The impact of chronic hypertension and pregestational diabetes on pregnancy outcomes

Comparison of Ultrasound Findings Associated with Adverse Fetal, Obstetric, and Neonatal Outcomes in Pregestational Type 1 And Type 2 Diabetes: A Systematic Review

We aimed to summarize the available evidence examining the association between prenatal ultrasound findings and adverse fetal, obstetric, and neonatal outcomes in pregnancies complicated by type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) and to evaluate whether the predictive value of ultrasound findings for adverse outcomes varies between T1DM and T2DM pregnancies.We conducted a systematic review of the existing literature through August 12, 2024. We included articles in English that reported associations between ultrasound findings and fetal, obstetric, and neonatal outcomes in pregnant people with T1DM and T2DM. The primary outcome of interest was stillbirth; secondary outcomes were neonatal demise, neonatal intensive care unit admission, neonatal hypoglycemia, respiratory distress syndrome, polycythemia, hyperbilirubinemia, organomegaly, electrolyte disturbances, shoulder dystocia, permanent brachial plexus injury, cord gas, Apgar scores, large for gestational age (LGA), small for gestational age (SGA), and preterm birth. Two independent reviewers examined articles at the abstract level and, if eligible, at the full-text level; disagreements were adjudicated by a third reviewer.Of the 2,088 unique citations reviewed, 12 studies met the inclusion criteria describing associations between ultrasound findings and fetal, obstetric, and neonatal outcomes among a total of 1,165 pregnant people with T1DM and 489 pregnant people with T2DM. Most studies (10/12) examined the association between ultrasound measures of growth, including estimated fetal weight and its individual components, abdominal wall thickness, head circumference to abdominal circumference ratio, and birth weight, LGA or SGA. Studies did not examine stillbirth, neonatal demise, or maternal outcomes other than cesarean section.This systematic review synthesizes the available literature on ultrasound risk markers of adverse fetal, obstetric, and neonatal outcomes separately in pregnant people with T1DM and T2DM. We identified very few studies that distinguished between pregnant people with T1DM and T2DM, and the majority focused on surrogate outcomes (e.g., LGA, SGA) of morbidity. Our findings highlight the need for further studies investigating these distinct diseases to provide evidence for antenatal management recommendations. · This systematic review compares ultrasound risk markers for adverse outcomes in pregnancies with T1DM and T2DM.. · Few studies compare ultrasound risk markers for adverse outcomes among pregnancies with T1DM and T2DM.. · Additional targeted studies to inform antenatal ultrasound care are necessary..

Review of Patient Perspectives and Psychosocial Experiences With Automated Insulin Delivery in Pregnancy With Type 1 Diabetes

Pregnancy adds unique medical and psychosocial complexity to the management of type 1 diabetes (TID). Automated insulin delivery (AID) use in pregnancy increasingly shows promise both in improving clinical outcomes and the patient experience for individuals living with T1D. Survey and qualitative data on psychosocial correlates of AID use in pregnancy demonstrate patient benefits compared with other glucose management strategies (such as multiple daily injections, continuous subcutaneous insulin infusion, or sensor-augmented pump therapy). Benefits include improved patient well-being, flexibility, and improved collaboration with health care provider teams. However, burdens have also been identified, including technical glitches, device maintenance, device bulk/visibility, frequent alarms, and the overwhelming quantity of available data. This review describes the lived experiences and perspectives of pregnant individuals with T1D using AID systems. Ongoing education and support for both patients and providers may help to maximize the psychosocial benefits of AID use and reduce potentially negative aspects for pregnant individuals with T1D. While AID represents a significant opportunity for optimizing glucose management for individuals with T1D, both patients and providers need to have realistic expectations based on evidence of what such systems can and cannot do.

Association of Early-life Trauma With Gestational Diabetes and Hypertensive Disorders of Pregnancy

BACKGROUND

Early-life trauma (before age of 18 years) is hypothesized to increase the risk for adverse pregnancy outcomes through stress pathways, yet epidemiologic findings are mixed.

METHODS

Sister Study participants (US women aged 35-74 years enrolled 2003-2009) completed an adapted Brief Betrayal Trauma Survey at the first follow-up visit. Lifetime history of gestational diabetes mellitus (GDM) or hypertensive disorders of pregnancy (HDP: pregnancy-related high blood pressure, pre-eclampsia/toxemia, or eclampsia) in pregnancies lasting ≥20 weeks was self-reported. We used log-binomial regression to estimate relative risks (RR) and 95% confidence intervals (CIs) for the association between early-life trauma (modeled using conventional measures [e.g., any experience, substantive domains, individual types] and latent classes of co-occurring traumas) and GDM or HDP among 34,879 parous women.

RESULTS

Approximately, 4% of participants reported GDM and 11% reported HDP. Relative to no early-life trauma, the RRs for any were 1.1 (95% CI = 1.0, 1.3) for GDM and 1.2 (95% CI = 1.2, 1.3) for HDP. Women reporting physical trauma had the highest risk of GDM and HDP in comparison to other substantive domains. In analyses using latent classes of early-life trauma, high trauma was associated with an elevated risk of both GDM (RR = 1.9, 95% CI = 1.5, 2.6) and HDP (RR = 1.7, 95% CI = 1.4, 2.0) compared with low trauma.

CONCLUSIONS

Women experiencing high levels of trauma in early life were at higher risk of GDM and HDP, adding to a growing evidence base for this association.

Pregnancy outcomes in type 2 versus type 1 diabetes: systematic review with meta-analyses

Objective

Increasing numbers of pregnancies are complicated by pregestational diabetes mellitus, especially type 2 diabetes (T2DM). Some studies have reported similar or greater risks of adverse pregnancy outcomes among women with T2DM relative to type 1 diabetes (T1DM). We aimed to compare the risk of four pregnancy complications: pre-eclampsia, preterm delivery, macrosomia, and perinatal mortality, in pregnant women with T2DM vs T1DM in high-income countries.

Design

Systematic review with meta-analyses.

Methods

Systematic literature searches in Medline and Embase were performed. We included observational studies with original data of outcome occurrence in both women with pregestational T2DM and T1DM. Two researchers independently evaluated full-text studies for inclusion and assessed the risk of bias using the Newcastle-Ottawa scale. Finally, we performed four meta-analyses.

Results

We included 35 publications in total. Meta-analyses demonstrated that, compared to T1DM, T2DM was associated with a lower risk of pre-eclampsia (risk ratio (RR): 0.76; 95% CI: 0.68-0.85), preterm delivery (RR: 0.69; 95% CI: 0.62-0.77), and macrosomia (RR: 0.75; 95% CI: 0.60-0.94). Perinatal mortality was more likely in pregnancies with T2DM (RR: 1.26; 95% CI: 1.06-1.50).

Conclusion

A summation of the research literature demonstrated that, compared to T1DM, women with T2DM had a lower risk of pre-eclampsia, preterm delivery, and macrosomia, but a higher risk of perinatal mortality.

Significance statement

Our review of pregnant women with diabetes suggests a higher risk of perinatal mortality for cases with maternal type 2 diabetes, even though the risks of pre-eclampsia, preterm delivery, and macrosomia were higher in cases with type 1 diabetes. Hence, the prevention of the development of type 2 diabetes and focus on improved gestational and diabetic care could be beneficial for fetal health.

Chronic hypertension diagnosed before or during pregnancy and its effects on pregnancy outcomes

Chronic hypertension (CH) during pregnancy, identified before or within the first 20 weeks, presents varying risks depending on the timing of diagnosis. This real-world study was conducted from January 2018 to June 2023 and included singleton pregnancies with CH to compare pre-pregnancy CH (Group 1) and newly diagnosed CH (Group 2). There were 565 women in the final analysis, with 307 in Group 1 with pre-pregnancy CH and 258 in Group 2 with new-onset CH. Those in Group 1 more frequently had pre-gestational diabetes and a history of hypertensive disorders in pregnancy, whereas Group 2 had a higher incidence of excessive gestational weight gain. Notably, 56.2% of Group 2 patients did not receive antihypertensive treatment before 20 weeks, while the proportion was 36.2% in Group 1, resulting in a significant difference in baseline blood pressure. The study revealed higher incidences of preterm preeclampsia (44.2% vs. 34.9%) and placental abruption (5.4% vs. 2.0%) in Group 2 compared to Group 1. After adjustment, logistic regression indicated that Group 2 had a 1.8-fold higher risk of preterm preeclampsia than Group 1. These findings suggest that pregnant women newly diagnosed with CH in the first 20 weeks face increased adverse outcomes compared to those diagnosed before pregnancy. Intense monitoring and earlier intervention may help manage women with new-onset CH.

