First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry.

BACKGROUND: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

Racial bias in cesarean decision-making.

BACKGROUND: Category II fetal heart tracing noted during continuous external fetal monitoring is a frequent indication for cesarean delivery in the United States despite its somewhat subjective interpretation. Black patients have higher rates of cesarean delivery and higher rates for this indication. Racial bias in clinical decision-making has been demonstrated throughout medicine, including in obstetrics. OBJECTIVE: We sought to examine if racial bias affects providers' decisions about cesarean delivery for an indication of category II fetal heart tracings. STUDY DESIGN: We constructed an online survey study consisting of 2 clinical scenarios of patients in labor with category II tracings. Patient race was randomized to Black and White; the vignettes were otherwise identical. Participants had the option to continue with labor or to proceed with a cesarean delivery at 3 decision points in each scenario. Participants reported their own demographics anonymously. This survey was distributed to obstetrical providers via email, listserv, and social media. Data were analyzed using chi-square tests at each decision point in the overall sample and in subgroup analyses by various participant demographics. RESULTS: A total of 726 participants contributed to the study. We did not find significant racial bias in cesarean delivery decision-making overall. However, in a scenario of a patient with a previous cesarean delivery, Fisher's exact tests showed that providers <40 years old (n=322; P=.01) and those with <10 years of experience (n=239; P=.050) opted for a cesarean delivery for Black patients more frequently than for White patients at the first decision point. As labor progressed in this scenario, the rates of cesarean delivery equalized across patient race. CONCLUSION: Younger providers and those with fewer years of clinical experience demonstrated racial bias in cesarean delivery decision-making at the first decision point early in labor. Providers did not show racial bias as labor progressed, nor in the scenario with a patient without a previous cesarean delivery. This bias may be the consequence of provider training with the Maternal-Fetal Medicine Unit Network Vaginal Birth After Cesarean Calculator, developed in 2007, and widely used to estimate the probability of successful vaginal birth after a cesarean delivery. This calculator used race as a predictive factor until it was removed in June 2021. Future studies should investigate if this bias persists following this change, while also focusing on interventions to address these findings.

Accuracy of anemia screening by point-of-care hemoglobin testing in patients seeking abortion.

OBJECTIVE: Accurate and timely diagnosis of anemia in pregnancy is necessary for safe management of abortion care. Screening for anemia in abortion care is often accomplished using commercially-available point-of-care tests from capillary blood, but the validity of this test has not been investigated in the context of abortion care. We sought to determine the accuracy of a capillary hemoglobin (Hb) among pregnant patients seeking induced abortion. STUDY DESIGN: We conducted a retrospective study of patients seeking abortion care at the University of Illinois at Chicago. We identified 108 subjects with paired capillary Hb and venous complete blood count (CBC) hemoglobin measurements within 7 days of each other and within 14 days before abortion. Agreement analysis was performed using Passing-Bablok regression and Bland-Altman plots. RESULTS: More patients were deemed anemic by capillary than by venous Hb measurement (32% vs 19%, p = 0.030). Capillary Hb correlated with venous Hb (r = 0.85, p < 0.001). The average bias for capillary Hb was -1.1 ± 1.0 g/dL. Step-wise, multivariable linear regression identified venous Hb as the only determinant of capillary Hb, and failed to identify any other predictors of bias. The agreement analysis between capillary and venous Hb by Passing-Bablok regression demonstrated systematic and proportional differences. CONCLUSION: Results from capillary Hb may be biased toward diagnosing anemia and should be interpreted with caution. IMPLICATIONS: Misdiagnosing anemia in abortion care can have several consequences and may prevent timely medical abortion or cause delayed procedural abortion. Clinical correlation, and possibly confirmation by venous complete blood count measurement, should be considered before clinical decision-making based solely upon the capillary point-of-care assay.

Peripartum Cardiomyopathy: Management Strategies for Pregnancy Termination.

