Trends, Characteristics, and Maternal Morbidity Associated With Unhoused Status in Pregnancy.

Importance: Unhoused status is a substantial problem in the US. Pregnancy characteristics and maternal outcomes of individuals experiencing homelessness are currently under active investigation to optimize health outcomes for this population. Objective: To assess the trends, characteristics, and maternal outcomes associated with unhoused status in pregnancy. Design, Setting, and Participants: This cross-sectional study analyzed data from the Healthcare Cost and Utilization Project National (Nationwide) Inpatient Sample. The study population included hospitalizations for vaginal and cesarean deliveries from January 1, 2016, to December 31, 2020. Unhoused status of these patients was identified from use of International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code Z59.0. Statistical analysis was conducted from December 2022 to June 2023. Main Outcomes and Measures: Primary outcomes were (1) temporal trends; (2) patient and pregnancy characteristics associated with unhoused status, which were assessed with a multivariable logistic regression model; (3) delivery outcomes, including severe maternal morbidity (SMM) and mortality at delivery, which used the Centers for Disease Control and Prevention definition for SMM indicators and were assessed with a propensity score-adjusted model; and (4) choice of long-acting reversible contraception method and surgical sterilization at delivery. Results: A total of 18 076 440 hospital deliveries were included, of which 18 970 involved pregnant patients who were experiencing homelessness at the time of delivery, for a prevalence rate of 104.9 per 100 000 hospital deliveries. These patients had a median (IQR) age of 29 (25-33) years. The prevalence of unhoused patients increased by 72.1% over a 5-year period from 76.1 in 2016 to 131.0 in 2020 per 100 000 deliveries (P for trend < .001). This association remained independent in multivariable analysis. In addition, (1) substance use disorder (tobacco, illicit drugs, and alcohol use disorder), (2) mental health conditions (schizophrenia, bipolar, depressive, and anxiety disorders, including suicidal ideation and past suicide attempt), (3) infectious diseases (hepatitis, gonorrhea, syphilis, herpes, and COVID-19), (4) patient characteristics (Black and Native American race and ethnicity, younger and older age, low or unknown household income, obesity, pregestational hypertension, pregestational diabetes, and asthma), and (5) pregnancy characteristics (prior uterine scar, excess weight gain during pregnancy, and preeclampsia) were associated with unhoused status in pregnancy. Unhoused status was associated with extreme preterm delivery (<28-week gestation: 34.3 vs 10.8 per 1000 deliveries; adjusted odds ratio [AOR], 2.76 [95% CI, 2.55-2.99]); SMM at in-hospital delivery (any morbidity: 53.8 vs 17.7 per 1000 deliveries; AOR, 2.30 [95% CI, 2.15-2.45]); and in-hospital mortality (0.8 vs <0.1 per 1000 deliveries; AOR, 10.17 [95% CI, 6.10-16.94]), including case fatality risk after SMM (1.5% vs 0.3%; AOR, 4.46 [95% CI, 2.67-7.45]). Individual morbidity indicators associated with unhoused status included cardiac arrest (AOR, 12.43; 95% CI, 8.66-17.85), cardiac rhythm conversion (AOR, 6.62; 95% CI, 3.98-11.01), ventilation (AOR, 6.24; 95% CI, 5.03-7.74), and sepsis (AOR, 5.37; 95% CI, 4.53-6.36). Conclusions and Relevance: Results of this national cross-sectional study suggest that unhoused status in pregnancy gradually increased in the US during the 5-year study period and that pregnant patients with unhoused status were a high-risk pregnancy group.

Uptake of postplacental intrauterine device placement at cesarean delivery.

