Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People with Gestational Diabetes.

OBJECTIVE: We aimed to evaluate uptake of the glucose tolerance test performed during delivery hospitalization as part of routine clinical care. STUDY DESIGN: This is a retrospective cohort study of people with GDM at a tertiary center. We collected 9 months of postimplementation data after the in-hospital ("early") glucose tolerance test was adopted as a routine screening option. Adherence was compared between those who elected early glucose tolerance testing versus those who deferred testing to the standard postpartum period. Bivariable statistics including demographics, care team, and postpartum testing/visit attendance were compared between those who received early testing and those who did not using chi-square, Fisher's exact, and t-tests. RESULTS: A total of 681 patients with GDM delivered during the study period. Of those who had an early glucose tolerance test ordered (n = 408), 340 (83.3%) completed the test. Among those who did not complete an early glucose tolerance test (ordered and not completed or never ordered), only 104/341 (30.5%) completed any postpartum glucose testing in the first 12 months of postpartum. There were significant differences in characteristics in terms of race/ethnicity, insurance, type of gestational diabetes (A1GDM vs. A2GDM), diabetes medications, obstetric care provider, and delivery mode. Among those who completed early testing, 43.7% of participants had impaired glucose metabolism and 6.5% had values concerning for overt diabetes mellitus. Among those who deferred testing to the standard 6- to 12-week period, 24.0% had impaired glucose metabolism and none had overt diabetes. Those who completed an early glucose tolerance test had a lower rate of postpartum visit attendance compared with those who deferred (75.6 vs. 91.5%, p < 0.01). CONCLUSION: In this cohort, when the early glucose tolerance test is offered in clinical practice, adherence rates are higher than when the test is deferred until the postpartum visit. KEY POINTS: · Adherence rates with the early glucose tolerance test (GTT) are higher than if the testing is deferred.. · Those who completed an early GTT had a lower rate of postpartum visit attendance compared with those who deferred.. · Offering an in-hospital postpartum GTT can help address low rates of glucose testing postpartum..

A pilot randomized control trial of topical capsaicin as adjunctive therapy for nausea and vomiting of pregnancy.

BACKGROUND: Nausea and vomiting is one of the most common complications of pregnancy, affecting 50% to 80% of pregnant persons. Moreover, despite its prevalence, it remains a challenging condition to treat. Treatment often involves oral and intravenous medications with potential side effects, particularly when taken in combination. Capsaicin cream is proven to decrease nausea and vomiting in cyclic vomiting syndrome; however, its use has not been well studied among pregnant patients. OBJECTIVE: This study aimed to test the feasibility of the off-label use of capsaicin for the treatment of nausea and vomiting in pregnancy. STUDY DESIGN: This was a double-blinded randomized controlled trial of pregnant individuals in their first trimester of pregnancy seeking care at a tertiary care hospital for nausea and vomiting. Consenting participants were randomized to abdominal application of topical capsaicin vs placebo. All participants received intravenous hydration and metoclopramide. The primary outcome, total treatment time, was recorded for all participants. In addition, symptom severity was assessed every 30 minutes using a visual analog scale. Data were analyzed using the Wilcoxon rank-sum test for continuous variables and the Fisher exact test for binary variables. RESULTS: Of the 38 eligible individuals approached, 30 were randomized. There was a trend toward decreased mean treatment time in the capsaicin group compared with the placebo group (79.9 vs 97.3 minutes; P=.1). There was no significant difference in visual analog scale scores at any time point between groups. Furthermore, capsaicin was well tolerated, with only 1 individual requesting the medication be removed. CONCLUSION: This study demonstrated that capsaicin is an acceptable treatment of nausea and vomiting in pregnancy and additional explorations of its use as treatment are feasible. A larger randomized controlled trial is needed to determine the efficacy of capsaicin in this population.

Prevention of Postoperative Surgical Site Infection Following Cesarean Delivery.

