Economic Analysis of Induction versus Elective Cesarean in Term Nulliparas with Supermorbid Obesity.

OBJECTIVE: We sought to evaluate the economic benefit of the induction of labor compared with elective cesarean delivery in individuals with supermorbid obesity (body mass index 60 kg/m2 or greater) at term. STUDY DESIGN: We developed an economic analysis model to compare induction of labor with elective cesarean delivery in nulliparous individuals with supermorbid obesity at term. The primary outcome was the total cost per strategy from a health system perspective with elective cesarean delivery as a reference group. Pregnancy outcomes for the index and subsequent pregnancies were considered. When available, probabilities of pregnancy outcomes were extracted from our institutions. Rare pregnancy outcomes, relative risks, and costs were derived from the literature. All costs in this analysis were inflated to 2022 USD (U.S. dollar). To determine the robustness of the decision model, we conducted one-way sensitivity analyses by changing point estimates of variables. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation repeating 1,000 times to test the robustness of the results in the setting of simultaneous changes in probabilities, relative risks, and costs. RESULTS: In the base-case analysis, assuming that 72.7% of nulliparous individuals undergoing induction of labor would have a cesarean delivery, induction of labor would cost $41,084 compared with $40,742 for elective cesarean delivery, resulting in a higher cost of $342 per nulliparous individuals with supermorbid obesity. In a sensitivity analysis, we found that induction of labor compared with elective cesarean is less economical if the probability of cesarean delivery after induction of labor exceeds 71%. Monte Carlo simulation suggests that elective cesarean delivery was the preferred cost-beneficial strategy with a frequency of 53.5%. CONCLUSION: Among our patient population, induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals with supermorbid obesity. KEY POINTS: · The prevalence of obesity in the United States continues to rise.. · Morbid obesity compared with normal weight is associated with increased risks of adverse pregnancy outcomes.. · Induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals..

Comparison of Labor Curves Between Spontaneous and Induced Labor.

OBJECTIVE: To compare the labor curve between individuals with induced labor and those undergoing spontaneous labor. METHODS: This was a secondary analysis of the Consortium on Safe Labor database, including nulliparous and multiparous individuals with singleton vertex pregnancy who delivered vaginally after spontaneous labor or induction of labor at term. Labor that resulted in uterine rupture and neonates with a 5-minute Apgar scores less than 7, birth injury, or neonatal intensive care unit admission was excluded. We modeled the course of cervical dilation using repeated-measures analysis with a polynomial function. We compared traverse time , defined as the elapsed time between two given dilation measures, between induced and spontaneous labor using interval-censored regression. RESULTS: Of 46,835 nulliparous individuals, 18,576 and 28,259 underwent induced and spontaneous labor, respectively. Of 77,503 multiparous individuals, 29,684 and 47,819 underwent induced and spontaneous labor, respectively. The start of the active phase on the labor curve was 6 cm in induced labor, regardless of parity. In nulliparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 1.8 hours [5th-95th percentile 0.4-8.6 hours] vs 2.3 hours [5th-95th percentile 0.6-9.4 hours]; P <.01). In multiparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 0.9 hours [5th-95th percentile 0.1-6.0 hours] vs 1.4 hours [5th-95th percentile 0.3-7.9 hours]; P <.01). CONCLUSION: Similar to spontaneous labor, the start of the active phase of induced labor was at 6 cm of dilation. Comparatively, induced labor had a shorter active phase than spontaneous labor. These findings suggest that the current criteria for active phase arrest provided by the American College of Obstetricians and Gynecologists do not need to be lengthened for individuals in induced labor.

An Externally Validated Model to Predict Prolonged Induction of Labor with an Unfavorable Cervix.

OBJECTIVE: To develop and externally validate a prediction model to calculate the likelihood of prolonged induction of labor (induction start to delivery time > 36 hours). STUDY DESIGN: This was a retrospective cohort study of all nulliparous women with singleton pregnancies and vertex presentation at term who underwent induction of labor and had a vaginal delivery at a single academic center. Women with contraindications for vaginal delivery were excluded. Analyses were limited to women with unfavorable cervix (both simplified Bishop score [dilation, station, and effacement: range 0-9] <6 and cervical dilation <3 cm). Prolonged induction of labor was defined as the duration of induction (induction start time to delivery) longer than 36 hours. A backward stepwise logistic regression analysis was used to identify the factors associated with prolonged induction of labor by considering maternal characteristics and comorbidities as well as fetal conditions. The final model was validated using an external dataset of the Consortium on Safe Labor after applying the same inclusion and exclusion criteria. We developed a receiver observer characteristic curve with area under the curve (AUC) in validation cohorts. RESULTS: Of 2,118 women, 364 (17%) had prolonged induction of labor. Factors associated with prolonged induction of labor included body mass index at admission, hypertension, fetal conditions, and epidural. Factors including younger maternal age, prelabor rupture of membranes, and a more favorable simplified Bishop score were associated with a decreased likelihood of prolonged induction of labor. In the external validation cohort, 4,418 women were analyzed, of whom 188 (4%) had prolonged induction of labor. The AUC of the final model was 0.76 (95% confidence interval: 0.73-0.80) for the external validation cohort. The online calculator was created and is available at: https://medstarapps.org/obstetricriskcalculator. CONCLUSION: Our externally validated model was efficient in predicting prolonged induction of labor with an unfavorable cervix. KEY POINTS: · The number of inductions of labor at 39 weeks' gestation and beyond has been increasing.. · Our model had a good prediction of prolonged induction of labor.. · An online calculator has been created and available..

