ACOG Committee Opinion No. 736: Optimizing Postpartum Care

Clinical and demographic factors associated with increased risk of postpartum readmission among patients presenting to the emergency department by 6 weeks postpartum

OBJECTIVE

Postpartum emergency department (ED) visits complicate 12% of births and rates of postpartum readmission are on the rise. While there are a wide range of etiologies, prior studies have sought to delineate causes and risk for readmission. Furthering our understanding of risk factors and etiologies for postpartum readmissions may help develop quality metrics and targeted strategies to address the rising rate of readmissions. We aimed to characterize demographic and perinatal characteristics in postpartum ED visits and evaluate risk factors for readmission.

METHODS

A retrospective cohort study was performed on all ED visits that took place within 42 days of delivery at a single tertiary care center between 2017 and 2022. Inclusion criteria were age 18 years or above and both delivery and ED visit/readmission at the institution. Exclusion criteria included patients who did not deliver at the study institution, previable deliveries (<24 weeks gestation), intrauterine fetal demise, and termination of pregnancy. Chief complaint was used to determine the main reason for presentation to the ED. Patients who presented with concern for elevated blood pressures had hypertension listed as their chief complaint. Maternal demographics and delivery outcomes were compared between patients who were readmitted to those managed outpatient.

RESULTS

Of 16162 deliveries, 548 (3.4%) patients presented to the ED for total 616 encounters. 52 (9.5%) patients presented to the ED more than once. Out of the patients who presented to the ED, 221 (40.3%) patients were readmitted, 8 of whom were readmitted twice (1.3%). The majority (63%) of ED visits occurred within 14 days of delivery. Hypertension was the most common reason for presenting to the ED (23.8%), followed by GI complaints (10.8%) and vaginal bleeding (9.7%). Advanced maternal age, higher BMI, Black race, chronic hypertension, maternal medical comorbidity, and longer postpartum length of stay were all associated with higher likelihood of being readmitted. Multivariate logistic regression controlling for potential confounders found higher risk of readmission with hypertensive disorder of pregnancy (adjusted odds ratio [aOR], 2.28; 95% confidence interval [CI], 1.57-3.3; p < 0.001), preeclampsia with severe features (aOR, 1.91; 95% CI, 1.07-3.42; p = 0.03), and presenting for hypertension (aOR, 5.69; 95% CI, 3.56-9.09; p < 0.001). There were also higher odds of readmission with any delivery complication (aOR, 1.77; 95% CI, 1.24-2.52; p = 0.002) and having more than one ED visit (aOR, 3.42; 95% CI, 1.86 to 6.28; p < 0.001).

CONCLUSION

Most ED visits took place within 2 weeks of delivery, and postpartum hypertension was the leading cause. Risk of readmission after an ED visit was higher for patients with medical comorbidities, hypertensive disorders of pregnancy, and delivery complications. Future research is needed to evaluate patient-centered models to improve outcomes and support patients during the postpartum period.

Risk factors for emergency department visits and readmissions for postpartum hypertension

OBJECTIVE

Postpartum hypertension accounts for 15 to 20% of postpartum Emergency Department (ED) visits and readmissions in the United States. Postpartum readmission is a quality metric and target of quality improvement as it indicates poor control of hypertension and can portend increased morbidity. We aim to evaluate risk factors for postpartum ED visits and readmissions for hypertension.

METHODS

This was a retrospective cohort study of all birthing patients with peripartum hypertension at a single tertiary care center over a 5-year period (2017-2022). Inclusion criteria were age 18 years or above, existing diagnosis of chronic hypertension or hypertensive disease of pregnancy diagnosed during the intrapartum or postpartum course, and both delivery and ED visit or readmission at the study institution. Maternal baseline and intrapartum characteristics were chart abstracted. Primary outcome was ED visit or readmission (EDR) for postpartum hypertension. Patients who had EDR within 42 days of delivery were compared to those who underwent routine outpatient surveillance. For all analyses, p values were two-way, and the level of statistical significance was set at p < 0.05.

RESULTS

Of 16,162 patients who gave birth during the study period, 2403 (14.9%) patients met the definition of peripartum hypertension. 218 (9.1%) presented to the ED or were readmitted for hypertension. Risk factors for EDR were as follows: maternal age ≥40 years (22.9% vs 15.3%, p = 0.003), prenatal aspirin use (6.9% vs 3.9%, p = 0.039), cesarean delivery (42.7% vs 35.8%, p = 0.044), chronic hypertension (37.2% vs 31.6%, p = 0.029), preeclampsia with severe features (32.6% vs 15.6%, p < 0.001), postpartum hemorrhage (22.9% vs 12.0%, p < 0.001), and intrapartum need for intravenous anti-hypertensives (23.9% vs 3.3%, p < 0.001). Factors at discharge that increased risk of EDR included prescription of anti-hypertensives at discharge (27.5% vs 8.6%, p < 0.001) and having >50% elevated blood pressures within the 24 h prior to discharge (16.5% vs 11.9%, p = 0.046). In a multivariable logistic regression controlling for prenatal aspirin use, mode of delivery, postpartum hemorrhage, and chorioamnionitis, a higher risk of EDR remained for maternal age ≥40 years (aOR, 1.56; 95% confidence interval (CI), 1.11-2.20; p = 0.011), PO anti-hypertensives at discharge (aOR, 4.05; 95% CI, 2.86-5.73; p < 0.001), preeclampsia with severe features (aOR, 2.50; 95% CI, 1.83-3.42; p < 0.001), and history of IV anti-hypertensive exposure (aOR, 9.30; 95% CI, 6.20-13.95; p < 0.001).

CONCLUSIONS

Maternal age of 40 years and above, chronic hypertension, preeclampsia with severe features, prescription of anti-hypertensives on discharge, and elevated blood pressures leading up to discharge are associated with postpartum ED visits or readmissions for hypertension. Risk factor identification can aid in the development of predictive tools to determine high risk groups and interventions to reduce ED visits and readmissions.

Placental ischemia during pregnancy induces hypertension, cerebral inflammation, and oxidative stress in dams postpartum

BACKGROUND

Preeclampsia (PE) is characterized as de novo hypertension (HTN) with end-organ damage, especially in the brain. PE is hypothesized to be caused by placental ischemia. PE affects ~5-8% of USA pregnancies and increases the risk for HTN and cerebrovascular diseases (CVD) later in life. We hypothesize that blood pressure (BP), cerebral oxidative stress, and cerebral inflammation will increase in postpartum (PP) placental ischemic dams.

METHODS

Placental ischemia was induced in pregnant Sprague Dawley dams, utilizing reduced uterine perfusion pressure (RUPP) surgery. At 6 weeks PP (~3 human years), BP was measured via carotid catheterization, and cerebral oxidative stress and inflammation were assessed via ELISAs, biochemical assays, and Western blots.

RESULTS

BP, cerebral pro-inflammatory cytokines (TNF-α and IL-6), and GFAP (a marker of astrocyte activity) were increased in PP RUPP dams. Cerebral hydrogen peroxide (H2O2) was also increased in PP RUPP dams, and had a strong correlation with PP RUPP BP, proinflammatory cytokines (TNF- α and IL-6), and GFAP astrocyte activation.

CONCLUSION

PP RUPP dams have increased BP, cerebral oxidative stress, and cerebral inflammation at 6 weeks postpartum. These changes in cerebral inflammation and oxidative stress may contribute to the pathology and development of HTN and CVDs in postpartum dams.

Physical Problems, Fatigue, and Healthy Lifestyle Behaviors Experienced by Women in the First 48 Hours of Postpartum Period

The postpartum period is a crucial phase in women's lives, characterized by physical challenges, fatigue, and lifestyle behaviors. This descriptive study aimed to assess physical challenges, fatigue, and healthy lifestyle behaviors in women during the first 48 h postpartum. Data were collected from 548 women hospitalized in the postpartum service of Meram Medical Faculty at Necmettin Erbakan University between December 2021 and August 2022, using a convenience sampling method. Data collection tools included the Personal Information Form, Postpartum Assessment Form, Fatigue Assessment Scale, and Healthy Lifestyle Behavior-II Scale. Linear regression analysis (ENTER model) was conducted for advanced statistical evaluation. The study found that women employed outside the home (p = 0.001) and those with a high monthly income (p = 0.008) had higher levels of fatigue, while their levels of healthy lifestyle behaviors were also higher (p < 0.001, p = 0.002) compared to other groups. Breastfeeding challenges were associated with increased nipple pain (p = 0.002), incision pain (p = 0.003), and back pain (p = 0.012). Women accompanied by a partner reported higher fatigue levels (p = 0.005). Fatigue levels were affected by employment, cesarean section, breastfeeding experience, and incomplete areola compression by the baby.

Tailored Prenatal Care Delivery for Pregnant Individuals: ACOG Clinical Consensus No. 8

SUMMARY

Prenatal care is one of the most common preventive services in the United States; it is designed to improve the health and well-being of pregnant and birthing individuals and their children through evidence-based services. Despite the prevalence of prenatal care, formalized models of prenatal care delivery have changed little since they were first published in 1930. The purpose of this Clinical Consensus document is to offer guidance on a transformative approach to the provision of prenatal care in three key areas: 1) addressing unmet social needs, 2) frequency of prenatal visits and monitoring, and 3) incorporation of telemedicine and alternative care modalities. Implementing a sustainable paradigm shift in a century-old care-delivery approach will take time; however, this document will guide maternity care professionals and their teams in the use of new prenatal care delivery models.

Secondary Postpregnancy Hemorrhage: Guide for Diagnosis and Management

Secondary postpregnancy hemorrhage (PPH) is increasing in incidence, especially in developed countries such as the United States. PPH occurs after 24 hours and up to 12 weeks in the postpregnancy period and may be associated with significant maternal morbidity. Common causes of secondary PPH are subinvolution of the placental site (SIPS) and retained or residual products of conception (RPOC). Other less common and rare causes include bleeding diathesis, endo(myo)metritis, gestational trophoblastic disease, and vascular anomalies such as congenital arteriovenous malformation (AVM), iatrogenic arteriovenous fistula, or pseudoaneurysm. A common finding encountered during imaging evaluation of secondary PPH is increased vascularity in the myometrium deep to an implantation site, termed enhanced myometrial vascularity (EMV). EMV typically represents the physiologic reversion of the uterus back to its prepregnancy state. The appearance of EMV varies from mild to marked and is also associated with SIPS and RPOC. Interpretation or reporting of EMV as an AVM or other rare uterine vascular anomaly may lead to unnecessary testing and overtreatment. The authors review placental physiology, describe the causes of secondary PPH and their imaging appearances, and present an algorithm to assist the radiologist in diagnosis of this important condition and management options. ©RSNA, 2025 Supplemental material is available for this article. See the invited commentary by Gomez in this issue.

