BACKGROUND: Optic nerve sheath diameter (ONSD) reflects intracranial pressure and is increased in pre-eclampsia. Administrating a significant volume of epidural solution into the epidural space can potentially increase ONSD. We investigated the impact of epidural local anesthetic injection on ONSD in patients with pre-eclampsia.
METHODS: Patients with pre-eclampsia (n=11) and normotensive pregnant women (n=11) received de novo epidural anesthesia for cesarean delivery. We administered 21 mL of an epidural solution containing 2% lidocaine and 50 μg fentanyl into the lumbar epidural space in incremental doses. ONSD was measured at baseline, 3, 10, and 20 min after completing the epidural injection, after delivery, and at the end of surgery. Primary outcome was the change in ONSD from baseline to 3 min after epidural injection in patients with pre-eclampsia and normotensive pregnant women. Serial changes in the ONSD were analyzed using a linear mixed model.
RESULTS: At baseline and 3 min after epidural drug injection, ONSD was significantly larger in patients with pre-eclampsia than in normotensive mothers (5.7 vs 4.1 mm, p=0.001 and 5.4 vs 4.1 mm, p<0.001, respectively). However, there were no significant changes in ONSD at 3 min after injection from baseline in either group (p>0.999). Linear mixed model demonstrated that ONSD did not change after epidural anesthesia in either group (p=0.279 and p=0.347, respectively).
CONCLUSIONS: Despite a higher baseline ONSD in pre-eclampsia, epidural anesthesia did not further increase ONSD. Our findings indicate that epidural anesthesia can be safely administered in patients with pre-eclampsia at risk of increased intracranial pressure, without other intracranial pathology.
BACKGROUND: NCT04095832.

Background: Individuals with disabilities may require specific medications in pregnancy. The prevalence and patterns of medication use, overall and for medications with known teratogenic risks, are largely unknown. Methods: This population-based cohort study in Ontario, Canada, 2004-2021, comprised all recognized pregnancies among individuals eligible for public drug plan coverage. Included were those with a physical (n = 44,136), sensory (n = 13,633), intellectual or developmental (n = 2,446) disability, or multiple disabilities (n = 5,064), compared with those without a disability (n = 299,944). Prescription medication use in pregnancy, overall and by type, was described. Modified Poisson regression generated relative risks (aRR) for the use of medications with known teratogenic risks and use of ≥2 and ≥5 medications concurrently in pregnancy, comparing those with versus without a disability, adjusting for sociodemographic and clinical factors. Results: Medication use in pregnancy was more common in people with intellectual or developmental (82.1%), multiple (80.4%), physical (73.9%), and sensory (71.9%) disabilities, than in those with no known disability (67.4%). Compared with those without a disability (5.7%), teratogenic medication use in pregnancy was especially higher in people with multiple disabilities (14.2%; aRR 2.03, 95% confidence interval [CI]: 1.88-2.20). Furthermore, compared with people without a disability (3.2%), the use of ≥5 medications concurrently was more common in those with multiple disabilities (13.4%; aRR 2.21, 95% CI: 2.02-2.41) and an intellectual or developmental disability (9.3%; aRR 2.13, 95% CI: 1.86-2.45). Interpretation: Among people with disabilities, medication use in pregnancy is prevalent, especially for potentially teratogenic medications and polypharmacy, highlighting the need for preconception counseling/monitoring to reduce medication-related harm in pregnancy.

