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Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate impact on women of color. While numerous factors contribute to the inequities in pregnancy-related mortality, access to health insurance is among the most significant. Military Tricare models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzed maternal delivery outcomes for all women with Tricare coverage, including deliveries in the civilian sector. We analyzed data from 6.2 million births in the Centers for Disease Control (CDC) Wide-ranging Online Data for Epidemiology Research (WONDER) Linked Birth/Infant Death Records for 2017-2019. Data included all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and ICU admissions), severe maternal morbidity (SMM) excluding lacerations, and SMM excluding transfusion. Risk ratios were calculated by comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race. In conclusion, there is an increased risk for women identifying as racial minorities for SMM and SMM excluding transfusion. While Tricare coverage seems to decrease the risk, the decrease is not significant and disparities in outcomes persist among women identifying as minorities. The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Brooke Army Medical Center Institutional Review Board (IRB) issued approval C.2019.109n /eIRB 912978. Your protocol has been APPROVED by the Human Research Protection Office. Your protocol was determined to meet the criteria for research IAW 32 CFR 219.102(l), not involving human subjects IAW 32 CFR 219.102(e)(1); therefore it will be reported as RESEARCH NOT INVOLVING HUMAN SUBJECTS. You may begin work upon receipt of this letter. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Iodice et al.)

Objective: To evaluate the association between sonographic features of placenta previa and vaginal bleeding (VB)., Study Design: Retrospective cohort study of women with placenta previa identified on ultrasound between 16 0/7 and 27 6/7 weeks gestation. Placental distance past the cervical os (DPO), placental thickness, edge angle, and cervical length (CL) were measured. The primary outcome was any VB and the secondary outcome was VB requiring delivery. Median values of the sonographic features were compared for each of the outcomes using the Mann-Whitney U test. Receiver operating characteristic curves were used to compare the predictive value of sonographic variables markers and to determine optimal cut points for each measurement. Logistic regression was used to estimate the association between each measure and the outcomes while controlling for confounders., Results: Of 149 women with placenta previa, 37% had VB and 15% had VB requiring delivery. Women with VB requiring delivery had significantly more episodes of VB than those who did not require delivery for VB (1.5, interquartile range [IQR] [1-3] vs 1.0 [1-5]; p  = 0.001). In univariate analysis, women with VB had decreased CL (3.9 vs. 4.2 cm; p  < 0.01) compared with those without. Women with VB requiring delivery had increased DPO (2.6 cm IQR [1.7-3.3] vs. 1.5 cm [1.1-2.4], p  = 0.01) compared with those without. After adjusting for confounders, only CL < 4 cm remained independently associated with increased risk of VB (adjusted odds ratio: 2.27, 95% confidence interval [1.12-4.58], p  = 0.01). None of the measures were predictive of either outcome (area under the curve < 0.65)., Conclusion: Decreased CL may be associated with risk of VB in placenta previa., Key Points: · Placenta previa is associated with VB.. · Sonographic markers of placenta previa are associated with VB.. · CL is associated with VB in placenta previa, whereas placental DPO is associated with higher rates of bleeding leading to delivery.., Competing Interests: None declared., (Thieme. All rights reserved.)