Cesarean delivery is the most common major surgical procedure performed among birthing persons in the United States, and surgical-site infection is a significant complication. Several significant advances in preventive measures have been shown to reduce infection risk, while others remain plausible but not yet proven in clinical trials.

Intrapartum Glucose Management in Women With Gestational Diabetes Mellitus: A Randomized Controlled Trial.

OBJECTIVE: To assess the effect of tight compared with liberalized intrapartum maternal glucose management on neonatal hypoglycemia risk in pregnancies complicated by gestational diabetes mellitus (GDM). METHODS: This was a randomized controlled trial of women with singleton gestations and GDM attempting vaginal delivery. After written informed consent, women were randomly allocated to one of two intrapartum maternal glucose management protocols: tight control (glucose measurements hourly and treatment for maternal glucose levels lower than 60 mg/dL or greater than 100 mg/dL) or liberalized control (glucose measurements every 4 hours and treatment for maternal glucose levels lower than 60 mg/dL or greater than 120 mg/dL). The primary outcome was the first neonatal blood glucose level; a total sample size of 74 was necessary to have 80% power to detect a mean difference of 10 mg/dL between groups. Secondary outcomes included neonatal blood glucose concentrations within the first 24 hours of life, number of glucose treatments (intravenous or oral) received to treat neonatal hypoglycemia, neonatal intensive care unit admission, and neonatal hyperbilirubinemia. RESULTS: From February 2016 to April 2018, 76 women were randomized (38 in each group), and all were included in the analysis. Baseline characteristics of the two groups were comparable for all relevant obstetric variables; mean gestational age was 39 weeks in both groups. Antepartum, two thirds of women in each group were treated medically (almost exclusively with insulin). The primary outcome was similar between the tight and liberalized control groups: 53 mg/dL vs 58 mg/dL, mean difference -4.18, 95% CI -12.66 to 4.29. However, mean neonatal glucose level within the first 24 hours of life was lower in the tight control group: 54 mg/dL vs 58 mg/dL, mean difference -3.39, 95% CI -7.07 to 0.29. Other secondary outcomes were similar between groups. CONCLUSION: A protocol aimed at tight maternal glucose management in labor compared with liberalized management for women with GDM did not result in better initial neonatal glucose concentrations and was associated with lower mean neonatal blood glucose levels in the first 24 hours of life. This study supports raising the upper threshold for intrapartum maternal glucose and decreasing the frequency of intrapartum glucose assessment for women with GDM. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02596932.

The Effect of Intrapartum Vancomycin on Vaginal Group B Streptococcus Colony Counts.

OBJECTIVE: To define the temporal relationship between intrapartum intravenous vancomycin administration and vaginal group B streptococcus (GBS) colony counts. STUDY DESIGN: Prospective cohort study conducted from October 2014 to February 2017. Women with antenatal cultures demonstrating GBS colonization and a plan for vancomycin administration were eligible. Intrapartum vaginal cultures were collected prior to the first vancomycin infusion and every 2 hours up to five collections or delivery. Results were analyzed in two groups: participants with at least one positive intrapartum culture and those without any positive intrapartum cultures. RESULTS: A total of 63 women were enrolled. Among consented women, a total of 8 were excluded and 3 participants' cultures were never plated, thus leaving a total of 52 women for analysis. The degree of vaginal GBS colonization varied between subjects and was not normally distributed. Colony counts dropped rapidly from hour 0 to hour 2 (median: 6.0 × 108 vs. 1.0 × 108, p < 0.01). Standardizing hour 0 colony counts to 100%, the percent decline in colony counts from hour 0 to hour 2 was significant (p = 0.03), and at each subsequent time point fell further. CONCLUSION: GBS vaginal colony counts fall rapidly after intrapartum vancomycin administration.

Interventions to Improve Rate of Diabetes Testing Postpartum in Women With Gestational Diabetes Mellitus.

