Objective The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine endorse checklist use to improve obstetric care. However, there is limited research into development, implementation, and sustained use of perinatal emergency checklists to inform individual institutions. This study aimed to investigate the development and implementation of perinatal emergency checklists in diverse hospital settings in the United States.Study Design A qualitative study was conducted individually with clinicians from three health care systems. The participants developed and implemented institution-tailored perinatal emergency checklists. Interview transcriptions were coded using the Consolidated Framework for Implementation Research.Results The study sites included two health care systems and one individual hospital. Delivery volumes ranged from 3,500 to 48,000 deliveries a year. Interviews were conducted with all 10 participants approached. Checklists for 19 perinatal emergencies were developed at the three health care systems. Ten of the checklist topics were the same at all three institutions. Participants described the checklists as improving patient care during crises. The tools were viewed as opportunities to promote a shared mental model across clinical roles, to reduce redundancy and coordinate obstetric crisis management. Checklist were developed in small groups. Implementation was facilitated by those who developed the checklists. Participants agreed that simulation was essential for checklist refinement and effective use by response teams. Barriers to implementation included limited clinician availability. There was also an opportunity to strengthen integration of checklists workflow early in perinatal emergencies. Participants articulated that culture change took time, active practice, persistence, reinforcement, and process measurement.Conclusion This study outlines processes to develop, implement, and sustain perinatal emergency checklists at three institutions. Participants agreed that multiple, parallel implementation tactics created the culture shift for integration. The overview and specific Consolidated Framework for Implementation Research components may be used to inform adaptation and sustainability for others considering implementing perinatal emergency checklists.

The National Survey of Family Growth 2017-2019 survey reported an overall 65.3% current use of contraception: 18% tubal, 5.6% vasectomy, 18% hormonal therapy, 8.4% intrauterine devices (IUD), and 8.4% condoms. We want to evaluate the use of contraception among women with cardiovascular disease (CVD) in pregnancy seen in the combined cardio-obstetric clinic. We used the California Maternal Quality Care Collaborative (CMQCC) criteria for cardiology consultation. CVD risk factors included: age ≥40, body mass index (BMI) ≥35, african american race, chronic hypertension (CHTN), diabetes (DM), renal disease, congenital or acquired heart disease, arrhythmias or palpitations. All clinic consultations from 3/2021 to 7/2022 were reviewed. Patient demographics, contraception plans, and final birth control methods were recorded. We classified the methods as highly to moderately effective contraception (tubal ligation, vasectomy, IUD, implant, and hormonal methods) and least effective (condom, diaphragm, natural methods, and no contraception). 98 of 131 (82.3%) women with CVD were delivered and had complete data. During prenatal visits, 56% of women had an identified contraception plan. During the postpartum visit, actual contraception plans were confirmed in 66.3%. 60% of women chose highly to moderately effective methods. Further, Hispanic women and those with BMI ≥30 chose highly to moderately effective contraceptive methods more frequently than white women. Most Hispanic women were under emergency insurance. Medical comorbidities and CVD diagnosis were not different between the groups (Table 1). The preferred methods were hormonal therapies 22% (oral, injectable, patch, ring) followed by IUD 19.4%. Of those, 47.3% of IUDs were post-placental insertions (Table 2). In our clinic, 63% of women with CVD during pregnancy had a contraceptive method. The final choice of contraceptive methods was driven by race, culture and access to medical care rather than by medical conditions complicating pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND: Incarceration of the gravid uterus is an infrequent obstetric complication that can cause severe complications. CASE: A 37-year-old woman, G3P2002, at 14 weeks of gestation presented with vomiting, back pain, and urinary retention. She was noted to be in acute renal failure, with a creatinine level of 9.24 mg/dL, and results of her physical examination were concerning for uterine incarceration. Passive maneuvers and manual pressure failed to resolve the incarceration. Under spinal anesthesia, a Bakri balloon was inflated in the posterior vagina, elevating the fundus and relieving the incarcerated uterus. CONCLUSION: An intravaginal balloon may aid in the alleviation of uterine incarceration.

