Anna Merport Modest

Background: Placenta previa (PP) is a well‐recognized obstetric complication with established maternal risks, particularly hemorrhage, that contribute significantly to maternal morbidity. In contrast, low‐lying placenta (LLP) has historically been grouped with previa in both coding and clinical practice, limiting our ability to study its imparted associated outcomes as a distinct entity. However, in 2017, coding revisions allowed for a parsed diagnosis of LLP and PP and enabled the current study of differentiated associated outcomes. Objective(s): To describe and compare the independent rates of hemorrhage and severe maternal morbidity (SMM) associated with LLP and PP relative to normal placentation. Methods: We conducted a retrospective analysis using the Nationwide Readmissions Database (NRD) from 2017 through 2019, reflecting the initial 3 years of coding for LLP. Patients with multifetal gestation, ectopic/molar pregnancies, and other placental abnormalities were excluded. The primary outcome was hemorrhage, defined using international classification of diseases (ICD)‐10 codes for ante‐, intra‐, and postpartum hemorrhage (PPH). SMM was defined using the Centers for Disease Control and Prevention's index, which includes a range of life‐threatening complications such as disseminated intravascular coagulation, hysterectomy, and shock. Baseline characteristics and maternal outcomes were compared using chi‐square tests for categorical variables and Kruskal–Wallis tests for continuous variables. Multivariable regression analysis was used to evaluate the risk ratios (RRs) of adverse outcomes across these groups. Results: Among 5,625,432 singleton deliveries, 11,486 were diagnosed with LLP and 21,356 with PP. Compared to normal placentation, LLP was associated with a significantly higher rate of hemorrhage (21.1% vs. 4.0%, p < 0.001), SMM (4.5% vs. 1.8%, p < 0.001), maternal blood transfusion (3.3% vs. 1.1%, p < 0.001), hysterectomy (0.2% vs. < 0.1%, p < 0.001), and hysterectomy within 30 days (0.2% vs. 0.0%, p < 0.001). LLP was also associated with longer median hospital stay (3 vs. 2 days, p < 0.001) and higher total charges ($21,410 vs. $17,024; p < 0.001). In adjusted analyses using normal placentation as the referent group, LLP remained independently associated with hemorrhage (adjusted relative risk [aRR], 4.72; 95% CI, 4.56–4.89), SMM (aRR, 2.16; 95% confidence interval [CI], 1.99–2.35), and transfusion (aRR, 2.61; 95% CI, 2.36–2.88). PP was associated with even higher risks of hemorrhage (aRR, 8.93), SMM (aRR, 4.22), and transfusion (aRR, 5.69) compared to those with normal placentation (all p < 0.001). Conclusion: With the institution of distinct coding for LLP in 2017, we were able to distinguish between patients with LLP and PP. While PP remains associated with the highest risk of poor maternal outcomes, patients with an antenatal diagnosis of LLP also have an increased risk of hemorrhage and SMM relative to those with normal placentation. These findings should be considered during the prenatal counseling and management of patients with LLP.

