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Background: Delivery at 34 0/7 - 35 6/7 weeks is recommended for patients with prenatally suspected placenta accreta spectrum (PAS); however, there is limited data to support these recommendations. As a large volume tertiary care center, in an otherwise uncomplicated pregnancy with prenatal concern for PAS, we have historically planned delivery at 36 0/7 - 37 6/7 weeks., Objectives: To describe the impact of our later delivery timing in cases of suspected PAS on maternal and fetal outcomes., Study Design: We examined pregnancies ≥ 24w0d gestation complicated by prenatally suspected PAS from August 2009 to April 2022. Maternal and neonatal outcomes were compared according to delivery timing (beyond 36 0/7 weeks versus prior to this gestational age). Indication for early delivery was also extracted. Statistical analysis included χ 2 for categorical variables and student's t-test for continuous variables., Results: Of 202 patients with prenatal concern for PAS, 65 (32%) had an early indication for delivery (bleeding, preeclampsia, premature rupture of membranes or labor) whereas 137 (68%) were planned deliveries beyond 36 0/7 weeks for concern for PAS. There was no difference in maternal age, race/ethnicity, parity, BMI, or number of prior cesarean deliveries. Median gestational age at delivery in the indicated group was 35 (31-36) weeks, versus 37 (36-37) weeks for those without complications (p< 0.001). Prenatally suspected severity of PAS did not differ between the groups, nor on pathology. Of patients delivered for an indication 42 (65%) were delivered for bleeding, 11 (17%) for labor, and 12 (18%) for other indications. The only maternal outcomes of noted difference between the groups was increased whole blood transfusions (more commonly used at our institution in emergent situations) in those with indicated deliveries (0 [0-6] vs 0 [0-4], p=0.007) and decreased platelet transfusions (0 [0-6] vs 0 [0-10], p=0.021). Neonates in the indicated cohort were more likely to have lower birthweights, neonatal intensive care unit admission, respiratory distress syndrome, need for mechanical ventilation, and longer hospital stays, all likely secondary to prematurity., Conclusion: Patients with suspected placenta accreta spectrum without other indications for delivery such as bleeding, labor, rupture of membranes, or preeclampsia can have a planned delivery in the late preterm or early term period at specialized centers that are geographically in close proximity to the patient. Later delivery does not impact maternal outcomes and improves neonatal outcomes., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Objective:  This study aimed to evaluate the frequency of adverse maternal and neonatal outcomes associated with maternal obesity in a Hispanic population. We hypothesized that obesity confers a dose-dependent risk associated with these outcomes., Study Design:  This was a retrospective cohort study of singleton pregnancies delivered between 24 and 42 weeks gestation at an urban county hospital between 2013 and 2021. Body mass index (BMI) at the first prenatal visit was used as a proxy for prepregnancy weight. Patients were excluded if their first-trimester BMI was not available. Trends in adverse outcomes across increasing obesity classes were assessed., Results:  During the study period, 58,497 patients delivered a singleton infant, of which 12,365 (21.1%), 5,429 (9.3%), and 3,482 (6.0%) were in class I, II, and III obesity, respectively. Compared with nonobese patients, obese patients were more likely to be younger and nulliparous with a higher incidence of hypertension and pregestational diabetes. Higher BMI was associated with a significant dose-dependent increase in cesarean delivery (27% for nonobese, 34% for class I, 39% for class II, and 46% for class III obesity); severe preeclampsia (8% in nonobese and 19% for class III obesity); and gestational diabetes (5% in nonobese and 15% in class III obesity). There were significant trends in increasing morbidity for infants born to patients with correspondingly higher obesity classes. Some of these adverse outcomes included respiratory distress syndrome, neonatal intensive care unit admission, fetal anomalies, and sepsis (all p  < 0.001)., Conclusion:  Increasing body mass index is associated with a significant dose-dependent increase in multiple adverse perinatal outcomes in a Hispanic population. Associated adverse maternal outcomes include severe preeclampsia, gestational diabetes, and cesarean delivery. Infants born to patients with correspondingly higher BMI class have significantly increased associated morbidity. Often, only higher BMI classes are significantly associated with these adverse outcomes., Key Points: · As BMI increases, pregnant patients are more likely to experience adverse maternal and neonatal outcomes.. · Many adverse pregnancy outcomes are associated only with a BMI greater than 40 kg/m2.. · Obesity is associated with cesarean delivery, likely due to an increase in labor dystocia.., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: To evaluate and consider how prescribing practices have changed in relation to high-risk overactive bladder (OAB) medications., Objective: The objective of this study was to evaluate trends in the prevalence of OAB and pharmacologic treatment over time in the United States., Study Design: Data from the National Health and Nutrition Examination Survey (NHANES, 2001-2018, n = 30,478) and the National Ambulatory Medical Care Survey (NAMCS, 2003-2019, n = 251,330) were used to identify women with symptomatic incontinence and overactive bladder (OAB) (NHANES) as well as determine the frequency of prescription use for OAB medications (NHANES and NAMCS) using sampling-based weights. Joinpoint regression was used to determine adjusted annual percent change (APC, adjusting for race, age, body mass index, and insurance status). Trends were assessed overall and by race, age, body mass index, and insurance status., Results: The prevalence of OAB was 31.2% in the final survey year of NHANES (2017-2018). Women aged >65 years had the highest prevalence of OAB at 54% compared with other age groups. There was an overall increase in OAB (APC 1.24 [0.64, 1.84], P = 0.002) over time. Overall, only 3.5% of patients with symptoms of OAB reported pharmacologic treatment in NHANES. The NAMCS demonstrated a significant decrease in anticholinergic prescriptions from 2003 until 2019 (APC -6.44 [-9.77, -2.98], P = 0.001). However, in NHANES, there was no significant change in anticholinergic use (APC 0.62 [-20.2, 26.8], P = 0.944). There was a stable prevalence of β3-adrenergic agonist prescriptions since they were introduced to market (APC 0.65 [-2.24, 3.62], P = 0.616)., Conclusion: This study demonstrates an increasing prevalence of OAB and highlights the likely undertreatment of symptomatic patients. The high and increasing prevalence coupled with the relative undertreatment of OAB underscores the importance of screening for this condition., Competing Interests: M.E.F.-R. is a consultant for Boston Scientific. The other authors have declared they have no conflicts of interest., (Copyright © 2024 American Urogynecologic Society. All rights reserved.)

