Unscheduled Delivery Research Articles

Impact of automated dispensing solutions in long-term care facilities and closed-door pharmacies: A mixed methods study of medication management

BackgroundFinancial, operational, and clinical workflow impacts of deploying an automated dispensing cabinet (ADC) in long-term care (LTC) facilities based on actual observations have not been documented in peer-reviewed literature. ObjectivesTo evaluate the impact of a closed-door pharmacy (CDP) implementing an ADC with unique secure, removable, and transportable locked pockets in an unstudied setting (LTC facilities) for management of first and emergency dose medications. Practice DescriptionThis study was conducted in 1 CDP and 2 LTC facilities. Practice InnovationEnhancing emergency medication management and inventory tracking in an unstudied setting through implementation of an ADC system featuring unique electronically encoded medication storage pockets that can be prepared in the CDP, locked and securely transported to the LTC, and when inserted into ADC it informs staff of its presence, position, and contents. Evaluation MethodsMixed methods, pre- and poststudy to assess the impact of replacing manual emergency medication kits with an ADC. Outcomes were evaluated using rapid ethnography with workflow modeling; inventory and delivery reports; a nursing perception survey; and transactional data from the ADC during postimplementation phase. ResultsPharmacy technician preparation time and pharmacist checking time decreased by 59% and 80%, respectively, and standing inventory was reduced by more than $10,000 combined for the CDP and 2 LTCs by replacing emergency medication kits with the ADC. In the LTCs, this change led to a 71% reduction in emergency medication retrieval time, an increase in emergency medication utilization, and a 96% reduction in the cost of unscheduled deliveries. Over 70% of the nurses surveyed favored replacement of the emergency medication kits with the ADC system. ConclusionReplacing manual emergency medication kit with the described ADC system improved workflow efficiency in the CDP and LTC. It also significantly reduced unscheduled (STAT) deliveries and standing inventory and increased the availability of medications commonly used.

Perinatal Mortality Despite Prenatal Diagnosis of Vasa Previa: A Systematic Review.

To determine the causes and potential preventability of perinatal deaths in prenatally identified cases of vasa previa. Reports of prenatally identified cases of vasa previa published in the English language literature since 2000 were identified in Medline and ClinicalTrials.gov with the search terms "vasa previa," "abnormal cord insertion," "velamentous cord," "marginal cord," "bilobed placenta," and "succenturiate lobe." All cases from the above search with an antenatally diagnosed vasa previa present at delivery in singleton or twin gestations with perinatal mortality information were included. Cases meeting inclusion criteria were manually abstracted, and multiple antenatal, intrapartum, and outcome variables were recorded. Deaths and cases requiring neonatal transfusion were analyzed in relation to plurality, routine hospitalization, and cervical length monitoring. A total of 1,109 prenatally diagnosed cases (1,000 singletons, 109 twins) were identified with a perinatal mortality rate attributable to vasa previa of 1.1% (95% CI 0.6-1.9%). All perinatal deaths occurred with unscheduled deliveries. The perinatal mortality rate in twin pregnancies was markedly higher than that in singleton pregnancies (9.2% vs 0.2%, P<.001), accounting for 80% of overall mortality despite encompassing only 9.8% of births. Compared with individuals with singleton pregnancies, those with twin pregnancies are more likely to undergo unscheduled delivery (56.4% vs 35.1%, P=.01) despite delivering 2 weeks earlier (33.2 weeks vs 35.1 weeks, P=.006). An institutional policy of routine hospitalization is associated with a reduced need for neonatal transfusion (0.9% vs 6.0%, P<.001) and a reduction in the perinatal mortality rate in twin pregnancies (0% vs 25%, P=.002) but not in singleton pregnancies (0% vs 0.5%, P=.31). Routine hospitalization and earlier delivery of twins may result in a reduction in the perinatal mortality rate. A smaller benefit from routine admission of individuals with singleton pregnancies cannot be excluded. There is currently insufficient evidence to recommend the routine use of cervical length measurements to guide clinical management.

