessary prolonged observation admissions.

Association between obsessive-compulsive disorder and obstetrical and neonatal outcomes in the USA: a population-based cohort study.

Obsessive-compulsive disorder (OCD) is a mental disorder linked to functional impairments and adverse health outcomes. We sought to examine the association between pregnant women with OCD and obstetrical and neonatal outcomes in the USA. A retrospective population-based cohort study was conducted using data provided by pregnant women from the Nationwide Inpatient Sample, a nationally representative database of hospitalizations in the USA, from 1999 to 2015. Using diagnostic and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), we identified births and classified women by OCD status. Demographic and clinical characteristics were compared for women with and without OCD and multivariate logistic regressions were used to obtain odds ratios (OR) to compare obstetrical and neonatal outcomes between the two groups, adjusting for relevant demographic and clinical variables. Between 1999 and 2015, there were 3365 births to women with OCD, corresponding to an overall prevalence of 24.40 per 100,000 births. Women with OCD were more likely to be older than 25, Caucasian, of higher socioeconomic status, smokers or used drugs and alcohol, and have other comorbid psychiatric conditions. In adjusted models, OCD was associated with a higher risk of gestational hypertension, preeclampsia, premature rupture of membranes, caesarean and instrumental deliveries, venous thromboembolisms and preterm birth. Pregnancies in women with OCD are at high risk of adverse obstetrical and neonatal outcomes. A multidisciplinary approach should be used to identify high risk behaviours and ensure adequate prenatal follow-up and care be available for those with high risk pregnancies.

Induction of labor at 39 weeks and risk of cesarean delivery among obese women: a retrospective propensity score matched study.

OBJECTIVES: To evaluate if induction of labor (IOL) in obese women at 39 weeks of gestation decreases the risk of cesarean delivery (CD). METHODS: We conducted a retrospective propensity score matched study using the Center for Disease Control's (CDC's) Period Linked Birth-Infant Death data. The study population consisted of cephalic singleton births to women with BMI greater or equal to 30.0 kg/m2 who delivered at or beyond 39 weeks between 2013 and 2017. Women with prior CD were excluded. Women who underwent IOL at 39 weeks were propensity score matched 1:5 on the basis of CD risk factors to women who did not undergo IOL at 39 weeks but may have had an IOL at a later gestational age. Conditional logistic regression compared CD rates and maternal outcomes between obese women induced at 39 weeks with those not induced at 39 weeks. RESULTS: Our cohort consisted of 197,343 obese women induced at 39 weeks and 986,715 obese women not induced at 39 weeks. Overall, the risk of CD among women who had an IOL at 39 weeks was lower than those without an IOL at 39 weeks, 0.59 (0.58-0.60). The decrease in CD risk was more pronounced in multiparas, 0.47 (0.46-0.49) than nulliparas, 0.81 (0.79-0.83). When stratified by BMI, the effect of IOL on lowering CD risk was similar across all obesity classes. Aside from an increased risk of instrumental deliveries, morbidities were comparable in both groups. CONCLUSIONS: IOL at 39 weeks among obese women appears to lower the risk of CD, without compromising maternal outcomes.

Maternal and neonatal outcomes among pregnant women with myasthenia gravis.

Objectives Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction marked by weakness and fatiguability of skeletal muscle. MG has an unpredictable course in pregnancy. Our purpose was to evaluate the effect of MG on maternal and neonatal outcomes. Methods Using the United States' Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2005 to 2015, we conducted a retrospective cohort study consisting of women who delivered during that period. Multivariate logistic regression models, adjusted for baseline maternal demographics and comorbidities, were used to compare maternal and neonatal outcomes among pregnancies in women with and without MG. Results During the study period, 974 deliveries were to women diagnosed with MG. Women with MG were more likely to be older, African American, obese, have Medicare insurance and be discharged from an urban teaching hospital. Women with MG were also more likely to have chronic hypertension, pre-gestational diabetes, hypothyroidism, and chronic steroid use. Women with MG were at greater risk for acute respiratory failure (OR 13.7, 95% CI 8.9-21.2) and increased length of hospital stay (OR 2.5, 95% CI 1.9-3.3). No significant difference was observed in the risk of preterm premature rupture of membranes, caesarean section or instrumental vaginal delivery. Neonates of women with MG were more likely to be premature (OR 1.4, 95% CI 1.2-1.8). Conclusions MG in pregnancy is a high-risk condition associated with greater risk of maternal respiratory failure and preterm birth. Management in a tertiary care center with obstetrical, neurological, anesthesia and neonatology collaboration is recommended.

