Breastfeeding Initiation, Duration, and Associated Factors Among People With Hepatitis C Virus Infection.

OBJECTIVE: To characterize breastfeeding behaviors and identify factors associated with breastfeeding initiation among people with hepatitis C virus (HCV) infection. METHODS: We conducted a secondary analysis of a multicenter observational cohort of pregnant people with singleton gestations and HCV seropositivity. This analysis includes individuals with data on breastfeeding initiation and excludes those with human immunodeficiency virus (HIV) co-infection. The primary outcome was self-reported initiation of breastfeeding or provision of expressed breast milk. Secondary outcomes included duration of breastfeeding. Demographic and obstetric characteristics were compared between those who initiated breastfeeding and those who did not to identify associated factors. Univariable and multivariable analyses were performed. RESULTS: Overall, 579 individuals (75.0% of participants in the parent study) were included. Of those, 362 (62.5%) initiated breastfeeding or provided breast milk to their infants, with a median duration of breastfeeding of 1.4 months (interquartile range 0.5-6.0). People with HCV viremia , defined as a detectable viral load at any point during pregnancy, were less likely to initiate breastfeeding than those who had an undetectable viral load (59.4 vs 71.9%, adjusted odds ratio [aOR] 0.61, 95% CI, 0.41-0.92). People with private insurance were more likely to initiate breastfeeding compared with those with public insurance or no insurance (80.0 vs 60.1%; aOR 2.43, 95% CI, 1.31-4.50). CONCLUSION: Although HCV seropositivity is not a contraindication to breastfeeding regardless of viral load, rates of breastfeeding initiation were lower among people with HCV viremia than among those with an undetectable viral load. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT01959321 .

Noninvasive Bioelectronic Treatment of Postcesarean Pain: A Randomized Clinical Trial.

Importance: Improved strategies are needed to decrease opioid use after cesarean delivery but still adequately control postoperative pain. Although transcutaneous electrical stimulation devices have proven effective for pain control after other surgical procedures, they have not been tested as part of a multimodal analgesic protocol after cesarean delivery, the most common surgical procedure in the United States. Objective: To determine whether treatment with a noninvasive high-frequency electrical stimulation device decreases opioid use and pain after cesarean delivery. Design, Setting, and Participants: This triple-blind, sham-controlled randomized clinical trial was conducted from April 18, 2022, to January 31, 2023, in the labor and delivery unit at a single tertiary academic medical center in Ohio. Individuals were eligible for the study if they had a singleton or twin gestation and underwent a cesarean delivery. Of 267 people eligible for the study, 134 (50%) were included. Intervention: Participants were randomly assigned in a 1:1 ratio to a high-frequency (20 000 Hz) electrical stimulation device group or to an identical-appearing sham device group and received 3 applications at the incision site in the first 20 to 30 hours postoperatively. Main Outcomes and Measures: The primary outcome was inpatient postoperative opioid use, measured in morphine milligram equivalents (MME). Secondary outcomes included pain scores, measured with the Brief Pain Inventory questionnaire (scale, 0-10, with 0 representing no pain), MME prescribed at discharge, and receipt of additional opioid prescriptions in the postpartum period. Normally distributed data were assessed using t tests; otherwise via Mann-Whitney or χ2 tests as appropriate. Analyses were completed following intention-to-treat principles. Results: Of 134 postpartum individuals who underwent a cesarean delivery (mean [SD] age, 30.5 [4.6] years; mean [SD] gestational age at delivery, 38 weeks 6 days [8 days]), 67 were randomly assigned to the functional device group and 67 to the sham device group. Most were multiparous, had prepregnancy body mass index (calculated as weight in kilograms divided by height in meters squared) higher than 30, were privately insured, and received spinal anesthesia. One participant in the sham device group withdrew consent prior to treatment. Individuals assigned to the functional device used significantly less opioid medication prior to discharge (median [IQR], 19.75 [0-52.50] MME) than patients in the sham device group (median [IQR], 37.50 [7.50-67.50] MME; P = .046) and reported similar rates of moderate to severe pain (85% vs 91%; relative risk [RR], 0.77 [95% CI, 0.55-1.29]; P = .43) and mean pain scores (3.59 [95% CI, 3.21-3.98] vs 4.46 [95% CI, 4.01-4.92]; P = .004). Participants in the functional device group were prescribed fewer MME at discharge (median [IQR], 82.50 [0-90.00] MME vs 90.00 [75.00-90.00] MME; P < .001). They were also more likely to be discharged without an opioid prescription (25% vs 10%; RR, 1.58 [95% CI, 1.08-2.13]; P = .03) compared with the sham device group. No treatment-related adverse events occurred in either group. Conclusions and Relevance: In this randomized clinical trial of postoperative patients following cesarean delivery, use of a high-frequency electrical stimulation device as part of a multimodal analgesia protocol decreased opioid use in the immediate postoperative period and opioids prescribed at discharge. These findings suggest that the use of this device may be a helpful adjunct to decrease opioid use without compromising pain control after cesarean delivery.