Change in Postpartum Visit and Contraception Rates Pre-COVID-19 to Post-Lockdown in Six U.S. Federally Qualified Health Centers

Background: Postpartum care, including contraception, benefits maternal health and decreases mortality, which increased in the United States with COVID-19. Pandemic disruptions to postpartum health care access in vulnerable populations are not well understood. We utilize electronic health record (EHR) data for prenatal patients (n = 2,265) at six urban Federally Qualified Health Centers (FQHCs) from one year prepandemic (January 1, 2019) through one year after the first stay-at-home orders ("lockdown") (March 31, 2021). Objective: We investigated (1) changes in rates of postpartum visit (PPV) and postpartum contraception receipt in the post-lockdown versus prepandemic periods and (2) characteristics predictive of differential changes in PPV and contraception rates. Materials and Methods: Visit and prescription records from EHR were used to classify if patients received PPV and most/moderately effective contraception within 60 days postpartum, analyzed separately and as a composite variable: PPV and contraception, PPV only, or no PPV. Risk differences comparing post-lockdown with pre-COVID-19 pandemic were estimated using binomial regression and generalized logistic regression models adjusted for age, race/ethnicity, language, and clinical site. Effect modification by sociodemographic and clinical covariates was examined. Results: Total patient volume fell 21% in the post-lockdown versus pre-COVID-19 period. Rates of PPV decreased in absolute terms by 9.6 (95% confidence interval: -13.6, -5.6) and contraception by 8.1 (-13.3, -2.8) percentage points. After adjustment, PPV and contraception decreased by 9.3 percentage points (-13.1, -5.4), while PPV only was stable (-0.4 [-4.3, 3.6]). Conclusions: These findings suggest a substantial impact of the COVID-19 pandemic on postpartum care in FQHCs and community health centers. Supply and demand drivers require further examination to inform strategies to improve postpartum care access and subsequent maternal health outcomes.

The neonatal intensive care unit as a site of perinatal iatrogenesis: An ethnographic analysis of postpartum health support in a U.S. children's hospital

Postpartum parents with infants in neonatal intensive care units (NICUs) disproportionately lack access to adequate postpartum care, particularly in pediatric hospital settings. Building upon Liese's (2021) framework of obstetric iatrogenesis 'ranging from unintentional harm (UH) to overt disrespect, violence, and abuse (DVA)', this paper proposes an extended analytic of perinatal iatrogenesis. It explores how the experiences of postpartum parents in the NICU exemplify perinatal iatrogenesis, highlighting how iatrogenesis manifests beyond birth and in non-obstetric settings, ultimately contributing to worse health outcomes for postpartum persons. Drawing on twelve months of ethnographic observations between 1/31/2023 and 1/31/24 and 30 semi-structured interviews in a large, urban children's hospital Level IV NICU in the Northeastern U.S., this analysis positions the NICU as a site of perinatal iatrogenesis, exposing how neglectful and inaccessible postpartum care for NICU parents is a normalized form of mistreatment of perinatal persons within the U.S. healthcare system. It also argues that the embodiment of societal notions of motherhood reduces maternal motivations for self-care, contributing to postpartum care underutilization among NICU parents. Centering the postpartum period as key for maternal health and dyadic health, this paper demonstrates the utility of the perinatal iatrogenesis framework for understanding maternal experiences in the NICU and advocates for improved postpartum health support for NICU parents in a pediatric hospital setting.

Postpartum Readmission after Unscheduled Cesarean Delivery in Patients with Class 3 Obesity

This study aimed to identify risk factors for postpartum readmission (PPR) in class 3 obese patients undergoing unscheduled cesarean deliveries.Retrospective cohort study of patients with a body mass index (BMI) of ≥40 kg/m2 undergoing unscheduled cesarean delivery from 2017 to 2020 comparing patients with and without PPR (unexpected admission, emergency room/overnight observation visit, unscheduled outpatient visit, or ambulatory surgery within 30 days). Medical history, operative data, and postpartum outcomes were compared between the cohorts.The electronic medical record was queried to identify cesarean deliveries documented as "unscheduled." In total, 255 of 1,273 identified patients (20.0%) had a PPR. Median BMI was similar between the cohorts (44.2 kg/m2, interquartile range [IQR]: [41.8, 47.9] vs. 44.8 kg/m2 [42.0, 48.9], p = 0.066). Readmitted patients were more likely to have a history of smoking during or prior to pregnancy (p = 0.046). A subgroup exploratory analysis excluding outpatient and emergency room visits demonstrated higher rates of type II diabetes mellitus in patients with PPR (11.5 vs. 4.6%, p = 0.030). Patients with readmission in comparison to those without readmissions were less likely to receive cefazolin prophylaxis (78.0 vs. 84.3%, p = 0.014) in comparison to gentamicin/clindamycin prophylaxis. Patients with readmission were less likely to have had vaginal preparation (56.9 vs. 64.3%, p = 0.027). On multivariable logistic regression analysis, smoking history (odds ratio [OR] = 1.44, 95% confidence interval [CI]: 1.06-1.96, p = 0.0220) and hypertensive disease (OR = 1.57, 95% CI: 1.18-2.09, p = 0.002) were associated with readmission. Cefazolin preoperative prophylaxis (OR = 0.59, 95% CI: 0.41-0.84, p = 0.004) and vaginal sterile preparation (OR = 0.72, 95% CI: 0.54-0.95, p = 0.022) were associated with decreased risk of readmission.In class 3 obese patients, a history of smoking and a diagnosis of hypertensive disease are associated with an increased risk of PPR. Perioperative antibiotic prophylaxis with cefazolin along with vaginal sterile preparation associate with a decreased risk of PPR. · Class 3 obesity and unscheduled cesarean deliveries are high risks for postpartum complications.. · Hypertensive disorders and smoking are associated with PPR.. · Cefazolin prophylaxis and vaginal preparation are associated with decreased PPR..

Texting in the Fourth Trimester: mHealth for Postpartum Care

Rising maternal morbidity and mortality in the United States is a complex problem and is often tied to the postpartum period. Postpartum visits are poorly attended leading to gaps in contraception, mental health care, and care for chronic conditions. mHealth, health care supported by mobile technologies, has been shown to improve antenatal care adherence. Our study aims to determine whether an mHealth intervention of interactive, educational text messages can improve care for women postpartum.We conducted a randomized control trial of 191 women receiving OB/GYN care in our clinic from November 2019 to April 2020. Patients were randomized postpartum to receive either routine care or routine care with mHealth text messages and appointment reminders specific to delivery type. The primary endpoint was attendance at the 6-week postpartum visit with secondary endpoints of breastfeeding, contraception use, emergency visits, and postpartum depression scores (Edinburgh Postnatal Depression Scale). A subgroup analysis was additionally conducted to assess the impact of some visits shifting to telehealth due to the timing of the coronavirus disease 2019 (COVID-19) pandemic.Patient demographics were similar between the two groups. There was no significant difference in postpartum appointment attendance between text messages (n = 57, 59%) and control groups (n = 62, 66%; p = 0.31). In total, 117 patients were scheduled for in-person postpartum visits, and 74 for telehealth visits during the COVID-19 pandemic, with no significant difference in attendance rate between groups for either visit modality.Automated text messages alone did not increase our primary outcome of adherence to postpartum care, even when visits were conducted by telehealth. While mHealth has proven successful in other care areas, such as antepartum follow-up, further research is needed to determine whether it is an effective method to improve adherence to postpartum care, or whether other strategies must be developed, including augmentation with human navigators. · Interactive text messages did not improve postpartum visit adherence.. · COVID-19 disrupted routine postpartum care.. · More research is needed into mHealth interventions postpartum..

Non-pharmacological interventions for perineal trauma in the postpartum period: A scoping review

BACKGROUND

Non-pharmacological interventions for perineal trauma are crucial for postpartum women's care, providing an alternative to excessive medication use and the associated potential adverse effects for both the woman and her newborn.

AIM

To map the non-pharmacological interventions studied in the context of childbirth-related perineal trauma over the years.

METHODS

A systematic search was conducted on PubMed, BVS/Bireme, CINAHL, Embase, Scielo, ProQuest, ProQuest theses, Medline, Web of Science, and Scopus electronic databases. Studies were included if their population consisted of puerperal women with perineal trauma, the concept being non-pharmacological interventions, and the context being the immediate postpartum period. A descriptive summary presents the most studied non-pharmacological interventions for perineal trauma, the main outcomes investigated, the types of perineal trauma of greatest interest, and publications about the topic over the years.

RESULTS

This review encompassed 41 studies. Cryotherapy emerged as the most extensively studied non-pharmacological intervention, with 22 studies (53.65%). Other interventions were heat therapy, low-level light and electromagnetic therapy, therapeutic ultrasound, transcutaneous electrical nerve stimulation, pelvic floor muscle exercise, and complementary and alternative medicine. Perineal pain was the most investigated outcome (32 studies, 78.04%). Episiotomy was frequently the subject of research (20 studies, 48.78%). Interest in this topic has notably surged over the past 15 years.

CONCLUSION

A range of non-pharmacological interventions have been investigated for managing perineal trauma related to childbirth. Future studies could explore the efficacy and cost-effectiveness of these interventions to identify the most suitable options for postpartum women and facilitate their integration into clinical practice.

Disparities in Postpartum Care After a Hypertensive Disorder of Pregnancy in the United States

BACKGROUND

The postpartum period is a critical time for blood pressure monitoring and cardiovascular risk factor modification in individuals with hypertensive disorders of pregnancy (HDP), who are at increased risk for cardiovascular disease.

METHODS

We analyzed data from the Pregnancy Risk Assessment Monitoring System, a nationally representative US population-based survey of postpartum women with live births from 2016 to 2022. Among individuals with HDP, we evaluated the association between race, ethnicity, and other socioeconomic factors and (1) postpartum visit attendance and (2) postpartum counseling/screening.