BACKGROUND: The current Institute of Medicine pregnancy weight gain guidelines were developed using the best available evidence, but were limited by substantial knowledge gaps. Some have raised concern that the guidelines for individuals affected by overweight or obesity are too high and contribute to short- and long-term complications for the mother and child.
OBJECTIVE: To determine the association between pregnancy weight gain below the lower limit of the current Institute of Medicine (IOM) recommendations and risk of 10 adverse maternal and child health outcomes among individuals with overweight and obesity.
METHODS: We used data from a prospective cohort study of US nulliparae with prepregnancy overweight (n=955) or obesity (n=897) followed from the first trimester to 2-7 years postpartum. We used multivariable Poisson regression to relate pregnancy weight gain z-scores with a severity-weighted composite outcome consisting of ≥1 of 10 adverse outcomes (gestational diabetes, preeclampsia, unplanned cesarean delivery, maternal postpartum weight increase >10kg, maternal postpartum metabolic syndrome, infant death, stillbirth, preterm birth, small-for-gestational age birth, and childhood obesity).
RESULTS: Pregnancy weight gain z-scores below, within, and above the IOM-recommended ranges occurred in 5%, 13%, and 80% of pregnancies with overweight and 17%, 13%, and 70% of pregnancies with obesity. There was a positive association between pregnancy weight gain z-scores and all adverse maternal outcomes, childhood obesity, and the composite outcome. Pregnancy weight gain z-scores below the lower limit of the recommended ranges (<6.8 kg for overweight, <5 kg for obesity) were not associated with the severity-weighted composite outcome. For example, compared with the lower limit, adjusted rate ratios (95% confidence interval) for z-scores of -2 standard deviations in pregnancies with overweight (equivalent to 3.6kg at 40 weeks) and obesity (-2.8kg at 40 weeks) were 0.99 (0.91, 1.06) and 0.97 (0.87, 1.07).
CONCLUSIONS: These findings support arguments to decrease the lower limit of recommended weight gain ranges in these prepregnancy BMI groups.

BACKGROUND: Current postpartum hemorrhage (PPH) risk stratification is based on traditional statistical models or expert opinion. Machine learning could optimize PPH prediction by allowing for more complex modeling.
OBJECTIVE: We sought to improve PPH prediction and compare machine learning and traditional statistical methods.
METHODS: We developed models using the Consortium for Safe Labor data set (2002-2008) from 12 US hospitals. The primary outcome was a transfusion of blood products or PPH (estimated blood loss of ≥1000 mL). The secondary outcome was a transfusion of any blood product. Fifty antepartum and intrapartum characteristics and hospital characteristics were included. Logistic regression, support vector machines, multilayer perceptron, random forest, and gradient boosting (GB) were used to generate prediction models. The area under the receiver operating characteristic curve (ROC-AUC) and area under the precision/recall curve (PR-AUC) were used to compare performance.
RESULTS: Among 228,438 births, 5760 (3.1%) women had a postpartum hemorrhage, 5170 (2.8%) had a transfusion, and 10,344 (5.6%) met the criteria for the transfusion-PPH composite. Models predicting the transfusion-PPH composite using antepartum and intrapartum features had the best positive predictive values, with the GB machine learning model performing best overall (ROC-AUC=0.833, 95% CI 0.828-0.838; PR-AUC=0.210, 95% CI 0.201-0.220). The most predictive features in the GB model predicting the transfusion-PPH composite were the mode of delivery, oxytocin incremental dose for labor (mU/minute), intrapartum tocolytic use, presence of anesthesia nurse, and hospital type.
CONCLUSIONS: Machine learning offers higher discriminability than logistic regression in predicting PPH. The Consortium for Safe Labor data set may not be optimal for analyzing risk due to strong subgroup effects, which decreases accuracy and limits generalizability.

BACKGROUND: Interoception encompasses the conscious awareness of homeostasis in the body. Given that fetal movement awareness is a component of interoception in pregnant women, the timing of initial detection of fetal movement may indicate individual differences in interoceptive sensitivity.
OBJECTIVE: The aim of this study is to determine whether the association between the gestational week of initial movement awareness and interoception can be a convenient evaluation index for interoception in pregnant women.
METHODS: A cross-sectional study was conducted among 32 pregnant women aged 20 years or older at 22-29 weeks of gestation with stable hemodynamics in the Obstetric Outpatient Department. Interoception was assessed using the heartbeat-counting task, with gestational weeks at the first awareness of fetal movement recorded via a questionnaire. Spearman rank correlation was used to compare the gestational weeks at the first awareness of fetal movement and heartbeat-counting task scores.
RESULTS: A significant negative correlation was found between the gestational weeks at the first fetal movement awareness and heartbeat-counting task performance among all participants (r=-0.43, P=.01) and among primiparous women (r=-0.53, P=.03) but not among multiparous women.
CONCLUSIONS: Individual differences in interoception appear to correlate with the differences observed in the timing of the first awareness of fetal movement.

