Considering Criteria for Active Phase Labor Management of Nulliparous Women: A Cost-Effectiveness Analysis

2021 ◽  
Author(s):  
Eleanor M. Schmidt ◽  
Alyssa R. Hersh ◽  
Methodius Tuuli ◽  
Alison G. Cahill ◽  
Aaron B. Caughey
Keyword(s):  
Sensitivity Analysis ◽  
Brachial Plexus Injury ◽  
Cost Effective ◽  
Active Phase ◽  
Neonatal Outcomes ◽  
Maternal Outcomes ◽  
Cervical Dilation ◽  
Cesarean Deliveries ◽  
Active Labor ◽  
Adverse Neonatal Outcomes

Objective The aim of the study is to evaluate differences in maternal and neonatal outcomes based on updated criteria for defining active labor at 6 cm of cervical dilation and to determine if these recommendations are cost-effective. Study Design A decision-analytic model was built using TreeAge Pro 2020 software. We included maternal outcomes of mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and death. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. Costs and quality-adjusted life years (QALYs) were included from the maternal and infant perspectives. We used a willingness-to-pay threshold of $100,000 per QALY and all model inputs were subjected to sensitivity analysis. Results In a theoretical cohort of 1.4 million women, a threshold of 6 cm to define active labor resulted in 373,668 fewer cesarean deliveries, 33,181 fewer cases of endometritis, 143 fewer postpartum hemorrhages requiring transfusions, and seven fewer maternal deaths when compared with a threshold of 4 cm. However, there were higher rates of adverse neonatal outcomes, including 484 more cases of shoulder dystocia and 17 more instances of permanent brachial plexus injury. Using 6 cm as the threshold resulted in lower costs and greater effectiveness, making it a dominant strategy. Multivariate sensitivity analysis demonstrated the model was robust over a wide range of assumptions. Conclusion In this model, considering 6 cm of cervical dilation as the threshold for the active phase of labor compared with 4 cm was a cost-effective strategy to prevent primary cesarean deliveries, lower costs, and improve maternal outcomes, despite associated increased adverse neonatal outcomes. Key Points

Impact of Peanut Ball Device on the Duration of Active Labor: A Randomized Control Trial

2018 ◽  
Vol 35 (10) ◽  
pp. 1006-1011 ◽  
Author(s):  
Mei Kwan ◽  
Rebecca Mercier
Keyword(s):  
Cesarean Delivery ◽  
Statistical Significance ◽  
Active Phase ◽  
Cervical Dilation ◽  
Nulliparous Women ◽  
Significant Difference ◽  
Active Labor ◽  
English Speaking ◽  
Randomized Control ◽  
Singleton Pregnancies

Objective To evaluate whether the use of a peanut ball device shortens the duration of active labor in nulliparas. Study Design Single-site, nonblinded randomized trial in nulliparous women admitted for labor or labor induction. English-speaking women > 18 years of age with singleton pregnancies were enrolled. Participants were randomized to the use of peanut ball or usual care upon reaching the active phase of labor (≥ 6 cm cervical dilation) with an epidural. Primary outcome was rate of cervical dilation. Secondary outcomes were rates of cesarean delivery and fetal presentation at time of full dilation or delivery. Results Ninety-six patients enrolled; 63 reached full cervical dilation. There was no statistically significant difference in rates of cervical dilation (0.98cm/h vs. 0.79cm/h, p = 0.27) or length of labor (315 minutes vs. 387 minutes, p = 0.14) between the groups. There was no difference in the rates of cesarean delivery (33% vs. 35%, p = 0.8) or occiput posterior presentation. (28% vs. 9%, p = 0.09). Among the subgroup who had labor arrest, fewer patients using the peanut ball experienced arrest of dilation; this approached but did not reach statistical significance (30% vs. 73% p = 0.05). Conclusion Use of the peanut ball does not significantly increase rates of cervical dilation or decrease time in active labor.

Timing of Repeat Cesarean Delivery for Women with a Prior Classical Incision

2020 ◽  
Author(s):  
Marwan Ma'ayeh ◽  
Paulina Haight ◽  
Emily A. Oliver ◽  
Mark B. Landon ◽  
Kara M. Rood
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Cesarean Delivery ◽  
Secondary Analysis ◽  
Neonatal Morbidity ◽  
Neonatal Outcomes ◽  
Maternal Outcomes ◽  
Adverse Neonatal Outcomes ◽  
Nicu Admission ◽  
Repeat Cesarean Delivery