Pregnancy outcomes among women with peptic ulcer disease.

Background Little is known about the impact of peptic ulcer disease (PUD) on pregnancy. Our objective was to evaluate the effect of PUD on pregnancy and newborn outcomes. Methods A retrospective cohort study was carried out using the Healthcare Cost and Utilization Project (HCUP)-National Inpatient Sample (NIS) from the United States. The cohort consisted of all births that took place from 1999 to 2015. PUD was classified on the basis of the International Classification of Diseases-Ninth Revision (ICD-9) coding. Multivariate logistic regression was used to evaluate the adjusted effect of PUD on maternal and neonatal outcomes. Results Of the 13,792,544 births in this cohort, 1005 were to women with PUD (7/100,000 births). Between 1999 and 2015, prevalence of PUD in pregnancy increased from 4/100,000 to 11/100,000, respectively. Women with PUD were more commonly older and more likely to have comorbid illnesses. Women with PUD were at greater risk of preeclampsia [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.67-2.66], preterm premature rupture of membranes (PPROM; OR 2.16, 95% CI 1.30-3.59), cesarean delivery (OR 1.60, 95% CI 1.40-1.82), venous thromboembolism (OR 3.77, 95% CI 2.08-6.85) and maternal death (OR 24.50, 95% CI 10.12-59.32). Births to women with PUD were at increased risk of intrauterine growth restriction (IUGR; OR 1.54, 95% CI 1.11-2.14), preterm birth (OR 1.84, 95% CI 1.54-2.21), intrauterine fetal death (OR 2.18, 95% CI 1.35-3.52) and congenital anomalies (OR 2.69, 95% CI 1.59-4.56). Conclusion The prevalence of PUD in pregnancy has risen over the last several years. PUD in pregnancy should be considered a high-risk condition associated with important adverse maternal and neonatal outcomes.

Neonatal outcomes of pregnancy-associated breast cancer: Population-based study on 11 million births.

BACKGROUND: As the age at first pregnancy continues to rise in the United States so does the incidence of breast cancer diagnosed during pregnancy. Our objective was to evaluate temporal trends in the incidence of pregnancy-associated breast cancer (PABC) and to measure neonatal outcomes associated with PABC. METHODS: We conducted a population-based cohort study using the 1999-2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) from the United States. Logistic regression models, adjusted for maternal baseline characteristics, examined the effect of PABC on neonatal outcomes. RESULTS: There were 11 846 300 deliveries between 1999 and 2012, of which 772 cases of PABC were identified, resulting in an overall incidence of 6.5 cases/100 000 pregnancies. There was a significant increase in the incidence of PABC during the study period (P < 0.05). Women with PABC tended to be older, of white ethnicity, belong to a higher income quartile and to be treated in an urban teaching hospital. In pregnancies complicated by breast cancer, there was a greater risk of preterm delivery (OR 4.84, 95% CI 4.05-5.79) and preterm premature rupture of membranes (OR 1.79, 95% CI 1.06-3.05). No associations were observed between PABC and intrauterine growth restriction, congenital anomalies or intrauterine fetal demise. CONCLUSION: There is an uptrend in the incidence of PABC and therefore, the need for counseling these patients is also increasing. Although pregnancies with the diagnosis of maternal breast cancer are more prone to premature births, it is encouraging that these babies do not appear to be at increased risk for congenital anomalies, growth restriction, or fetal demise.

