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Previous studies have shown race as a significant risk factor for postpartum hemorrhage (PPH), but the association of race and PPH during the second delivery has not been investigated. The objective of this study was to see if there was an association between race and PPH during the second delivery in women with a PPH during their first delivery. STUDY DESIGN: This is a retrospective study of women who had their first two deliveries in California (2000California ( -2011. We further restricted the data for all women who presented with PPH during their noted first delivery (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011) and had second delivery with singletons, non-anomalous, 23-42 weeks gestational age babies between the duration of 2007-2011. Exclusion criteria were multiple babies, anomalies, gestational age42 weeks, and missing race/ethnicity of women during second deliveries. PPH was identified using ICD-9 diagnosis codes (666.0-666.2). Demographics were compared using chi-square tests. Multivariable logistic regression models were used to examine the association between race and PPH during second delivery. RESULTS: In this study, 5260 women had PPH during their first delivery and delivered their second baby between 2007 and 2011. Of these, 8.4% had PPH during second delivery. Multivariable logistic regression results showed that Non-Hispanic Black (aOR¼1.75, 95% CI: 1.07-2.87), Hispanic (aOR¼1.72; 95% CI: 1.27-2.33), Asian (aOR¼2.27; 95% CI: 1.58-3.26), and Native American (aOR¼1.82 (95% CI: 0.62-5.37) women had higher odds of PPH at second delivery as compared to Non-Hispanic White women, after controlling for age, education, body mass index, insurance, smoking, inter-pregnancy interval, mode of delivery (first and second birth) and birthweight at second birth. CONCLUSION: Non-Hispanic Black, Hispanic, and Asian women exhibited significantly higher odds of PPH during the second delivery as compared to White women. There may be differences in care management or biologic factors that influence postpartum hemorrhage in these populations.

Preterm birth is a major risk factor for neonatal mortality. Studies show that aspirin decreases the development of preeclampsia in nulliparous women. Additionally, the ASPIRIN trial showed that aspirin initiation between 6 and 13 weeks gestation reduces preterm birth incidence. This study investigates the costeffectiveness of aspirin initiation in the 1st trimester for prevention of preterm birth in nulliparous women. STUDY DESIGN: A cost-effectiveness model using TreeAge 2020 software was designed to compare maternal and neonatal outcomes of aspirin administration versus no aspirin administration in nulliparous women with singleton pregnancies. We used a theoretical cohort of 100,000 women. Outcomes included preterm delivery < 34 weeks, preterm delivery < 37 weeks, maternal death, hypertensive disorders, spontaneous abortion, intrauterine fetal demise, neonatal neurodevelopmental delay, and infant death. All values were derived from the literature. The willingness-to-pay threshold was $100,000/ quality adjusted life year (QALY) and QALYs were discounted at a rate of 3%. Sensitivity analyses evaluated the power of our model. RESULTS: In our theoretical cohort, we found that aspirin prophylaxis in the 1st trimester would result in 523 fewer cases of preterm delivery < 37 weeks and 539 fewer cases of preterm delivery < 34 weeks. Additionally, there would be 3,873 decreased cases of hypertensive disorders. Aspirin therapy was the dominant strategy, resulting in increased QALYs and decreased costs, saving $194 million. Sensitivity analyses showed that the results were consistent over a wide range of assumptions. Even if there was less of a reduction in hypertensive disorders (baseline probability 0.057) than predicted with aspirin administration, there was still an impact in reduction of preterm deliveries. CONCLUSION: Our model found that aspirin initiation during the 1st trimester in all nulliparous women results in decreased rates of preterm delivery. These results are significant as it is cost effective to administer aspirin to all nulliparous singleton women regardless of hypertensive status.

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