Objective This study aimed to compare neonatal outcomes for delivery at 36 weeks compared with 37 weeks in women with prior classical cesarean delivery (CCD). Study Design This was a secondary analysis of the prospective observational cohort of the Eunice Kennedy National Institute for Child and Human Development's Maternal-Fetal Medicine Unit Network Cesarean Registry. Data on cases of repeat cesarean delivery (RCD) in the setting of a prior CCD were abstracted and used for analysis. This study compared outcomes of women who delivered at 360/7 to 366/7 versus 370/7 to 376/7 weeks. The primary outcome was a composite of adverse neonatal outcomes that included neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), hypoglycemia, mechanical ventilation, sepsis, length of stay ≥5 days, and neonatal death. A composite of maternal outcomes that included uterine rupture, blood transfusion, general anesthesia, cesarean hysterectomy, venous thromboembolism, maternal sepsis, intensive care unit admission, and surgical complications was also evaluated. Results There were 436 patients included in the analysis. Women who delivered at 36 weeks (n = 176) were compared those who delivered at 37 weeks (n = 260). There were no differences in baseline characteristics. Delivery at 37 weeks was associated with a reduction in composite neonatal morbidity (24 vs. 34%, adjusted odds ratio [aOR] = 0.61 [0.31–0.94]), including a decrease in NICU admission rates (20 vs. 29%, aOR = 0.63 [0.40–0.99]), hospitalization ≥5 days (13 vs. 24%, aOR = 0.48 [0.29–0.8]), and RDS or TTN (9 vs. 19%, aOR = 0.43 [0.24–0.77]). There was no difference in adverse maternal outcomes (7 vs. 7%, aOR = 0.98 [0.46–2.09]). Conclusion Delivery at 37 weeks for women with a history of prior CCD is associated with a decrease in adverse neonatal outcomes, compared with delivery at 36 weeks. Key Points

scholarly journals Pregnancy outcomes in women with a hemoglobinopathy trait: a multicenter, retrospective study

2021 ◽  
Author(s):  
Jan Kasparek ◽  
Tilo Burkhardt ◽  
Irene Hoesli ◽  
Gabriela Amstad Bencaiova
Keyword(s):  
Pregnant Women ◽  
Neonatal Outcomes ◽  
University Hospital ◽  
Control Group ◽  
Maternal Outcomes ◽  
Adverse Neonatal Outcomes ◽  
Maternal And Neonatal Outcomes ◽  
Clinical Records ◽  
The University ◽  
Fetal Acidosis

Abstract Purpose To determine the risk of adverse maternal and neonatal outcomes in pregnant women with a hemoglobinopathy trait. Materials and methods Retrospective cohort study was conducted to compare adverse maternal and neonatal outcomes between pregnant women with a hemoglobinopathy trait (study group; n = 172), and without a hemoglobinopathy trait (control group; n = 360). The medical data were extracted from clinical records of pregnant women attending antenatal care and delivering at the University Hospital Basel or University Hospital Zurich between 2015 and 2018. Results A total of 172 pregnant women with a hemoglobinopathy trait and 360 controls were recruited. Apart from fetal acidosis, the groups did not differ significantly in any variables of adverse neonatal outcomes. Whereas, among the maternal outcomes the rate of abortion, gestational diabetes mellitus, bacteriuria or urinary tract infection, intrahepatic cholestasis, abnormal placentation and anemia postpartum were significantly increased in women with a hemoglobinopathy trait. Conclusion In our study, a hemoglobinopathy trait increased the risk of adverse maternal outcomes but did not increase adverse neonatal outcomes.

Antibiotic Timing in Previable Prelabor Rupture of Membranes Less Than 24 Weeks of Gestation

2020 ◽  
Author(s):  
Rubymel J. Knupp ◽  
Sarah Pederson ◽  
Christina Blanchard ◽  
Jeff Szychowski ◽  
Deepa Etikala ◽  
...  
Keyword(s):  
Birth Weight ◽  
Gestational Age ◽  
Tertiary Care ◽  
Prophylactic Antibiotic ◽  
Neonatal Outcomes ◽  
Maternal Outcomes ◽  
Antibiotic Administration ◽  
Neonatal Birth Weight ◽  
Significant Difference ◽  
Adverse Neonatal Outcomes