Robotic Radical Hysterectomy for Cervical Cancer: A Population-Based Study of Adoption and Immediate Postoperative Outcomes in the United States.

STUDY OBJECTIVE: To compare the use of robotic radical hysterectomy (RRH) and abdominal radical hysterectomy (ARH) in the United States, with secondary outcomes of perioperative complications, hospital length of stay (LOS), immediate postoperative mortality, cost and a subanalysis compared with laparoscopic radical hysterectomy (LRH). DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Data from the National Inpatient Sample (NIS), a government-funded database of hospitalization in the United States. PATIENTS AND INTERVENTIONS: All women with cervical cancer undergoing RH between 2008 and 2015 in the United States and included in the NIS database. MEASUREMENTS AND MAIN RESULTS: Trends in surgical modality, baseline characteristics, LOS, perioperative outcomes, mortality, and hospital charges were compared between RRH and ARH. Regression models were adjusted for baseline characteristics. Among 41,317 women with cervical cancer, 3563 underwent RH, including 21.0% with a robotic procedure, 6.5% with a laparoscopic procedure, and 72.5% with open surgery. The annual rates of ARH declined significantly over the study period, whereas those of RRH increased. Baseline characteristics were comparable between the RRH and ARH groups. Compared with the ARH group, women undergoing RRH had a lower rate of cumulative postoperative complications (18.16% vs 21.21%; odds ratio [OR], 0.81; 95% confidence interval [CI], 0.6-1.0; p = .05), including lower rates of wound infection (0.27% vs 1.82%; OR, 0.14; 95% CI, 0.03-0.6; p < .01), sepsis (0.27% vs 1.20%; OR, 0.22; 95% CI, 0.05-0.9; p = .03), fever (1.87% vs 4.06%; OR, 0.44, 95% CI, 0.3-0.8; p < .01), and ileus (2.8% vs 9.13%; OR, 0.28; 95% CI, 0.12-0.4; p < .01). The LOS was significantly shorter in the RRH group (median, 2 days vs 4 days; p < .01). The total median hospitalization charge was $47,218 for the RRH group, compared with $38,877 for the ARH group (p < .01). CONCLUSION: RRH is being increasingly performed in the United States and is associated with shorter LOS and less postoperative morbidity; however, long-term oncologic outcomes require additional attention.

Behcet's disease and pregnancy: obstetrical and neonatal outcomes in a population-based cohort of 12 million births.

Background Behcet's disease (BD) is a rare, multi-systemic inflammatory disorder for which only limited and contradictory data exists in the context of pregnancy. Our objective was to estimate the prevalence of BD in pregnancy and to evaluate maternal and fetal outcomes associated with pregnant women living with BD. Methods Using the 1999-2013 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from the United States, we performed a population-based retrospective cohort study consisting of pregnancies that occurred during this time period. ICD-9 codes were used to identify delivery admissions to women with or without BD. Multivariate logistic regression was used to estimate the adjusted effects of BD on maternal and fetal outcomes. Results Among the 12,592,676 pregnancies in our cohort, 144 were to women with BD, for an overall prevalence of 1.14 cases/100,000 births between 1999 and 2013. Over the study period, the prevalence of BD rose from 0.5 to 2.4/100,000 births. Women with BD demonstrated a two-fold greater frequency of non-delivery hospital admissions during pregnancy, and were more likely to be Caucasian, have private medical insurance, be of the upper income quartiles, and deliver at an urban teaching hospital. Women with BD were at greater risk for preterm labor and postpartum venous thromboembolism, while their newborns were more likely to be born premature. Conclusion BD-associated pregnancies are increasing in prevalence and are associated with a greater risk for adverse maternal and fetal outcomes in pregnancy. Appropriate thromboprophylaxis during pregnancy should be considered given the increased risk for venous thromboembolism.

Pregnancy outcomes after thyroid cancer.