Objective: Identify factors associated with persistent sexual dysfunction and pain 12-months postpartum in an underserved population., Methods: Extending Maternal Care After Pregnancy (eMCAP) is a program addressing health needs/disparities of patients at risk for worse perinatal outcomes. Participants completed the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and Urinary Distress Index (UDI-6) 12-months postpartum. The PISQ-12 was dichotomized with scores < 32.5 indicating sexual dysfunction. Urinary incontinence (UI) was defined as at-least-somewhat bothersome (vs. none or not-at-all bothersome) urgency urinary incontinence (UUI) or stress urinary incontinence (SUI). Screening for anxiety and depression was completed using Generalized Anxiety Disorder-7 (GAD-7) and Edinburgh Postnatal Depression Scale (EPDS). Bivariate and multivariable logistic regression analyses were performed for sexual dysfunction vs. normal-function, and pain vs. no-pain, using demographic, peri/postpartum, and social-determinant-of-health variables as correlating factors., Results: 328 sexually active patients provided data. On bivariate analysis, sexual dysfunction (n = 31, 9.5%) vs. normal function (n = 297, 90.5%) groups showed no differences in age, BMI, parity, mode of delivery, episiotomy/laceration types, or breastfeeding. Sexual dysfunction was significantly associatedwith both UUI and SUI: 12 (39%) vs. 46 (15%) had UUI, p = 0.001, and 20 (65%) vs. 97 (33%) had SUI, P < 0.001; the dysfunction group also had higher GAD-7 and EPDS scores and greater overall stress levels. On multivariable analysis, SUI and stress remained significantly associated: OR (95% CI) 2.45 (1.02-6.03) and 1.81 (1.32-2.49), respectively. Comparing pain (n = 45, 13.7%) vs. no-pain (n = 283, 86.2%), dyspareunia patients endorsed greater stress levels., Conclusion: The interplay between sexual health, incontinence, and mental health deserves further study, and all three should be routinely addressed in postpartum care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: As the muscular and connective tissue components of the vagina are estrogen responsive, clinicians may recommend vaginal estrogen to optimize tissues preoperatively and as a possible means to reduce prolapse recurrence, but long-term effects of perioperative intravaginal estrogen on surgical prolapse management are uncertain., Objective: This study aimed to compare the efficacy of perioperative vaginal estrogen vs placebo cream in reducing composite surgical treatment failure 36 months after native tissue transvaginal prolapse repair., Study Design: This was an extended follow-up of a randomized superiority trial conducted at 3 tertiary US sites. Postmenopausal patients with bothersome anterior or apical vaginal prolapse were randomized 1:1 to 1-g conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally twice weekly for ≥5 weeks preoperatively and continued twice weekly for 12 months postoperatively. All participants underwent vaginal hysterectomy (if the uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The primary report's outcome was time to failure by 12 months postoperatively, defined by a composite outcome of objective prolapse of the anterior or posterior walls beyond the hymen or the vaginal apex descending below one-third the total vaginal length, subjective bulge symptoms, and/or retreatment. After 12 months, participants could choose to use-or not use-vaginal estrogen for atrophy symptom bother. The secondary outcomes included Pelvic Organ Prolapse Quantification points, subjective prolapse symptom severity using the Patient Global Impression of Severity and the Patient Global Impression of Improvement, and prolapse-specific subscales of the 20-Item Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire-Short Form 7. Data were analyzed as intent to treat and "per protocol" (ie, ≥50% of expected cream use per medication diary)., Results: Of 206 postmenopausal patients, 199 were randomized, and 186 underwent surgery. Moreover, 164 postmenopausal patients (88.2%) provided 36-month data. The mean age was 65.0 years (standard deviation, 6.7). The characteristics were similar at baseline between the groups. Composite surgical failure rates were not significantly different between the estrogen group and the placebo group through 36 months, with model-estimated failure rates of 32.6% (95% confidence interval, 21.6%-42.0%) and 26.8% (95% confidence interval, 15.8%-36.3%), respectively (adjusted hazard ratio, 1.55; 95% confidence interval, 0.90-2.66; P=.11). The results were similar for the per-protocol analysis. Objective failures were more common than subjective failures, combined objective and subjective failures, or retreatment. Using the Patient Global Impression of Improvement, 75 of 80 estrogen participants (94%) and 72 of 76 placebo participants (95%) providing 36-month data reported that they were much or very much better 36 months after surgery (P>.99). These data included reports from 51 of 55 "surgical failures." Pelvic Organ Prolapse Quantification measurements, Patient Global Impression of Severity scores, and prolapse subscale scores of the 20-Item Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire-Short Form 7 all significantly improved for both the estrogen and placebo groups from baseline to 36 months postoperatively without differences between the groups. Of the 160 participants providing data on vaginal estrogen usage at 36 months postoperatively, 40 of 82 participants (49%) originally assigned to the estrogen group were using prescribed vaginal estrogen, and 47 of 78 participants (60%) assigned to the placebo group were using vaginal estrogen (P=.15)., Conclusion: Adjunctive perioperative vaginal estrogen applied ≥5 weeks preoperatively and 12 months postoperatively did not improve surgical success rates 36 months after uterosacral or sacrospinous ligament suspension prolapse repair. Patient perception of improvement remained very high at 36 months., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Knowledge of clitoral neuroanatomy is critical to vulvar surgery. We sought to characterize the density and distribution of autonomic