BACKGROUND: Several studies have investigated the effectiveness of intrauterine device placement at cesarean delivery as a contraceptive method. However, national-level use and outcomes of a postplacental intrauterine device at cesarean delivery are currently understudied in the United States. OBJECTIVE: This study aimed to examine the trends, characteristics, and outcomes of patients who received a postplacental intrauterine device at cesarean delivery. STUDY DESIGN: This retrospective cohort study used the National Inpatient Sample. The study cohort included patients who underwent cesarean delivery from October 2015 to December 2018. The exclusion criteria included hemorrhage, chorioamnionitis, uterine anomaly, hysterectomy, and permanent surgical sterilization. Eligible cases were grouped on the basis of the use of a postplacental intrauterine device at cesarean delivery. The primary outcome measures were temporal trends and characteristics associated with the use of a postplacental intrauterine device at cesarean delivery, assessed using the generalized estimating equation model in multivariable analysis. The secondary outcome measure was perioperative morbidity (leukocytosis, endometritis, myometritis, and sepsis). Propensity score matching was used to balance the baseline characteristics. RESULTS: Among 2,983,978 patients who met the inclusion criteria, 10,145 patients (0.3%) received a postplacental intrauterine device at cesarean delivery. The use of a postplacental intrauterine device increased from 0.1% in the fourth quarter of 2015 to 0.6% in the fourth quarter of 2018 (P<.001). In a multivariable analysis, the use of a postplacental intrauterine device increased by 14% every quarter-year (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.15). In addition, (1) patient characteristics of young age, non-White race, obesity, tobacco use, lowest quartile median household income, and insured with Medicaid; (2) hospital characteristics of large bed capacity and urban teaching setting in Northeast region; and (3) pregnancy characteristics of early gestational age at cesarean delivery, hypertensive disease, previous cesarean delivery, multifetal pregnancy, grand multiparity, placenta previa, and nonelective cesarean delivery represented the independent characteristics associated with the use of a postplacental intrauterine device (all P<.05). A regression tree model identified 35 discrete patterns of the use of a postplacental intrauterine device based on 8 factors (time, race or ethnicity, primary expected payer, obesity, hospital bed capacity, hospital teaching status, hospital region, and previous cesarean delivery). There were 9 patterns, representing 8.8% of the study population, exhibiting a use rate of ≥1.0%, whereas there were 7 patterns, representing 16.0% of the study population, exhibiting no use of a postplacental intrauterine device (absolute rate difference from the highest group to the lowest group, 4.7%). In a propensity score-matched model, postplacental intrauterine device placement at cesarean delivery was not associated with increased risk of measured morbidity (any, 1.8% vs 1.7%; odds ratio, 1.06; 95% confidence interval, 0.66-1.69; P=.812), including postpartum endometritis (1.2% vs 1.0%; odds ratio, 1.19; 95% confidence interval, 0.67-2.14; P=.554). CONCLUSION: The use of a postplacental intrauterine device at cesarean delivery increased significantly in recent years in the United States.

Metastatic extent-specific prognosis of women with stage IVB cervical cancer: multiple versus single distant organ involvement.

PURPOSE: Despite the heterogeneity of anatomical sites that metastases may affect, within the current cancer staging schematic, stage IVB encompasses all distant metastasis. This study examined survival outcomes based on the extent of distant organ metastasis in stage IVB cervical cancer. METHODS: This retrospective cohort study utilized the National Cancer Institute's Surveillance, Epidemiology, and End Result Program from 2010 to 2018. The study population included 1772 women with stage IVB cervical cancer who had tumor metastasis to one or more of the following four organs: bone, brain, liver, or lung. Overall survival was assessed based on the metastatic extent in multivariable analysis. RESULTS: The most common metastatic site was lung (68.3%) followed by bone (35.2%), liver (30.0%), and brain (1.2%). Multiple organ metastases were seen in 26.5% of study population, with lung / liver metastases being the most frequent combination pattern (9.6%) followed by lung / bone (9.4%), and lung / bone / liver (6.4%). A total of 1442 (81.4%) deaths occurred during the follow-up. The cohort-level median overall survival was 7 months, ranging from 3 months in all four organ metastases to 11 months in bone metastasis alone when stratified (absolute difference 8 months, P < 0.001). Multiple organ metastases were independently associated with nearly 50% increased all-cause mortality risk compared to single organ metastasis (adjusted-hazard ratio 1.51, 95% CI 1.34-1.70). CONCLUSION: Survival outcomes in those with stage IVB cervical cancer with distant organ involvement can vary based on the extent of metastasis. Incorporation of single versus multiple distant organ metastasis into the cancer staging schema may be valuable (IVB1 versus IVB2).

Endometrial cancer arising in adenomyosis versus endometrial cancer coexisting with adenomyosis: are these two different entities?