Implementation of an Educational Intervention to Improve HIV Pre-Exposure Prophylaxis Services for Women in an Urban Sexual Health Clinic.

To test the hypothesis that implementation of a multicomponent, educational HIV pre-exposure prophylaxis (PrEP) intervention to promote universal PrEP services for cisgender women (subsequently "women") in sexual and reproductive health centers would improve the proportion of women screened, offered, and prescribed PrEP, we implemented a multicomponent, educational intervention in a Washington D.C. Department of Health-sponsored sexual health clinic. The clinic serves a patient population with high-potential exposure to HIV. The intervention included clinic-wide PrEP trainings, an electronic health record prompt for PrEP counseling by providers, and educational videos in the waiting room. We collected preimplementation data from March 22, 2018 to July 4, 2018, including 331 clinical encounters for 329 women. Between July 5, 2018 and July 1, 2019, there were 1733 clinical encounters for 1720 HIV-negative women. We used mixed methods to systematically assess intervention implementation using the Reach Effectiveness Adoption Implementation Maintenance framework. Additionally, we assessed the interventions' acceptability and feasibility among providers through semistructured interviews. The proportion of women screened by providers for PrEP (5.6% preimplementation to a mean of 89.2% of women during the implementation period, p < 0.01), offered (6.2 to 69.8%, p < 0.01), and prescribed PrEP (2.6 to 8.1%, p < 0.01) by providers increased significantly in the implementation period. Providers and clinic staff found the intervention both highly feasible and acceptable and demonstrated increased knowledge of PrEP and HIV prevention associated with the clinic-wide trainings. Our results demonstrate the effectiveness of a low-cost educational intervention to increase provision of integrated PrEP services in an urban sexual health clinic serving women with high-potential exposure to HIV. ClinicalTrials.gov ID NCT03705663.

Adverse maternal outcomes associated with major fetal malformations after singleton live birth.

BACKGROUND: Major fetal malformations complicate 2% to 5% of live births. It is unclear what effect fetal malformations have on severe maternal morbidity. OBJECTIVE: This study aimed to compare maternal outcomes between individuals with a fetus with major or minor fetal malformations and those with a fetus without major or minor fetal malformations. STUDY DESIGN: This was a secondary analysis of the Consortium on Safe Labor database. Our study was limited to the current analysis of pregnant individuals with a singleton live birth. Major fetal malformations based on the Centers for Disease Control and Prevention's criteria were defined. Fetal malformations that did not meet the criteria for major fetal malformations were categorized as minor fetal malformations. Our primary maternal outcome was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Missing values were imputed by multiple imputation using the k-nearest neighbor imputation method. Poisson regression with robust error variance was used to obtain adjusted relative risks with 95% confidence intervals, controlling for confounders. RESULTS: Of 216,881 deliveries, there were 201,860 cases (93.1%) with no congenital malformation, 12,106 cases (5.6%) with minor fetal malformations, and 2845 cases (1.3%) with major fetal malformations. Compared with individuals with no fetal malformation, those with major fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.2%; adjusted relative risk, 1.51; 95% confidence interval, 1.07-2.12), postpartum hemorrhage (3.6% vs 6.9%; adjusted relative risk, 1.76; 95% confidence interval, 1.50-2.06), preeclampsia (5.1% vs 8.3%; adjusted relative risk, 1.48; 95% confidence interval, 1.31-1.67), and cesarean delivery (26.7% vs 42.3%; adjusted relative risk, 1.51; 95% confidence interval, 1.45-1.58). Compared with individuals with no fetal malformation, those with minor fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.4%; adjusted relative risk, 1.73; 95% confidence interval, 1.48-2.02), maternal death (0.01% vs 0.03%; adjusted relative risk, 4.50; 95% confidence interval, 1.18-17.19), postpartum hemorrhage (3.6% vs 6.1%; adjusted relative risk, 1.54; 95% confidence interval, 1.41-1.68), preeclampsia (5.1% vs 8.6%; adjusted relative risk, 1.50; 95% confidence interval, 1.41-1.60), superimposed preeclampsia (1.2% vs 2.4%; adjusted relative risk, 1.25; 95% confidence interval, 1.14-1.38), cesarean delivery (26.7% vs 39.6%; adjusted relative risk, 1.38; 95% confidence interval, 1.35-1.41), chorioamnionitis (3.0% vs 4.7%; adjusted relative risk, 1.41; 95% confidence interval, 1.29-1.53), and postpartum endometritis (0.6% vs 1.0%; adjusted relative risk, 1.58; 95% confidence interval, 1.31-1.90). CONCLUSION: Major and minor congenital fetal malformations are independent risk factors for severe maternal morbidity and other pregnancy complications.

