Racial/Ethnic Disparities in Peripartum Pain Assessment and Management.

OBJECTIVE: This study was conducted to determine if there were racial/ethnic disparities in pain assessment and management from labor throughout the postpartum period. METHODS: This was a retrospective cohort study of all births from January 2019 to December 2021 in a single urban, quaternary care hospital, excluding patients with hysterectomy, ICU stay, transfusion of more than 3 units of packed red blood cells, general anesthesia, or evidence of a substance abuse disorder. We characterized and compared patterns of antepartum and postpartum pain assessments, epidural use, pain scores, and postpartum pain management by racial/ethnic group with bivariable analyses. Multivariable regression was performed to test for an association between race/ethnicity and amount of opioid pain medication in milligram equivalent units, stratified by delivery mode. RESULTS: There were 18,085 births between 2019 and 2021 with available race/ethnicity data. Of these, 58.3% were white, 15.0% were Hispanic, 11.9% were Asian, 7.4% were Black, and the remaining 7.4% were classified as Other/Declined. There were no significant differences by race/ethnicity in the number of antepartum or postpartum pain assessments or the proportion of patients who received epidural analgesia. Black and Hispanic patients reported the highest maximum postpartum pain scores after vaginal and cesarean birth compared to white and Asian patients. However, Black and Hispanic patients received lower daily doses of opioid medications than white patients, regardless of delivery mode. After adjusting for patient factors and non-opioid medication dosages, all other racial/ethnic groups received less opioid medication than white patients. CONCLUSION: Inequities were found in postpartum pain treatment, including among patients reporting the highest pain levels.

Association of Primary Cesarean Delivery Rate With Dissemination of Nurse-Specific Cesarean Delivery Rates.

Strategies to safely reduce the rate of nulliparous, term, singleton, vertex (NTSV) cesarean deliveries have thus far largely ignored the contribution that labor and delivery nurses make to the delivery mode. We used a recently developed method to calculate nurse-specific cesarean delivery rates and provide these to labor and delivery nursing leadership, who shared the rates with labor and delivery nurses beginning in September 2020. We performed a 3-year interrupted time series analysis comparing our NTSV cesarean delivery rates before and after nurse-specific rates were released. On release of nurse-specific rates, our labor and delivery unit's NTSV cesarean delivery rate declined from 25.7% to 22.0%. Further work to find strategies to sustain nurse engagement is warranted.

Race/ethnicity differences in response to acute antihypertensive treatment of peripartum severe hypertension.

BACKGROUND: Hypertensive disorders of pregnancy increase maternal morbidity, mortality, and long-term risk for cardiovascular disease. The rising incidence of chronic hypertension and preeclampsia disproportionately affects people of color. There is a paucity of published data examining differences in the effectiveness of acute antihypertensive agents between pregnant patients of different races/ethnicities. We aimed to determine if the effectiveness of acute antihypertensive agents for peripartum severe hypertension differs by race/ethnicity. METHODS: A retrospective cohort study of patients with severe peripartum hypertension (systolic blood pressure ≥ 160 mmHg and/or diastolic blood pressure ≥ 110 mm Hg confirmed within 15 min) to determine whether the effectiveness of blood pressure control using nationally recommended medications (hydralazine, labetalol, nifedipine) differed by race/ethnicity. The primary outcome was reduction and maintenance of blood pressure to target ranges (140-150/90-100 mm Hg or below) for ≥4 h in each race/ethnicity group. Statistical tests included χ2, Fisher's exact, analysis of variance, and multivariable logistic regression. RESULTS: Of 729 patients receiving treatment for severe peripartum hypertension, all medications were effective (overall 86.4% efficacy) at controlling blood pressure. Labetalol was the most effective medication in White patients (93.0 vs. 74.7% for nifedipine and 86.5% for hydralazine, p < .001). No overall differences in medication effectiveness were found in Black, Asian, or LatinX patients. Black and Asian patients were more likely to experience >1 hypertensive episode [51.0 and 49.0%, respectively vs. 35.4% (White) and 40.0% (LatinX), p = .008]. CONCLUSION: Currently recommended therapies for severe peripartum hypertension are effective in controlling blood pressure for ≥4 h in patients of all race/ethnic groups. Labetalol was the most effective medication in White patients with no overall differences in medication effectiveness in Black, Asian, or LatinX patients.

The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas.