Integration of ABC Analysis with Fuzzy DEMATEL and Fuzzy TOPSIS in Supplier Selection and Ranking Problems

While performing Always Better Control (ABC) analysis in an automobile industry, A category items are given higher priority, neglecting B and C category items which comprise 80% of the total inventory. Little attention to tail spend account poses problems in managing suppliers, unscheduled deliveries, and environmental issues. To address this gap a Multi-criteria decision making approach is proposed for supplier selection in each inventory class by integrating ABC Analysis with Fuzzy Decision-making trial and evaluation laboratory and Fuzzy Technique for Order Preference by Similarity to Ideal Solution. The best suppliers are selected based on criteria weights and criteria interrelationships for each A, B, and C inventory items. The study shows that managers have to focus on key criteria rather than a whole set of criteria for A, B, and C inventory suppliers thus saving costs and effort. The results show that delivery and environmentally friendly products as common and important criteria for supplier selection in each inventory items. The research results will help the decision-makers and policymakers in solving the supplier selection problems in the automobile sector and other similar sectors.

Clinical Correlates of Placenta Accreta Spectrum Disorder Depending on the Presence or Absence of Placenta Previa: A Systematic Review and Meta-analysis.

To evaluate whether there are differences in risk factors and maternal outcomes of pregnancies complicated by placenta accreta spectrum depending on the presence or absence of placenta previa. We performed a systematic search in Medline, EMBASE, ClinicalTrials.gov , and Web of Science from inception through April 25, 2022, without language or date restrictions. Search strategy included the key words "placenta accreta," "placenta increta," "placenta percreta," "adherent placenta," "invasive placenta," "abnormal placent*," "placenta previa," and "marginal placent*." Of the 1,122 articles screened, seven studies were included in the final review. Studies were included if they compared the risk factors and maternal outcomes of pregnancies complicated by placenta accreta spectrum depending on the presence or absence of placenta previa. A random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% CIs using RevMan software. A total of 3,342 pregnancies complicated by placenta accreta spectrum were included in the meta-analysis (2,365 without previa and 977 with previa). Pregnancies complicated by placenta accreta spectrum without previa were more likely to have been conceived by in vitro fertilization (IVF) (OR 3.11, 95% CI 1.93-5.02, P <.001, I 2 =52.0%) and to be associated with prior dilation and curettage (D&C) (OR 1.60, 95% CI 1.15-2.22, P =.005, I 2 =0.0%) and myomectomy (OR 2.47, 95% CI 1.31-4.66, P =.005, I 2 =0.0%), but they were less likely to be associated with prior cesarean delivery (OR 0.15, 95% CI 0.06-0.37, P <.001, I 2 =87.0%). Placenta accreta spectrum without previa was less likely to be diagnosed antenatally (OR 0.07, 95% CI 0.04-0.11, P <.001, I 2 =38.0%). Also, women with pregnancies without previa had lower rates of red blood cell transfusion, intensive care unit admission, risk of hysterectomy, unscheduled delivery, and intraoperative bowel or bladder injuries. Pregnancies complicated by placenta accreta spectrum without previa had a more prominent association with IVF and prior D&C and myomectomy but were much less likely to be associated with prior cesarean delivery. Further, placenta accreta spectrum without previa was less likely to be diagnosed antenatally, although it had better maternal outcomes as compared with placenta accreta spectrum with previa. PROSPERO, CRD42022307637.

Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy.

This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy. This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition. Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts. A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases. · An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..

Timing of delivery for placenta accreta spectrum: the Pan-American Society for the Placenta Accreta Spectrum experience

