Length of the second stage of labor and preterm delivery risk in the subsequent pregnancy.

BACKGROUND: Cervical injury is regarded as an important risk factor for preterm delivery. A prolonged second stage of labor may increase the risk of cervical injury that, in turn, may be associated with increased risk of spontaneous preterm delivery in the subsequent pregnancy. OBJECTIVE: We sought to evaluate whether the duration of the second stage of labor in a term primiparous singleton delivery is associated with an increased risk of singleton spontaneous preterm delivery (<37 weeks) in the second pregnancy. STUDY DESIGN: We carried out a retrospective cohort analysis of women with 2 consecutive pregnancies: a first term (≥37 weeks) delivery and second birth. Data were derived from a single institution's prospectively collected obstetrical database from January 2005 through January 2015. Duration of the second stage of labor was examined as a continuous variable, modeled based on nonparametric restricted cubic regression spline with 4 degrees of freedom. Second-stage duration was also examined as short (<30 minutes), normal (30-179 minutes), and prolonged, defined as ≥180 minutes. The association between the duration of the second stage of labor in the first term pregnancy and the risk for spontaneous preterm delivery in the second pregnancy was evaluated before and after adjusting for potential confounders based on the Cox proportional hazards regression model. Associations were expressed based on the adjusted hazard ratio and 95% confidence interval. RESULTS: In all, 6715 women met inclusion criteria. The hazard of spontaneous preterm delivery in the second pregnancy trended higher with both shorter and longer second-stage labors. The length of the second stage of labor in the first term delivery was categorized as short (<30 minutes) in 1749 (26.0%), normal (30-179 minutes) in 4551 (67.8%), and prolonged (≥180 minutes), in 415 (6.2%) women. Of these 6715 women with a first term delivery, 4.2% (n = 279) delivered spontaneously preterm in the second pregnancy. The risks of spontaneous preterm delivery among women with prolonged (≥180 minutes) second stage of labor and normal labor duration (30-179 minutes) were 5.4% (n = 22) and 3.5% (n = 158), respectively (adjusted hazard ratio, 1.81; 95% confidence interval, 1.15-2.84). This increased risk for prolonged second stage of labor was primarily seen among women who underwent a cesarean (hazard ratio, 3.38; 95% confidence interval, 1.09-10.49), but was imprecise among women who delivered vaginally (hazard ratio, 1.52; 95% confidence interval, 0.62-3.74). The risk of spontaneous preterm delivery among women with short second stage of labor (<30 minutes) in their first term pregnancy was 5.8% (n = 99; hazard ratio, 1.28; 95% confidence interval, 0.99-1.67). CONCLUSION: The risk of spontaneous preterm delivery in the second pregnancy was increased in women with a prolonged (≥180 minutes) second stage in the first term pregnancy. This risk was even greater among women who were delivered by cesarean in the first pregnancy.

Concurrent progestogen and cerclage to reduce preterm birth: a multicenter international retrospective cohort.