A Review of Third-Trimester Complications in Pregnancies Complicated by Diabetes Mellitus

Pregnancies affected by both pregestational and gestational diabetes mellitus carry an increased risk of adverse maternal and neonatal outcomes. While the risks associated with diabetes in pregnancy have been well documented and span across all trimesters, maternal and neonatal morbidity have been associated with select third-trimester complications. Further, modifiable risk factors have been identified that can help improve pregnancy outcomes. This review aims to examine the relationship between select third-trimester complications (large for gestational age, intrauterine fetal demise, hypertensive disorders of pregnancy, preterm birth, perineal lacerations, shoulder dystocia, and cesarean delivery) and the aforementioned modifiable risk factors, specifically glycemic control, blood pressure control, and gestational weight gain. It also highlights how early optimization of these modifiable risk factors can reduce adverse maternal, fetal, and neonatal outcomes. KEY POINTS: · Diabetes mellitus in pregnancy increases the risk of third-trimester complications.. · Modifiable risk factors exist for these complications.. · Optimizing these modifiable risk factors improves maternal and neonatal outcomes..

Stillbirth: we can do better

Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.

Outcomes of Moderately Preterm Infants of Insulin-Dependent Diabetic Mothers

OBJECTIVE

Little is known about the hospital outcomes of moderately preterm (MPT; 29 0/7-33 6/7 weeks gestational age) infants born to insulin-dependent diabetic mothers (IDDMs). We evaluated characteristics and outcomes of MPT infants born to IDDMs compared with those without IDDM (non-IDDM).

STUDY DESIGN

Cohort study of infants from 18 centers included in the MPT infant database from 2012 to 2013. We compared characteristics and outcomes of infants born to IDDMs and non-IDDMs.

RESULTS

Of 7,036 infants, 527 (7.5%) were born to IDDMs. Infants of IDDMs were larger at birth, more often received continuous positive pressure ventilation in the delivery room, and had higher risk of patent ductus arteriosus (adjusted relative risk or aRR: 1.49, 95% confidence interval [CI]: 1.20-1.85) and continued hospitalization at 40 weeks postmenstrual age (aRR: 1.55, 95% CI: 1.18-2.05).

CONCLUSION

MPT infants of IDDM received more respiratory support and prolonged hospitalizations, providing further evidence of the important neonatal health consequences of maternal diabetes.

KEY POINTS

· Little data are available on moderate preterm infants of IDDMs.. · MPT infants of IDDMs need more respiratory support.. · Longer neonatal intensive care unit stays among MPT infants of IDDMs..

Trends and Disparities in Perinatal Opioid Use Disorder Treatment in Medicaid, 2007-2012

We described Medicaid-insured women by receipt of perinatal opioid use disorder (OUD) treatment; and trends and disparities in treatment. Using 2007 to 2012 Medicaid Analytic eXtract data from 45 states and D.C., we identified deliveries among women with OUD. Regressions modeled the association between patient characteristics and receipt of any OUD treatment, medication for OUD (MOUD), and counseling alone during the perinatal period. Rates of any OUD treatment and MOUD for women with perinatal OUD increased over the study period, but trends differed by subgroup. Compared with non-Hispanic White women, Black and American Indian/Alaskan Native (AI/AN) women were less likely to receive any OUD treatment, and Black women were less likely to receive MOUD. Over time, the disparity in receipt of MOUD between Black and White women increased. Overall gains in OUD treatment were driven by improvements in perinatal OUD care for White women and obscured disparities for Black and AI/AN women.

Association between multimorbidity of pregnancy and adverse birth outcomes: A systemic review and meta-analysis

Multimorbidity (≥2 co-existing conditions) in pregnancy is a significant public health issue with a rising prevalence worldwide. However, the association between pregnancy multimorbidity and adverse birth outcomes is unclear. So, this review assessed the association between pregnancy-multimorbidity and adverse birth outcomes (preterm birth, abnormal birth weight, neonatal mortality, and stillbirth). Relevant peer-reviewed papers in PubMed, Web of Science, Elsevier/ScienceDirect, and Google Scholar were systematically search from January 1990 to March 2023. We used the random-effects model to calculate the multimorbidity pooled odds ratio, quantified heterogeneity using I2 statistics, and performed subgroup and sensitivity analyses in Stata version 17. The review protocol is registered with PROSPERO (CRD42023421336). The meta-analysis included 21 observational studies involving 6,523,741 pregnant women. The overall pooled odds of pregnancy multimorbidity associated with adverse birth outcomes were 3.11(2.14-4.09), 3.76(2.56-4.96) in Europe, 3.38(1.18-5.58) in North America, and 2.94(0.78-5.09) in Asia. Pregnant women with psychological and physical multimorbidity had increased odds of 5.65(1.71-9.59) and 2.75(1.71-9.58), respectively, for adverse birth outcomes. Pregnancy multimorbidity was associated with preterm birth 4.28(2.23-6.34), large gestational age (>90 percentile) 3.33(1.50-5.17), macrosomia (≥4000 g) 2.16(0.34-3.98), and small gestational age (<10th percentile) 3.52(1.54-5.51). There is substantial variance in the odds of pregnancy multimorbidity by type of comorbidity and type of adverse birth outcome, attributed to differences in the healthcare system by geographical location. Therefore, prioritizing pregnant women with multimorbidity is crucial for effective and integrative interventions.

Disparities in Perinatal and Emergency Care Receipt Among Women With Perinatal Opioid Use Disorder in Medicaid, 2007 to 2012

OBJECTIVES

This study aimed to better understand receipt of perinatal and emergency care among women with perinatal opioid use disorder (OUD) and explore variation by race/ethnicity.

METHODS

We used 2007-2012 Medicaid Analytic eXtract (MAX) data from all 50 states and the District of Columbia to examine 6,823,471 deliveries for women 18 to 44 years old. Logistic regressions modeled the association between (1) OUD status and receipt of perinatal and emergency care, and (2) receipt of perinatal and emergency care and race/ethnicity, conditional on OUD diagnosis and controlling for patient and county characteristics. We used robust SEs, clustered at the individual level, and included state and year fixed effects.

RESULTS

Women with perinatal OUD were less likely to receive adequate prenatal care (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.44-0.46) and attend the postpartum visit (aOR, 0.46; 95% CI, 0.45-0.47) and more likely to seek emergency care (aOR, 1.48; 95% CI, 1.45-1.51) than women without perinatal OUD. Among women with perinatal OUD, Black, Hispanic, and American Indian and Alaskan Native (AI/AN) women were less likely to receive adequate prenatal care (aOR, 0.68 [95% CI, 0.64-0.72]; aOR, 0.86 [95% CI, 0.80-0.92]; aOR, 0.71 [95% CI, 0.64-0.79]) and attend the postpartum visit (aOR, 0.85 [95% CI, 0.80-0.91]; aOR, 0.86 [95% CI, 0.80-0.93]; aOR, 0.83 [95% CI, 0.73-0.94]) relative to non-Hispanic White women. Black and AI/AN women were also more likely to receive emergency care (aOR, 1.13 [95% CI, 1.05-1.20]; aOR, 1.12 [95% CI, 1.00-1.26]).

CONCLUSIONS

Our findings suggest that women with perinatal OUD, in particular Black, Hispanic, and AI/AN women, may be missing opportunities for preventive care and comprehensive management of their physical and behavioral health during pregnancy.

Continuous glucose monitor use in type 2 diabetes mellitus in pregnancy and perinatal outcomes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to assess whether continuous glucose monitor use in type 2 diabetes mellitus in pregnancy is associated with improved perinatal outcomes.

DATA SOURCES

We searched Ovid MEDLINE, Scopus, ClinicalTrials.gov, and Cochrane library from inception through May 9, 2022.

STUDY ELIGIBILITY CRITERIA

We included all studies that compared continuous glucose monitor use with fingerstick glucose monitoring in women with type 2 diabetes mellitus.

METHODS

The initial search yielded 2463 unique citations that were screened in Covidence by 2 independent reviewers. Study types included randomized controlled trials, cohort studies, and cross-sectional studies. Our outcomes of interest were macrosomia or large-for-gestational-age infants, hemoglobin A1c, cesarean delivery, hypertensive disorders of pregnancy including preeclampsia, gestational age at delivery, and neonatal hypoglycemia.

RESULTS

Three randomized controlled trials met the inclusion criteria. We performed random-effects meta-analyses of estimates from 2 studies without risk of significant bias and reported summary adjusted odds ratios and 95% confidence intervals. Meta-analysis of 56 women with continuous glucose monitor use and 53 control women without continuous glucose monitor use showed that there was no difference in the incidence of large-for-gestational-age infants between continuous glucose monitor users and standard-of-care controls (odds ratio, 0.78; 95% confidence interval, 0.34-1.78) with an I2 of 0%. In addition, there was no difference in the development of preeclampsia between continuous glucose monitor users and standard-of-care controls (odds ratio, 1.63; 95% confidence interval, 0.34-7.22) with an I2 of 0%.

CONCLUSION

Continuous glucose monitor use was not associated with improved perinatal outcomes as assessed by large-for-gestational-age infants and preeclampsia. This review is limited by the small amount of data available for this population, and further research is needed.

Association of community walkability and glycemic control among pregnant individuals with pregestational diabetes mellitus

BACKGROUND

Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined.

