Explore the vast range of titles available.

Background To evaluate whether tranexamic acid (TXA) administration reduces the prevalence of severe postpartum hemorrhage (sPPH), defined as a hemoglobin drop of ≥ 3 g/dL, in primiparous women undergoing vacuum-assisted vaginal delivery (VAVD). Methods A retrospective cohort study was conducted at a large tertiary medical center, including all primiparous women undergoing VAVD between January 2021 and December 2022. TXA (1 g IV within 30 min of delivery) was administered at the discretion of the attending clinician, such that some women received TXA while others did not. The primary outcome was sPPH. Secondary outcomes included postpartum transfusion of blood products, absolute decline in hemoglobin levels, and additional clinical interventions related to hemorrhage, such as manual removal of the placenta or administration of uterotonic agents for the treatment of uterine atony. Initial comparisons were performed between TXA-treated and untreated women in the overall cohort. To account for baseline differences in the likelihood of receiving TXA, propensity score matching was performed using relevant clinical predictors; neonatal birthweight, prolonged second or third stage of labor, manual uterine revision. Logistic regression models were used for adjusted analyses. Results During the study period, 6,580 primiparous women delivered, of whom 1,048 (15.9%) met the inclusion criteria and comprised the study cohort ( N  = 1,048). Of these, 383 (36.5%) received TXA, and 274 (26.1%) experienced sPPH. TXA-treated women had higher sPPH rates compared to untreated women (33.5% vs. 22.1%, p  < 0.001), greater mean hemoglobin drop (2.54 ± 1.3 vs. 2.18 ± 1.3 g/dL, p  < 0.001), and increased postpartum blood transfusion rates (3.7% vs. 1.5%, p  = 0.031). Propensity score matching (367 pairs) yielded similar results, with sPPH remaining more prevalent in the TXA group (31.7% vs. 18.8%, p  < 0.001). Conclusions Primiparous women undergoing VAVD are at increased risk for sPPH. Administration of 1 gram of TXA within 30 min of delivery was not associated with a reduction in the prevalence of sPPH or the need for postpartum blood transfusion. Given the non-randomized design and retrospective nature of the study, it was not possible to determine whether TXA was administered prophylactically or in response to active bleeding. Nevertheless, TXA did not appear to reduce the prevalence of sPPH. Further research is needed to identify effective interventions for sPPH prevention in this high-risk population.

To assess feasibility, acceptability, and early efficacy of monetary incentive-based interventions on fostering oral hygiene in young children measured with a Bluetooth-enabled toothbrush and smartphone application. A stratified, parallel-group, three-arm individually randomized controlled pilot trial. Two Los Angeles area Early Head Start (EHS) sites. 36 parent-child dyads enrolled in an EHS home visit program for 0-3 year olds. Eligible dyads, within strata and permuted blocks, were randomized in equal allocation to one of three groups: waitlist (delayed monetary incentive) control group, fixed monetary incentive package, or lottery monetary incentive package. The intervention lasted 8 weeks. Primary outcomes were a) toothbrushing performance: mean number of Bluetooth-recorded half-day episodes per week when the child's teeth were brushed, and b) dental visit by the 2-month follow-up among children with no prior dental visit. The a priori milestone of 20% more frequent toothbrushing identified the intervention for a subsequent trial. Feasibility and acceptability measures were also assessed, including frequency of parents syncing the Bluetooth-enabled toothbrush to the smartphone application and plaque measurement from digital photographs. Digital monitoring of toothbrushing was feasible. Mean number of weekly toothbrushing episodes over 8 weeks was 3.9 in the control group, 4.1 in the fixed incentive group, and 6.0 in the lottery incentive group. The lottery group had 53% more frequent toothbrushing than the control group and 47% more frequent toothbrushing than the fixed group. Exploratory analyses showed effects concentrated among children ≤24 months. Follow-up dental visit attendance was similar across groups. iPhone 7 more reliably captured evaluable images than Photomed Cannon G16. Trial protocol and outcome measures were deemed feasible and acceptable. Results informed the study protocol for a fully powered trial of lottery incentives versus a delayed control using the smart toothbrush and remote digital incentive program administration. ClinicalTrials.gov identifier NCT03862443.

