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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 interventio

Objective The objective of this study was to evaluate whether weekly administration of 17 α-hydroxyprogesterone caproate (17-OHPC) increases the number of women who achieve 34 weeks of gestation after preterm premature rupture of membranes (PPROM). Study Design We conducted a multicenter double-blind, randomized controlled trial of 17-OHPC versus placebo among women with PPROM. Women with singleton pregnancy, clinically confirmed PPROM, and without evidence of active infection or major fetal malformation between 240/7 and 320/7 weeks of pregnancy were offered enrollment. Women received weekly injections of 17-OHPC versus placebo until 340/7 weeks of gestation or delivery. The remainder of care was per hospital protocol. The primary outcome was achievement of 34 weeks of gestation. Secondary outcomes included length of latency and maternal and fetal outcomes. Results In this study, 21 women were enrolled. Eleven women received placebo and 10 received 17-OHPC. The study was closed prematurely secondary to poor enrollment. None of the women remained pregnant until 34 weeks of gestation. The median latency periods were 8 and 14.5 days for the placebo and 17-OHPC groups, respectively (p = 0.14). There were no differences in maternal or neonatal outcomes. Conclusion We did not identify any benefit from administration of 17-OHPC in pregnancies complicated by PPROM.

Importance Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood. Objective To analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels. Design, Setting, and Participants Randomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks’ gestation (n = 710). Interventions A computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353). Main Outcomes and Measures The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks’ gestation. Results Women randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret. Conclusions and Relevance Full implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing. Trial Registration clinicaltrials.gov Identifier:NCT00505596

To determine whether the change in human chorionic gonadotropin after manual vacuum aspiration is predictive of an early abnormal intrauterine pregnancy in women with pregnancy of unknown location.This is a prospective cohort study of 23 clinically stable patients with an early abnormal pregnancy who had abnormally rising human chorionic gonadotropins and absence of sonographic evidence of an intrauterine pregnancy or ectopic pregnancy. The change in human chorionic gonadotropin within 24 hours after manual vacuum aspiration was compared with the pathologic diagnosis and the ultimate clinical diagnosis.Ten patients hador = 50% decrease (mean, 74%; range, 58-80%) in human chorionic gonadotropin after manual vacuum aspiration with confirmed chorionic villi on pathology results. Two patients had a50% drop in human chorionic gonadotropin but absence of chorionic villi, clinically consistent with complete spontaneous abortion. The remaining 10 patients who had either rising or50% decrease in human chorionic gonadotropin post manual vacuum aspiration all had no chorionic villi on pathology results. The sensitivity, specificity, positive predictive value, and negative predictive value of aor = 50% decrease in human chorionic gonadotropin after manual vacuum aspiration in predicting an abnormal intrauterine pregnancy were 92% (95% confidence interval [CI], 0.62-0.99), 100% (95% CI, 0.62-1.0), 100% (95% CI, 0.70-1.0), and 90% (95% CI, 0.54-0.99), respectively.Aor = 50% decrease in human chorionic gonadotropin within 24 hours after manual vacuum aspiration is predictive of an abnormal intrauterine pregnancy, thereby excluding an ectopic pregnancy and expediting the management of women with pregnancy of unknown location.

To examine the association between race/ethnicity, perineal length and the risk of perineal laceration.This is a prospective cohort study of a diverse group of women with singleton gestations in the third trimester of pregnancy. Perineal length was measured and mean values calculated for several racial/ethnic groups. Chi-squared analyses were used to examine rates of severe perineal laceration (third or fourth degree laceration) by race/ethnicity among women considered to have a short perineal length. Further, subgroup analyses were performed comparing nulliparas to multiparas.Among 344 study participants, there was no statistically significant difference in mean perineal length by race/ethnicity (White 4.0 ± 1.1 cm, African-American 3.7 ± 1.0 cm, Latina 4.1 ± 1.1 cm, Asian 3.8 ± 1.0 cm, and other/unknown 4.0 ± 0.9 cm). Considering parity, more multiparous Asian and African-American women had a short perineal length (20.7 and 23.5%, respectively, p = 0.05). Finally, the rate of severe perineal lacerations in our cohort was 2.6% overall, but was 8.2% among Asian women (p = 0.04).We did not find a relationship between short perineal length and risk of severe perineal laceration with vaginal delivery, or a difference in mean perineal length by maternal race/ethnicity. However, we did find that women of different racial/ethnic groups have varying rates of severe perineal laceration, with Asian women comprising the highest proportion.

