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Objective: Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population., Study Design: PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care., Results: A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10)., Conclusion: Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE., Methods: TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care., Results: A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care., Conclusion: Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States., (© 2017 Wiley Periodicals, Inc.)

Objective: To identify the relationship between pathologically diagnosed placenta accreta and risk of major morbidity in a subsequent pregnancy., Methods: We conducted a retrospective cohort study of patients with pathologically diagnosed placenta accreta in an index pregnancy who returned with a subsequent pregnancy at our academic center from 2007 to 2015. Subsequent delivery outcomes included minor, major, or no morbidity. Minor morbidity included estimated blood loss 500-1,500 cc for vaginal and 1,000-1,500 cc for cesarean delivery, transfusion of one to three units of red cells, and minor surgical procedures. Major morbidity included estimated blood loss greater than 1,500 cc, transfusion of greater than three units of red cells, uterine artery embolization, unplanned laparotomy, or hysterectomy., Results: Three hundred thirty-nine patients with pathologically diagnosed accreta did not undergo hysterectomy, and 39 (11.5%) of these returned for subsequent delivery. Of these, 14 (36%) had accretas that had been identified clinically in the index pregnancy. Twenty-one (54%) experienced morbidity in the index pregnancy, 16 of these (76%) minor and five (24%) major. Of patients without morbidity in the first pregnancy, none experienced major morbidity in a subsequent pregnancy, whereas 6 of 21 (29%) with any index morbidity had a subsequent major morbid outcome (P=.02). Of those with a morbid index delivery, 25% had either a clinical or pathologic accreta diagnosis at follow-up compared with none of those who index accreta was nonmorbid (P=.05)., Conclusion: Risk for major hemorrhagic morbidity after a prior pathologically diagnosed accreta depends on the clinical context. Preparation for major blood loss is indicated after any prior pregnancy complicated by hemorrhage or treatment of retained placenta with a pathologic accreta.

Study Objective: To examine the effect of maternal age on indication for primary cesarean delivery in low-risk nulliparous women., Design: Retrospective cohort study., Setting: Urban academic tertiary care center., Participants: Nulliparous women younger than 35 years of age delivering vertex-presenting singletons at term., Interventions: Participants underwent spontaneous, operative or cesarean delivery., Main Outcome Measures: Mode of delivery, indication, and timing of cesarean delivery., Results: Adolescents were half as likely to undergo cesarean delivery overall (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.43-0.54), and more than one-third less likely to undergo cesarean delivery in labor (OR, 0.59; 95% CI, 0.53-0.66). Adjustment for potential confounders did not alter the strength of these associations. Adolescents were half as likely to undergo cesarean delivery for failure to progress (OR, 0.49; 95% CI, 0.43-0.54). There was no difference in the odds of cesarean delivery for nonreassuring fetal status (OR, 0.91; 95% CI, 0.77-1.06), or genital herpes (OR, 1.44; 95% CI, 0.57-3.68). Induction, macrosomia, oxytocin augmentation, and any labor complication were all associated with increased risk of cesarean delivery. There was no difference in the duration of second stage for adolescents who delivered by cesarean delivery compared with adults (240.0 vs 237.7 minutes; P = .84), but adolescents who delivered vaginally had a second stage that was one-third shorter than adults (62.5 vs 100.3 minutes; P < .001)., Conclusion: Adolescents are half as likely to undergo primary cesarean delivery overall, and 40% less likely to undergo a primary cesarean delivery in labor, even after adjustment for multiple maternal, neonatal, and labor characteristics. This difference is not explained by differences in the duration of the second stage of labor., (Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Objective: We examined the morbidities from delivery at earlier gestational ages versus intrauterine fetal demise (IUFD) for women with intrahepatic cholestasis of pregnancy (ICP) to determine the optimal gestational age for delivery., Methods: A decision-analytic model was created to compare delivery at 35 through 38 weeks gestation for different delivery strategies: (1) empiric steroids; (2) steroids if fetal lung maturity (FLM) negative; (3) wait a week and retest if FLM negative; or (4) deliver immediately. Literature review identified 18 studies that estimated IUFD in ICP; we used the mean rate, 1.74%, and assumed a uniform distribution from 34 to 40 weeks gestation. Large cohort data was used to calculate neonatal morbidity rates at each gestational age. Maternal and neonatal quality-adjusted life years (QALYs) were combined. Univariate sensitivity and Monte Carlo analyses were performed to test for robustness., Results: Immediate delivery at 36 weeks without FLM testing and steroid administration was the optimal strategy as compared to delivery at 36 weeks with steroids (+47 QALYs) and as compared to immediate delivery at 35 weeks (+210 QALYs). Our results were robust up to a 30% increase in the rate of IUFD., Conclusion: Immediate delivery at 36 weeks in women with ICP is the optimal delivery strategy.

