Development of a comorbidity index for use in obstetric patients

Association of Prenatal Exposure to Triptans, Alone or Combined With Other Migraine Medications, and Neurodevelopmental Outcomes in Offspring

BACKGROUND AND OBJECTIVES

The long-term reproductive safety of migraine medications remains uncertain. This study sought to examine the effect of different intensities and durations of prenatal exposure to triptans, alone and combined with other preventive migraine medications, on neurodevelopmental disorders (NDDs) in children.

METHODS

This nationwide health registry study in Norway included pregnancies of women with migraine before pregnancy and followed up their children up to 14 years of age. Single and multiple group-based trajectory models and group-based multitrajectory models were applied to cluster triptan exposure alone and combined with preventive antimigraine medications. Child outcomes, based on specialist outpatient and inpatient diagnoses, included autism spectrum and behavioral disorders, learning and intellectual disabilities, speech/language and developmental coordination disorders, and attention-deficit hyperactivity disorders (ADHDs). We fit adjusted and weighted pooled logistic regression models and standardized risk curves using propensity score-based overlap weighting.

RESULTS

We included 26,210 pregnancies of women with migraine; 4,929 and 21,281 were, respectively, nonmedicated and medicated with triptans in the year of prepregnancy. In the latter group, we identified 4 group-based trajectories of triptans alone and combined with preventive medications: discontinuers before (low use) (41.5%, 47.0%), early discontinuers (short-term low use) (31.3%, 28.8%), late discontinuers (moderate use) (21.3%, 9.1%), and late discontinuers (high use) (5.9%, 15.2%). Overall, 1,140 children (4.3%) had a NDD (mean follow-up time: 8 years). Children born to women with any triptan trajectory had a slightly higher risk of NDD compared with children of nonmedicated women (magnitude range of the weighted hazard ratio [wHR]: 1.05-1.16). These risks decreased to the null when discontinuers before (low use) acted as a comparator (magnitude of wHR: 0.94-1.01) or when analyzing speech/language disorders or ADHD (magnitude of wHR: 0.82-1.14). There was a slightly elevated risk of autism disorders with both triptan late discontinuation trajectories (wHR 1.24, 95% CI [0.78-1.97]; wHR 1.30, 95% CI [0.66-2.56]), but the 95% CI crossed the null and the weighted risk difference remained low.

DISCUSSION

Our findings indicate that prenatal exposure to triptans, alone or combined with other migraine medications, does not substantially increase the risk of a broad range of neurodevelopmental outcomes in children up to adolescence.

Severe maternal morbidity in twin pregnancies: the impact of body mass index and gestational weight gain

OBJECTIVES

The objective of this study was to determine whether body mass index (BMI) and gestational weight gain (GWG) are associated with severe maternal morbidity (SMM) in twin gestations.

METHODS

This was a retrospective cohort of all twin pregnancies delivered at seven hospitals in New York from 2019 to 2023. Multivariable logistic regression modeled the probability of SMM as a function of BMI group, adjusting for excessive GWG, race-ethnicity, and obstetric comorbidity index. A total of 1,976 twin gestations were included.

RESULTS

The SMM rate was 14.0 % (n=276).

CONCLUSIONS

Neither pre-pregnancy BMI nor GWG was associated with SMM, both before or after adjustment for covariates.

Hierarchical clustering analysis to inform classification of congenital malformations for surveillance of medication safety in pregnancy

There is growing interest in the secondary use of health care data to evaluate medication safety in pregnancy. Tree-based scan statistics (TBSS) offer an innovative approach to help identify potential safety signals; they use hierarchically organized outcomes, generally based on existing clinical coding systems that group outcomes by organ system. When assessing teratogenicity, such groupings often lack a sound embryologic basis, given the etiologic heterogeneity of congenital malformations. The study objective was to enhance the grouping of congenital malformations to be used in scanning approaches through implementation of hierarchical clustering analysis (HCA) and to pilot test an HCA-enhanced TBSS approach for medication safety surveillance in pregnancy in 2 test cases using > 4.2 million mother-child dyads from 2 US-nationwide databases. Hierarchical clustering analysis identified (1) malformation combinations belonging to the same organ system already grouped in existing classifications, (2) known combinations across different organ systems not previously grouped, (3) unknown combinations not previously grouped, and (4) malformations seemingly standing on their own. Testing the approach with valproate and topiramate identified expected signals and a signal for an HCA-cluster missed by traditional classification. Augmenting existing classifications with clusters identified through large data exploration may be promising when defining phenotypes for surveillance and causal inference studies.

