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Citing the risks of administering anesthesia to patients with obesity, few fertility centers offer in vitro fertilization as a treatment modality for patients with body mass indexes ≥40 kg/m2. Although previous studies have assessed clinical pregnancy and cumulative live birth rates in patients who spontaneously conceive with body mass indexes ≥50 kg/m2, there is a paucity of in vitro fertilization, obstetrical, and neonatal outcome data in patients with severe obesity who conceive after in vitro fertilization. This study aimed to evaluate the impact of increasing body mass index on in vitro fertilization, obstetrical, and neonatal outcomes in patients with obesity undergoing in vitro fertilization. This was a retrospective cohort study within an academic fertility center including 2069 fresh in vitro fertilization/intracytoplasmic sperm injection and frozen embryo transfer cycles from January 1, 2012 to April 30, 2020; this cohort was used to determine in vitro fertilization treatment outcomes. A second embedded cohort of 867 fresh in vitro fertilization/intracytoplasmic sperm injection and frozen embryo transfer cycles that resulted in ongoing clinical pregnancies and deliveries within a single tertiary hospital system was used to determine pregnancy, maternal, and neonatal outcomes. All patients with a body mass index ≥40 kg/m2 underwent consultation with a maternal–fetal medicine specialist before starting treatment and a preoperative evaluation with an anesthesiologist before oocyte retrieval. Cycles were grouped by body mass index at cycle start (30–34.9, 35–39.9, 40–44.9, 45–49.9, and ≥50 kg/m2). Log-binomial regression and Poisson regression with an offset were fitted with body mass index of 30 to 34.9 kg/m2 as the reference group, adjusting for potential confounders including oocyte age, patient age, embryo quality, transfer type, and coexisting comorbidities. The primary outcome was live birth rate. Secondary outcomes included fertilization rate, blastulation rate, miscarriage rate, incidence of preeclampsia with severe features, gestational diabetes, labor induction, cesarean delivery, preterm delivery, and birthweight. There were 2069 fresh in vitro fertilization/intracytoplasmic sperm injection and frozen embryo transfer cycle starts from January 1, 2012 to April 30, 2020. Of these, 1008 cycles were in the 30 to 34.9 kg/m2 group, 547 in the 35 to 39.9 kg/m2 group, 277 in the 40 to 44.9 kg/m2 group, 161 in the 45 to 49.9 kg/m2 group, and 76 in the ≥50 kg/m2 body mass index group. Live birth rate was not significantly different between groups. The body mass index ≥50 kg/m2 group was significantly more likely to experience preeclampsia with severe features when compared with the 30 to 34.9 kg/m2 body mass index group (absolute risk reduction, 2.75; 95% confidence interval, 1.13–6.67). Fertilization rate, blastulation rate, miscarriage rate, incidence of gestational diabetes, labor induction, cesarean delivery, preterm delivery, and neonatal birthweights were not significantly different between groups. Among patients with body mass indexes from 30 to 60 kg/m2 who conceived via in vitro fertilization and received comprehensive prenatal care at a tertiary care hospital, in vitro fertilization, obstetrical, and neonatal outcomes were largely comparable. These data support a collaborative care approach with maternal–fetal medicine specialists and skilled anesthesiologists, reinforcing the notion that in vitro fertilization should not be withheld as a treatment modality from patients with obesity. [ABSTRACT FROM AUTHOR]