Sodium intake and the development of hypertensive disorders of pregnancy.

BACKGROUND: In nonpregnant populations, sodium intake has been associated with the development of chronic hypertension, and sodium restriction has been identified as a strategy to reduce blood pressure. Data regarding the relationship between sodium intake and the development of hypertensive disorders of pregnancy are limited and conflicting. OBJECTIVE: This study aimed to assess the association between daily periconceptional sodium intake and the risk of hypertensive disorders of pregnancy. STUDY DESIGN: This was a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be study. Individuals with nonanomalous, singleton pregnancies who completed food frequency questionnaires with recorded sodium intake in the 3 months before pregnancy were included in the analysis. Individuals whose pregnancies did not progress beyond 20 weeks of gestation were excluded from the analysis. Sodium intake was categorized as low (<2 g per day), medium (2 to <3 g per day), or high (≥3 g per day), based on thresholds used in the nonpregnant population. The primary outcome was the development of a new-onset hypertensive disorder of pregnancy, including gestational hypertension; preeclampsia; hemolysis, elevated liver enzymes, and low platelet count syndrome; superimposed preeclampsia; or eclampsia. Bivariable analyses were performed using Kruskal-Wallis and chi-square tests. Poisson regression was used to estimate adjusted incidence risk ratios with 95% confidence intervals after controlling for potentially confounding factors. RESULTS: Among 7458 individuals included in this analysis, 2336 (31%) reported low sodium intake, 2792 (37%) reported medium sodium intake, and 2330 (31%) reported high sodium intake. Individuals with high sodium intake were more likely to have chronic hypertension, to use tobacco, and to be living with obesity. The risk of developing a hypertensive disorder of pregnancy was similar among groups (medium vs low adjusted incidence risk ratio: 1.10 [95% confidence interval, 0.94-1.28]; high vs low adjusted incidence risk ratio: 1.17 [95% confidence interval, 1.00-1.37]). There was no difference in neonatal outcomes by sodium intake, including preterm birth, small-for-gestational-age neonate, and admission to the neonatal intensive care unit. CONCLUSION: Sodium intake was not associated with the risk of developing a hypertensive disorder of pregnancy. This lack of association contrasts with that between sodium intake and hypertension in the nonpregnant state and may reflect differences in the pathophysiology underlying pregnancy- vs non-pregnancy-related hypertensive disorders.

Association of maternal body mass index with success and outcomes of attempted operative vaginal delivery.