PURPOSE: While adenomyosis is one of the most common benign histologic findings in hysterectomy specimens of endometrial cancer, demographics of endometrial cancer arising in adenomyosis (EC-AIA) has not been well elucidated. The aim of this study is to evaluate histopathological findings and disease-free survival (DFS) of EC-AIA in comparison to endometrial cancer coexisting with adenomyosis (EC-A). METHODS: EC-AIA cases were identified via a systematic literature search (n = 46). EC-A cases were identified from a historical cohort that underwent hysterectomy-based surgical staging in two institutions (n = 350). Statistical comparisons of the two groups were based on univariate and multivariate analyses. RESULTS: The EC-AIA group was significantly older than the EC-A group (58.9 versus 53.8, p = 0.002). As to tumor characteristics, 63.6% of EC-AIA cases reported tumor within the myometrium without endometrial extension. The EC-AIA group was significantly associated with more non-endometrioid histology (23.9 versus 14.8%; p = 0.002) and deep myometrial tumor invasion (51.6 versus 19.4%; p < 0.001) than EC-A. Tumor grade, stage, and nodal metastasis risk were similar (all, p > 0.05). In a univariate analysis, the EC-AIA group had a significantly decreased DFS compared to EC-A (5-year rates, 72.2 versus 85.5%, p = 0.001). After controlling for age, histology, tumor grade, and stage, EC-AIA remained an independent prognostic factor associated with decreased DFS compared to EC-A (adjusted-hazard ratio 2.87, 95% confidence interval 1.44-5.70, p = 0.031). CONCLUSION: Our study demonstrated that EC-AIA has distinct tumor characteristics and a poorer survival outcome compared to EC-A. This suggests a benefit of recognition of this unique entity as an aggressive variant of endometrial cancer.

Association of Low-Dose Aspirin and Survival of Women With Endometrial Cancer.

OBJECTIVE: To examine the survival outcomes in women with endometrial cancer who were taking low-dose aspirin (81-100 mg/d). METHODS: A multicenter retrospective study was conducted examining patients with stage I-IV endometrial cancer who underwent hysterectomy-based surgical staging between January 2000 and December 2013 (N=1,687). Patient demographics, medical comorbidities, medication types, tumor characteristics, and treatment patterns were correlated to survival outcomes. A Cox proportional hazard regression model was used to estimate adjusted hazard ratio for disease-free and disease-specific overall survival. RESULTS: One hundred fifty-eight patients (9.4%, 95% confidence interval [CI] 8.8-11.9) were taking low-dose aspirin. Median follow-up time for the study cohort was 31.5 months. One hundred twenty-seven patients (7.5%) died of endometrial cancer. Low-dose aspirin use was significantly correlated with concurrent obesity, hypertension, diabetes mellitus, and hypercholesterolemia (all P<.001). Low-dose aspirin users were more likely to take other antihypertensive, antiglycemic, and anticholesterol agents (all P<.05). Low-dose aspirin use was not associated with histologic subtype, tumor grade, nodal metastasis, or cancer stage (all P>.05). On multivariable analysis, low-dose aspirin use remained an independent prognostic factor associated with an improved 5-year disease-free survival rate (90.6% compared with 80.9%, adjusted hazard ratio 0.46, 95% CI 0.25-0.86, P=.014) and disease-specific overall survival rate (96.4% compared with 87.3%, adjusted hazard ratio 0.23, 95% CI 0.08-0.64, P=.005). The increased survival effect noted with low-dose aspirin use was greatest in patients whose age was younger than 60 years (5-year disease-free survival rates, 93.9% compared with 84.0%, P=.013), body mass index was 30 or greater (92.2% compared with 81.4%, P=.027), who had type I cancer (96.5% compared with 88.6%, P=.029), and who received postoperative whole pelvic radiotherapy (88.2% compared with 61.5%, P=.014). These four factors remained significant for disease-specific overall survival (all P<.05). CONCLUSION: Our results suggest that low-dose aspirin use is associated with improved survival outcomes in women with endometrial cancer, especially in those who are young, obese, with low-grade disease, and who receive postoperative radiotherapy.

Weight Change Pattern and Survival Outcome of Women with Endometrial Cancer.

OBJECTIVE: The aim of this study was to determine the association between weight change patterns and survival outcomes of women with endometrial cancer. METHODS: This retrospective study examined surgically-staged endometrial cancer cases with available weight information between 1999 and 2013 (n = 665). Proportional body mass index (delta-BMI) change at 6 months, 1 and 2 years after hysterectomy was compared with baseline BMI and correlated to patient demographics, tumor characteristics, treatment type, and disease-free survival (DFS) and overall survival (OS). RESULTS: Mean BMI was 35.6, and 69 % of cases were obese. At 6 months, 1 and 2 years after surgery, 39.1, 51.6, and 57.0 % of the study population, respectively, gained weight compared with pre-treatment baseline. In univariate analysis, 6-month delta-BMI change was significantly associated with DFS and OS, demonstrating bidirectional effects (both p < 0.001): 5-year rates, ≥15.0 % delta-BMI loss (33.5 and 59.1 %), 7.5-14.9 % loss (67.3 and 70.0 %), <7.5 % loss (87.8 and 95.7 %), <7.5 % gain (87.2 and 90.3 %), 7.5-14.9 % gain (64.6 and 67.6 %), and ≥15.0 % gain (32.5 and 66.7 %). In multivariable analysis controlling for age, ethnicity, baseline BMI, histology, grade, stage, chemotherapy, and radiotherapy, 6-month delta-BMI change remained an independent prognostic factor for DFS and OS (all p < 0.05): adjusted hazard ratios, ≥15 % delta-BMI loss (3.35 and 5.39), 7.5-14.9 % loss (2.35 and 4.19), 7.5-14.9 % gain (2.58 and 3.33), and ≥15.0 % gain (2.50 and 3.45) compared with <7.5 % loss. Similar findings were observed at a 1-year time point (p < 0.05). Baseline BMI was not associated with survival outcome (p > 0.05). CONCLUSION: Our results demonstrated that endometrial cancer patients continued to gain weight after hysterectomy, and post-treatment weight change had bidirectional effects on survival outcome.