Abstract Objectives Preterm birth occurs in more than 10% of U.S. births and is the leading cause of U.S. neonatal deaths, with estimated annual costs exceeding $25 billion USD. Using real-world data, we modeled the potential clinical and economic utility of a prematurity-reduction program comprising screening in a racially and ethnically diverse population with a validated proteomic biomarker risk predictor, followed by case management with or without pharmacological treatment. Methods The ACCORDANT microsimulation model used individual patient data from a prespecified, randomly selected sub-cohort (N = 847) of a multicenter, observational study of U.S. subjects receiving standard obstetric care with masked risk predictor assessment (TREETOP; NCT02787213). All subjects were included in three arms across 500 simulated trials: standard of care (SoC, control); risk predictor/case management comprising increased outreach, education and specialist care (RP-CM, active); and multimodal management (risk predictor/case management with pharmacological treatment) (RP-MM, active). In the active arms, only subjects stratified as higher risk by the predictor were modeled as receiving the intervention, whereas lower-risk subjects received standard care. Higher-risk subjects’ gestational ages at birth were shifted based on published efficacies, and dependent outcomes, calibrated using national datasets, were changed accordingly. Subjects otherwise retained their original TREETOP outcomes. Arms were compared using survival analysis for neonatal and maternal hospital length of stay, bootstrap intervals for neonatal cost, and Fisher’s exact test for neonatal morbidity/mortality (significance, p < .05). Results The model predicted improvements for all outcomes. RP-CM decreased neonatal and maternal hospital stay by 19% (p = .029) and 8.5% (p = .001), respectively; neonatal costs’ point estimate by 16% (p = .098); and moderate-to-severe neonatal morbidity/mortality by 29% (p = .025). RP-MM strengthened observed reductions and significance. Point estimates of benefit did not differ by race/ethnicity. Conclusions Modeled evaluation of a biomarker-based test-and-treat strategy in a diverse population predicts clinically and economically meaningful improvements in neonatal and maternal outcomes. PLAIN LANGUAGE SUMMARY Preterm birth, defined as delivery before 37 weeks’ gestation, is the leading cause of illness and death in newborns. In the United States, more than 10% of infants are born prematurely, and this rate is substantially higher in lower-income, inner-city and Black populations. Prematurity associates with greatly increased risk of short- and long-term medical complications and can generate significant costs throughout the lives of affected children. Annual U.S. health care costs to manage short- and long-term prematurity complications are estimated to exceed $25 billion. Clinical interventions, including case management (increased patient outreach, education and specialist care), pharmacological treatment and their combination can provide benefit to pregnancies at higher risk for preterm birth. Early and sensitive risk detection, however, remains a challenge. We have developed and validated a proteomic biomarker risk predictor for early identification of pregnancies at increased risk of preterm birth. The ACCORDANT study modeled treatments with real-world patient data from a racially and ethnically diverse U.S. population to compare the benefits of risk predictor testing plus clinical intervention for higher-risk pregnancies versus no testing and standard care. Measured outcomes included neonatal and maternal length of hospital stay, associated costs and neonatal morbidity and mortality. The model projected improved outcomes and reduced costs across all subjects, including ethnic and racial minority populations, when predicted higher-risk pregnancies were treated using case management with or without pharmacological treatment. The biomarker risk predictor shows high potential to be a clinically important component of risk stratification for pregnant women, leading to tangible gains in reducing the impact of preterm birth.