RESULTS

Among 42 858 participants with HDP (weighted n=2 011 284), 90% reported attending a postpartum visit. Adjusting for other factors, Hispanic individuals (odds ratio, 0.75 [95% CI, 0.60-0.94]), non-Hispanic Black individuals (odds ratio, 0.75 [95% CI, 0.62-0.91]), and individuals of other or multiple races (odds ratio, 0.57 [95% CI, 0.44-0.74]) were less likely to attend a postpartum visit, compared with non-Hispanic White individuals. Individuals with lower income, lower educational attainment, and those with Medicaid or no insurance were significantly less likely to report attending a postpartum visit. Among those who reported attending a postpartum visit, only 56.3% reported receiving postpartum counseling on healthy lifestyle, 60.9% reported receiving screening for cigarette smoking, and 23.7% reported receiving testing for diabetes.

CONCLUSIONS

Most individuals with HDP reported attending a postpartum visit, but there were significant disparities in postpartum visit attendance by race/ethnicity, health insurance, and socioeconomic status. In addition, many participants reported not receiving postpartum counseling or screening for cardiovascular risk factors. This represents a missed opportunity to equitably improve the long-term cardiovascular health of individuals with HDP.

Postpartum Care Recommendations from Parents of Premature Infants Requiring Intensive Care

OBJECTIVE

To describe postpartum care preferences and experiences among individuals who deliver a premature infant requiring neonatal intensive care.

METHODS

In this qualitative description study, we recruited patients 2 to 8 weeks after delivery of a premature infant requiring neonatal intensive care to participate in semi-structured interviews. We asked participants to share their postpartum care experiences including their expectations and preferences regarding what is addressed during postpartum visits, their decision-making process in attending scheduled postpartum visits, and their suggestions for how to optimize postpartum care to serve their needs. We used thematic analysis to generate codes and identify themes.

RESULTS

Of 26 participants, 8 (31%) had attended a postpartum visit, 4 (15%) had missed their appointment, and 14 (54%) had a visit scheduled to occur after the time of the study interview. We found that participants weigh the perceived benefits of attending a postpartum visit against barriers to care, such as insurance restrictions, competing responsibilities and priorities when deciding whether to attend their postpartum visit. At their postpartum visit, participants preferred when clinicians centered the visits around the participants' goals and tailored the encounter to their specific concerns. Lastly, participants recognize that screening for postpartum mood disorders is important; however, the current screening tools do not differentiate between mood disorders and expected responses to a stressful neonatal intensive care experience.

CONCLUSIONS FOR PRACTICE

Postpartum visits tailored to patient preferences for care in the early postpartum period are needed alongside system-level interventions to address barriers to accessing postpartum care for patients who deliver premature infants.

Leaving Placenta In Situ for Management of Placenta Accreta Spectrum Disorder

OBJECTIVE

To evaluate maternal outcomes when leaving the placenta in situ for placenta accreta spectrum (PAS) according to planned surgical management.

METHODS

We conducted a single-center retrospective cohort study of patients with PAS managed by leaving the placenta in situ from January 2015 to October 2024. At our center, patients are given options other than cesarean hysterectomy for the management of PAS. These include leaving the placenta in situ for either planned uterine preservation or planned delayed hysterectomy. We analyzed maternal outcomes with leaving the placenta in situ, including risk of infection, significant bleeding resulting in hysterectomy, blood transfusion rates, and serious maternal morbidity. We also analyzed outcomes according to planned procedure (uterine preservation or delayed hysterectomy) and final procedure performed (successful uterine preservation or interval hysterectomy).

RESULTS

Of 180 patients with antenatal diagnosis of PAS, 50 were planned for leaving the placenta in situ: seven (14%) underwent cesarean hysterectomy because of antepartum or intraoperative hemorrhage, and 43 (86%) were managed by leaving the placenta in situ. In the 43 managed with leaving the placenta in situ, five (12%) had bleeding necessitating a hysterectomy, and four (9%) had endometritis. There were no cases of venous thromboembolism or maternal death. Twenty-nine patients were planned for uterine preservation, and 14 were planned for delayed hysterectomy. Among the 29 patients planned for uterine preservation, 13 (45%) were successful, with median time to expulsion or resorption of 17 weeks, and 16 (55%) underwent interval hysterectomy (9/16 indicated and 7/16 patient request). According to the final procedure performed, compared with the 30 patients who ultimately underwent an interval hysterectomy, those with successful uterine preservation (n=13) had lower median estimated total blood loss (700 mL vs 1,950 mL, P<.01), blood transfusion rates (31% vs 73%, P<.01), and blood transfusion exceeding 4 units (8% vs 47%, P=.01). Five patients had subsequent pregnancies, with no placenta previa or PAS. When analyses were conducted by planned procedure (planned uterine preservation vs planned interval hysterectomy), there were no differences in median estimated total blood loss, blood transfusion rates, and blood transfusion exceeding 4 units.

CONCLUSION

The majority of patients with PAS who were managed by leaving the placenta in situ did not experience complications of infection or bleeding necessitating hysterectomy. Leaving placenta in situ may be appropriate to offer as an alternative to cesarean hysterectomy in those desiring uterine preservation or those who have PAS with concern for life-threatening bleeding if cesarean hysterectomy is performed. These results should be interpreted with caution given the small sample size, which could preclude detection of rare but potentially serious complications.

New Approaches to Perinatal Depression

Perinatal depression (PD) is one of the most common complications of pregnancy and childbirth affecting as many as one out of five women in high-income countries. The prevalence is even higher in low- and middle-income countries. Untreated PD can result in serious short- and long-term negative effects on both the mother and newborn including adverse perinatal outcomes and negatively impacting mother-infant bonding, breastfeeding, and child neurocognitive development. Therefore, evaluation of the current standard of treatment is necessary. Historically, PD has lacked effective evidenced-based treatment guidelines. Current first-line treatment options include psychotherapy, psychopharmacology, or both, but lack specificity regarding good clinical practice guidelines. New approaches consist of a combination of early screening, preventative psychoeducation, optimizing timely diagnosis, and novel synergistic psychotherapy and psychopharmacology approaches to provide a comprehensive therapeutic approach. Future initiatives and research should evaluate improving screening tools, enhancing patient engagement, and exploring the efficacy of therapy utilizing multiple treatment modalities, to refine good clinical practice guidelines. · PD is a common perinatal complication with potentially severe negative effects.. · Early diagnosis and treatment of PD are vital for both mother and infant's health.. · Future research is critical to improve screening and optimal management for PD..

Factors Affecting Follow-up for Specialty Postpartum Care after Obstetric Anal Sphincter Injury at a Single U.S. Institution

INTRODUCTION AND HYPOTHESIS

Early postpartum specialist care may improve outcomes for birthing people who sustain obstetric anal sphincter injuries (OASIS). This study was aimed at describing follow-up rates in a postpartum recovery clinic (PPRC) for patients who sustained OASIS at delivery, and at identifying factors associated with failure to follow up. We hypothesized that providing care in PPRC would result in high rates of access to specialized care for OASIS.

METHODS

This was a retrospective cohort study of patients with OASIS at a single institution from January 2018 to December 2023. Patients who sustain OASIS receive an automatic referral to PPRC within 3 weeks postpartum. Demographic and follow-up data were extracted from the medical records, including Edinburgh Postpartum Depression Scale (EPDS) score. The primary outcome was follow-up in PPRC. We examined associations between patient characteristics and failure to follow up using univariable and multivariable logistic regression.

RESULTS

Among 659 deliveries with OASIS during the study period, 540 (81.9%) followed up in a PPRC and of those 468 (86.7%) followed up within 3 weeks. Failure to follow up was associated with multiparity, Black race, Hispanic ethnicity, having Medicaid or state insurance, and elevated EPDS score on univariable analysis. On multivariable analysis, having Medicaid or state medical assistance and elevated depression screening remained associated with failure to follow up in a PPRC.

CONCLUSIONS

There was a high overall attendance rate at a urogynecologist-led postpartum clinic in birthing people who sustained OASIS. An elevated depression screening score and having Medicaid or state medical assistance were associated with failure to follow up.

Hospitalization for cardiovascular disease in the year after delivery of twin pregnancies

BACKGROUND AND AIMS

Increased cardiovascular demand in twin pregnancies, even those without hypertensive disease of pregnancy (HDP), may pose a greater risk for cardiovascular complications compared with singletons. In this study, the risk of cardiovascular disease (CVD)-related hospitalizations and mortality within the year following delivery in relation to HDP was compared between twin and singleton pregnancies.

METHODS

Using the Nationwide Readmissions Database of US hospitals from 2010 to 2020, the rates of CVD readmission in four exposure groups (twin deliveries with and without HDP and singleton deliveries with and without HDP) were estimated. Cox proportional hazard regression models were used to determine associations with singletons without HDP as the reference.

RESULTS

Of 36 million delivery hospitalizations, the rates of CVD readmission in twin and singleton pregnancies were 1105.4 and 734.1 per 100 000 delivery admissions, respectively. Compared with singletons without HDP, the adjusted hazard ratio (HR) of CVD readmission was highest for twins with HDP [HR 8.21, 95% confidence interval (CI) 7.48-9.01], followed by singletons with HDP (HR 5.89, 95% CI 5.70-6.08) and then twins without HDP (HR 1.95, 95% CI 1.75, 2.17).

CONCLUSIONS

Compared with singletons without HDP, twin pregnancies, even in the absence of HDP, are associated with increased risks for CVD complications in the first year post-partum. These findings highlight the increased strain twin pregnancies place on the maternal cardiovascular system. These findings advocate the need for appropriate pre-conception counselling for those with cardiovascular risk factors undergoing infertility treatment, which increase the risks of multi-foetal gestation, and increased post-partum surveillance in twin pregnancies.

Perinatal care experiences of women living with disability in Africa: a qualitative systematic review protocol

OBJECTIVE

This review will explore the perinatal care experiences of women living with disability in African countries.

INTRODUCTION

In many African countries, most women with disability face stigma and discrimination. They are also at risk of unwanted pregnancy and sexually transmitted diseases due to gender-based violence and sexual abuse. Qualitative studies on perinatal care experiences of women with disability in Africa indicate challenges such as social stereotypes, lack of access to health facilities, and insensitivity from health professionals. Synthesizing the qualitative findings about the perinatal care experiences of women with disability in Africa will provide insights into the needs of this population and identify gaps in health care practice.