OBJECTIVE

This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes.

STUDY DESIGN

This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type.

RESULTS

Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability.

CONCLUSION

Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.

Determinants of Small for Gestational Age in Women With Type 2 Diabetes in Pregnancy: Who Should Receive Metformin?

OBJECTIVE

In the MiTy (Metformin in Women With Type 2 Diabetes in Pregnancy) randomized trial of metformin versus placebo added to insulin, we found numerous benefits with metformin but identified an increased proportion of infants who were small for gestational age (SGA). We aimed to determine the predictors of SGA in order to individualize care.

RESEARCH DESIGN AND METHODS

Using logistic regression, we assessed baseline maternal characteristics as predictors of SGA. We compared maternal/neonatal outcomes in SGA metformin and placebo groups using the t, χ2, or Fisher exact test, as appropriate.

RESULTS

Among the 502 mothers, 460 infants were eligible for this study. There were 30 infants with SGA in the metformin group (12.9%) and 15 in the placebo group (6.6%) (P = 0.026). Among SGA infants, those in the metformin group were delivered significantly later than those in the placebo group (37.2 vs. 35.3 weeks; P = 0.038). In adjusted analyses, presence of a comorbidity (chronic hypertension and/or nephropathy) (odds ratio [OR] 3.05; 95% CI 1.58-5.81) and metformin use (OR 2.26; 95% CI 1.19-4.74) were predictive of SGA. The absolute risk of SGA was much higher in women receiving metformin with comorbidity compared with women receiving metformin without comorbidity (25.0% vs. 9.8%).

CONCLUSIONS

In this study, we observed a high percentage of SGA births among women with type 2 diabetes and chronic hypertension and/or nephropathy who were treated with metformin. Therefore, with the aim of reducing SGA, it is reasonable to be cautious in our use of metformin in those with type 2 diabetes and chronic hypertension or nephropathy in pregnancy.

Planned vaginal and planned cesarean delivery outcomes in pregnancies complicated with pregestational type 1 diabetes - A three-year academic tertiary hospital cohort study

Background

Finland has the world’s highest incidence of 62.5/100000 of diabetes mellitus type 1 (DM1) with approximately 400 (1%) DM1 pregnancies annually. Pregnancies complicated by DM1 are accompanied with increased risk for perinatal morbidity and mortality. Timing and mode of delivery are based on the risk of complications, yet the data on labor induction is limited. The aim of this study was to compare delivery outcomes in planned vaginal (VD) and planned cesarean deliveries (CD) in late preterm and term DM1 pregnancies, and to evaluate the feasibility of labor induction.

Materials and Methods

Pregnant women with DM1, live singleton fetus in cephalic presentation ≥34 gestational weeks delivering in Helsinki University Hospital between January 1st 2017 and December 31st 2019 were included. The primary outcome were the rates of adverse maternal and perinatal outcome. The study population was classified according to the 1980-revised White’s classification. Statistical analyses were performed by IBM SPSS Statistics for Windows.

Results

Two hundred four women were included, 59.8% (n = 122) had planned VD. The rate of adverse maternal outcome was 27.5% (n = 56), similar between the planned modes of delivery and White classes. The rate of perinatal adverse outcome was 38.7% (n = 79), higher in planned CD (52.4% vs. 29.5%;p = 0.001). The most common adverse perinatal event was respiratory distress (48.8% vs. 23.0%;p <  0.001). The rate of adverse perinatal outcome was higher in White class D + Vascular compared to B + C (45.0% vs. 25.0%, OR after adjustment by gestational age 2.34 [95% CI 1.20–4.50];p = 0.01). The total rate of CD was 63.7% (n = 130), and 39.3% (n = 48) in planned VD. Women with White class D + Vascular more often had emergency CD compared to White Class B + C (48.6% vs. 25.0%;p = 0.009). The rate of labor induction was 51%, being 85.2% in planned VD. The rate of VD in induced labor was 58.7% (n = 61) and the rate of failed induction was 14.1% (n = 15).

Conclusion

Planned VD was associated with lower rate of adverse perinatal outcome compared to planned CS, with no difference in the rates of adverse maternal outcome. Induction of labor may be feasible option but should be carefully considered in this high-risk population.

Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus

OBJECTIVE

To compare breastfeeding (BF) initiation among 317 women with chronic hypertension (CHTN) and 106 women with CHTN superimposed on pregestational diabetes (CHTN-DM) who intended exclusive or partial BF.

METHODS

Retrospective cohort study of women who delivered at≥34 weeks of gestation. At discharge, exclusive BF was defined by direct BF or BF complemented with expressed breast milk (EBM) while partial BF was defined by formula supplementation.

RESULTS

CHTN and CHTN-DM groups were similar in prior BF experience (42 vs 52%), intention to BF exclusively (89 vs 79%) and intention to partially BF (11 vs 21%). Women in the CHTN group were younger (31 vs 33y), more likely primiparous (44 vs 27%), and delivered vaginally (59 vs 36%) at term (85 vs 75%). Women in the CHTN-DM group had higher repeat cesarean rates (32 vs 18%), preterm birth (25 vs 15%), neonatal hypoglycemia (42 vs 14%) and NICU admission (38 vs 16%). At discharge, exclusive BF rates among CHTN was higher (48 vs 19%), while rates of partial BF (34 vs 44%) and FF (18 vs 37%) were lower than in the CHTN-DM group. BF initiation (exclusive plus partial BF) occurred in 82%of CHTN and in 63% of CHTN-DM.

CONCLUSION

Although intention to BF was similar, BF initiation rates were higher for the CHTN compared to the CHTN-DM group. Exclusive BF was low in the CHTN and even lower in the CHTN-DM group signaling the need for targeted interventions if BF initiation rates are to be improved.

The effect of preexisting medical comorbidities on the preeclamptic phenotype: a retrospective cohort study

Objective:To compare the effect of comorbidities on the phenotype and outcomes of preeclampsia.Methods: A matched retrospective cohort study of women delivering at a tertiary maternity center following a diagnosis of preeclampsia. We collected data on signs and symptoms, biochemical markers, and maternal and perinatal outcomes.Results:We studied 474 women; 158 women with and 316 without comorbidities. Compared to women without comorbidities, women with comorbidities delivered earlier. They suffered fewer maternal but more neonatal complications.Conclusion: Women with comorbidities receive earlier intervention than women without comorbidities, which may lead to fewer maternal complications but worse neonatal outcomes.

Racial and Ethnic Disparities in Health Care and Health Outcomes for Pregnant Women With Diabetes

This article summarizes the current literature on racial and ethnic differences among women with diabetes in pregnancy. The PubMed, Scopus, CINAHL, and Embase databases were searched for original qualitative or quantitative studies published in English from January 1, 2009, to May 31, 2020. Consensus statements were excluded. Results of this synthesis indicate that racial and ethnic differences exist among pregnant women with diabetes, including social determinants of health, disparities in maternity care and perinatal care, and maternal and neonatal health outcomes. Health care providers should implement tailored interventions that specifically target racial and ethnic disparities in maternal and neonatal health to promote health equity in pregnant women with diabetes and their offspring, including later in life.

Maternal Complications and Prescription Opioid Exposure During Pregnancy: Using Marginal Structural Models

INTRODUCTION

Prescription opioids are frequently used for pain management in pregnancy. Studies examining perinatal complications in mothers who received prescription opioids during pregnancy are still limited.

OBJECTIVES

The aim of this study was to assess the association of prescription opioid use and maternal pregnancy and obstetric complications.

METHODS

This retrospective cohort study with the Rhode Island (RI) Medicaid claims data linked to vital statistics throughout 2008-2015 included pregnant women aged 12-55 years with one or multiple live births. Women were excluded if they had cancer, opioid use disorder, or opioid dispensing prior to but not during pregnancy. Main outcomes included adverse pregnancy and obstetric complications. Marginal Structural Cox Models with time-varying exposure and covariates were applied to control for baseline and time-varying covariates. Analyses were conducted for outcomes that occurred 1 week after opioid exposure (primary) or within the same week as exposure (secondary). Sensitivity studies were conducted to assess the effects of different doses and individual opioids.

RESULTS

Of 9823 eligible mothers, 545 (5.5%) filled one or more prescription opioid during pregnancy. Compared with those unexposed, no significant risk was observed in primary analyses, while in secondary analyses opioid-exposed mothers were associated with an increased risk of cesarean antepartum depression (HR 3.19; 95% CI 1.22-8.33), and cardiac events (HR 9.44; 95% CI 1.19-74.83). In sensitivity analyses, results are more prominent in high dose exposure and are consistent for individual opioids.

CONCLUSIONS

Prescription opioid use during pregnancy is associated with an increased risk of maternal complications.

Prepregnancy Counseling Among U.S. Women With Diabetes and Hypertension, 2016-2018

INTRODUCTION

Individuals who have diabetes or hypertension established before pregnancy are at increased risk for maternal and infant health complications. Guidelines recommend that providers deliver prepregnancy counseling, but little is known about the receipt of those services among patients with chronic conditions.