Some women have underlying cardiovascular disease that leads to increased morbidity and mortality with pregnancy. These women may choose to terminate a pregnancy rather than face this increased risk. The optimal approach for pregnancy termination in women with cardiomyopathy is not well defined. We present two women with peripartum cardiomyopathy, both modified World Health Organization (mWHO) class IV and with elevated Cardiac Disease in Pregnancy (CARPREG II) pregnancy risk stratification scores who are at the highest risk for pregnancy continuation. Both underwent induced abortion, although the procedure was performed in very different settings. These cases illustrate factors that influence the mode and setting of pregnancy termination performance.

Patient preferences for method of cesarean skin closure: secondary outcomes from a randomized trial.

Objective: To assess patient preference for sutures or staples for cesarean wound closure.Methods: This is a planned secondary analysis of a randomized controlled trial of 746 women in which suture and staples were compared for cesarean skin closure. Enrolled patients were asked to complete preoperative and postoperative surveys to assess preferred closure. Reasons for expressed preferences were elicited for each patient. Preferences were stratified by a number of cesarean deliveries (CD). We sought to determine if patients had a specific preference for wound closure due to personal experience or a personal belief that one method may be more beneficial with respect to pain and appearance.Results: We surveyed 550 patients preoperatively and 627 postoperatively. Women with a prior CD were more likely to have a skin closure preference compared with women having a primary CD (p < .05). Women who had a prior closure with suture rather than staples were significantly more likely to have a preference for the same wound closure method (p < .01). Avoiding the need for staple removal was the main reason women preferred suture closure, both preoperatively and postoperatively. The higher the number of the previous CD, the greater the preference for future closure with suture over staples (p < .05).Conclusions: Women undergoing cesarean delivery prefer suture as the method for skin closure compared with staples.

Patient satisfaction and cosmetic outcome in a randomized study of cesarean skin closure.

Objective: To evaluate patient satisfaction and patient and physician assessment of scar appearance after cesarean skin closure with suture versus staples. Methods: Women undergoing cesarean delivery (CD) at ≥23 weeks' gestation via low-transverse skin incisions at three hospitals in the CROSS Consortium were randomized to receive skin closure using subcuticular absorbable suture or nonabsorbable metal staples. The primary outcome of this substudy, patient satisfaction, was assessed by surveys at the postpartum visit using a 10-point Likert scale. Scar outcomes according to patients and trained observers were assessed at the primary research site using the Patient and Observer Scar Assessment Scale (POSAS). The POSAS is comprised of a patient-completed assessment including subjective data such as pain and itchiness, and an observer-completed assessment about cosmetic criteria. Results: Between June 2010 and August 2012, 746 women were randomized; 370 received suture and 376 received staples. Satisfaction data were available for 606 (81%). Complete patient scar assessment data were available for 577 (77%) and complete observer scar assessment data were available for 275 (57% of the 480 planned for evaluation at the primary research site). Demographic data for women in the two groups were similar. Satisfaction with the closure method was higher (superior) among women who received suture closure: median 10 (interquartile range 9, 10) versus 9 (interquartile ranges (IQR) 6, 10); p < .01. The suture group also had higher satisfaction with the scar's appearance at the postpartum visit: median nine (IQR 7, 10) versus 8 (IQR 6, 10); p = .02. Receiving one's preferred closure method was associated with higher patient satisfaction, and wound complications were associated with lower satisfaction. POSAS scores were superior (lower) in the suture group. Patient Scar Assessment Scale scores were median 15 (IQR 10, 25) for sutures versus 20 (IQR 11, 28) for staples; p < .01. Observer Scar Assessment Scale scores were median 12 (IQR 9, 15) for sutures versus 13 (IQR 9, 16) for staples; p = .01. Conclusions: Satisfaction with the closure method, satisfaction with the scar's appearance, and patient and physician assessments of scar cosmesis were all superior in those closed with suture. These results further support the use of sutures for cesarean skin closure.

Pain Associated With Cesarean Delivery Skin Closure: A Randomized Controlled Trial.