Newly diagnosed malignancy during pregnancy is rare affecting approximately 1 in 1,000 pregnancies. Breast followed by hematologic malignancies are most common. Hodgkin's lymphoma (HL) is a lymphoid neoplasm which can present with lymphadenopathy or mediastinal mass and represents 6% of all malignancies diagnosed during pregnancy. Treatment involves a combination of chemotherapy with or without adjuvant radiation which poses significant challenges when diagnosed antepartum. We highlight a 28-year-old primigravida at 26 weeks gestation who presented to the emergency department in Japan with cough, dyspnea, and sore throat for 3-5 days. Initial chest radiography demonstrated a large perihilar mass with mediastinal shift. Follow-up CT chest revealed an anterior mediastinal mass measuring 8 cm × 19 cm × 16 cm with features concerning for aggressive lymphoma. The patient was subsequently transferred to a stateside tertiary care center for expedited workup. She underwent two core needle biopsies, both of which were non-diagnostic. Cardiothoracic surgery performed a cervical mediastinoscopy with excision of the enlarged right supraclavicular lymph node. Pathologic analysis revealed classical HL, nodular sclerosis subtype. Treatment was initiated with adriamycin, bleomycin, vinblastine, and dacarbazine with two cycles planned antepartum followed by additional cycles postpartum. The patient had an uncomplicated vaginal delivery at 38 weeks gestation. Diagnosis of HL in pregnancy is rare, and expedited diagnosis can be challenging as multiple diagnostic and treatment modalities may impact pregnancy. Management in pregnancy requires a multidisciplinary approach, and decisions regarding treatment and delivery timing should be weighed against risk to the fetus., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: This study aimed to compare the uterocervical angles in term and spontaneous preterm birth cohorts and to compare the test characteristics of the uterocervical angle and cervical length in the prediction of spontaneous preterm birth., Data Sources: A systematic search of published literature from January 1, 1945, to May 15, 2022, was performed using the following databases: PubMed, Cochrane Central Register of Controlled Trials, Embase, World Health Organization International Clinical Trials Registry Platform, Web of Science, and ClinicalTrials.gov. The search was not restricted. The references of all relevant articles were reviewed., Study Eligibility Criteria: Randomized control trials, nonrandomized control trials, and observational studies were evaluated for primary comparisons. Included studies compared the uterocervical angles in term and spontaneous preterm birth cohorts and compared the uterocervical angle with cervical length in the prediction of spontaneous preterm birth., Methods: Of note, 2 researchers independently selected studies and evaluated the risk of bias with the Newcastle-Ottawa Scale for cohort and case-control studies. Mean differences and odds ratios were calculated using a random effects model for inclusion and methodological quality. The primary outcomes were uterocervical angle and successful prediction of spontaneous preterm birth. Moreover, posthoc analysis comparing the uterocervical angle and cervical length together was performed., Results: A total of 15 cohort studies with 6218 patients were included. The uterocervical angle was larger in the spontaneous preterm birth cohorts (mean difference, 13.76; 95% confidence interval, 10.61-16.91; P <.00001; I 2 =90%). Sensitivity and specificity analyses demonstrated lower sensitivities with cervical length alone and uterocervical angle plus cervical length than with uterocervical angle alone. Pooled sensitivities for uterocervical angle and cervical length alone were 0.70 (95% confidence interval, 0.66-0.73; I 2 =90%) and 0.46 (95% confidence interval, 0.42-0.49; I 2 =96%), respectively. Pooled specificities for uterocervical angle and cervical length were 0.67 (95% confidence interval, 0.66-0.68; I 2 =97%) and 0.90 (95% confidence interval, 0.89-0.91; I 2 =99%), respectively. The areas under the curve for uterocervical angle and cervical length were 0.77 and 0.82, respectively., Conclusion: Uterocervical angle alone or with cervical length was not superior to cervical length alone in predicting spontaneous preterm birth.

Background: In the United States, Black women die at 2.5 times the rate of White women and 3.5 times the rate of Hispanic women. These racial health care disparities have been largely attributed to access to health care and other social determinants of health., Objective: We hypothesize that the Military healthcare system models universal health care access seen in other developed countries and should equalize these rates., Study Design: Delivery data from 41 Military treatment facilities across the Department of Defense (Army, Air Force, and Navy) including over 36,000 deliveries from 2019 to 2020 were compiled in a convenience dataset through the National Perinatal Information Center. After aggregation, the parameters of percent of deliveries complicated by Severe Maternal Morbidity and percent of severe maternal morbidity secondary to pre-eclampsia with and without transfusion were calculated. Risk ratios were calculated by race for the resulting summary data. American Indian/Alaska Native were excluded because of limited total number deliveries preventing statistical analyses., Results: Overall, the risk of severe maternal morbidity was increased among Black women compared to White women. The risk of severe maternal morbidity related to pre-eclampsia showed no significant difference among races with or without transfusion. When other races were set as reference group, there was a significant difference for White women, suggesting a protective effect., Conclusion: Although women of color still experience overall severe maternal morbidity at higher rates than their White counterparts, TRICARE may have equalized the risk of severe maternal morbidity for deliveries complicated by pre-eclampsia.

Background: Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare., Objective: This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background., Study Design: This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion., Results: A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45-2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93-1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02-3.8) among Asian Pacific Islander women when compared with Black or White women., Conclusion: Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant., (© 2023 The Authors.)