INCLUSION CRITERIA

We will include all settings in which women with disability in Africa receive maternal health care services, such as hospitals, clinics, primary care, community health centers, and homes. We will consider studies published from 2008 onward that present qualitative data, including designs such as phenomenology, grounded theory, ethnography, action research, and feminist research.

METHODS

The review will be conducted in line with the JBI methodology for systematic reviews of qualitative evidence. The following databases will be searched: Global Health, CINHAL (EBSCOhost), MEDLINE (Ovid), Web of Science, Embase (Ovid), Sabinet African Journals, and PsycINFO (EBSCOhost). Theses and dissertations will be searched through ProQuest Dissertations and Theses and Google Scholar. Two independent reviewers will conduct study selection, critical appraisal, data extraction, and meta-aggregation. Confidence in the findings will be assessed in accordance with the ConQual approach.

REVIEW REGISTRATION

PROSPERO CRD42023431799.

Overview of ADPKD in Pregnancy

Autosomal dominant polycystic kidney disease (ADPKD) is a systemic disorder that often affects patients in their third to fifth decades of life and is characterized by kidney cysts, chronic kidney disease (CKD), hypertension, and hepatic cysts. The development of clinical symptoms often coincides with childbearing years. Consequently, there are several considerations regarding pregnant patients with ADPKD. In this review, we detail the effects and management of ADPKD in the peripartum period and discuss family planning options, including assisted reproductive techniques (ART) and preimplantation genetic testing.

Gestational Blood Pressure Trajectories and 5-Year Postpartum Hypertension Risk in the MADRES Study

BACKGROUND

Blood pressure (BP) changes during pregnancy, but less is known about heterogeneous changing patterns within a population and long-term hypertension risk.

OBJECTIVES

The purpose of this study was to identify distinct gestational systolic blood pressure (SBP) trajectories and examine their association with postpartum hypertension risk.

METHODS

The MADRES (Maternal and Developmental Risks from Environmental and Social Stressors) (2015-present) cohort followed 854 pregnant individuals from early pregnancy to 5 years postpartum and collected information on demographics, lifestyle, and medical records, including BP at each prenatal visit. Latent class growth modeling was used to identify gestational SBP trajectories. Incident postpartum hypertension was identified from interviews and BP measurements. Cox modeling was used to assess the association of trajectory groups with the risk of hypertension at 2 to 5 years postpartum.

RESULTS

We identified 3 distinct gestational SBP trajectory groups. The majority (n = 685, 80.2%) had a "consistently low" trajectory over pregnancy. A "consistently elevated" trajectory group (n = 106, 12.4%) was characterized by modestly elevated SBP within a clinically normal range but lacked a midpregnancy dip. A "high-drop-high" trajectory group (n = 63, 7.4%) consisted of most cases of gestational hypertension or pre-eclampsia. Risk of hypertension in 5 years postpartum was 4.91 (95% CI: 2.01-12.0) fold higher in the "consistently elevated" group and 5.44 (95% CI: 1.89-15.7) fold higher in the "high-drop-high" group than the "consistently low" group, after adjusting for covariates.

CONCLUSIONS

Pregnant individuals with consistently elevated SBP yet within the subclinical range face longer-term risk of hypertension but may not be captured by standard prenatal clinical guidelines.

Association Between Comorbidities and Inpatient Postpartum Permanent Contraception Completion

OBJECTIVE

To evaluate whether comorbidities (defined as both medical conditions and peripartum complications) are associated with inpatient postpartum permanent contraception by tubal surgery completion.

METHODS

This is a secondary analysis of a multisite retrospective cohort study of patients who had documented plans for permanent contraception. Our primary outcome was inpatient completion of postpartum permanent contraception by tubal surgery. We used univariable and multivariable logistic regression analyses to examine associations between aggregate and individual comorbidities and the attainment of inpatient postpartum permanent contraception.

RESULTS

In this study of 2,226 pregnant people, 53.4% of patients received postpartum permanent contraception by the time of hospital discharge, and 70.8% of patients had documented comorbidities. Although patients with medical conditions initially had lower odds of permanent contraception completion compared with those without any comorbidities (adjusted odds ratio [aOR] 0.77, 95% CI, 0.64-0.93), this association was no longer significant after adjusting for multiple comparisons (adjusted P =.06). This association also was not significant for patients with peripartum complications (aOR 0.86, 95% CI, 0.64-1.16, adjusted P =.42). Similarly, when individual comorbidities were assessed, patients with hypertension (aOR 0.80, 95% CI, 0.65-0.97, adjusted P =.06), mental health diagnoses (aOR 0.80, 95% CI, 0.66-0.96, adjusted P =.06), and elevated body mass index (BMI, 40 or higher) (aOR 0.77, 95% CI, 0.63-0.95, adjusted P =.06) had no significant differences in odds of immediate permanent contraception attainment after adjusting for multiple comparisons.

CONCLUSIONS

Though the balance of risks and benefits is imperative for surgical care, it is imperative that modifiable barriers to desired permanent contraception are mitigated. There were no statistically significant differences in inpatient postpartum permanent contraception attainment for patients with medical conditions in our study; however, further study is needed to better elucidate the complex relationships between medical comorbidities and contraception.

Advancing gender equity in sport: a scoping review of international sport federation policies for pregnant, postpartum and parenting elite athletes

OBJECTIVE

The aim was to synthesise international-level sport policies for pregnant, postpartum or parenting high-performance athletes in order to understand what policies currently exist and to identify policy gaps to be addressed.

DESIGN

Scoping review.

DATA SOURCES

Online databases (MEDLINE, EMBASE, CINAHL, SPORTDiscuss, Evidence-Based Medicine Reviews (Ovid), Scopus, Web of Science and ClinicalTrials.gov) and Google up to 14 June 2024. Additionally, a targeted search of existing policies was conducted via the websites of International Federations (IFs) and continental sporting organisations (CSOs) in September 2023.

ELIGIBILITY CRITERIA

We included policies from IFs recognised by the International Olympic Committee, and CSOs associated with the IFs that specifically address pregnant, postpartum or parenting athletes. Policies were a written principle of action adopted by the IFs/CSOs that provided any form of support during pregnancy, post partum or for parents.

RESULTS

A total of 219 organisations (49 IFs; 170 CSOs) were identified and contacted, with 47/49 (96%) IFs and 15/170 (9%) CSOs responding. Sport policies related to pregnancy, postpartum or parenting athletes were identified from 20 IFs including (1) guidance on training/competition during and following pregnancy; (2) eligibility affected or training not advised; (3) protection from dismissal; (4) special rank, points or quota protection; (5) protections apply to adoption, surrogacy, miscarriage, stillbirth, egg freezing and/or fertility treatment; (6) duration of leave and if leave is paid and (7) breastfeeding support/space. No policies identified specific provisions for childcare support/space.

CONCLUSIONS

Less than half of all IFs have developed sport policies to support pregnant, postpartum and parenting athletes. Of the policies that do exist, most are limited in the extent to which they address the broad range of biopsychosocial supports that are necessary for facilitating optimal performance, enhancing long-term athlete health and addressing gender inequities that are deeply entrenched across all levels of sport. This review provides a critical piece of evidence needed to inform future policy development.

Blood Pressure Monitoring and Knowledge in the First Year after a Hypertensive Disorder of Pregnancy

Introduction: In the first year postpartum, hypertension is a leading cause of morbidity and mortality, particularly for those with hypertensive disorders of pregnancy (HDPs). Given that timely recognition of hypertension is key to reducing short- and long-term cardiovascular risk, we assessed knowledge of when to seek medical attention for blood pressure (BP) elevations and rates of BP measurement in the first year postpartum. Methods: This was a secondary analysis of a cohort of 405 primiparas who enrolled in a randomized trial during pregnancy. We calculated the proportion who stated they would contact a clinician for a systolic BP above 140 and a diastolic BP above 90 at 3 months postpartum, and the frequency and location of BP checks reported from 2 to 12 months postpartum by HDP status. Results: HDPs were reported by 16% of participants. Mean age was 32 ± 5 years; 40% identified as non-White, and 25% had public insurance. At 3 months postpartum, 44.6% with HDPs and 23.5% without identified a systolic BP of 140 as the threshold above which to contact a clinician (p < 0.01); 52.4% with HDPs and 28.5% without identified a diastolic BP threshold of 90 (p < 0.01). From 3 to 12 months postpartum, people with HDPs were more likely to report a BP check (83.1% versus 59.4%, p < 0.01) and home BP monitoring (41.6% versus9.7%, p < 0.01). Home monitoring was not associated with awareness of when to seek help for hypertension among those with HDPs. Conclusions: Efforts are needed to improve awareness of when to seek medical attention for postpartum hypertension.

Associations between Health-Related Social Needs and Postpartum Linkage to Care

INTRODUCTION

Ongoing care after pregnancy is recommended. Health-related social needs are recognized barriers to care, yet their pregnancy-related prevalence and associations with care are unknown. Researchers sought to assess (1) the prevalence of health-related social needs during pregnancy-based care, and (2) their associations with ongoing care after pregnancy.

METHODS

Electronic health record data were analyzed for individuals with prenatal care and delivery (2018-2021) at an urban safety-net hospital, with routine screening for health-related social needs multiple times during pregnancy through 6 weeks postpartum. Health-related social needs were summarized as screened negative, screened positive, or not screened. Linkage to ongoing care was defined as a completed non-urgent visit separate from pregnancy-based care, >6 weeks through 1 year postpartum. Data were collected in 2022 and analyzed in 2023-2024.

RESULTS

Of 4,941 individuals, 53% identified as Black non-Hispanic and 21% as Hispanic, 68% were publicly insured, and 93% completed ≥1 health-related social needs screening. Nearly 1 in 4 screened positive for health-related social needs, and 53% linked to ongoing care. Compared with those who screened negative for health-related social needs (n=3,491), linkage to ongoing care was similar among those who screened positive (n=1,079; adjusted risk ratio, aRR=1.04, 95% CI=0.98, 1.10) and lower among those not screened (n=371; aRR=0.77, 95% CI=0.68, 0.86).

CONCLUSIONS

Researchers identified a 24% prevalence of pregnancy-related health-related social needs and 53% subsequent linkage to ongoing care. Compared with screening negative for health-related social needs, screening positive was not associated with linkage to care, while being not screened was associated with a 20% lower likelihood of linkage to ongoing care.