Intention to Initiate HIV Pre-exposure Prophylaxis Among Cisgender Women in a High HIV Prevalence U.S. City.

OBJECTIVE: Our objective was to identify the individual, interpersonal, community, health-system, and structural factors that influence HIV pre-exposure prophylaxis (PrEP) initiation among cisgender women seeking sexual and reproductive health care in a high HIV prevalence community to inform future clinic-based PrEP interventions. METHODS: We collected anonymous, tablet-based questionnaires from a convenience sample of cisgender women in family planning and sexual health clinics in the District of Columbia. The survey used the lens of the socio-ecological model to measure individual, interpersonal, community, institutional, and structural factors surrounding intention to initiate PrEP. The survey queried demographics, behavioral exposure to HIV, perceived risk of HIV acquisition, a priori awareness of PrEP, intention to initiate PrEP, and factors influencing intention to initiate PrEP. RESULTS: A total of 1437 cisgender women completed the survey. By socio-ecological level, intention to initiate PrEP was associated with positive attitudes toward PrEP (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.13-2.15) and higher self-efficacy (OR, 1.32; 95% CI, 1.02-1.72) on the individual level, perceived future utilization of PrEP among peers and low fear of shame/stigma (OR, 1.65; 95% CI, 1.33-2.04) on the community level, and having discussed PrEP with a provider (OR. 2.39; 95% CI, 1.20-4.75) on the institutional level. CONCLUSION: Our findings highlight the importance of multilevel, clinic-based interventions for cisgender women, which promote sex-positive and preventive PrEP messaging, peer navigation to destigmatize PrEP, and education and support for women's health medical providers in the provision of PrEP services for cisgender women.

Post Antenatal Late Preterm Steroids trial: interrupted time series analysis of respiratory outcomes in twin and pregestational diabetes.

BACKGROUND: The Antenatal Late Preterm Steroids trial found that corticosteroid administration decreased respiratory complications by 20% among late preterm singleton deliveries. After the Antenatal Late Preterm Steroids trial, corticosteroid administration increased by 76% among twin pregnancies and 113% among singleton pregnancies complicated by pregestational diabetes mellitus compared with expected rates based on the pre-Antenatal Late Preterm Steroids trial trend. However, the effect of corticosteroids on twin pregnancies and pregnancies complicated by pregestational diabetes mellitus is not well studied, as the Antenatal Late Preterm Steroids trial excluded twin pregnancies and pregnancies complicated by pregestational diabetes mellitus. OBJECTIVE: This study aimed to examine the change in the incidence rate of immediate assisted ventilation use and ventilation use for more than 6 hours among 2 populations after the dissemination of the Antenatal Late Preterm Steroids trial at the population level. STUDY DESIGN: This study was a retrospective analysis of publicly available US birth certificate data. The study period was from August 1, 2014, to April 30, 2018. The dissemination period of the Antenatal Late Preterm Steroids trial was from February 2016 to October 2016. Population-based interrupted time series analyses were performed for 2 target populations: (1) twin pregnancies not complicated by pregestational diabetes mellitus and (2) singleton pregnancies complicated by pregestational diabetes mellitus. For both target populations, analyses were limited to individuals who delivered nonanomalous live neonates between 34 0/7 and 36 6/7 weeks of gestation (vaginal or cesarean delivery). As a sensitivity analysis, a total of 23 placebo tests were conducted before (5 tests) and after (18 tests) the dissemination period. RESULTS: For the analysis of late preterm twin deliveries, 191,374 individuals without pregestational diabetes mellitus were identified. For the analysis of late preterm singleton pregnancy with pregestational diabetes mellitus, 21,395 individuals were identified. After the dissemination period, the incidence rate of immediate assisted ventilation use for late preterm twin deliveries was significantly lower than the expected value based on the pre-Antenatal Late Preterm Steroids trial trend (11.6% observed vs 13.0% expected; adjusted incidence rate ratio, 0.87; 95% confidence interval, 0.78-0.97). The incidence rate of ventilation use for more than 6 hours among late preterm twin deliveries did not change significantly after the dissemination of the Antenatal Late Preterm Steroids trial. A significant increase in the incidence rate of immediate assisted ventilation use and ventilation use for more than 6 hours was found among singleton pregnancies with pregestational diabetes mellitus. However, the results of placebo tests suggested that the increase in incidence was not necessarily due to the dissemination period of the Antenatal Late Preterm Steroids trial. CONCLUSION: The dissemination of the Antenatal Late Preterm Steroids trial was associated with decreased incidence of immediate assisted ventilation use, but no change in ventilation use for more than 6 hours, among late preterm twin deliveries in the United States. In contrast, the incidence of neonatal respiratory outcomes among singleton deliveries with pregestational diabetes mellitus did not decrease after the dissemination of the Antenatal Late Preterm Steroids trial.