Contributing factors for menopausal symptoms after surgical staging for endometrial cancer.

OBJECTIVE: The aim of the study was to examine contributing factors associated with developing menopausal symptoms after surgical staging in women with endometrial cancer. METHODS: This is a retrospective study examining patients with endometrial cancer who were premenopausal at the time of hysterectomy-based surgical staging including bilateral oophorectomy between January 2000 and October 2013. Cox proportional hazard regression model was used to evaluate demographics, medical comorbidity, liver function tests, tumor factors, and medication history for menopausal symptoms. RESULTS: There were 269 premenopausal women who were eligible. Mean age was 44.5 years, and the majority had endometrioid histology (91.1%), grade 1 tumor (60.2%), and stage I disease (65.8%). Postoperatively, 73 (27.1%) women developed menopausal symptoms, with hot flushes (20.1%) being the most common symptom followed by night sweats (4.1%). On multivariate analysis, younger age was independently associated with increased risk of developing menopausal symptoms (hazard ratio per unit 0.91, 95% CI 0.88-0.94, P < 0.01). In addition, lower albumin level remained an independent predictor for decreased risk of developing menopausal symptoms (hazard ratio per unit 2.16, 95% CI 1.19-3.93, P = 0.012). Lower albumin level was associated with medical comorbidity (hypertension and diabetes mellitus), use of antihypertensive/glycemic agents (angiotensin-converting enzyme inhibitors or receptor blocker, hydrochlorothiazide, sulfonylurea, and insulin), aggressive tumor (high cancer antigen 125 level, nonendometrioid histology, and advanced stage), and abnormal liver function (high alkaline phosphatase level and low total protein level; all, P < 0.05). CONCLUSIONS: Assessing albumin level, medical comorbidity, and medication type for the development of postoperative menopausal symptoms is a valuable step in the preoperative management of women with endometrial cancer.

Surgical menopause and increased risk of nonalcoholic fatty liver disease in endometrial cancer.

OBJECTIVE: Our objective was to examine risk factors associated with development of nonalcoholic fatty liver disease (NAFLD) among women with endometrial cancer who underwent surgical staging with or without oophorectomy. METHODS: This is a retrospective study that evaluated endometrial cancer cases that underwent surgical staging (n = 666) and endometrial hyperplasia cases that underwent hysterectomy-based treatment (n = 209). This study included 712 oophorectomy cases and 163 nonoophorectomy cases. Archived records were reviewed for participant demographics, medical comorbidities, operative notes, histology results, and radiology reports for NAFLD. Cumulative risks of NAFLD after surgical operation were correlated to demographics and medical comorbidities. RESULTS: The cumulative prevalence of NAFLD in 875 women with endometrial tumor was 14.1%, 20.5%, and 38.4% at 1, 2, and 5 years after surgical operation, respectively. On multivariate analysis, after controlling for age, ethnicity, body mass index, medical comorbidities, tumor type, hormonal treatment pattern, and oophorectomy status, age younger than 40 years (2-y cumulative prevalence, 26.6% vs 16.8%; hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = 0.001) and age 40 to 49 years (2-y cumulative prevalence, 23.1% vs 16.8%; HR, 1.49; 95% CI, 1.08-2.04; P = 0.015) remained significant predictors for developing NAFLD after surgical operation compared with age 50 years or older. Oophorectomy was an independent predictor for increased risk of NAFLD (20.9% vs 15.9%; HR, 1.70; 95% CI, 1.01-2.86; P = 0.047). In addition, NAFLD was significantly associated with postoperative development of diabetes mellitus (39.2% vs 15.3%; HR, 2.26; 95% CI, 1.52-3.35; P < 0.0001) and hypercholesterolemia (34.3% vs 17.5%; HR, 1.71; 95% CI, 1.12-2.63; P = 0.014). CONCLUSIONS: Oophorectomy in young women with endometrial cancer significantly increases the risk of NAFLD. This is associated with development of diabetes mellitus and hypercholesterolemia after oophorectomy.