Objective: The objective of our study is to determine whether the use of a self‐retaining panniculus retraction device (traxi) in patients with obesity will improve operative time, pulmonary function, or patient and provider experience for non‐emergent cesarean delivery. Methods: Pregnant patients with body mass index (BMI) ≥40 kg/m ² undergoing non‐emergent cesarean delivery were recruited from two academic hospitals and randomized to traxi panniculus retraction or to no traxi. Computer‐generated block randomization, stratified by prior abdominal surgery, was used to randomize participants in a 1:1 ratio to the traxi or standard care. Demographic information was collected by self‐report. Surgical time from skin incision to closure and clinical data was collected by review of the electronic health record. Pulmonary function testing via spirometer was performed before and after application of retraction. Participant and provider experience was collected postoperatively. Intention‐to‐treat analysis was performed using a Wilcoxon rank‐sum test and a chi‐squared test for continuous and dichotomous variables, respectively. Results: We enrolled 135 participants from 2018 to 2024 at two academic hospitals; 67 were randomized to traxi and 68 were randomized to no traxi. Of these, 43 (31.9%) reported no prior abdominal surgery (including prior cesarean or other laparotomy) and the median BMI was 48.9 (interquartile range [IQR] 45.0, 52.5). The trial was terminated before the target sample size of 220 participants was achieved due to slow accrual and waning clinical equipoise. Baseline characteristics of each group were similar. Median surgical time was 65.0 min (IQR 55.0, 81.0) in the traxi group and 70.0 min (IQR 57.0, 86.0) in the no traxi group, but this difference was not statistically significant ( p = 0.31). There was less restrictive pulmonary physiology associated with application of traxi compared to no traxi; the forced expiratory volume in 1 second (FEV1) difference was −0.03 L (−0.20, 0.10) and −0.11 L (−0.45, −0.02) ( p = 0.048), respectively. Providers were significantly more likely to report that the traxi was very effective, not really difficult to use, not really physically uncomfortable to use, very satisfying to use, and a form of retraction that they would very likely recommend to another colleague. All patients in the traxi arm reported they would choose this retraction method in a future cesarean delivery compared to 91% of patients in the no traxi arm; however, this finding was not statistically significant ( p = 0.05). “A little bit” of rash where the method of taping was used within 2 days of surgery was reported by 0% of patients in the traxi arm, compared to the no traxi arm (20%, p = 0.0048). Conclusions: Traxi panniculus retraction did not significantly improve surgical time but was associated with less restrictive pulmonary function testing compared with the control arm; these findings should be interpreted in the context of the study's limited sample size. There were higher reports of provider satisfaction with use of traxi compared to the control arm. Patient‐reported satisfaction with use of traxi was high but not statistically different when compared to the control arm with the exception of patient‐reported rash (less in traxi arm).

Introduction: Prenatal diagnosis of placenta accreta spectrum (PAS) depends on reliable ultrasound markers and skilled image interpretation. Existing PAS markers emphasize placental features suggestive of abnormal adherence and require advanced image optimization. However, emerging hypotheses suggest that uterine dehiscence—not placental invasion—is the central mechanism underlying PAS, particularly in severe (Grade 3) disease. Despite this, few established ultrasound markers address this uterine dehiscence. We describe a novel ultrasound marker, the taper sign, which uniquely represents the uterine dehiscence in severe PAS with anterior placenta previa, and outline a standardized technique for image acquisition and interpretation. Methods: This descriptive report details the sonographic appearance of the taper sign on grayscale ultrasound in pregnancies with anterior placenta previa and prior cesarean delivery with surgically and histopathologically confirmed Grade 3 PAS. Ultrasound images from cases at our center were reviewed to characterize the morphologic features of the taper sign and define optimal imaging parameters. Representative images illustrate this novel marker and the required anatomical landmarks. Results: The taper sign is characterized by progressive myometrial thinning until it disappears at the level of the prior cesarean scar, producing a wedge‐shaped appearance; this is distinct from previously described PAS markers. It is best seen using transvaginal ultrasound with a partially full bladder. Beginning in a midsagittal 2D grayscale view of the cervix, the anterior cervical lip is traced proximally as it transitions into the lower uterine segment myometrium. With the placenta previa bulging anteriorly, the overlying myometrium tapers to a point, terminating at the margin of the uterine dehiscence. This correlates with the deepest placental infiltration seen in Grade 3 PAS. In our experience, the taper sign is easily obtained and consistently identified in Grade 3 PAS with anterior placenta previa and prior cesarean delivery. Conclusion: The taper sign represents a novel ultrasound marker of severe PAS, reflecting the distinct wedge‐like appearance of attenuated myometrium as it terminates at the uterine dehisence. This report provides a standardized description and imaging protocol to facilitate recognition of patients at increased risk for severe maternal morbidity. Ongoing studies aim to validate this marker's diagnostic performance.

