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Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those in a younger pregnant population, even in healthy individuals with no other comorbidities. There are several studies that suggest advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetric care with anticipated delivery at age 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.

The Yaari Extractor is intended to wrap around and guide the fetal shoulder to facilitate vaginal delivery in cases of shoulder dystocia.The Yaari Extractor is a single-use device for fetal shoulder extraction. The device consists of two curved, rigid plastic-coated metal arms with handles and an elastic engagement element that includes two hollow sleeves that cover the portion of the device that enters the vagina and contacts the fetus.The device has been used in three cases of shoulder dystocia. In all three cases, the shoulder dystocia was resolved without the need for ancillary obstetric maneuvers, and there was no reported maternal or fetal injury.The Yaari Extractor is a novel technology that can be used to successfully resolve shoulder dystocia.

To evaluate whether perinatal collaborative care model implementation was associated with a reduction in racial disparities in depression care.This retrospective cohort study included pregnant and postpartum people who self-identified as either Black or White, and received prenatal care at academic faculty offices affiliated with an urban quaternary medical center. Individuals were divided into two cohorts to reflect the epochs of implementation. The primary outcome was the frequency of depression screening. The secondary outcome was the frequency of provision of a treatment recommendation for those with a positive depression screen. Antenatal and postpartum care were analyzed separately. A propensity score was used in multivariable models to control for confounders chosen a priori across implementation epoch. Interaction terms were created between race and implementation epoch to identify whether effect modification was present. Subgroup analyses were performed for outcomes with significant race-by-epoch interaction terms.Of the 4,710 individuals included in these analyses, 4,135 (87.8%) self-identified as White and 575 (12.2%) self-identified as Black. Before implementation, Black individuals were more likely to receive screening (adjusted odds ratio [aOR] 2.44) but less likely to have a treatment recommended when a positive screen was identified (aOR 0.05). In multivariable models, race-by-epoch interaction terms were significant for both antenatal screening (P.001) and antenatal treatment recommendation (P=.045), demonstrating that implementation of the perinatal collaborative care model was associated with reductions in extant racial disparities. After implementation, there were no significant differences by race (referent=White) in screening for antenatal depression (aOR 1.22, 95% CI 0.89-1.68) or treatment recommendations for those who screened positive (aOR 0.64, 95% CI 0.27-1.53). Race-by-epoch interaction terms were not significant in multivariable models for either postpartum screening or treatment recommendation.Implementation of the perinatal collaborative care model is associated with a mitigation of racial disparities in antenatal depression care and may be an equity-promoting intervention for maternal health.

To assess whether antenatal corticosteroid treatment is associated with improved neonatal outcomes in twins.We searched MEDLINE, PubMed, EMBASE, and the Cochrane Library, from inception through August 12, 2021. We did not search ClinicalTrials.gov because our inclusion criteria were restricted to nonrandomized studies.Records (n=7,802) were screened in Rayyan by two independent reviewers. We included all nonrandomized studies that compared antenatal corticosteroid treatment with no treatment in twins. Our outcomes of interest were neonatal mortality, respiratory distress syndrome (RDS), intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, periventricular leukomalacia, and retinopathy of prematurity.We used the ROBINS-I tool (Risk Of Bias In Non-randomised Studies - of Interventions) to assess risk of bias. We performed random-effects meta-analyses of estimates from studies without critical risk of bias due to confounding, and reported summary adjusted odds ratios (aORs) and 95% CIs. Eighteen cohort studies (that reported on 33,152 neonates) met inclusion criteria. Sixteen studies restricted to preterm gestational ages, and 11 defined exposed neonates based on an optimal corticosteroid administration-to-birth interval. Limitations due to confounding and selection bias were common concerns for the risk-of-bias assessments (n=14 at critical or higher), and 11 studies did not account for clustering within twin pairs in their analyses. All included studies had at least moderate risk of bias. Meta-analysis showed that antenatal corticosteroid administration was associated with lower odds of neonatal mortality (aOR 0.59, 95% CI 0.43-0.80, I2 69%, five studies, 20,312 neonates) and RDS (aOR 0.70, 95% CI 0.57-0.86, I2 67%, seven studies, 20,628 neonates) in twins. Results were inconclusive for the other outcomes.Evidence from nonrandomized studies suggests antenatal corticosteroids are associated with lower incidence of neonatal mortality and RDS in twins.PROSPERO, CRD42020205302.

Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics., OBJECTIVE: To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes. DATA SOURCES: We conducted a comprehensive search for primary literature in ClinicalTrials.gov, Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. METHODS OF STUDY SELECTION: Qualifying primary studies had a comparison group, were conducted in countries ranked very high on the United Nations Human Development Index, published in English, and evaluated obstetric and gynecologic health outcomes. Cochrane Collaboration's tool and ROBINS-I tool were used for assessing risk of bias. Summary of evidence tables were created using the United States Preventive Services Task Force Summary of Evidence Table for Evidence Reviews. TABULATION, INTEGRATION, RESULTS: Of the 3,926 published abstracts identified, 47 met criteria for inclusion and included 31,967 participants. Telehealth interventions overall improved obstetric outcomes related to smoking cessation and breastfeeding. Telehealth interventions decreased the need for high-risk obstetric monitoring office visits while maintaining maternal and fetal outcomes. One study found reductions in diagnosed preeclampsia among women with gestational hypertension. Telehealth interventions were effective for continuation of oral and injectable contraception; one text-based study found increased oral contraception rates at 6 months. Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Few studies suggested utility for telehealth to improve notification of sexually transmitted infection test results and app-based intervention to improve urinary incontinence symptoms. CONCLUSION: Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics. Further well-designed studies are needed to examine these interventions and others to generate evidence that can inform decisions about implementation of newer telehealth technologies into obstetrics and gynecology practice.

Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal or neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight, monitoring of clinical performance, and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed in order to match the anticipated care complexity with appropriate resources to achieve an optimal outcome at an institutional and regional level. A level 1 fetal therapy center should be capable of offering fetal interventions that may be associated with obstetric risks of preterm birth or membrane rupture, but which would be very unlikely to require maternal medical subspecialty or intensive care, with neonatal risks not exceeding those of moderate prematurity. A level 2 center should have the incremental capacity to provide maternal intensive care and to manage extreme neonatal prematurity. A level 3 therapy center should offer the full range of fetal interventions (including open fetal surgery), and could manage any of the associated maternal complications and comorbidities, as well as have access to neonatal and pediatric surgical intervention including indicated surgery for neonates with congenital anomalies.

Three coronavirus disease 2019 (COVID-19) vaccines have been authorized for use in the United States; specifically, the Pfizer–BioNTech, Moderna, and Johnson & Johnson–Janssen COVID-19 vaccines were granted an emergency use authorization (EUA) by the U.S. Food and Drug Administration in early 2021. Vaccination coverage and intent among adults are lowest among those aged 18–39 years and among females in particular. In females of reproductive age, enthusiasm for receiving a COVID-19 vaccine may be negatively affected by claims currently circulating widely on diverse social media platforms regarding SARS-CoV-2 vaccines adversely affecting fertility and pregnancy. Yet it is important to note that these claims are anecdotal in nature and not supported by the available scientific evidence. It is also imperative that the effects of COVID‐19 vaccine on reproductive health are clarified. Herein, we discuss the existing scientific data supporting COVID-19 vaccine safety and efficacy in people that are planning to conceive or who are pregnant or lactating, and highlight the importance of COVID-19 vaccination in females of reproductive age.

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) OBJECTIVE: To test the effectiveness of cervical pessary in addition to vaginal progesterone for the prevention of preterm birth in women with midpregnancy short cervixes. METHODS: We performed a multicenter, open-label, randomized controlled trial in 17 perinatal centers. Asymptomatic women with singleton or twin pregnancies and cervical lengths of 30 mm or less, measured at 18 0/7– 22 6/7 weeks of gestation, were randomized to cervical pessary plus vaginal progesterone (pessary plus progesterone group) or vaginal progesterone only (progesteroneonly group) (200 mg/day). Treatments were used from randomization to 36 weeks of gestation or delivery. The primary outcome was a composite of neonatal mortality and morbidity. Secondary outcomes were delivery before 37 weeks and before 34 weeks of gestation. Analysis was performed according to intention to treat. RESULTS: Between July 9, 2015, and March 29, 2019, 8,168 women were screened, of whom 475 were randomized to pessary and 461 to progesterone only. The composite perinatal outcome occurred in 19.2% (89/463) of the women in the pessary group compared with 20.9% (91/436) of the women in the progesterone-only group (adjusted risk ratio [aRR] 0.88, 95% CI 0.69–1.12). Delivery rates before 37 weeks of gestation were 29.1% compared with 31.4% (aRR 0.86, 95% CI 0.72–1.04); delivery rates before 34 weeks were 9.9% compared with 13.9% (aRR 0.66, 95% CI 0.47–0.93). Women in the pessary group had more vaginal discharge (51.6% [245/476] vs 25.4% [117/479] [P,.001]), pain (33.1% [157/476] vs 24.1% [111/479] [P5.002]), and vaginal bleeding (9.7% [46/476] vs 4.8% [22/479] [P5.004]). CONCLUSION: In asymptomatic women with short cervixes, the combination of pessary and progesterone did not decrease rates of neonatal morbidity or mortality when compared with progesterone only. Bill & Melinda Gates Foundation [OPP1107597], the Brazilian Ministry of Health, and the Brazilian National Council for Scientific and Technological Development (CNPq) [401615/20138].