STUDY OBJECTIVE: To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity. DESIGN: Retrospective cohort study. SETTING: Quaternary care academic hospital in the United States. PATIENTS: Patients undergoing hysterectomy or myomectomy for uterine myomas between March 15, 2015, and March 14, 2020 (N = 1311). Cases involving correction of pelvic organ prolapse, malignancy, peripartum hysterectomy, or combined procedures with nongynecologic specialties were excluded. Racial/ethnic composition of the study population was 40.0% non-Hispanic white (white), 27.9% non-Hispanic black (black), 14.0% Hispanic, 13.7% non-Hispanic Asian (Asian), and 4.3% non-Hispanic American Indian/Alaska Native/Pacific Islander/Other. INTERVENTIONS: Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS: Of the 1311 cases, 35.9% were minimally invasive hysterectomy, 16.4% abdominal hysterectomy, 35.6% minimally invasive myomectomy, and 12.1% abdominal myomectomy. MIS rates were 94.7% among fellowship-trained minimally invasive gynecologic surgery subspecialists, 44.2% among obstetrics and gynecology specialists, and 46.8% among gynecologic oncologists. There were disparities in surgeon type based on race/ethnicity, with 59.8% of white patients having undergone surgery with a minimally invasive gynecologic surgery subspecialist vs 44.0% of black patients and 45.7% of Hispanic patients. Black and Hispanic patients were less likely to undergo MIS overall vs white patients (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.22-0.48 and aOR 0.44, 95% CI 0.28-0.72, respectively). Black and Hispanic patients undergoing hysterectomy were less likely than white patients to undergo MIS (aOR 0.33, 95% CI 0.21-0.51 and aOR 0.35, 95% CI 0.20-0.60, respectively). There were no significant differences in rates of MIS based on race/ethnicity for myomectomies nor differences in major or minor complications by race/ethnicity overall. CONCLUSION: At a quaternary care institution, black and Hispanic patients were significantly less likely than white patients to undergo MIS for uterine myomas, particularly for hysterectomy.

Pregnancy outcomes in very advanced maternal age women.

BACKGROUND: Advanced maternal age is associated with adverse pregnancy and delivery outcomes. Few studies have directly compared outcomes between women of advanced maternal age (35-44 years old) and women of very advanced maternal age (≥45 years old). OBJECTIVE: We aimed to determine the differences in outcomes between women of advanced maternal age and women of very advanced maternal age. STUDY DESIGN: This was a retrospective cohort study conducted at a large urban US medical center. Demographic and obstetrical data were collected in all patients who delivered within the study window (2012-2018). Characteristics and outcomes were compared between women of advanced maternal age and women of very advanced maternal age. Chi-square analyses were used to compare categorical variables. The Student t test or Wilcoxon tests were used, depending on the distribution, to compare continuous variables. RESULTS: A total of 45,435 women had delivery data for analysis. Of these women, 26,700 (59%) were not of advanced maternal age, 18,286 (40%) were of advanced maternal age, and 449 (1%) were of very advanced maternal age. Race and ethnicity varied significantly by age group. Nulliparity and postpartum hemorrhage were statistically higher in the very advanced maternal age group. Of note, cesarean delivery rates were 69.5% in the very advanced maternal age group and 39.5% in the advanced maternal age group (P<.001). Chronic hypertension, gestational hypertension, preeclampsia with and without severe features, superimposed preeclampsia, and eclampsia were all statistically significantly higher (at least 2-fold) in the very advanced maternal age group than the advanced maternal age group (P<.001). There was no significant difference in the rates of hemolysis, elevated liver enzymes, and low platelet count between the 2 groups. Rates of neonatal intensive care unit admission, Apgar score of <7 at 5 minutes, and neonatal length of stay of >5 days after cesarean delivery were higher in neonates from mothers of very advanced maternal age. Birthweights of neonates were significantly lower in mothers of very advanced maternal age. CONCLUSION: There were several important significant differences in the outcomes between women of very advanced maternal age women and women of advanced maternal age, especially concerning hypertensive disorders and cesarean delivery rates. These findings may influence patient counseling and strategies for antepartum surveillance.

Risk factors for re-presentation for postpartum hypertension in patients without a history of hypertension or preeclampsia.