BACKGROUND: Increasing maternal body mass index is associated with increased morbidity at cesarean delivery in a dose-dependent manner. In some clinical scenarios, operative vaginal delivery is a strategy to prevent the morbidity associated with second-stage cesarean delivery, but the relationship between maternal body mass index and outcomes of attempted operative vaginal delivery is not well characterized. OBJECTIVE: This study aimed to assess whether the success of and adverse outcomes after attempted operative vaginal delivery are associated with maternal body mass index at delivery among nulliparous individuals. STUDY DESIGN: This was a secondary analysis from the prospective cohort Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be study. This analysis included cephalic live-born nonanomalous singleton pregnancies ≥34 weeks at delivery with an attempted operative vaginal delivery (either forceps or vacuum). The primary exposure was maternal body mass index at delivery (≥30 vs <30 kg/m2 [referent]). The primary outcome was an unsuccessful operative vaginal delivery attempt, defined as a cesarean delivery after an attempted operative vaginal delivery. The secondary outcomes included maternal and neonatal adverse outcomes. Multivariable logistic regression was used, and statistical interaction between operative instrument type (vacuum vs forceps) and body mass index was assessed. RESULTS: Of 10,038 assessed individuals, 791 (7.9%) had an attempted operative vaginal delivery and were included in this analysis. Of note, 325 individuals (41%) had a body mass index ≥30 kg/m2 at delivery. Overall, 42 of 791 participants (5%) experienced an unsuccessful operative vaginal delivery. Individuals with a body mass index ≥30 kg/m2 at delivery were more than twice as likely to have an unsuccessful operative vaginal delivery than those with a body mass index <30 kg/m2 (8.0% vs 3.4%; adjusted odds ratio, 2.23; 95% confidence interval, 1.16-4.28; P=.005). Composite maternal morbidity and composite neonatal morbidity did not vary by body mass index group. There was no evidence of interaction or effect modification by operative instrument type for the rate of unsuccessful operative vaginal delivery attempt, composite maternal morbidity, or composite neonatal morbidity. CONCLUSION: Among nulliparous individuals who underwent an attempted operative vaginal delivery, those with a body mass index ≥30 kg/m2 at delivery were more likely to have an unsuccessful operative vaginal delivery attempt than those with a body mass index <30 kg/m2. There was no difference in composite maternal or neonatal morbidity after attempted operative vaginal delivery by body mass index category.

Impact of Enhanced Recovery After Surgery pathway for cesarean delivery on postoperative pain.

BACKGROUND: Enhanced Recovery After Surgery pathways provide evidence-based recommendations to optimize perioperative care. OBJECTIVE: This study aimed to holistically investigate the effect of implementing an Enhanced Recovery After Surgery pathway for all cesarean deliveries on postoperative pain experience. STUDY DESIGN: This was a prepost study comparing subjective and objective measures of postoperative pain before and after the implementation of an Enhanced Recovery After Surgery pathway for cesarean delivery. The Enhanced Recovery After Surgery pathway was developed by a multidisciplinary team and included preoperative, intraoperative, and postoperative components, with emphasis on preoperative preparation, hemodynamic optimization, early mobilization, and multimodal analgesia. All individuals undergoing cesarean delivery, whether scheduled, urgent, or emergent, were included. Demographic, delivery, and inpatient pain management data were obtained through medical record review. Of note, 2 weeks after discharge, patients were surveyed about their delivery experience, analgesic usage, and complications. The primary outcome was inpatient opioid use. RESULTS: The study included 128 individuals, 56 in the preimplementation cohort and 72 in the Enhanced Recovery After Surgery cohort. Baseline characteristics between the 2 groups were similar. The survey response rate was 73% (94/128). Opioid use in the first 48 hours postoperatively was significantly lower in the Enhanced Recovery After Surgery group than the preimplementation group (9.4 vs 21.4 morphine milligram equivalents 0-24 hours after delivery [P<.001]; 14.1 vs 25.4 morphine milligram equivalents 24-48 hours after delivery [P<.001]) with no increase in either average or maximum postoperative pain scores. Individuals in the Enhanced Recovery After Surgery group used fewer opioid pills after discharge (10 vs 20; P<.001). Patient satisfaction and complication rates did not change after the implementation of an Enhanced Recovery After Surgery pathway. CONCLUSION: The implementation of an Enhanced Recovery After Surgery pathway for all cesarean deliveries decreased both inpatient and outpatient postpartum opioid use without increasing pain scores or decreasing patient satisfaction.

Cervical change times during induction in nulliparas using vaginal or buccal misoprostol.