The CIPHER (Collaborative Integrated Pregnancy High-Dependency Estimate of Risk) prognostic model was not predictive of risk of death, prolonged organ support, or lifesaving intervention among critically ill patients in Brazil., OBJECTIVE: To externally validate the CIPHER (Collaborative Integrated Pregnancy High-Dependency Estimate of Risk) prognostic model for pregnant and postpartum women admitted to the intensive care unit. METHODS: A retrospective and a prospective validation study were conducted at two reference centers in Brazil. A composite outcome was defined as maternal death or need for prolonged organ support (more than 7 days) or acute lifesaving intervention. To evaluate the performance of the CIPHER model, a receiver operating characteristic curve was used and score calibration was assessed by the Hosmer-Lemeshow test. We conducted a descriptive analysis comparing the results of the current study with the results of the model development study. RESULTS: A total of 590 women were included. The composite outcome was observed in 90 (15.2%) women. Of these, 13 (2.2%) were maternal deaths and 77 (13%) required one or more component of organ support or lifesaving intervention. The CIPHER model's area under the curve (AOC) did not show significant predictive ability (AOC 0.53, 95% CI 0.46–0.60), and consequently its calibration was poor (Hosmer-Lemeshow test P

To examine whether the coronavirus disease 2019 (COVID-19) pandemic altered risk of adverse pregnancy-related outcomes and whether there were differences by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection status among pregnant women.In this retrospective cohort study using Epic's Cosmos research platform, women who delivered during the pandemic (March-December 2020) were compared with those who delivered prepandemic (matched months 2017-2019). Within the pandemic epoch, those who tested positive for SARS-CoV-2 infection were compared with those with negative test results or no SARS-CoV-2 diagnosis. Comparisons were performed using standardized differences, with a value greater than 0.1 indicating meaningful differences between groups.Among 838,489 women (225,225 who delivered during the pandemic), baseline characteristics were similar between epochs. There were no significant differences in adverse pregnancy outcomes between epochs (standardized difference0.10). In the pandemic epoch, 108,067 (48.0%) women had SARS-CoV-2 testing available; of those, 7,432 (6.9%) had positive test results. Compared with women classified as negative for SARS-CoV-2 infection, those who tested positive for SARS-CoV-2 infection were less likely to be non-Hispanic White or Asian or to reside in the Midwest and more likely to be Hispanic, have public insurance, be obese, and reside in the South or in high social vulnerability ZIP codes. There were no significant differences in the frequency of preterm birth (8.5% vs 7.6%, standardized difference=0.032), stillbirth (0.4% vs 0.4%, standardized difference=-0.002), small for gestational age (6.4% vs 6.5%, standardized difference=-0.002), large for gestational age (7.7% vs 7.7%, standardized difference=-0.001), hypertensive disorders of pregnancy (16.3% vs 15.8%, standardized difference=0.014), placental abruption (0.5% vs 0.4%, standardized difference=0.007), cesarean birth (31.2% vs 29.4%, standardized difference=0.039), or postpartum hemorrhage (3.4% vs 3.1%, standardized difference=0.019) between those who tested positive for SARS-CoV-2 infection and those classified as testing negative.In a geographically diverse U.S. cohort, the frequency of adverse pregnancy-related outcomes did not differ between those delivering before compared with during the pandemic, nor between those classified as positive compared with negative for SARS-CoV-2 infection during pregnancy.

Obstetrician-gynecologists are the leading experts in the health care of women, and obesity is the most common medical condition in women of reproductive age. Obesity in women is such a common condition that the implications relative to pregnancy often are unrecognized, overlooked, or ignored because of the lack of specific evidence-based treatment options. The management of obesity requires long-term approaches ranging from population-based public health and economic initiatives to individual nutritional, behavioral, or surgical interventions. Therefore, an understanding of the management of obesity during pregnancy is essential, and management should begin before pregnancy and continue through the postpartum period. Although the care of the obese woman during pregnancy requires the involvement of the obstetrician or other obstetric care professional, additional health care professionals, such as nutritionists, can offer specific expertise related to management depending on the comfort level of the obstetric care professional. The purpose of this Practice Bulletin is to offer an integrated approach to the management of obesity in women of reproductive age who are planning a pregnancy.