Severe Maternal Morbidity and Postpartum Care: An Investigation Among a Privately Insured Population in the United States, 2008-2019

Objective: This study examines postpartum health care utilization among women with severe maternal morbidity (SMM) subtypes (e.g., blood transfusion, renal), focusing on both early (within 7 days) and late (8-42 days) postpartum periods. By including outpatient visits alongside inpatient and emergency department (ED) visits, the study offers a comprehensive view of postpartum health care needs among women with SMM. Methods: This retrospective cohort study used data from Optum's de-identified Clinformatics® Data Mart Database from 2008 to 2019. The primary outcomes were early and late postpartum inpatient readmissions, early and late ED visits, and outpatient care within 42 days after delivery. Multilevel logistic regression models were used to estimate the association between SMM subtypes and postpartum readmission, ED, and outpatient care. Results: Except for hemorrhage, most SMM subtypes increased the postpartum odds of health care utilization. Women with other medical SMM (e.g., puerperal cerebrovascular disorders or sickle cell disease with crisis) had 2.9 times the odds (odds ratio [OR]: 2.87, 95% confidence interval [CI]: 1.30-6.34) of experiencing early readmissions compared with those without other medical SMM. Women with sepsis had 4.5-fold elevated odds (OR: 4.53, 95% CI: 2.48-8.28) of late readmission, a 1.9-fold increased odds (OR: 1.85, 95% CI: 1.12-3.04) of early ED visits, and over a 2-fold increased odds (OR: 2.27, 95% CI: 1.67-3.08) of postpartum outpatient visits compared with those without sepsis. Conclusion: This study reveals that certain SMM subtypes significantly increase postpartum health care utilization, emphasizing the need for further research and interventions to improve outcomes for affected women.

A systematic review of postpartum psychosis resulting in infanticide: missed opportunities in screening, diagnosis, and treatment

PURPOSE

Impacting 1 in 1000 women, untreated postpartum psychosis is associated with a 4% infanticide rate. This systematic review aims to identify factors that are associated with infanticide resulting from psychosis in the puerperal period and pinpoint areas of missed opportunity for intervention.

METHODS

A systematic literature review was conducted in accordance with PRISMA guidelines to identify and synthesize cases of maternal infanticide among perinatal females with evidence of postpartum psychosis. Four independent reviewers screened 231 articles identified in searches of three databases (PsycInfo, PubMed, and Web of Science) for studies conducted from 2013 to 2023.

RESULTS

Twelve studies were included in the final review. Findings indicate that those experiencing puerperal psychosis have increased incidence of infanticide suggesting missed opportunities for intervention and treatment. Common factors in mothers who committed infanticide as a result of delusions and/or hallucinations associated with PMADs were identified, including lack of standardized screening tools, preference for traditional and/or cultural healing practices, and access to care.

CONCLUSION

The current body of evidence supports developing and evaluating clinical interventions aimed at improving maternal mental health outcomes and infant outcomes in perinatal women experiencing puerperal psychosis.

Barriers to postpartum health and opinions on a postpartum peer navigator program amongst refugee women resettled in California

BACKGROUND

The aim of this study is to identify postpartum challenges and assess for interest in a postpartum peer navigator program amongst refugee women resettled in California.

METHODS

Participants were recruited through ethnic community-based organizations in California using convenience and snowball sampling. Arabic, Dari, or Pashto speaking women who have given birth in the United States within the last five years and entered the country as refugees, special immigrant visa holders, or asylum seekers were eligible to participate. Semi-structured interviews were analyzed using Braun and Clarke's thematic analysis.

RESULTS

We interviewed 26 participants. The mean age was 30 years (SD = 6.3) and mean length of time in the United States was 4.5 years (SD = 3.0). All participants are state insurance recipients. Most participants (89%, n = 23) utilize an interpreter. We identified seven themes: (1) lack of comprehensible postpartum information; (2) displacement and isolation worsen postpartum mental health; (3) stigma and fear discourage seeking postpartum mental health care; (4) barriers in interpretation undermine postpartum care recommendations; (5) interest in a language concordant postpartum navigator.

CONCLUSION

Refugee women encounter challenges with contraception and mental health care postpartum exacerbated by language barriers and difficulties with interpreter use. There is interest in language concordant postpartum peer navigation as tool to mitigating these challenges.

Cardiomyopathy Prevalence and Pregnancy-Related Mortality: United States, 2010 to 2020

BACKGROUND

Cardiomyopathies, particularly peripartum cardiomyopathy (PPCM), significantly contribute to maternal morbidity in the United States.

OBJECTIVES

The authors estimated the prevalence and mortality of PPCM and other cardiomyopathies (OCMs) during pregnancy among women aged 15 to 55 years from 2010 to 2020 in the United States using a cross-sectional analysis of multiple data sets.

METHODS

We identified PPCM, OCM, and deliveries using International Classification of Diseases and diagnosis related group codes in the National Inpatient Sample. We calculated PPCM and OCM prevalence and adjusted prevalence ratios (aPRs) by select covariates. We identified pregnancy-related deaths from all cardiomyopathies combined and PPCM exclusively from 2015 to 2020 Pregnancy Mortality Surveillance System. We calculated pregnancy-related mortality ratios (PRMR) by select covariates.

RESULTS

The overall PPCM and OCM prevalence were 105.1 (95% CI: 101.8-108.3) and 76.1 (95% CI: 73.6-78.7) cases per 100,000 delivery hospitalizations, respectively. PPCM prevalence increased with advancing maternal age and decreasing neighborhood income and exhibited marked differences among Black and American Indian or Alaska Native women (aPR: 3.58 [95% CI: 3.36-3.82] and aPR: 1.96 [95% CI: 1.57-2.45], respectively). PPCM prevalence was higher among those with chronic hypertension and diabetes (aPR: 12.17 [95% CI: 11.51-12.88] and aPR: 6.25 [95% CI: 5.77-6.78], respectively). The overall cardiomyopathy and PPCM PRMR were 2.1 and 1.0 deaths per 100,000 live births, respectively. PRMR were highest among those aged ≥40 years and among American Indian and Black women (overall cardiomyopathy PRMR: 7.3, 6.0 deaths per 100,000 live births respectively).

CONCLUSIONS

Intensifying efforts to address cardiomyopathies and enhance cardiovascular health before, during, and following pregnancy may reduce the burden of maternal morbidity.

Adverse Pregnancy Outcomes and Cardiovascular Disease: A Spanish Cohort

Background and Aims: Emerging evidence suggests adverse pregnancy outcomes (APOs) may increase future cardiovascular risk. This study aimed to assess in a Spanish cohort the long-term risk of cardiovascular disease in women with APOs compared to those without such complications. Methods: A retrospective longitudinal cohort study was conducted at Hospital Vall d'Hebron (Barcelona, Spain), including pregnant women delivering between January 2010 and December 2015. Women with pre-existing medical conditions were excluded. APOs included preeclampsia, gestational diabetes, preterm birth, late miscarriage, and stillbirth. Cardiovascular events were defined as acute myocardial infarction or stroke. Both APO and non-APO groups were compared for their risk of cardiovascular events in the years following delivery, using unadjusted and adjusted models. Results: Out of 12,071 pregnant women delivered at Hospital Vall d'Hebron during the study period. 10,734 met the inclusion criteria (8234 in the non-APO group and 2500 in the APO group). The adjusted model revealed a significant association between APOs and cardiovascular events post-delivery (HR 2.5; 95% CI 1.4-4.4). Furthermore, an increased number of APOs (≥2) correlated with a higher risk of post-delivery cardiovascular events (HR 8.6; 95% CI 2.8-26.8). Conclusions: Women with adverse pregnancy outcomes (APOs), particularly those experiencing preeclampsia, preterm birth, and late miscarriage, exhibit an elevated long-term risk of cardiovascular events. Our findings highlight that these associations persist even after adjusting for traditional cardiovascular risk factors, indicating that APOs may independently influence long-term cardiovascular health. This underscores the importance of recognizing pregnancy as a critical window for early cardiovascular health interventions and counseling. Addressing these risks proactively could improve long-term health outcomes for women with a history of APOs.

The Role of Race in Pregnancy, Hypertension, and Long-Term Outcomes

PURPOSE OF REVIEW

This review aims to discuss racial and ethnic differences in the prevalence of hypertensive disorders of pregnancy (HDP), disparities in peripartum and postpartum outcomes, and strategies to improve health equity.

RECENT FINDINGS

Racial disparities in HDP are significant contributors to maternal morbidity and mortality. The prevalence of preeclampsia has increased over the last 20 years, with the highest prevalence among non-Hispanic Black, non-Hispanic American Indian and Alaska Native individuals. Black birthing individuals are at increased risk for cardiovascular-related morbidity and mortality, particularly from complications of HDP. Factors such as social determinants of health and systemic racism have a significant impact on disparities in maternal and fetal outcomes related to HDP. System changes and provider implicit bias training can help address systemic racism. Interventions aimed at improving access to care, such as telehealth and home blood pressure monitoring, as well as incorporating health system navigators that provide peripartum and postpartum support can improve outcomes and promote health equity.

The Translation of Policy to Person: A Qualitative Analysis of Elite Athletes' Perceptions of Pregnancy in the United Kingdom

BACKGROUND

An increasing number of female athletes are navigating an athletic career alongside pregnancy. Limited qualitative research has investigated the experiences of elite athletes in the United Kingdom (UK). This study aimed to explore the experiences of elite athletes in the UK as they navigated pregnancy, employing a socio-ecological framework to inform future research and policy recommendations on sport participation during pregnancy.

METHODS

A descriptive qualitative study design, adopting a relativist ontology and constructivist epistemology, was implemented. Semi-structured online interviews were conducted with elite athletes ≥ 18 years old, who resided in the UK, and who trained and/or competed at the highest level of their sport prior to and/or during pregnancy. Interviews were recorded, transcribed and analysed using reflexive thematic analysis.

RESULTS

Eleven athletes (mean age 31 ± 3 years) from nine team and individual sports participated in the study. Four key themes were developed: (1) From the Podium to Parenthood: Institutional versus Individual Influence on Reproductive Planning; (2) Is My Career Over? Micro Level Support versus Macro Level Doubt and Worry; (3) Athlete to Mother: Internal Conflict to Community Role Model; (4) Navigating the Bump: Individual Drive to Tackle Systemic Gaps.