METHODS

Data from the 2016-2018 Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births, were used. Self-reported receipt of prepregnancy counseling on folic acid supplementation, pregnancy desire, contraceptive use, and improving health before pregnancy was examined overall and by diabetes and hypertension status. Multivariable logistic regression examined the association between diabetes and hypertension status and the 4 prepregnancy counseling outcomes. Analyses were conducted in 2020.

RESULTS

Overall, 2.1% of women reported having both diabetes and hypertension, 1.3% reported having diabetes alone, and 3.1% reported having hypertension alone. Less than half of the sample reported receiving each prepregnancy counseling outcome. In adjusted models, women with hypertension alone were more likely to report each counseling outcome than women without diabetes or hypertension. Women with diabetes alone were only more likely to report receiving counseling about improving health, and women with both conditions were not more likely to report the receipt of any counseling outcome under study.

CONCLUSIONS

Women with prepregnancy diabetes, hypertension, or both reported low levels of the recommended prepregnancy counseling, suggesting an evidence-practice gap that should be addressed to optimize maternal and infant health outcomes. There is a need for evidence-based and patient-centered models of prepregnancy counseling for those with diabetes and hypertension.

Pregnancy outcomes in women with chronic kidney disease and chronic hypertension: a National cohort study

BACKGROUND

Maternal chronic kidney disease and chronic hypertension have been linked with adverse pregnancy outcomes. We aimed to examine the association between these conditions and adverse pregnancy outcomes over the last 3 decades.

OBJECTIVE

We conducted this national cohort study to assess the association between maternal chronic disease (CH, CKD or both conditions) and adverse pregnancy outcomes with an emphasis on the effect of parity, maternal age, and BMI on these associations over the last three decades. We further investigated whether different subtypes of CKD had differing effects.

STUDY DESIGN

We used data from the Swedish Medical Birth Register, including 2,788,490 singleton births between 1982 and 2012. Women with chronic kidney disease and chronic hypertension were identified from the Medical Birth Register and National Patient Register. Logistic regression models were performed to assess the associations between maternal chronic disease (chronic hypertension, chronic kidney disease, or both conditions) and pregnancy outcomes, including preeclampsia, in-labor and prelabor cesarean delivery, preterm birth, small for gestational age, and stillbirth.

RESULTS

During the 30-year study period, 22,397 babies (0.8%) were born to women with chronic kidney disease, 13,279 (0.48%) to women with chronic hypertension and 1079 (0.04%) to women with both conditions. Associations with chronic hypertension were strongest for preeclampsia (adjusted odds ratio, 4.57; 95% confidence interval, 4.33-4.84) and stillbirth (adjusted odds ratio, 1.65; 95% confidence interval, 1.35-2.03) and weakest for spontaneous preterm birth (adjusted odds ratio, 1.07; 95% confidence interval, 0.96-1.20). The effect of chronic kidney disease varied from (adjusted odds ratio, 2.05; 95% confidence interval, 1.92-2.19) for indicated preterm birth to no effect for stillbirth (adjusted odds ratio, 1.16; 95% confidence interval, 0.95-1.43). Women with both conditions had the strongest associations for in-labor cesarean delivery (adjusted odds ratio, 1.86; 95% confidence interval, 1.49-2.32), prelabor cesarean delivery (adjusted odds ratio, 2.68; 95% confidence interval, 2.18-3.28), indicated preterm birth (adjusted odds ratio, 9.09; 95% confidence interval, 7.61-10.7), and small for gestational age (adjusted odds ratio, 4.52; 95% confidence interval, 3.68-5.57). The results remained constant over the last 3 decades. Stratified analyses of the associations by parity, maternal age, and body mass index showed that adverse outcomes remained independently higher in women with these conditions, with worse outcomes in multiparous women. All chronic kidney disease subtypes were associated with higher odds of preeclampsia, in-labor cesarean delivery, and medically indicated preterm birth. Different subtypes of chronic kidney disease had differing risks; strongest associations of preeclampsia (adjusted odds ratio, 3.98; 95% confidence interval, 2.98-5.31) and stillbirth (adjusted odds ratio, 2.73; 95% confidence interval, 1.13-6.59) were observed in women with congenital kidney disease, whereas women with diabetic nephropathy had the most pronounced increase odds of in-labor cesarean delivery (adjusted odds ratio, 3.54; 95% confidence interval, 2.06-6.09), prelabor cesarean delivery (adjusted odds ratio, 7.50; 95% confidence interval, 4.74-11.9), and small for gestational age (adjusted odds ratio, 4.50; 95% confidence interval, 2.92-6.94). In addition, women with renovascular disease had the highest increased risk of preterm birth in both spontaneous preterm birth (adjusted odds ratio, 3.01; 95% confidence interval, 1.57-5.76) and indicated preterm birth (adjusted odds ratio, 8.09; 95% confidence interval, 5.73-11.4).

CONCLUSION

Women with chronic hypertension, chronic kidney disease, or both conditions are at an increased risk of adverse pregnancy outcomes which were independent of maternal age, body mass index, and parity. Multidisciplinary management should be provided with intensive clinical follow-up to support these women during pregnancy, particularly multiparous women. Further research is needed to evaluate the effect of disease severity on adverse pregnancy outcomes.

Recurrent short interpregnancy interval: Maternal and neonatal outcomes

OBJECTIVE

To evaluate maternal and neonatal outcomes associated with recurrent short interpregnancy interval (IPI) in women in their third delivery.

METHODS

A retrospective computerized database study of all women who delivered their first three consecutive deliveries in a single tertiary medical center over 20 years (1999-2019). Maternal and neonatal outcomes of women with recurrent short IPI (<6 months between the 1st and 2nd pregnancy and the 2nd and 3rd pregnancy) were compared to women with recurrent optimal IPI (18-48 months), and to women with a single short IPI (<6 months between the 1st and 2nd pregnancy followed by an optimal IPI of 18-48 months between the 2nd and 3rd pregnancy). Additionally, in the recurrent short IPI groups, outcomes of the 2nd and 3rd pregnancies were compared in order to achieve an ideal adjustment to background characteristics. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

During the study period 10,569 women had three consecutive deliveries at our medical center, of those 338 (3.2%) women had recurrent short IPIs, and 1,021 (9.7%) had recurrent optimal IPIs. Recurrent short IPI was associated with a significantly higher risk of maternal anemia (Hb < 10gr%) on admission to labor (aOR 3.4 [95% CI 1.09-10.65], p = 0.04) and higher risk of small for gestational age neonates (aOR 10.4 [95% CI 2.32-46.93], p < 0.01), as compared with women with recurrent optimal IPI and significantly higher rates of low neonatal birth weights (2500 gr) and anemia (Hb < 10gr%) alongside lower rates of operative vaginal deliveries as compared with women with single short IPI followed by an optimal IPI. In the recurrent short IPI groups, the 3rd deliveries had significantly higher rates of in-labor cesarean and anemia (Hb < 10gr%) on admission as compared to their 2nd deliveries.

CONCLUSION

Recurrent short IPI is associated with maternal anemia and small for gestational age neonates. Guiding patients towards prolongation of the IPI should include explanatory comments on these outcomes.

Risk factors for pregnancy outcomes in Type 1 and Type 2 diabetes

BACKGROUND

Understanding the risk factors and pregnancy outcomes in women affected by Type 1 and Type 2 diabetes is important for pre-pregnancy counselling.

AIM

To explore differences in pregnancy outcomes between women with Type 1 and Type 2 diabetes, and healthy controls, and to examine the relationships between potential adverse risk factors and pregnancy outcomes in this cohort of women.

METHODS

This is a 10-year retrospective study of women with Type 1 diabetes (n = 92), Type 2 diabetes (n = 106) and healthy women without diabetes (controls) (n = 119) from a tertiary obstetric centre. Clinical and biochemical characteristics of women with Type 1 and Type 2 diabetes were determined and related to major obstetric outcomes using univariate analysis.

RESULTS

Women with pre-existing diabetes had higher adverse pregnancy outcomes (preeclampsia, emergency caesarean section, preterm birth <32 and 37 weeks, large for gestational age, neonatal jaundice, Apgar score < 7 at 5 min, neonatal intensive care admission and neonatal hypoglycaemia) compared to controls. A higher birth weight gestational centile (97.4% vs 72.4%, P = 0.001) and large for gestational age rate (63.4% vs 35.8%, P = 0.001) were observed in Type 1 diabetes compared to Type 2 diabetes. There were no differences in other outcomes between women with Type 1 and 2 diabetes.

CONCLUSION

In this exploratory study, risk factors for maternal adverse outcomes differ between Type 1 and Type 2 diabetes. Maternal and foetal adverse outcomes were higher in pregnancies affected by diabetes compared to healthy women but occurred with similar frequency in women with Type 1 and Type 2 diabetes.

