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Study Objective: We sought to assess the factors that are associated with ovarian preservation in the setting of surgically confirmed ovarian torsion, specifically focusing on the time to surgery after the emergency department (ED) presentation. Methods: We conducted a retrospective cohort study at a single tertiary care academic hospital from 2008 to 2021. Patients aged 12–40 with ovarian torsion were identified using diagnosis codes. We compared the outcome of ovarian preservation versus removal based on time to surgery after ED presentation, age, parity, Doppler flow, presence of ovarian mass, detorsion attempt, intraoperative suspicion of necrosis, and time of day. Results: We identified 60 surgical cases of ovarian torsion, with 25 undergoing oophorectomy (58.3% preserved). The median time from ED presentation to surgery was 8.6 hours, and only six surgeries occurred in <4 hours, which was not associated with ovarian preservation. Preservation was associated with Doppler flow (60% vs. 27%, p = 0.019) and was less likely when necrosis was suspected (20% vs. 84%, p < 0.001) and age ≥25 years (34% vs. 68%, p = 0.010). Detorsion attempts resulted in the preservation of 25% of ovaries with suspected necrosis. Parity and presentation time of day were not associated with preservation. Discussion: Time to surgery was not associated with ovarian preservation, possibly because few cases occurred in <4 hours. Setting goal times might improve outcomes. Ovaries are more likely to be preserved when detorsion is attempted despite necrotic appearance and when Doppler flow is present on sonographic exam. The surgical decision for oophorectomy may be based on factors unrelated to functional loss of the ovary. [ABSTRACT FROM AUTHOR]

Objective The American College of Obstetricians and Gynecologists (ACOG) suggests expectant management until 34 weeks for patients with preterm premature rupture of membranes (PPROM). New data suggest extending to 37 weeks might enhance neonatal outcomes, reducing prematurity-linked issues. This study aims to assess adverse neonatal outcomes across gestational ages in women with PPROM. Study Design A retrospective cohort study was performed using linked vital statistics and the International Classification of Diseases, Ninth Revision data. Gestational age at delivery ranged from 32 to 36 weeks. Outcomes include neonatal intensive care unit (NICU) admission >24 hours, neonatal sepsis, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. Multivariate regression analyses and chi-square tests were employed for statistical comparisons. Results In this cohort of 28,891 deliveries, there was a statistically significant decline in all studied adverse neonatal outcomes with increasing gestational age, without an increase in neonatal sepsis. At 32 weeks, 93% of newborns were in the NICU >24 hours compared with 81% at 34 weeks and 22% at 36 weeks (p < 0.001). At 32 weeks, 20% had neonatal sepsis compared with 11% at 34 weeks and 3% at 36 weeks (p < 0.001). At 32 weeks, 67% had respiratory distress syndrome compared with 44% at 34 weeks and 12% at 36 weeks (p < 0.001). Conclusion In the setting of PPROM, later gestational age at delivery is associated with decreased rates of adverse neonatal outcomes without an increase in neonatal sepsis. Key Points The ACOG recommends expectant management until 34 weeks for patients with PPROM. However, expectant management to 37 weeks might improve neonatal outcomes. Later gestational age at delivery was associated with decreased rates of adverse neonatal outcomes. Later gestational age at delivery was not associated with an increase in neonatal sepsis. The management of PPROM is complex and should be individualized. [ABSTRACT FROM AUTHOR]

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

Background: Recommendations from the American College of Obstetricians and Gynecologists for the safe prevention of primary cesarean deliveries propose that cesarean delivery for active phase arrest in the first stage of labor should be performed only if women fail to progress despite four hours of adequate uterine activity and no cervical change. This is a change in recommendation from a two-hour threshold. Objective: To determine the economic and clinical implications of waiting four hours compared to two hours for cervical progression before diagnosing active phase labor arrest. Study Design: We designed a cost-effectiveness analysis using TreeAge Pro 2020 software with model inputs derived from the literature. We used a theoretical cohort of 1.4 million women, the approximate number of nulliparous U.S. women reaching four centimeters in spontaneous labor. We compared maternal and neonatal outcomes and costs associated with defining active phase arrest after four hours of no cervical progression versus two hours. As a baseline assumption, active labor was defined at four centimeters. It was assumed that women with active phase arrest were delivered via cesarean delivery. In addition to cost and maternal quality-adjusted life years (QALY), outcomes included mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and maternal deaths. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. The willingness-to-pay threshold was set at $100,000/QALY. Results: In a theoretical cohort of 1.4 million women, waiting four hours instead of two hours led to 322,253 fewer cesarean deliveries, 6 fewer maternal deaths, 123 fewer postpartum hemorrhages requiring transfusions, and 28,615 fewer episodes of endometritis. There were 418 more instances of neonatal shoulder dystocia and 14 more cases of permanent brachial plexus injuries with a four-hour threshold. A four-hour threshold leads to 56% more women having a vaginal delivery in our theoretical cohort. Results from our model show that waiting four hours versus two hours to diagnose active phase labor arrest led to increased total QALYs with increased costs, with an incremental cost effectiveness ratio (ICER) below our willingness-to-pay threshold of $100,000 per QALY. Thus, it was cost effective to wait for at least four hours in the diagnosis of active phase arrest. Multivariable sensitivity analysis demonstrated the model was robust over a wide range of assumptions. Conclusions: Increasing the time threshold from two to four hours for diagnosing active phase labor arrest beyond four centimeters is a cost-effective strategy, resulting in fewer primary cesarean deliveries and improved maternal outcomes, despite a small increase in adverse neonatal outcomes. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate maternal outcomes with an extended second stage of labor and determine if an extended second stage is cost effective. This theoretical model evaluated expectant management to 4 h compared to delivery at 3 h in the setting of a prolonged second stage of labor in nulliparous women with epidural analgesia. In our theoretical cohort of 165,000 women, we found that an extended second stage resulted in 53,268 more spontaneous vaginal deliveries, 14,163 fewer operative vaginal deliveries, and 39,105 fewer cesarean deliveries. This approach also resulted in 1 fewer instance of maternal death. An extended second stage, however, led to 14,025 more cases of chorioamnionitis, 1699 more episodes of postpartum hemorrhage requiring transfusion, and 119 more severe perineal lacerations, suggesting that while an extended second stage of labor results in overall improved maternal outcomes, there are tradeoffs. Expectant management to 4 h was the dominant strategy in the model, as it saved over $114 million US dollars and resulted in 4000 additional QALYs over our theoretical cohort. Sensitivity analysis indicated that expectant management until 4 h was cost-effective as long as the probability of cesarean delivery at 4 h was below 41.8%, and was the dominant strategy below 38.2% (baseline input: 19.5%). Multivariable sensitivity analysis demonstrated that the model was robust over a wide range of assumptions. Expectant management of the second stage of labor until 4 h is a cost-effective strategy to prevent primary cesarean deliveries, decrease costs, and improve some maternal outcomes, despite tradeoffs. [ABSTRACT FROM AUTHOR]