Objective This study aimed to compare neonatal and maternal outcomes between immediate and delayed prophylactic antibiotic administration after previable prelabor premature rupture of membranes (PROM) less than 24 weeks of gestation. Study Design Retrospective cohort study of singleton pregnancies with PROM between 160/7 and 236/7 weeks of gestational age conducted at a single tertiary care referral center between June 2011 and December 2015. Patients with multiple gestations, fetal anomalies, those who elected augmentation, or with a contradiction to expectant management, such as suspected intra-amniotic infection or stillbirth, were excluded from the study. We compared pregnancy characteristics, maternal complications, and neonatal outcomes between women who received a course of antibiotics within 24 hours of PROM and women who received antibiotics after 24 hours of PROM. The primary outcome was neonatal survival to hospital discharge. Secondary outcomes included gestational age at delivery, time from PROM to delivery, neonatal birth weight, days in the neonatal intensive care unit (NICU), composite adverse neonatal outcomes, and maternal morbidity. Results Ninety-four women met inclusion criteria, 57 (61%) received antibiotics within 24 hours of PROM and 37 (39%) received antibiotics 24 hours after PROM. Baseline maternal characteristics were similar in both groups. The mean gestational age at PROM was similar between groups at 20.8 ± 2.3 weeks in the immediate antibiotics group and 20.6 ± 2.1 weeks in the delayed antibiotics group (p = 0.48). Compared with delayed antibiotic administration, immediate antibiotic administration was not associated with a significant difference in latency time from PROM to delivery, rate of stillbirth, days in an ICU, or adverse neonatal outcomes. Maternal outcomes also did not differ significantly between groups. Neonatal birth weight was lower in the immediate antibiotics group (p = 0.012). Conclusion Our data suggest that there is no maternal or neonatal benefit to immediate administration of latency antibiotics compared with delayed administration. Key Points

scholarly journals The Contribution of Untreated and Treated Anxiety and Depression to Prenatal, Intrapartum, and Neonatal Outcomes

2018 ◽  
Vol 08 (03) ◽  
pp. e146-e157 ◽  
Author(s):  
Dotun Ogunyemi ◽  
Andrew Jovanovski ◽  
James Liu ◽  
Perry Friedman ◽  
Nathaniel Sugiyama ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Psychotropic Drugs ◽  
Postpartum Hemorrhage ◽  
Adverse Outcomes ◽  
Neonatal Outcomes ◽  
Anxiety And Depression ◽  
Cesarean Deliveries ◽  
Adverse Neonatal Outcomes ◽  
Neonatal Adaptation ◽  
Anxiety Depression

Objective To determine independent perinatal associations of anxiety and depression in women who were and were not treated with psychotropic drugs in comparison to unaffected pregnancies. Study Design From 2013 to 2014, 978 (6.3%) cases of anxiety/depression, of which 35% used psychotropic drugs, were compared with 14,514 (93.7%) unaffected pregnancies using logistic regression. Results Subjects were more likely to be Non-Hispanic Whites, use tobacco and illegal substances, be unmarried, use public insurance, and have medical complications of pregnancy. For independent maternal outcomes, untreated anxiety/depression was associated with labor induction (adjusted odds ratio [aOR] = 2.02), cesarean deliveries (aOR = 1.69), longer length of stay (aOR = 1.96), readmission (aOR = 2.40), fever (aOR = 2.03), magnesium exposure (aOR = 1.82), and postpartum hemorrhage (aOR = 2.57), whereas treated cases were associated with increased blood transfusion (aOR = 4.81), severe perineal lacerations (aOR = 2.93), and postpartum hemorrhage (aOR = 3.85), but decreased risk of cesarean deliveries (aOR = 0.59). Independent neonatal outcomes included small for gestational age (aOR = 3.04), meconium-stained fluid (aOR = 1.85; 2.61), respiratory failure (aOR = 5.84), neonatal adaptation syndrome (aOR = 11; 10.2), and neonatal seizures (aOR = 12.3) in treated cases, whereas untreated cases were associated with hypoxia (aOR = 2.83), low Apgar score (aOR = 3.82), and encephalopathy (aOR = 18.3). Exposure to multiple psychotropic medications independently increased the risk of neonatal adaptation syndrome, neonatal length of stay, and hypoglycemia. Conclusion Untreated cases were associated with increased maternal adverse outcomes, whereas treated cases were associated with more adverse neonatal outcomes when compared with unaffected pregnancies.

scholarly journals Telemammography for breast cancer screening: a cost-effective approach in Argentina

2021 ◽  
Vol 28 (1) ◽  
pp. e100351
Author(s):  
Victoria Alba Malek Pascha ◽  
Li Sun ◽  
Ramiro Gilardino ◽  
Rosa Legood
Keyword(s):  
Breast Cancer ◽  
Sensitivity Analysis ◽  
Cancer Screening ◽  
Breast Cancer Screening ◽  
Probabilistic Sensitivity Analysis ◽  
Mammography Screening ◽  
Cost Effective ◽  
Access To Healthcare ◽  
Over 40 Years ◽  
Improve Access