Impact of Chronic Hypertension and Antihypertensive Treatment on Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis

Background Maternal chronic hypertension is associated with adverse pregnancy outcomes. Previous studies examined the association between either chronic hypertension or antihypertensive treatment and adverse pregnancy outcomes. We aimed to synthesize the evidence on the effect of chronic hypertension/antihypertensive treatment on adverse pregnancy outcomes. Methods and Results Medline/PubMed, EMBASE, and Web of Science were searched; we included observational studies and assessed the effect of race/ethnicity, where possible, following a registered protocol (CRD42019120088). Random-effects meta-analyses were used. A total of 81 studies were identified on chronic hypertension, and a total of 16 studies were identified on antihypertensive treatment. Chronic hypertension was associated with higher odds of preeclampsia (adjusted odd ratio [aOR], 5.43; 95% CI, 3.85-7.65); cesarean section (aOR, 1.87; 95% CI, 1.6-2.16); maternal mortality (aOR, 4.80; 95% CI, 3.04-7.58); preterm birth (aOR, 2.23; 95% CI, 1.96-2.53); stillbirth (aOR, 2.32; 95% CI, 2.22-2.42); and small for gestational age (SGA) (aOR, 1.96; 95% CI, 1.6-2.40). Subgroup analyses indicated that maternal race/ethnicity does not influence the observed associations. Women with chronic hypertension on antihypertensive treatment (versus untreated) had higher odds of SGA (aOR, 1.86; 95% CI, 1.38-2.50). Conclusions Chronic hypertension is associated with adverse pregnancy outcomes, and these associations appear to be independent of maternal race/ethnicity. In women with chronic hypertension, those on treatment had a higher risk of SGA, although the number of studies was limited. This could result from a direct effect of the treatment or because severe hypertension during pregnancy is a risk factor for SGA and women with severe hypertension are more likely to be treated. The effect of antihypertensive treatment on SGA needs to be further tested with large randomized controlled trials.

Adverse pregnancy outcomes among mothers with hypertensive disorders in pregnancy: A meta-analysis of cohort studies

BACKGROUND

Presently, the results of studies assessing the association of hypertensive disorders in pregnancy (HDP) with adverse pregnancy outcomes (APOs) in offspring remain inconclusive, and a complete overview is missing. We performed a meta-analysis of cohort studies to review and summarize the association between HDP and risk of APOs in offspring.

METHODS

PubMed, Embase, Web of Science and Chinese databases were searched through May 2019 to identify eligible studies. Outcomes of interest were APOs including perinatal death, fetal death, stillbirth, neonatal death, congenital malformations, preterm birth (PTB), very preterm birth (VPTB), intrauterine growth restriction (IUGR), small for gestational age (SGA), low birth weight (LBW), and very low birth weight (VLBW). Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. Subgroup analysis was performed to explore potential heterogeneity moderators.

RESULTS

Total 152 cohort studies involving 1,426,742 mothers with HDP and 36,374,542 mothers without HDP were included for analysis. Overall, mothers with HDP compared with those without HDP had a significantly higher risk of perinatal death (OR = 2.86), fetal death (OR = 2.82), stillbirth (OR = 1.93), neonatal death (OR = 1.55), congenital malformations (OR = 2.66), IUGR (OR = 5.48), SGA (OR = 3.39), LBW (OR = 5.02), VLBW (OR = 1.74), PTB (OR = 4.20) and VPTB (OR = 3.26) in offspring. Relevant heterogeneity moderators were identified by subgroup analyses. The sensitivity analysis yielded consistent results. No evidence of publication bias was observed.

CONCLUSION

The present study indicates that HDP significantly increases risk of APOs. Further research is needed to explore efficient management methods to minimize the risk of APOs associated with HDP.

Fetal-Maternal Exposure to Endocrine Disruptors: Correlation with Diet Intake and Pregnancy Outcomes

Endocrine-disrupting chemicals (EDCs) are exogenous substances able to mimic or to interfere with the endocrine system, thus altering key biological processes such as organ development, reproduction, immunity, metabolism and behavior. High concentrations of EDCs are found in several everyday products including plastic bottles and food containers and they could be easily absorbed by dietary intake. In recent years, considerable interest has been raised regarding the biological effects of EDCs, particularly Bisphenol A (BPA) and phthalates, on human pregnancy and fetal development. Several evidence obtained on in vitro and animal models as well as by epidemiologic and population studies strongly indicated that endocrine disruptors could negatively impact fetal and placental health by interfering with the embryonic developing epigenome, thus establishing disease paths into adulthood. Moreover, EDCs could cause and/or contribute to the onset of severe gestational conditions as Preeclampsia (PE), Fetal Growth Restriction (FGR) and gestational diabetes in pregnancy, as well as obesity, diabetes and cardiovascular complications in reproductive age. Therefore, despite contrasting data being present in the literature, endocrine disruptors must be considered as a therapeutic target. Future actions aimed at reducing or eliminating EDC exposure during the perinatal period are mandatory to guarantee pregnancy success and preserve fetal and adult health.

The comparison of side effects of methyldopa, amlodipine, and metoprolol in pregnant women with chronic hypertension

OBJECTIVE

The aim of the study was to compare the complication of Antihypertensive drug; in pregnant women with chronic hypertension.

METHOD

This retrospective cohort study was performed on 300 pregnant women  with chronic hypertension. Results:  a relative risk of preeclampsia among methyldopa group was 3.45 times higher than the metoprolol, the relative risk of preterm labor was not significantly between methyldopa and metoprolol group, LBW, and IUGR in methyldopa and amlodipine groups .

CONCLUSION

Methyldopa and amlodipine are associated with the least side effects in pregnant women treated for chronic hypertension.the incidence of preeclampsia was greater in methyldopa group.

Impact of diabetes, obesity and hypertension on preterm birth: Population-based study

OBJECTIVE

To determine the impact of pre-pregnancy diabetes mellitus (D), obesity (O) and chronic hypertension (H) on preterm birth (PTB).

METHODS

Retrospective population-based cohort study in Ontario, Canada between 2012-2016. Women who had a singleton livebirth or stillbirth at > 20 weeks gestation were included in the cohort. Exposures of interest were D, O and H, individually, and in various combinations. The primary outcome was PTB at 241/7 to 366/7 weeks. PTB was further analyzed by spontaneous or provider-initiated, early (< 34 weeks) or late (34-37 weeks), and the co-presence of preeclampsia, large for gestational age (LGA), and small for gestational age (SGA). Multivariable Poisson regression models with robust error variance were used to generate relative risks (RR), further adjusted for maternal age and parity (aRR). Population attributable fractions (PAF) were calculated for each of the outcomes by exposure state.

RESULTS

506,483 women were eligible for analysis. 30,139 pregnancies (6.0%) were complicated by PTB < 37 weeks, of which 7375 (24.5%) had D or O or H. Relative to women without D or O or H, the aRR for PTB < 37 weeks was higher for D (3.51; 95% CI 3.26-3.78) and H (3.81; 95% CI 3.55-4.10) than O (1.14; 95% CI 1.10-1.17). The combined state of DH was associated with a significantly higher aRR of PTB < 37 weeks (6.34; 95% CI 5.14-7.80) and < 34 weeks (aRR 10.33, 95% CI 6.96-15.33) than D alone. The risk of provider initiated PTB was generally higher than that for spontaneous PTB. Pre-pregnancy hypertension was associated with the highest risk for PTB with preeclampsia (aRR 45.42, 95% CI 39.69-51.99) and PTB with SGA (aRR 9.78, 95% CI 7.81-12.26) while pre-pregnancy diabetes was associated with increased risk for PTB with LGA (aRR 28.85, 95% CI 24.65-33.76).

CONCLUSION

Combinations of DOH significantly magnify the risk of PTB, especially provider initiated PTB, and PTB with altered fetal growth or preeclampsia.

Obstetric Care Consensus #10: Management of Stillbirth: (Replaces Practice Bulletin Number 102, March 2009)

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained, even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

Management of Stillbirth: Obstetric Care Consensus No, 10

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

Maternal characteristics and pregnancy outcomes of women with chronic hypertension: a population-based study

Background We aimed to study the maternal characteristics and obstetric and neonatal outcomes in pregnant mothers with chronic hypertension (CHTN) compared to non-CHTN. Methods The study was a population-based cohort study, and a PEARL-Peristat Study (PPS) for the year of 2017. There were 20,210 total births including 19,762 singleton and 448 multiple births. We excluded multiple gestations from the analysis as they differ in fetal growth, duration of gestation and have a higher rate of obstetric and neonatal complications. We compared the maternal characteristics of mothers with pre-existing HTN with non-hypertensive mothers and studied the obstetric and neonatal outcomes including cesarean section, stillbirths, prematurity, macrosomia and postpartum hemorrhage (PPH). Results We identified 223 births of mothers with essential HTN. The overall prevalence of CHTN in our population was 1.1% (223/20,210). In regard to maternal characteristics, women with CHTN were at or above 35 years of age at the time of delivery 58.9% compared to non-CHTN women 18.7%, P-value <0.001. Pre-existing diabetes was found more in women with CHTN 15.1% compared to non-CHTN women 1.9%, P-value <0.001; while obesity was found in 64% of women with CHTN compared to 32.5% in non-CHTN women, P-value <0.001. Preterm birth was noted in 26% compared to 8% in CHTN compared to non-CHTN women, respectively, P-value <0.001. The rate of stillbirth was similar between the two groups, 0.9% compared to 0.6% in CHTN compared to non-CHTN women, respectively, P-value 0.369. Conclusion Hypertensive mothers have multiple other comorbidities. When compared to the general population, they are older, parous, diabetic and obese with an increased risk of preterm birth and cesarean deliveries. Lifestyle modification, extensive pre-conceptional counseling and multidisciplinary antenatal care are required for such a high-risk group.

