Cerclage Plus Adjuvant Vaginal Progesterone for Preterm Birth Prevention in Patients with a Short or Dilated Cervix without Prior Preterm Birth.

OBJECTIVE: The primary objective was to determine if vaginal progesterone following cerclage for cervical length <10 mm or cervical dilation in patients without a history of spontaneous preterm birth (sPTB) decreased the risk of preterm birth at <34 weeks' gestation compared with cerclage alone. Secondary objectives were to determine if vaginal progesterone following cerclage (1) decreased the risk of preterm birth at <24, <28, and <37 weeks' gestation and (2) increased the latency period from cerclage placement to delivery compared with treatment with cerclage alone. STUDY DESIGN: Multicenter retrospective cohort study from 2015 to 2020 of singleton pregnancies, without prior sPTB, who had cerclage placement <24 weeks' gestation for cervical length <10 mm or cervical dilation. Exposure defined as cerclage plus vaginal progesterone postoperatively (dual therapy) and unexposed as cerclage alone (monotherapy), based on surgeon preference. RESULTS: We included 122 patients, 78 (64%) treated with dual therapy and 44 (36%) treated with monotherapy. In the crude analysis, dual therapy was associated with a lower risk of delivery at <28 weeks' gestation (13%) compared with monotherapy (34%; crude risk ratio: 0.38 [95% confidence interval (CI): 0.19-0.75]). When adjusted for preoperative vaginal progesterone, results were attenuated (adjusted risk ratio: 0.45 [95% CI: 0.20-1.01]). In both the crude and adjusted analyses, the risk of sPTB was not statistically different at <24, <34 or <37 weeks' gestation. Dual therapy was associated with a greater pregnancy latency from cerclage to delivery (16.3 vs. 14.4 weeks; p = 0.04), and greater gestational age at delivery (37.3 vs. 35.8 weeks' gestation; p = 0.02) compared with monotherapy. CONCLUSION: While not statistically significant, the risk of sPTB was lower at all gestational ages studied in patients treated with dual therapy compared with monotherapy. Dual therapy was associated with longer pregnancy latency and greater gestational age at delivery compared with monotherapy. KEY POINTS: · Dual therapy did not decrease preterm birth risk compared with monotherapy.. · Dual therapy prolonged pregnancy compared with monotherapy.. · Dual therapy can be considered but further studies are needed..

The association between decision and incision time by race and ethnicity.

BACKGROUND: Identifying and reducing inequities in the delivery of care is crucial to improving health disparities in obstetric outcomes. This study sought to evaluate the effect of race and ethnicity on time from decision for cesarean delivery to incision following implementation of a case classification system. METHODS: A retrospective cohort study was performed to identify women who had cesarean deliveries from October 1, 2020, to March 31, 2021, at a single, tertiary care institution. Medical records were reviewed for demographics and cesarean delivery case classification. Case classification was divided into STAT cesarean delivery (within 10 minutes), level A (within 30 minutes), level B (within 60 minutes), or scheduled/unscheduled other. The "decision to incision time" was determined from the time the case surgical order was placed to the case start time. RESULTS: There were 565 eligible individuals who had a cesarean delivery during the study period, with 13.6% identifying as Black/African American, 29.0% as Hispanic/Latina, and 57.3% as White. Hispanic women were more likely to need interpreter services than other race/ethnicity groups. There was no statistically significant difference in "decision to incision time" by race/ethnicity. Within the total cohort, 51.8% of cesarean delivery cases went within the goal time according to case classification, which also did not differ by race/ethnicity. CONCLUSIONS: Race and ethnicity do not impact cesarean delivery "decision to incision time" or case classification. Only half of cesarean deliveries went within the goal time, so further evaluation to improve workflow and improve this metric for all patients is needed.