Toward Achieving Risk-Appropriate Maternity Care: Maternal Morbidity Prediction No abstract available

Predictive Model of Factors Associated With Maternal Intensive Care Unit Admission OBJECTIVE: Severe maternal morbidity has increased in the United States over the past two decades by approximately 200%, to 144 cases per 10,000 delivery hospitalizations. There are limited data available to assist in identifying at-risk women before parturition. We sought to evaluate risk factors associated with maternal admission to an intensive care unit (ICU). METHODS: We conducted a population-based cohort study of all live births delivered between 20 and 44 weeks of gestation in the United States during 2012–2016. Our primary objective was to identify prenatal factors associated with increased risk of maternal ICU admission to build a multivariable predictive model to estimate the association of these factors with ICU admission risk. We performed k-fold cross-validation for internal validation and then externally validated the model on a separate live birth cohort (2006–2011, n=856,255). RESULTS: There were 18,745,615 live births in the United States between 2012 and 2016. Among the mothers of these live newborns, 27,602 (0.15%) were admitted to the ICU in the peripartum period. Fourteen variables were selected for inclusion in the predictive model for maternal ICU admission. The predicted minimal and maximal risk for ICU admission ranged 0–25%. The receiver operating characteristic curve for these 14 variables achieved an area under the curve (AUC) of 0.81 (95% CI 0.79–0.81). External validation with a separate live birth cohort demonstrated a consistent measure of discrimination with an AUC of 0.83 (95% CI 0.82–0.84). Using a relatively high cut point of 5.0% or more predicted risk for ICU admission, achieved a positive predictive value (PPV) of only 4.0%. CONCLUSION: This model provides insight as to the cumulative effect of multiple risk factors on maternal ICU admission risk. The predictive model achieves an AUC of 0.81, discriminating women with significantly increased risk (30-fold) for ICU admission. Nonetheless, because of the low frequency of maternal ICU admission, the PPV of the model was low and therefore whether models such as ours may be beneficial in future efforts to reduce the prevalence and burden of maternal morbidity is uncertain.

Rising From the Ashes: Minimally Invasive Surgery in the Wake of Power Morcellation No abstract available

Laparoscopic Hysterectomy Route, Resource Use, and Outcomes: Change After Power Morcellation Warning OBJECTIVE: To examine changes in utilization of different types of laparoscopic hysterectomy, as well as their associated resource use and surgical outcomes, after the U.S. Food and Drug Administration (FDA) safety statement in April 2014 regarding power morcellation. METHODS: We retrospectively analyzed data from the 2012–2016 American College of Surgeons National Surgical Quality Improvement Program and identified 145,746 women undergoing hysterectomy for benign indications. We measured use of laparoscopic supracervical hysterectomy compared to total laparoscopic hysterectomy (including laparoscopic-assisted vaginal hysterectomy) in these patients, as well as operative time, surgical setting (inpatient vs outpatient), length of stay, and 30-day surgical outcomes (wound complication, medical complication, reoperation, and readmission). We used an interrupted time series analysis to examine the association between FDA warning and changes in utilization and outcomes of laparoscopic hysterectomy. RESULTS: After adjusting for patient characteristics and background trends in practice, use of laparoscopic supracervical hysterectomy was significantly lower in the postwarning than prewarning period (odds ratio [OR]=0.49, 95% CI 0.45–0.53), whereas use of total laparoscopic hysterectomy was not affected (OR 1.01, 95% CI 0.96–1.06). Overall, after an initial reduction, use of laparoscopic hysterectomy (laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy combined) increased over time in the postwarning period (adjusted OR of utilization for each calendar quarter elapsed=1.03, 95% CI 1.02–1.03). After the FDA warning, operative time for laparoscopic supracervical hysterectomy increased by 11.45 minutes (95% CI 6.22–16.69), whereas the decreasing trend in the likelihood of inpatient stay for total laparoscopic hysterectomy was attenuated (OR for each calendar quarter elapsed=0.92 in prewarning period, 95% CI 0.91–0.93; and 0.97 in postwarning period, 95% CI 0.97–0.98). There was no significant change in 30-day surgical outcomes after the FDA warning. CONCLUSION: Rates of laparoscopic supracervical hysterectomy fell in association with power morcellation safety warnings, whereas rates of other laparoscopic hysterectomies continued to rise. There was no change in patient outcomes among laparoscopic hysterectomies.

To Live and Let Dye No abstract available

Urologic Injury and Fistula After Hysterectomy for Benign Indications OBJECTIVE: To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications. METHODS: In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005–2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed. RESULTS: Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14–0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16–0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30–1.58), an incontinence procedure (OR 1.40, 95% CI 1.21–1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31–1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36–1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01–1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53–0.64) or laparoscopic (OR 0.80, 95% CI 0.75–0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach. CONCLUSION: Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.

Use and Misuse of Opioids After Gynecologic Surgical Procedures OBJECTIVE: To examine the rate of opioid use for gynecologic surgical procedures and to investigate persistent opioid use among those women who received an initial opioid prescription. METHODS: A retrospective cohort study using the MarketScan database was performed. MarketScan is a claims-based data source that captures claims from more than 50 million privately insured patients and 6 million Medicaid enrollees from 12 states. We identified women who underwent major and minor gynecologic surgery from 2009 to 2016. Among women who received an opioid prescription, new persistent opioid use was defined as receipt of one or more opioid prescriptions from 90 to 180 days after surgery with no intervening additional procedures or anesthesia. Multivariable models were used to examine associations between clinical characteristics and any use and new persistent use of opioids. RESULTS: A total of 729,625 patients were identified. Overall, 60.0% of patients received a perioperative opioid prescription. Receipt of an opioid prescription ranged from 36.7% in those who underwent dilation and curettage to 79.5% of patients who underwent minimally invasive hysterectomy. Among patients who received a perioperative opioid prescription, the rate of new persistent opioid use overall was 6.8%. The rate of new persistent opioid use was 4.8% for myomectomy, 6.6% for minimally invasive hysterectomy, 6.7% for abdominal hysterectomy, 6.3% for endometrial ablation, 7.0% for tubal ligation, and 7.2% for dilation and curettage (P<.001). In a multivariable model, patients who underwent dilation and curettage and endometrial ablation were at highest risk for new persistent opioid use. Younger patients, Medicaid recipients, and patients with depression, anxiety, and substance use disorder more commonly had new persistent opioid use (P<.001 for all). Among women who received an opioid prescription, the rate of new persistent opioid use decreased over time from 7.0% in 2010 to 5.5% in 2016 (P<.001). CONCLUSION: The rate of new persistent opioid use after major and minor gynecologic procedures is substantial.