The purpose of this Committee Opinion is to offer guidance about indications for and timing and frequency of antenatal fetal surveillance in the outpatient setting. Antenatal fetal surveillance is performed to reduce the risk of stillbirth. However, because the pathway that results in increased risk of stillbirth for a given condition may not be known and antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth, it is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered. This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition. Table 1 presents suggestions for the timing and frequency of testing for specific conditions. As with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth. It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions; this guidance should not be construed as mandates or as all encompassing. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.

To characterize asthma prevalence and outcomes during U.S. delivery hospitalizations.For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with asthma were identified in the 2000-2018 National Inpatient Sample, which approximates a 20% stratified sample of all hospitalizations nationally. Temporal trends in asthma were analyzed using joinpoint regression to estimate the average annual percent change with 95% CIs. The association of asthma with other comorbid conditions was analyzed. The relationship between asthma and several adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted odds ratios and adjusted odds ratios (aORs) as measures of effect. Risk for and trends in a composite of rare, but severe, respiratory complications also were analyzed.An estimated 73,109,790 delivery hospitalizations from 2000 to 2018 were included in the analysis, of which 2,221,644 (3.0%) had a diagnosis of asthma. (Unweighted, the study sample included 15,213,024 deliveries, of which 462,276 [3.0%] had a diagnosis of asthma.) Asthma diagnoses rose from 1.2% in 2000 to 5.3% in 2018, representing an average annual percent change of 8.3% (95% CI 7.4-9.2%). Asthma was more common among women with obesity and chronic hypertension. In adjusted analyses, asthma was associated with severe maternal morbidity (aOR 1.50, 95% CI 1.45-1.55), preeclampsia and gestational hypertension (aOR 1.29, 95% CI 1.26-1.30), postpartum hemorrhage (aOR 1.21, 95% CI 1.19-1.24), cesarean delivery (aOR 1.16, 95% CI 1.15-1.18), gestational diabetes (aOR 1.20, 95% CI 1.18-1.21), venous thromboembolism (aOR 1.79, 95% CI 1.65-1.95), and preterm delivery (aOR 1.27, 95% CI 1.25-1.29). From 2000 to 2018, severe respiratory complications decreased from 72 per 10,000 deliveries with asthma to 14 per 10,000 deliveries with asthma (average annual percent change -9.4%, 95% CI -13.3% to -5.3%). This decreasing risk was offset on a population level by an increase in the risk of asthma.Asthma is increasing during deliveries, is associated with adverse maternal outcomes, and is associated with comorbid conditions. Severe respiratory complications are decreasing proportionately among deliveries with asthma, but are stable on a population basis.

In recent years, several new antimicrobials have become available that are safer and more effective compared with older agents commonly used in obstetrics. Basic knowledge of these agents is of paramount importance to obstetricians and maternal fetal medicine specialists, as administration of early adequate broad-spectrum empiric antibiotic coverage plays a pivotal role in the management of septic patients. Of particular importance is the critically ill pregnant patient with life-threatening infectious processes in whom poor initial antibiotic selection may result in higher mortality and significant side effects from antibiotics themselves. In this article we aim to provide a guide for clinicians to select an adequate empirical antibiotic regimen for the most common severe infections that may affect pregnant individuals.

To perform a literature review of key aspects of prenatal care delivery to inform new guidelines.A comprehensive review of Ovid MEDLINE, Elsevier's Scopus, Google Scholar, and ClinicalTrials.gov.We included studies addressing components of prenatal care delivery (visit frequency, routine pregnancy assessments, and telemedicine) that assessed maternal and neonatal health outcomes, patient experience, or care utilization in pregnant individuals with and without medical conditions. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach. Articles were independently reviewed by at least two members of the study team for inclusion and data abstraction.Of the 4,105 published abstracts identified, 53 studies met inclusion criteria, totaling 140,150 participants. There were no differences in maternal and neonatal outcomes among patients without medical conditions with reduced visit frequency schedules. For patients at risk of preterm birth, increased visit frequency with enhanced prenatal services was inconsistently associated with improved outcomes. Home monitoring of blood pressure and weight was feasible, but home monitoring of fetal heart tones and fundal height were not assessed. More frequent weight measurement did not lower rates of excessive weight gain. Home monitoring of blood pressure for individuals with medical conditions was feasible, accurate, and associated with lower clinic utilization. There were no differences in health outcomes for patients without medical conditions who received telemedicine visits for routine prenatal care, and patients had decreased care utilization. Telemedicine was a successful strategy for consultations among individuals with medical conditions; resulted in improved outcomes for patients with depression, diabetes, and hypertension; and had inconsistent results for patients with obesity and those at risk of preterm birth.Existing evidence for many components of prenatal care delivery, including visit frequency, routine pregnancy assessments, and telemedicine, is limited.

