While antenatal corticosteroids (ACS) administered in the late preterm period have been shown to reduce respiratory morbidity, this finding was demonstrated in a well-designed randomized controlled trial (ALPS) with strict inclusion/exclusion criteria that may differ from clinical practice. The aim of this study was to investigate whether there has been indication creep since use of late preterm ACS became standard of care. Retrospective cohort study of pregnant women who received late preterm ACS between 2016 and 2019 were identified and separated into epochs of 2016-2017 and 2018-2019 based upon year of exposure. The primary outcome was rate of inappropriate ACS exposure, defined as non-adherence to the inclusion/exclusion criteria of the ALPS trial. Secondary outcomes were rates of non-optimal ACS exposure (delivery >7 days from ACS or term delivery). Logistic regression was used to generate adjusted odds ratios (aOR) between epochs for the primary outcome adjusting for confounders. There were 660 women who received late preterm ACS during the study period with 229 (34.6 %) deemed inappropriate exposures. The most common reason for inappropriate treatment was PPROM (29.0%) with exclusionary cervical exam or contraction frequency. No difference was observed in inappropriate ACS exposure between epochs (aOR 0.83, CI 0.59-1.2). However, there was a reduction in non-optimal exposure over time (aOR 0.67, 0.47-0.97) . Women receiving inappropriate ACS were more likely to deliver at term if indicated for maternal/fetal status (50.0% vs 19.5%; p<.001) and preterm labor (66.0% vs 41.9%; p=.015). Further, inappropriate exposure in PTL had higher rates of exposure latency >7 days (62.3% vs 39.1%; p=.006) with a longer latency to delivery (3 vs 16 days; p<.001). Over one third of women received late preterm ACS for an indication that could be classified as indication creep. Depending on indication, inappropriate administration is associated with higher rates of non-optimal exposure.
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Although both cytology and HPV testing are sound methods for surveillance of CIN 1, it is more cost-effective to use HPV testing.
INTRODUCTION: Intrahepatic Cholestasis of Pregnancy (ICP) is associated with intrauterine fetal demise (IUFD) and severity of disease is associated with higher rates of IUFD. Antepartum management of (ICP) is highly variable. Consensus in clinical practice is to encourage delivery at 37 weeks regardless of severity. We evaluated if standardizing the management of ICP based on bile acid level would affect maternal and neonatal outcomes. METHODS: Women diagnosed with ICP and delivered at our hospital were prospectively followed from 01/02/2012-01/01/2018. Maternal and neonatal outcomes were evaluated before and after institution of a standardized management protocol. A 6 month wash-out period was utilized. Statistical methods performed included the Chi Square test, Fischer exact probability test and the two sample t-test. IRB approval was obtained and standards upheld. RESULTS: Ninety-two patients were included in the analysis. The bile acid level was higher in the post guideline group 69 umol/L vs the pre guideline group 30 umol/L (p =0.002). No difference was noted in the cesarean rate (p=0.56), NICU admissions (p=0.075), or 5 minute APGAR (p=0.609). The rate of composite neonatal respiratory morbidity was higher in the post guideline group (p=0.0023). There was one IUFD in the post-guideline group that occurred at 28 weeks in the setting of a twin pregnancy and bile acids of 264. CONCLUSION: Induction at 39 weeks for pregnancies with bile acids 20 or less did increase composite neonatal respiratory morbidity. Guidelines and standardization of care for cholestasis of pregnancy would help reduce variability between providers and deliveries prior to 39 weeks.
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