Short-Term Health-Related Quality of Life After Hysterectomy Compared With Myomectomy for Symptomatic Leiomyomas OBJECTIVE: To compare short-term health-related quality of life (HRQOL) 6–12 weeks after hysterectomy or myomectomy for the treatment of symptomatic leiomyomas. METHODS: We conducted a prospective comparative effectiveness analysis of data. In an existing multisite registry, we compared 6–12-week postsurgical HRQOL using the disease-specific Uterine Fibroid Symptom Quality of Life and the generic EuroQoL 5-Dimension Health Questionnaire, in women from the ages of 18–54 years with documented leiomyomas undergoing hysterectomy or myomectomy. Propensity score weighting was used to adjust for confounding, and analyses were also stratified by route of surgery. RESULTS: A total of 1,295 patients (727 with hysterectomy and 568 with myomectomy) enrolled from registry initiation in November 2015 until June 2018 met inclusion criteria. At baseline, leiomyoma-specific HRQOL (44.0±25.4 and 50.2±25.3, P<.01), symptom severity (60.7±23.6 and 51.7±24.6, P<.01), and generic HRQOL (69.3±20.4 and. 73.4±18.9, P<.01) were significantly different between the hysterectomy compared with myomectomy groups, respectively. Differences were eliminated by propensity adjustment. Substantial improvement in HRQOL measures were seen in both groups at 6–12 weeks, with the mean propensity-adjusted symptom severity score 4 points lower in hysterectomy patients (mean difference −4.6; 95% CI −7.0 to −2.3), compared with myomectomy patients. Hysterectomy patients had better scores on the concern and self-consciousness subscales compared with myomectomy patients. When stratified by surgical route, these two subscale findings were similar between minimally invasive hysterectomy and minimally invasive myomectomy. Symptom severity scores did not differ after abdominal myomectomy compared with abdominal hysterectomy, but subscale scores on activity and energy/mood were higher with myomectomy. CONCLUSION: Both hysterectomy and myomectomy were associated with substantial improvement in HRQOL at short-term follow-up, with small but statistically significant differences in symptom severity and certain subscales. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02260752.

Overcoming Barriers to Accessing Obstetric Care in Underserved Communities Changes in the current workforce of obstetrician–gynecologists and other health care providers of obstetric care, as well as changes in the delivery of health care services, prompt health care leaders to consider alternative strategies for approaching the essential shortage of obstetric care providers and facilities. Geographic variations in health care needs and resources require a tailored approach by individual communities and local health care providers. New and emerging technologies can support a range of innovative solutions to health care access limitations. This article describes an alternative model for remote obstetric care and quality review in Santa Fe, New Mexico, that is applicable to any community facing limited access to full-spectrum obstetric care.

Association Between First-Trimester Subchorionic Hematomas and Pregnancy Loss in Singleton Pregnancies OBJECTIVE: To assess the association of a first-trimester subchorionic hematoma with pregnancy loss in women with singleton pregnancies. METHODS: We conducted a retrospective cohort study of all women with singleton pregnancies presenting for prenatal care before 14 weeks of gestation over a 3-year period at a single obstetric practice. All patients had routine first-trimester ultrasound scans. We reviewed ultrasound data from the first ultrasound scan performed between 6 0/7 and 13 6/7 weeks of gestation and compared rates of pregnancy loss before 20 weeks in women with and without a subchorionic hematoma. Logistic regression analysis was used to control for potential confounding variables. RESULTS: From January 2015 to December 2017, a total of 2,446 women met inclusion criteria, 451 (18.4%) of whom had subchorionic hematomas. Women with subchorionic hematomas had their first ultrasound scans at an earlier gestational age (8 5/7 vs 9 6/7 weeks of gestation, P<.001) and were more likely to have vaginal bleeding (33.3% vs 8.1%, P<.001). Maternal age, race, use of in vitro fertilization, body mass index, prior number of losses, and medical comorbidities did not differ between the groups. On univariable analysis, subchorionic hematoma was associated with an increased risk of pregnancy loss before 20 weeks of gestation (7.5% vs 4.9%, P=.026); however, after adjusting for gestational age and vaginal bleeding, this association was no longer significant (adjusted odds ratio 1.13, 95% CI 0.74–1.74). In the 451 women with subchorionic hematomas, no characteristics of the subchorionic hematoma, including size by volume, largest diameter, presence of vaginal bleeding, and presence of an additional subchorionic hematoma, were associated with pregnancy loss. Post hoc power analysis showed we had 80% power to detect an increase in pregnancy loss before 20 weeks of gestation from 4.9% in women with no subchorionic hematoma to 8.3% in women with subchorionic hematoma. CONCLUSION: In this cohort of women with singleton pregnancies, subchorionic hematoma before 14 weeks of gestation was not independently associated with pregnancy loss before 20 weeks of gestation.