AbstractObjectiveTo develop and validate mid-trimester preterm preeclampsia (PE) risk predictors combining clinical factors and serum protein analytes, and to compare their performance with those of widely used clinical and risk assessment algorithms endorsed by professional societies.MethodsThis was a secondary analysis of data from two large, multicenter studies in pregnant individuals (PAPR,NCT01371019; TREETOP,NCT02787213), originally conducted to discover, verify, and validate a serum proteomic predictor of preterm birth risk. Serum protein abundances were determined by mass spectrometry. Classifier models combined one or two novel protein ratio(s) with a composite clinical variable, denoted as ClinRisk3, which included prior PE, pre-existing hypertension, or pregestational diabetes. Predictive performance was assessed for the full validation cohort and for a subset that had early gestational age (GA) dating via ultrasound. Classifier performance was compared directly to the U.S. Preventive Services Task Force (USPSTF) algorithm for identification of pregnancies that should receive low-dose aspirin (LDASA) for PE prevention.ResultsNine of nine prespecified classifier models were validated for risk of preterm PE with delivery <37 weeks’ gestation. Areas under the receiver operating characteristic curve ranged from 0.72-0.78 in the full validation cohort, compared to 0.68 for both ClinRisk3 alone and for the USPSTF algorithm. In the early GA dating subcohort, an exemplar predictor, ClinRisk3 + inhibin subunit beta C chain/sex hormone binding globulin (ClinRisk3+INHBC/SHBG) showed a markedly lower screen positive rate (11.1% vs 43.3%) and higher positive predictive value (13.0% vs 5.0%) and odds ratio (9.93 vs 5.24) than USPSTF. Its performance was similar in nulliparas and all parities.ConclusionNine preterm PE risk predictors were identified, validated in an independent cohort, and shown to be more predictive than the USPSTF-endorsed algorithm. Our results indicate that a single blood test performed in the first half of pregnancy can be used for personalized PE risk assessment, particularly for pregnancies with minimal or no identified clinical risk factors, including nulliparas. Results can be used to guide personalized pregnancy management, including but not restricted to LDASA for PE prophylaxis, and serve as a basis for developing new prevention strategies.Funding SourceSera Prognostics, Inc.PrécisCombining novel serum protein biomarkers and selected clinical variables for preterm preeclampsia prediction outperforms widely used clinical risk assessment algorithms currently recommended by practice guidelines.

Introduction Uterine prolapse in pregnancy is an uncommon occurrence that can lead to a wide spectrum of complications. Postpartum Group A Streptococcus (GAS) endometritis is a rare but life-threatening condition. Our aim was to review the literature regarding management of prolapse in pregnancy and maternal infection as a rare complication. Methods and results We present a case of uterine prolapse with cervical elongation presenting in the third trimester. The patient’s prolapse was refractory to pessary management. She was induced at 36 weeks due to an abnormal fetal heart tracing and had an uncomplicated vaginal delivery. Her postpartum course was complicated by GAS endometritis and septic shock. She recovered after antibiotic therapy and her prolapse did not recur postpartum. Conclusion Prolapse during pregnancy carries a risk of several complications but does not preclude a vaginal delivery. Management must be patient-centered and individualized. GAS sepsis is a potential, rare, and life-threatening postpartum complication requiring swift identification and treatment.

Objective We aimed to decrease our surgical site infection (SSI) rate by 30% by sequential implementation of vaginal cleansing and azithromycin for women who underwent a cesarean delivery (CD) after having labored or experienced rupture of membranes. Methods This is a quality improvement project that assessed the stepwise implementation of two interventions within three time periods: (1) 12 months prior to implementation of either intervention; (2) 14 months of vaginal cleansing as infection prophylaxis; (3) 16 months of vaginal cleansing and azithromycin as infection prophylaxis. The primary outcome measure was the SSI as defined by the Center for Disease Control and Prevention and analyzed by control charts. The process measures were compliance rates of vaginal cleansing and azithromycin. Significance was detected by rules for determining a special cause variation. This study followed the SQUIRE 2.0 guidelines for reporting on quality improvement. Results There were 1033 patients included from the three study periods. The total rate of SSI decreased from 22.8% to 15.2% after implementing vaginal cleansing. Special cause variation was detected with an 8-point shift starting 4 months after implementation of vaginal cleansing. This decrease was sustained during the following 26 months. Adding azithromycin did not significantly lower the SSI rate further. When examined separately, deep SSI (p = .009) and endometritis (p = .001) significantly decreased in the post-intervention periods. Pre-operative vaginal cleansing compliance rose to 74%, and then further increased to 85% 1 year after implementation. Azithromycin compliance rose to 75%. Total length of postpartum stay decreased over the study periods from 3.5 +/- 1.4 days to 3.2 +/- 0.8 days (p = .001). Conclusion In this quality improvement study, implementation of vaginal cleansing decreased the SSI rate by 33%, from 22.8% to 15.2%. The addition of azithromycin did not result in any additional change in SSI rate.