and somatic nerves supplying the clitoris., Methods: Pelvic tissue harvested from female cadavers was sectioned axially at three anatomic levels: the proximal aspect of the clitoral body (CB), the distal CB, and the glans. The CB, glans, and the surrounding connective tissue (dorsal, lateral, and ventral) were outlined microscopically. An area containing large nerve bundles dorsal to the CB, referred to as the dorsal nerve subregion, was analyzed separately. Double-immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image-segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and βIIIT and MBP respectively. Comparisons were made using nonparametric Friedman tests., Results: Seven cadavers, aged 22-81, were examined. Somatic (mean 4.42%, SD ± 1.97) and autonomic (2.14% ± 2.42) nerve density was highest in the dorsal nerve subregion and dorsal region at the distal CB level. Compared with the CB, somatic density was higher in proximal (0.05% ± 0.03 vs 1.27% ± 0.69, p = 0.03) and distal (0.29% ± 0.25 vs 1.09% ± 0.41, p = 0.05) dorsal regions. Somatic density was greater in the glans than in the surrounding lateral (0.78% ± 0.47 vs 0.43% ± 0.23, p = 0.03) and ventral (0.78% ± 0.47 vs 0.52% ± 0.2, p = 0.03) regions. Autonomic density was greater than somatic in all areas, except for the dorsal nerve subregion., Conclusions: Somatic and autonomic nerve density were greatest in a well-defined region dorsal to the CB. Surgical preservation of this region is critical for maintaining nerve supply to the clitoris., (© 2024. The International Urogynecological Association.)

Objective: Three primary neuraxial techniques reduce labor pain: epidural, dural puncture epidural (DPE), and combined spinal-epidural (CSE). This study aims to determine whether neuraxial analgesia techniques changed after the onset of the coronavirus disease 2019 (COVID-19) pandemic. Given that a dural puncture confirms neuraxial placement, we hypothesized that DPE was more frequent in women with concerns for COVID-19., Study Design: A single-center retrospective cohort study comparing neuraxial analgesia techniques for labor and delivery pain management before and after the onset of the COVID-19 pandemic and in patients with and without SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) at a maternity hospital in Dallas, Texas, with a large delivery service. Statistical analyses included the Chi-square test for categorical and Kruskal-Wallis test for nonparametric ordinal comparisons. The Cochran-Mantel-Haenszel test was used to assess the association between neuraxial technique and accidental dural puncture or postdural puncture headache., Results: Of 10,971 patients who received neuraxial analgesia for labor, 5,528 were delivered in 2019 and 5,443 in 2020. Epidural analgesia was the most common neuraxial technique for labor pain in 2019 and 2020. There was no difference in the frequency of neuraxial analgesia techniques or the rates of accidental dural puncture or postdural puncture headaches comparing all deliveries in 2019 to 2020. Despite a significant increase in DPEs relative to epidurals in the SARS-CoV-2-positive group compared with the SARS-CoV-2-negative group in 2020, there was no significant difference in postdural puncture headaches or accidental dural punctures., Conclusion: The advantages of a DPE, specifically the ability to confirm epidural placement using a small gauge spinal needle, likely led to an increase in the placement of this neuraxial in SARS-CoV-2-positive patients. There was no effect on the frequency of postdural puncture headaches or accidental dural punctures within the same period., Key Points: · Epidural analgesia was the most common neuraxial technique for labor pain management.. · Dural puncture epidural placements increased in SARS-CoV-2-positive patients.. · Rates of postdural puncture headaches and accidental dural puncture after neuraxial placement did not change.., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: Urinary incontinence is a common postpartum morbidity that negatively affects quality of life., Objective: This study aimed to identify factors associated with persistent (ie, 12 months postpartum) bothersome urinary symptoms, including stress urinary incontinence (SUI) and urgency urinary incontinence (UUI), and explore their association with mental health in medically underserved communities., Study Design: This was a cross-sectional analysis of a prospective study of individuals enrolled into "extending Maternal Care After Pregnancy," a program providing 12 months of postpartum care to individuals with health disparities. Patients were screened at 12 months for urinary dysfunction, anxiety, and depression using the Urinary Distress Index-6, Generalized Anxiety Disorder-7, and Edinburgh Postnatal Depression Scale, respectively. Bivariate and multivariable logistic regression analyses were performed for at-least-somewhat-bothersome SUI versus no-SUI, UUI versus no-UUI, and for bothersome versus asymptomatic urinary symptoms, using demographic and peripartum and postpartum variables as associated factors., Results: Four hundred nineteen patients provided data at median 12 months postpartum. Patients were 77% Hispanic White and 22% non-Hispanic Black. After multivariable analysis, SUI (n = 136, 32.5%) was significantly associated with increasing body mass index at the time of delivery and greater depression screening scores. Fetal birthweight, mode of delivery, degree of laceration, and breastfeeding status were not associated. Urgency urinary incontinence (n = 69, 16.5%) was significantly associated with increasing parity and higher anxiety screening scores. Similarly, participants with urinary symptom bother had significantly greater parity and higher anxiety screening scores., Conclusions: At 12 months postpartum, bothersome urinary symptoms and incontinence were quite common. Since these are treatable, postpartum screening for urinary complaints-and associated anxiety and depression-is essential, as is assisting patients in achieving a healthy weight., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2024 American Urogynecologic Society. All rights reserved.)