PURPOSE OF REVIEW: Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. In the USA, four million women are screened annually for GDM in pregnancy in part to improve pregnancy outcomes but also because diagnosis predicts a high risk of future type 2 diabetes mellitus (T2DM). Therefore, among women with GDM, postpartum care should be focused on T2DM prevention. This review describes the current literature aimed to increase postpartum diabetes testing among women with GDM. RECENT FINDINGS: Data suggest that proactive patient contact via a health educator, a phone call, or even postal mail is associated with higher rates of postpartum diabetes testing. There may also be utility to changing the timing of postpartum diabetes testing. Despite the widespread knowledge regarding the importance of postpartum testing for women with GDM, testing rates remain low. Alternative testing strategies and large randomized trials addressing postpartum testing are warranted.

Cost-effectiveness of transvaginal ultrasound cervical length screening in singletons without a prior preterm birth: an update.

OBJECTIVE: We sought to reevaluate the cost-effectiveness of universal transvaginal ultrasound (TVU) cervical length (CL) screening in singleton pregnancies without prior spontaneous preterm birth. STUDY DESIGN: We developed a decision model to assess costs and effects of universal TVU CL screening at 18-23 weeks' gestation compared to routine care for singleton pregnancies without prior preterm birth. Based on recent data, the model contains the following updates: (1) reduced incidence of CL ≤20 mm at initial screening ultrasound (0.83%), (2) vaginal progesterone supplementation for women with CL ≤20 mm, (3) additional ultrasound(s) for women with CL 21-24.9 mm, and (4) the assumption that vaginal progesterone reduces the rate of preterm birth <34 weeks' gestation by 39% if a short CL is diagnosed. The primary outcome was incremental cost-effectiveness ratio. We assumed a willingness to pay of $100,000 per quality-adjusted life year (QALY) gained. Additional outcomes included incidence of offspring with long-term neurological deficits and neonatal death. Sensitivity analyses were performed to assess the robustness of the results. RESULTS: For every 100,000 women screened, universal TVU CL screening costs $9132 compared to routine care. Screening results in 215 QALYs gained and 10 fewer neonatal deaths or neonates with long-term neurologic deficits per 100,000 women screened. Based on the updated data, universal CL screening in low-risk women remains a cost-effective strategy (incremental cost-effectiveness ratio = $43/QALY), but is not cost saving as previously estimated. Sensitivity analyses reveal that when incidence of TVU CL ≤20 mm is <0.31%, universal TVU CL screening is no longer cost-effective. Additionally, when TVU CL costs >$314, progesterone reduces preterm delivery risk before 34 weeks <19%, or the incidence of a TVU CL 21-24.9 mm is >6.5%, CL screening is also no longer cost-effective. CONCLUSION: Despite the reduced incidence and efficacy used in this model, universal TVU CL continues to be cost-effective when compared to routine care in singletons without prior preterm birth.

Whither oxygen for intrauterine resuscitation?

Oxygen is frequently administered to women in labor in the hope of improving fetal status. However, there is a paucity of outcome data to support this practice. Although maternal oxygen administration may make physiological sense, unwarranted faith in maternal oxygen therapy may delay the indicated intervention or result in continued labor stimulation when neither is in the best interests of the fetus. A properly designed clinical trial would help answer whether maternal oxygen supplementation in labor should be considered an indicated intervention for nonreassuring fetal status.

Oxygen for intrauterine resuscitation: of unproved benefit and potentially harmful.

Maternal oxygen is often given to laboring women to improve fetal metabolic status or in an attempt to alleviate nonreassuring fetal heart rate patterns. However, the only 2 randomized trials investigating the use of maternal oxygen supplementation in laboring women do not support that such supplementation is likely to be of benefit to the fetus. And by increasing free radical activity, maternal oxygen supplementation may even be harmful. Based on a review of the available literature, we conclude that until it is studied properly in a randomized clinical trial, maternal oxygen supplementation in labor should be reserved for maternal hypoxia, and should not be considered an indicated intervention for nonreassuring fetal status.