Objective: Magnesium sulfate is standard of care for prevention of eclampsia in women with preeclampsia with severe features. The American College of Obstetrics and Gynecology endorses its use throughout labor, delivery and the immediate postpartum period. Some providers pause magnesium sulfate infusion preoperatively due to concern for increased risk of uterine atony and postpartum hemorrhage. Using a non-inferiority analysis, we investigated the effect of interrupted versus continuous infusion of magnesium sulfate on postpartum hemorrhage in women with preeclampsia with severe features undergoing cesarean delivery., Study Design: Retrospective non-inferiority cohort study of women with preeclampsia with severe features treated with magnesium sulfate undergoing cesarean delivery with singleton pregnancies at tertiary care hospital from 2013 to 2018. The primary outcome was postpartum hemorrhage. Secondary outcomes included estimated blood loss, change in hematocrit and a composite of postpartum hemorrhage severity, including transfusion of blood products, use of more than one uterotonic and additional surgical interventions., Results: Of 249 women, magnesium sulfate infusion was interrupted in 171 (69%) and continued in 78 (31%). Women with interrupted magnesium sulfate infusion were more likely to be Caucasian (73% vs 67%, p  = .024), have chronic hypertension (23% vs 1%, p  < .001), labor prior to cesarean delivery (84% vs 55%, p  < .001), undergo primary cesarean delivery (86% vs 67%, p  = .005), and experience shorter surgical time (50 vs 55 min, p  = .026). The rate of postpartum hemorrhage for those receiving interrupted magnesium sulfate infusion (9.9%) and continuous magnesium sulfate infusion (10.2%) was similar, falling within the non-inferiority margin (absolute difference 0.3%, 95% CI -7.8 to 8.4%, p  = .88). There were no significant differences in the secondary outcomes., Conclusion: Interrupted magnesium sulfate infusion is non-inferior to continued magnesium sulfate infusion for rates of postpartum hemorrhage in women with preeclampsia with severe features undergoing cesarean delivery.

Objective: To review the evidence regarding gestational age at birth, length of stay, sepsis incidence, days on mechanical ventilation, and mortality between preterm and term deliveries in pregnancies complicated by gastroschisis., Data Sources: We conducted database searches of PubMed, Cochrane Central Register of Controlled Trials, Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov without language restrictions through August 16, 2021. References of all relevant articles were reviewed., Study Eligibility Criteria: Randomized controlled trials, nonrandomized controlled trials, and observational studies were evaluated comparing length of stay, sepsis, days on mechanical ventilation, and mortality between either elective preterm delivery and expectant management (Group 1) or preterm gestational age and term gestational age (Group 2)., Methods: Two researchers independently selected studies and evaluated risk of bias with the Risk of Bias 2 tool for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Mean differences and odds ratios were calculated using a random-effects model for inclusion and methodological quality. The primary outcome was length of stay. Secondary outcomes were incidence of sepsis, mortality, days on mechanical ventilation, and gestational age., Results: Thirty studies with a total of 7409 patients were included in the systematic review, of which 25 were included in the analysis. Group 1 studies found no difference in length of stay or mortality and a trend toward fewer days on mechanical ventilation (mean difference, -0.40; 95% confidence interval, -0.89 to -0.10; P=.12; I 2 =35%). Subgroup analysis excluding premature delivery demonstrated lower sepsis incidence in elective preterm delivery (odds ratio, 0.46; 95% confidence interval, 0.25-0.84; P=.01; I 2 =0%). Group 2 studies found increased length of stay (mean difference, 15.44; 95% confidence interval, 8.44-21.83; P<.00001; I 2 =94%), sepsis (odds ratio, 1.69; 95% confidence interval, 1.15-2.50; P=.008; I 2 =51%), days on mechanical ventilation (mean difference, 1.38; 95% confidence interval, 0.10-2.66; P=.03; I 2 =66%), and mortality (odds ratio, 2.97; 95% confidence interval, 1.59-5.55; P=.0007; I 2 =0%). Gestational age was significantly lower in Group 2 studies than in Group 1 studies., Conclusion: Data continue to be conflicting, but subgroup analysis suggested a possible reduction in sepsis incidence and mean days on mechanical ventilation with elective early term delivery., (Published by Elsevier Inc.)

Background: LDA triggers biosynthesis of endogenous anti-inflammatory molecules, aspirin-triggered 15-epi-lipoxin A 4 (15-epi-LXA 4 ), which may counteract inflammatory process of preeclampsia (PE), and play role in LDA's mechanism of action in PE prevention in high-risk patients., Objective: Investigate the effects of daily LDA on levels of 15-epi-LXA 4 in pregnancies at high-risk for developing PE., Materials and Methods: Secondary analysis of multi-centered randomized controlled trial investigating effects of daily LDA (60 mg) in high-risk pregnancies. Maternal samples were drawn at three points: before LDA initiation (13-26 weeks' gestation), 24-28 weeks' gestation (at least two weeks after LDA) and 34-36 weeks' gestation. 15-epi-LXA 4 levels were measured by ELISA., Results: Analysis included 82 patients: 63 receiving daily LDA and 29 receiving daily placebo starting between 13 and 25 weeks gestation. Prior to randomization, baseline 15-epi-LXA 4 levels were similar between both groups (75.9 pg/mL [IQR; 63.8-114.0] vs 136.2 pg/mL [52.4-476.2]; p = 0.10). Patients receiving daily LDA were noted to have significantly increased levels of 15-epi-LXA 4 after LDA administration (136.2 pg/mL [IQR; 52.4-476.2] vs 1758.2 pg/mL [905.4-6638.5]; p < 0.001). They also had higher 15-epi-LXA 4 levels compared to those receiving placebo at 24-28 weeks' (50.3 [38.1-94.2] vs 1758.2 [905.4-6638.5]; p < 0.001 and 34-38 weeks' gestation (57.9 [41.9-76.7] vs 2310.3 pg/mL [656.9-10609.4]; p < 0.001). After LDA administration in the second trimester, patients who developed PE had decrease in 15-epi-LXA 4 levels compared to those without PE (942 pg/mL [348.3-1810.3] vs 1758.2 pg/mL [905.4-6638.5]; p = 0.129)., Conclusion: Daily LDA administration increases 15-epi-LXA 4 levels in high-risk pregnancies for PE. In LDA group, pregnancies complicated by PE have lower levels of 15-epi-LXA 4 compared to pregnancies without PE., (Published by Elsevier B.V.)

