Mode of Delivery in Antepartum Singleton Stillbirths and Associated Risk Factors

OBJECTIVE

 This study was aimed to investigate delivery management of patients with antepartum stillbirth.

STUDY DESIGN

 Using data from fetal death certificates and linked maternal hospital discharge records, we identified a population-based sample of patients with singleton antepartum stillbirth at 20 to 42 weeks of gestation in California in 2007 to 2011. Primary outcomes were intended mode of delivery and actual mode of delivery. We used multivariable regressions to examine the association between patient demographic, clinical, and hospital characteristics and their mode of delivery. Separate analysis was performed for patients who had prior cesarean delivery versus those who did not.

RESULTS

 Of 7,813 patients with singleton antepartum stillbirth, 1,356 had prior cesarean, while 6,457 had no prior cesarean. Labor was attempted in 51.8% of patients with prior cesarean and 93.7% of patients without prior cesarean, with 76.2 and 95.8% of these patients, respectively, delivered vaginally. Overall, 18.9% of patients underwent a cesarean delivery (60.5% among those with prior cesarean and 10.2% among those without prior cesarean). Multivariable regression analysis identified several factors associated with the risk of cesarean delivery that were not medically indicated. For instance, among patients without prior cesarean, malpresentation (of which the vast majority was breech presentation) was associated with an increased likelihood of planned cesarean (adjusted odds ratio [OR] = 3.26, 95% confidence interval [CI]: 2.53-4.22) and cesarean delivery after attempting labor (adjusted OR = 3.09, 95% CI: 2.25-4.25). For both patients with and without prior cesarean, delivery at an urban teaching hospital was associated with a lower likelihood of planned cesarean and a lower likelihood of cesarean delivery after attempting labor (adjusted ORs ranged from 0.28 to 0.56, p < 0.001 for all).

CONCLUSION

 Over one in six patients with antepartum stillbirth underwent cesarean delivery. Among patients who attempted labor, rate of vaginal delivery was generally high, suggesting a potential opportunity to increase vaginal delivery in this population.

KEY POINTS

· In singleton antepartum stillbirths, 18.9% underwent cesarean delivery.. · Rate of vaginal delivery was high when labor was attempted.. · Both clinical and non-clinical factors were associated with risk of cesarean delivery..

Assessing the predictive accuracy of the new vaginal birth after cesarean calculator

BACKGROUND

The vaginal birth after cesarean (VBAC) calculator by the Maternal-Fetal Medicine Units (MFMU) Network was created to help providers counsel patients on predicted success of trial of labor after cesarean (TOLAC) using individualized risk assessment. The inclusion of race and ethnicity as predictors of VBAC in the 2007 calculator was problematic and potentially exacerbated racial disparities in obstetrics. Thus, a modified calculator without race and ethnicity was published in June 2021.

OBJECTIVE

This study aims to assess the accuracy of the 2007 and 2021 MFMU VBAC calculators in predicting VBAC success among racial/ethnic minority patients receiving obstetric care at a single urban tertiary medical center.

STUDY DESIGN

All patients with one prior low transverse cesarean delivery (CD) who underwent a trial of labor at term with a vertex singleton gestation from an urban tertiary medical center from May 2015 to December 2018 were reviewed. Demographic and clinical data were collected retrospectively. Associations between maternal characteristics and VBAC success were assessed using univariate and multivariable logistic regression. Predicted VBAC success rates using MFMU calculator were compared to actual outcomes (i.e. successful TOLAC/VBAC vs repeat cesarean delivery) across each racial and ethnic group.

RESULTS

A total of 910 deliveries met eligibility criteria and attempted TOLAC. A total of 662 (73%) achieved VBAC. The rate of VBAC was highest among Asian women (81%) and lowest among Black women (61%). Univariate analyses demonstrated that VBAC success was associated with maternal body mass index (BMI) < 30 kg/m², history of prior vaginal delivery, and absence of indication of arrest of dilation or descent for prior CD. Multivariate analyses evaluating predictors of VBAC reported in the 2021 VBAC Calculator showed that maternal age, history of arrest disorder for prior CD, and treated chronic hypertension were not significant in our patient population. The majority of patients who were White, Asian, or Other race with a VBAC had a 2007 Calculator predicted probability of VBAC >65%, while the majority of Black and Hispanic patients with a VBAC were more likely to have a predicted probability of VBAC between 35-65% (p<0.001). The majority of White, Asian, or Other race patients with a repeat CD had a 2007 Calculator predicted probability of VBAC >65%, while the majority of Black and Hispanic patients with a repeat CD had a predicted probability of VBAC between 35-65%. Across all racial and ethnic groups, the majority of patients with a VBAC had a 2021 Calculator predicted probability of VBAC >65%.