BACKGROUND: Both progestogens and cerclage are individually effective in preterm birth prevention in high risk pregnancies. However, national and international guidelines cite a lack of data available to comment on the potential benefit of concurrent progestogen therapy after cerclage has been placed. Studies to date have been small with mixed results regarding benefit of concurrent progestogen with cerclage leaving uncertainty regarding best clinical practice. OBJECTIVE: This study aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth in singleton pregnancies. METHODS: This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016 to June 2020. Exclusion criteria were lack of documentation regarding whether progestogen was prescribed, unavailable delivery outcome, and pregnancy termination (spontaneous or induced) before 16 weeks' gestation. The exposure of interest was progestogen use with cerclage placement, which included those who continued to use progestogen or who started progestogen after cerclage. The comparison group consisted of those without progestogen use after cerclage placement, which included those who had no progestogen use during the entire pregnancy or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. The primary outcome was spontaneous preterm birth at <37 weeks. The secondary outcomes were spontaneous preterm birth at <34 weeks, gestational age at delivery, and a composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia. There were planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate), preterm birth history, and site. Continuous variables were compared in adjusted analyses with analysis of covariance, and categorical variables were compared with multivariable logistic regression, adjusting for potential confounders with adjusted odds ratio. A Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. RESULTS: During the study period, a total of 699 singletons met the inclusion criteria: 561 in the progestogen with cerclage group and 138 with cerclage alone. Baseline characteristics were similar, except the higher likelihood of previous spontaneous preterm birth in the progestogen group (61% vs 41%; P<.001). Within the progestogen group, 52% were on 17-hydroxyprogesterone caproate weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of spontaneous preterm birth <37 weeks (31% vs 39%; adjusted odds ratio, 0.59 [0.39-0.89]; P=.01) and <34 weeks (19% vs 27%; adjusted odds ratio, 0.55 [0.35-0.87]; P=.01), increased latency to spontaneous delivery (hazard ratio for spontaneous preterm birth <37 weeks, 0.66 [0.49-0.90]; P=.009), and lower frequency of perinatal death (7% vs 16%; adjusted odds ratio, 0.37 [0.20-0.67]; P=.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a previous preterm birth, those with ultrasound- or examination-indicated cerclage, those who started progestogen therapy before cerclage, and in sites restricted to the United States. CONCLUSION: Use of progestogen with cerclage was associated with reduced rates of spontaneous preterm birth and early spontaneous preterm birth compared with cerclage alone. Although this study was not sufficiently powered for subgroup analysis, the strength of evidence for benefit appeared greatest for those with ultrasound- or examination-indicated cerclage, and with vaginal progesterone.

Continuation Rates of the Etonogestrel Implant and Factors Associated With Early Discontinuation.

BACKGROUND: The etonogestrel implant is generally considered an effective, three-year, long-acting reversible contraceptive device. Previous research, such as the landmark CHOICE study, has reported a one-year continuation rate of 72% to 84%, however, in a real-world setting these rates may be significantly lower. OBJECTIVE: To study etonogestrel implant continuation rates and factors associated with early discontinuation in a specific clinical setting. STUDY DESIGN: Single-center, retrospective cohort study of patients who received the etonogestrel implant between January 1, 2015, and December 31, 2017, at several practices at an academic community hospital network. Records were reviewed up to three years after implant insertion to determine continuation rates (one to three years), early discontinuation rates (≤12 months), and reasons for early discontinuation. A sample size calculation was performed to guide a subanalysis of side effects. RESULTS: A total of 774 patients underwent etonogestrel insertion during the study period. The one-year continuation rate was lower than that of the CHOICE study (62% vs. 83%, P <0.001). A subanalysis (n=216) revealed that a majority (82%, n=177) of patients reported side effects. Side effects were more common in patients with early discontinuation compared with patients who continued use longer than one year (93% vs. 71%, P <0.001). The most common side effect, abnormal uterine bleeding, was not significantly associated with early discontinuation. A significant association (P=0.02) was found between early discontinuation and neurologic/psychiatric complaints. CONCLUSIONS: The one-year continuation rate of the etonogestrel implant in our population is significantly lower than the value reported by CHOICE. Implant side effects are common and significantly affect rates of discontinuation. Our data suggest there is an opportunity for education and counseling for individuals opting for this method of long-acting contraception.

Enhanced recovery protocol after cesarean delivery: impact on opioid use and pain perception.