Previous analyses have demonstrated the cost effectiveness of elective induction of labor at 39 weeks of gestation for healthy nulliparous people. However, elective induction of labor is resource intensive, and optimal resource allocation requires a thorough understanding of which subgroups of patients will benefit most. This study aimed to determine whether induction of labor at 39 weeks of gestation is more cost-effective in patients with favorable or unfavorable cervical examinations. We constructed 2 decision analysis models using TreeAge software: one modeling induction of labor at 39 weeks of gestation vs expectant management for a group of nulliparous patients with unfavorable cervical examinations and the other modeling induction of labor at 39 weeks of gestation vs expectant management for a group with favorable cervical examinations. Estimates of cost, probability, and health state utility were derived from the literature. Based on previous literature, we assumed that people with favorable cervical examinations would have a lower baseline rate of cesarean delivery and higher rates of spontaneous labor. In our base case analysis, induction of labor at 39 weeks of gestation was cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. The incremental cost per quality-adjusted life year was 50-fold lower for people with unfavorable cervical examinations ($2150 vs $115,100). Induction of labor resulted in 3885 fewer cesarean deliveries and 58 fewer stillbirths per 100,000 patients for those with unfavorable examinations, whereas induction of labor resulted in 2293 fewer cesarean deliveries and 48 fewer stillbirths with labor induction for those with favorable cervical examinations. The results were sensitive to multiple inputs, including the likelihood of cesarean delivery, the cost of induction, the cost of vaginal or cesarean delivery, and the probability of spontaneous labor. In Monte Carlo analysis, the base case findings held true for 64.1% of modeled scenarios for patients with unfavorable cervixes and 55.4% of modeled scenarios for patients with favorable cervixes. With a willingness-to-pay threshold of $100,000 per quality-adjusted life year, induction of labor at 39 weeks of gestation may be cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. This result was driven by the likelihood of labor in patients with favorable cervical examinations, and the resultant avoidance of prolonged pregnancy and its complications, including hypertensive disorders of pregnancy and stillbirths. Health systems may wish to prioritize patients with unfavorable cervical examinations for elective induction of labor at 39 weeks of gestation, which may be opposite to common practice. [ABSTRACT FROM AUTHOR]

Study Objective: To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population.Design: Retrospective data analysis (Canadian Task Force classification II-2).Setting: The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data.Patients: Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other."Intervention: Receipt of hysterectomy (TAH, TVH, or TLH).Measurements and Main Results: We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends.Conclusion: We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies. [ABSTRACT FROM AUTHOR]

Background Racial disparities in receipt of a laparoscopic operation for ectopic pregnancy are attributed to inequalities in access to care. This study sought to determine if racial disparities in laparoscopic operation for ectopic pregnancy exist among a universally insured population. Methods Using 2006–2010 TRICARE (insurance for members of the United States Armed Services and their dependents) data, patients who received a laparoscopic operation or laparotomy for ectopic pregnancy were stratified into direct/military or purchased/civilian system of care. Odds of receipt of a laparoscopic operation in each racial group were compared adjusting for patient demographics, system of care, and severity of ectopic pregnancy. Results Among 3,041 patients in the study sample, 1,878 (61.7%) received laparotomy and 1,163 (38.2%) received a laparoscopic operation within 30 days of diagnosis. Overall, 42.4% of white women received a laparoscopic operation compared with 33.1% of Asian women and 34.9% of black women ( P < .001). On multivariable analysis, black women had a 33% lesser odds of receiving a laparoscopic operation (odds ratio: 0.67; confidence interval: 0.55–0.83) compared with white women. These disparities were absent within direct care (odds ratio: 0.93; confidence interval: 0.71–1.21) but were present within purchased care (odds ratio: 0.54; confidence interval: 0.40–0.73). Conclusion Racial minority patients are less likely to receive a laparoscopic operation for ectopic pregnancy despite universal insurance coverage within civilian/purchased care. Further work is warranted to better understand the factors other than insurance access that may contribute to racial disparities in selection of operative approach. [ABSTRACT FROM AUTHOR]

Background: Readmission rates are used as a quality metric in medical and surgical specialties; however, little is known about obstetrics readmissions.Objective: Our goals for this study were to describe the trends in postpartum readmissions over time; to characterize the common indications and associated diagnoses for readmissions; and to determine maternal, delivery, and hospital characteristics that may be associated with readmission.Study Design: Postpartum readmissions occurring within the first 6 weeks after delivery in California, Florida, and New York were identified between 2004 and 2011 in State Inpatient Databases. Of the 5,949,739 eligible deliveries identified, 114,748 women were readmitted over the 8-year period. We calculated the rates of readmissions and their indications by state and over time. The characteristics of the readmission stay, including day readmitted, length of readmission, and charge for readmission, were compared among the diagnoses. Odds ratios were calculated using a multivariate logistic regression to determine the predictors of readmission.Results: The readmission rate increased from 1.72% in 2004 to 2.16% in 2011. Readmitted patients were more likely to be publicly insured (54.3% vs 42.0%, P < .001), to be black (18.7% vs 13.5%, P < .001), to have comorbidities such as hypertension (15.3% vs 2.4%, P < 0.001) and diabetes (13.1% vs 6.8%, P < .001), and to have had a cesarean delivery (37.2% vs 32.9%, P < .001). The most common indications for readmission were infection (15.5%), hypertension (9.3%), and psychiatric illness (7.7%). Patients were readmitted, on average, 7 days after discharge, but readmission day varied by diagnosis: day 3 for hypertension, day 5 for infection, and day 9 for psychiatric disease. Maternal comorbidities were the strongest predictors of postpartum readmissions: psychiatric disease, substance use, seizure disorder, hypertension, and tobacco use.Conclusion: Postpartum readmission rates have risen over the last 8 years. Understanding the risk factors, etiologies, and cause-specific timing for postpartum readmissions may aid in the development of new quality metrics in obstetrics and targeted strategies to curb the rising rate of postpartum readmissions in the United States. [ABSTRACT FROM AUTHOR]