The Society for Maternal-Fetal Medicine recommends cesarean delivery with potential hysterectomy scheduled in the late preterm period between 34 0/7 and 35 6/7 weeks of gestation for prenatally suspected placenta accreta spectrum. We aimed to investigate clinical compliance with the recommended delivery timing window for placenta accreta spectrum and its impact on maternal and neonatal outcomes. We performed a retrospective multicenter review of data from referral centers within the Pan-American Society for Placenta Accreta Spectrum. Patients with placenta accreta spectrum with both antenatal diagnosis and confirmed histopathologic findings were included. We investigated adherence to the Society for Maternal-Fetal Medicine-recommended gestational age window for delivery, and compliance was further stratified by scheduled and unscheduled delivery. We compared the outcomes for patients with scheduled delivery within vs immediately 2 weeks outside the recommended window. Among 744 patients with a prenatal diagnosis of placenta accreta spectrum and placental histopathologic confirmation, 488 (66%) had scheduled delivery. Among all prenatally diagnosed placenta accreta spectrum patients, 252 (39%) delivered within the recommended window of 34 0/7 and 35 6/7 weeks gestation. For the subgroup of patients who underwent scheduled delivery (n=426), 209 (49%) had delivery in this window, 120 (28%) delivered before 34 weeks, and 97 (23%) delivered at or later than 36 weeks. In the patients with scheduled delivery, 27% of placenta accreta spectrum patients with accreta delivered in the 2 weeks immediately after the recommended window (36 0/7-37 6/7 weeks), and 22% of placenta accreta spectrum pregnancies with increta/percreta delivered in the 2 weeks immediately before the recommended delivery (32 0/7-33 6/7 weeks). The maternal outcomes among those who delivered within the recommended range vs those delivering 2 weeks before and after the recommended range were similar, regardless of placenta accreta spectrum severity. Less than half of placenta accreta spectrum patients had scheduled delivery within the recommended gestational age of 34 0/7 to 35 6/7 weeks. The reasons for deviation from recommendations and the risks and benefits of individualized timing of delivery on the basis of risk factors and predicted outcomes warrant further investigation.

Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care.

Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.

Cervical length and risk of unplanned cesarean hysterectomy in patients with placenta accreta-previa spectrum

Short cervix and sentinel bleeding have been associated with unscheduled delivery in patients with placenta previa. We sought to determine if these factors were associated with unplanned delivery in patients with placenta previa and placenta accreta spectrum (PAS).

Risk of unscheduled delivery in women with placenta accreta according to planned gestational age at delivery

Background The optimal gestational age at delivery for stable women with suspected placenta accreta is still subject of debate. Objective To estimate the likelihood of vaginal bleeding necessitating expedited delivery in women with placenta accreta according to gestational age at planned cesarean hysterectomy. Study design This was a multicenter cohort study. Singleton pregnancies at risk of placenta accreta because of placenta previa in the setting of prior cesarean delivery were included. Outcomes were compared in cohort of women who had planned cesarean hysterectomy at 34 0/7 − 34 6/7 weeks versus at 35 0/7 − 35 6/7 weeks. The primary outcome was incidence of vaginal bleeding severe enough to necessitate delivery. Results 118 singleton pregnancies with placenta previa in the setting of prior cesarean delivery, and confirmed placenta accreta at the time of delivery were included in the study. Women who had planned cesarean hysterectomy at 34 weeks had lower episodes of vaginal bleeding severe enough to necessitate immediate or emergency delivery (20.6% vs 38.0%; odds ratio (OR) 0.42, 95% confidence interval (CI) 0.19 to 0.96). Eight women (11.8%) in the 34 weeks group and 6 women (12.0%) in the 35 weeks group delivered before the planned date due to onset of spontaneous labor (OR 0.98, 95% CI 0.32 to 3.02). Conclusion In singleton gestations with suspected placenta accreta, planned cesarean hysterectomy at 34 0/7 − 34 6/7 weeks was associated with a decreased chance of unscheduled delivery due to severe vaginal bleeding. Condensation In case of placenta accreta, planned cesarean hysterectomy at 34 weeks was associated with decreased chance of unscheduled delivery due to severe vaginal bleeding.

Should pregnant women with anticoagulant prophylaxis benefit from scheduled delivery?