AIM: To determine if the time to cervical change and time to active labor were different when misoprostol was administered by a vaginal or buccal route for cervical ripening in nulliparas undergoing labor induction at term. METHODS: This was a secondary analysis of nulliparous participants in the IMPROVE Study-A comparison of vaginal versus buccal misoprostol for cervical ripening for labor induction at term: a triple-masked randomized controlled trial (NCT02408315). The parent study was a non-inferiority randomized controlled trial in which patients beginning induction with a modified Bishop score ≤6 received either vaginal or buccal misoprostol and simultaneous placebo via the opposite route. The primary outcome of the parent study was time to delivery. Primary outcomes for this secondary analysis were the time to active labor (at least 6 cm dilated) and time to change in cervical dilation. Kaplan-Meier analysis was used to compare routes for time to active labor and multistate Markov modeling was used to compare sojourn times at each cervical dilation. RESULTS: Of the 300 participants enrolled in the parent trial, 124 (41.3%) were nulliparous; 59 (47.6%) nulliparous participants underwent induction with vaginal misoprostol and 65 (52.4%) received buccal dosing. Nulliparas receiving vaginal dosing required fewer doses of misoprostol to reach active labor (median 2 vs 3, p = .003). However, this did not result in shorter time to active labor (median vaginal 23.1 h, 95% CI = [21.6, 27.2 h]; buccal 25.6 h [21.5, 29.3 h], p = .45) or higher rate of vaginal delivery within 24 h; (33.9% vs 35.4%, p = .86). There was also no significant difference in time to active labor after adjusting for covariates (adjusted HR for dose route (buccal vs vaginal) = 0.91 [0.61, 1.36], p = .649). Among people that delivered vaginally, the mean sojourn times, measuring cervical dilation state change, were not significantly different, with mean duration to active labor of 20.5 [17.6, 24.5] h for buccal and 21.8 [17.7, 28.2] h for vaginal dosing (p = .092). Satisfaction and preference for dosing routes were not different between groups. CONCLUSION: Buccal and vaginal dosing of misoprostol for cervical ripening in nulliparas appear to have similar times to active labor and progression of cervical change during ripening.

Skin Incision Selection in Superobese Women Undergoing Cesarean Birth.

OBJECTIVE: The aim of this study was to examine whether vertical versus transverse skin incision is associated with increased wound complications in superobese women undergoing cesarean. STUDY DESIGN: This is a secondary analysis of a retrospective cohort study that included women with a body mass index (BMI) ≥ 50 kg/m2 and a cesarean birth with documented skin incision type from 1/1/2008 to 12/31/2015 at a single academic medical center. The primary outcome was a composite of wound complications: infection requiring antibiotics including superficial cellulitis, deep and organ space infections requiring packing, vacuum placement or exploration and debridement in the operating room. Secondary outcomes included estimated blood loss (EBL), time from skin incision to delivery, need for classical or T-hysterotomy, prolonged hospital admission (>4 days), and a composite of adverse neonatal outcomes. The primary exposure was skin incision type, transverse or vertical. Modified Poisson regression variance was used to adjust for differences in baseline characteristics. RESULTS: During the study period, 298 women underwent a cesarean with a known skin incision type. Vertical skin incision occurred in 25.8%. Women with a vertical skin incision were younger, had a higher BMI at delivery, had less weight gain in pregnancy, and were less likely to have labored prior to cesarean. Wound complications were not significantly more common in women with a vertical skin incision after adjusting for covariates (vertical 48.1 vs. transverse 29.4%, adjusted relative risk (aRR): 1.31, 95% confidence interval [CI]: 0.92-1.86). Compared with a transverse skin incision, vertical skin incision was associated with an increased risk for classical hysterotomy (67 vs. 17%, aRR: 2.96, 95% CI: 2.12-4.14), higher EBL, prolonged hospital stay, and composite neonatal morbidity. There were no statistically significant differences in the time from skin incision to delivery. CONCLUSION: In superobese women, vertical skin incision was not associated with increased wound complications, but was associated with increased risk for classical hysterotomy. KEY POINTS: · Vertical skin incision was not associated with a higher risk for composite wound morbidity after adjusting for covariates.. · Vertical skin incision was significantly associated with classical hysterotomy without associated decrease in incision to delivery time or neonatal morbidity.. · When selecting a skin incision approach in superobese women, clinicians should consider whether potential benefits outweigh known risks..

Controversies in antenatal corticosteroids.