CONCLUSIONS

The inclusion of race/ethnicity in the 2007 MFMU VBAC calculator underestimates predicted VBAC success rates among Black and Hispanic patients receiving obstetric care at an urban tertiary medical center, thus we support the use of the 2021 VBAC calculator without race/ethnicity. Removing inclusion of race and ethnicity from VBAC counseling may be one way in which providers can ultimately contribute towards the reduction of racial and ethnic disparity in maternal morbidity in the United States. Further research is needed to understand the implication of treated chronic hypertension in VBAC success.

Dyslipidemia and Risk of Preeclampsia: A Multiancestry Mendelian Randomization Study

BACKGROUND

Preeclampsia is a leading cause of maternal morbidity, and dyslipidemia has been associated with preeclampsia in observational studies. We use Mendelian randomization analyses to estimate the association between lipid levels, their pharmacological targets, and the risk of preeclampsia in 4 ancestry groups.

METHODS

We extracted uncorrelated (R²<0.001) single-nucleotide polymorphisms strongly associated (P<5×10^-8) with LDL-C (low-density lipoprotein cholesterol), HDL-C (high-density lipoprotein cholesterol), and triglycerides from genome-wide association studies of European, admixed African, Latino, and East Asian ancestry participants. Genetic associations with risk of preeclampsia were extracted from studies of the same ancestry groups. Inverse-variance weighted analyses were performed separately for each ancestry group before they were meta-analyzed. Sensitivity analyses were conducted to evaluate bias due to genetic pleiotropy, demography, and indirect genetic effects.

RESULTS

The meta-analysis across 4 ancestry groups included 1.5 million subjects with lipid measurements, 7425 subjects with preeclampsia, and 239 290 without preeclampsia. Increasing HDL-C was associated with reduced risk of preeclampsia (odds ratio, 0.84 [95% CI, 0.74-0.94]; P=0.004; per SD increase in HDL-C), which was consistent across sensitivity analyses. We also observed cholesteryl ester transfer protein inhibition-a drug target that increases HDL-C-may have a protective effect. We observed no consistent effect of LDL-C or triglycerides on the risk of preeclampsia.

CONCLUSIONS

We observed a protective effect of elevated HDL-C on risk of preeclampsia. Our findings align with the lack of effect in trials of LDL-C modifying drugs but suggest that HDL-C may be a new target for screening and intervention.

Racial and ethnic differences in severe maternal morbidity among singleton stillbirth deliveries

BACKGROUND

Despite growing evidence suggesting racial or ethnic disparities in the risk of severe maternal morbidity among live births, there is little research investigating potential differences in severe maternal morbidity risk among stillbirths across race and ethnicity.

OBJECTIVE

This study aimed to compare the risk of severe maternal morbidity by race and ethnicity among patients with singleton stillbirth pregnancies.

STUDY DESIGN

We used the California Linked Birth File database to perform a retrospective analysis of singleton stillbirth pregnancies delivered at 20 to 42 weeks' gestation between 2007 and 2011. The database contained information from fetal death certificates linked to maternal hospital discharge records. We defined severe maternal morbidity using the Centers for Disease Control and Prevention composite severe maternal morbidity indicator and compared rates of severe maternal morbidity across racial and ethnic groups. Multivariable regression analysis was used to examine how race and ethnicity were associated with severe maternal morbidity risk after accounting for the influence of patients' clinical risk factors, socioeconomic characteristics, and attributes of the delivery hospital.

RESULTS

Of the 9198 patients with singleton stillbirths, 533 (5.8%) experienced severe maternal morbidity. Non-Hispanic Black patients had a significantly higher risk of severe maternal morbidity (10.6% vs 5.2% in non-Hispanic White patients, 5.2% in Hispanic patients, and 5.1% in patients with other race or ethnicity; P<.001). The higher risk of severe maternal morbidity among non-Hispanic Black patients persisted even after adjusting for patients' clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.74; 95% confidence interval, 1.21-2.50). Further analysis separating blood-transfusion and nontransfusion severe maternal morbidity showed a higher risk of blood transfusion in non-Hispanic Black patients, which remained significant after adjusting for patients' clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.64; 95% confidence interval, 1.11-2.43). However, the higher risk of nontransfusion severe maternal morbidity in non-Hispanic Black patients was no longer significant after adjusting for patients' clinical risk factors (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.38; 95% confidence interval, 0.83-2.30).