Feto-maternal outcomes of pregnancy complicated by ovarian malignant germ cell tumor: a systematic review of literature.

Malignant germ cell tumors (MGCT) are a rare type of ovarian cancer with poorly understood behavior during pregnancy. This systematic review evaluated feto-maternal outcomes and management patterns of 102 ovarian MGCT-complicated pregnancies identified in PubMed/MEDLINE. Mean age was 25.8. The most common histology type was dysgerminoma (38.2%) followed by yolk sac tumor (30.4%). Abdomino-pelvic pain (35.3%) was the most common symptom. The majority were stage I disease (76.4%) with a mean tumor size of 17.9cm. Most cases had live births (77.5%) at term (56.6%). Tumor surgery without fetal conservation took place in 22 (21.6%) cases (Group 1). This group was characterized by the first trimester tumor detection and intervention, non-viable pregnancy, and frequent concurrent hysterectomy. There were 59 (57.8%) cases which underwent expectant management of pregnancy: mean delay 16.4 weeks for 46 (45.1%) cases with tumor surgery and fetal conservation (Group 2); and 7.8 weeks for 13 (12.7%) cases with tumor surgery after delivery (Group 3). The live birth rate in Groups 2 and 3 was 98.3%. There were 21 (20.6%) cases in which the tumor was incidentally found intra/postpartum (Group 4). Group 2 showed the highest 5-year overall survival rate (92.8%) followed by Group 4 (79.5%), Group 3 (71.4%), and Group 1 (56.2%, p=0.028). Group 1 had more advanced-stage disease when compared to Group 2 (proportion of stages II-IV disease, 36.4% versus 11.4%, p=0.023). In multivariate analysis, age ≤20 (p=0.032) and stages II-IV (p=0.02) remained independent prognosticators for decreased overall survival in all cases. Expectant management of pregnancy was not associated with poor survival outcome in multivariate analysis (p=0.43). In conclusion, our analysis demonstrated that timing of tumor intervention and delivery significantly impacted feto-maternal outcome of ovarian MGCT-complicated pregnancies. It is suggested that early detection and tumor intervention with expectant management of pregnancy is an acceptable option in early-stage ovarian MGCT-complicated pregnancies.

Significance of adenomyosis on tumor progression and survival outcome of endometrial cancer.

BACKGROUND: To examine the effects of adenomyosis on tumor progression and survival outcome of endometrial cancer patients. METHODS: This is a retrospective study examining stage I-IV endometrial cancer patients who underwent hysterectomy-based surgical staging (n = 571), and endometrial hyperplasia patients who underwent hysterectomy (n = 213). Clinical demographics, histopathological factors, and survival outcomes were analyzed based on the presence or absence of adenomyosis. RESULTS: Among the endometrial cancer cohort, adenomyosis was observed in 47.5 % of cases and was significantly associated with lower grade (grade 1-2 tumors, 81.2 vs. 73.3 %; p = 0.028), earlier stage (stage I disease, 74.8 vs. 64.3 %; p = 0.023), and lower likelihood of deep myometrial invasion (19.2 vs. 28.2 %; p = 0.039) and cervical invasion (13.7 vs. 21.2 %; p = 0.024) than those without adenomyosis. In survival analysis, endometrial cancer coexisting with adenomyosis was associated with a significantly better disease-free survival (5-year rate, 89.2 vs. 78.2 %; p < 0.001) and overall survival (91.8 vs. 83.9 %; p = 0.004) after hysterectomy. In multivariate analysis, controlling for other significant variables in univariate analysis, presence of adenomyosis remained an independent prognostic factor associated with decreased risk of disease recurrence after surgery (hazard ratio [HR] 0.53; 95 % confidence interval [CI] 0.30-0.92; p = 0.023). Endometrial hyperplasia had a significantly increased incidence of adenomyosis when compared with type I endometrial cancer (grade 1-2 endometrioid adenocarcinoma, n = 411) on multivariate analysis (62.9 vs. 48.9 %; HR 1.88; 95 % CI 1.32-2.69; p < 0.001). CONCLUSIONS: Adenomyosis appears to be associated with less aggressive tumor behavior of endometrial cancer, suggesting that it may have inhibitory effects on the progression of this disease.