Objective Hypertensive disorders of pregnancy (HDP) are common complications associated with severe maternal and neonatal morbidity. One goal of prenatal care, especially at term, is to screen for HDP. As treatment of HDP centers on delivery when appropriate, timely diagnosis is crucial. We postulated that reduced in-person visits during the coronavirus disease 2019 (COVID-19) pandemic may have resulted in delayed diagnosis of HDP with concomitant higher rates of maternal morbidity. We sought to investigate the prevalence of HDP during the COVID-19 pandemic, as well as median gestational age at time of delivery as compared with the prepandemic median. Study Design This was a retrospective cohort analysis comparing singleton deliveries at four large-volume hospitals during the COVID-19 pandemic (April–July 2020 during a statewide "stay-at-home" order) to those in a pre-COVID era (April–July 2019). Deliveries complicated by HDP were identified by International Classification of Disease, Tenth Revision codes. Rates of HDP and markers of severe disease were the primary outcomes compared between the groups; multivariate regression was used to calculate the odds ratio of severe disease among women with any diagnosis of HDP. Results The cohort included 9,974 deliveries: 5,011 in 2020 and 4,963 in 2019. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ significantly between the groups. There was an increase in HDP during the COVID era (9.0 vs. 6.9%; p < 0.01), which was significant even when controlling for patient parity (odds ratio = 1.41, 95% confidence interval: 1.20–1.66). Among women with HDP, gestational age at delivery did not differ between the cohorts, nor did the proportion of patients with severe disease. Conclusion We found a statistically significant increase in the rate of HDP during the COVID-19 pandemic. However, there was no change in the proportion of severe disease, suggesting that this increase did not significantly impact clinical morbidity. Key Points Rates of HDP increased during the COVID-19 pandemic. There was no change in the proportion of severe HDP. HDP-related maternal/neonatal morbidity was unchanged. [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]

Objective The objective of this study was to compare spontaneous labor outcomes in women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better counsel women. Study Design A 4-year retrospective cohort.We included women at term in spontaneous labor with vertex singletons and no more than one prior cesarean delivery. In planned secondary analysis, we focused on a subset of women with a prior cesarean and a predicted likelihood of a successful vaginal delivery of 70% or more based on the Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator. Results Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p < 0.001). Severe maternal hemorrhage (1.5 vs. 0.2%; p = 0.02) and uterine rupture (1.9 vs. 0.0%; p < 0.01) were more likely in the TOLAC group. For the subset of women with a predicted likelihood of VBAC of 70% or more, there were no differences in cesarean delivery (16.7 vs. 14.7%; p = 0.51), maternal, or immediate neonatal complications. Conclusion Women undergoing TOLAC were more likely to have a cesarean delivery, hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of VBAC were no more likely to experience these outcomes. These findings help contextualize the risks of TOLAC for women considering this option. [ABSTRACT FROM AUTHOR]

Background Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity ( SAMM) and common postpartum complications between direct and purchased care systems within TRICARE. Methods TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care. Results A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds ( aOR 1.37 [ CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery ( aOR[ CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery ( aOR 1.31 [ CI 1.19-1.44]) compared with direct care. Conclusion Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States. [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]

Objectives: To report our contemporary experience with PUBS, including indications and complications, stratified by the presence of hydrops fetalis.Study Design: All PUBS performed from 1988 to 2013 at a single tertiary care center were identified using a comprehensive ultrasound database. We recorded patient demographics, relevant obstetric, fetal and neonatal data, indication for and success of PUBS and any complications. Data were analyzed using SAS, version 9.3 (SAS Institute Inc., Cary, NC).Results: 455 PUBS were performed on 208 pregnant women, 97.8% of which were successful. The average gestational age at the time of PUBS was 26.7 weeks (SD 5.1 weeks, range 17.5-41.3 weeks). Indications were available for 441: 245 (55.6%) isoimmunization, 77 (17.5%) non-immune hydrops fetalis (NIHF), 98 (22.2%) chromosomal diagnosis, and 21 (4.8%) other indications. Isoimmunization was a less common indication for PUBS in 2008-2013 as compared to 1988-1992 (51.7% vs 66.2%, p=0.07). Amongst PUBS performed in the setting of hydrops, isoimmunization was much less common in the later time period (61.1% vs 0%, respectively; p<0.01). The procedure complication rate (bradycardia or fetal demise at procedure) of 2.5% was stable over the study period and was most common with NIHF (2.0% without hydrops, 0% with immune hydrops and 6.3% with NIHF; p=0.04). Of the 208 women with a PUBS performed, 74 had more than one PUBS procedure (mean 2.2, max 18). Transfusions were performed in 233 of the 455 (51.2%). Overall, 10.2% of the pregnancies had an intrauterine fetal demise (IUFD) within 2 weeks of the procedure, which was most common in pregnancies with NIHF (3.2% without hydrops, 9.1% with immune hydrops and 31.7% with NIHF; p<0.01). The IUFD rate was 60% (3/5) in fetuses with parvovirus-mediated NIHF.Conclusions: PUBS has a high likelihood of success with a relatively low complication rate. The complication rate is highest in pregnancies with NIHF, and these pregnancies are also at a significantly higher risk of IUFD, particularly those patients with parvovirus-mediated NIHF. Our findings can be used when counseling patients who are considering PUBS for diagnostic or therapeutic purposes. [ABSTRACT FROM AUTHOR]