Background Thyroid cancer is one of the most common cancers in women of reproductive age. Our purpose was to evaluate the association between thyroid cancer and maternal and neonatal outcomes of pregnancy. Methods We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) database from the US. A cohort consisting of women who delivered between 1999 and 2014 was created. Multivariate logistic regression, controlling for baseline maternal characteristics, was used to compare pregnancy complications and neonatal outcomes of pregnant women with thyroid cancer [International Classification of Diseases, ninth edition (ICD-9) code 193] diagnosed before or during pregnancy with those of the obstetric population without thyroid cancer. Results The study included 14,513,587 pregnant women, of which 581 women had a diagnosis of thyroid cancer (4/100,000). During the observation period, there was an upward trend in the prevalence of thyroid cancer among pregnant women, though not statistically significant (P = 0.147). Women with thyroid cancer were more likely to be Caucasian, belong to a higher income quartile, have private insurance, to be discharged from an urban teaching hospital and to have pre-gestational hypertension. Women with thyroid cancer had a greater chance of delivering vaginally, requiring transfusion of blood and developing venous thromboembolism (VTE). Neonates of mothers with thyroid cancer were not found to be at increased risk for the adverse neonatal outcomes examined, specifically, congenital malformations, intrauterine growth restriction, fetal death and preterm labor. Conclusion Pregnancies complicated by thyroid cancer have higher incidences of VTE and need for transfusions, with comparable overall newborn outcomes.

Effect of Sjögren's syndrome on maternal and neonatal outcomes of pregnancy.

Background Sjögren's syndrome (SS) is an autoimmune connective tissue disease affecting the body's moisture-producing glands. Some studies have linked SS to adverse maternal/neonatal outcomes, but sample sizes have tended to be small, with few outcomes examined. The purpose of this study was to evaluate the effect of SS on pregnancy outcomes for mother and neonate using a large dataset. Methods We carried out a retrospective cohort study of women who delivered between 1999 and 2014 using data from the Nationwide Inpatient Sample from the United States. SS categorization is based on ICD-9 coding. Baseline characteristics were compared in both groups and multivariate logistic regression was used to compare maternal and fetal outcomes of pregnancies in women with and without SS. Results The prevalence of SS in our population was 1.34 cases/10,000 births, with the rate increasing over the study period. Women with SS tended to be older, Caucasian and to have pre-existing comorbidities. Births to women with SS were at greater risk of pre-eclampsia [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.34-1.99]; premature rupture of membranes (OR 1.28, 95% CI 1.04-1.57); preterm delivery (OR 1.56, 95% CI 1.34-1.81); cesarean delivery (OR 1.29, 95% CI 1.17-1.41); and venous thromboembolic events (OR 3.71, 95% CI 2.57-5.35). Infants of women with SS were more likely to have intrauterine growth restriction (IUGR) (OR 3.00, 95% CI 2.46-3.65); and congenital malformations (OR 3.26, 95% CI 2.30-4.62). Conclusion SS is a high-risk pregnancy condition associated with significant comorbidities and adverse maternal and fetal outcomes. Women with SS may benefit from increased surveillance during their pregnancies.

Effect of Pregnancy on the Management and Outcomes of Ovarian Torsion: A Population-Based Matched Cohort Study.

STUDY OBJECTIVE: To compare the treatment and surgical outcomes of ovarian torsion in pregnant and nonpregnant women. DESIGN: A population-based matched cohort study (Canadian Task Force classification II.1). SETTING: The United States Health Care Cost and Utilization Project Nationwide Inpatient Sample from 2003 to 2011. PATIENTS: All cases of ovarian torsion among pregnant women and nonpregnant women with ovarian torsion (matched by age in a ratio of 1:1). INTERVENTIONS: Outcomes of interest included the type of treatment received for ovarian torsion and the complications of surgery. MEASUREMENTS AND MAIN RESULTS: There were 1366 women diagnosed with ovarian torsion among 8 532 163 pregnant women for an incidence of 1.6 in 10 000. Surgery was the predominant treatment, with laparotomy being more commonly performed on pregnant women versus nonpregnant women (57.0% vs 51.0%; odds ratio = 1.28; 95% confidence interval, 1.08-1.51; p < .01). Overall conservative management was less likely performed; however, it was more common among pregnant women versus nonpregnant women (odds ratio = 1.85; 95% confidence interval, 1.44-2.37; p < .01). In general, adverse events were uncommon in both groups although ovarian infarction was more commonly reported among nonpregnant women. CONCLUSION: The diagnosis of ovarian torsion in pregnancy is rare. Compared with nonpregnant women, laparotomy and conservative management are more common among pregnant women. Treatment of ovarian torsion in pregnancy has comparable outcomes with treatment in nonpregnant women.