ObjectiveTo examine time trends in US pregnant women with type 1 diabetes mellitus for maternal characteristics and pregnancy outcomes.Study designWe abstracted clinical data from the medical records of 700 pregnant women from 2004 to 2017. For each time period, means and percentages were calculated. P values for trend were calculated using linear and logistic regression.ResultsHbA1c in each trimester was unchanged across the analysis period. The prevalence of nephropathy decreased from 4.8% to 0% (P = 0.002). Excessive gestational weight gain increased (P = 0.01). Gestation length also increased (P = 0.01), as did vaginal deliveries (P = 0.03). There were no change in birthweight over time (P = 0.07) and the percentage of neonates with macrosomia and large for gestational age (LGA) neonates also remained unchanged.ConclusionObstetric guideline changes may have improved gestation length and mode of delivery; however, other outcomes need more attention, including excessive gestational weight gain, macrosomia, and LGA.

Background: Studies have found an association between second-stage cesarean sections (SSCSs) and subsequent preterm birth (PTB). We aimed to evaluate if secundiparas with previous second-stage cesarean sections due to a failed vacuum delivery (SSCS-F-VD) are associated with PTB in the subsequent delivery compared with secundiparas with previous spontaneous vaginal birth (SVB) at term. A secondary aim was to compare this association with secundiparas with a previous SSCS at term. Methods: A historical, prospective, longitudinal cohort study was conducted in a large tertiary university hospital between 2006 and 2019. Matched mothers who experienced first and second births at the indexed hospital, excluding those with a previous miscarriage or multiple pregnancy in either the first or second birth were grouped based on the mode of delivery and gestational week of the first birth. Results: Parturients with term SVB and term SSCSs were less likely to experience PTB in the following delivery compared with those who underwent an SSCS-F-VD, with 496/14,551 (3.4%) versus 6/160 (3.8%) versus 5/61 (8.2%), respectively, at p < 0.001. A logistic regression model revealed that secundiparas with previous SSCS-F-VD had an association with PTB in the following delivery compared with term SVB, with an OR of 2.756 (1.097; 6.922, p = 0.031). Conclusion: Previous SSCS-F-VD is associated with PTB in the following delivery, offering valuable insights for pregnancy management and patient counseling.

(1) Background: We aimed to investigate whether second-stage cesarean delivery (SSCD) had a higher occurrence of low-segment uterine incision extensions compared with cesarean delivery (CD) at other stages of labor and to study the association of these extensions with preterm birth (PTB). (2) Methods: In this retrospective longitudinal follow-up cohort study, spanning from 2006 to 2019, all selected mothers who delivered by CD at first birth (P1) and returned for second birth (P2) were grouped by cesarean stage at P1: planned CD, first-stage CD, or SSCD. Mothers with a PTB at P1, multiple-gestation pregnancies in either P1 or P2 and those with prior abortions were excluded. (3) Results: The study included 1574 selected women who underwent a planned CD at P1 (n = 483 (30.7%)), first-stage CD (n = 878 (55.8%), and SSCD (n = 213 (13.5%)). There was a higher occurrence of low-segment uterine incision extensions among SSCD patients compared to first-stage CDs and planned CDs: 50/213 (23%), 56/878 (6.4%), and 5/483 (1%), respectively (p < 0.001). A multivariate logistic regression showed that women undergoing an SSCD are at risk for low-segment uterine incision extensions compared with women undergoing a planned CD, OR 28.8 (CI 11.2; 74.4). We observed no association between the occurrence of a low-segment uterine incisional extension at P1 and PTB ≤ 37 gestational weeks in the subsequent delivery, with rates of 6.3% (7/111) for those with an extension compared to 4.5% (67/1463) for those without an extension (p = 0.41). Notably, parturients experiencing a low-segment uterine incisional extension during their first childbirth were six times more likely to have a preterm delivery before 32 weeks of gestation compared to those without extensions, with two cases (1.8%) compared to four cases (0.3%), respectively. A similar trend was observed for preterm deliveries between 32 and 34 weeks of gestation, with those having extensions showing twice the prevalence of prematurity compared to those without, with a p-value of 0.047. (4) Conclusions: This study highlights that mothers undergoing SSCD experience higher prevalence of low uterine incision extensions compared to other CDs. To further ascertain whether the presence of these extensions is associated with preterm birth (PTB) in subsequent births, particularly early PTB before 34 weeks of gestation, larger-scale future studies are warranted.