Validation of the obstetric comorbidities index for predicting maternal mortality and severe maternal morbidity in South Korea

To validate the Obstetric Comorbidity Index (OB-CMI) and estimate its predictive and discriminative performance for maternal outcomes in the South Korean population. This study used data on births from the National Health Insurance Service Delivery Cohort database in South Korea. The data on pregnant people who gave birth during 2003-2019 were included. The obstetric comorbidities were identified using the Bateman's OB-CMI. The outcomes were severe maternal morbidity (SMM) as defined by the CDC in the US; severe acute maternal morbidity (SAMM), as defined by EURONET; and maternal death within 30 days postpartum. The predictive and discriminative abilities of the index were calculated using the Brier score and area under the receiver operating characteristic curve (AUC). Of 6,527,810 births, 143,392 (2.2%), 84,994 (1.3%), and 555 (< 0.1%) resulted in SMM, SAMM, and maternal death, respectively. The predictive ability and discriminative performance of the OB-CMI were moderate and good (Brier scores of 0.02, 0.01, and 0.00 and AUC of 0.72, 0.68, and 0.78 for SMM, SAMM, and maternal death, respectively). The OB-CMI demonstrated moderate and good predictive and discriminative performance for SMM, SAMM, and maternal mortality in the South Korean population. These findings align with previous research, supporting OB-CMI as a valuable tool for identifying high-risk pregnancies.

Incidence of Medical Complexity in Military-Connected Children

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) are at substantially increased risk for adverse health outcomes and mortality, justifying programs and policies to support their specialized needs. To inform such efforts, this study estimated the cumulative incidence of CMC-defining diagnoses by age 60 months in a cohort of live births among US military families and measured associations between birth outcomes and these diagnoses.

METHODS

This retrospective cohort study analyzed Department of Defense Birth and Infant Health Research program data from 2005 to 2020. Health care claims were used to identify CMC born between 2005 and 2015 and diagnosed from birth until age 60 months using the Complex Chronic Condition Classification System and Pediatric Medical Complexity Algorithm. The cumulative incidence of medical complexity was estimated, and Fine-Gray regression models calculated adjusted hazard ratios (aHRs) and 95% CIs for associations between birth outcomes and CMC-defining diagnoses.

RESULTS

Among 975 233 live births, the estimated cumulative incidence of CMC-defining diagnoses by age 60 months was 12.0% (95% CI, 11.9-12.1, n = 108 133), with one-third diagnosed during the neonatal period and almost two-thirds diagnosed during infancy. Risk was highest for children born with vs without congenital anomalies (aHR = 25.2; 95% CI, 24.4-25.9), very preterm vs nonpreterm (aHR = 17.6; 95% CI, 17.0-18.2), and very low birthweight vs normal/high birthweight (aHR = 13.7; 95% CI, 13.3-14.2).

CONCLUSIONS

Approximately 1 in 9 military-connected children were diagnosed with complex medical conditions by age 5, with risk highly associated with preterm delivery, congenital anomalies, and low birthweight. These findings can inform clinical counseling and justify resource allocation to support this population.

Association of Influenza Vaccination During Pregnancy with Health Outcomes in Mothers and Children: A Population-Based Cohort Study

Immunization rates of maternal influenza vaccination during pregnancy remain suboptimal, with concerns about potential harm to the mothers and their offspring. We conducted a population-based cohort study, using mother-child linked database in Korea: (a) maternal cohort between December 2019, and March 2022; (b) neonatal cohort between September 2020, and June 2021. Exposure was defined as influenza vaccination during pregnancy. Study outcomes included gestational outcomes, vaccine-related adverse events, and other health outcomes in mothers and childbirth and immune-related health outcomes in children. After 1-to-1 propensity score matching using diverse potential confounders, effect estimates with 95% confidence intervals were estimated using the log-binomial model for cumulative outcomes and the Cox proportional model for time-to-event outcomes. After 1-to-1 propensity score matching, we identified 174,008 and 53,344 pairs for the maternal and neonatal cohorts, respectively. In the maternal cohort, influenza vaccination during pregnancy was not associated with preeclampsia, antenatal bleeding, and various adverse outcomes, including neurological, vascular, blood, and lymphatic system disorders, except for marginally elevated risks of gestational diabetes mellitus (effect estimate 1.06, 95% confidence interval 1.05 to 1.08) and postpartum hemorrhage (1.05, 1.01 to 1.08). In the neonatal cohort, maternal influenza vaccination did not increase risks of childbirth (e.g., preterm/low birth weight, congenital malformations, mortality) and immune-related outcomes, except for a slightly increased risk of lower respiratory tract infection (1.06, 1.007 to 1.12). In this population-based cohort study, influenza vaccination during pregnancy was not associated with an increased risk of a range of adverse outcomes in mothers and their offspring.