Cost-effectiveness of history-indicated cerclage vs cervical length assessment for prevention of preterm birth.

BACKGROUND: Preterm birth is one of the major causes of neonatal morbidity and mortality. Preterm delivery is a large burden to our health care system, and a history of preterm birth is one of the most common risk factors for subsequent preterm birth. OBJECTIVE: We sought to examine the cost-effectiveness of the history-indicated cerclage strategy compared with the transvaginal ultrasound cervical length assessment strategy in individuals with a history of preterm birth. STUDY DESIGN: We developed a decision analysis model to compare history-indicated cerclage and cervical length assessment. The primary outcome was the net monetary benefit from a maternal and neonatal perspective of both strategies, defined as the value of an intervention with a known willingness to pay threshold for a unit of benefit. The time horizon was set to be a lifetime. Costs (in 2022 USD) included those for the cerclage, serial transvaginal ultrasounds, maternal care for admission, neonatal care, and severe disability. Probabilities, utilities, and costs were derived from the literature. A cost-effectiveness threshold was set at $100,000 per QALY (quality-adjusted life year). We first conducted 1-way sensitivity analyses with associated variables as sensitivity analyses. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation with 1000 trials to test the robustness of the results in the setting of simultaneous changes in probabilities, costs, and utilities. RESULTS: In our base-case analysis, the history-indicated cerclage strategy compared to transvaginal ultrasound cervical length assessment was associated with more cost ($85,038 vs $70,155), with slightly less effectiveness from the maternal perspective (26.74 QALY vs 26.78 QALY) and from the neonatal perspective (28.91 QALY vs 29.06 QALY), and with less maternal and neonatal net monetary benefit. Therefore, the history-indicated cerclage strategy was dominated. With the 1000 trials of Monte Carlo simulation, transvaginal ultrasound cervical length assessment was the preferred strategy 84% and 88% of the time from the maternal and neonatal perspectives, respectively. CONCLUSION: The history-indicated cerclage strategy was more expensive and slightly less effective than the transvaginal ultrasound cervical length assessment strategy with a lower net monetary benefit.

Decision and economic analysis of hostile abortion laws compared with supportive abortion laws.

BACKGROUND: On June 24, 2022, the US Supreme Court overturned Roe v Wade in Dobbs v Jackson Women's Health Organization. Therefore, several states banned abortion, and other states are considering more hostile abortion laws. OBJECTIVE: This study aimed to assess the incidence of adverse maternal and neonatal outcomes in the hypothetical cohort where all states have hostile abortion laws compared with the pre-Dobbs v Jackson cohort (supportive abortion laws cohort) and examine the cost-effectiveness of these policies. STUDY DESIGN: This study developed a decision and economic analysis model comparing the hostile abortion laws cohort with the supportive abortion laws cohort in a sample of 5.3 million pregnancies. Cost (inflated to 2022 US dollars) estimates were from a healthcare provider's perspective, including immediate and long-term costs. The time horizon was set to a lifetime. Probabilities, costs, and utilities were derived from the literature. The cost-effectiveness threshold was set to be at $100,000 per quality-adjusted life year. Probabilistic sensitivity analyses using the Monte Carlo simulation with 10,000 simulations were performed to assess the robustness of our results. The primary outcomes included maternal mortality and an incremental cost-effectiveness ratio. The secondary outcomes included hysterectomy, cesarean delivery, hospital readmission, neonatal intensive care unit admission, neonatal mortality, profound neurodevelopmental disability, and incremental cost and effectiveness. RESULTS: In the base case analysis, the hostile abortion laws cohort had 12,911 more maternal mortalities, 7518 more hysterectomies, 234,376 more cesarean deliveries, 102,712 more hospital readmissions, 83,911 more neonatal intensive care unit admissions, 3311 more neonatal mortalities, and 904 more cases of profound neurodevelopmental disability than the supportive abortion laws cohort. The hostile abortion laws cohort was associated with more cost ($109.8 billion [hostile abortion laws cohort] vs $75.6 billion [supportive abortion laws cohort]) and 120,749,900 fewer quality-adjusted life years with an incremental cost-effectiveness ratio of negative $140,687.60 than the supportive abortion laws cohort. Probabilistic sensitivity analyses suggested that the chance of the supportive abortion laws cohort being the preferred strategy was more than 95%. CONCLUSION: When states consider enacting hostile abortion laws, legislators should consider an increase in the incidence of adverse maternal and neonatal outcomes.