Given the concern for aerosolization of SARS-COV-2 with oxygen administration and evidence from randomized controlled trials that supplemental oxygen does not improve outcomes in labor, our institution developed a guideline that oxygen would no longer be given to labor patients with oxygen saturation >95%. Our objective was to examine the compliance with this policy change through a quality improvement study. All deliveries in an urban academic medical center from January 1 to July 31, 2020 were assessed. Pre-intervention group was defined as those who delivered January 1-March 19, 2020. Post-intervention group delivered March 20-July 31, 2020. Exclusion criteria were planned cesarean delivery, multiple gestations, delivery at <24 weeks, intrauterine fetal demise, and patients who required oxygen for a saturation <95%. COVID-19 patients that were included did not have an oxygen requirement. The primary outcome was the percentage of patients who received oxygen in labor analyzed by control charts and the rules of special cause variation. Chi-squared and T-test were used for secondary outcome assessment. A p<0.05 was considered significant. A total of 1,334 patients were included, 474 patients in the pre-intervention group and 860 in the post-intervention group. COVID-19 positive patients were exclusively in the post-intervention group. For the primary outcome, prior to intervention, oxygen was administered to 22.6% of patients, versus 0.6% following intervention (Figure). Special cause variation was detected with an 8-point shift starting the month that the guideline was implemented. There were no differences in any secondary maternal or fetal outcomes (Table). This quality improvement study demonstrates significant adherence to the guideline that supplemental oxygen would no longer be given to patients with normal oxygen saturation in labor, with no change in maternal or fetal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The U.S. has the highest rate of preterm birth (PTB), of all developed countries, especially among African American women. Social determinants of health and inequalities in health outcomes are understudied areas. The intersectionality of race and socioeconomic status has been shown to contribute to chronic stress, stress has been shown to be associated with PTB, yet the mechanisms that affect pregnancy outcomes have not been explicit. Mindfulness-based Interventions that address stress reduction during pregnancy may improve quality of life during pregnancy, perhaps enhancing resilience, and be on the pathway to reducing the risk of negative pregnancy outcomes such as PTB. We over-enrolled African American women and those covered by Medicaid to reach women at higher risk for PTB and included women in substance use treatment. Participants were enrolled in a 6-week mindfulness in pregnancy (MIP) intervention at the obstetric clinic. Sociodemographic characteristics and psychosocial assessments were obtained at three time points. We enrolled 35 women who self-identified as: non-white, Medicaid recipients, aged 25–35 years, with high school or less education. We found reductions in perceived stress, pregnancy specific stress, trait anxiety and depression and increases in mindfulness that sustained post-intervention at 2 and 7 months. Social determinants and stress in particular have been associated with negative birth outcomes. This paper describes a brief intervention and results of MIP tailored to women who have significantly more stress due to race, poverty, homelessness, substance use treatment and other comorbid health risks including PTB.

Objective Evaluate clinical utility and cost effectiveness of identifying pregnancies at increased risk of preterm birth using a validated proteomic biomarker risk predictor to enable proactive intervention Study Design Pregnancies at elevated risk ([≥]15%) of preterm birth were identified in a cohort from TREETOP (NCT02787213), a study independent of biomarker development. In the screening arm, higher-risk subjects received simulated interventions based on published efficacy of multimodal treatment or care-management alone. Subjects in the non-screening arm received no interventions. Neonatal and maternal length of stay, neonatal mortality and morbidity and neonatal costs were compared between arms. Results Multimodal/care-management modeled treatments predicted reductions in neonatal (30%/22%) and maternal (9.2%/8.5%) hospital stays, neonatal morbidity and mortality (41%/29%), and neonatal costs (34%/16%) for the screening vs. non-screening arm. Conclusion Modeled interventions applied to pregnancies identified as higher-risk by a proteomic biomarker risk predictor demonstrate clinically and economically meaningful improvements in neonatal and maternal outcomes.