When vaginal delivery is considered in women with low-molecular-weight heparin (LMWH) treatment, epidural analgesia is contraindicated for 12-24h after the last injection. We evaluated the proportion of epidural analgesia depending on whether this is scheduled delivery (labor induction after stopping LMWH) or unscheduled delivery (stopping LMWH at labor onset). Retrospective hospital study running from 2015 to 2017. Inclusion criteria for patients with LMWH treatment were: singleton pregnancy, gestational age ≥ 38weeks of gestation and possible vaginal delivery. The primary endpoint was the epidural analgesia rate. Secondary endpoints included risks for caesarean section, deep vein thrombosis, and postpartum hemorrhage. Among 129 patients, 54 had scheduled delivery (41.9%). In practice, only 44 of them had labor induction (81.5%) and 54 of the 75 patients in the unscheduled delivery group had spontaneous delivery (72.0%). There was no significant difference in the rate of epidural analgesia between the "scheduled" and "unscheduled" groups (52/54 (96.3%) vs. 66/75 (88.0%) (p = 0.12)), and no difference in the secondary endpoints. High access rates to epidural analgesia are observed in both scheduled and unscheduled deliveries. Scheduled delivery does not appear to be a really advantageous strategy for women with LMWH prophylaxis.

Association between Number of Prior Cesareans and Early Preterm Delivery in Women with Abnormal Placentation.

Delivery timing at 34 to 36 weeks is nationally recommended for pregnancies complicated by placenta accreta spectrum (PAS). However, it has recently been suggested that those with ≥2 prior cesarean deliveries (CD) and PAS should be delivered earlier than 34 weeks because of a higher risk of unscheduled delivery and complications. We sought to evaluate whether the number of prior CD in women with PAS is associated with early preterm delivery (PTD) (<34 weeks). We also evaluated the same relationship in women with placenta previa alone (without PAS). This is a secondary analysis of a multicenter and observational study that included women with prior CD (maternal-fetal medicine unit cesarean registry). Women with a diagnosis of PAS (regardless of placenta previa) were included for our primary analysis, and women with known placenta previa (without a component of PAS) were independently analyzed in a second analysis. Two groups of patients from the registry were studied: patients with PAS (regardless of placenta previa) and patients with placenta previa without PAS. The exposure of interest was the number of prior CD: ≥2 CD compared with <2 CD. The primary outcome was PTD <34 weeks. Secondary outcomes included preterm labor requiring hospitalization or tocolysis, transfusion of blood products, composites of maternal and neonatal morbidities, and NICU admission. Outcomes by prior CD number groups were compared in both cohorts. Backward selection was used to identify parsimonious logistic regression models. There were 194 women with PAS, 97 (50%) of whom had <2 prior CD and 97 (50%) of whom had ≥2 prior CD. The rate of PTD <34 weeks in women with ≥2 prior CD compared with <2 in the setting of PAS was 23.7 versus 29.9%, p = 0.27; preterm labor requiring hospitalization was 24.7 versus 13.5%; p = 0.05. The rates of plasma transfusion were increased with ≥2 prior CD (29.9 vs. 17.5%, p = 0.04), but there were no differences in transfusion of other products or in composite maternal or neonatal morbidities. After multivariable adjustments, having ≥2 CDs was not associated with PTD <34 weeks in women with PAS (adjusted odds ratio (aOR): 0.73, 95% confidence interval [CI]: 0.39-13.8) despite an association with preterm labor requiring hospitalization (aOR: 2.69; 95% CI: 1.15-6.32). In our second analysis, there were 687 women with placenta previa, 633 (92%) with <2 prior CD, and 54 (8%) with ≥2 prior CD. The rate of PTD <34 weeks with ≥2 CD in the setting of placenta previa was not significantly increased (27.8 vs. 22.1%, aOR: 1.49; 95% CI: 0.77-2.90, p = 0.08); the maternal composite outcome (aOR: 4.85; 95% CI: 2.43-9.67) and transfusion of blood products (aOR: 6.41; 95% CI: 2.30-17.82) were noted to be higher in the group with ≥2 prior CD. Women with PAS who have had ≥2 prior CD as compared with women with <2 prior CD did not appear to have a higher risk of complications leading to delivery prior to 34 weeks. As such, considering the associated morbidity with early preterm birth, we would not recommend scheduled delivery prior to 34 weeks in this population. · We do not recommend delivery prior to 34 weeks of gestational age in PAS.. · PTD was not significantly increased in PAS with ≥2 CDs.. · PTD < 34 weeks of gestational age was not increased in placenta previa with ≥2 prior CDs..