Importance Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood. Objective To analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels. Design, Setting, and Participants Randomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks’ gestation (n = 710). Interventions A computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353). Main Outcomes and Measures The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks’ gestation. Results Women randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret. Conclusions and Relevance Full implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing. Trial Registration clinicaltrials.gov Identifier:NCT00505596

epidural analgesia: a randomized controlled trial Gregory Kanter, Matthew Garabedian, Brittany Rowe, Neena Duggal, Anita Sit Santa Clara Valley Medical Center, Obstetrics & Gynecology, San Jose, CA OBJECTIVE: Racial/ethnic disparities exist in the proportion of patients receiving epidural analgesia. We sought to determine if targeted prenatal educational program on womens’ perceptions of epidural increases the acceptance of intrapartum epidural analgesia. STUDY DESIGN: During prenatal care visits, patients were randomized to a video targeted at cultural myths and perceived risks of epidural presented in the subjects’ native language (English or Spanish) in addition to routine care versus routine prenatal care alone. They were asked to fill out a survey before and after their assigned intervention to assess desire and perception of epidurals. Desire for epidural and actual epidural rate at delivery were analyzed in the two groups. RESULTS: 111 women were randomized: 59 to the intervention group and 52 to the control group. The groups only differed on race/ethnicity, with the intervention group having more Hispanic women than the control group (65 v 43%, p 0.02). Rates of attending the routine prenatal epidural class were similar (40 v 40% p 0.97). The actual epidural rate was greater in the intervention group than the control group (81 v 67%; adjusted risk ratio [aRR] 1.4, 95% confidence interval [CI] 1.1-1.7). There were no significant differences in the stated desire to receive epidural rate in the educational intervention group compared to the control group (51 v 40%, p 0.19). After adjusting for race/ethnicity, the targeted educational video increased the likelihood of receiving a intrapartum epidural in all subjects regardless of stated desire for intrapartum epidural as indicated on the survey (Table). CONCLUSION: Participation in culturally-sensitive, targeted prenatal education increased epidural rate compared to routine prenatal care. This finding highlights the importance of patient-centered and culturally-sensitive educational efforts to improve informed decision making of intrapartum pain control to decrease the racial/ethnic disparity of epidural use in women. 828 Early hospital readmission after low risk cesarean delivery: evidence for racial and ethnic disparities Ilona Goldfarb, Erin Madden, Allison Bryant Harvard Medical School, Department of Maternal Fetal Medicine, Massachusetts General Hospital, Boston, MA, Northern California Institute for Research and Education, Department of Research, San Francisco, CA OBJECTIVE: Early hospital readmission rates following delivery are now recognized as a health care quality measure. We evaluated the impact of race/ethnicity on early postoperative readmission (within 14 days) in a population of patients undergoing a “low risk” cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of all presumed “low risk” cesarean deliveries in California from 1999 to 2004. The cohort was defined as women with term gestations who had no antepartum hospital admissions, delivered a live born infant by cesarean on the same day as hospital admission (thus likely unlabored) and were discharged on or before the fourth post-operative day. Multivariate logistic regression was performed to control for maternal age, gestational age, parity, race/ethnicity, education, length of stay, rural county, as well as payer and hospital type. The results were also adjusted for maternal chronic conditions, antenatal disorders and immediate post-partum complications. RESULTS: Of 391,433 women delivered by a low risk cesarean, 3375 (0.9%) were readmitted within 2 weeks. Black women were 48% more likely to be readmitted compared to white women, while Hispanic and Asian women were less likely to be readmitted (see table). Other risk factors for readmission included extremes of age, nulliparity and maternal conditions such as hypertension and diabetes. Obstetrical conditions such as placenta previa or multiple gestations did not statistically increase the risk for early readmission, though the occurrence of a postpartum hemorrhage or uterine rupture did. The most common indications for readmissions in this cohort were infection (28%) and wound disorders (25%). CONCLUSION: Even among a lower risk population, black women are at significantly increased risk of early readmission after cesarean delivery. Strategies to minimize this disparity in a significant quality of care outcome may need to focus upon hospital discharge procedures and transitions of care for this and other high risk groups. A bar chart to show the proportion of women from areas with a ‘high’, ‘low’ or ‘neither high nor low’ IMD score who booked for antenatal care prior to 14 weeks gestation or later than 20 weeks of gestation Effect of educational video on actual epidural use

Follistatin (FS) is an activin/inhibin binding protein which is believed to act in an autocrine/paracrine manner to regulate growth and differentiation. Although FS has been identified in human follicular fluid, it remains unclear how its concentration changes during selection and atresia, and what the concentrations of FS are in follicles of women with polycystic ovary syndrome (PCOS). Towards this goal, we have measured by radioimmunoassay the concentrations of FS in follicular fluid obtained from dominant and atretic cohort follicles of normal cycling women, preovulatory follicles of in-vitro fertilization (IVF) patients, and small Graafian follicles of patients with PCOS. In all cases, the follicular fluid concentration of FS was much higher (approximately 100-fold) than that reported in serum. The FS concentrations (ng/ml) were 203 +/- 42 (normal dominant), 185 +/- 17 (atretic cohort), 185 +/- 5 (IVF), and 250 +/- 14 (PCOS). There was no statistical difference between these mean values of FS. Further, there were no significant correlations between the follicular fluid concentrations of FS and the concentrations of oestradiol, progesterone, or androstenedione. These results indicate that human Graafian follicles, regardless of whether they are healthy or atretic, normal or PCOS, contain high steady-state concentrations of FS in the micro-environment. Collectively, these data fit with the hypothesis that major increases and decreases in the concentration of FS in the micro-environment may not play a key role in the mechanisms of selection, atresia, and PCOS in women. The possibility of regulation of intrinsic activin and inhibin activity through FS binding is discussed.