Background/Objectives: The safety of trial of labor after cesarean (TOLAC) following prior preterm low-segment transverse cesarean delivery (pCD) was compared to that following term low-segment transverse cesarean delivery (tCD) in terms of the rate of uterine rupture (UR) and adverse maternal and neonatal outcomes. Methods: A multicenter retrospective cohort study evaluated the delivery outcomes among women with a prior primary pCD and those with a primary tCD. The primary outcome was UR, defined as a full-thickness uterine wall defect. The secondary outcomes included maternal and neonatal morbidities. Chi-square, Fisher’s exact test, and Mann–Whitney tests, with the results reported as means ± SDs or medians + interquartile ranges (IQRs), were employed. Results: The cohort comprised 5340 women, including 186 with a prior pCD and 5154 with a prior tCD. The median gestational age at pCD was 28 weeks, compared to 39 weeks for tCD. Women in the pCD group had higher rates of hypertensive disorders (20.4% vs. 2.5%; p < 0.001). No significant difference in UR incidence was observed at subsequent delivery (0% vs. 0.6%; p = 0.3). However, the pCD group had higher rates of subsequent preterm delivery (19.9% vs. 4.7%; p < 0.01) and vaginal birth after cesarean (VBAC) success (86.1% vs. 77.3%; p = 0.015). Adjusted analyses showed no significant association between pCD and composite adverse neonatal outcomes (OR = 0.796, 95% CI [0.487–1.301]; p = 0.363). Conclusions: This study underscores the safety of trial of labor after a primary preterm cesarean delivery, indicating no increased risk of uterine rupture compared to term cesarean deliveries. Care should be directed toward lowering subsequent preterm delivery and its associated risks.

Purpose To revisit risk factors of major obstetric hemorrhage in a large obstetric center. Study design A retrospective case control study was conducted based on institutional electronic database and blood bank registry of a single center, 2005–2014. The major obstetric hemorrhage event was defined as transfusion of ≥5 red blood cells units within 48 h of birth and compared to matched group (ratio 1:4) based on the time of birth. Multivariable stepwise backward logistic regression models were fitted to determine risk factors for major obstetric hemorrhage. Odds ratio (OR), further evaluated by standard measures of the predictive accuracy of the logistic regression models, C statistics, and associated neonatal adverse outcome are reported. Results 113,342 women delivered during the study; 122 (0.1 %) women experienced major obstetric hemorrhage. There was one major obstetric hemorrhage fatality (0.8 %). Compared to the controls, we identified historical as well as significant current modifiable risk factors for major obstetric hemorrhage: multifetal pregnancy (OR 3.92; 95 % CI 1.34–11.52; p  = 0.013), induction of labor (OR 2.81; 95 % CI 1.22–7.05; p  = 0.027), cesarean section (OR 25.56; 95 % CI 12.88–50.75; p  < 0.001), and instrumental delivery (OR 6.58; 95 % CI 2.36–18.3; p  < 0.001). C statistics of the model for major obstetric hemorrhage prediction was 0.919 (95 % CI 0.890–0.948, p  < 0.001). Conclusion Major obstetric hemorrhage is a rare event with potentially modifiable risk factors which represent a platform of interventions for lessening obstetric morbidity.