Background: Induction of labor is common in the United States. Multiple previous studies have tried to outline a faster time to delivery to improve maternal and fetal outcomes.Objective: This study aimed to evaluate whether women who undergo induction of labor with a single-balloon catheter and oxytocin have a shorter time to delivery with planned removal of the catheter at 6 vs 12 hours.Study Design: In this randomized controlled trial, induction of labor was performed using a combination of single-balloon catheter and oxytocin. Term women, both nulliparous and multiparous, aged 18 to 50 years old with cephalic singletons were included if they were undergoing induction of labor with a Bishop score of <6 and cervical dilation of <2 cm. Women were randomized to planned removal of the single-balloon catheter at 6 hours vs 12 hours. The primary outcome was time from catheter insertion to delivery. We were powered to show a 4-hour time difference with a sample size of 89 women per group (n=178). Planned sensitivity analyses were performed to account for cesarean delivery in labor.Results: From February 2019 to June 2020, 237 women were screened, 178 women were randomized, and 177 women were included in the final analysis (89 women in the 6-hour group and 88 women in the 12-hour group). Insertion to delivery time was significantly shorter in the 6-hour group (19.2 vs 24.3 hours; P=.04), and the proportion of women delivered by 24 hours was significantly greater in the 6-hour group (67.4% vs 47.4%; P<.01). There was no difference in the Bishop score at removal of the catheter or secondary maternal or neonatal outcomes. In a Cox proportional-hazards model censoring for cesarean delivery, the 6-hour group had a significantly shorter insertion to delivery time (hazard ratio, 0.67; P=.02).Conclusion: Induction of labor with a single-balloon catheter and oxytocin with planned removal of the catheter at 6 hours rather than 12 hours results in a shorter time from insertion to delivery without increasing the rate of cesarean delivery. Decreasing the length of time a single-balloon catheter is in place should be considered in clinical protocols. [ABSTRACT FROM AUTHOR]

Background: Cesarean delivery rates vary widely across the United States. Health care usage in many other areas of medicine also varies widely across the United States; it is unknown whether the variation in cesarean delivery rates across US communities is correlated with this broader underlying variation in health care usage patterns.Objective: The purpose of this study was to determine whether the variation in cesarean delivery rates across US communities is correlated with other measures of health care usage in that community.Study Design: We performed a population-based observational study that combined multiple national data sources, which included 2010 birth certificate data and Medicare claims data. Cesarean delivery rates in each US community, as defined by the Hospital Service Area, Medicare total spending per beneficiary, and hospital days in the last 6 months were calculated. Cesarean delivery and Medicare spending were on different patient populations; the Medicare variables were used to characterize the broader health care usage and spending pattern of that community. We examined the relationship between a community's cesarean delivery rates and these measures of health care usage using Pearson correlation coefficients. We also stratified by quartile of Medicare spending and hospital use in the last 6 months of life and calculated the cesarean delivery rates per quartile, adjusting for underlying differences in patient characteristics, demographics, hospital structure, and the malpractice environment using a least-squared means method. We compared the amount of variation in cesarean delivery rates across communities that could be explained by differences in health care usage patterns to the amount of variation that was explained by other factors using the R-squared from multivariable models.Results: Cesarean delivery rates varied from 4-65% across communities in the United States. Cesarean delivery rates were correlated positively with total Medicare spending (r = 0.48; P < .001) and hospital use in the last 6 months of life (r = 0.45; P < .001). Similar variation was seen in nulliparous women with a term fetus in vertex presentation (nulliparous, term, singleton, vertex cesarean deliveries), which is a common subset used for analysis of cesarean delivery rates. Communities in the lowest quartile of Medicare spending had the lowest rates of cesarean delivery (29.1% vs 35.7% in the highest quartile; P < .001 for differences across quartiles), which is a difference that persisted after adjustment (29.5% vs 31.8%; P < .001). Similar results were seen for nulliparous, term, singleton, vertex cesarean deliveries and when data were stratified by hospital days in the last 6 months of life. Overall, 28.6% of the total variation in cesarean delivery rates was explained by differences in health care usage patterns, as compared with 16.6% by differences in obstetric procedures, 7.9% by hospital structure, and 2.3% by variations in the malpractice environment. Of the 56.3% of variation that was unexplained by differences in patient characteristics and area demographics, 8.2% could be accounted for by differences in health care usage patterns, as compared with 4.6% by differences in obstetric procedures, 2.1% by hospital structure, and 1.2% by variation in the malpractice environment.Conclusion: Cesarean delivery rates vary widely across US communities; this variation is correlated broadly with the variation that is seen in other measures of health care usage across US communities. [ABSTRACT FROM AUTHOR]