Antenatal corticosteroids (ACS) successfully reduce the rates of neonatal mortality and morbidity after preterm birth. However, this translational success story is not without controversies. This chapter explores some contemporary controversies with ACS, including the choice of corticosteroid, use in threatened preterm birth less than 24 weeks' gestation, use in late preterm birth, use at term before cesarean delivery, and issues surrounding repeated and rescue dosing of antenatal corticosteroids. The use of ACS in special populations is also discussed. Finally, areas of future research in ACS are presented, focusing on the ability to individualize therapy.

Trial of Labor Compared With Cesarean Delivery in Superobese Women.

OBJECTIVE: To examine whether labor compared with planned cesarean delivery is associated with increased maternal and neonatal morbidity. METHODS: We conducted a retrospective cohort study of all women with body mass indexes (BMIs) at delivery of 50 or greater delivering a live fetus at 34 weeks of gestation of greater between January 1, 2008, and December 31, 2015. Pregnancies with multiple gestations and major fetal anomalies were excluded. The primary outcome was a composite of maternal and neonatal morbidity and was estimated to be 50% in superobese women based on institutional data. A sample size of 338 women determined the study period and was selected to show a 30% difference in the incidence of the primary outcome between the two groups. Multivariate logistic regression adjusted for potential confounders. RESULTS: There were 344 women with BMIs of 50 or greater who met eligibility criteria, of whom 201 (58%) labored and 143 (42%) underwent planned cesarean delivery. Women who labored were younger, more likely to be nulliparous, and less likely to have pre-existing diabetes. Among women who labored, 45% underwent a cesarean delivery, most commonly for labor arrest (61%) or nonreassuring fetal status (28%). Composite maternal and neonatal morbidity was reduced among women who labored even after adjusting for age, parity, pre-existing diabetes, and prior cesarean delivery (adjusted odds ratio 0.42, 95% CI 0.24-0.75). In the subgroup of women (n=234) who underwent a cesarean delivery, whether planned (n=143) or after labor (n=91), there were no differences in maternal and neonatal morbidity except that severe maternal morbidity was increased in women (n=12) who labored (8.8% compared with 2.1%, relative risk 4.2, 95% CI 1.14-15.4). CONCLUSION: Despite high rates of cesarean delivery in women with superobesity, labor is associated with lower composite maternal and neonatal morbidity. Severe maternal morbidity may be higher in women who require a cesarean delivery after labor.

Postdischarge Opioid Use After Cesarean Delivery.

OBJECTIVE: To characterize postdischarge opioid use and examine factors associated with variation in opioid prescribing and consumption. METHODS: We conducted a prospective observational cohort study by recruiting all women undergoing cesarean delivery during an 8-week period, excluding those with major postoperative morbidities or chronic opioid use. Starting on postoperative day 14, women were queried weekly regarding number of opioid pills used, amount remaining, and their pain experience until they had stopped opioid medication. Demographic and delivery information and in-hospital opioid use were recorded. The state Substance Monitoring Program was accessed to ascertain prescription-filling details. Morphine milligram equivalents were calculated to perform opioid use comparisons. Women in the highest quartile of opioid use (top opioid quartile use) were compared with those in the lowest three quartiles (average opioid use). RESULTS: Of 251 eligible patients, 246 (98%) agreed to participate. Complete follow-up data were available for 179 (71% of eligible). Most women (83%) used opioids after discharge for a median of 8 days (interquartile range 6-13 days). Of women who filled their prescriptions (165 [92%]), 75% had unused tablets (median per person 75 morphine milligram equivalents, interquartile range 0-187, maximum 630) and the majority (63%) stored tablets in an unlocked location. This amounts to an equivalent of 2,540 unused 5-mg oxycodone tablets over our study period. Women who used all prescribed opioids (n=40 [22%]) were more likely to report that they received too few tablets than women who used some (n=109 [61%]) or none (n=30 [17%]) of the prescribed opioids (33% compared with 4% compared with 5%, P<.001). The top quartile was more likely to be smokers than average users and consumed more opioid morphine milligram equivalents per hour of inpatient stay than average opioid users (1.6, interquartile range 1.1-2.3 compared with 1.0, interquartile range 0.5-1.4, P<.001). CONCLUSION: Most women-especially those with normal in-hospital opioid use-are prescribed opioids in excess of the amount needed.