Background The frequency of planned out-of-hospital birth in the United States has increased in recent years. The value of studies assessing the perinatal risks of planned out-of-hospital birth versus hospital birth has been limited by cases in which transfer to a hospital is required and a birth that was initially planned as an out-of-hospital birth is misclassified as a hospital birth. Methods We performed a population-based, retrospective cohort study of all births that occurred in Oregon during 2012 and 2013 using data from newly revised Oregon birth certificates that allowed for the disaggregation of hospital births into the categories of planned in-hospital births and planned out-of-hospital births that took place in the hospital after a woman’s intrapartum transfer to the hospital. We assessed perinatal morbidity and mortality, maternal morbidity, and obstetrical procedures according to the planned birth setting (out of hospital vs. hospital). Results Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P = 0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures. Conclusions Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.)

INTRODUCTION Little is known about the relationship between disability and mode of delivery. Prior research has indicated elevated risk of cesarean delivery among women with certain disabilities, but has not examined patterns across multiple types of disability or by parity. OBJECTIVE To determine whether physical, sensory, or intellectual and developmental disabilities are independently associated with primary cesarean delivery. METHODS We conducted a retrospective cohort study of all deliveries in California 2000–2010 using linked birth certificate and hospital discharge data. We identified physical, sensory, and intellectual and developmental disabilities using ICD-9 codes. We used logistic regression to examine the association of these disabilities and primary cesarean delivery, controlling for socio-demographic characteristics and co-morbidities and stratified by parity. RESULTS In our sample, 0.45% (20,894/4,610,955) of deliveries were to women with disabilities. A larger proportion of women with disabilities were nulliparous, had public insurance, and had co-morbidities (e.g., gestational diabetes) compared with women without disabilities (p<0.001 for all). The proportion of primary cesarean in women with disabilities was twice that in women without disabilities (32.7% versus 16.3%, p<0.001; aOR = 2.05; 95% CI = 1.94–2.17). The proportion of deliveries by cesarean was highest among women with physical disabilities due to injuries compared with women without disabilities (57.8% versus 16.3%, p<0.001; aOR = 6.83; 95%CI = 5.46–8.53). CONCLUSION Women across disability subgroups have higher odds of cesarean delivery, and there is heterogeneity by disability type. More attention is needed to this population to ensure better understanding of care practices that may impact maternal and perinatal outcomes.

Background Approximately 12% of women of reproductive age have some type of disability. Very little is known about sexual and reproductive health issues among women with disabilities, including what proportion of women with disabilities experience pregnancy. Data on pregnancy are important to inform needs for preconception and pregnancy care for women with disabilities. Objective The purpose of this study was to describe the occurrence of pregnancy among women with various types of disability and with differing levels of disability complexity, compared to women without disabilities, in a nationally representative sample. Study Design We conducted cross-sectional analyses of 2008–2012 Medical Expenditure Panel Survey annualized data to estimate the proportion of women ages 18–44 with and without disabilities who reported a pregnancy during one year of their participation on the survey panel. We used multivariable logistic regression to test the association of pregnancy with presence, type, and complexity of disability, controlling for other factors associated with pregnancy. Results Similar proportions of women with and without disabilities reported a pregnancy (10.8% vs. 12.3%, with 95% confidence intervals overlapping). Women with the most complex disabilities (those that impact activities such as self-care and work) were less likely to have been pregnant (AOR=0.69, 95%CI=0.52–0.93), but women whose disabilities only affected basic actions (seeing, hearing, movement, cognition) did not differ significantly from women with no disabilities. Conclusion Women with a variety of types of disabilities experience pregnancy. Greater attention is needed to the reproductive healthcare needs of this population in order to ensure appropriate contraceptive, preconception, and perinatal care.

Background-The frequency of planned out-of-hospital birth in the United States has increased in recent years. The value of studies assessing the perinatal risks of planned out-of-hospital birth versus hospital birth has been limited by cases in which transfer to a hospital is required and a birth that was initially planned as an out-of-hospital birth is misclassified as a hospital birth.