Importance: Evaluation of racial and ethnic differences in apical suspension during prolapse repair is crucial for equitable gynecological care., Objective: The objective was to assess racial and ethnic disparities in apical suspension during native tissue prolapse repair., Study Design: We analyzed data from the 2019 Healthcare Cost and Utilization Project National Inpatient Sample and Nationwide Ambulatory Surgery Sample, using Current Procedural Terminology and International Classification of Diseases, Tenth Revision, codes. Bivariate analysis identified demographic and hospital-based differences between native tissue apical suspension procedures versus non-apical suspension during vaginal hysterectomy for prolapse, further analyzed with multivariable logistic regression. A separate analysis examined posthysterectomy prolapse surgical procedures., Results: Of the 62,553 vaginal hysterectomies, 26,094 (41%) were for prolapse. Among these, 14,027 (54%) included apical suspension. The cohort's racial and ethnic identity was 73% non-Hispanic White, 5% Black, 15% Hispanic, 3% Asian, 0% Native American, and 3% other. Multivariable analysis confirmed Black patients were more likely to receive apical suspension compared to non-Hispanic White patients (adjusted odds ratio [aOR] 1.26, 95% CI: 1.04-1.53, P = 0.02), and Hispanic patients were less likely to receive apical suspension (aOR 0.74, 95% CI: 0.63-0.87, P < 0.001). Among 60,074 posthysterectomy prolapse surgical procedures, only 18% included apical suspension. Compared to non-Hispanic Whites, Black, Hispanic, and Asian patients were less likely to receive apical suspension (Black: aOR 0.8, 95% CI: 0.68-0.95, P = 0.013; Hispanic: aOR 0.89, 95% CI: 0.77-1.04, P = 0.14; Asian: aOR 0.52, 95% CI: 0.41-0.66, P < 0.001)., Conclusions: The study highlights persistent racial and ethnic disparities in apical suspension provision. There is a notable lack of apical suspension in native tissue repairs, especially after hysterectomy., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2025 American Urogynecologic Society. All rights reserved.)

Objective: Prior studies have demonstrated the potential benefit of nonmedically indicated induction of labor for nulliparous women at 39 weeks of gestation, yet few have studied the impact of this management strategy in different maternal age groups on obstetric outcomes. We sought to assess whether obstetric outcomes among women undergoing nonmedically indicated induction of labor at 39 weeks of gestation as compared with expectant management vary based on maternal age., Study Design: This was a retrospective cohort study of singleton, nonanomalous, deliveries between 2007 and 2012 in California. We defined nonmedically indicated induction of labor as induction of labor without a specific medical indication, and women with planned cesarean sections were excluded. We compared induction of labor with expectant management beyond the gestational age of induction and examined this comparison in different maternal age groups. Numerous maternal and neonatal outcomes were examined. Chi-squared and multivariable logistic regression analyses were used for statistical comparisons and a p -value of less than 0.05 was used to indicate statistical significance., Results: A total of 630,485 women-infant dyads met our inclusion criteria and were included in this study. At 39 weeks' gestation, 6% of women underwent nonmedically indicated induction of labor and 94% underwent expectant management. Women 20 to 34 and ≥35 years old had lower odds of cesarean delivery if they underwent induction of labor. Women of all ages undergoing nonmedically indicated induction of labor had higher odds of operative vaginal delivery. Neonatal outcomes were better with nonmedically indicated induction of labor, including lower odds of neonatal intensive care unit admission and neonatal respiratory distress., Conclusion: Our study demonstrated that obstetric outcomes vary among women undergoing nonmedically indicated induction of labor compared with expectant management when stratified by maternal age. These findings illustrate the importance of understanding age-related differences in outcomes associated with nonmedically indicated induction of labor., Key Points: · Outcomes are different by age with nonmedically indicated induction of labor (IOL).. · The odds of cesarean delivery with IOL decreases with increasing maternal age compared with expectant management.. · Neonatal outcomes were improved with IOL compared with expectant management.., Competing Interests: None declared., (Thieme. All rights reserved.)