CONCLUSION

Severe maternal morbidity occurred in 5.8% of patients with a singleton stillbirth. Risk of severe maternal morbidity in stillbirth was higher in patients with non-Hispanic Black race, which was likely owing to a higher risk of hemorrhage, as evidenced by increased rate of blood transfusion.

Unindicated cervical cancer screening in adolescent females within a large healthcare system in the United States

BACKGROUND

Current consensus recommendations are to not initiate cervical cancer screening for immunocompetent adolescent females before 21 years of age. This is in part because of the very low rate of 0.8 per 100,000 new cervical cancer cases diagnosed among women aged between 20 to 24 years. Timely human papillomavirus vaccination further decreases the incidence of cervical cancer to 4 cases per 100,000 persons by the age of 28 years. Screening before 21 years of age has demonstrated no clear benefit in cancer risk reduction or outcomes. In addition, unindicated screening among adolescents can lead to patient harm and increasing costs to the healthcare system.

OBJECTIVE

It is important to assess the rates of overutilization of cervical cancer screening and to identify areas where improvements have occurred and where further opportunities exist. This study aimed to assess the trends over time and the practice and provider factors associated with unindicated cervical cancer screening tests in adolescent females within the largest healthcare system in the state.

STUDY DESIGN

Cross-sectional data from patients aged 13 to 20 years who underwent cervical cancer screening between January 1, 2012, and December 31, 2018, across a large multihospital health system were reviewed. All cervical cancer screening results were included. The incidence rate of unindicated screening was analyzed over 6-month intervals using the Poisson regression analysis.

RESULTS

The study included data from 118 providers and 794 women. Among the 900 screening results, most (90%) were unindicated: 87% with unindicated cytology testing alone and 14% with unindicated human papillomavirus testing. Screening tests were collected from patients aged 13 to 20 years, many of whom had multiple unindicated cytology tests, with 25 patients having ≥3 tests before the age of 21 years. Most results of cytology testing were negative for intraepithelial lesion or malignancy (77%). Moreover, 52 invasive diagnostic or therapeutic procedures (49 colposcopies and 3 conizations) were performed, of which 45 (87%) followed an unindicated screening test. Between 2012 and 2018, the incidence rate of unindicated cytology decreased by 33% (12.6 to 8.5 unindicated cytology per 1000 encounters). The incidence rate of unindicated screening was lower in the academic setting than in the community setting (incidence rate ratio, 0.43; P<.01). Even with decreases in the overall rates of unindicated screening throughout the study period, there were still 58 unindicated screening tests performed in the final year of this study.

CONCLUSION

Despite substantial reductions in unindicated screening for women aged <21 years, there remained areas for improvement. Our data reflected practices of guideline nonadherence up to 7 years after the 2012 guideline. Now, with a new series of changes to the guidelines, which may be even more challenging for patients and providers, it is more important than ever to utilize evidence-based strategies to improve guideline dissemination and adherence.

SARS-CoV-2 infection of the placenta

BACKGROUNDThe effects of the novel coronavirus disease 2019 (COVID-19) in pregnancy remain relatively unknown. We present a case of second trimester pregnancy with symptomatic COVID-19 complicated by severe preeclampsia and placental abruption.METHODSWe analyzed the placenta for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through molecular and immunohistochemical assays and by and electron microscopy and measured the maternal antibody response in the blood to this infection.RESULTSSARS-CoV-2 localized predominantly to syncytiotrophoblast cells at the materno-fetal interface of the placenta. Histological examination of the placenta revealed a dense macrophage infiltrate, but no evidence for the vasculopathy typically associated with preeclampsia.CONCLUSIONThis case demonstrates SARS-CoV-2 invasion of the placenta, highlighting the potential for severe morbidity among pregnant women with COVID-19.FUNDINGBeatrice Kleinberg Neuwirth Fund and Fast Grant Emergent Ventures funding from the Mercatus Center at George Mason University. The funding bodies did not have roles in the design of the study or data collection, analysis, and interpretation and played no role in writing the manuscript.