Effect of Calcium Channel Blocker on Labor Curve in Pregnant Individuals with Chronic Hypertension.

OBJECTIVE: This study aimed to compare the labor progress between individuals who received calcium channel blocker (CCB) and those who did not receive CCB during labor. STUDY DESIGN: This was a secondary analysis of a retrospective cohort study of individuals with chronic hypertension who underwent vaginal delivery at a tertiary care center from January 2010 to December 2020. We excluded individuals with prior uterine surgeries and a 5-minute Apgar score of less than 5. We used a repeated-measures regression with a third-order polynomial function to compare the average labor curves according to antihypertensive medication. Estimates of the median (5th-95th percentile) traverse times between two dilations were computed using interval-censored regression. RESULTS: Of 285 individuals with chronic hypertension, 88 (30.9%) received CCB. Individuals who received CCB during labor compared with those who did not were more likely to deliver at earlier gestational age and to have pregestational diabetes and superimposed preeclampsia (p < 0.01). The progress of labor in the latent phase was not found to be significantly different between both groups (median: 11.51 vs. 8.74 hours; p = 0.08). However, after stratification by parity, nulliparous individuals who received CCB during labor were more likely to have a longer latent phase of labor (median: 14.4 vs. 8.5 hours; p = 0.03) CONCLUSION: A calcium channel blocker may slow the latent phase of labor in individuals with chronic hypertension. Aiming to minimize intrapartum iatrogenic interventions, allowing adequate time for pregnant individuals during the latent phase of labor is especially important if individuals are on a calcium channel blocker. KEY POINTS: · Calcium channel blockers seem to be associated with a longer latent phase of labor.. · The effect of calcium channel blocker on labor was not observed in multiparous individuals.. · Allowing adequate labor time for individuals taking calcium channel blocker is important..

Comparison of Adverse Maternal Outcomes between Early- and Late-Onset Superimposed Preeclampsia.

OBJECTIVE: Superimposed preeclampsia (SIPE), defined as preeclampsia in individuals with chronic hypertension, is one of the most common complications, accounting for 13 to 40% of pregnancies with chronic hypertension. However, there are limited data regarding maternal outcomes of early- and late-onset SIPE in individuals with chronic hypertension. We hypothesized that early-onset SIPE was associated with increased odds of adverse maternal outcomes compared with late-onset SIPE. Therefore, we aimed to compare adverse maternal outcomes between individuals with early-onset SIPE and those with late-onset SIPE. STUDY DESIGN: This was a retrospective cohort study of pregnant individuals with SIPE who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as the onset of SIPE before 34 weeks' gestation. Late-onset SIPE was defined as the onset of SIPE at or after 34 weeks' gestation. Our primary outcome was a composite of eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, maternal death, placental abruption, pulmonary edema, SIPE with severe features, and thromboembolic disease. Maternal outcomes were compared between early- and late-onset SIPE. We used simple and multivariate logistic regression models to calculate crude and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Of 311 individuals, 157 (50.5%) had early-onset SIPE, 154 (49.5%) had late-onset SIPE. There were significant differences in the proportions of obstetric complications, including the primary outcome, HELLP syndrome, SIPE with severe features, fetal growth restriction (FGR), and cesarean delivery between early- and late-onset SIPE. Compared with individuals with late-onset SIPE, those with early-onset SIPE had increased odds of the primary outcome (aOR: 3.28; 95% CI: 1.42-7.59), SIPE with severe features (aOR: 2.72; 95% CI: 1.25-5.90), FGR (aOR: 6.07; 95% CI: 3.25-11.36), and cesarean delivery (aOR 3.42; 95% CI: 2.03-5.75). CONCLUSION: Individuals with early-onset SIPE had higher odds of adverse maternal outcomes compared with those with late-onset SIPE. KEY POINTS: · We revealed the incidence of maternal outcomes in early- and late-onset SIPE.. · Severe features were common in individuals with SIPE.. · Early-onset SIPE was associated with increased adverse maternal outcomes compared with late-onset SIPE..

Risk Factors for Early- and Late-Onset Superimposed Preeclampsia.

