INTRODUCTION:Although antifibrinolytic agents are used to prevent and treat hemorrhage, there are concerns about a potential increased risk for peripartum venous thromboembolism. We sought to determine the impact of tranexamic acid and ɛ-aminocaproic acid on in vitro clotting properties in pregnancy.METHODS:Blood samples were obtained from healthy pregnant, obese, and preeclamptic pregnant women (n = 10 in each group) prior to delivery as well as from healthy non-pregnant controls (n = 10). Maximum clot firmness (MCF) and clotting time (CT) were measured using rotation thromboelastometry in the presence of tranexamic acid (3, 30, or 300 μg/mL) or ɛ-aminocaproic acid (30, 300, or 3000 μg/mL). ANOVA and regression analyses were performed.RESULTS:Mean whole blood MCF was significantly higher in healthy pregnant vs. non-pregnant women (66.5 vs. 57.5 mm, p < 0.001). Among healthy pregnant women, there was no significant difference between mean MCF (whole blood alone, and with increasing tranexamic acid doses = 66.5, 66.1, 66.4, 66.3 mm, respectively; p = 0.25) or mean CT (409, 412, 420, 424 sec; p = 0.30) after addition of tranexamic acid. Similar results were found using ɛ-aminocaproic acid. Preeclamptic women had a higher mean MCF after the addition of ɛ-aminocaproic acid and tranexamic acid (p = 0.05 and p = 0.04, respectively) compared to whole blood alone.CONCLUSIONS:Pregnancy is a hypercoagulable state, as reflected by an increased MCF compared to non-pregnant women. Addition of antifibrinolytic therapy in vitro does not appear to increase MCF or CT for non-pregnant, pregnant, and obese women. Whether antifibrinolytics are safe in preeclampsia may require further study.

OBJECTIVE: To examine the association between state-mandated insurance coverage for in vitro fertilization (IVF) and the incidence of multiple birth while controlling for differences in baseline patient characteristics. METHODS: We conducted a retrospective cohort study using the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System from 2007 to 2011 to examine the association between state-mandated insurance coverage for IVF and the incidence of multiple birth while controlling for differences in baseline patient characteristics. Analyses were stratified according to patient age and day of embryo transfer (3 or 5). RESULTS: Of the 173,968 cycles included in the analysis, 45,011 (25.9%) were performed in mandated states and 128,957 (74.1%) in nonmandated states. The multiple birth rate was significantly lower in mandated states (29.0% compared with 32.8%, adjusted odds ratio [OR] 0.87, 99.95% confidence interval [CI] 0.80–0.94). After stratification, this association remained statistically significant only in women younger than 35 years old who underwent transfer on day 5 (33.1% compared with 38.6%, adjusted OR 0.81, 99.95% CI 0.71–0.92). Among women younger than 35 years with day 5 transfer, the elective single embryo transfer rate was significantly higher in mandated states (21.8% compared with 13.1%, adjusted OR 2.36, 99.95% CI 2.09–2.67). CONCLUSION: State-mandated insurance coverage for IVF is associated with decreased odds of multiple birth. This relationship is driven by increased use of elective single embryo transfer among young women undergoing day 5 transfer.

OBJECTIVE:To evaluate experiences related to obstetric hemorrhage and suspected abnormal placentation among first year maternal-fetal medicine fellows.STUDY DESIGN:A cross-sectional anonymous survey was administered at the Society for Maternal-Fetal Medicine fellow retreat in March 2013. Fellows were asked about management strategies that reflected both their individual and institutional practices.RESULTS:There was a 56% response rate (55/98). In cases of postpartum hemorrhage due to uterine atony, there was variable use of the uterine tamponade device. The median incremental time for balloon deflation was every 5 hours (IQR = 2-12). Compared to the east coast, fellows from the west coast performed more hysterectomies (mean±SD; 2.9±2.4 vs. 1.2±1.2, p = 0.004). During a peripartum hysterectomy, 29% of fellows used a handheld cautery device such as Ligasure® or Gyrus®. Fifty-six percent responded that their institution never recommend planned delayed hysterectomies for abnormal placental implantation.CONCLUSION:There is wide variation in practice among first year maternal-fetal medicine fellows in management of peripartum hysterectomy and postpartum hemorrhage.

The optimal approach to patients with locally recurrent, non-metastatic rectal cancer is unclear. This study evaluates the outcomes and toxicity associated with pelvic re-irradiation.