Objective Pregnancies that have been conceived through in vitro fertilization (IVF) have been associated with higher rates of preeclampsia and other complications that are associated with placental dysfunction. We evaluated whether IVF pregnancies, when compared with those conceived spontaneously, would be associated with alterations in serum angiogenic markers. Study Design This was a retrospective cohort study from 3 US academic institutions (2006-2008). Women with singleton pregnancies who conceived via IVF or spontaneously were included. Placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured at 4 time points throughout gestation. Pregnancy outcomes that included diagnosis of preeclampsia or other obstetric complications were ascertained from the medical record. The relationship among IVF status, PlGF, and sFlt-1 were modeled over gestation and stratified by clinical pregnancy outcome. Results Of the included 2392 singleton pregnancies, 4.5% (108 pregnancies) were conceived though IVF. IVF pregnancies were significantly more likely to be complicated by preeclampsia (15.7% vs 7.7%). IVF pregnancies had significantly higher levels of sFlt-1 at 18, 26, and 35 weeks of gestation ( P = .04, P = .004, P < .0001, respectively) and lower levels of PlGF at 18 and 35 weeks of gestation ( P = .007 and .0006, respectively). These differences persisted even after being controlled for maternal comorbidities or obstetric outcomes such as preeclampsia. Conclusion Pregnancies conceived via IVF were found to have an increased antiangiogenic profile (elevated sFlt-1 and decreased PlGF) at multiple time points throughout gestation when compared with spontaneously conceived pregnancies. Alterations in the angiogenic profile persisted even after we controlled for maternal comorbidities of clinically evident disorders of abnormal placentation such as preeclampsia. The increased antiangiogenic profile suggests fundamentally aberrant placentation related to in vitro fertilization, which may warrant closer fetal surveillance in these pregnancies. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to investigate whether knowledge of ultrasound-obtained estimated fetal weight (US-EFW) is a risk factor for cesarean delivery (CD). Study Design: Retrospective cohort from a single center in 2009-2010 of singleton, term live births. CD rates were compared for women with and without US-EFW within 1 month of delivery and adjusted for potential confounders. Results: Of the 2329 women in our cohort, 50.2% had US-EFW within 1 month of delivery. CD was significantly more common for women with US-EFW (15.7% vs 10.2%; P < .001); after we controlled for confounders, US-EFW remained an independent risk factor for CD (odds ratio, 1.44; 95% confidence interval, 1.1–1.9). The risk increased when US-EFW was >3500 g (odds ratio, 1.8; 95% confidence interval, 1.3–2.7). Conclusion: Knowledge of US-EFW, above and beyond the impact of fetal size itself, increases the risk of CD. Acquisition of US-EFW near term appears to be an independent and potentially modifiable risk factor for CD. [ABSTRACT FROM AUTHOR]

Objective: To investigate the cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women. Study Design: A decision analytic model comparing induction of labor at 41 weeks vs expectant management with antenatal testing until 42 weeks in nulliparas was designed. Baseline assumptions were derived from the literature as well as from analysis of the National Birth Cohort dataset and included an intrauterine fetal demise rate of 0.12% in the 41st week and a cesarean rate of 27% in women induced at 41 weeks. One-way and multiway sensitivity analyses were conducted to examine the robustness of the findings. Results: Compared with expectant management, induction of labor is cost-effective with an incremental cost of $10,945 per quality-adjusted life year gained. Induction of labor at 41 weeks also resulted in a lower rate of adverse obstetric outcomes, including neonatal demise, shoulder dystocia, meconium aspiration syndrome, and severe perineal lacerations. Conclusion: Elective induction of labor at 41 weeks is cost-effective and improves outcomes. [ABSTRACT FROM AUTHOR]