Treatment of Refractory Vulvar Lichen Sclerosus With Methotrexate

We report the successful treatment of severe vulvar lichen sclerosus refractory to topical corticosteroids in 3 adult female patients using low-dose oral methotrexate. All cases reported symptomatic and clinical improvement within 12 weeks.

Adverse Perinatal and Neonatal Outcomes Among Adolescent Pregnancies in the United States

BACKGROUND

Despite a downward trend in recent years, adolescent pregnancies in the United States remain higher than any other Western country. Adolescent pregnancies have been inconsistently associated with adverse perinatal outcomes.

OBJECTIVE

To investigate the association between adolescent pregnancies and adverse perinatal and neonatal outcomes in the United States.

METHODS

This is a retrospective cohort study of singleton births in the US from 2014 to 2020 using national vital statistics data. Perinatal outcomes included gestational diabetes (GDM), gestational hypertension (gHTN), preterm delivery <37 weeks (PTB), cesarean delivery (CD), chorioamnionitis, small for gestational age (SGA), large for gestational age (LGA), and neonatal composite outcome. Chi-square tests were used to compare outcomes among adolescent (13-19 years) vs. adult (20-29 years) pregnancies. Multivariable logistic regression models were used to examine association of adolescent pregnancies with perinatal outcomes. For each outcome, we utilized three models: unadjusted logistic regression, adjusted for demographics, and adjusted for demographics and medical comorbidities. Similar analyses were used to compare younger (13-17 years) and older (18-19 years) adolescent pregnancies to adults.

RESULTS

In a cohort of 14,014,078 pregnancies, we found that adolescents were at an increased risk of PTB (adjusted odds ratio (aOR) 1.12, 99% confidence interval (CI)1.12-1.13) and SGA (aOR 1.02, 99% CI 1.01-1.03) compared to adult pregnancies. We also found that multiparous adolescents with a prior history of CD were at an increased risk of CD, compared to adults. For all other outcomes, adult pregnancies were at higher risk for adverse outcomes in the adjusted models. When comparing birth outcomes among adolescents, we found that older adolescents are at an increased risk of PTB, while younger adolescents are at an increased risk of both PTB and SGA.

CONCLUSION

After adjusting for confounders, our study demonstrates adolescents have an increased risk of preterm birth and SGA, compared to adults.

Cesarean delivery rates by hospital type among nulliparous and multiparous patients

BACKGROUND

Cesarean delivery rates continue to remain high despite recent attempts to decrease these rates. Prior data suggest that there is great variation in cesarean rates by hospital.

OBJECTIVE

The intent of this study is to examine the association of several hospital characteristics and cesarean delivery rates in California.

METHODS

We performed a retrospective study of singleton, non-anomalous, term (37-42 week) deliveries in California. We excluded hospitals with <50 deliveries per year and missing hospital information. We separated hospitals by volume based on previously published categories: low-volume (<1200 deliveries/year), medium-volume (1200-2399 deliveries/year), and medium-high-volume (2400-3599 deliveries/year, and high-volume (3600 deliveries/year). We also evaluated rural versus urban and non-teaching versus teaching hospitals. We examined overall cesarean rates as well as stratified by parity and with and without prior cesarean. We analyzed data with chi-square tests and multivariable logistic regression models.

RESULTS

In a total of 2,545,464 pregnancies, 772,539 (30.35%) resulted in cesarean deliveries. After controlling for race/ethnicity, age, body mass index, education, and insurance, rates of cesarean delivery were higher in low-volume hospitals (aOR: 1.07; 95% CI: 1.0-1.08) and lower in medium-high-volume hospitals (aOR: 0.97; 95% CI: 0.96-0.98) as compared to high-volume hospitals. Rural hospitals had higher rates of cesarean delivery (aOR: 1.08; 95% CI: 1.06-1.10) as compared to urban hospitals while non-teaching hospitals had higher odds of cesarean deliveries (aOR: 1.27; 95% CI: 1.25-1.28) as compared with teaching hospitals. Among nulliparous patients, medium- and medium-high-volume hospitals had lower rates of cesarean deliveries (aOR: 0.95; 95% CI: 0.93-0.96; aOR: 0.93; 95% CI: 0.91-0.94) as compared to high-volume hospitals, while non-teaching hospitals had higher rates of cesarean deliveries than teaching hospitals (aOR: 1.11; 95% CI: 1.10-1.13). Multiparous patients without prior cesarean had higher rates of cesarean delivery at low-volume hospitals and lower rates of cesarean delivery at medium-high-volumes (aOR: 1.07; 95% CI: 1.05-1.10; aOR: 0.96; 95% CI: 0.94-0.098) as compared to high-volume hospitals. Additionally, multiparous patients without prior cesarean had higher rates of cesarean delivery at non-teaching hospitals than teaching hospitals (aOR: 1.16; 95% CI: 1.13-1.19). Multiparous patients with prior cesarean had high rates of cesarean delivery at all volume hospitals with the highest odds at low-volume hospitals (aOR: 1.81; 95% CI: 1.74, 1.89) as well as at rural and non-teaching hospitals.

CONCLUSION

Cesarean delivery rates were higher at low and high-volume hospitals for nulliparous and multiparous patients without prior cesarean, but increased with decreasing hospital volume for multiparous patients with prior cesarean. Additionally, cesarean delivery was more likely at rural and non-teaching hospitals. Our results suggest that further investigation is necessary to determine the structural and mechanistic causes of the differences in practice by hospital type in order to identify targets for approaches in reducing cesarean deliveries.