BACKGROUND: Re-presentation for evaluation of hypertension following discharge after delivery is common. However, a subset of patients who re-present for evaluation of postpartum hypertension do not have a history of hypertension. Identification of those at risk may help guide postpartum management and prevent re-presentations to the hospital. OBJECTIVE: This study aimed to establish risk factors for re-presentation for hypertension within 30 days of discharge after delivery in patients without a history of hypertension compared with women who did not re-present and to distinguish from risk factors for re-presentation for another reason. STUDY DESIGN: Subjects were identified through data extraction from a single institution between January 2012 and December 2018. We included subjects without an International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision code for (1) chronic hypertension or (2) a hypertensive disorder of pregnancy during their delivery encounter who re-presented to the hospital within 30 days. Thus, the re-presentation group was divided into the following 2 groups: those who re-presented for hypertension and those who re-presented for any other reason. Each re-presentation group was compared with the cohort of patients who delivered within the study window and did not re-present using the Student t test or Wilcoxon tests for continuous variables and chi-square or Fisher's exact tests for categorical variables. Multivariable regression was also performed on all potentially important risk factors. RESULTS: Factors that emerged as uniquely significant in the re-presentation group for hypertension were maternal age of ≥40 years and antenatal prescription of low-dose aspirin. Black race and body mass index of ≥30 kg/m2, although significant in both re-presentation groups, were more strongly predictive of re-presentation for hypertension. These factors remained independently significant when compared with each other in a multivariable analysis. CONCLUSION: There are identifiable risk factors for postpartum re-presentation for hypertension in patients without a history of hypertension. Upon discharge, providers may consider close blood pressure monitoring and follow-up in patients who have any of the following risk factors: age of ≥40 years, black race, body mass index of ≥30 kg/m2, or those who were prescribed low-dose aspirin in pregnancy.

Risk of Urinary Tract Infection Symptoms after Posthysterectomy Cystoscopy with 50% Dextrose as Compared with Saline Cystoscopy with Indigo Carmine.

STUDY OBJECTIVE: Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine. DESIGN: Retrospective cohort study. SETTING: Two tertiary care centers. PATIENTS: All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon. INTERVENTIONS: We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014). MEASUREMENTS AND MAIN RESULTS: A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p <.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p <.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p <.01), recatheterization (10.4% vs 0%, p <.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p <.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group. CONCLUSION: Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population.

Postoperative Urinary Retention after Benign Gynecologic Surgery with a Liberal versus Strict Voiding Protocol.

STUDY OBJECTIVE: Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void before discharge). The primary objective of this study was to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol with more strict voiding protocols. Secondary outcomes included length of hospital stay (LOS) and urinary tract infection (UTI). DESIGN: Retrospective cohort study. SETTING: Quaternary-care academic hospital in the United States. PATIENTS: Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n = 652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded. INTERVENTIONS: Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS: POUR, defined as the need for recatheterization within 24 hours of catheter removal, along with UTI and LOS were compared between liberal and strict voiding protocols. A subgroup analysis was performed for those undergoing minimally invasive surgery (MIS). A total of 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) women with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different between the groups (2.6% liberal vs. 4.9% strict, p = .14). UTIs also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p = .86). Similar results were seen specifically among those who underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p = .17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p = .28). The median LOS (interquartile range) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall [interquartile range 15 hours], 9 [4] hours liberal vs. 36 [34] hours strict, p <.01). Among those discharged the same day (72.6% of the MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean [standard deviation] 9.4 [2.5] hours vs. 10.6 [35] hours, p <.01). Postoperative complications occurred less frequently in those with MIS procedures (11.8% in MIS vs. 20.2% in laparotomies, p <.01) and those with liberal voiding protocols (11.2% liberal vs. 16.9% strict p = .04). CONCLUSION: Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ between those with liberal and strict voiding protocols. Our data suggest that same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the postanesthesia recovery unit and may contribute to enhanced recovery after surgery protocols.

Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic.