Effect of Maternal and Pregnancy Risk Factors on Early Neonatal Death in Planned Home Births Delivering at Home.

OBJECTIVE: The prevalence of home birth in the United States is increasing, although its safety is undetermined. The objective of this study was to investigate the effects of obstetrical risk factors on early neonatal death in planned home births delivering at home. METHODS: The authors conducted a retrospective 3-year cohort study consisting of planned home births that delivered at home in the United States between 2011 and 2013. The study excluded infants with congenital and chromosomal anomalies and infants born at ≤34 weeks' gestation. Multivariate logistic regression models were used to estimate the adjusted effects of individual obstetrical variables on early neonatal deaths within 7 days of delivery. RESULTS: During the study period, there were 71 704 planned and delivered home births. The overall early neonatal death rate was 1.5 deaths per 1000 planned home births. The risks of early neonatal death were significantly higher in nulliparous births (OR 2.71; 95% CI 1.71-4.31), women with a previous CS (OR 2.62, 95% CI 1.25-5.52), non-vertex presentations (OR 4.27; 95% CI 1.33-13.75), plural births (OR 9.79; 95% CI 4.25-22.57), preterm births (OR 4.68; 95% CI 2.30-9.51), and births at ≥41 weeks of gestation (OR 1.76; 95% CI 1.09-2.84). CONCLUSION: Early neonatal deaths occur more commonly in certain obstetrical contexts. Patient selection may reduce adverse neonatal outcomes among planned home births.

Recommendation Patterns among Gynaecologists and Radiologists for Adnexal Masses on Ultrasound.

OBJECTIVE: Ultrasound is the primary modality used to evaluate adnexal lesions. Follow-up recommendations for ovarian cysts remain controversial between gynaecologists and radiologists. The objective of this study was to compare practice patterns for adnexal masses described on ultrasound on the basis of the interpreter's field of specialty. METHODS: This study was conducted within the McGill University Hospital Network at two hospitals that differ in the department of interpretation of pelvic ultrasounds. In one hospital, all studies are reported by gynaecologists, and in the other, by radiologists. The study investigators collected data from pelvic ultrasounds of newly diagnosed ovarian lesions performed from May to June 2014. Multivariate logistic regression analyses were used to compare recommendation patterns between the two groups. RESULTS: A total of 201 of 1110 pelvic ultrasound studies performed met our inclusion criteria. Gynaecologists interpreted 69 (34%) pelvic ultrasounds, and radiologists reported on 132 (66%). Reported adnexal mass types were not significantly different between the two groups. As compared with gynaecologists, radiologists were more likely to recommend MRI or CT scans (OR 11.76; 95% CI 1.17-117.78), as well as follow-up ultrasound studies (OR 4.67; 95% CI 1.66-13.1), and they were less likely to recommend no further imaging (OR 0.18; 95% CI 0.07-0.45). Groups did not differ in recommendation patterns for referral to a specialist. CONCLUSION: There are significant differences in recommendation patterns between gynaecologists and radiologists in evaluating new adnexal masses on ultrasound. This difference can have important effects on resource use and patients' concerns.

Laparoscopic and Robotic-Assisted Hysterectomy for Uterine Leiomyomas: A Comparison of Complications and Costs.