Management of pregestational diabetes mellitus: a comparison of guidelines

Background: Pregestational diabetes is associated with adverse maternal and neonatal outcomes. The aim of this study was to summarize and compare evidence-based recommendations on pregestational diabetes and to focus especially on issues related to the management of this entity.Materials and methods: A descriptive review of three recently published national guidelines on pregestational diabetes was conducted: the American Diabetes Association on "Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2019," the National Institute for Health and Care Excellence on "Diabetes in pregnancy: management from preconception to the postnatal period" and the American College of Obstetricians and Gynecologists on "Pregestational Diabetes Mellitus." These guidelines were compared according to recommendations on management, during the preconception, antenatal, intrapartum and postpartum period.Results: There were many similar recommendations regarding the preconception counseling, the antepartum assessment by specialists, the glycemic control target levels, the pharmacologic treatment and the postpartum period among the three guidelines. On the other hand, the American Diabetes Association makes no recommendations regarding fetal monitoring and obstetric management during pregnancy and the intrapartum period, while there are several similarities between the other two guidelines.Conclusions: The adoption of an international consensus based on evidence - based guidelines will increase the awareness of the healthcare professionals on the management of pregestational diabetes, leading that way to more favorable perinatal outcomes.

The Ethics of Perinatal Care for Black Women: Dismantling the Structural Racism in "Mother Blame" Narratives

Perinatal and neonatal nurses have a critical role to play in effectively addressing the disproportionate prevalence of adverse pregnancy outcomes experienced by black childbearing families. Upstream inequities in maternal health must be better understood and addressed to achieve this goal. The importance of maternal health before, during, and after pregnancy is illustrated with the growing and inequitable prevalence of 2 common illnesses, pregestational diabetes and chronic hypertension, and 2 common conditions during and after pregnancy, gestational diabetes and preterm birth. New care models are needed and must be structured on appropriate ethical principles for serving black families in partnership with nurses. The overarching purpose of this article is to describe the ethics of perinatal care for black women; to discuss how social determinants of health, health disparities, and health inequities affecting women contribute to poor outcomes among their children; and to provide tools to dismantle structural racism specific to "mother blame" narratives." Finally, strategies are presented to enhance the provision of ethical perinatal care for black women by nurses.

[Microbiological analysis of the maternal genital tract and umbilical cord blood and its association with neonatal damage]

The etiology leading to neonatal damage is multifactorial, being genital infections one of the causes. The objective of the study was to identify microorganisms of the maternal genital tract that are associated with neonatal damage, in order to prevent future perinatal complications. Seven hundred and eleven pregnant patients attended their prenatal control during the period January 2010-July 2013. Ureaplasma urealyticum and Mycoplasma hominis presence was investigated in umbilical cord blood by metabolic substrates (Micofast-Biomerieux) and that of T.vaginalis, by PCR using specific primers. The microbiological study of the vaginal contents of 288 pregnant patients at weeks 35 to 37 was performed by conventional methods, adding the modified thioglycolate culture for T.vaginalis. GroupB streptococcus (GBS) was investigated in anorectal and vaginal introitus swabs, using selective broth enrichment and subsequent isolation in chromogenic medium. The χ² Yates test and Fisher's test were used for independent samples. A p value <0.05 was considered statistically significant. The pathogens significantly related to neonatal damage were M.hominis (p=0.03), T.vaginalis (p=0.03), and BV (p=0.02). Main complications were preterm birth, premature rupture of membranes (PRM), low weight and Apgar score ≤7. U.urealyticum (p=0.35), Candidaspp. (p=0.94) and GBS (p=0.18) were not related to neonatal damage. Since different microorganisms of the maternal genital tract were related to neonatal damage, it is very important to perform the microbiological study of vaginal contents during pregnancy to prevent possible maternal and perinatal complications.

Comorbid hypertension and diabetes among U.S. women of reproductive age: Prevalence and disparities

AIMS

Diabetes is associated with significant pregnancy complications, which can be further exacerbated by comorbid hypertension. Racial/ethnic differentials in the burden of comorbid hypertension and diabetes among women of reproductive age have not been described.

METHODS

Using Wave IV of the nationally representative National Longitudinal Study of Adolescent to Adult Health (Add Health), we analyzed survey and biological data from 6576 non-pregnant women who were aged 24-32 in 2007-2008. Hypertension and diabetes were identified by self-report of diagnosis and biological measurements taken during in-home interviews. We used logistic regression models to predict the presence of comorbid hypertension and diabetes and whether each was diagnosed.

RESULTS

Over a third (36.0%) of women with diabetes had comorbid hypertension. Compared to non-Hispanic white women, more non-Hispanic black women had comorbid hypertension and diabetes (adjusted odds ratio (aOR) 5.93, 95% CI 3.84-9.16), and, if comorbid, were less likely to have a diabetes diagnosis (aOR 0.03, 95% CI 0.007-0.1) or hypertension diagnosis (aOR 0.22, 95% CI 0.08-0.65).

CONCLUSION

Comorbid hypertension and diabetes are more common among non-Hispanic black women and less likely to be diagnosed, signaling disparities threatening maternal and child health among women with diabetes.

Bariatric Surgery in Obese Women of Reproductive Age Improves Conditions That Underlie Fertility and Pregnancy Outcomes: Retrospective Cohort Study of UK National Bariatric Surgery Registry (NBSR)

Background

The aims of this study are the following: to describe the female population of reproductive age having bariatric surgery in the UK, to assess the age and ethnicity of women accessing surgery, and to assess the effect of bariatric surgery on factors that underlie fertility and pregnancy outcomes.

Methods

Demographic details, comorbidities, and operative type of women aged 18–45 years were extracted from the National Bariatric Surgery Registry (NBSR). A comparison was made with non-operative cases (aged 18–45 and BMI ≥40 kg/m²) from the Health Survey for England (HSE, 2007–2013). Analyses were performed using “R” software.

Results

Data were extracted on 15,222 women from NBSR and 1073 from HSE. Women aged 18–45 comprised 53 % of operations. Non-Caucasians were under-represented in NBSR compared to HSE (10 vs 16 % respectively, p < 0.0001). The NBSR group was older than the HSE group—median 38 (IQR 32–42) vs 36 (IQR 30–41) years (Wilcoxon test p < 0.0001). Almost one third of women in NBSR had menstrual dysfunction at baseline (33.0 %). BMI fell in the first year postoperatively from 48.2 ± 8.3 to 37.4 ± 7.5 kg/m² (t test, p < 0.001). From NBSR, in the postoperative period, the prevalence of type 2 diabetes fell by 54 %, polycystic ovarian syndrome by 15 %, and any menstrual dysfunction by 12 %.

Conclusions

Over half of all bariatric procedures are carried out on women of reproductive age. More work is required to provide prompt and equal access across ethnic groups. At least one in three women suffers from menstrual dysfunction at baseline. Bariatric surgery improves factors that underlie fertility and pregnancy outcomes. A prospective study is required to verify these effects.

Gestational Age of Delivery in Pregnancies Complicated by Chronic Hypertension

OBJECTIVE

To identify the gestational age of planned delivery in pregnancies complicated by chronic hypertension that minimizes the risk of perinatal death and severe adverse events.

METHODS

This was a retrospective cohort study of all singletons complicated by hypertension. Detailed patient-level information was collected by chart review, including indication for delivery. Planned delivery at 36-36 6/7, 37-37 6/7, 38-38 6/7, and 39-39 6/7 weeks of gestation was compared with expectant management beyond each respective gestational age. Patients were excluded for fetal anomalies, inaccurate dating, and major medical problems other than hypertension, diabetes, or renal disease. The primary outcome was a composite of stillbirth, neonatal death, assisted ventilation, cord pH less than 7.0, 5-minute Apgar score of 3 or less, and neonatal seizures. Secondary outcomes were preeclampsia, severe preeclampsia, primary cesarean delivery, and neonatal length of stay greater than 5 days. Groups were compared using Student's t test and χ tests.

RESULTS

Six hundred eighty-three women with hypertension reached 36 weeks of gestation. Patients with planned delivery at less than 39 weeks of gestation were more likely to have baseline renal disease. Before 37 weeks of gestation, planned delivery was associated with a statistically significant increase in the primary composite adverse neonatal outcome (10.0% compared with 2.6%, P=.04); after 38 weeks of gestation, expectant management was associated with a nonstatistically significant increase in the primary composite outcome (0% compared with 2.3%, P=.40). Expectant management beyond 39 weeks of gestation was associated with a statistically significant increase in severe preeclampsia (0% compared with 10.3%, P=.001).