BACKGROUND: Opioids are routinely prescribed to patients postoperatively after cesarean delivery. With rates of cesarean deliveries increasing globally and the opioid epidemic continuing to have deleterious effects, finding methods to achieve effective pain control without opioids is of increasing importance. The ERAS (Enhanced Recovery After Surgery) protocol applied following cesarean delivery engages multimodal perioperative management techniques to encourage early recovery. In the obstetrical surgery setting, these interventions include increasing scheduled nonsteroidal anti-inflammatory drug administration and laxative use to improve postoperative gastrointestinal motility and pain scores. Postcesarean patients are also encouraged to use abdominal binders, incentive spirometry, and early movement as pain modulators. OBJECTIVE: This quality improvement study aimed to measure whether the introduction of an ERAS protocol following cesarean delivery at a United States-based health network would improve outcomes such as the use of opioid medications for pain and pain control. STUDY DESIGN: This single-center retrospective cohort study compared patients who gave birth via cesarean delivery before (n=1425) and after (n=3478) the implementation of the postsurgical recovery protocol. Outcomes of interest included total postoperative opioid medications used, discharge opioid prescription, average pain score, pain scores by postoperative day, and highest pain score. Patients with a history of opioid use disorder, those who underwent a cesarean hysterectomy, and those who experienced a major surgical complication at delivery were excluded. Data were collected from the electronic medical record. RESULTS: Patients in the postimplementation period used significantly fewer opioid medications than those who gave birth before the protocol was introduced at the institution. The total median opioid use before implementation was 75 morphine milligram equivalents (interquartile range, 45-112.5) vs 30 (interquartile range, 15-52.5) after implementation (P<.001). The median discharge prescription was 225 (interquartile range, 150-225) before implementation vs 112.5 (interquartile range, 75-150) after implementation (P<.001). Pain scores were also significantly lower after implementation. The median highest pain score was 8 (interquartile range, 6-8) on a 10-point pain scale before implementation vs 7 (interquartile range, 6-8) after implementation (P<.001). The average pain score before implementation was 3.4 (interquartile range, 2.4-4.5) vs 2.9 (interquartile range, 1.9-3.9) after implementation (P<.001). Results of paired-sample analyses of 177 patients who gave birth by cesarean delivery in both time periods showed statistically significant outcomes similar to those of the larger cohort groups. CONCLUSION: Implementation of multimodal pain regimens following cesarean delivery, such as the ERAS protocol, which incorporate both pharmacologic (nonsteroidal anti-inflammatory drugs, laxatives) and nonpharmacologic methods (abdominal binders, deep breathing, movement) can be effective for pain control and may decrease postoperative opioid prescribing needs, thus mitigating the potential for opioid misuse and dependence.

Comparison of 12-hour urine protein and protein:creatinine ratio with 24-hour urine protein for the diagnosis of preeclampsia.

OBJECTIVE: The purpose of this study was to evaluate the performance of the 12-hour urine protein >165 mg and protein:creatinine ratio >0.15 for the prediction of 24-hour urine protein of ≥300 mg in patients with suspected preeclampsia. STUDY DESIGN: We performed a prospective observational study of 90 women who had been admitted with suspected preeclampsia. Protein:creatinine ratio and 12- and 24-hour urine specimens were collected for each patient. Test characteristics for the identification of 24-hour urine protein ≥300 mg were calculated. RESULTS: A 12-hour urine protein >165 mg and protein:creatinine ratio of >0.15 correlated significantly with 24-hour urine protein ≥300 mg (r = 0.99; P < .001; and r = 0.54; P < .001, respectively). A 12-hour urine protein >165 mg performed better than protein:creatinine ratio as a predictor of a 24-hour urine protein ≥300 mg (sensitivity, 96% and 89%; specificity, 100% and 49%; positive predictive value, 100% and 32%; negative predictive value, 98% and 91%, respectively). CONCLUSION: The high correlation of a 12-hour urine protein >165 mg with a 24-hour urine protein ≥300 mg (with the benefit of a shorter evaluation time) and the high negative predictive value of protein:creatinine ratio suggest that the use of both these tests have a role in the evaluation and treatment of women with suspected preeclampsia.

Oxytocin discontinuation during active labor in women who undergo labor induction.

OBJECTIVE: The purpose of this study was to determine whether there is an increase in the cesarean delivery rate in women who undergo induction when oxytocin is discontinued in the active phase of labor. STUDY DESIGN: We conducted a prospective randomized controlled trial of women who underwent induction of labor at term; they were assigned randomly to either routine oxytocin use (routine) or oxytocin discontinuation (DC) once in active labor. Analysis was by intention to treat. RESULTS: Two hundred fifty-two patients were eligible for study analysis: 127 patients were assigned randomly to the routine group and 125 patients were assigned randomly to the DC group. Cesarean delivery rate was similar between the groups (routine, 25.2% [n = 32] vs the DC group, 19.2% [n = 24]; P = .25). There was a higher chorioamnionitis rate and slightly longer active phase in those women who were assigned to the DC group. In adjusted analysis, the rate of chorioamnionitis was not different by randomization group but was explained by the duration of membrane rupture and intrauterine pressure catheter placement. CONCLUSION: Discontinuation of oxytocin in active labor after labor induction does not increase the cesarean delivery rate significantly.