Prenatally diagnosed vasa previa: association with adverse obstetrical and neonatal outcomes

Vasa previa represents a rare prenatal finding with potentially life-threatening risk to the fetus. This study aimed to describe the natural history of prenatally diagnosed vasa previa and evaluate the association between antenatally diagnosed vasa previa and adverse obstetrical and neonatal outcomes. This was a multicenter descriptive and retrospective study of patients diagnosed prenatally with vasa previa on transvaginal ultrasound in the New York City Maternal-Fetal Medicine Research Consortium centers between 2012 and 2018. Outcomes evaluated included persistence of vasa previa at the time of delivery, gestational age at delivery, indications for unplanned unscheduled delivery, and neonatal course. A total of 165 pregnancies with vasa previa were included, of which 16 were twin gestations. Forty-three cases (26.1%) were noted to resolve on subsequent ultrasound. Of the remaining 122 cases with persistent vasa previa, 46 (37.7%) required unscheduled delivery. Twin gestations were nearly 3 times as likely to require unscheduled delivery as singleton gestations (73.3% vs 25.2%; P<.001). Most infants (70%) were admitted to the neonatal intensive care unit. There was 1 neonatal death (0.9%) because of complications related to prematurity. Despite the low neonatal mortality rate with prenatal detection of vasa previa, one-third of patients required unscheduled delivery, and more than half of neonates experienced complications related to prematurity.

Proposed Determination of Product-Replenishment Policy on Multi-Source Problems to Minimize Over Stock in DC PT. XYZ Area Bandung With Mixed-Integer Programming Method

PT. XYZ is one of the companies which engages in fast moving consumer goods (FMCG) sector and has soft drinks as its main product. In supporting the product distribution to its customers, PT XYZ has several administrative offices and distribution centers (DC) which spread across each region. The DC has main function as the warehouse which has storage activity before the products are distributed.&#x0D; One of the DC is located in Bandung, West Java. DC Bandung itself received product shipments from three factories, such as Cibitung, Cakung and Tambun. Related to the product shipment, DC Bandung has not determined the replenishment policy, and this condition results over stock at some periods, due to the unscheduled delivery time and undetermined product quantity. This condition gives a big impact to the total inventory cost that has to be borne by DC Bandung.&#x0D; This research was conducted to give the proposal of product replenishment policy with mixed-integer programming method, as one of the linear programming types, which aimed to minimize over stock and total holding cost in DC Bandung. Mathematical model is also involved in this research as an approximation to the real replenishment system in the DC.&#x0D; The results of application of the proposed method are in the form of analytical solution, such as order quantity, and reorder point of each product that will give an impact to the total unit inventory and the total holding cost in the DC. The results calculation of replenishment policy provide savings on total inventory costs as much as IDR 23,800,981.20

Proposal of Product-Replenishment Policy Determination on Multi-Source Problems to Minimize Over Stock in DC PT. XYZ Area Bandung Using Mixed-Integer Programming Method

XYZ is one of the companies engaging in fast moving consumer goods (FMCG) sector and produce soft drinks as its main product. In supporting the product distribution to its customers, PT XYZ has several administrative offices and distribution centers (DC) which spread across each region. The DC has main function as the warehouse which has storage activity before the products are distributed. One of the DC is located in Bandung, West Java. DC Bandung itself received product shipments from three factories, such as Cibitung, Cakung and Tambun. Related to the product shipment, DC Bandung has not determined the replenishment policy, and this condition results over stock at some periods, due to the unscheduled delivery time and undetermined product quantity. This condition gives a big impact to the total inventory cost that has to be borne by DC Bandung. This research was conducted to give the proposal of product replenishment policy using mathematical model with mixed-integer programming method as one of the linear programming types, which aimed to minimize over stock and total holding cost in DC Bandung with several constraints. Mathematical modeling is involved in this research as an approximation to the real replenishment system in the DC. The results of application of the proposed method are in the form of analytical solution, such as order quantity, and reorder point of each product that will give an impact to the total unit inventory and the total holding cost in the DC. The results calculation of replenishment policy provide savings on total inventory costs as much as IDR 23,800,981.20&#x0D; Keywords—Mixed-Integer Programming, Order Quantity, Over Stock, Replenishment Policy.