Synthesis of pooled data on herbal medicinal products used during and after pregnancy highlights the need for robust safety studies., OBJECTIVE: To report the incidence and nature of herbal medicinal products' adverse events and herb–drug interactions used by some pregnant and postnatal women. DATA SOURCES: The Allied and Complementary Medicine Database, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, the Cochrane Library, MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov were searched from inception until August 2018. METHODS OF STUDY SELECTION: Any studies reporting adverse events, herb–drug interactions or absence thereof associated with herbal medicinal products used during pregnancy or the postnatal period were included. Conference abstracts, pilot studies, and nonhuman studies were excluded. All included studies were critically appraised by two independent reviewers. TABULATION, INTEGRATION AND RESULTS: Database searches retrieved 3,487 citations. After duplicate removal and review of titles, abstracts, and full-text, 115 articles were critically appraised. After excluding irrelevant and low-quality articles, 74 articles were included for data extraction and synthesis. Adverse drug reactions, congenital malformations, fetal growth retardation or herb–drug interactions were the primary study objective reported by 19 of the 74 included studies, 16 cohort studies, one cross-sectional survey, and two randomized controlled trials. A total of 47 herbal medicinal products and 1,067,071 women were included in this review. Use of almond oil was associated with preterm birth (odds ratio 2.09, 95% CI 1.07–4.08), oral raspberry leaf was associated with cesarean delivery (adjusted odds ratio [AOR] 3.47, 95% CI 1.45–8.28); heavy licorice use was associated with early preterm birth by 3.07-fold (95% CI 1.17–8.05). African herbal medicine mwanaphepo was associated with maternal morbidity (AOR 1.28; 95% CI 1.09–1.50), and neonatal death or morbidity. Fourteen studies reported absence of adverse events. Four studies reported herb–drug interactions, but none studied adverse events arising from them. CONCLUSION: The use of herbal medicinal products during pregnancy and the postnatal period should be discouraged until robust evidence of safety is available. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42017081058.

Cognitive behavioral therapy for insomnia is an effective treatment for prenatal insomnia disorder., OBJECTIVE: To evaluate the effectiveness of cognitive behavioral therapy for insomnia during pregnancy. METHODS: Randomized, unmasked, 3-site controlled trial. Participants were randomly allocated to cognitive behavioral therapy for insomnia (a first-line, empirically supported psychosocial intervention that addresses sleep-related behaviors and cognitions) or a control intervention consisting of imagery exercises that paired patient-identified distressing nighttime experiences with patient-identified neutral images. Participants were eligible if they met diagnostic criteria for insomnia disorder and were between 18 and 32 weeks of gestation. Patients were ineligible if they met diagnostic criteria for major psychiatric disorders, including depression, or were receiving nonstudy treatments that could affect sleep (or both). The primary outcome was the Insomnia Severity Index score, a validated brief questionnaire, with scores between 14 and 21 representing clinically meaningful insomnia of moderate severity, scores higher than 21 representing severe insomnia, and scores less than 8 representing no insomnia. Secondary outcomes included remission of insomnia (Insomnia Severity Index score less than 8), objectively measured and self-reported time awake (ie, total wake time), and the Edinburgh Postnatal Depression Scale score. All outcomes were measured weekly. Analysis included 48 participants who did not complete treatment. We estimated that 184 women would be required to have 80% power, with a two-tailed test, to detect a moderate Cohen's d effect size (.5) with α=.05. RESULTS: Between May 2013 and April 2017, 194 pregnant women were randomized and 149 completed treatment; 179 with available baseline data (92%) were ultimately analyzed, 89 in the cognitive therapy group and 90 in the control group. Women assigned to cognitive behavioral therapy for insomnia experienced significantly greater reductions in insomnia severity (scores decreased from 15.4±4.3 to 8.0±5.2 in the cognitive behavioral therapy group vs from 15.9±4.4 to 11.2±4.9 in the control therapy group [P

Trauma is experienced throughout the life span, and traumatic experiences may be remote events or current and ongoing. The health care community continues to learn the many ways in which trauma affects an individual's health, relationships, utilization of the health care system, health care experience, and ability to adopt health-related recommendations. It is important for obstetrician-gynecologists and other health care practitioners to recognize the prevalence and effect of trauma on patients and the health care team and incorporate trauma-informed approaches to delivery of care. Although trauma spans all races, ages, and socioeconomic statuses, some populations are exposed to trauma at higher rates and with greater frequency of repeated victimization. A number of health effects that may be associated with trauma are seen frequently in obstetrics and gynecology, including chronic pelvic pain, sexually transmitted infections, unintended pregnancy, conflicted feelings about pregnancy and sexuality, and difficulty with infant attachment postpartum. Obstetrician-gynecologists should become familiar with the trauma-informed model of care and strive to universally implement a trauma-informed approach across all levels of their practice with close attention to avoiding stigmatization and prioritizing resilience.