OBJECTIVE:To examine compliance with a guideline to reduce exposure to supplemental oxygen for category II fetal heart rate (FHR) tracings in normally oxygenated laboring patients.METHODS:All patients in labor in an urban academic medical center from January 1 to July 31, 2020 were assessed. The preintervention group included those who delivered from January 1 to March 19, 2020. On March 20, 2020, a new guideline took effect that recommended no maternal supplemental oxygen for category II FHR tracings. The postintervention group delivered from March 20 to July 31, 2020. Exclusion criteria were planned cesarean delivery, multiple gestations, delivery at less than 24 weeks of gestation, intrauterine fetal death, and patients who received supplemental oxygen for an oxygen saturation lower than 95%. The primary outcome was the percentage of patients who received oxygen in labor analyzed by control charts and the rules of special cause variation. Chi-squared and t tests were used for secondary outcome assessment. P<.05 was considered significant.RESULTS:A total of 1,333 patients were included, 474 patients in the preintervention group and 859 in the postintervention group. Oxygen was administered to 22.6% of patients before guideline implementation, compared with 0.6% after the guideline. Special cause variation was detected with an 8-point shift starting the month that the guideline was implemented, indicating statistical significance. There were no differences in any studied secondary maternal or fetal outcomes, although our statistical power to detect differences in infrequent outcomes was limited.CONCLUSION:This quality-improvement study demonstrated significant adherence to the guideline that supplemental oxygen would no longer be given to patients with category II FHR tracings in the absence of maternal hypoxemia, with no significant change in maternal or perinatal outcomes.

Background: Medications for opioid use disorder, including methadone, combined with comprehensive wraparound services, are the gold standard for treatment in pregnancy. Higher methadone doses are associated with treatment retention in pregnancy and relapse prevention. Given known inequities where individuals of color tend to be prescribed lower doses of opioids for other conditions, the purpose of this study was to determine whether there is racial inequity in methadone dose at delivery in pregnant women with opioid use disorder. Methods: Retrospective review of medical charts identified pregnant women (N = 339) treated with methadone for opioid use disorder during pregnancy at one center from 2012 to 2017. Variables extracted from medical records included race, demographic and relevant clinical information (e.g., methadone dose at delivery, height, weight, etc.). Analyses used simple and multiple linear regressions to determine associations between these characteristics and methadone dose at delivery. Results: The mean methadone doses at delivery among women of color and white women were 105.8 mg and 144.9 mg, respectively (p < .0001). After adjusting for maternal age, gestational age at delivery, body mass index, type of opioid used, and parity, race was significantly and independently associated with methadone dose at delivery, with women of color receiving 36.2 mg less than white women (p = .0003). Conclusions: Pregnant women of color with opioid use disorder received 67% of the dose of methadone at delivery that white women received. Antiracist responses to prevent provider bias in evaluating dose needs are needed to correct this inequity and prevent undertreatment of opioid use disorder among women of color.

Abstract Background: Preterm birth is a leading cause of neonatal morbidity and mortality worldwide; evidence-based strategies to decrease preterm birth are desperately needed. Objective: The purpose of this study was to estimate which of three strategies for screening for shortened cervix in asymptomatic low-risk women is the most cost-effective in terms of prevention of preterm birth and associated morbidity. Study design: A decision analysis model was developed from available published evidence comparing three strategies in screening asymptomatic low-risk women for shortened cervix: (1) cervicometer with subsequent referral for transvaginal ultrasound, (2) transvaginal ultrasound screening, and (3) no screening. The cost and effectiveness of each strategy was assessed in terms of quality-adjusted life-years (QALYs), and cost in US dollars. Results: Screening with a cervicometer with referral was the most cost-effective strategy and represented a savings of $999.65 ($11,617.28 versus $12,616.93) over screening with ultrasound, and a savings of $15,601.62 ($11,617.28 versus $27,218.90) over no screening. Costs for outcomes ranged from $3528 for a healthy neonate ≥34 weeks to $717,467.5 for a neonate <34 weeks with severe morbidity. The cervicometer strategy avoided 11.68 neonatal deaths per 1000 deliveries (3.59 deaths versus 15.27 deaths) compared with no screening, and avoided 0.73 neonatal deaths per 1000 deliveries (3.59 deaths versus 4.32 deaths) compared with ultrasound strategy. The cervicometer strategy prevented 82.44 preterm births per 1000 deliveries (22.56 versus 105.00) compared with no screening, and 5.10 preterm births per 1000 deliveries (22.56 versus 27.66) compared with ultrasound strategy. Per QALY, cervicometer screening cost $386.57, transvaginal ultrasound cost $420.31, and no screening cost $922.73. Sensitivity analyses confirmed the robustness of these findings, including evaluation across the range of quoted transvaginal ultrasound costs ($43–$300). Conclusion: A simulation of universal screening of asymptomatic low-risk women with a cervicometer with subsequent referral for ultrasound for those with a cervix <25 mm is cost-effective and yields the greatest reduction in preterm births at <34 weeks. A risk simulation trial noted that a cervicometer strategy may be more expensive than a universal transvaginal ultrasound strategy, but both are less expensive than a no screening strategy.