Influence of maternal age in mode of delivery after term induction of labor.

OBJECTIVE: To determine the impact of maternal age on the rate of cesarean delivery in women undergoing induction at term. STUDY DESIGN: Retrospective cohort study of term singleton gestations in nulliparous women induced for any indication at Lehigh Valley Health Network from July 2010 to July 2013. Exposure of interest was maternal age. Primary outcome was cesarean delivery. For every one woman ≥35 years of age (exposed), 2-3 women <35 years of age were selected as unexposed subjects for comparison. Statistical analysis included bivariate and multivariable techniques. RESULTS: 406 patients were included; 101 women ≥35 years of age and 305 women <35 years of age. Women in the ≥35 group were more likely to be induced for maternal medical conditions and less likely to be induced for prolonged pregnancy; few inductions were elective. Few women were induced electively in either group. More than half of women in both groups required cervical ripening. Method of cervical ripening and/or induction and percentage of women with a Bishop score <5 were similar between groups. The primary outcome, cesarean delivery, was similar between groups (45.5% in age ≥35 group vs 40.0% in age <35 group, p = .33). After adjustment for potential confounders, the rate of cesarean delivery was not influenced by maternal age (AOR 1.21 [0.76, 1.91], p = .42) but was higher in women with a Bishop score <5 at the time of induction of labor [AOR 1.64 [1.09, 2.47], p = .02]. CONCLUSION: In the wake of several recent trials underscoring the safety and potential maternal and fetal benefit of labor induction, identifying predictors of induction success (and failure) takes on increasing importance. Our findings suggest that maternal age is not an independent risk factor for cesarean delivery in women undergoing induction.

Comparison of management options for twin pregnancies with cervical shortening.

OBJECTIVE: To compare the effectiveness of expectant management (EM), cervical cerclage (CC) and vaginal progesterone (VP) in decreasing the rate of spontaneous preterm birth in twin gestations with midtrimester cervical shortening. STUDY DESIGN: This is a retrospective cohort study comparing pregnancy outcomes of twin gestations with midtrimester cervical shortening, defined as a cervical length (CL) on routine transvaginal ultrasound between 15 weeks 0 days and 24 weeks 6 days gestation of <2.5 cm, managed with either EM, CC or VP. Women were categorized by final management strategy. Primary outcome was gestational age at delivery. Secondary outcomes included latency period (defined as number of weeks between a diagnosis of cervical shortening and delivery), gestational age at delivery <32 weeks, mode of delivery, perinatal death, neonatal birthweight and rate of chorioamnionitis. Subanalysis of women with a CL < 1.5 cm was also performed. Logistic regression was used to identify predictors of delivery <32 weeks, controlling for potential confounders. RESULTS: Between January 2006 and July 2016, 64 pairs of twins with midtrimester cervical shortening were identified, 18 managed with EM (28.1%), 29 CC (45.3%), and 17 VP (26.6%), 52 of which had information regarding delivery outcomes. 90.4% of women delivered prematurely (<37 weeks). Women in the CC group were diagnosed with cervical shortening at a significantly earlier mean gestational age (CC 20.6 ± 1.7 weeks versus EM 22.2 ± 2.9 weeks and VP 22.2 ± 2.0 weeks, p = .02) and had a shorter mean cervical length at the time of diagnosis (CC 1.18 ± 0.7 cm vs. EM 1.56 ± 0.7 and VP 1.95 ± 0.6, p = .002), as compared to those in the EM and VP groups. There was no difference in gestational age at delivery (EM 30.9 ± 5.2 weeks, CC 30.4 ± 4.9 weeks and VP 32.4 ± 4.1 weeks, respectively) or any of the secondary outcomes listed above. Women with a CL <1.5 cm delivered significantly earlier than those with a cervical length ≥1.5 cm (28.4 ± 4.7 weeks vs. 33.2 ± 3.6 weeks, p = .0001). After adjusting for potential confounders, cervical length <1.5 cm, not the management strategy, was the predictor of PTB before 32 weeks in this twin population [AOR 6.56 (95% CI 1.78, 24.20), p = .005]. CONCLUSION: Twin pregnancies with midtrimester cervical shortening are at high risk for preterm delivery, and outcomes were similar regardless of management strategy. Large prospective trials are needed to evaluate the effect of different management strategies for cervical shortening in twins.

Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes.

OBJECTIVE: The objective of the study was to determine the optimal procedure for midtrimester uterine evacuation. STUDY DESIGN: This was a retrospective cohort study of women undergoing midtrimester uterine evacuation by prostaglandin induction or dilation and evacuation (D&E). Primary outcome was composite complication, defined as any of the following: infection, need for additional surgery, unexpected admission or readmission, serious maternal morbidity, and/or maternal death. RESULTS: Two hundred twenty patients met inclusion criteria: 94 D&E and 126 induction. D&E was associated with less composite complications (15% vs 28%, P = .02), which persisted in adjusted analysis (adjusted odds ratio, 0.38; 95% confidence interval, 0.15-0.99; P = .05). Women in the induction group had higher rates of retained placenta requiring curettage (22% vs 2%, P = .01), whereas cervical injury was more common in the D&E group (5% vs 0%, P = .01). Median length of stay was significantly shorter in the D&E group (5.7 hours vs 28.4 hours, P < .001). CONCLUSION: Midtrimester D&E is associated with fewer complications than prostaglandin induction.

Impact of type of maternal cardiovascular disease on pregnancy outcomes among women managed in a multidisciplinary cardio-obstetrics program.

BACKGROUND: Maternal cardiovascular disease complicates up to 4% of pregnancies in the United States. Knowledge regarding the impact of the cardiovascular disease category is limited. OBJECTIVE: The purpose of this study was to compare the maternal and neonatal outcomes among women with different types of cardiovascular diseases managed in a multidisciplinary program. STUDY DESIGN: This was a retrospective cohort study of patients with documented structural or functional cardiovascular disease who received care in a multidisciplinary program with maternal-fetal medicine and cardiology specialists at a single institution between March 2010 and November 2019. Women were categorized as having congenital heart disease, acquired heart disease, arrhythmias and channelopathies, or aortopathies. Women were excluded from the pregnancy outcome analysis if they never became pregnant or delivered at a different institution. The outcomes were analyzed according to the disease category using univariate techniques. RESULTS: A total of 232 women with 253 pregnancies met the inclusion criteria for pregnancy outcome analysis. Of these, 77 (30.4%) had congenital heart disease, 63 (24.9%) had acquired heart disease, 94 (37.2%) had arrhythmias or channelopathies, and 19 (7.5%) had aortopathies. Obesity and hypertension were more common among women with acquired heart disease, and women with acquired heart disease and arrhythmias had higher Cardiac Disease in Pregnancy II scores. Most of the pregnancies had good maternal and neonatal outcomes. Preeclampsia occurred more commonly in women with acquired heart disease (27% among those with acquired heart disease vs 10.4% among those with congenital heart disease, 13.8% among those with arrhythmias or channelopathies, and 0% among those with aortopathies; P=.009). Indicated preterm birth was highest among women with acquired heart disease (15.9%). Significant postpartum arrhythmias occurred in 2.4% of women. Preconception counseling was underutilized. CONCLUSION: Most women with preexisting cardiovascular disease experienced good pregnancy and neonatal outcomes when managed in a specialized, multidisciplinary program. Women with acquired heart disease were at highest risk for pregnancy complications such as preeclampsia and preterm birth.

Novel collaborative cardiology and maternal fetal medicine practice - experience at the heart and pregnancy program.

PURPOSE: The Heart and Pregnancy Program (HPP) was created to evaluate and manage pregnant women with cardiac conditions simultaneously by cardiology and maternal-fetal medicine (MFM). The objective of our study was to describe the experience at this multidisciplinary program. METHODS: This is a retrospective review of women managed at HPP for over 4.5 years. Subjects were compared based on indication for referral. RESULTS: One hundred and seventy-three women were seen during the time period. Referral indications included cardiac complaints without history of cardiac disease (n = 49, 28.3%), known cardiac disease (n = 96, 55.5%), and other high-risk conditions (n = 28, 16.2%). Those with a known history of cardiac disease were significantly more likely to be nulliparous, and those referred for other high-risk conditions were significantly more likely to be obese. Most women underwent echocardiography (n = 137, 79.2%). For the 140 women who delivered at our hospital, the average gestational age at delivery was 38.8 weeks and the Cesarean rate was 41.4% (n = 58). No significant adverse perinatal outcomes were noted. CONCLUSIONS: In our collaborative cardiology/MFM practice, most pregnant women had known cardiac disease. No significant adverse outcomes were noted. Our experience provides support for creating a joint model of care for pregnant women with cardiac disease.