CONCLUSIONS

Findings highlight the complexity female athletes face when navigating pregnancy, motherhood and elite sport. There is a need for high-quality research focusing on preconception and pregnancy-specific training and nutrition modifications for elite athletes, particularly regarding nutrient intake and supplementation. Additionally, efforts to improve the translation of evidence-based research into practical applications remain essential.

Factors associated with clinician adherence to guidelines for postpartum care: results from a California survey

BACKGROUND

In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued multiple recommendations to optimize care within the first 12 weeks postpartum. We explored the extent to which clinicians follow ACOG's recommendations at the first postpartum visit and identified factors associated with overall adherence to clinical recommendations.

METHODS

Between September 2023 and February 2024, we collected data from an online survey about the care practices of 174 obstetric clinicians practicing in California. The response rate was 76%. Adherence was measured by asking the extent to which clinicians always complete care components drawn from a list of 26 of ACOG's clinical recommendations. We used descriptive statistics and ran linear regression models to quantify the association between adherence to guidelines and years of clinical practice, proportion of patients utilizing Medi-Cal, the method of reimbursement received by the provider, perceived organizational, financial and patient barriers, duration of the visit and number of collaborations with other providers.

RESULTS

The median percentage of components checked by clinicians was 62%. Significantly higher adherence was found among clinicians with at least 12 years of practice compared with those with approximately 5 years or less and among clinicians who collaborated with 5 or more multidisciplinary providers versus fewer than 3. Adherence was also higher among clinicians who on average spent at least 30 min vs. less than 20 min with their patients and those who perceived high financial barriers to care among their patients. In contrast, clinicians who served highly mixed practices of Medi-Cal and non-Medi-Cal recipients reported lower adherence.

CONCLUSION

We sought to understand which clinicians were more able to align their practice with ACOG guidelines at the first postpartum visit. We found that more experienced clinicians, those who simplified their practices to either all Medi-Cal or few Medi-Cal recipients, and those who collaborated more with other providers from various disciplines were best able to provide the care recommended in the guidelines. Our findings highlight where policy, resources and training are needed to improve guideline adherence and whole person care.

The state of postpartum contraceptive use in India: descriptive lessons from nationally representative survey data

BACKGROUND

Postpartum contraception is a key tool to delay or prevent subsequent pregnancy after birth. Though prior research has demonstrated substantial dynamism in contraceptive use throughout the postpartum period, most measurement of postpartum contraception has focused on aggregate use of any method at a single time point. We sought to more thoroughly examine the continuum of postpartum contraceptive use amongst women in India.

METHODS

We use 2019-21 National Family and Health Survey reproductive calendar data from n = 149,518 women with a birth in the one to five years prior to survey. We present estimates of postpartum contraceptive use by month postpartum, use of specific methods, initiation, duration, stopping, method switching, and subsequent pregnancy. We examine sociodemographic and birth factors associated with postpartum contraceptive use using multivariate logistic regression models. We also examine patterns of postpartum utilization for subpopulations of interest (adolescent mothers age 15-19 and first time mothers) and test whether conclusions are sensitive to a two-year rather than one-year postpartum time period definition.

RESULTS

We find that 59% of Indian women used a method of contraception within the first year postpartum, that condoms and female sterilization were the most commonly used methods, and that patterns of postpartum contraceptive use differed substantially by month, method, and subpopulation. Among postpartum contraceptive users, 9% switched methods, 19% stopped using contraception entirely, and 5% had another pregnancy within the first year postpartum. A number of sociodemographic and birth factors are associated with postpartum contraceptive utilization, and patterns of use differ meaningfully for adolescent and first-time mothers. Most findings were consistent when using a two-year rather than one-year time frame.

CONCLUSIONS

The dynamic nature of postpartum contraceptive use suggests limited value of static contraceptive uptake targets, whether for program planning or as measures of success, and bolsters the need to center and to improve reproductive agency, empowerment, and access throughout the postpartum period.

Preliminary impact of an mHealth education and social support intervention on maternal health knowledge and outcomes among postpartum mothers in Punjab, India

BACKGROUND

Significant disruptions in the perinatal continuum of care occur postpartum in India, despite it being a critical time to optimize maternal health and wellbeing. Group-oriented mHealth approaches may help mitigate the impact of limited access to care and the lack of social support that characterize this period. Our team developed and pilot tested a provider-moderated group intervention to increase education, communication with providers, to refer participants to in-person care, and to connect them with a virtual social support group of other mothers with similarly aged infants through weekly calls and text chat.

METHODS

We analyzed the preliminary effectiveness of the pilot intervention on maternal health knowledge through 6 months postpartum among 135 participants in Punjab, India who responded to baseline and endline surveys. We described change in knowledge of maternal danger signs, birth preparedness, postpartum care use, postpartum physical and mental health, and family planning use over time between individuals in group call (synchronous), other intervention (asynchronous), and control groups.

RESULTS

Participant knowledge regarding danger signs was low overall regarding pregnancy, childbirth and the postpartum period (mean range of 1.13 to 2.05 at baseline and 0.79 to 2.10 at endline). Synchronous participants had a significantly higher increase over time in knowledge of danger signs than asynchronous and control group participants. Birth preparedness knowledge ranged from mean 0.89-1.20 at baseline to 1.31-2.07 at follow-up, with synchronous participants having significantly greater increases in comparison to the control group. Synchronous participants had nearly three-fold increased odds of postpartum health check with a clinical provider than asynchronous participants (OR 2.88, 95% CI 1.07-7.74). No differences were noted in postpartum depressive and anxiety symptoms.

CONCLUSIONS

Preliminary effectiveness results are promising, yet further robust testing of the MeSSSSage intervention effectiveness is needed. Further development of strategies to support health knowledge and behaviors and overcoming barriers to postpartum care access can improve maternal health among this population.

Postpartum Acute Care Utilization in a Health Care System in the Southeastern United States

Introduction: Postpartum acute care utilization (PACU), including visits to an emergency department, obstetric triage, or urgent care ("outpatient"), and hospital readmissions, may indicate medical complications and signal unmet health needs. Methods: We estimated the incidence of PACU and examined patterns by sociodemographic factors, pregnancy and birth characteristics, time since discharge from the birth hospitalization, and medical indications. We constructed a retrospective cohort of people aged ≥18 years who delivered ≥1 liveborn infant >20 weeks of gestation from July 1, 2021, to December 31, 2022, using electronic health record data from a quaternary maternity hospital in the Southeastern United States PACU data throughout the health care system were collected through March 31, 2023. We excluded people with a hospital stay >6 days (n = 29). Results: In this cohort of 6,041 birthing people, 11.3% had ≥1 outpatient encounters (range 0-6) and 3.2% had ≥1 hospital readmissions (range 0-4) within 12 weeks of discharge from the birth hospitalization. Median time to first outpatient PACU was 10 days post-discharge and 6 days for first hospital readmission. Among encounters for the top five medical indications, time to first postpartum acute care encounter varied by medical indication (log-rank test of equality over strata Chi-square = 69.93, degrees of freedom = 4, p < 0.0001). Complications specified during the puerperium (n = 234) and hypertension and hypertensive-related conditions complicating the puerperium (n = 87) were the two most frequent indications. Conclusion: These findings can inform efforts to direct health resources to improve postpartum health care and health outcomes.

Socioeconomic, Demographic, and Clinical Factors Associated with Postpartum Readmission

Purpose: To determine if socioeconomic, demographic, and clinical characteristics are associated with postpartum readmission. Methods: A retrospective cohort study evaluating all pregnant patients that delivered at seven hospitals within a large academic health system in New York between January 1, 2018 and March 1, 2020. Demographic information, medical comorbidities, and characteristics of antepartum, intrapartum, and postpartum care were compared between patients who were readmitted within 6 weeks postpartum and those who were not. Postpartum patients who presented to the emergency department but remained less than 23 hours were excluded. Patient ZIP codes were linked to data from the United States Census Bureau's American Community Survey and used as a proxy for neighborhood socioeconomic status. Mixed effects logistic regression was used to evaluate factors associated with an increased risk of postpartum readmission while adjusting for potential confounders. Results: A total of 57,507 delivery hospitalizations were evaluated, and 1,481 (2.5%) patients were readmitted. Black race (aOR: 1.56, 95% CI: 1.30-1.86, p < 0.001) and public health insurance (aOR: 1.19, 95% CI: 1.05-1.35, p = 0.007) were associated with an increased likelihood of postpartum readmission. Chronic hypertension (aOR: 2.83, 95% CI: 2.33-3.44, p < 0.001), body mass index >25 kg/m2 (aOR: 1.22, 95% CI: 1.05-1.42, p = 0.01), gestational weight gain >40 lb (aOR: 1.19, 95% CI: 1.01-1.40, p = 0.04), and administration of blood products (aOR: 2.18, 95% CI: 1.68-2.82, p < 0.001) were associated with an increased odd of readmission. Neighborhood characteristics were not associated with postpartum readmission. Conclusion: Efforts to reduce postpartum readmissions should focus on high-risk populations. Specific sociodemographic and clinical characteristics are associated with this complication.

Digital Health Interventions for the Optimization of Postpartum Cardiovascular Health: A Systematic Scoping Review

Background

Digital health technologies have been proposed as a potential solution to improving maternal cardiovascular (CV) health in the postpartum (PP) period. In this context we performed a systematic scoping review of digital health interventions designed to improve PP CV health.

Methods

We conducted a systematic review of PubMed/MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library. We included studies of PP women, with an intervention involving digital or mobile health (wearable devices, telemedicine, or remote monitoring). We included studies that measured an outcome related to CV health.

Results

110 full studies were reviewed for eligibility and 38 were included. Studies were categorized into 4 broad CV outcomes: blood pressure (BP), physical activity (PA), diet/weight loss and cardiometabolic markers. Digital health interventions included mobile applications, text-based coaching, interactive websites, virtual reality, wearable devices. The majority of remote BP monitoring programs (N = 5 studies) were successful in optimizing BP. 14 studies examined interventions aimed at improving PA levels of which 6/14 studies showed modest benefit at increasing PA. The majority of interventions aimed at weight loss (N = 27 studies) showed no significant benefit in terms of lowered caloric intake and/or weight loss up to 1 year PP. 6 studies examined improvements in cardiometabolic markers such as lipids and glucose levels, of which the majority showed no benefit.