Maternal immunity impacts the infant, but how is unclear. To understand the implications of the immune exposures of vaccination and infection in pregnancy for neonatal immunity, we evaluated antibody functions in paired peripheral maternal and cord blood. We compared those who in pregnancy received mRNA coronavirus disease 2019 (COVID-19) vaccine, were infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the combination. We found that vaccination enriched a subset of neutralizing activities and Fc effector functions that was driven by IgG1 and was minimally impacted by antibody glycosylation in maternal blood. In paired cord blood, maternal vaccination also enhanced IgG1. However, Fc effector functions compared to neutralizing activities were preferentially transferred. Moreover, changes in IgG posttranslational glycosylation contributed more to cord than peripheral maternal blood antibody functional potency. These differences were enhanced with the combination of vaccination and infection as compared to either alone. Thus, Fc effector functions and antibody glycosylation highlight underexplored maternal opportunities to safeguard newborns., Competing Interests: Potential conflicts of interest . All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objective: To identify clinical and demographic characteristics associated with prolapse recurrence by 12 months after native tissue transvaginal repair., Methods: This was a planned secondary analysis of a randomized trial including postmenopausal participants with stage 2 or greater apical or anterior vaginal prolapse scheduled for surgical repair at three U.S. sites. Participants underwent vaginal hysterectomy (if uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The intervention was perioperative (5 weeks or more preoperatively and 12 months postoperatively) vaginal estrogen compared with placebo cream. The primary outcome was time to failure by 12 months after surgery, defined by objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, symptomatic vaginal bulge, or retreatment. For this analysis, participants were grouped according to failure compared with success, and multiple factors were compared, including age, time since menopause, race and ethnicity, parity, body mass index (BMI), baseline genital hiatus measurement, prolapse stage and point of maximal prolapse, surgery type (uterosacral or sacrospinous ligament suspension), and concomitant procedures. Factors were assessed for association with the hazard of surgical failure using Cox proportional hazards models, adjusted for site and treatment group. Factors with P <.50 from this analysis were considered for inclusion in the final multivariable model; site and treatment group were kept in this model., Results: One hundred eighty-six participants underwent surgery; 183 provided complete data. There were 30 failures (16.4%) and 153 successes (83.4%) at 12 months. On bivariate analysis, failure was associated with decreasing age, shorter duration since menopause, Latina ethnicity, and greater baseline genital hiatus. In the final multivariable model, which included age, BMI, and point of maximal prolapse, only age remained significantly associated with surgical failure (adjusted hazard ratio [per year] 0.92, 95% CI, 0.86-0.98, P =.016)., Conclusion: Among postmenopausal women, younger age was associated with increased frequency of prolapse recurrence by 12 months after native tissue repair., Clinical Trial Registration: ClinicalTrials.gov , NCT02431897., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Infants born less than 29 weeks, or extremely preterm (EPT), experience increased morbidity and mortality. We hypothesized that exposure to maternal infection might contribute to neurodevelopmental impairment (NDI) or death at 2 years of age., Methods: We conducted a retrospective cohort study of EPT infants from January 2010 to December 2020. Maternal data extracted included maternal infections, classified as extrauterine or intrauterine. Placental pathologic and infant data were extracted. The primary outcome was NDI or death at 2 years of age., Results: 548 EPT infants were born to 496 pregnant people: 379 (69%) were not exposed to any documented maternal infection prenatally, 124 (23%) to extrauterine infection, and 45 (8%) to intrauterine infection. Neither diagnosis of maternal extrauterine nor intrauterine infection was associated with NDI or death at 2 years of age (p > 0.05). Acute histologic chorioamnionitis was associated with NDI or death at 2 years of age (p = 0.033)., Conclusions: Maternal infection was not associated with NDI or death at 2 years of age in EPT infants. However, acute histologic chorioamnionitis was associated with this outcome. Further work should investigate the differential influence of infection and immune response with this pathology as relates to outcomes in EPT infants., Impact: Maternal infection was not associated with neurodevelopmental impairment (NDI) or death at 2 years of age in extremely preterm (EPT) infants. This is reassuring support that mechanisms at the maternal-fetal interface largely protect the EPT infant. However, pathologic findings of acute histologic chorioamnionitis were associated with NDI and death at 2 years of age. Further work should investigate the differential influence of infection and immune response with acute histologic chorioamnionitis on pathology as relates to outcomes in EPT infants., (© 2023. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Introduction and Hypothesis: Retropubic procedures may disrupt nerves supplying the pelvic viscera; however, knowledge of pelvic neuroanatomy is limited. We sought to characterize somatic and autonomic nerve density within the urethra, periurethral tissue, and anterior vagina., Methods: Axial sections were obtained from pelvic tissue harvested from female cadavers ≤24 h from death at three anatomical levels: the midurethra, proximal urethra, and upper trigone. Periurethral/perivesical tissue was divided into medial and lateral sections, and the anterior vagina into middle, medial, and lateral sections. Double immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and with βIIIT and MBP respectively. Statistical comparisons were made using nonparametric Friedman tests., Results: Six cadavers, aged 22-73, were examined. Overall, autonomic nerve density was highest at the midurethral level in the lateral and middle anterior vagina. Somatic density was highest in the external urethral sphincter (midurethra mean 0.15%, SD ±0.11; proximal urethra 0.19%, SD ±0.19). Comparison of annotated sections revealed significant differences in autonomic density among the lateral, medial, and middle vagina at the midurethra level (0.71%, SD ±0.48 vs 0.60%, SD ±0.48 vs 0.70%, SD ±0.63, p=0.03). Autonomic density was greater than somatic density in all sections., Conclusions: Autonomic and somatic nerves are diffusely distributed throughout the periurethral tissue and anterior vagina, with few significant differences in nerve density among sections analyzed. Minimizing tissue disruption near urethral skeletal muscle critical for urinary continence may prevent adverse postoperative urinary symptoms., (© 2023. The International Urogynecological Association.)

Background: Current guidelines for antiretroviral therapy in pregnancy include the use of a dual-nucleoside reverse transcriptase inhibitor with either an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, although there is no designation of which is the preferred option., Objective: This study aimed to compare viral suppression at delivery among patients on dual-nucleoside reverse transcriptase inhibitors combined with either an integrase strand transfer inhibitor or a protease inhibitor. A hypothesis was made that the incidence of viral suppression is higher with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with an integrase strand transfer inhibitor than with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with a protease inhibitor., Study Design: This study was an observational study of pregnant patients living with HIV who received prenatal care and delivered after 20 weeks of gestation at an urban safety net hospital. All pregnant patients with HIV were referred to a centralized clinic for HIV counseling, medication management, and prenatal care. Antiretroviral therapy was continued or initiated according to protocols based on national guidance. Among patients on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor vs protease inhibitor at delivery, we compared the demographics and HIV disease characteristics, including year of diagnosis, viral load, and antiretroviral therapy class. The outcome of interest was viral suppression at delivery, defined as a viral load of <50 copies/mL., Results: From January 2011 to December 2021, 604 patients on dual-nucleoside reverse transcriptase inhibitor met the inclusion criteria, including 411 patients (68%) on protease inhibitor and 193 patients (32%) on integrase strand transfer inhibitor at delivery. Demographic distribution was similar, and prenatal care was initiated at 12 weeks of gestation. Among the integrase strand transfer inhibitor group, 101 (17%) were on antiretroviral therapy at initiation of prenatal care compared with 169 (28%) in the protease inhibitor group. At delivery, the frequency of viral load suppression was higher among those on an integrase strand transfer inhibitor (147/193 [76%]) than among those on a protease inhibitor (275/411 [67%]) (odds ratio, 1.59; 95% confidence interval, 1.08-2.33). Among those with a detectable virus, quantitative viral load was not different. During the study period, the use of a protease inhibitor decreased, whereas the use of an integrase strand transfer inhibitor increased., Conclusion: Among pregnant patients living with HIV, viral suppression was more common among those on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor than among those on a dual-nucleoside reverse transcriptase inhibitor backbone protease inhibitor at delivery. Our results support the use of dual-nucleoside reverse transcriptase inhibitor with integrase strand transfer inhibitor as a first-line antiretroviral therapy regimen in pregnancy., (Published by Elsevier Inc.)