OBJECTIVE: To assess pain perception and pain medication use between women who underwent suture and those who underwent stapling for skin closure after cesarean delivery. METHODS: This was a secondary analysis of a prospective, multicenter, randomized clinical trial conducted from 2010 to 2012 at three hospitals in the United States. We evaluated pain outcomes associated with skin closure of a low transverse skin incision for cesarean delivery. Patient-reported pain and pain medication use during hospitalization and 6 weeks postpartum were evaluated as prespecified secondary outcomes of the trial. RESULTS: A total of 746 women were randomized to cesarean skin closure with sutures (n=370) or staples (n=376). There were no significant differences between the two groups with regard to pain perception during hospitalization (median average in-hospital pain score 3.9 in each group, P=.914), or at 4-8 weeks postsurgery (one in each group, P=.949). There were no significant differences in pain medication use during hospitalization (suture: 56 mg of intravenous morphine; staples: 54 mg, P=.545) or 4-8 weeks postpartum. CONCLUSION: We observed no differences in patient-reported pain or pain medication use among women who underwent skin closure with suture and those who underwent stapling after cesarean delivery. Taken in conjunction with the primary analysis that showed decreased wound morbidity with suture closure, the results of this study support the use of suture closure of the cesarean delivery skin incision. CLINCAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01211600. LEVEL OF EVIDENCE: I.

Suture compared with staple skin closure after cesarean delivery: a randomized controlled trial.

OBJECTIVE: To compare the incidence of wound complications between suture and staple skin closure after cesarean delivery. METHODS: This prospective, randomized clinical trial conducted at three hospitals in the United States between 2010 and 2012 included women undergoing cesarean delivery at 23 weeks of gestation or greater through a low-transverse skin incision. Women were randomized to closure of the skin incision with suture or staples after stratifying by body mass index and primary compared with repeat cesarean delivery. The primary outcome was incidence of wound complications, predefined as a composite of infection, hematoma, seroma, separation of 1 cm or longer, or readmission for wound complications. Analysis was according to the intention-to-treat principle; results were stratified by randomization group and adjusted for hospital by including it as a covariate. RESULTS: A total of 746 women were randomized, 370 to suture and 376 to staple closure. The median gestational age was 39 weeks. Fifty-eight women (7.8%) had wound complications-4.9% in the suture group and 10.6% in the staple group (adjusted odds ratio [OR] 0.43, 95% confidence interval [CI] 0.23-0.78); this was largely the result of the decreased incidence of wound separation in the respective groups (1.6% compared with 7.4%; adjusted OR 0.20, 95% CI 0.07-0.51). CONCLUSIONS: Suture closure of the skin incision at cesarean delivery is associated with a 57% decrease in wound complications compared with staple closure. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT01211600. LEVEL OF EVIDENCE: I.

Gene-environment interactions in a mutant mouse kindred with native airway constrictor hyperresponsiveness.

We mutagenized male BTBR mice with N-ethyl-N-nitrosourea and screened 1315 of their G3 offspring for airway hyperresponsiveness. A phenovariant G3 mouse with exaggerated methacholine bronchoconstrictor response was identified and his progeny bred in a nonspecific-pathogen-free (SPF) facility where sentinels tested positive for minute virus of mice and mouse parvovirus and where softwood bedding was used. The mutant phenotype was inherited through G11 as a single autosomal semidominant mutation with marked gender restriction, with males exhibiting almost full penetrance and very few females phenotypically abnormal. Between G11 and G12, facility infection eradication was undertaken and bedding was changed to hardwood. We could no longer detect airway hyperresponsiveness in more than 37 G12 offspring of 26 hyperresponsive G11 males. Also, we could not identify the mutant phenotype among offspring of hyperresponsive G8-G10 sires rederived into an SPF facility despite 21 attempts. These two observations suggest that both genetic and environmental factors were needed for phenotype expression. We suspect that rederivation into an SPF facility or altered exposure to pathogens or other unidentified substances modified environmental interactions with the mutant allele, and so resulted in disappearance of the hyperresponsive phenotype. Our experience suggests that future searches for genes that confer susceptibility for airway hyperresponsiveness might not be able to identify some genes that confer susceptibility if the searches are performed in SPF facilities. Experimenters are advised to arrange for multigeneration constancy of mouse care in order to clone mutant genes. Indeed, we were not able to map the mutation before losing the phenotype.