To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare in pregnancy) panel process and key recommendations for prenatal care delivery.We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists). Because prenatal services (eg, laboratory tests, vaccinations) have robust evidence, panelists considered only how services are delivered (eg, visit frequency, telemedicine).The appropriateness of key aspects of prenatal care delivery across individuals with and without common medical and pregnancy complications, as well as social and structural determinants of health, was determined by the panel. Panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for: 1) prenatal visit schedules (care initiation, visit timing and frequency, routine pregnancy assessments), 2) integration of telemedicine (virtual visits and home devices), and 3) care individualization. Panelists recognized significant gaps in existing evidence and the need for policy changes to support equitable care with changing practices.The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals.

To compare mode of delivery between monochorionic and dichorionic twin pregnancies.This was a retrospective cohort study of women undergoing delivery of diamniotic twins in a single maternal-fetal medicine practice in New York City between 2005 and 2021. We compared baseline characteristics and delivery outcomes between monochorionic and dichorionic gestations. The primary outcome was mode of delivery. For monochorionic-diamniotic twin pregnancies at or after 34 weeks of gestation, we also compared neonatal outcomes between women who did and did not attempt vaginal delivery. Data were analyzed using the χ2 test, Fisher exact test, and t test when appropriate.A total of 1,121 diamniotic twin pregnancies were identified, of which 202 (18%) were monochorionic and 919 (82%) were dichorionic. Mode of delivery did not differ between monochorionic and dichorionic pregnancies, both in the overall cohort (cesarean delivery rate 61% vs 63%, P=.54) and in the subgroup of women who attempted vaginal delivery (cesarean delivery rate 22% vs 21%, P=.80). For patients with a vaginal delivery of twin A, the mode of delivery for twin B did not differ between the groups. Among the patients with monochorionic pregnancies at or after 34 weeks of gestation, neonatal outcomes did not differ between women who did and did not attempt vaginal delivery.Monochorionic-diamniotic pregnancies are not at an increased risk of cesarean delivery when compared with their dichorionic-diamniotic counterparts.

To evaluate high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) as an inexpensive, noninvasive pain management approach for first-trimester aspiration abortion.We conducted a noninferiority, single-blind, randomized controlled trial of patients seeking aspiration abortion at up to 83 days of gestation. Participants received TENS (placed posteriorly, T10-L1 and S2-S4) or intravenous (IV) sedation (fentanyl, midazolam). The primary outcome was pain with aspiration, as self-reported by visual analog scale (VAS, 100 mm). To detect at least a 15 mm mean difference on the 100 mm VAS with 90% power and a significance level of .05, a total of 90 participants were required.Between January 2018 and October 2019, we enrolled 109 participants (55 TENS, 54 IV). Participant median gestation was 53 days (range 36-82) in the TENS group and 58 days (range 35-82) in the IV group (P=.65). Group demographics and clinical histories were similar. Intention-to-treat analysis (n=109) yielded noninferior results for the primary outcome (mean difference 4.8 mm, 95% CI -5.9 to 13.5 mm). In the per-protocol analysis, 9 (16%) in the TENS group were excluded after receiving IV sedation; 100 participants were included (46 TENS, 54 IV). Median (range) reported VAS for aspiration was 73 mm (13-97) and 66 mm (0-99) in the TENS and IV groups, respectively (P=.40). With a mean difference of 4.4 mm (95% CI -5.6 to 14.5 mm), we found TENS to be noninferior to IV. Physicians underestimated participant pain, perceiving pain to be 34 mm (6-91) in the TENS group and 25 mm (0-83) in the IV group (P=.003).We found TENS to be a noninferior alternative to IV sedation for aspiration pain during first-trimester abortion. Expanding pain management options can improve quality of and access to abortion. Transcutaneous electrical nerve stimulation could be a standalone or adjunct approach for abortion pain management for those without access to or are ineligible to receive IV sedation due to the lack of sedation practitioner, designated driver, or local restrictions.ClinicalTrials.gov, NCT03187002.