UNASSIGNED: Preterm birth is the leading cause of neonatal morbidity and mortality worldwide. Most cases of preterm birth occur spontaneously and result from preterm labor with intact (spontaneous preterm labor [sPTL]) or ruptured (preterm prelabor rupture of membranes [PPROM]) membranes. The prediction of spontaneous preterm birth (sPTB) remains underpowered due to its syndromic nature and the dearth of independent analyses of the vaginal host immune response. Thus, we conducted the largest longitudinal investigation targeting vaginal immune mediators, referred to herein as the immunoproteome, in a population at high risk for sPTB.
UNASSIGNED: Vaginal swabs were collected across gestation from pregnant women who ultimately underwent term birth, sPTL, or PPROM. Cytokines, chemokines, growth factors, and antimicrobial peptides in the samples were quantified via specific and sensitive immunoassays. Predictive models were constructed from immune mediator concentrations.
UNASSIGNED: Throughout uncomplicated gestation, the vaginal immunoproteome harbors a cytokine network with a homeostatic profile. Yet, the vaginal immunoproteome is skewed toward a pro-inflammatory state in pregnant women who ultimately experience sPTL and PPROM. Such an inflammatory profile includes increased monocyte chemoattractants, cytokines indicative of macrophage and T-cell activation, and reduced antimicrobial proteins/peptides. The vaginal immunoproteome has improved predictive value over maternal characteristics alone for identifying women at risk for early (<34 weeks) sPTB.
UNASSIGNED: The vaginal immunoproteome undergoes homeostatic changes throughout gestation and deviations from this shift are associated with sPTB. Furthermore, the vaginal immunoproteome can be leveraged as a potential biomarker for early sPTB, a subset of sPTB associated with extremely adverse neonatal outcomes.
UNASSIGNED: This research was conducted by the Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS) under contract HHSN275201300006C. ALT, KRT, and NGL were supported by the Wayne State University Perinatal Initiative in Maternal, Perinatal and Child Health.
Human pregnancies last 40 weeks on average. Preterm births, defined as live births before 37 weeks, occur in about one in ten pregnancies. Being born too early is the main cause of a number of diseases and death in newborn babies. Preterm births are further divided into those that happen early – before 34 weeks – and those that happen late – between 34 and 37 weeks. There are also differences between preterm births in which the amniotic sac ruptures before or after the start of labor. Although several factors can lead to spontaneous preterm birth, bacteria getting into the amniotic fluid around the fetus are a well-known trigger. These bacteria usually come from the vagina. In the past, researchers have studied the number and types of bacteria in the vagina of people who had a normal pregnancy and those that had a preterm birth to predict who is more at risk of preterm birth. However, predictions based only on data about bacteria have been less useful so far. Instead, it might be better to investigate a person’s immune response during pregnancy. Shaffer et al. addressed this gap by asking whether measuring the levels of proteins involved in the immune response could help predict preterm births. Shaffer et al. collected vaginal fluids from 739 individuals of predominately African American ethnicity with an average BMI of 28.7 – representing a population at high risk for spontaneous preterm birth. The swabs were taken at multiple points during their pregnancy, and 31 different immune-related proteins in those fluids were measured. The researchers further noted whether these individuals had a normal or a preterm birth. The data showed that, compared to normal births, preterm births are associated with higher levels of proteins that attract white blood cells and promote inflammation, such as IL-6 and IL-1β. Vaginal fluids from individuals who went on to have an early preterm birth where the amniotic sac ruptured before labor, contained lower levels of proteins known as defensins, which defend the body from bacteria. With these new data from vaginal swabs, Shaffer et al. could make better predictions about the likelihood of preterm birth in general and early preterm birth with the amniotic sac ruptured before labor. For the latter scenario, the predictions were not improved when combining immune protein data with other characteristics of the pregnant person, such as age. These findings suggest that clinicians may be able to use measurements of immune-related proteins to help predict preterm births, so that pregnant individuals at high risk can receive extra care. Further research will have to validate the data and determine whether the findings apply more widely.