OBJECTIVE: Risk factors of early- and late-onset preeclampsia among pregnant individuals with chronic hypertension are not well described in the literature. We hypothesized that early- and late-onset superimposed preeclampsia (SIPE) have different risk factors. Therefore, we aimed to examine the risk factors of early- and late-onset SIPE among individuals with chronic hypertension. STUDY DESIGN: This was a retrospective case-control study of pregnant individuals with chronic hypertension who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as SIPE diagnosed before 34 weeks' gestation. To identify risk factors, we compared individuals' characteristics between individuals who developed early- and late-onset SIPE and those who did not. We then compared characteristics between individuals who developed early-onset SIPE and late-onset SIPE. Characteristics with p-values of less than 0.05 by bivariable variables were analyzed by simple and multivariable logistic regression models to calculate crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Missing values were imputed with multiple imputation. RESULTS: Of 839 individuals, 156 (18.6%) had early-onset, 154 (18.4%) had late-onset SIPE and 529 (63.1%) did not have SIPE. The multivariate logistic regression model showed that serum creatinine ≥ 0.7 mg/dL compared to less than 0.7 mg/dL (aOR: 2.89 [95% CI: 1.63-5.13]), increase of creatinine (1.33 [1.16-1.53]), nulliparity compared to multiparity (1.77 [1.21-2.60]), and pregestational diabetes (1.70 [1.11-2.62]) were risk factors for early-onset SIPE. The multivariate logistic regression model showed that nulliparity compared to multiparity (1.53 [1.05-2.22]) and pregestational diabetes (1.74 [1.14-2.64]) was a risk factor for late-onset SIPE. Serum creatinine ≥ 0.7 mg/dL (2.90 [1.36-6.15]) and increase of creatinine (1.33 [1.10-1.60]) were significantly associated with early-onset SIPE compared to late-onset SIPE. CONCLUSION: Kidney dysfunction seemed to be associated with the pathophysiology of early-onset SIPE. Nulliparity and pregestational diabetes were common risk factors for both early- and late-onset SIPE. KEY POINTS: · Serum creatinine level was positively associated with early-onset superimposed preeclampsia (SIPE).. · Pregestational diabetes and nulliparity were associated with both early- and late-onset SIPE.. · The identification of risk factors may provide an opportunity to decrease the rates of SIPE..

The effect of cervical cerclage on the labor curve.

BACKGROUND: Cervical cerclage is an effective intervention to prevent preterm birth among individuals with a history of cervical insufficiency, individuals with a short cervix and history of preterm birth, or individuals with second-trimester painless dilation. Although cerclage reduces the mechanical stress on the cervix by reinforcing it with sutures, cerclage could also cause scarring of the cervix, which may affect the progress of labor. OBJECTIVE: This study aimed to compare the labor curves between individuals who underwent cerclage and those who did not undergo cerclage. STUDY DESIGN: This was a retrospective cohort study of individuals with singleton term pregnancy, vertex presentation, and vaginal delivery, using the data from the Consortium on Safe Labor. We excluded individuals with fetal anomalies, stillbirth, or abnormal perinatal outcomes, including 5-minute Apgar score of <7, birth injury, and neonatal intensive care unit admission. We modeled the course of cervical dilation using repeated-measures analysis with a polynomial function and generated smoothed labor curves. An interval-censored regression analysis was performed to estimate traverse times (the elapsed time between 2 cervical dilation measures). The traverse times were compared between individuals who underwent cerclage and those who did not undergo cerclage, controlling for induction of labor and parity. RESULTS: There were 245 individuals who underwent cerclage and 110,080 individuals who did not undergo cerclage. Individuals who underwent cerclage compared with those who did not undergo cerclage had a similar traverse time from 1 to 6 cm (median, 9.1 vs 10.3 hours; adjusted P=.37) and from 6 to 10 cm (median, 1.5 vs 1.5 hours; adjusted P=.23). Individuals who underwent cerclage compared with those who did not undergo cerclage had a longer traverse time from rupture of membranes to delivery (median, 4.0 vs 3.0 hours; adjusted P<.01). CONCLUSION: Cervical cerclage did not affect the overall progress of labor.

Understanding Psychosocial Determinants of PrEP Uptake Among Cisgender Women Experiencing Heightened HIV Risk: Implications for Multi-Level Communication Intervention.

Pre-exposure prophylaxis (PrEP) is a highly effective daily pill that decreases the likelihood of HIV acquisition by up to 92% among individuals at risk for HIV. PrEP can be discretely used, autonomously controlled, and in place at the time of risk exposure, making it an especially promising method for HIV prevention for cisgender women (CGW). But, PrEP is underutilized by CGW relative to the demonstrable need. We apply the Integrative Model of Behavioral Prediction to identify the critical psychosocial factors that shape CGW's intentions to use PrEP and their relevant underlying beliefs. We surveyed (N = 294) community- and clinic-recruited PrEP eligible CGW to understand the relative importance of attitudes, norms, and efficacy in shaping PrEP intentions. We utilized structural equation modeling to identify the relevant paths. We inspected the summary statistics in relation to three message three selection criteria. We identified beliefs that demonstrated (1) an association with intention, (2) substantial room to move the population, (3) practicality as a target for change through communication intervention. Results show that PrEP awareness was low. When women learned about PrEP, they voiced positive intentions to use it. There were significant and positive direct effects of SE (0.316***), attitudes (0.201**), and subjective norms (0.249***) on intention to initiate PrEP. We illustrate the strategic identification of beliefs within the relevant paths using the 3 belief selection criteria. We also discuss implications for social and structural communication interventions to support women's HIV prevention.