Objective To evaluate whether a 12-mL paracervical block is noninferior to a 20-mL block in reducing pain with osmotic dilator insertion. Methods In this single-blinded noninferiority trial, we randomized individuals undergoing insertion of osmotic dilators before second-trimester abortion to receive either a 12-mL or 20-mL 1% lidocaine paracervical block. The primary outcome was pain immediately after insertion of osmotic dilators. Prespecified secondary outcomes included pain with paracervical block administration, overall pain, and side effects, with 88 participants being required for a noninferiority margin of 15 mm on a 100-mm visual analog scale assuming an SD of 28. We analyzed data using Wilcoxon rank sum, χ2, and t tests and performed analysis of variance to account for repeated measures. Secondary analysis included multivariable regression to explore potential confounders. Results From January 2018 to October 2020, of 232 eligible individuals, 174 were approached and 96 randomized (48 participants to each group); 91 were available for analysis (45: 12 mL, 46: 20 mL). Group demographics were similar, with a mean gestation of 21 weeks and four osmotic dilators placed. The 12-mL paracervical block was noninferior to the 20-mL paracervical block for pain with osmotic dilator insertion with a difference in means of -1.36 (95% CI -12.56 to 9.85) favoring 12 mL. Median pain scores after dilator placement were 47 mm (interquartile range 22-68) and 50 mm (interquartile range 27-67) in 12-mL compared with 20-mL paracervical block, respectively (P=.81). No difference was seen in median pain at baseline, with paracervical block administration, postprocedure or with overall pain or experience. At least one lidocaine-related side effect occurred in 4% of participants in the 12-mL group compared with 13% for those receiving 20 mL (P=.15), with metallic taste, ringing in ears, and lightheadedness being most common. Conclusion A 12-mL paracervical block is noninferior to a 20-mL block for pain reduction with osmotic dilator insertion. Clinical trial registration ClinicalTrials.gov, NCT03356145.

To create a prediction model for external cephalic version (ECV) success using objective patient characteristics.This retrospective study included pregnant individuals of at least 18 years of age with a nonanomalous, singleton gestation who underwent an ECV attempt between 2006 and 2016 at a single quaternary care hospital. Variables assessed included maternal age, height, weight, body mass index (BMI), parity, fetal sex, gestational age, estimated fetal weight, type of fetal malpresentation, placental location, and amniotic fluid volume. Univariable and multivariable logistic regression models were used to determine the association of patient characteristics with ECV success. Estimated odds ratios and corresponding 95% CIs were calculated for each variable, and backward elimination and bootstrapping were used to find a parsimonious model for ECV success with the highest discriminatory capacity (as determined by the area under the receiver operating characteristic curve [AUC]). This model was evaluated with a calibration curve across deciles of success.A total of 1,138 individuals underwent an ECV attempt and were included in this analysis. The overall ECV success frequency was 40.6%. Factors significantly associated with ECV success were maternal age, parity, placental location, estimated fetal weight, and type of fetal malpresentation. A final model with BMI, parity, placental location, and type of fetal malpresentation had the highest AUC (0.667 [95% CI 0.634-0.701]), resulted in good calibration, and is represented by the following equation: 1/[1+e-x] where x=1.1726-0.0314 (BMI)-0.9299 (nulliparity)+1.0218 (transverse or oblique presentation at ECV)-0.5113 (anterior placenta). An interactive version of this equation was created and can be accessed at www.ecvcalculator.com.A prediction model that estimates the probability of ECV success was created and internally validated. This model incorporates easily obtainable and objective patient factors known before ECV and may be used in decision making and patient counseling about ECV.

Objective To estimate the association between habitus measures and pelvic floor support and symptoms in primiparous women 1 year after term vaginal delivery. Methods In this cross-sectional study including women enrolled at seven academic and community sites, we assessed pelvic floor support, weight, height, waist circumference, and percent fat using air displacement plethysmography and participants completed questionnaires, all at one year postpartum. We tested the association of quintiles of habitus measure, including body mass index (BMI), waist circumference, percent body fat, and waist/height ratio, with the primary outcomes: anatomic support, dichotomized as maximal vaginal descent less than 0 cm (better support) compared with 0 cm or more (worse support) per the pelvic organ prolapse quantification examination and symptom burden (positive with bothersome symptoms in two or more of six symptom domains), and on five secondary outcomes. The sample size provides 90% power to detect odds ratios (ORs) of 1.78 or greater between women at mean compared with mean+1 SD of habitus measure. Results Of 592 participants, 55 (9.3%) demonstrated worse support and 321 (54.2%) symptom burden. In multivariable analyses, habitus measures were not significantly associated with anatomic support or, except for the highest waist/height ratio quintile, with symptom burden. Compared with women in the first quintile of each habitus measure, those in most higher quintiles demonstrated elevated odds of moderate to severe urinary incontinence (UI); increased odds for stress urinary incontinence (SUI) were mainly limited to the highest quintile. After adjusting for percent body fat, the increased odds for BMI on SUI (OR 2.47, 95% CI 1.43-4.28) were no longer significant (OR 1.38, 95% CI 0.54, 3.51). Conclusion Habitus in primiparous patients at 1 year postpartum was not associated with anatomic support or symptom burden. Habitus was more associated with moderate to severe UI than mild UI. The association of higher BMI with SUI was attenuated by fitness, reflected by fat percentage.