Conclusion

The majority of studies we reviewed found that digital health interventions such as mobile health, telemonitoring and wearable devices were feasible and had mixed effectiveness in improving postpartum CV health in the postpartum period.

Systematic treatment and management of postpartum hypertension using remote patient monitoring

OBJECTIVE

To describe postpartum visit attendance and postpartum blood pressure control among patients enrolled in a remote patient monitoring program and compare these outcomes by race.

STUDY DESIGN

A prospective cohort study of postpartum patients with a diagnosis of hypertensive disorders of pregnancy at the University of Chicago between October 2021 and April 2022. All patients received remote patient monitoring as routine care but consented separately for the use of their data. Data were obtained from the electronic medical record for up to six weeks postpartum.

MAIN OUTCOME MEASURES

The primary outcome was attendance at the first postpartum blood pressure check visit. Secondary outcomes included postpartum blood pressure control, readmissions, and remote patient monitoring response rates. Outcomes were compared by patient-reported race.

RESULTS

545 patients were enrolled in the remote patient monitoring program, of which 306 consented to data collection. 64.7% of patients identified as Black/African American. Attendance for first postpartum blood pressure check was high (overall 84.0%, Black 81.3% and non-Black 88.9%, p = 0.08). The rate of Stage 2 hypertension at six weeks was higher among Black patients than non-Black patients (22.4% vs 2.2%, p < 0.0001). Engagement with remote patient monitoring decreased over the 6-week period, with more attrition among Black patients.

CONCLUSION

There was a high follow-up rate across all patients regardless of race and a decrease in hypertension over the six-week period. However, rates of hypertension were higher, and engagement with the program lower in Black patients, suggesting further work is needed to address this gap.

Comparing a Model of Augmented Postpartum Primary Care to Usual Care in an Urban Medical Center

BACKGROUND

The US faces a maternal health crisis and struggles to deliver recommended postpartum care. In some populations, less than half of mothers attend a postpartum visit.

OBJECTIVE

To determine if a two-generation (Two-Gen) model of interdisciplinary, postpartum primary care was associated with increased visit attendance for postpartum care, primary care, and behavioral health.

DESIGN

Retrospective study of care delivered at a single, urban, academic, safety-net medical center between 2020 and 2023.

PARTICIPANTS

Mothers who received postpartum care in Two-Gen and a comparison group who received usual postpartum care.

MAIN MEASURES

Adjusted logistic regression to estimate the effect of Two-Gen participation on the odds of attending an early (birth-to-3 weeks) postpartum visit, later (4-to-12 weeks) postpartum visit, OB/GYN visit, and primary care visit.

KEY RESULTS

A total of 247 mothers (98 Two-Gen and 149 usual care) were included for analysis. Most identified as Non-Hispanic Black (55%) or Hispanic (34%) and had Medicaid insurance (74%). On average, Two-Gen mothers were younger and more likely to be primiparous. Compared to usual care, Two-Gen mothers had similar rates of early postpartum visits (79% vs 64%; adjusted odds ratio (aOR) 1.70; 95% confidence interval (CI) 0.92-3.14) and were significantly more likely to have a later postpartum visit (92% vs 79%; aOR 2.46; 95%CI 1.06-5.74) in adjusted analyses. Almost all Two-Gen mothers (97%) had a visit with a primary care doctor in the first postpartum year, compared to 19% of mothers receiving usual care (aOR 12.95; 95%CI 6.80-24.68). Of those with behavioral health diagnoses, Two-Gen mothers had higher rates of psychiatrist visits than usual care mothers (49% vs 13%; p = 0.001).

CONCLUSIONS

Two-Gen clinic participation was associated with high rates of timely postpartum care in a group of predominantly young, publicly insured, racial, and ethnic minority mothers and compared favorably to usual care across multiple metrics, notably utilization of primary and behavioral health care.

An update on the pharmacotherapy of postpartum depression

Extensive research has been conducted on postpartum depression (PPD) over the past century, and yet no definitive answer regarding its etiopathogenesis, risk factors, genetic predilection, and treatment has been found. The few preclinical and clinical studies propose that maternal brain adaptations to the endocrinological, immunological, and behavioral changes and external sociodemographic risk factors in the perinatal period make women more vulnerable to anxiety and depression. Irrespective of the cause, a dilemma exists regarding the type of help to provide postpartum mothers. With very few treatment options at our disposal, deciding between psychotherapy, pharmacological, and non-pharmacological therapy on a case-by-case basis is unproductive because in developing countries infrastructure is limited and the availability of medications, especially for psychiatric illnesses, is still evolving. Hence, regardless of psychotherapy, antidepressants remain the first line of treatment with selective serotonin reuptake inhibitors (SSRIs); sertraline has the best efficacy and safety profile in breastfeeding women. As endocrine factors play a significant role in etiopathogenesis, hormonal therapy with oxytocin has been shown to be efficacious, and studies investigating the role of testosterone in treating PPD are also under way. In 2019, the US Food and Drug Administration (FDA) approved the first and only drug for the sole purpose of treating PPD, brexanolone. Zuranolone, a drug recently approved by the FDA, has a similar mechanism of action to brexanolone. For breastfeeding mothers reluctant to use pharmacotherapy, somatic therapy has been studied, including bright light therapy, vagal nerve stimulation, and newer noninvasive interventions. This article encompasses a short note on PPD, including its etiopathogenesis and clinical characteristics, and recapitulates the various available and evolving pharmacological and nonpharmacological therapies.

One Hundred Years of Seeking Respectful Maternity Care: History and Evolution

Growing awareness of poor maternal health outcomes and maternal health disparities in the United States has heightened urgency around the need to promote Respectful Maternity Care (RMC) as a fundamental tenet of obstetric/midwifery care and standardize efforts to improve safety, eliminate obstetric violence and racism, and optimize health outcomes for all birthing people. The historical context of prior and contemporary perspectives around childbirth influences our understanding of RMC and are shaped by varying scholarly, clinical, and community standards (e.g., religion, human rights, government, public health, midwifery, ethics, activism, and the law), which have changed significantly since the mid-19th century. In this commentary, we share results of a contextual question scoped as part of a larger systematic review of RMC to help inform consensus around a shared definition and development of a metric to standardize delivery and evaluation of RMC. Synthesis of this literature identified landmark historical influences on RMC over the past 100 years, highlighting the multidisciplinary scholarship and historical context influencing the progress toward RMC. Further understanding of this history may also inform policies and guidance for ongoing efforts to center respect and accountability in all aspects of maternity care, with particular attention to populations who are disproportionally impacted by disrespectful care.

Understanding VA Maternity Care Coordinators Interactions and Collaboration With Primary Care Providers

INTRODUCTION

Maternal morbidity is higher among the Veteran population in part because of high rates of chronic medical and mental health conditions. To improve care for pregnant Veterans, the Department of Veteran Affairs created the position of the Maternity Care Coordinator (MCC) to provide care coordination during a Veteran's pregnancy. Maternity Care Coordinators must work with primary care providers (PCPs); yet, little is known about their collaboration and interaction. The objective of this work is to better understand how MCCs interact with PCPs.

METHOD

Between March and May of 2021, we conducted qualitative interviews with 30 MCCs using a semi-structured interview guide to learn about their role and interactions with PCPs.

RESULTS

We identified 3 main themes in interactions between MCCs and PCPs, which correlated to times during the Veteran's pregnancy: initial interactions, care coordination during the pregnancy, and end of pregnancy transitions of care. Most MCCs indicated a positive and collaborative relationship with PCPs. There was significant variability in how closely MCCs worked with PCPs. MCCs reported that PCPs were not always comfortable caring for pregnant Veterans.

DISCUSSION

Although MCCs generally indicated a positive and collaborative interaction with PCPs, our data suggest that there are opportunities to improve communication between PCPs and MCCs and to educate PCPs on knowledge of maternity benefits, the role of the MCC, and how to care for pregnant and postpartum Veterans. The Veteran Affairs MCC can also serve as a model for other health systems aiming to improve care coordinator among pregnant patients.

Pelvic Floor Health Knowledge With Enhanced Education During Pregnancy

IMPORTANCE

Prior to delivery, there are postpartum pelvic floor recovery topics to provide education on; however, because of a variety of factors, the majority of these are commonly unaddressed, leaving a patient unknowledgeable and unsatisfied.

OBJECTIVE

The primary aim of this study was to determine if providing tailored/targeted pelvic floor disorder education in the peripartum period will improve nulliparous patients' knowledge of pelvic organ prolapse (POP) and urinary incontinence (UI). Our secondary aim was to evaluate if a difference exists in patient satisfaction and understanding.

STUDY DESIGN

This was a single-site nonrandomized interventional study evaluating pregnant patients currently enrolled in an interactive electronic educational platform. We evaluated the change in Prolapse and Incontinence Knowledge Questionnaire (PIKQ) scores at 26-27 weeks antepartum and 6 weeks postpartum in 2 separate cohorts, before and after our education intervention was implemented. We also compared the magnitude of the change in PIKQ scores between the nonintervention and intervention postpartum cohorts as our primary outcome.

RESULTS

We compared the change in PIKQ mean scores between the control and intervention cohorts and found no statistical difference in change of UI (0.1 ± 1.8 vs 0.5 ± 1.9, P = 0.218) or POP knowledge (0.9 ± 2.5 vs 0.8 ± 2.4, P = 0.681). In addition, no significant change was detected in mean PIKQ UI scores for the control group between the antepartum and postpartum period (9.9 ± 2.4 vs 10.1 ± 2.1, P = 0.445), but there was a statistically significant change in POP knowledge scores (7.0 ± 3.3 vs 7.9 ± 3.1, P < 0.001). In the intervention cohort, there was a statistically significant change in both UI (9.3 ± 2.6 vs 9.8 ± 2.2, P = 0.012) and POP knowledge scores (6.7 ± 3.4 vs 7.5 ± 3.2, P = 0.001).

CONCLUSIONS

We did not detect a significant difference in mean score change between our cohorts following implementation of a targeted educational intervention using an online educational platform. However, both cohorts had higher than anticipated baseline knowledge on pelvic floor disorders.