Factors Associated with Intention to Initiate Pre-exposure Prophylaxis in Cisgender Women at High Behavioral Risk for HIV in Washington, D.C.

Pre-exposure prophylaxis (PrEP) for HIV prevention is underutilized by cisgender women at risk for HIV in the USA. Published research on PrEP initiation among cisgender women at risk for HIV focuses on identifying barriers and facilitators associated with intention to initiate, but few apply a behavioral theoretical lens to understand the relative importance of these diverse factors. This study provides a theoretically grounded view of the relative importance of factors associated with intention to initiate PrEP. We conducted an anonymous, cross-sectional survey of 1437 cisgender women seeking care at family planning and sexual health clinics to evaluate hypothesized barriers and facilitators of PrEP initiation. We categorized cisgender women with ≥ 3 behavioral risk-factors as "high-risk" for HIV acquisition; 26.9% (N = 387) met high-risk criterion. Among cisgender women in the high-risk sample, the majority were Black and single. Perceived risk of HIV acquisition was low and 13.7% reported intention to initiate PrEP. Positive attitudes toward PrEP, self-efficacy, perceived support from medical providers and social networks, and prior discussion about PrEP with medical providers were associated with intention to initiate PrEP; stigma was negatively associated. Background characteristics (other than age), risk factors for HIV acquisition, prior awareness of PrEP, and perceived risk of HIV were not associated with uptake intention. These findings support interventions that center on the role of providers in the provision of PrEP and on social networks in destigmatization of PrEP use.

Awareness, acceptability, and intention to initiate HIV pre-exposure prophylaxis among pregnant women.

HIV prevention is critically important during pregnancy, however, pre-exposure prophylaxis (PrEP) is underutilized. We conducted a survey of pregnant and non-pregnant women in a high HIV prevalence community in Washington D.C. to evaluate determinants of PrEP initiation during pregnancy. 201 pregnant women and a reference population of 1103 non-pregnant women completed the survey. Among pregnant women, mean age was 26.9 years; the majority were Black with household-incomes below the federal poverty level. Despite low perceived risk of HIV acquisition and low prior awareness of PrEP, 10.5% of respondents planned to initiate PrEP during pregnancy. Pregnant women identified safety, efficacy, and social network and medical provider support as key factors in PrEP uptake intention. The belief that PrEP will "protect (their) baby from HIV" was associated with PrEP uptake intention during pregnancy. Concerns regarding maternal/fetal side effects, and safety in pregnancy or while breastfeeding were not identified as deterrents to uptake intention. When compared to a nonpregnant sample, there were no significant differences in uptake intention between the two samples. These findings support the need for prenatal educational interventions to promote HIV prevention during pregnancy, as well as interventions that center on the role of providers in the provision of PrEP.

Educational Video on Pain Management and Subsequent Opioid Use After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether viewing an educational video on pain management reduces opioid use after cesarean delivery. METHODS: We conducted a randomized, controlled trial of women aged 18 years or older who underwent cesarean delivery at a tertiary care center. Eligible women were randomized in a 1:1 ratio to usual discharge pain medication instructions plus an educational video on pain management or to usual discharge pain medication instructions alone. All women received the same opioid prescription at discharge: Twenty 5-mg oxycodone tablets. Participants were contacted at 7 days and at 14 days after delivery to assess the number of oxycodone tablets used, adjunct medication (acetaminophen and ibuprofen) use, pain scores, and overall satisfaction of pain control. The primary outcome was the number of oxycodone tablets used from discharge through postpartum day 14. A sample size of 23 per group (n=46) was planned to detect a 25% difference in mean number of oxycodone tablets used between groups, as from 20 to 15. RESULTS: From July 2019 through December 2019, 61 women were screened and 48 were enrolled-24 in each group. Women who viewed the educational video used significantly fewer opioid tablets from discharge through postpartum day 14 compared with women who received usual pain medication instructions (median 1.5, range 0-20 vs median 10, range 0-24, P<.001). Adjunct medication use, pain scores, and satisfaction with pain control did not differ significantly between groups. CONCLUSION: Among women who underwent cesarean delivery, viewing an educational video on pain management reduced postdischarge opioid use. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03959969.

Refining the clinical definition of active phase arrest of dilation in nulliparous women to consider degree of cervical dilation as well as duration of arrest.