OBJECTIVE: Robotic surgery is increasingly being used for treatment of malignant and benign gynaecologic diseases. The purpose of our study is to compare patient perioperative complications and costs of laparoscopic versus robotic-assisted hysterectomy for uterine leiomyomas. METHODS: A retrospective cohort study using the Nationwide Inpatient Sample database from the United States was conducted, comparing patients who underwent robotic-assisted hysterectomy and laparoscopic hysterectomy (total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy) for uterine fibroids between 2008 and 2012. Baseline characteristics were compared between the two groups, and logistic regression was used to compare postoperative outcomes between laparoscopic and robotic approaches. Direct costs were compared between the two groups using linear regression models. RESULTS: Over a five-year period, the total number of hysterectomies performed increased. Patients undergoing robotic hysterectomy were older and had more comorbidities. In adjusted analyses, women who underwent robotic surgery were more likely to have respiratory failure (0.71% vs. 0.39%; P < 0.0108), postoperative fever (1.05% vs. 0.67%, P < 0.0002), and ileus (1.76% vs. 1.3%; P < 0.0060), and less likely to require transfusions (3.4% vs. 3.96%; P < 0.0037). Robotic surgery was consistently more expensive, with a median cost of $33 928.00 compared with $23 753.00 for laparoscopic hysterectomy. CONCLUSION: While there are only slight differences in postoperative complications between laparoscopic-assisted hysterectomy and robotic-assisted hysterectomy, robotic-assisted hysterectomy is associated with considerably greater direct costs. Unless specific indications for robotic-assisted hysterectomy exist, laparoscopic-assisted hysterectomy should be the preferred approach for minimally invasive surgical treatment of leiomyomas.

Evaluation of management and surgical outcomes in pregnancies complicated by acute cholecystitis.

OBJECTIVE: To evaluate the management of pregnancies complicated by acute cholecystitis (AC) and determine whether pregnant women are more likely to have medical and surgical complications. METHODS: We carried out a population-based matched cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011. Pregnant women with AC were age matched to non-pregnant women with AC on a 1:5 ratio. Management and outcomes were compared using descriptive analysis and conditional logistic regression. RESULTS: There were 11,835 pregnant women admitted with AC who were age matched to 59,175 non-pregnant women. As compared to non-pregnant women, women with AC were more commonly managed conservatively, odds ratio (OR) 6.1 (5.8-6.4). As compared to non-pregnant women, pregnant women with AC more commonly developed sepsis [OR 1.4 (1.0-1.9)], developed venous thromboembolism [OR 8.7 (4.3-17.8)] and had bowel obstruction [OR 1.3 (1.1-1.6)]. Among pregnant women with AC, surgical management was associated with a small but significant increased risk of septic shock and bile leak. CONCLUSION: AC, in the context of pregnancy, is associated with an increased risk of adverse outcomes. Although the literature favors early surgical intervention, pregnancies with AC appear to be more commonly managed conservatively with overall comparable outcomes to surgically managed AC. Conservative management may have a role in select pregnant women with AC.

The effects of tocolysis on neonatal septic death in women with PPROM: a retrospective cohort study.

PURPOSE: In women with preterm premature rupture of membranes (PPROM), particularly those with suspected chorioamnionitis, the benefit of tocolysis on neonatal outcome remains unclear. Our purpose was to evaluate the effect of tocolysis on neonatal septic death in women with PPROM with and without chorioamnionitis. METHODS: A retrospective cohort study was used to address our study objective. We created a cohort consisting of all live births between 24 and 32 weeks' gestation that were registered in the Linked Birth and Infant Death data files (2009-2013) from the United States. Multivariate logistic regression was used to evaluate the effect of tocolysis on neonatal septic death at 7 and 28 days in births with and without chorioamnionitis. RESULTS: Of the 46,968 births that met our inclusion criteria, tocolysis was administered to 6264 (13.3%). Tocolysis was more commonly prescribed to Caucasians, smokers, in multiple birth pregnancies, and to women with a history of preterm births. Tocolysis was not significantly associated with neonatal septic death at 7 days (OR 0.66, 95% CI 0.39-1.13) or at 28 days (OR 0.85, 95% CI 0.60-1.19). This was consistent in pregnancies with and without chorioamnionitis. Furthermore, tocolysis was associated with a reduced risk of neonatal septic death at 7 days when administered between 24 and 27 weeks' gestation (OR 0.44, 95% CI 0.22-0.88). CONCLUSIONS: In the setting of PPROM, tocolysis does not appear to increase the risk of neonatal septic death at 7 and 28 days. Therefore, consideration should be given to its administration if clinically indicated.