Patient Selection for Later Delivery Timing With Suspected Previa-accreta

(Acta Obstet Gynecol Scand. 2017;96(8):1021–1028) There is a lack of agreement among organizations regarding the recommended timing of delivery for patients with placenta previa-accreta. The American Congress of Obstetricians and Gynecologists and The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) suggest scheduled delivery at 34 weeks and 34 to 356/7 weeks, respectively, while the Royal College of Obstetricians and Gynaecologists does not recommend delivery before 36 to 37 weeks’ gestation for asymptomatic women. Avoiding emergency hemorrhage and other forms of maternal morbidity is an argument for early delivery, but alternatively, there have been findings of adverse neonatal outcomes when women with placental implantation abnormalities deliver prematurely. This study aimed to provide guidance for individualized patient care, hypothesizing that as maternal morbidity in these patients is driven by unscheduled delivery, hemorrhage due to hypervascularity and placental invasion, and surgical complexity, patients at high risk of these outcomes may benefit from earlier planned delivery while those at lower risk may have later deliveries.

Optimal Timing of Delivery in Women with Higher Order Cesareans: A Cohort Study.

To evaluate whether a planned early term delivery or a planned 39-week delivery is associated with differences in perinatal outcomes in women undergoing a higher order cesarean (HOC). This cohort study included women with singleton gestations with a history of three or more prior cesareans who delivered at one of two urban tertiary care hospitals. One center routinely delivered HOC at 39 weeks' gestation and the other at 37 weeks. Maternal and neonatal morbidities were compared using bivariable and multivariable analyses. The policy of 37-week delivery was associated with a decrease in unscheduled deliveries (15.3 vs. 41.1%; p < 0.001). Planned delivery at 37 weeks was associated with a decreased incidence of composite maternal morbidity (1.6 vs. 7.9%; p = 0.002) and 5-minute Apgar score less than 7 (0.4 vs. 6.4%; p < 0.001), but these differences were not significant after controlling for potential confounders (adjusted odds ratio [aOR]: 0.30, 95% confidence interval [CI]: 0.08-1.17; aOR: 0.13, 95% CI: 0.01-1.30, respectively). There were no other differences in perinatal outcomes. Compared with planned delivery at 39 weeks, a policy of planned delivery at 37 weeks was associated with a reduction in unscheduled deliveries, but there were no measured differences in perinatal outcomes.

Monetary vs. Non-Monetary Macro News: Announcement Equity Premium in China

This paper examines stock market returns in an environment in which the dates of central bank’s information supply through public announcements are not pre-fixed. We document that positive excess returns accumulate for 3 days before China’s central bank releases data of monetary aggregates, which may be announced either early or late in a month. In particular, large pre-announcement premium is associated with late arrivals of announcements. We then present a model to rationalize these facts by highlighting the channel of investors’ rational attention allocation reacting to unscheduled deliveries of announcements. Investors with limited attention would learn about the to-be-announced data only when it’s late in an announcement cycle, whereby an announcement is still pending but investors know better the announcement would soon arrive. Increasingly focused attention then drives down market uncertainty and boosts equity prices ex-ante. We show that China’s unique setting of “quasi-scheduled” central bank announcements provides the exact data structure for identifying the causal mechanism of the attention allocation channel.

Maternal and neonatal outcomes among scheduled versus unscheduled deliveries in women with prenatally diagnosed, pathologically proven placenta accreta

Objective: To evaluate maternal and neonatal outcomes among scheduled versus unscheduled deliveries in cases of prenatally diagnosed, pathologically proven placenta accreta.Study design: Retrospective cohort of placenta accreta cases delivered in five University of California hospitals.Results: Of 151 cases of histopathologically proven placenta accreta, 82% were prenatally diagnosed. Sixty-seven percent of women underwent scheduled deliveries and 33% were unscheduled. There were no differences in demographics between groups except a higher rate of antepartum bleeding in the unscheduled delivery group (81 versus 53%; p = .003). Scheduled deliveries were associated with a later gestational age at delivery (34.6 versus 32.6 weeks; p = .001), lower blood loss (2.0 versus 2.5 l; p = .04), higher birth weight (2488 versus 2010 g; p < .001), shorter postpartum length of stay (4 versus 5 d; p = .03) and neonatal length of stay (12 versus 20 d; p = .005).Conclusion: Despite a prenatal diagnosis of placenta accreta, 1/3 of these cases require unscheduled delivery, portending poorer maternal and neonatal outcomes.