We sought to provide a clinical practice protocol for our labor and delivery (L&D) unit, to care for confirmed or suspected COVID-19 patients requiring cesarean delivery. A multidisciplinary team approach guidance was designed to simplify and streamline the flow and care of patient with confirmed or suspected COVID-19 requiring cesarean delivery. A protocol was designed to improve staff readiness, minimize risks, and streamline care processes. This is a suggested protocol which may not be applicable to all health care settings but can be adapted to local resources and limitations of individual L&D units. Guidance and information are changing rapidly; therefore, we recommend continuing to update the protocol as needed. KEY POINTS: · Cesarean delivery for confirmed or suspected novel coronavirus disease 2019 (COVID-19) patients. · Team-based approach for streamline care. · Labor and delivery protocols for COVID-19 positive patients., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Low-dose aspirin is used for preeclampsia prevention in high-risk women, but the precise mechanism and optimal dose are unknown. Evidence suggests that an imbalance in prostacyclin and thromboxane A 2 (TXA 2 ) plays a key role in the pathogenesis of preeclampsia. Aspirin has a dose-dependent effect blocking production of TXA 2 , a potent stimulator of platelet aggregation and promoter of vasoconstriction. Incomplete inhibition of platelet aggregation, designated aspirin resistance, can be reduced by increasing the aspirin dose. Evidence in the nonobstetric literature suggests that aspirin resistance may be more common among patients with a high body mass index., Objective: To investigate the association of obesity on platelet-derived thromboxane inhibition in high-risk women treated with low-dose aspirin., Materials and Methods: This was a secondary analysis of a prospective multi-centered study investigating the effect of low-dose aspirin (60-mg) administration in women at high risk for preeclampsia. Maternal serum TXB 2 (an indirect measure of TxA 2 ) levels were drawn at 3 time points: randomization (13-26 weeks' gestation), second trimester (at least 2 weeks after randomization and 24-28 weeks' gestation), and third trimester (34-38 weeks' gestation). Patients were included in the analysis if a TXB 2 level was recorded at randomization and at least 1 time point thereafter. Patients were stratified by body mass index category and treatment arm. Median TXB 2 levels were calculated at each time point, as well as rates of complete TXB 2 inhibition (<0.01 ng/mL). A multivariate logistic regression analysis was performed to generate odds ratios (OR) for complete TXB 2 inhibition by body mass index category, adjusting for maternal age, race, high-risk group at randomization, nulliparity, and rate of randomization less than 16 weeks' gestation., Results: A total of 1002 patients were included in the analysis, 496 (49.5%) and 506 (50.5%) in the low-dose aspirin and placebo groups respectively. There were substantial decreases in TXB 2 levels among low-dose aspirin-treated women in all body mass index categories. In contrast, women assigned to placebo did not show a marked decrease in TXB 2 levels after randomization, and obese women had higher median TXB 2 levels in both the second (16.5, interquartile range [IQR] 8.0-31.8 vs 14.0, IQR 6.9-26.7, ng/mL; P = .032) and third (15.7, IQR 7.6-28.5 vs 11.9, IQR 4.6-25.9, ng/mL; P = .043) trimesters. When comparing among stratified body mass index low-dose aspirin groups, women with class III obesity had the lowest odds of undetectable TXB 2 levels in the second trimester (adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.15-0.72) and third trimester (aOR, 0.30; 95% CI, 0.11-0.78) as well as at both time points (aOR, 0.09; 95% CI, 0.02-0.41)., Conclusion: High-risk obese women receiving low-dose aspirin for the prevention of preeclampsia have lower rates of complete inhibition of TXB 2 . These data suggest that an increase in aspirin dosing or frequency may be necessary in this population., (Copyright © 2019 Elsevier Inc. All rights reserved.)