BACKGROUND: As surgery is an essential aspect of healthcare around the globe, it is necessary to consider complications related to it. Therefore, this study was conducted to evaluate the impact of the World Health Organization Surgical Safety Checklist (WHO SSC) on reducing the incidence of postoperative complications Methods: This single-center, prospective, comparative study was conducted at the Department of Gynecology and Obstetrics in a government hospital in Patna, Bihar. To assess the efficacy of the WHO SSC, the patients were divided into two groups, in which one group undergoing surgery was assessed with the checklist, and the other group was not. The rates of surgery-related complications were then compared in both groups.
RESULTS: Our results showed a reduction in surgery-related complications in patients assessed with the WHO SSC. No statistically significant difference in duration of surgery was found between the groups. However, a statistically significant difference was observed in the rates of surgery-related complications between groups, especially in sepsis (p=0.0009), hemorrhage (p<0.0001), and infection at the site of surgery (p<0.0001). Mortality rates were not affected by the use of the SSC.
CONCLUSIONS: The WHO SSC is a simple yet effective tool for reducing postoperative complications by improving communication between the various team members working in the operation theatre, although it has no effect on reducing mortality. Further research is needed to enhance its successful implementation and ensure its sustained use.

OBJECTIVE: It is unclear if postoperative pain experience and opioid consumption differ in patients undergoing primary vs repeat Cesarean delivery (CD) as prior studies have yielded conflicting results and none used the same patients as their own controls. We sought to compare opioid consumption and pain scores in patients undergoing both a primary and a first repeat CD, using the same patients as their own controls.
METHODS: We conducted a single-centre historical cohort study of patients who underwent both a primary and a first repeat CD under neuraxial anesthesia between 1 January 2016 and 30 November 2022. The same standardized multimodal analgesic regimen was used for all patients. The primary outcome was opioid consumption in oral morphine equivalents (OME) at 48 hr after surgery. Secondary outcomes included area under the curve for pain scores at 24 and 48 hr, and opioid consumption at 24 hr.
RESULTS: We included 409 patients. In unadjusted analysis, there were no significant differences between primary and repeat CD in median [interquartile range] opioid consumption at 48 hr (45 [15-89] mg vs 45 [15-83] mg OME) or in any of the secondary outcomes. In the multivariable model adjusting for age, body mass index, anxiety, depression, priority, surgery duration, gestational age, receipt of postoperative ketorolac, and neuraxial type, repeat CD was still not associated with increased opioid consumption compared with primary CD (adjusted rate ratio, 1.20; 95% confidence interval, 0.95 to 1.51).
CONCLUSIONS: In this retrospective study, we found no differences in postoperative opioid consumption or reported pain scores in patients who underwent both a primary and a first repeat CD.
RéSUMé: OBJECTIF: Nous ne savons pas si l’expérience de la douleur postopératoire et la consommation d’opioïdes diffèrent chez la patientèle accouchant par césarienne pour la première fois ou pour la seconde fois. En effet, les études antérieures ont donné des résultats contradictoires et aucune n’a utilisé la même patientèle comme témoins. Nous avons cherché à comparer la consommation d’opioïdes et les scores de douleur chez les personnes parturientes exposées à la fois à un premier puis un deuxième accouchement par césarienne en recrutant les mêmes personnes en tant que leurs propres témoins. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique auprès de personnes parturientes ayant subi à la fois une première et une seconde césarienne sous anesthésie neuraxiale entre le 1er janvier 2016 et le 30 novembre 2022. Le même régime analgésique multimodal standardisé a été utilisé pour toutes les personnes dans l’étude. Le critère d’évaluation principal était la consommation d’opioïdes en équivalents morphine oraux (EMO) 48 heures après la chirurgie. Les critères d’évaluation secondaires comprenaient la surface sous la courbe pour les scores de douleur à 24 et 48 heures, et la consommation d’opioïdes à 24 heures. RéSULTATS: Nous avons inclus 409 personnes. Dans l’analyse non ajustée, il n’y avait pas de différence significative entre le premier et le deuxième accouchement par césarienne en ce qui concerne la consommation médiane d’opioïdes [écart interquartile] à 48 heures (45 [15 à 89] mg vs 45 [15–83] mg EMO) ou dans l’un des critères d’évaluation secondaires. Dans le modèle multivarié ajusté en fonction de l’âge, l’indice de masse corporelle, l’anxiété, la dépression, la priorité, la durée de la chirurgie, l’âge gestationnel, l’administration de kétorolac postopératoire et le type d’anesthésie neuraxiale, une deuxième césarienne n’était toujours pas associée à une consommation accrue d’opioïdes par rapport à une première césarienne (rapport de taux ajusté, 1,20; intervalle de confiance à 95 %, 0,95 à 1,51). CONCLUSION: Dans cette étude rétrospective, nous n’avons trouvé aucune différence dans la consommation d’opioïdes postopératoires ou les scores de douleur rapportés chez la patientèle ayant accouché par césarienne pour la première ou pour la deuxième fois.