Objective We characterized independent and joint impacts of maternal race/ethnicity and obesity on adverse birth outcomes, including preeclampsia, low birthweight (LBW), and macrosomia. Methods Retrospective cohort study of all 2007 California births using vital records and claims data. Maternal race/ethnicity and maternal BMI were the key exposures; we analyzed their independent and joint impact on outcomes using regression models. Results Racial/ethnic minority women of normal weight generally had higher risk as compared to white women of normal weight (e.g., African-American women, preeclampsia aOR, 1.60, 95% CI: 1.48 – 1.74, versus white women). However, elevated BMI did not usually confer additional risk (e.g., preeclampsia aOR comparing African-American women with morbid obesity to white women with morbid obesity; 1.17, 95% CI: 0.89 – 1.54). Obesity was a risk factor for LBW only among white women (morbid obesity aOR, 95% CI: 1.24, 1.04 – 1.49, versus white women of normal weight), and not among racial/ethnic minority women (e.g., African-American women, 0.95, 0.83 – 1.08). Conclusions These findings add nuance to our understanding of the interplay between maternal race/ethnicity, BMI, and perinatal outcomes. While the BMI/adverse outcome gradient appears weaker in racial/ethnic minority women, this reflects the overall risk increase in racial/ethnic minority women of all body sizes.

Objectives To evaluate the association of Oregon’s hard-stop policy limiting early elective deliveries (before 39 weeks of gestation) and the rate of elective early-term inductions and cesarean deliveries and associated maternal–neonatal outcomes. Methods This was a population-based retrospective cohort study of Oregon births between 2008 and 2013, using vital statistics data and multivariable logistic regression models. Our exposure was the Oregon hard-stop policy, defined as the time periods pre-policy (2008 – 2010) and post-policy (2012 – 2013). We included all term or postterm, cephalic, nonanomalous, singleton deliveries (N= 181,034 births). Our primary outcomes were induction of labor and cesarean delivery at 37 or 38 weeks of gestation without a documented indication on the birth certificate (i.e., elective early term delivery). Secondary outcomes included neonatal intensive care unit admission, stillbirth, macrosomia, chorioamnionitis, and neonatal death. Results The rate of elective inductions before 39 weeks declined from 4.0% in the prepolicy period to 2.5% during the postpolicy period (P<0.001); a similar decline was observed for elective early term cesareans (from 3.4% to 2.1%; P<0.001). There was no change in neonatal intensive care unit admission, stillbirth, or assisted ventilation pre-policy and post-policy, but chorioamnionitis did increase (from 1.2% to 2.2%, P<0.001; adjusted odds ratio, 1.94, 95% confidence interval, 1.80 – 2.09). Conclusions Oregon’s statewide policy to limit elective early-term delivery was associated with a reduction in elective early-term deliveries, but no improvement in maternal or neonatal outcomes.

Carcinosarcoma of the pancreas is a rare malignancy with high mortality. Diagnosis is based on pathologic demonstration of adjacent malignant epithelial and mesenchymal tissue. Due to inherent limitations of biopsy sampling, tumor heterogeneity is rarely recognized until definitive surgical resection. A 52-year-old woman presented to the emergency department with diarrhea. Abdominal CT imaging showed a 4.1×4.5 cm mass in the head of the pancreas with intrahepatic and extrahepatic ductal dilation. Endoscopic ultrasound (EUS) confirmed the mass with evidence of superior mesenteric vein involvement. Fine-needle aspiration (FNA) showed adenocarcinoma. After multi-disciplinary tumor board discussion, the patient was treated with four cycles of neoadjuvant of oxaliplatin, irinotecan, fluorouracil, and leucovorin (FOLFIRINOX) followed by 50-55 Gy photon radiation with concurrent capecitabine. Pancreaticoduodenectomy was performed after 6 months of neoadjuvant therapy. Pathologic examination revealed carcinosarcoma of the pancreas, with pathological partial response in the resected tumor. Patient has been disease-free for 15 months. Carcinosarcoma of pancreas is a rare clinical entity. There is no established systemic therapy and only two patients, inclusive of this case, have been treated with neoadjuvant chemotherapy. Here we report a case of pancreatic carcinosarcoma treated with neoadjuvant FOLFIRINOX followed by chemoradiation with pathological partial response. Modern treatment approaches for pancreatic ductal adenocarcinoma (PDAC) could be applied to this rare pathology.

baseline, delivery at gestational age of 36 weeks (OR¼ >12.64) optimized total QALYs. CONCLUSION: Delivery at 38 weeks' gestation optimizes total QALYs and intact neonatal survivors in women who use methamphetamines in pregnancy. While best practice would lead to diminished or cessation of methamphetamine use, in those who continue use during pregnancy, early intervention may improve outcomes.