OBJECTIVE: To systematically review the prevalence of antenatal depression and anxiety in women hospitalized on an antepartum unit for obstetric complications. DATA SOURCES: We searched Pubmed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and ClinicalTrials.gov for English-language articles published from database inception through March 2020. METHODS OF STUDY SELECTION: We included cross-sectional, cohort, case-control, quasi-experimental, and randomized-controlled studies from any country that reported the proportion of pregnant women with an elevated depression or anxiety screening scale or diagnostic interview during antepartum hospitalization of any duration and at any gestational age. TABULATION, INTEGRATION, AND RESULTS: We identified 8,799 articles and reviewed 79, thirty-nine of which were included in a systematic review and 18 in meta-analysis of the primary outcome. Two raters independently assessed quality of individual studies using a 14-question tool. A random effects meta-analysis model was used to estimate prevalence and 95% confidence interval of depression or anxiety. Heterogeneity was examined with the I(2) test and Funnel plots were used to assess publication bias. After meta-analysis, the estimated prevalence of depression was 34% (95% CI 27–41%) and of anxiety 29% (95% CI 16–43%). There was expected substantial clinical and methodologic heterogeneity between studies which persisted even after planned a priori subgroup analyses and meta-regression. Even so, the direction of effect was consistent across studies. No publication bias was found. CONCLUSION: The current meta-analysis suggests that one in three women hospitalized during pregnancy for obstetric complications report clinical levels of depression or anxiety symptoms, twice the reported prevalence of antenatal depression or anxiety in the general obstetric population.

Evaluation of a wireless fetal heart rate monitor demonstrates high agreement with heart rate, as assessed by cardiotocography, and is feasible for use at home., OBJECTIVE: To evaluate the accuracy, clinical utility, and usability of a wireless fetal and maternal heartbeat monitor to monitor fetal heart rate (FHR). METHODS: We conducted a prospective, single-center study of a convenience sample of women aged 18 years or older with a singleton pregnancy of at least 12 weeks of gestation. Fetal heart rate recordings were performed using both the heartbeat monitor and cardiotocography to evaluate accuracy. Clinicians used the heartbeat monitor in the clinic. Women used the device, unassisted, during a clinic visit or at home. Obstetricians assessed the clinical utility of FHR traces. Women rated the heartbeat monitor using the System Usability Scale. RESULTS: A total of 81 participants provided 126 recordings. The accuracy of the heartbeat monitor was excellent compared with cardiotocography, with limits of agreement (95%) for mean FHR between −1.6 (CI −2.0 to 1.3) and +1.0 (CI 0.7–1.4) beats per minute (bpm), mean difference −0.3 bpm, intraclass coefficient 0.99. The FHR was detected on all occasions. Clinicians took a median (interquartile range) of 0.5 (0.2–1.2) minutes to detect the FHR, obtaining a continuous trace of longer than 1 minute in 95% (39/41) of occasions. Home users took a median of 0.5 (0.2–2.0) minutes to detect the FHR, obtaining a continuous trace of longer than 1 minute in 92% (24/26) of occasions, with a median total trace time of 4.6 (4.4–4.8) minutes. The traces were deemed clinically useful in 100% (55/55) of clinician and 97% (31/32) of home recordings. The heartbeat monitor ranked in the 96–100th percentile for usability and learnability. CONCLUSION: The heartbeat monitor was accurate and easy for clinicians and participants to use. Data recorded at home were equivalent to those obtained using current assessment protocols for low-risk pregnancies, potentially allowing the device to be used in telehealth consultations. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry, ACTRN12620000739910. FUNDING SOURCES: The HeraBEAT devices used in this study were loaned by HeraMED Pty Ltd (HeraMED, Netanya, ISRAEL). The study was supported by PHI Research Group (not-for-profit), which was responsible for Statistician fees and Research Assistants' salaries. Joondalup Health Campus provided infrastructure support, and IT services in-kind to the PHI research group.