UNASSIGNED: A cesarean delivery is regarded as a comparatively favourable and secure approach to childbirth when contrasted with vaginal delivery. Over the past decade, its frequency has risen in both industrialized and developing nations. Maternal request for cesarean delivery has been explained for the escalating rate along with other factors like anxiety, fear of childbirth, previous cesarean delivery, previous negative vaginal birth experience, maternal age, maternal education, and socioeconomic factors. Hence, this study was undertaken to assess pregnant women\'s tendency to have a cesarean birth and to investigate the factors associated with the inclination for cesarean delivery.
UNASSIGNED: A hospital-based cross-sectional study was carried out in the Department of Obstetrics and Gynaecology of a tertiary care hospital, a systematic sampling procedure was utilized, and 368 antenatal mothers after 36 weeks of gestation, who do not have any specific medical reasons against vaginal delivery were included in the study. Data collection was done by questionnaire. The information regarding socio-demographic factors, preexisting comorbidities, current obstetric risk factors, emotional factors, previous delivery experience, and their information preference toward the mode of delivery were collected. Univariate and multivariate analysis were performed to identify the independent variables associated with preference for cesarean delivery.
UNASSIGNED: The preference for cesarean delivery and non-preference for cesarean delivery was 114 (30.9%) and 201 (54.6%), respectively whereas 53 (14.4%) participants remained neutral. The Chi-square analysis revealed a notable connection between the inclination towards a preference for cesarean delivery and factors such as obstetric score, parity, comorbidities, and among obstetric risk factors such as pregnancy after in-vitro fertilization (IVF), with a history of abortion, and having a prior history of cesarean delivery. Nevertheless, no meaningful association was observed between the preference for cesarean delivery and the remaining variables. On multivariate logistic analysis, independent variables like preexisting anxiety or depression, pregnancy through IVF, and having a history of previous cesarean delivery have increased the odds of preferring cesarean delivery. The independent variables like increasing gestational age, graduates, and unemployed have decreased the odds of preferring a cesarean delivery.
UNASSIGNED: In conclusion, the prevalence of cesarean delivery is influenced by a complex interplay of medical, cultural, socioeconomic, and healthcare system factors. While cesarean delivery is essential in cases of medical necessity, efforts should be made to avoid unnecessary cesarean delivery that does not provide clear benefits over vaginal delivery. Balancing the risks and benefits of cesarean delivery and promoting evidence-based obstetric practices are crucial for ensuring optimal maternal and infant outcomes.

BACKGROUND: Depression is a severe and treatable mental illness that significantly affects individuals\' daily activities. Obstetric care providers are the most vulnerable group for depression because they work in an emergency to save two lives at a time, share the stress of women during labor, and are at great risk for contamination.
OBJECTIVE: To assess depression and associated factors among obstetric care providers working in public health facilities.
METHODS: A cross-sectional study was conducted among 423 obstetric care providers working in public health facilities found in the West Arsi Zone, Ethiopia, from June 1 to 30, 2023. Study participants were selected through a simple random sampling technique. A pretested, face-to-face interviewer-administered structured questionnaire was used to collect data. Bi-variable and multivariable logistic regression analyses were employed to identify factors associated with depression. The level of statistical significance was declared at P < 0.05 with a 95% CI.
UNASSIGNED: Overall, the prevalence of depression among obstetric care providers was 31.1% (95% CI: 26.6%, 35.5%). Marital status not in union (AOR = 2.86, 95%CI: 1.66, 4.94), working more than 40 hours per week (AOR = 2.21, 95%CI: 1.23, 3.75), current substance use (AOR = 2.73, 95%CI: 1.64, 4.56), not being satisfied with their job (AOR = 3.52, 95%CI: 2.05, 6.07) and having burnout symptoms (AOR = 5.11, 95%CI: 2.95, 8.83) were factors significantly associated with depression.
CONCLUSIONS: We recommend that health professionals take care of themselves and avoid substance use. We also recommended that stakeholders enhance job satisfaction and avoid burnout by implementing various programs, like raising wages for workers, increasing staff members, offering various benefits, and regularly monitoring issues that arise.