To determine whether mandated insurance coverage for in vitro fertilization (IVF) has influenced changes in embryo transfer practices and multiple birth rates over time. Retrospective cohort study. We utilized the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database to identify fresh, autologous IVF cycles performed between 2007 and 2011 in women aged 20-42 years. Only first IVF cycles performed in each woman's state of residence were included in the analysis. Cycles were excluded if the indication for IVF was "non-infertile" or "preimplantation genetic diagnosis," if they were performed in a state with only one reporting clinic, or if embryo transfer occurred on days other than 3 or 5. Among the 40 states with more than one clinic, 6 have legislation requiring insurance coverage for at least one IVF cycle and were designated "mandated:" CT, HI, IL, MA, MD, and NJ. The remaining 34 states were designated "non-mandated." Regression models with a mandate*year of cycle interaction term were used to examine the effect of mandate status on changes in multiple birth rate per live birth, the proportion of transfers with elective single embryo transfer (eSET), and the mean number of embryos transferred over time. A total of 173,968 cycles were included in the analysis. The multiple birth rate was lower in mandated than non-mandated states (P < 0.001) and decreased over time in both groups (P < 0.001). Similarly, the proportion of transfers with eSET was higher in mandated than non-mandated states (P < 0.001), and increased over time in both groups (P < 0.001). The mean number of embryos transferred was lower in mandated than non-mandated states (P < 0.001), and decreased along a similar trajectory over time when embryo transfer was performed on day 5 (P < 0.001). Conversely, there was a significant interaction between mandate status and time among cycles with day-3 embryo transfer (P < 0.001). The mean number of embryos transferred decreased over time in both groups (P < 0.001), but the trajectory of decline was steeper for non-mandated states between 2007 and 2009 (P < 0.001). Between 2010 and 2011, the trajectory of decline was similar between the groups (P = NS). Multiple birth rates have decreased over time in both mandated and non-mandated states. Although the gap between these two groups has narrowed with respect to the mean number of embryos transferred on day 3, providers in mandated states still transfer fewer day-5 embryos and are more likely to perform eSET.

Insurance mandates for in vitro fertilization (IVF) vary with respect to eligibility criteria and the maximum number of covered cycles. Our objective was to examine associations among embryo transfer practices and multiple birth rates in states with mandated insurance coverage for IVF. Retrospective cohort study. We utilized the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database to identify fresh, autologous IVF cycles performed between 2007 and 2011 in women aged 20-42 years. Cycles were included if they were performed in one of 6 states with legislation requiring insurance coverage for at least one IVF cycle: CT, HI, IL, MA, MD, or NJ. Only first IVF cycles performed in each woman’s state of residence were included in the analysis. Cycles were excluded if the indication for IVF was “non-infertile” or “preimplantation genetic diagnosis,” if they were performed in a state with only one reporting clinic, or if embryo transfer occurred on days other than 3 or 5. Analysis of variance and the X2 test were used to compare continuous and categorical variables, respectively. P < 0.00019 was considered statistically significant after Bonferroni adjustment for multiple comparisons. Multivariate regression models were used to examine factors associated with multiple birth and elective single embryo transfer (eSET). A total of 45,011 cycles were included in the analysis. Embryo transfer practices and multiple birth rates differed significantly among the 6 states with IVF insurance mandates (Table). After adjustment for potential confounders, there was a significant association between day-5 embryo transfer and multiple birth (OR = 1.56, 95% CI 1.43-1.71). Elective single embryo transfer was more common on day 5 than day 3 (17% vs. 4%, P < 0.0001; adjusted OR = 3.64, 95% CI 3.16-4.19); however, the vast majority (83%) of day-5 transfers still involved more than 1 embryo (mean 1.80 ± 0.54). Among states with mandated insurance coverage for IVF, day-5 embryo transfer is associated with a 56% increased odds of multiple birth compared to embryo transfer on day 3. This association is driven by the transfer of multiple embryos with higher implantation rates.Tabled 1Embryo Transfer Practices and Outcomes in Mandated States.CTHIILMDMANJP ValueDay 5 transfer (%)30.034.452.544.817.842.7<0.0001--------------------------------DAY 3 TRANSFER-------------------------Mean # embryos transferred2.23.02.42.22.02.4<0.0001eSET rate/transfer (%)1.10.01.00.512.10.5<0.0001Implantation rate/embryo transferred (%)30.016.019.023.028.025.0<0.0001Multiple birth rate/live birth (%)30.227.224.524.925.329.9<0.0001--------------------------------DAY 5 TRANSFER-------------------------Mean # embryos transferred1.72.11.91.61.52.0<0.0001eSET rate/transfer (%)28.11.513.831.634.96.6<0.0001Implantation rate/embryo transferred (%)43.036.038.047.046.045.0<0.0001Multiple birth rate/live birth (%)26.637.432.024.519.038.7<0.0001 Open table in a new tab

have an Apgar of 7 at 5min (p 0.5), a cord pH of 7.1 (p 0.5) or require admission to the neonatal unit (p 0.47) regardless of onset of labor. CONCLUSION: This study represents robust and reliable data relating to IOL in multiparous twin pregnancies. Women who were induced were more likely to be older, and deliver larger infants. IOL did not carry an increased risk of Cesarean or instrumental delivery. There was also no evidence of increased maternal or neonatal morbidity associated with IOL.