Relationship Between Sexual Activity, Contraceptive Utilization and Biopsychosocial Characteristics Among Homeless Shelter Adolescents.

Objective: To determine whether biopsychosocial factors are associated with sexual activity and contraceptive utilization among homeless shelter adolescents. Methods: A retrospective study of 440 adolescents at a shelter in Pennsylvania between February 2015 and September 2019 was conducted. The cohort was evaluated to determine what relationship age, gender identity, substance use, and trauma history have with sexual activity and contraceptive utilization. Results: Sexual activity was significantly related to age (mean 15.8+1.4 years in sexually active vs. 14.7+1.6 years in abstinent youth, p<0.001); remote history of self-harm behavior (relative risk ratio (RR) 1.23 [95% CI 1.03-1.46]; p=0.02), history of aggressive behavior (RR 1.21 [95% CI 1.01-1.46]; p=0.04), history of trauma (RR 1.24 [95% CI 1.04-1.48]; p=0.03), and substance use (RR 2.27 [95%CI 1.86-2.77]; p<0.001). There were 55.7% sexually active females vs. 42.50% males reporting contraception use (p=0.01). After adjustment, older age and substance use remained significantly associated with sexual activity (adjusted odds ratio (AOR) 1.58 [95% CI 1.36-1.83]; p<0.001 and AOR 5.18 [95% CI 3.28-8.18]; p<0.001, respectively). Conclusions: Females self-reported sexual activity using contraception more than males. After adjustment, older age and substance use were associated with sexual activity. By better understanding the impact these factors can have on contraceptive utilization, informed policy and practice interventions can be developed and implemented to help increase safe sex practices in spaces where homeless adolescents access healthcare.

Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery.

OBJECTIVE: The purpose of this study was to determine the wound complication rates and patient satisfaction for subcuticular suture vs staples for skin closure at cesarean delivery. STUDY DESIGN: This was a randomized prospective trial. Subjects who underwent cesarean delivery were assigned randomly to stainless steel staples or subcuticular 4.0 Monocryl sutures. The primary outcomes were composite wound complication rate and patient satisfaction. RESULTS: A total of 435 patients were assigned randomly. Staple closure was associated with a 4-fold increased risk of wound separation (adjusted odds ratio [aOR], 4.66; 95% confidence interval [CI], 2.07-10.52; P < .001). Having a wound complication was associated with a 5-fold decrease in patient satisfaction (aOR, 0.18; 95% CI, 0.09-0.37; P < .001). After confounders were controlled for, there was no difference in satisfaction between the treatment groups (aOR, 0.71; 95% CI, 0.34-1.50; P = .63). CONCLUSION: Use of staples for cesarean delivery closure is associated with an increased risk of wound complications. Occurrence of a wound complication is the most important factor that influenced patient satisfaction.

Clinical evaluation during postpartum hemorrhage.

Obstetric hemorrhage remains the most important cause of maternal mortality worldwide, accounting for 30% of all direct maternal deaths. As the method of management depends on multiple concurrent and sequential evaluations of the patient's status, it is helpful to have an evaluation strategy prepared for when a postpartum hemorrhage is encountered to facilitate interventions. This review describes an etiology-based approach to the clinical evaluation of postpartum hemorrhage and a suggested systems process that allows both a timely and appropriate evaluation of the hemorrhaging mother.

A randomized trial of cerclage vs. 17 alpha-hydroxyprogesterone caproate for treatment of short cervix.