P28.06: Perinatal management in cases of fetal abdominal wall defects (fAWD): retrospective survey on predictors of final outcome

Perinatal management in cases [cs.] of fAWD, in particular timing of delivery, is an issue of debate and strategies changed from scheduled late preterm towards early term delivery. We address the questions: Is intended prolongation until 38 weeks of gestation [wksGA] justified in cases of fAWD and are there predictors to optimise outcome? In a retrospective study all cs. transferred to either of 2 level 1 perinatal centres in Thuringia/Germany (Jena [JE], ∼1500; Erfurt [EF] ∼1800 del./year) with suspected fAWD between 2003-2014 were reviewed. Data on prenatal care, perinatal management and pediatric surgery were collected from patient's records. The initial cohort consisted of 74 cs.; 64 were applicable to analysis (complex syndromes/TOP 4; LOF 3; diagnosis not confirmed 3). Gastroschisis [GSC] was present in 42 (JE 24; EF 18), omphalocele [OMPH] in 22 cs. (JE 14; EF 8). 2 perinatal deaths occurred in association with early PTB [GSC, maternal HELLP, 28+6 wksGA; OMPH, preterm labour [PTL], 23+5 wksGA]; 1 fetus was born at 28+2 wks GA [OMPH]. 21/41 [GSC] and 4/20 [OMPH] of the remaining deliveries (all >33+0 wksGA) were rescheduled or performed as an emergency (GSC: progressive dilation of bowel 5, PTL 7, fetal compromise 8, mat. disease 1; 11/16 >36+0 wksGA; OMPH: PTL 4, none <36+0 wks GA). Perinatal outcome parameters were positively correlated (GA, weight, APGAR, pHart) and negatively to duration of postnatal hospital stay (R2 between -0.35 to -0.41). 5 infants (8%) required surfactant administration. Where available (31 cs.) a longer duration of the primary operation was associated with a higher risk for secondary surgery. In our cohort intended prolongation >36 wksGA did improve perinatal outcome but increased the probability of unscheduled delivery. Premature contractions are a predictor of early labour in cs. of OMPH; fetuses with GSC are more likely to develop IUGR (22%). Surgical outcome was generally favourable but still related to perinatal outcome after delivery >33+0 wksGA.

Patient selection for later delivery timing with suspected previa-accreta.

We identified patients with previa and suspected accreta who are at lowest risk of unscheduled delivery or major morbidity with planned delivery beyond 34 weeks' gestation. This was a retrospective cohort study of patients who had reached 34.0 weeks' gestational age with a suspected previa-accreta. We evaluated rates of unscheduled and emergent delivery based on known risk factors for premature birth. In a second analysis, we stratified patients based on level of preoperative morbidity concern and evaluated rates of major transfusion and Intensive Care Unit admission by delivery week (34 weeks, 35 weeks or 36 weeks and beyond). Of 84 available patients, we classified 31 patients as low risk for unscheduled delivery and 52 as high risk. The low risk group was scheduled later (36.6 vs. 36.0 weeks; p < 0.01), but demonstrated lower rates of unscheduled delivery prior to 36 weeks (3% vs. 19%, p = 0.05). Of the patients with no prior cesarean section, only one (7%) experienced massive blood loss even though 36% had unscheduled deliveries. We observed no significant increase in major transfusion or massive blood loss with advancing gestational age, likely due to selection of the most concerning patients for early, scheduled delivery. Patients with suspected previa-accreta and no risk factors for preterm birth are at low risk for an unscheduled delivery prior to 36 weeks. Those with no concern for percreta or increta or no prior cesarean section may also be candidates for later delivery.