Severe Maternal Morbidity among Women in the U. S. Military, 2003-2015.

OBJECTIVE: This study aimed to assess trends and correlates of severe maternal morbidity at delivery among active duty women in the U.S. military, all of whom are guaranteed health care and full employment. STUDY DESIGN: Linked military personnel and medical encounter data from the Department of Defense Birth and Infant Health Research program were used to identify a cohort of delivery hospitalizations among active duty military women from January 2003 through August 2015. Cases of severe maternal morbidity were identified by applying 21- and 20-condition algorithms (with and without blood transfusion) developed by the Centers for Disease Control and Prevention. Rates (per 10,000 delivery hospitalizations) were reported overall and by specific condition. Multivariable Poisson regression models estimated associations with demographic, clinical, and military characteristics. RESULTS: Overall, 187,063 hospitalizations for live births were included for analyses. The overall 21- and 20-condition severe maternal morbidity rates were 111.7 (n = 2089) and 37.4 (n = 699) per 10,000 delivery hospitalizations, respectively. The 21-condition rate increased by 184% from 2003 to 2015; the 20-condition rate increased by 40%. Compared with non-Hispanic White women, the adjusted 21-condition rate of severe maternal morbidity was higher for Hispanic (adjusted rate ratio [aRR] = 1.28, 95% confidence interval [CI]: 1.13-1.46), non-Hispanic Black (aRR = 1.34, 95% CI: 1.21-1.49), Asian/Pacific Islander (aRR = 1.35, 95% CI: 1.13-1.61), and American Indian/Alaska Native (aRR = 1.39, 95% CI: 1.06-1.82) women. Rates also varied by age, clinical factors, and deployment history. CONCLUSION: Active duty U.S. military women experienced an increase in severe maternal morbidity from 2003 to 2015 that followed national trends, despite protective factors such as stable employment and universal health care. Similar to other populations, military women of color were at higher risk for severe maternal morbidity relative to non-Hispanic White military women. Continued surveillance and further investigation into maternal health outcomes are critical for identifying areas of improvement in the Military Health System. KEY POINTS: · Cesarean delivery and multiple birth were the strongest correlates of severe maternal morbidity in this population.. · Racial disparities persisted across indicators of severe maternal morbidity.. · Rates of disseminated intravascular coagulation were higher than those reported nationally..

Urinary symptoms after bladder flap at the time of primary cesarean delivery: a randomized controlled trial (RTC).

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate urinary symptoms in the postpartum period after omission of the bladder flap at the time of primary cesarean delivery. METHODS: This was a single-blind parallel-group randomized comparison (bladder flap, no bladder flap) in women scheduled for a primary cesarean delivery at 37 weeks gestation or later. The primary outcome was urinary symptom scores at 6-8 weeks postpartum. Secondary outcomes included comparisons of preoperative and postoperative pelvic floor symptom scores and the proportions of symptom bother responses between the study groups. RESULTS: A total 43 women were available for analysis. Randomization was as follows: omission of the bladder flap (n = 22) and bladder flap (n = 21). Demographic characteristics and baseline pelvic floor symptom scores were similar between the groups. The primary outcome, urinary symptom scores at 6-8 weeks postpartum, did not differ significantly between the groups, but urinary symptom bother was significantly higher in women who received a bladder flap. Pelvic floor symptom scores improved significantly following delivery. CONCLUSIONS: Urinary symptom scores as measured by the UDI-6 did not differ between women randomized to bladder flap or omission of the bladder flap, but the proportion of women with urinary symptom bother was significantly higher among those who received a bladder flap.

Magnification effects on distance estimation during robotic suturing.

We aimed to understand the impact of magnification on distance estimation during robotic suturing. Twenty subjects estimated the lengths of various sutures externally, in plain sight, to validate their ability to measure distances. They then robotically repaired a 3-cm cystotomy, suturing 10 mm above and below the incision and 10 mm on either side of the incision. The bladder was removed and distances measured. A total of 20 surgeons were analyzed: 7 residents, 8 fellows, and 5 staff. Specialties comprised four urologists, eight general gynecologists, two urogynecologists, three gynecologic oncologists, and three reproductive endocrinologists. The mean estimation for external suture length was not significant at 10 mm: mean = 9.6 (±3.2) mm (p = 0.59). When comparing these data sets, the externally visualized 10-mm suture versus the suture-to-suture and the suture-to-incision distances were both significantly different (p = 0.002 and p < 0.001, respectively). The mean distance between each suture was 6.5 (±1.8) mm, which was significantly different from the 10-mm goal (p < 0.001, 95 % confidence interval (CI) [-4.4,-2.6]). The mean distance from the suture to the incision was 4.1 (±1.0) mm, which was also statistically significantly different from the goal (p < 0.001, 95 % CI [-6.3,-5.4]). Surgical experience was negatively associated with suture-to-incision distance (r s = -0.53, p = 0.016). Inter-suture distance was also negatively associated with experience (r s = -0.30, p = 0.22), though not statistically significant. In vivo distances are significantly underestimated during robotic suture placement. Interestingly, the most experienced surgeons had the worst distance estimation from the incision to the suture.