Background: Although there is growing awareness of the relationship between air pollution and preterm birth, limited data exist regarding the relationship with spontaneous preterm birth and severe neonatal outcomes., Objective: This study aimed to examine the association between traffic-associated air pollution exposure in pregnancy and adverse perinatal outcomes including extremes of preterm birth, neonatal intensive care unit admissions, low birthweight, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation., Study Design: This was a retrospective cohort study of singleton pregnancies of patients residing in a metropolitan area in the southern United States. Using monitors strategically located across the region, average nitrogen dioxide concentrations were obtained from the Environmental Protection Agency Air Quality System database. For patients living within 10 miles of a monitoring station, average exposure to nitrogen dioxide was estimated for individual patients' pregnancy by trimester. Logistic regression models were used to assess the effect of pollutant exposure on gestational age at birth, indicated vs spontaneous delivery, and neonatal outcomes while adjusting for maternal age, self-reported race, parity, season of conception, diabetes mellitus, body mass index, registered Health Equity Index, and nitrogen dioxide monitor region. Adjusted odds ratios and 95% confidence intervals were calculated for an interquartile increase in average nitrogen dioxide exposure., Results: Between January 1, 2013 and December 31, 2021, 93,164 patients delivered a singleton infant. Of these, 62,189 had measured nitrogen dioxide exposure during the pregnancy from a nearby monitoring station. Higher average nitrogen dioxide exposure throughout pregnancy was significantly associated with preterm birth (adjusted odds ratio, 1.94; 95% confidence interval, 1.77-2.12) and an increase in neonatal intensive care unit admissions, low birthweight infants, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation. This relationship persisted for nulliparous patients and spontaneous preterm birth, and had a greater association with earlier preterm birth., Conclusion: In a metropolitan area, increased exposure to the air pollutant nitrogen dioxide in pregnancy was associated with spontaneous preterm birth and had a greater association with extremely preterm birth. A greater association with neonatal intensive care unit admissions, low-birthweight infants, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation was found even in term infants., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Metabolic acidemia is a known risk factor for serious adverse neonatal outcomes in both preterm and term infants., Objective: This study aimed to evaluate the clinical significance of delivery umbilical cord gas measurements with regard to serious adverse neonatal outcomes, and to determine if distinct thresholds for defining metabolic acidemia differ in their ability to predict such adverse neonatal complications., Study Design: This is a retrospective cohort study of singleton live-born deliveries between January 2011 and December 2019. Stratification according to gestational age at birth (≥35 and <35 weeks of gestation) was performed, and comparisons of maternal characteristics, obstetrical complications, intrapartum events, and adverse neonatal outcomes were made between neonates with metabolic acidemia and those without. Metabolic acidemia (based on delivery umbilical cord gas analyses) was defined using both American College of Obstetricians and Gynecologists and Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria. The primary outcome of interest was hypoxic-ischemic encephalopathy requiring whole-body hypothermia., Results: A total of 91,694 neonates born at ≥35 weeks of gestation met the inclusion criteria. By American College of Obstetricians and Gynecologists criteria, 2659 (2.9%) infants had metabolic acidemia. Neonates with metabolic acidemia were at markedly increased risk for neonatal intensive care unit admission, seizures, need for respiratory support, sepsis, and neonatal death. Metabolic acidemia by American College of Obstetricians and Gynecologists criteria was associated with an almost 100-fold increased risk of hypoxic-ischemic encephalopathy requiring whole-body hypothermia (relative risk, 92.69; 95% confidence interval, 64.42-133.35) in neonates born at ≥35 weeks of gestation. Diabetes mellitus, hypertensive disorders of pregnancy, postterm deliveries, prolonged second stages, chorioamnionitis, operative vaginal deliveries, placental abruption and cesarean deliveries were associated with metabolic acidemia in neonates born ≥ 35 weeks of gestation. The highest relative risk was in those diagnosed with placental abruption (relative risk, 9.07; 95% confidence interval, 7.25-11.36). The neonatal cohort born <35 weeks of gestation had similar findings. When comparing those infants born ≥ 35 weeks of gestation with metabolic acidemia by American College of Obstetricians and Gynecologists criteria vs Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria, the Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria identified more neonates at risk for serious adverse neonatal outcomes. In particular, 4.9% more neonates were diagnosed with metabolic acidemia, and 16 more term neonates were identified as requiring whole-body hypothermia. Mean 1-minute and 5-minute Apgar scores were similar and reassuring among neonates born at ≥35 weeks of gestation with and without metabolic acidemia as defined by both American College of Obstetricians and Gynecologists and Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria (8 vs 8 and 9 vs 9, respectively; P<.001). Sensitivity and specificity were 86.7% and 92.2%, respectively, with the Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria, and 74.2% and 97.2% with the American College of Obstetricians and Gynecologists criteria., Conclusion: Infants with metabolic acidemia identified on cord gas collection at delivery are at considerably greater risk of serious adverse neonatal outcomes, including an almost 100-fold increased risk of hypoxic-ischemic encephalopathy requiring whole-body hypothermia. Use of the more sensitive Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria for defining metabolic acidemia identifies more neonates born at ≥35 weeks of gestation at risk for adverse neonatal outcomes, including hypoxic-ischemic encephalopathy requiring whole-body hypothermia., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Menopause and the decline in systemic estrogen are associated with the development of pelvic floor disorders, such as prolapse, urinary incontinence, overactive bladder, and vulvovaginal atrophy symptoms. Past evidence suggests that postmenopausal women with symptomatic prolapse gain benefit from the preoperative application of intravaginal estrogen, but it is unknown whether they would experience improvement in other pelvic floor symptoms when treated with intravaginal estrogen., Objective: This study aimed to determine the effects of intravaginal estrogen (compared with placebo) on stress and urgency urinary incontinence, urinary frequency, sexual function and dyspareunia, and vaginal atrophy symptoms and signs in postmenopausal women with symptomatic prolapse., Study Design: This was a planned ancillary analysis of a randomized, double-blind trial, "Investigation to Minimize Prolapse