Heather A. Frey

Objective This study aimed to identify characteristics of patients with frequent obstetric triage visits (“superusers”) compared to those with fewer visits and to evaluate the association of frequent obstetric triage visits with preterm birth and cesarean delivery. Study Design This retrospective cohort included patients presenting to the obstetric triage unit at a tertiary care center from March through April 2014. Superusers were defined as individuals having four or more triage visits. Participant characteristics, including demographic, clinical, visit acuity, and health care characteristics of superusers and nonsuperusers, were summarized and compared. In the subset of patients where data were available regarding prenatal care, prenatal visit patterns were analyzed and compared between the two groups. The outcomes of preterm birth and cesarean were compared between groups using modified Poisson regression to control for confounding. Results Of the 656 patients evaluated in the obstetric triage unit during the study period, 648 patients met the inclusion criteria. Factors associated with frequent triage use included race/ethnicity, multiparity, insurance status, high-risk pregnancy, and a prior preterm birth. Superusers were more likely to present at an earlier gestational age and had a higher proportion of visits for hypertensive disease. Patient acuity scores were not different between the groups. In the subset of patients receiving prenatal care at the institution, prenatal visit patterns were similar. The risk of preterm birth (adjusted risk ratio [aRR]: 1.06; 95% confidence interval [CI]: 0.66–1.70) did not differ between groups; however, the risk of a cesarean delivery was increased in superusers (aRR: 1.39; 95% CI: 1.01–1.92) when compared to nonsuperusers. Conclusion Superusers, compared to nonsuperusers, have distinct clinical and demographic characteristics and are more likely to be seen in the triage unit at earlier gestational ages. Superusers tended to have a higher proportion of visits for hypertensive disease and had an increased risk of cesarean delivery. Key Points

Objective We estimated the association between diabetes and shoulder dystocia by infant birth weight subgroups (<4,000, 4,000–4,500, and >4,500 g) in an era of prophylactic cesarean delivery for suspected macrosomia. Study Design A secondary analysis from the National Institute of Child Health and Human Development U.S. Consortium for Safe Labor of deliveries at ≥24 weeks with a nonanomalous, singleton fetus with vertex presentation undergoing a trial of labor. The exposure was either pregestational or gestational diabetes compared with no diabetes. The primary outcome was shoulder dystocia and secondarily, birth trauma with a shoulder dystocia. We calculated adjusted risk ratios (aRRs) with modified Poison's regression between diabetes and shoulder dystocia and the number needed to treat (NNT) to prevent a shoulder dystocia with cesarean delivery. Results Among 167,589 assessed deliveries (6% with diabetes), pregnant individuals with diabetes had a higher risk of shoulder dystocia at birth weight <4,000 g (aRR: 1.95; 95% confidence interval [CI]: 1.66–2.31) and 4,000 to 4,500 g (aRR: 1.57; 95% CI: 1.24–1.99), albeit not significantly at birth weight >4,500 g (aRR: 1.26; 95% CI: 0.87–1.82) versus those without diabetes. The risk of birth trauma with shoulder dystocia was higher with diabetes (aRR: 2.29; 95% CI: 1.54–3.45). The NNT to prevent a shoulder dystocia with diabetes was 11 and 6 at ≥4,000 and >4,500 g, versus without diabetes, 17 and 8 at ≥4,000 and >4,500 g, respectively. Conclusion Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered. Guidelines providing the option of cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights. Key Points