Objective: To examine time trends in US pregnant women with type 1 diabetes mellitus for maternal characteristics and pregnancy outcomes: maternal pre-pregnancy body mass index and gestational weight gain; treatment factors: glycemic control, insulin pump and continuous glucose monitor (CGM) use; and delivery outcomes: gestational age at delivery, birth weight and mode of delivery.Research Design and methods: We abstracted clinical data from the medical records of 700 pregnant women seeking care at the Joslin and Beth Israel Deaconess Medical Center Diabetes in Pregnancy Program from 2004-2017. Eligible women were >18 years old, had a singleton pregnancy, had clinically diagnosed type 1 diabetes mellitus and delivered a live birth during this time period. For each time period, means and percentages were calculated. P-values for trend were calculated using linear and logistic regression.Results: From 2004-2017, the use of insulin pumps and CGMs increased from 50% to 72.7%, and 0% to 39.9%, respectively (p<0.001). HbA1c in each trimester was unchanged across the analysis period. The prevalence of nephropathy decreased from 4.8% to 0% (p=0.002). Excessive gestational weight gain increased (p=0.01). Gestation length also increased (p=0.01), as did vaginal deliveries (p=0.03). There were no change in birth weight percenties over time (p=0.77). and the percentage of neonates with macrosomia and large for gestational age (LGA) neonates also remained unchanged.Conclusion: Obstetric guideline changes may have improved gestation length and mode of delivery; however, other outcomes need more attention, including excessive gestational weight gain, macrosomia, and LGA.Objective: To evaluate birth weight and other delivery outcomes among women with type 1 diabetes with and without chronic hypertension (cHTN), with cHTN treatment targeting blood pressure (BP) 110-129/65-79 mmHg.Research Design and methods: Clinical data were abstracted from medical records of 516 pregnancies among 393 women seeking prenatal care at Joslin Diabetes Center and Beth Israel Deaconess Medical Center’s Diabetes in Pregnancy Program (2004-2017). Means and percentages were calculated, along with t test or χ2 test. We used linear regression to compare birth weight percentiles in women with type 1 diabetes and cHTN to those with type 1 diabetes and no cHTN.Results: Type 1 diabetes and cHTN co-occurred in 51 (7.3%) of pregnancies. Per trimester, BP values were higher in pregnancies with type 1 diabetes and cHTN compared to pregnancies with type 1 diabetes and no cHTN (p<0.001). In pregnancies with type 1 diabetes and cHTN, women were older (33.4 vs. 31.6 years, p=0.01) and had greater prevalence of nephropathy (10.4% vs. 1.8% p<0.001). Gestational age at delivery and birth weight were lower in the cHTN group (36.5 weeks vs. 37.4 weeks, p=0.03) and (3482g vs. 3722g, p=0.03, respectively). There were no differences in birth weight percentiles and small for gestational age (SGA) was rare in both groups (2% vs. 1.7%, p=0.9).Conclusion: SGA was rare in pregnancies complicated by type 1 diabetes and cHTN, even when BP targets were110-129/65-79 mmHg. These findings may provide reassurance for reestablishing lower BP targets rather than adopting recent higher targets of 120-160/80-105 mmHg followed by ACOG (2013) and ADA (2017).

Background: Induction of labor (IOL) in nulliparas with premature rupture of membranes (PROM) and an unfavorable cervix at term poses challenges. Our study sought to investigate the impact of prostaglandin E2 (PGE2) compared to oxytocin on the duration of IOL in this specific group of parturients. Methods: This was retrospective matched-case study. All nulliparas with term PROM who underwent induction between January 2006 to April 2023 at Shaare Zedek Medical Center were identified. Cases induced by either PGE2 or oxytocin were matched by the following criteria: (1) time from PROM to IOL; (2) modified Bishop score prior to IOL ≤ 5; (3) newborn birthweight; and (4) vertex position. The primary outcome was time from IOL to delivery. Results: Ninety-five matched cases were identified. All had a modified Bishop score ≤ 5. Maternal age (26 ± 4.7 years old, p = 0.203) and gestational age at delivery (38.6 ± 0.6, p = 0.701) were similar between the groups. Matched factors including time from PROM to IOL (23.5 ± 19.2 versus 24.3 ± 21.4 p = 0.780), birth weight of the newborn (3111 g versus 3101 g, p = 0.842), and occiput anterior position (present on 98% in both groups p = 0.687) were similar. Time from IOL to delivery was significantly shorter by 3 h and 36 min in the group induced with oxytocin than in the group induced with PGE2 (p = 0.025). Within 24 h, 55 (58%) of those induced with PGE2 delivered, compared to 72 (76%) of those induced with oxytocin, (p = 0.033). The cesarean delivery rates [18 (19%) versus 17 (18%)], blood transfusion rates [2 (2%) versus 3 (3%)], and Apgar scores (8.8 versus 8.9) were similar between the groups (PGE2 versus oxytocin, respectively), p ≥ 0.387. Conclusions: Induction with oxytocin, among nulliparas with term PROM and an unfavorable cervix, was associated with a shorter time from IOL to delivery and a higher rate of vaginal delivery within 24 h, with no difference in short-term maternal or neonatal adverse outcomes.