Recurrence Of the Vagina using Estrogen," which included participants with ≥stage 2 apical and/or anterior prolapse scheduled for transvaginal native tissue apical repair at 3 US sites. The intervention was 1 g conjugated estrogen intravaginal cream (0.625 mg/g) or identical placebo (1:1), inserted nightly for 2 weeks and then twice weekly for ≥5 weeks total before surgery and continued twice weekly for 1 year postoperatively. For this analysis, question responses were compared from participants' baseline and preoperative visits: lower urinary tract symptoms (Urogenital Distress Inventory-6 Questionnaire); sexual health questions, including dyspareunia (Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised); and atrophy-related symptoms (dryness, soreness, dyspareunia, discharge, and itching; each scored 1-4, 4 being quite a bit bothersome). Masked examiners assessed vaginal color, dryness, and petechiae (each scored 1-3, total range 3-9, with 9 being the most estrogenized appearing). Data were analyzed by intent to treat and "per protocol" (ie, those adherent with ≥50% of expected intravaginal cream use, per objective tube before and after weights)., Results: Of 199 participants randomized (mean age of 65 years) and contributing baseline data, 191 had preoperative data. The characteristics were similar between groups. Total Urogenital Distress Inventory-6 Questionnaire scores showed minimal change during this median time of 7 weeks between baseline and preoperative visits, but for those with at least moderately bothersome baseline stress urinary incontinence (32 in the estrogen group and 21 in the placebo group), 16 (50%) in the estrogen group and 9 (43%) in the placebo group showed improvement (P=.78). In addition, 43% of participants in the estrogen group and 31% of participants in the placebo group showed improvement in urgency urinary incontinence (P=.41), and 41% of participants in the estrogen group and 26% of participants in the placebo group showed improvement in urinary frequency (P=.18). There was minimal change in the Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised scores among sexually active women; dyspareunia rates did not differ between intravaginal estrogen and placebo at the preoperative assessment: 42% and 48%, respectively (P=.49). The maximum score for most bothersome atrophy symptom (among those with baseline symptoms and adherent to study cream) improved slightly more with intravaginal estrogen (adjusted mean difference, -0.33 points; 95% confidence interval, -0.98 to 0.31), but this was not statistically significant (P=.19). However, on examination, among adherent participants, objective signs of atrophy were more improved with intravaginal estrogen treatment (+1.54 vs +0.69; mean difference, 0.85; 95% confidence interval, 0.05-1.65; P=.01)., Conclusion: Despite objective changes in the vaginal epithelium consistent with increased estrogenization among drug-adherent participants, the results were inconclusive regarding whether 7 weeks of preoperative intravaginal estrogen cream in postmenopausal women with symptomatic pelvic organ prolapse was associated with improved urinary function, sexual function, dyspareunia symptoms, and other symptoms commonly attributed to atrophy. Additional study is needed., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Surgical repairs of apical/uterovaginal prolapse are commonly performed using native tissue pelvic ligaments as the point of attachment for the vaginal cuff after a hysterectomy. Clinicians may recommend vaginal estrogen in an effort to reduce prolapse recurrence, but the effects of intravaginal estrogen on surgical prolapse management are uncertain., Objective: To compare the efficacy of perioperative vaginal estrogen vs placebo cream on prolapse recurrence following native tissue surgical prolapse repair., Design, Setting, and Participants: This randomized superiority clinical trial was conducted at 3 tertiary US clinical sites (Texas, Alabama, Rhode Island). Postmenopausal women (N = 206) with bothersome anterior and apical vaginal prolapse interested in surgical repair were enrolled in urogynecology clinics between December 2016 and February 2020., Interventions: The intervention was 1 g of conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally nightly for 2 weeks and then twice weekly to complete at least 5 weeks of application preoperatively; this continued twice weekly for 12 months postoperatively. Participants underwent a vaginal hysterectomy (if uterus present) and standardized apical fixation (either uterosacral or sacrospinous ligament fixation)., Main Outcomes and Measures: The primary outcome was time to failure of prolapse repair by 12 months after surgery defined by at least 1 of the following 3 outcomes: anatomical/objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, subjective vaginal bulge symptoms, or repeated prolapse treatment. Secondary outcomes included measures of urinary and sexual function, symptoms and signs of urogenital atrophy, and adverse events., Results: Of 206 postmenopausal women, 199 were randomized and 186 underwent surgery. The mean (SD) age of participants was 65 (6.7) years. The primary outcome was not significantly different for women receiving vaginal estrogen vs placebo through 12 months: 12-month failure incidence of 19% (n = 20) for vaginal estrogen vs 9% (n = 10) for placebo (adjusted hazard ratio, 1.97 [95% CI, 0.92-4.22]), with the anatomic recurrence component being most common, rather than vaginal bulge symptoms or prolapse repeated treatment. Masked surgeon assessment of vaginal tissue quality and estrogenization was significantly better in the vaginal estrogen group at the time of the operation. In the subset of participants with at least moderately bothersome vaginal atrophy symptoms at baseline (n = 109), the vaginal atrophy score for most bothersome symptom was significantly better at 12 months with vaginal estrogen., Conclusions and Relevance: Adjunctive perioperative vaginal estrogen application did not improve surgical success rates after native tissue transvaginal prolapse repair., Trial Registration: ClinicalTrials.gov Identifier: NCT02431897.

Immunization in pregnancy is a critical tool that can be leveraged to protect the infant with an immature immune system but how vaccine-induced antibodies transfer to the placenta and protect the maternal-fetal dyad remains unclear. Here, we compare matched maternal-infant cord blood from individuals who in pregnancy received mRNA COVID-19 vaccine, were infected by SARS-CoV-2, or had the combination of these two immune exposures. We find that some but not all antibody neutralizing activities and Fc effector functions are enriched with vaccination compared to infection. Preferential transport to the fetus of Fc functions and not neutralization is observed. Immunization compared to infection enriches IgG1-mediated antibody functions with changes in antibody post-translational sialylation and fucosylation that impact fetal more than maternal antibody functional potency. Thus, vaccine enhanced antibody functional magnitude, potency and breadth in the fetus are driven more by antibody glycosylation and Fc effector functions compared to maternal responses, highlighting prenatal opportunities to safeguard newborns as SARS-CoV-2 becomes endemic., Competing Interests: Conflict-of-interest statement The authors have declared that no conflict of interest exists.

