Objective Despite the Centers for Disease Control and Prevention (CDC) and U.S. Preventive Services Task Force (USPSTF) recommending universal hepatitis C virus (HCV) screening in pregnancy Society for Maternal-Fetal Medicine (SMFM) and American College of Obstetricians and Gynecologists (ACOG) continue to endorse risk-based screening for HCV in pregnancy. We hypothesized that universal screening is associated with increased HCV diagnosis and postpartum linkage to HCV care compared with risk-based screening. Study Design This retrospective cohort study included pregnant women screened for HCV at a single tertiary-care center. We defined two cohorts: women managed with risk-based (January 2014–October 2016) or universal HCV screening (November 2016–December 2018). Screening was performed with ELISA antibody testing and viremia confirmed with HCV ribonucleic acid (RNA) polymerase chain reaction (PCR). Primary outcomes were the rate of HCV screen positivity and postpartum linkage to care. Results From 2014 to 2018, 16,489 women delivered at our institution, of whom 166 screened positive for HCV. A total of 7,039 pregnant women were screened for HCV: 266 with risk-based and 6,773 with universal screening; 29% (76/266) were positive HCV antibody screening (HCVAb + ) in the risk-based cohort and 1.3% (90/6,773) in the universal cohort. HCVAb+ women in the risk-based cohort were more likely to have a positive drug screen. Only 69% (62/90) of HCVAb+ women in the universal cohort met the criteria for risk-based testing. Of the remaining 28 women, 6 (21%) had active viremia (HCV RNA+). Of the 166 HCVAb+ women, 64% (103/166) were HCV RNA+—51 of 266 (19%) in the risk-based and 52 of 6,773 (0.8%) in the universal cohort. Of HCVAb+ women, 75% (125/166) were referred postpartum for HCV evaluation and 27% (34/125) were linked to care. Only 9% (10/103) of women with viremia initiated treatment within 1 year of delivery. Conclusion Universal HCV screening in pregnancy identified an additional 31% of HCVAb+ women compared with risk-based screening. Given low rates of HCV follow-up and treatment regardless of screening modality, further studies are needed to address barriers to postpartum linkage to care. Key Points

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OBJECTIVE: To characterize racial disparities in the rate of and complications related to peripartum hysterectomy. STUDY DESIGN: This retrospective cross sectional study utilized the 2002-2014 Nationwide Inpatient Sample (NIS) to analyze risk of peripartum hysterectomy and associated morbidity by maternal race. Peripartum hysterectomy rates and complication rates were estimated and stratified by five race and ethnicity categories: non-Hispanic white, non-Hispanic black, Hispanic, other, and unknown. Multivariable log linear regression models were performed to assess (i) risk of peripartum hysterectomy and (ii) severe maternal morbidity (SMM) in the setting of hysterectomy; these models were adjusted by maternal race and patient, clinical, and hospital risk factors. A sensitivity analysis was performed on lower risk cesareans excluding women with placenta accreta or placenta previa in the setting of prior cesarean. Results are reported as adjusted risk ratios (aRR) and 95% confidence intervals (CI). RESULTS: 59.9 million delivery hospitalizations were identified with a peripartum hysterectomy rate of 7.6 per 10,000 deliveries. In adjusted analysis, compared to white race, black race (aRR 1.24, 95% CI 1.21-1.28), Hispanic ethnicity (aRR 1.27, 95% CI 1.24-1.30), and other race (RR 1.22, 95% CI 1.18-1.26) were at significantly higher risk of peripartum hysterectomy (Table 1). When the analysis was restricted to low-risk cesareans, results were similar. Evaluating SMM, 28.6% of women undergoing peripartum hysterectomy (n¼12,964) experienced this outcome. In adjusted analysis, compared to white women who underwent hysterectomy, black (aRR 1.26, 95% CI 1.19-1.33) women and women of other non-white race were at increased risk for SMM compared to white patients (Table 2). CONCLUSION: Significant racial disparities related to peripartum hysterectomy are present both in terms of risk for the procedure and associated complications. Further research is needed to identify interventions to provide optimized care and reduce differentials in these outcomes.

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