BACKGROUND:Currently, all obese women in the United States (US) are recommend to gain the same amount of weight during pregnancy, regardless of class of obesity. Limited literature has looked at the risk of cesarean, and possible mitigation of this risk, by specific class of obesity. OBJECTIVE:To determine the influence of weight gain on the odds of cesarean delivery for obese women (as determined by pre-pregnancy body mass index [BMI]), by class of obesity. STUDY DESIGN:Retrospective cohort, from the Pregnancy Risk Assessment Monitoring System (PRAMS) in the US. Specifically, the unadjusted odds of cesarean delivery were determined for each class of BMI (underweight, normal weight, overweight, class I obesity, class II obesity, and class III obesity). These odds were then adjusted by demographic and prenatal care factors influencing either weight gain during pregnancy or risk of cesarean delivery. Finally, the association of weight gain (insufficient <11 lbs, adequate 11-20 lbs, and excessive >20 lbs) on the odds of cesarean delivery in obese women was noted via multivariate logistic regression analysis. RESULTS:60,431 women (including 21,208 with a cesarean delivery) were included in this study, with an adjusted odds ratios (OR) of cesarean delivery by BMI: underweight 0.92 (95% CI 0.83, 1.01), normal weight (referent group), overweight 1.38 (95% CI 1.32, 1.45), class I obesity 1.77 (95% CI 1.68, 1.88), class II obesity 2.17 (95% CI 2.02, 2.34), and class III obesity 3.07 (95% CI 2.82, 3.34). Class I and II obese women are more likely to have a cesarean with excessive weight gain, with class I OR 1.20 (95% CI 1.06, 1.36) and class II OR 1.24 (1.04, 1.48) when compared to women in their same class of obesity with adequate weight gain. There was no difference in risk for cesarean for class III obese women by weight gain. CONCLUSION:Although obesity is a known risk factor for cesarean delivery, this risk is thought to be mitigatable by appropriate weight gain during the pregnancy. Weight gain of 11-20 pounds was associated with the least risk of cesarean delivery among obese (specifically class I and II) individuals.