OBJECTIVE: To determine pregnancy outcome in patients with short cervix on transvaginal ultrasound between 16 and 24 weeks' gestation treated with McDonald cerclage compared to weekly intramuscular injections of 17 alpha-hydroxyprogesterone caproate (17OHP-C). METHODS: From November 2003 through December 2006, asymptomatic, singleton pregnancies were screened with transvaginal ultrasound between 16-24 weeks' gestation. Patients with a cervical length (CL) < or =25 mm were offered enrollment. Patients were randomly assigned to treatment with McDonald cerclage or weekly intramuscular injections of 17OHP-C. The primary outcome was spontaneous preterm birth (PTB) prior to 35 weeks' gestation. RESULTS: Seventy-nine patients met inclusion criteria; 42 were randomly assigned to the cerclage and 37 to 17OHP-C. Spontaneous PTB prior to 35 weeks' gestation occurred in 16/42 (38.1%) of the cerclage group and in 16/37 (43.2%) of the 17OHP-C group (relative risk, 1.14 95% CI, 0.67, 1.93). A post hoc analysis of patients with a prior PTB showed no difference in spontaneous PTB <35 weeks between groups. A similar analysis of patients with a CL< or =15 mm showed a reduction in spontaneous PTB <35 weeks in the cerclage group (relative risk 0.48, 0.24-0.97). CONCLUSION: Women with CL < or =25 mm in the second-trimester appear to have similar risks of delivering prior to 35 weeks' gestation when treated with 17OHP-C or McDonald cerclage. However, cerclage may be more effective in preventing spontaneous PTB in women with CL< or =15 mm.

Discontinuing Oxytocin Infusion in the Active Phase of Labor: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the benefits and harms of discontinuation of oxytocin after the active phase of labor is reached. DATA SOURCES: Electronic databases (ie, MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, ScienceDirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) were searched from their inception until April 2017. METHODS OF STUDY SELECTION: We included all randomized controlled trials comparing discontinuation (ie, intervention group) and continuation (ie, control group) of oxytocin infusion after the active phase of labor is reached, either after induction or augmentation of labor. Discontinuation of oxytocin infusion was defined as discontinuing oxytocin infusion when the active phase of labor was achieved. Continuation of oxytocin infusion was defined as continuing oxytocin infusion until delivery. Only trials in singleton gestations with vertex presentation at term were included. The primary outcome was the incidence of cesarean delivery. TABULATION, INTEGRATION, AND RESULTS: Nine randomized controlled trials, including 1,538 singleton gestations, were identified as relevant and included in the meta-analysis. All nine trials included only women undergoing induction of labor. In the discontinuation group, if arrest of labor occurred, usually defined as no cervical dilation in 2 hours or inadequate uterine contractions for 2 hours or more, oxytocin infusion was restarted. Women in the control group had oxytocin continued until delivery usually at the same dose used at the time the active phase was reached. Women who were randomized to have discontinuation of oxytocin infusion after the active phase of labor was reached had a significantly lower risk of cesarean delivery (9.3% compared with 14.7%; relative risk 0.64, 95% CI 0.48-0.87) and of uterine tachysystole (6.2% compared with 13.1%; relative risk 0.53, 95% CI 0.33-0.84) compared with those who were randomized to have continuation of oxytocin infusion until delivery. Discontinuation of oxytocin infusion was associated with an increase in the duration of the active phase of labor (mean difference 27.65 minutes, 95% CI 3.94-51.36). CONCLUSION: In singleton gestations with cephalic presentation at term undergoing induction, discontinuation of oxytocin infusion after the active phase of labor at approximately 5 cm is reached reduces the risk of cesarean delivery and of uterine tachysystole compared with continuous oxytocin infusion. Given this evidence, discontinuation of oxytocin infusion once the active stage of labor is established in women being induced should be considered as an alternative management plan.

Catecholaminergic Polymorphic Ventricular Tachycardia in Pregnancy.

BACKGROUND: Catecholaminergic polymorphic ventricular tachycardia is a genetic disorder in which ventricular tachycardia occurs in the absence of structural heart disease or a prolonged QT interval. If untreated, there is a high incidence of sudden cardiac death. Management of this cardiac condition during pregnancy merits a multidisciplinary approach. CASE: A nulliparous woman with catecholaminergic polymorphic ventricular tachycardia presented at 15 weeks of gestation. Her care involved a multidisciplinary team including cardiology, maternal-fetal medicine, obstetric nursing, cardiac nursing, and anesthesia. A simulation scenario was designed to prepare for cardiac events during labor. A term intrapartum cesarean delivery was performed for fetal indications. CONCLUSION: A multidisciplinary approach to the antepartum, intrapartum, and postpartum care of women with catecholaminergic polymorphic ventricular tachycardia is critical to a team-based successful pregnancy outcome.