Knowledge of Pelvic Floor Disorders in English- and Spanish-Speaking Postpartum Patients

IMPORTANCE

Postpartum patients generally have limited knowledge of urinary incontinence (UI) and pelvic organ prolapse (POP). However, it is unclear what differences exist in knowledge level between English- and Spanish-speaking postpartum patients for each condition.

OBJECTIVE

The objective of this study was to report rates of knowledge proficiency on UI and POP in English- and Spanish-speaking postpartum patients.

STUDY DESIGN

In this cross-sectional study of postpartum patients at a tertiary care center, knowledge was assessed using the English and Spanish language-validated Prolapse and Incontinence Knowledge Questionnaire. Knowledge proficiency on UI was defined as answering correctly ≥80% of the questions and for POP as answering correctly ≥50% of the questions, based on cutoffs implemented by Geynisman-Tan et al previously. Pelvic floor disorder symptom severity was assessed using the Pelvic Floor Distress Inventory-20 and the Pelvic Floor Impact Questionnaire-7.

RESULTS

Fifty English- and 50 Spanish-speaking patients completed the survey questionnaires. Spanish-speaking patients had lower rates of UI proficiency compared to English-speaking patients (10.0% vs 40.0%, P < 0.001) and were less likely to identify childbirth to be a risk factor for UI compared to English-speaking patients. For POP, proficiency levels were low but similar between English and Spanish speakers. Pelvic floor disorder symptom severity and impact on quality of life were low, did not differ between the 2 groups, and did not correlate with knowledge scores.

CONCLUSION

English- and Spanish-speaking postpartum patients have low knowledge of both UI and POP. Postpartum patients need educational resources to understand the risks and treatments for pelvic floor disorders.

Usability and Acceptability of a Pregnancy App for Substance Use Screening and Education: A Mixed Methods Exploratory Pilot Study

Background

Increasing opioid and other substance use has led to a crisis of epidemic proportions, with substance use now recognized as a leading cause of maternal morbidity and mortality in the United States. Interventions will only be effective if those who would benefit are identified early and connected to care. Apps are a ubiquitous source of pregnancy information, but their utility as a platform for evaluating substance use during pregnancy is unknown.

Objective

This study aims to explore the usability and acceptability of a pregnancy app for opioid and other substance use screening and education.

Methods

This mixed methods, exploratory pilot study examined adult pregnant people with a history of substance use who were recruited from outpatient and inpatient settings at a tertiary care obstetric hospital. After completing a baseline survey collecting demographics, substance use, and technology use, participants accessed an existing pregnancy support app for 4 weeks. Qualitative methods were used to measure the acceptability of embedding substance use screening, education, and information within the tool. App use frequency and access to substance use educational content and treatment referral information were evaluated.

Results

The 28 female participants had a mean (SD) age of 31 (0.46) years; most were White (21/28, 75%) and Medicaid insured (26/28, 93%), with an annual household income of

Conclusions

Incorporating substance use supports into a pregnancy app was found to be acceptable among those using substances. Participants reported frequent baseline use of prenatal apps, showed a high level of engagement with the pregnancy app during the study, and demonstrated interest in expanding the substance use support elements of this app. Embedding substance use screening, information, and connection to care into a tool with wide-scale use during pregnancy has the potential to identify at-risk individuals who may otherwise not be identified during routine prenatal care. It also has the potential to connect individuals, who might otherwise be hesitant to disclose their substance use, to recovery or harm reduction resources.

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Key Words

• mHealth
• mobile health apps
• pregnancy
• substance use disorder
• substance use screening
• technology

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Affiliation(s)

Haley Fitzgerald University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
Madison Frank Magee-Womens Research Institute, Pittsburgh, PA, United States
Katelyn Kasula Magee-Womens Research Institute, Pittsburgh, PA, United States
Elizabeth E Krans Magee-Womens Research Institute, Pittsburgh, PA, United States Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
Tamar Krishnamurti Division of General Internal Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, United States, 1 412-692-4855

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Implementation and Integration of a Hospital-Wide Postpartum Hypertension Clinic

Background

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal morbidity and mortality in the United States with an increased risk for hospital readmission and cardiovascular disease. The American College of Obstetricians and Gynecologists recommends that women with severe HDP follow-up within 72-hours post-discharge after childbirth. The purpose of this study is to evaluate if a postpartum hypertension (PPHTN) clinic improves follow-up and management.

Methods

Retrospective chart review of a referred cohort in a single-center, tertiary care hospital in Hartford, Connecticut. This study included women with severe HDP who were referred to the PPHTN clinic between March 2022 to February 2023. Primary outcomes were the percentage of patients seen within 72-hours postdischarge of hospitalization, percentage of patients achieving goal blood pressure (BP) (<130/80) at first and last follow-up visits, and hospital readmission rate. Secondary outcomes included the percentage of patients receiving HDP education materials, automatic BP cuff upon discharge from hospitalization, and antihypertensive medications prescribed postpartum.

Results

Our cohort had 157 women with a mean age of 32 years old (19-44), mean body mass index (BMI) 32 kg/m2 (16-49), and were 39% White, 24% African American, and 33% Hispanic. Comorbidities included 41% nulliparity, 19% gestational diabetes, 23% HTN, 28% gestational HTN and 10% prior preeclampsia. Among the women seen in the clinic, 53% were observed within 72 hours, 28% achieved their goal BP at first visit, and 58% achieved their goal BP at subsequent visits. Hospital readmission occurred in 5% of women. Overall, 86% received HDP education and 89% had or were prescribed a BP cuff upon discharge. Lastly, 85% were discharged on antihypertensives and 60% required antihypertensive modification postpartum.

Conclusion

Our initiative significantly improved the percentage of patients observed within 72 hours of discharge and facilitated longitudinal follow-up. Future analysis is needed to evaluate readmission rate reduction and the cost-effectiveness of the PPHTN clinic.

The Prospective Applications of Bioelectrical Impedance Analysis in Postpartum Women

Bioelectrical impedance analysis (BIA) has a wide range of applications. For over 25 years, it has primarily been utilized for assessing body composition. This method is non-invasive, portable, widely available, cost-effective, and user-friendly, offering the advantage of repeatability and minimal dependence on patient cooperation. BIA measures the impedance of the whole body, specifically the body's resistance to alternating current. In postpartum women, who undergo significant physiological changes following childbirth, BIA can serve as a valuable diagnostic and monitoring tool. It is commonly employed to track body weight and fat reduction, and it facilitates the differentiation of fat mass, muscle mass, and body water content. This enables the customization of nutritional plans and the development of individualized training regimens tailored to the patient's health status. Additionally, BIA aids in the assessment of hydration status, which is particularly critical during the postpartum period when women often experience fluid retention. Furthermore, optimal hydration is essential for lactation and maintaining favorable conditions for breastfeeding. BIA is also invaluable for evaluating nutritional status, micronutrient balance, and preventing both overweight and malnutrition. Moreover, BIA supports physical recovery by monitoring muscle mass, thereby assisting in the assessment of pelvic floor muscle regeneration following childbirth.

Trends in and characteristics of drug overdose morbidity among pregnant and postpartum individuals in California, 2010-2018

Fatal drug overdoses among pregnant and postpartum individuals have risen dramatically over the past 10 years. Trends in and characteristics of nonfatal drug overdoses in this population, however, remain unknown, despite the importance of this outcome for maternal and infant health. We used statewide, longitudinally linked hospital and emergency department administrative claims data from California to characterize the incidence, trends, drug type involvement, and sociodemographic disparities in pregnancy-associated drug overdose between 2010 and 2019. Generalized linear models accounting for multiple deliveries per individual were used to test for trends; descriptive statistics were used for other study analyses. Of California individuals with a live delivery between 2010 and 2018, approximately 0.2% had a pregnancy-associated drug overdose. Nonfatal overdoses were nearly 60 times more common than fatal overdoses. Incidence of overdoses involving stimulants increased in frequency, while incidence of overdoses involving sedative/hypnotic drugs and psychotropic medications decreased in frequency. Risk of overdose was substantially higher among delivering individuals who were young, non-Hispanic Black, Medicaid patients, or who lived in nonmetropolitan areas. Ongoing public health surveillance of pregnancy-associated nonfatal drug overdose events and clinical interventions to reduce these events are critical for prevention efforts.

Tennessee Medicaid patient immediate postpartum long-acting reversible contraception utilization

OBJECTIVES

To understand immediate postpartum long-acting reversible contraception (IPP LARC) desire and utilization trends among publicly insured patients delivering at one academic hospital in a state with health care barriers and high short-interval birth rates.

STUDY DESIGN

We conducted a retrospective cohort study of electronic delivery records between March 2018 and June 2023 for publicly insured patients. Patient demographics, IPP LARC desire and utilization trends were compared using χ2 or Fisher exact tests. Binary logistic regression explored the relationship between IPP LARC utilization and demographics. Multivariable logistic regression was performed on all statistically significant variables.

RESULTS

Analysis included 10,472 delivery encounters; 2459 (23.5%) requested IPP LARC on admission and 464 (4.4%) changed contraception to IPP LARC after admission. Among those obtaining IPP LARC (n = 2523, 24.1%), 1224 (48.5%) selected arm implants and 1299 selected intrauterine devices (IUDs). Patients who self-reported as non-Hispanic Black and non-Hispanic Other or multiple races utilized IPP LARC less (adjusted Odds Ratio (aOR)=0.84, 95% CI: 0.72-0.98, aOR=0.68, CI 95%: 0.48-0.97, respectively). Patients with cesarean delivery (aOR=1.45, 95% CI: 1.31-1.61) or inadequate prenatal care (aOR=1.54, CI 95%: 1.35-1.75) were more likely to utilize IPP LARC. Maternal age and years of education were inversely associated with utilization. Primiparous patients were less likely to utilize IPP LARC.

CONCLUSIONS

Long-acting reversible contraception (LARC) utilization was 24.1% during the immediate postpartum period; higher than the 11% nationally reported interval LARC use among publicly insured patients. Understanding the demographics of those desiring IPP LARC could highlight accessibility gaps. The impact of IPP LARC utilization on rates of short-interval birth is being evaluated.

IMPLICATIONS

Understanding the demographics of IPP LARC utilizers may contribute to understanding accessibility gaps and facilitate discernment of factors impacting patient initiation. Evidence suggests that comprehensive contraception access during delivery admission is feasible, patient-desired, and essential.