CONCLUSION

Expectant management beyond 39 weeks of gestation was associated with increasing incidence of severe preeclampsia; planned delivery before 37 weeks of gestation was associated with an increase in adverse neonatal outcomes. Further well-powered studies are needed to delineate the optimal gestational age of delivery.

A Systematic Review of DNA Methylation and Preterm Birth in African American Women

BACKGROUND

The causes of many cases of preterm birth (PTB) remain enigmatic. Increased understanding of how epigenetic factors are associated with health outcomes has resulted in studies examining DNA methylation (DNAm) as a contributing factor to PTB. However, few studies on PTB and DNAm have included African American women, the group with the highest rate of PTB.

METHODS

The objective of this review was to systematically analyze the existing studies on DNAm and PTB among African American women.

RESULTS

Studies ( N = 10) were limited by small sample size, cross-sectional study designs, inconsistent methodologies for epigenomic analysis, and evaluation of different tissue types across studies. African Americans comprised less than half of the sample in 50% of the studies reviewed. Despite these limitations, there is evidence for an association between DNAm patterns and PTB.

CONCLUSIONS

Future research on DNAm patterns and PTB should use longitudinal study designs, repeated DNAm testing, and a clinically relevant definition of PTB and should include large samples of high-risk African American women to better understand the mechanisms for PTB in this population.

A Cross-Sectional Study of Antenatal Care Attendance among Pregnant Women in Western Jamaica

Background:

Pregnancy complications are preventable with appropriate antenatal care (ANC). However, ANC attendance recommendations vary.

Objective:

This study investigated ANC practices and predictors of ANC visits among pregnant women in western Jamaica during 2010.

Methods:

A cross-sectional study was conducted among 356 pregnant women. ANC visits were categorized as not meeting recommendations (<4 ANC visits), meeting WHO and the Jamaican Ministry of Health recommendations of a minimum of 4 ANC visits (4–6 ANC visits) or meeting previously standard recommendation of ≥7 visits. Differences in demographic factors, health status, ANC services received and ANC knowledge by ANC attendance were assessed and a multinomial forward-selection stepwise logistic regression model was used to identify predictors of ANC attendance.

Results:

Most women had an adequate number of ANC visits with 53.4% attending ≥ 7 ANC visits and 27.2% attending 4–6 visits. Despite this, 19.4% of the women had inadequate ANC care and a large portion did not receive key ANC services such as folic acid supplementation (48%), information on breastfeeding (32%) and nutrition (13%). Employment status, number of live births, distance from clinic, history of diabetes or hypertension, possession of ANC card at delivery, receiving iron supplementation and HIV counseling and testing and antenatal care knowledge were predictors of ANC visits.

Conclusion:

Although most women met the WHO or Jamaican ANC recommendations, many women still did not receive key ANC services. Further investigation of ANC practices and a standardized ANC curriculum may improve provision of adequate ANC services.

The interaction between maternal race/ethnicity and chronic hypertension on preterm birth

BACKGROUND

In both the biomedical and public health literature, the risk for preterm birth has been linked to maternal racial/ethnic background, in particular African-American heritage. Despite this well-documented health disparity, the relationship of comorbid conditions, such as chronic hypertension, to maternal race/ethnicity and preterm birth has received relatively limited attention in the literature.

OBJECTIVE

The objective of the study was to evaluate the interaction between chronic hypertension and maternal racial/ethnic background on preterm birth.

STUDY DESIGN

This is a retrospective cohort study of singleton pregnancies among women who delivered between 2002 and 2015 at the University of California, San Francisco. The associations of chronic hypertension with both spontaneous and medically indicated preterm birth were examined by univariate and multivariate logistical regression, adjusting for confounders including for maternal age, history of preterm birth, maternal body mass index, insurance type (public vs private), smoking, substance abuse, history of pregestational diabetes mellitus, and use of assisted reproductive technologies. The interaction effect of chronic hypertension and racial/ethnicity was also evaluated. All values are reported as odds ratios, with 95% confidence intervals and significance set at P = .05.

RESULTS

In this cohort of 23,425 singleton pregnancies, 8.8% had preterm deliveries (3% were medically indicated preterm birth, whereas 5.5% were spontaneous preterm births), and 3.8% of women carried the diagnosis of chronic hypertension. Chronic hypertension was significantly associated with preterm birth in general (adjusted odds ratio, 2.74, P < .001) and medically indicated preterm birth specifically (adjusted odds ratio, 5.25, P < .001). When evaluating the effect of chronic hypertension within racial/ethnic groups, there was an increased odds of a preterm birth among hypertensive, African-American women (adjusted odds ratio, 3.91, P < .001) and hypertensive, Asian-American/Pacific Islander women (adjusted odds ratio, 3.51, P < .001) when compared with their nonhypertensive counterparts within the same racial/ethnic group. These significant effects were also noted with regard to medically indicated preterm birth for hypertensive African-American women (adjusted odds ratio, 6.85, P < .001) and Asian-American/Pacific Islander women (adjusted odds ratio, 9.87, P < .001). There was no significant association of chronic hypertension with spontaneous preterm birth (adjusted odds ratio, 0.87, P = .4).

CONCLUSION

The effect of chronic hypertension on overall preterm birth and medically indicated preterm birth differs by racial/ethnic group. The larger effect of chronic hypertension among African-American and Asian/Pacific Islander women on medically indicated and total preterm birth rates raises the possibility of an independent variable that is not captured in the data analysis, although data regarding the indication for medically indicated preterm delivery was limited in this data set. Further investigation into both social-structural and biological predispositions to preterm birth should accompany research focusing on the effect of chronic hypertension on birth outcomes.

Prediction of stillbirth from maternal demographic and pregnancy characteristics

OBJECTIVES

To develop a model for prediction of stillbirth based on maternal characteristics and components of medical history and to evaluate the performance of screening with this model for all stillbirths and those due to impaired placentation and to unexplained causes.

METHODS

This was a prospective screening study of 113 415 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation and at 19 + 0 to 24 + 6 weeks. The study population included 113 019 live births and 396 (0.35%) antepartum stillbirths; 230 (58%) were secondary to impaired placentation and 166 (42%) were due to other or unexplained causes. Multivariable logistic regression analysis was used to determine the factors from maternal characteristics and medical history which provided a significant contribution to the prediction of stillbirth.

RESULTS

The risk for stillbirth increased with maternal weight (odds ratio (OR), 1.01 per kg above 69 kg), was higher in women of Afro-Caribbean racial origin (OR, 2.01), those with assisted conception (OR, 1.79), cigarette smokers (OR, 1.71), and in those with a history of chronic hypertension (OR, 2.62), systemic lupus erythematosus/antiphospholipid syndrome (OR, 3.61) or diabetes mellitus (OR, 2.55) and was increased in women with a history of previous stillbirth (OR, 4.81). Screening with the model predicted 26% of unexplained stillbirths and 31% of those due to impaired placentation, at a false-positive rate of 10%; within the impaired-placentation group the detection rate of stillbirth < 32 weeks' gestation was higher than that of stillbirth ≥ 37 weeks (38% vs 28%).

CONCLUSIONS

A model based on maternal characteristics and medical history recorded in early pregnancy can potentially predict one-third of subsequent stillbirths. The extent to which such stillbirths could be prevented remains to be determined. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

The green tea polyphenol EGCG alleviates maternal diabetes-induced neural tube defects by inhibiting DNA hypermethylation

BACKGROUND

Maternal diabetes increases the risk of neural tube defects in offspring. Our previous study demonstrated that the green tea polyphenol, Epigallocatechin gallate, inhibits high glucose-induced neural tube defects in cultured embryos. However, the therapeutic effect of Epigallocatechin gallate on maternal diabetes-induced neural tube defects is still unclear.

OBJECTIVE

We aimed to examine whether Epigallocatechin gallate treatment can reduce maternal diabetes-induced DNA methylation and neural tube defects.

STUDY DESIGN

Nondiabetic and diabetic pregnant mice at embryonic day 5.5 were given drinking water with or without 1 or 10 μM Epigallocatechin gallate. At embryonic day 8.75, embryos were dissected from the visceral yolk sac for the measurement of the levels and activity of DNA methyltransferases, the levels of global DNA methylation, and methylation in the CpG islands of neural tube closure essential gene promoters. embryonic day 10.5 embryos were examined for neural tube defect incidence.