Cervical cancer remains the leading cause of cancer death among women in sub-Saharan Africa and is more severe in high HIV-burdened countries due to persistent high-risk human papillomavirus (hrHPV). In 2021, the World Health Organization recommended primary hrHPV testing for cervical cancer screening; however, optimal triage strategies following positive hrHPV tests remain unclear. We conducted a prospective cost analysis of triage methods for positive hrHPV results among women living with and without HIV in Gaborone, Botswana. We used a micro-costing approach from the perspective of the healthcare provider. The main outcomes were the implementation costs associated with three triage strategies following hrHPV testing: 8-type HPV genotype restriction, visual inspection with acetic acid (VIA), and colposcopy. We also compared the strategies by measuring the change in costs divided by the change in number of true cases of cervical intraepithelial neoplasia (CIN) 2 or worse (CIN2+) identified, based on the results of a prospective cohort study. Results indicated that the 8-type HPV genotype restriction strategy was the most cost-efficient, requiring no additional costs beyond hrHPV testing and identifying the highest number of true CIN2 + cases. VIA and colposcopy triage identified fewer true cases of CIN2+ and incurred additional costs, with colposcopy being the most expensive. Results were consistent in women with and without HIV. Sensitivity analysis highlighted personnel and hrHPV test kit cartridge costs as significant drivers of overall costs. Post-hoc analysis incorporating average treatment costs for precancer demonstrated that genotyping remained dominant at lower treatment costs but became less favorable as treatment costs increased. We found that 8-type genotype restriction was optimal compared to hrHPV screening combined with VIA or colposcopy. Cost estimates can inform future studies that examine the long-term costs and health outcomes of HPV-based two-stage screening algorithms.

Objectives International guidelines recommend cervical screening cessation at age 50 following two consecutive negative screens. However, many women aged 50 and older in low-income and middle-income countries (LMICs) have not had prior opportunity to screen. We examine the prevalence of cervical dysplasia and cervical cancer stage in Botswana women aged 50+ compared with 30–49, stratified by HIV status. Design Secondary analysis of data from two prospective cohort studies. Setting The screening cohort was recruited at health facilities in South East District. The cancer cohort was recruited from the primary public tertiary referral hospital and a private hospital in Gaborone, Botswana. Participants The screening cohort included 2570 women aged 30 and older recruited from February 2021 to August 2022. Screening eligibility included anyone with a cervix and without a prior history of cervical cancer. The cancer cohort included 1520 patients diagnosed with cervical cancer who sought care at the facilities where recruitment took place from January 2015 to December 2022. Primary and secondary outcome measures The prevalence of cervical intraepithelial neoplasia (CIN)2+ and cancer stage at diagnosis was compared across age groups, stratified by HIV status. Prevalence ratios were calculated for the association between age and CIN2+/CIN3+via log-binomial regression. Results The prevalence of CIN2+ was similar between 30–49 years old and 50+, both among women with HIV (WWH, 15.9% and 19.3%, respectively) and without HIV (13.3% and 10.4%, respectively). Similar findings were found when CIN3+ was used as the outcome. There were no statistically significant differences in prevalence ratios (PRs) across age groups for CIN2+ (adjusted PR (aPR) WWH 1.1 (95% CI 0.80 to 1.6); aPR HIV− 0.78 (95% CI 0.45 to 1.4) nor CIN3+ (aPR WWH 1.1 (95% CI 0.70 to 1.6); aPR HIV− 0.81 (95% CI 0.40 to 1.7)). Nearly half of cervical cancer diagnoses were made in women 50+; three-quarters of cases in women without HIV were diagnosed at 50+ years. Conclusions Our findings demonstrate the prevalence of high-grade cervical dysplasia and cervical cancer remains high beyond age 50 in both women with and without HIV in an LMIC context with high HIV prevalence. Screening women 50+ will allow treatment for cervical dysplasia and may provide early diagnosis of curable cervical cancer. These findings support the rapid introduction of high-performance cervical screening to increase access for women 50+. Trial registration number NCT04242823.