The effect of assisted reproductive technology on the incidence of birth defects among livebirths.

PURPOSE: Our study objective is to examine the association between births conceived with assisted reproductive technology (ART) and birth defects using a large database from the United States. METHODS: Using the Centers for Disease Control and Prevention's Period-linked birth-infant death data files and fetal death database for 2011-2013, we conducted a retrospective cohort study comprised of live births that occurred in the USA during that time. Multivariate logistic regression was used to estimate the association between ART and birth defects, both overall and by specific defects. RESULTS: There were 11,862,780 live births between 2011 and 2013. Of these births, 11,791,730 were spontaneous pregnancies and 71,050 were conceived by ART, with an increasing trend in incidence of ART during the study period and an overall increasing trend of birth defects. Overall, infants conceived by ART had a greater risk of having birth defects than did infants conceived spontaneously (77/10,000 vs 25/10,000, respectively, OR 2.14, 95% CI 1.94-2.35). The malformations most commonly associated with ART were cyanotic heart defects (OR 2.74, 95% CI 2.42-3.09), cleft lip and/or palate (OR 1.47, 95% CI 1.14-1.89), and hypospadias (OR 1.77, 95% CI 1.42-2.19). There were no differences in risk of omphalocele or neural tube defects between the two groups. CONCLUSIONS: There is an overall and type-specific increased risk of birth defects in the ART population. Appropriate counseling and specialized ultrasound evaluations should be considered in pregnancies conceived by ART.

Medical and obstetric outcomes among pregnant women with tuberculosis: a population-based study of 7.8 million births.

BACKGROUND: Worldwide, tuberculosis remains a major health concern, with an estimated 9.6 million people infected in the year 2014, of which one-third were women. Tuberculosis is estimated to be even more prevalent in pregnant women than the general population. To date there has been conflicting evidence on the maternal and neonatal complications of tuberculosis in pregnancy. OBJECTIVE: We sought to determine trends in the incidence of tuberculosis in pregnancy and to examine the associations between tuberculosis in pregnancy and maternal and fetal complications. STUDY DESIGN: We conducted a retrospective cohort study using the 2003 through 2011 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. We identified hospital admissions during which women with and without tuberculosis delivered. The temporal patterns in incidence of tuberculosis were estimated, as were the rates of pulmonary and nonpulmonary tuberculosis. Multivariate logistic regression was used to examine the adjusted effects of tuberculosis on maternal and neonatal outcomes. RESULTS: During the study period, there were 7,772,999 births, of which 2064 were to women with tuberculosis, for an overall incidence of 26.6 per 100,000 births. From 2003 through 2011, there was an upward trend in the incidence of tuberculosis from 1.92-4.06 per 10,000 births (P < .0001), mostly due to increasing numbers of nonpulmonary tuberculosis. Compared with noncases, tuberculosis occurred with greater frequency in women who were 25-34 years of age and of Hispanic ethnicity. Significantly more women with tuberculosis had concurrent HIV. In addition, delivery hospitalizations with tuberculosis compared with those without tuberculosis were more likely to experience chorioamnionitis, preterm labor, postpartum anemia, blood transfusion, pneumonia, acute respiratory distress syndrome, and mechanical ventilation. Maternal mortality was significantly increased in women with tuberculosis. Congenital anomalies were higher among babies delivered to women with tuberculosis. CONCLUSION: The rate of tuberculosis in pregnancy is rising in the United States. Although this increase appears to be mostly due to nonpulmonary disease, there was also a high incidence of maternal respiratory complications, mortality, and postpartum obstetric morbidity.