RESULTS

Epigallocatechin gallate treatment did not affect embryonic development because embryos from nondiabetic dams treated with Epigallocatechin gallate did not exhibit any neural tube defects. Treatment with 1 μM Epigallocatechin gallate did not reduce maternal diabetes-induced neural tube defects significantly. Embryos from diabetic dams treated with 10 μM Epigallocatechin gallate had a significantly lower neural tube defect incidence compared with that of embryos without Epigallocatechin gallate treatment. Epigallocatechin gallate reduced neural tube defect rates from 29.5% to 2%, an incidence that is comparable with that of embryos from nondiabetic dams. Ten micromoles of Epigallocatechin gallate treatment blocked maternal diabetes-increased DNA methyltransferases 3a and 3b expression and their activities, leading to the suppression of global DNA hypermethylation. Additionally, 10 μM Epigallocatechin gallate abrogated maternal diabetes-increased DNA methylation in the CpG islands of neural tube closure essential genes, including Grhl3, Pax3, and Tulp3.

CONCLUSION

Epigallocatechin gallate reduces maternal diabetes-induced neural tube defects formation and blocks the enhanced expression and activity of DNA methyltransferases, leading to the suppression of DNA hypermethylation and the restoration of neural tube closure essential gene expression. These observations suggest that Epigallocatechin gallate supplements could mitigate the teratogenic effects of hyperglycemia on the developing embryo and prevent diabetes-induced neural tube defects.

Type 2 diabetes mellitus induces congenital heart defects in murine embryos by increasing oxidative stress, endoplasmic reticulum stress, and apoptosis

BACKGROUND

Maternal type 1 and 2 diabetes mellitus are strongly associated with high rates of severe structural birth defects, including congenital heart defects. Studies in type 1 diabetic embryopathy animal models have demonstrated that cellular stress-induced apoptosis mediates the teratogenicity of maternal diabetes leading to congenital heart defect formation. However, the mechanisms underlying maternal type 2 diabetes mellitus-induced congenital heart defects remain largely unknown.

OBJECTIVE

We aim to determine whether oxidative stress, endoplasmic reticulum stress, and excessive apoptosis are the intracellular molecular mechanisms underlying maternal type 2 diabetes mellitus-induced congenital heart defects.

STUDY DESIGN

A mouse model of maternal type 2 diabetes mellitus was established by feeding female mice a high-fat diet (60% fat). After 15 weeks on the high-fat diet, the mice showed characteristics of maternal type 2 diabetes mellitus. Control dams were either fed a normal diet (10% fat) or the high-fat diet during pregnancy only. Female mice from the high-fat diet group and the 2 control groups were mated with male mice that were fed a normal diet. At E12.5, embryonic hearts were harvested to determine the levels of lipid peroxides and superoxide, endoplasmic reticulum stress markers, cleaved caspase 3 and 8, and apoptosis. E17.5 embryonic hearts were harvested for the detection of congenital heart defect formation using India ink vessel patterning and histological examination.

RESULTS

Maternal type 2 diabetes mellitus significantly induced ventricular septal defects and persistent truncus arteriosus in the developing heart, along with increasing oxidative stress markers, including superoxide and lipid peroxidation; endoplasmic reticulum stress markers, including protein levels of phosphorylated-protein kinase RNA-like endoplasmic reticulum kinase, phosphorylated-IRE1α, phosphorylated-eIF2α, C/EBP homologous protein, and binding immunoglobulin protein; endoplasmic reticulum chaperone gene expression; and XBP1 messenger RNA splicing, as well as increased cleaved caspase 3 and 8 in embryonic hearts. Furthermore, maternal type 2 diabetes mellitus triggered excessive apoptosis in ventricular myocardium, endocardial cushion, and outflow tract of the embryonic heart.

CONCLUSION

Similar to those observations in type 1 diabetic embryopathy, maternal type 2 diabetes mellitus causes heart defects in the developing embryo manifested with oxidative stress, endoplasmic reticulum stress, and excessive apoptosis in heart cells.

Glycemic control, compliance, and satisfaction for diabetic gravidas in centering group care

PURPOSE

To determine if diabetic gravidas enrolled in Centering® group care have improved glycemic control compared to those attending standard prenatal care. To compare compliance and patient satisfaction between the groups.

MATERIALS AND METHODS

We conducted a prospective cohort study of diabetics enrolled in centering group care from October 2013 to December 2015. Glycemic control, compliance and patient satisfaction (five-point Likert scale) were evaluated. Student's t-test, Chi-Square and mixed effects model were used to compare outcomes.

RESULTS

We compared 20 patients in centering to 28 standard prenatal care controls. Mean fasting blood sugar was lower with centering group care (91.0 versus 105.5 mg/dL, p =0.017). There was no difference in change in fasting blood sugar over time between the two groups (p = 0.458). The percentage of time patients brought their blood glucose logs did not differ between the centering group and standard prenatal care (70.7 versus 73.9%, p = 0.973). Women in centering group care had better patient satisfaction scores for "ability to be seen by a physician" (5 versus 4, p = 0.041) and "time in waiting room" (5 versus 4, p =0.001).

CONCLUSION

Fasting blood sugar was lower for patients in centering group care. Change in blood sugar over time did not differ between groups. Diabetic gravidas enrolled in centering group care report improved patient satisfaction.

New development of the yolk sac theory in diabetic embryopathy: molecular mechanism and link to structural birth defects

Maternal diabetes mellitus is a significant risk factor for structural birth defects, including congenital heart defects and neural tube defects. With the rising prevalence of type 2 diabetes mellitus and obesity in women of childbearing age, diabetes mellitus-induced birth defects have become an increasingly significant public health problem. Maternal diabetes mellitus in vivo and high glucose in vitro induce yolk sac injuries by damaging the morphologic condition of cells and altering the dynamics of organelles. The yolk sac vascular system is the first system to develop during embryogenesis; therefore, it is the most sensitive to hyperglycemia. The consequences of yolk sac injuries include impairment of nutrient transportation because of vasculopathy. Although the functional relationship between yolk sac vasculopathy and structural birth defects has not yet been established, a recent study reveals that the quality of yolk sac vasculature is related inversely to embryonic malformation rates. Studies in animal models have uncovered key molecular intermediates of diabetic yolk sac vasculopathy, which include hypoxia-inducible factor-1α, apoptosis signal-regulating kinase 1, and its inhibitor thioredoxin-1, c-Jun-N-terminal kinases, nitric oxide, and nitric oxide synthase. Yolk sac vasculopathy is also associated with abnormalities in arachidonic acid and myo-inositol. Dietary supplementation with fatty acids that restore lipid levels in the yolk sac lead to a reduction in diabetes mellitus-induced malformations. Although the role of the human yolk in embryogenesis is less extensive than in rodents, nevertheless, human embryonic vasculogenesis is affected negatively by maternal diabetes mellitus. Mechanistic studies have identified potential therapeutic targets for future intervention against yolk sac vasculopathy, birth defects, and other complications associated with diabetic pregnancies.

Maternal and neonatal outcomes of pregnancy in women with chronic hypertension: a retrospective analysis of a national register

INTRODUCTION

Pregnancies complicated by chronic hypertension are at increased risk of adverse pregnancy outcomes. To assess whether planned early delivery might prevent some of these adverse outcomes, we studied maternal and neonatal outcomes of pregnancy in women with chronic hypertension, including gestational-age-specific outcomes.

MATERIAL AND METHODS

We performed a retrospective, population-based cohort study, using data from the Netherlands Perinatal Register. We included women with chronic hypertension and normotensive controls who delivered a singleton without congenital anomalies in 2002-2007. We calculated crude and adjusted odds ratios (OR) with 95% CI, compared delivery and ongoing pregnancy using moving averages, and used multiple Cox regression to adjust for differences in baseline characteristics and to examine adverse neonatal outcomes across subgroups of hypertensive disorder. Main outcome measures were composite adverse maternal and neonatal outcomes.

RESULTS

We included 3457 (0.3%) women with chronic hypertension and 984 932 normotensive controls. Women with chronic hypertension had adverse maternal outcomes more often (28.7% vs. 6.6%, adjusted OR 5.7, 95% CI 5.3-6.2). Their offspring had an increased rate of neonatal morbidity (17.4% vs. 13.2%, adjusted OR 1.2, 95% CI 1.1-1.4) but not of severe adverse neonatal outcomes (2.5% vs. 2.2%, adjusted OR 0.8, 95% CI 0.6-1.0). The increased risk of adverse maternal outcomes for ongoing pregnancy remained stable around 17% at term. The risk of severe adverse neonatal outcomes for birth was at its lowest between 38 and 40 weeks, mainly in women with iatrogenic onset of delivery.

CONCLUSIONS

Women with chronic hypertension are at increased risk of adverse maternal and neonatal outcomes compared with controls throughout pregnancy, including at term. Our results suggest that the optimal timing of delivery might be between 38 and 40 weeks of gestation, but prospective randomized studies should confirm this.

Care of the Childbearing Family With Intrauterine Fetal Demise

Intrauterine fetal demise (IUFD), or stillbirth, is the death of a fetus greater than 20 weeks gestation. Several factors contribute to risk for IUFD, although in many cases the exact etiology is unknown. Nurses are a vital part of the interdisciplinary health care team caring for families with IUFD, who require timely and sensitive care to enable an uncomplicated birth and grieving process.