BACKGROUND: Maternal and neonatal outcomes associated with duration of arrest of dilation beyond 4 hours are not well known. In addition, the current definition of arrest does not consider the degree of cervical dilation (6 cm vs 7 cm vs 8 cm vs 9 cm) when arrest occurs. OBJECTIVE: We sought to examine maternal and neonatal outcomes in nulliparous women who achieved the active phase of labor according to the duration they required to achieve a cervical change of at least 1 cm (<4 hours vs 4-5.9 hours vs ≥6 hours) beginning at 6, 7, 8 and 9 cm. STUDY DESIGN: This was a retrospective cohort study of nulliparous women with term singleton cephalic pregnancies in spontaneous or induced active labor (≥6 cm). To evaluate the effect of labor duration on maternal and fetal outcomes at different degrees of cervical dilation, we categorized women based on time intervals they required to achieve a cervical change of at least 1 cm after membrane rupture ("<4 hours," "4-5.9 hours," and "≥6 hours"), and we correlated each time interval with referent cervical dilation status (6 cm, 7 cm, 8 cm, and 9 cm). Maternal and neonatal outcomes were analyzed according to the duration to progress at least 1 cm starting from each degree of cervical dilation. Our primary outcome was a composite of neonatal outcomes, including intensive care unit admission, neonatal death, seizure, ventilator use, birth injury, and neonatal asphyxia. In addition, we examined maternal outcomes. Adjusted odds ratios with 95% confidence intervals were calculated, controlling for predefined covariates. RESULTS: Of 31,505 nulliparous women included in this study, 13,142 (42%), 10,855 (34%), 11,761 (37%), and 17,049 (54%) reached documented cervical dilation of 6, 7, 8, and 9 cm, respectively. At cervical dilation of 6 or 7 cm, the arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal outcomes. When cervical dilation was 8 or 9 cm, arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal and neonatal outcomes. For example, women starting at a cervical dilation of 8 cm who required <4 hours to achieve a cervical change of 1 cm compared with those who required 4 to 5.9 hours had lower rates of cesarean delivery (adjusted odds ratio, 0.40; 95% confidence interval, 0.28-0.55), chorioamnionitis (adjusted odds ratio, 0.42; 95% confidence interval, 0.29-0.60), and the neonatal composite outcome (adjusted odds ratio, 0.51; 95% confidence interval, 0.36-0.72). CONCLUSION: When cervical dilation is 6 or 7 cm, allowing arrest of dilation of ≥4 hours is reasonable because it was not associated with increased risks of adverse neonatal outcomes. When cervical dilation is 8 or 9 cm, the benefit of allowing arrest of dilation of ≥4 hours should be balanced against the risk of adverse maternal and neonatal outcomes.

Maternal outcomes according to cesarean uterine incision between 23 and 27 weeks' gestation.

OBJECTIVE: Cesarean delivery between 23 and 27 weeks' gestation is a risk factor for performing classical and inverted T uterine incisions. When attempting cesarean delivery via a low transverse incision at a very preterm gestational age, having difficulty in delivery of the fetus may require conversion to an inverted T-incision. We sought to examine maternal short-term outcomes according to the type of attempted uterine incisions in preterm deliveries. STUDY DESIGN: This was a multihospital retrospective cohort study of women undergoing cesarean delivery between 23 0/7 and 27 6/7 week' gestation from 2005 through 2014. Cases were classified as attempting low transverse incision if the uterine incision was a low transverse or an inverted T incision. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and intensive care unit admission) was compared between cases where a low transverse incision was attempted and those with a classical uterine incision. We also examined operative time and Apgar score at 5 minutes. Multivariable logistic regression or linear regression was used to obtain adjusted p-value or adjusted odds ratios (aOR) with 95% confidence interval (95%CI), controlling for maternal age, gestational age, body mass index (kg/m2), and preterm premature rupture of membranes. RESULTS: Of 311 women undergoing cesarean delivery between 23 0/7 and 27 6/7 week' gestation, attempting low transverse incision occurred in 127 (41%). Of these, conversion to an inverted T or J uterine incision occurred in 14 (11%). There was no difference in the composite outcome between cases with attempting low transverse incision and those with classical incision (17.3 versus 23.4%, respectively; aOR 0.58 [95%CI 0.30-1.11]). Cases in which a low transverse uterine incision was attempted had shorter median operative time (46 versus 55 minutes; adjusted p-value < 0.01). No differences were seen in the Apgar score at 5 minutes (adjusted p-value = .81). CONCLUSION: The incidence of conversion from a low transverse to an inverted T uterine incision in very preterm cesarean deliveries was low. Attempting a low transverse compared to a classical uterine incision was associated with similar odds of the primary outcome and shorter operative time.