ObjectivesArgentina is a low and middle-income country (LMIC) with a highly fragmented healthcare system that conflicts with access to healthcare stated by the country’s Universal Health Coverage plan. A tele-mammography network could improve access to breast cancer screening decreasing its mortality. This research aims to conduct an economic evaluation of the implementation of a tele-mammography program to improve access to healthcare.MethodsA cost-utility analysis was performed to explore the incremental benefit of annual tele-mammography screening for at-risk Argentinian women over 40 years old. A Markov model was developed to simulate annual mammography or tele-mammography screening in two hypothetical population-based cohorts of asymptomatic women. Parameter uncertainty was evaluated through deterministic and probabilistic sensitivity analysis. Model structure uncertainty was also explored to test the robustness of the results.ResultsIt was estimated that 31 out of 100 new cases of breast cancer would be detected by mammography and 39/100 by tele-mammography. The model returned an incremental cost-effectiveness ratio (ICER) of £26 051/quality-adjusted life-year (QALY) which is lower than the WHO-recommended threshold of £26 288/QALY for Argentina. Deterministic sensitivity analysis showed the ICER is most sensitive to the uptake and sensitivity of the screening tests. Probabilistic sensitivity analysis showed tele-mammography is cost-effective in 59% of simulations.DiscussionTele-mammography should be considered for adoption as it could improve access to expertise in underserved areas where adherence to screening protocols is poor. Disaggregated data by province is needed for a better- informed policy decision. Telemedicine could also be beneficial in ensuring the continuity of care when health systems are under stress like in the current COVID-19 pandemic.ConclusionThere is a 59% chance that tele-mammography is cost-effective compared to mammography for at-risk Argentinian women over 40- years old, and should be adopted to improve access to healthcare in underserved areas of the country.

scholarly journals Maternal alcohol use, adverse neonatal outcomes and pregnancy complications in British Columbia, Canada: a population-based study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Svetlana Popova ◽  
Danijela Dozet ◽  
Graham O’Hanlon ◽  
Valerie Temple ◽  
Jürgen Rehm
Keyword(s):  
British Columbia ◽  
Risk Factor ◽  
Alcohol Use ◽  
Pregnancy Complications ◽  
Alcohol Exposure ◽  
Population Based ◽  
Neonatal Outcomes ◽  
Fiscal Year ◽  
Adverse Neonatal Outcomes ◽  
Icd 10

Abstract Background The current study aimed to estimate the prevalence of alcohol use identified as a risk factor during pregnancies by the antenatal care providers, resulting in live births in British Columbia (BC) and to examine associations between alcohol use, adverse neonatal outcomes, and pregnancy complications. Methods This population-based cross-sectional study utilized linked obstetrical and neonatal records within the BC Perinatal Data Registry (BCPDR), for deliveries that were discharged between January 1, 2015 and March 31, 2018. The main outcome measures were alcohol use identified as a risk factor during pregnancy, associated maternal characteristics, pregnancy complications, and adverse neonatal outcomes. Estimates for the period and fiscal year prevalence were calculated. Chi-square tests were used to compare adverse neonatal outcomes and pregnancy complications by alcohol use during pregnancy identified as a risk factor. Logistic regression was used to examine the association between alcohol use identified as a risk factor during pregnancy and adverse neonatal outcomes and pregnancy complications, after adjusting for identified risk factors. Results A total of 144,779 linked records within the BCPDR were examined. The period prevalence of alcohol use during pregnancy identified as a risk factor was estimated to be 1.1% and yearly prevalence was 1.1, 1.1, 1.3 and 0.9% from the 2014/2015 to 2017/2018 fiscal years, respectively. Alcohol use identified as a risk factor was associated with younger maternal age, fewer antenatal visits, being primiparous, a history of mental illness, substance use and smoking. Neonates with alcohol use during pregnancy identified as a risk factor had greater odds of being diagnosed with: “low birth weight (1000-2499g)” (ICD-10: P07.1; aOR = 1.25; 95% CI: 1.01, 1.53), “other respiration distress of newborn” (ICD-10: P22.8; aOR = 2.57; 95% CI: 1.52, 4.07), “neonatal difficulty in breastfeeding” (ICD-10: P92.5; aOR = 1.97; 95% CI: 1.27, 2.92) and “feeding problems, unspecified” (ICD-10: P92.9; aOR = 2.06; 95% CI: 1.31, 3.09). Conclusions The prevalence of alcohol use during pregnancy identified as a risk factor was comparable to previous estimates within the BCPDR. Identified prenatal alcohol exposure was associated with notable differences in maternal and neonatal characteristics and adverse neonatal outcomes. More consistent, thorough screening and prevention efforts targeting alcohol use in pregnancy are urgently needed in Canada.

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