Background: In response to the coronavirus disease 2019 pandemic, hospitals nationwide have implemented modifications to labor and delivery unit practices designed to protect delivering patients and healthcare providers from infection with severe acute respiratory syndrome coronavirus 2. Beginning in March 2020, our hospital instituted labor, and delivery unit modifications targeting visitor policy, use of personal protective equipment, designation of rooms for triage and delivery of persons suspected or infected with coronavirus disease 2019, delivery management, and newborn care. Little is known about the ramifications of these modifications in terms of maternal and neonatal outcomes. Objective: The objective of this study was to determine whether labor and delivery unit policy modifications we made during the coronavirus disease 2019 pandemic were associated with differences in outcomes for mothers and newborns. Study Design: We conducted a retrospective cohort study of all deliveries occurring in our hospital between January 1, 2020, and April 30, 2020. Patients who delivered in January and February 2020 before labor and delivery unit modifications were instituted were designated as the preimplementation group, and those who delivered in March and April 2020 were designated as the postimplementation group. Maternal and neonatal outcomes between the pre- and postimplementation groups were compared. Differences between the 2 groups were then compared with the same time period in 2019 and 2018 to assess whether any apparent differences were unique to the pandemic year. We hypothesized that maternal and newborn lengths of stay would be shorter in the postimplementation group. Statistical analysis methods included Student's t-tests and Wilcoxon tests for continuous variables and chi-square or Fisher exact tests for categorical variables. Results: Postpartum length of stay was significantly shorter after implementation of labor unit changes related to coronavirus disease 2019. A postpartum stay of 1 night after vaginal delivery occurred in 48.5% of patients in the postimplementation group compared with 24.9% of the preimplementation group (P<.0001). Postoperative length of stay after cesarean delivery of ≤2 nights occurred in 40.9% of patients in the postimplementation group compared with 11.8% in the preimplementation group (P<.0001). Similarly, after vaginal delivery, 49.0% of newborns were discharged home after 1 night in the postimplementation group compared with 24.9% in the preimplementation group (P<.0001). After cesarean delivery, 42.5% of newborns were discharged after ≤2 nights in the postimplementation group compared with 12.5% in the preimplementation group (P<.0001). Slight differences in the proportions of earlier discharge between mothers and newborns were due to multiple gestations. There were no differences in cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the 2 groups. Conclusion: Labor and delivery unit policy modifications to protect pregnant patients and healthcare providers from coronavirus disease 2019 indicate that maternal and newborn length of stay in the hospital were significantly shorter after delivery without increases in the rate of adverse maternal or neonatal outcomes. In the absence of long-term adverse outcomes occurring after discharge that are tied to earlier release, our study results may support a review of our discharge protocols once the pandemic subsides to move toward safely shortening maternal and newborn lengths of stay.

Can We Accurately Time the Administration of Antenatal Corticosteroids for Preterm Labor?

Background. Accurate timing of antenatal corticosteroids (ACS) has resulted in improved neonatal outcomes. Objectives. Our primary objective was to determine predictors for optimal timing of ACS in women presenting with spontaneous preterm labor. Study Design. A retrospective cohort study of women receiving ACS for spontaneous preterm birth was conducted. Women were included if they presented with preterm labor or preterm premature rupture of membranes. Accurate timing of ACS was defined as administration within 7 days of delivery. Maternal demographic and obstetrics characteristics were compared between the groups receiving ACS ≤7 days and >7 days from delivery. Statistical analyses were performed using parametric and nonparametric tests. P < 0.05 was considered significant. Results. The study included 215 subjects. Median latency from ACS administration to delivery was 6 days (IQR 32). Accurate timing of ACS occurred in 113 (53%) women and was associated with rupture of membranes (OR 13.8, 95% CI 5.9-32.6), cervical change (OR 7.1, 95% CI 3.0-17.1), and cervical dilation ≥ 2 cm (OR 3.9, 95% CI 1.5-10.3). Conclusions. Rupture of membranes, cervical change, and cervical dilation ≥ 2 cm were strong predictors of optimal timing. 53% of women with preterm labor received ACS optimally.

Prenatal prescription corticosteroids and offspring diabetes: a national cohort study.

BACKGROUND: Foetal exposure to excess glucocorticoids has been associated with altered development of multiple foetal systems that may persist after birth and lead to an increased risk of diseases. The purpose of this study is to investigate the role of prenatal prescription corticosteroids for the development of diabetes among offspring. METHODS: We conducted a national birth cohort study of children from singleton pregnancies born in Denmark between 1 January 1997 and 31 December 2004 with follow-up through 31 December 2008. Four Danish nationwide administrative registries were linked to identify specific exposures, outcomes and covariates of interest among 505 386 children from singleton pregnancies born alive to 360 484 women. We calculated hazard ratios (HRs) comparing diabetes incidence (separately for type 1 and type 2 diabetes/elevated blood glucose) in children exposed vs unexposed to prescription corticosteroids prenatally. RESULTS: Prenatal exposure to prescription corticosteroids was associated with a small increase in offspring type 1 diabetes incidence rate [HR = 1.20, 95% confidence limits (CL) = 0.94, 1.53] and with a 51% increase in type 2 diabetes/elevated blood glucose hazard ratio when comparing children exposed prenatally to prescription corticosteroids with those unexposed (HR = 1.51, 95% CL = 0.69, 3.31). The data were consistent with a monotonic increase in overall diabetes hazard ratios with increasing strength of the corticosteroid. CONCLUSIONS: There may be a relation between prenatal prescription corticosteroid use and childhood diabetes but further studies with more extensive assessment of foetal exposures are warranted. If prenatal prescription corticosteroids contribute to the development of offspring diabetes, the public health implications could be substantial.