Use of intracervical balloons and chorioamnionitis in term premature rupture of membranes.

OBJECTIVE: To determine whether ripening and induction in patients with term premature rupture of membranes (PROM) via intracervical balloon placement (ICB) increases the risk of chorioamnionitis when compared to women with term PROM ripened and induced with other methods. STUDY DESIGN: A retrospective cohort study of term singleton gestations undergoing ripening and induction after PROM between July 2009 and June 2012 was conducted. Exposure of interest was ICB placement. Primary outcome of interest was chorioamnionitis. Statistical analysis included bivariate and multivariate techniques. RESULTS: Of 124 term PROM patients, 42 were ripened by ICB with or without oxytocin (33.9%) and 82 were ripened and induced with oxytocin (66.1%). More women ripened with an ICB were nulliparous (n = 35, 83.3% ICB versus n = 44, 53.7% oxytocin, p = 0.001). Chorioamnionitis was slightly more common in women ripened with ICB and/or oxytocin versus oxytocin alone but difference did not reach statistical significance (p = 0.10). The rate of cesarean delivery, intrauterine pressure catheter (IUPC) use, and median lengths of membrane rupture and active labor were higher in the ICB group. After adjustment, chorioamnionitis was not correlated with ICB placement but with nulliparity [AOR 12.5 (1.36, 114.6), p = 0.03] and IUPC use [AOR 4.39 (1.04, 18.5), p = 0.04]. CONCLUSION: Nulliparity and IUPC, not ICB placement, were associated with chorioamnionitis.

Characteristics of participants in peripartum interventional research.

OBJECTIVE: To identify characteristics of pregnant women potentially influencing the decision to participate in peripartum interventional research. METHODS: Women screened as eligible to participate in two prospective interventional trials conducted in the labor and delivery unit at a single center were included. Characteristics of eligible women were compared based on their decision whether to participate or not. The best predictors of research participation were identified using multivariable logistic regression analyses. RESULTS: Of the 605 subjects who screened as eligible to participate, 363 (60%) agreed to participate and 242 (40%) declined. Women using a private obstetric provider or who had prior obstetrical complications were less likely to participate [aOR 0.6 (95% CI: 0.4-0.8)] and [aOR 0.6 (95% CI: 0.4-0.9)], respectively. A history of a mental health condition and a higher body mass index (BMI) were marginally more likely to participate [aOR 1.5 (95% CI: 1.0-2.3)] and [aOR 1.03 (95% CI: 1.0-1.1)], respectively. Overall logistic regression model R(2) was 0.23. CONCLUSIONS: There are differences between eligible subjects who decide to participate or not participate in prospective peripartum interventional research. There is a need to better understand non-participation in order to improve recruitment of representative populations that allow more generalizable research results.

Thromboprophylaxis after cesarean delivery: a decision analysis.

OBJECTIVE: To compare 4 strategies for managing patients after cesarean delivery. METHODS: Using decision analysis, we compared universal subcutaneous (SC) heparin prophylaxis, heparin prophylaxis only for patients with a genetic thrombophilia, use of pneumatic compression stockings (PCS), and no thromboprophylaxis. Outcomes included heparin-induced thrombocytopenia (HIT), HIT-related thrombosis, major maternal bleeding, and venous thromboembolism (VTE). RESULTS: Use of PCS was the strategy with the lowest number of adverse events. With heparin prophylaxis, 13 cases of HIT-induced thrombosis and hemorrhage would occur per VTE prevented. When heparin prophylaxis is administered only to thrombophilia-positive women, 1.2 cases of HIT-induced thrombosis and bleeding would occur per VTE prevented. In sensitivity analyses, the model was stable across virtually all variable ranges. CONCLUSION: Use of PCS after cesarean delivery is the strategy with the lowest number of adverse events. Universal prophylaxis with SC heparin is associated with an excess risk of HIT-induced thrombosis and bleeding per VTE prevented compared with PCS use. Until future studies are completed, postcesarean thromboprophylaxis with PCS should be used if the clinician elects to provide prophylaxis.