Importance: Postvoid dribbling is described well for men in urologic literature but is poorly defined for women, especially in those not presenting for urogynecologic care., Objective: The objective was to assess prevalence and bother of postvoid dribbling, urine spraying (ie, deviation of the urine stream), and other bothersome voiding/storage symptoms in a general gynecology population., Study Design: This was an anonymous cross-sectional survey study of women presenting to academic general gynecology practices for benign gynecologic care or well-woman visits; patients were not presenting for urinary incontinence or voiding dysfunction. A questionnaire was used to assess the presence and perceptions of voiding behavior and urinary symptoms with an emphasis on postvoid dribbling and urine spraying. The questionnaire included both the validated Questionnaire for Urinary Incontinence Diagnosis and nonvalidated questions., Results: Nonpregnant adult women (N = 355) were surveyed. The median age was 43 years (interquartile range, 33-51 years). The sample was 45% White, 23% Black, 3% Asian, and 13% other. Furthermore, 39% were Latina; 68%, parous; and 28%, postmenopausal. The prevalence (95% confidence interval) of immediate postvoid dribbling was 186 of 327 or 57% (51-62%), and of these, it was at least somewhat bothersome in 37% but moderately-to-quite-a-bit bothersome in 8%. Urine spraying occurred in 222 of 333 or 67% (61-72%), and of these, it was at least somewhat bothersome in 53% but moderately-to-quite-a-bit bothersome in 17%. Approximately 20% reported stress and/or urgency urinary incontinence; both postvoid dribbling and urine spraying were highly associated with these symptoms., Conclusions: This study of women seeking benign gynecologic care shows a high prevalence of postvoid dribbling and urine spraying symptoms. However, moderate-or-greater bother was relatively uncommon., (Copyright © 2022 American Urogynecologic Society. All rights reserved.)

Background: Although substantial efforts have been made to reduce the rates of adolescent pregnancy, the United States continues to have higher rates than other industrialized countries. Research and reporting usually focus on adolescents aged 15 to 19 years. Although less common, there are pregnant young adolescents that are ≤15 years of age, with developmental and social differences from older, high school-aged adolescents., Objective: Because adolescent pregnancies are of particular concern because of long-term socioeconomic consequences to parent and child, we sought to determine whether young adolescents (≤15 years old) had worse perinatal outcomes than older adolescents (16-19 years old) and older parents (≥20 to 34 years old) among those living in an urban inner city., Study Design: This was a study of pregnant individuals who delivered a singleton pregnancy without evidence of chronic hypertension or pregestational diabetes mellitus at a safety net hospital from January 2010 to May 2021. Parents were grouped by age at the time of delivery into young adolescents (≤15 years old) and older adolescents (16-19 years old). For a comparison group, nulliparous older parents aged 20 to 34 years with singleton pregnancies were analyzed for perinatal outcomes and compared with the adolescent cohorts. When analyzing baseline parental characteristics, a preponderance of obesity was noted in the young adolescent cohort. An analysis of parental characteristics and perinatal outcomes among young adolescents with obesity vs young adolescents without obesity ≤15 years old was performed. Statistical analysis included χ 2 and Student t test with P values of <.05 considered significant. Logistic regression analysis was performed to control for potentially confounding demographic variables., Results: Overall, 10,894 adolescent women delivered, with 868 young adolescents and 10,026 older adolescents. Pairwise comparisons showed young adolescents had a different race distribution than older adolescents (P=.006) and older parents (P<.001). Young adolescents were more likely to be Hispanic or non-Hispanic Black (P<.001) and accessed prenatal care at a later gestational age (19.7±8.9 weeks) compared with older adolescents (16.7±8.6 weeks) and the comparison older cohort of parents (15.7±8.7 weeks) (P<.001) and less frequently in pregnancy (P<.001) compared with older parents. Young adolescents were more likely to have preterm birth at <37 weeks of gestation (P<.001) and eclampsia (0.5% vs 0.1%) (P=.01) than older adolescents. Therefore, low birthweights of ≤2500 g (P=.02) and neonatal intensive care unit admission (P=.048) were also increased in adolescents. When adjusted for race, ethnicity, and body mass index, preeclampsia with severe features (P<.001) and preterm birth at <37 weeks of gestation (P=.048) remained significant. Young adolescents with obesity were more likely to have preeclampsia with severe features (odds ratio, 1.81; 95% confidence interval, 1.22-2.68) and be delivered via cesarean delivery (odds ratio, 2.71; 95% confidence interval, 1.85-3.99) than adolescents without obesity., Conclusion: In an urban inner city, young adolescent parents were more likely to be women of color, have later presentations to prenatal care, and have increased rates of preterm birth. Young adolescents had high rates of obesity, which was associated with increased rates of hypertensive disorders of pregnancy and cesarean delivery, than adolescents without obesity., (Copyright © 2022 Elsevier Inc. All rights reserved.)