Objective: To determine if quantitative fetal fibronectin (qFFN) in addition to transvaginal ultrasound (TVU) cervical length (CL) measurement between 180/7 and 236/7 weeks would be predictive of spontaneous preterm birth (sPTB) at <350/7 weeks among asymptomatic high-risk women as defined by those with prior sPTB > 200/7 weeks.Material and methods: A prospective observational study of asymptomatic women with singleton gestations between 180/7 and 236/7weeks and one or more prior SPTB was performed. Women at their anatomy scan who opted into universal CL screening were enrolled. At enrollment, a vaginal speculum exam was performed to collect cervico-vaginal fluid from the posterior fornix using fetal fibronectin (FFN) swab. These women were then followed until delivery. Women with multiple gestations, rupture of membranes, vaginal bleeding, intercourse, or vaginal exam within 48 h of enrollment were excluded. Physicians were blinded to the qFFN levels, but the CL measurements were made available. The primary outcome was sPTB < 350/7 weeks.Results: Of the 105 asymptomatic women with prior sPTB who were prospectively enrolled, 19 (18.1%) had recurrent sPTB < 370/7 weeks. None of the sPTB were iatrogenic. Using receiver-operating characteristic curves, qFFN ≥ 10 ng/mL had the highest sensitivity with subsequent lowest false negative rate, while FFN ≥ 50 ng/mL was identified as being the best balance of sensitivity and false positive rate for predicting sPTB < 350/7 weeks. As compared with CL ≤ 25 mm alone, with the use of CL ≤ 25 mm or qFFN ≥ 50 ng/mL as screening criteria for prediction of SPTB < 350/7 weeks, sensitivity improved from 18.2 to 63.6%, specificity decreased from 96.8 to 82.1%, positive predictive value (PPV) decreased from 40.0 to 29.2%, negative predictive value (NPV) marginally improved from 91.1 to 95.1%.Conclusion: In women with singleton gestations with prior SPTB, qFFN can be used as an adjunct to triage patients who are found to have a shortened cervix. Sensitivity and NPVs improved with the addition of qFFN to TVU CL screening alone in women with singleton gestations with prior SPTB. However, specificity and PPVs decreased.

Up to 2% of pregnant women develop a disease that requires nonobstetrical operative intervention during pregnancy. We discuss the issues unique to pregnant patients as they pertain to the presentation, diagnosis, and management of nonobstetric surgical disease, with an emphasis on 2 of the most common diseases that affect pregnant women: appendicitis and cholecystitis. Surgery has been demonstrated to be safe and effective during pregnancy, provided proper precautions are taken into account. It is the consensus of multiple professional committees and societies that no pregnant women should be delayed or denied a necessary surgery because of pregnancy.

To evaluate the predictive performance of established preterm birth biomarkers when combined with additional clinical and proteomic markers. Serum from subjects at 191/7 – 206/7wks gestation was analyzed in two independent prospective cohorts. PTB predictors combining insulin-like growth factor binding protein 4/sex hormone binding globulin (IBP4/SHBG), clinical variables and additional protein biomarkers were developed using data from 583 subjects in PAPR (NCT01371019). Predictor combinations were based on prediction parameters, and prespecified for verification in 847 randomly-selected subjects (representing ∼1/3 of eligible subjects) from TREETOP (NCT02787213). Outcomes included PTB at various gestations and composite neonatal outcome scores as recorded in the PREGNANT trial (NCT00615550). Scores of 0-3 reflect increasing number of morbidities or days of NICU admission, 4 represents perinatal mortality. Area under the receiver operating characteristics curves (AUC) and 95% confidence intervals (CI) were calculated, p< .05 was statistically significant 77 proteins and 20 clinical factors were evaluated in the PAPR discovery phase. Examples of the most predictive protein and clinical factor combinations (defined in the attached table) were prespecified. Verification in the TREETOP cohort showed AUCs of 0.68–0.72 (all p< .05) for delivery < 35 (n=29) vs delivery ≥35-42 (n=818) wks, and 0.76–0.82 (all p< .05) for delivery < 32 (n=9) vs delivery ≥32-42 (n=838) wks. Neonatal morbidity was a separate outcome: 21/847 infants had outcome scores ≥3, 4/21 infants had an outcome score=4. AUC performance was significant for prediction of neonatal outcomes: 0.72-0.75 for scores of ≥3 and 0.86-0.89 for score=4 (all p< .05-see table). An established predictor, IBP4/SHBG, combined with novel factors demonstrated strong performance for predicting PTB and neonatal morbidity in an independent cohort. Validation analyses on remaining TREETOP subjects are forthcoming. Next-generation predictors like these may be valuable in risk assessment and management of pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

There are now over 1,000 randomized controlled trials (RCTs) on the technical aspects of how to perform a cesarean delivery (CD) (McCurdy R. JayPee 2019). One important aspect of this most common of laparotomies is how to close the skin incision. About 20 RCTs have evaluated CD skin closure, comparing the options of sutures, staples, glue, and others, as well as different types of these options (e.g., different types of sutures or different types of staples). This article is protected by copyright. All rights reserved.