Drug use associated tricuspid valve infective endocarditis in pregnancy

BACKGROUND AND AIM

We report a case of intravenous drug use associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-week gestation.

METHODS

Patient management required a multidisciplinary collaboration between cardiac surgery, obstetrics and gynecology, and neonatal critical care.

RESULTS

Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement 1 week later.

CONCLUSIONS

Both the patient and her infant were successfully managed through the perioperative period.

Acute Transverse Myelitis Associated with Salmonella Bacteremia: A Case Report

Patient: Female, 28

Final Diagnosis: Acute transverse myelitis

Symptoms: Ascending paralysis

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

A Direct Comparison of Three Clinically Relevant Treatments in a Rat Model of Cervical Spinal Cord Injury

Recent preclinical studies have identified three treatments that are especially promising for reducing acute lesion expansion following traumatic spinal cord injury (SCI): riluzole, systemic hypothermia, and glibenclamide. Each has demonstrated efficacy in multiple studies with independent replication, but there is no way to compare them in terms of efficacy or safety, since different models were used, different laboratories were involved, and different outcomes were evaluated. Here, using a model of lower cervical hemicord contusion, we compared safety and efficacy for the three treatments, administered beginning 4 h after trauma. Treatment-associated mortality was 30% (3/10), 30% (3/10), 12.5% (1/8), and 0% (0/7) in the control, riluzole, hypothermia, and glibenclamide groups, respectively. For survivors, all three treatments showed overall favorable efficacy, compared with controls. On open-field locomotor scores (modified Basso, Beattie, and Bresnahan scores), hypothermia- and glibenclamide-treated animals were largely indistinguishable throughout the study, whereas riluzole-treated rats underperformed for the first two weeks; during the last four weeks, scores for the three treatments were similar, and significantly different from controls. On beam balance, hypothermia and glibenclamide treatments showed significant advantages over riluzole. After trauma, rats in the glibenclamide group rapidly regained a normal pattern of weight gain that differed markedly and significantly from that in all other groups. Lesion volumes at six weeks were: 4.8±0.7, 3.5±0.4, 3.1±0.3 and 2.5±0.3 mm³ in the control, riluzole, hypothermia, and glibenclamide groups, respectively; measurements of spared spinal cord tissue confirmed these results. Overall, in terms of safety and efficacy, systemic hypothermia and glibenclamide were superior to riluzole.

Cardiometabolic risk profiles in pre- versus postmenopausal women with spinal cord injury:: preliminary findings

OBJECTIVE

To compare the cardiometabolic risk (CMR) profile of premenopausal and postmenopausal women with spinal cord injury (SCI).

METHOD

Post hoc analysis of a multicenter cross-sectional study assessing CMR. Seventeen women with ASIA Impairment Scale (AIS) A or B SCI between C5 and T12 were stratified into 2 groups according to menopausal status (11 premenopausal vs 6 postmenopausal women). Data collected included demographic, social, medical, menopausal, hormone use, and menstrual histories. Assessments included physical, anthropometric, and blood pressure measures; fasting serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), and hemoglobin A1C (Hb1Ac); calculated low-density lipoprotein (LDL-C); and an oral glucose tolerance test.

RESULTS

The premenopausal group had a mean age of 32.4 years compared with 56.0 years in the postmenopausal group. Similar group findings included body mass index (BMI) (22.4 vs 22.2), HDL-C (52.5 vs 53 mg/dL), HbA1c (4.9 vs 5.1%), fasting blood glucose (FBG) (79.3 vs 84.8 mg/dL), and systolic blood pressure (SBP) (104.6 vs 111.8 mm Hg). TG, TC and LDL-C were significantly higher in postmenopausal group (55.7 vs 101.8 mg/dL, P = .01; 158.3 vs 191.6 mg/dL, P = .04; 94.7 vs 118.2 mg/dL, P = .04).

CONCLUSIONS

The findings from this study suggest that postmenopausal women with SCI have CMR trends similar to those observed in nondisabled women, characterized by increases in TG, TC, and LDL-C despite favorable BMIs and glycemic indices. Even though the present study includes significant limitations, future evidence may also suggest that heightened surveillance and guideline-driven interventions are indicated for perimenopausal and postmenopausal women with SCI.