Cancer diagnosis during pregnancy is associated with severe maternal and neonatal morbidity

BACKGROUND

Data on maternal and fetal outcomes in patients diagnosed with cancer during pregnancy are limited. Given expected increase in patients diagnosed with cancer during pregnancy, there is a growing need to evaluate clinical outcomes.

OBJECTIVE

To evaluate obstetric outcomes among women with early-stage gynecologic or breast cancer who were diagnosed during pregnancy compared to women without cancer in a population-based cohort.

STUDY DESIGN

We performed a population-based study of women aged 18 to 45 years with stage I gynecologic or stage I to III breast cancer reported to the California Cancer Registry for the years 2000 to 2012. Data were linked to the 2000 to 2012 California birth data to produce a database with cancer characteristics and obstetric outcomes. We included patients who had a delivery within the 10 months following cancer diagnosis. The primary outcome was severe maternal morbidity. Secondary outcomes included preterm birth and neonatal morbidity. Propensity scores were used to match similar controls to cases in a 2:1 ratio based on demographic attributes and medical comorbidities included in the Obstetric Comorbidity Index. Logistic regressions were used to evaluate outcomes.

RESULTS

The cohort consisted of 503 women with cancer in pregnancy (319 breast, 125 ovarian, 59 cervical) and 1006 matched controls. Cancer during pregnancy was associated with higher odds of severe maternal morbidity (6.8% vs <1.1%; odds ratio 8.03, 95% confidence interval 3.82-16.88), preterm birth between 32 and 36 weeks (32.6% vs 8.3%, odds ratio 5.38, 95% confidence interval 4.02-7.20), and neonatal morbidity (12.5% vs 6.1%; odds ratio 2.22, 95% confidence interval 1.53-3.21) compared to matched controls. In subanalysis of severe maternal morbidity indicators, hysterectomy and sepsis were significantly associated with cancer during pregnancy (4.8% vs <1.1%, P<.001; <2.2% vs 0.0%, P=.037, respectively).

CONCLUSION

Cancer during pregnancy is associated with increased risk of maternal and neonatal morbidity. These findings highlight the need for careful management and consideration of obstetric outcomes in these patients.

Characteristics and Medication Use Patterns of Pregnancies With COVID-19 Ending in Live-Birth in the Sentinel System

BACKGROUND

Pregnant women are at high risk for developing severe illness related to COVID-19. We adapted the "COVID-19 infectiOn aNd medicineS In pregnancy" (CONSIGN) study protocol as part of an international collaboration to examine medication use patterns among pregnancies in the US.

METHODS

We identified eligible women aged 12-55 years with documented live-birth deliveries in the Sentinel Distributed Database who had at least one qualifying diagnosis for COVID-19 or a positive-confirmed test for SARS-CoV-2, by trimester of COVID-19 infection. We conducted two sets of analyses comparing medication groups and COVID-19 treatment utilization in the 30 days prior to or after COVID-19 among pregnancies with COVID-19 to: (1) pregnancies without COVID-19 during 6 months prior to or during pregnancy; and (2) non-pregnancy episodes with COVID-19.

RESULTS

From 2020 to 2022, we identified 52 355 pregnancies with COVID-19 matched to 52 355 pregnancies without COVID-19 (assigned same matched COVID-19 date), and 40 518 matched non-pregnancy episodes with COVID-19. Outpatient medication use in the 30 days prior to or after the COVID-19 date (or matched date) was quite low (< 15%) among pregnancies with and without COVID-19. Non-pregnancy episodes with COVID-19 had higher use of all medication groups in 30 days prior to COVID-19. However, in the 30 days post-COVID-19, anti-bacterials, anti-inflammatories such as NSAIDs, and analgesics were more common, and COVID-19-specific medications were less frequently used (< 1%) among pregnancies with COVID-19. Assessing COVID-19 severity, more pregnancies had a non-severe COVID-19 diagnosis than non-pregnancy episodes with COVID-19 (87.2% vs. 79.9%).

CONCLUSIONS

In this retrospective evaluation, selected medication utilization was higher post-COVID-19 among pregnancies with COVID-19, compared to those without COVID-19 and to non-pregnancy episodes with COVID-19. However, the low use of COVID-19-specific medications underscores the need for a safety evaluation of therapies used for COVID-19 management in the pregnant population.

Analyzing electronic medical records to extract prepregnancy morbidities and pregnancy complications: Toward a learning health system

Introduction

Preexisting and pregnancy-related medical conditions frequently co-occur, leading to multimorbidity (≥2 morbidities) in pregnant women, and much of this information is in semi-structured format in electronic medical records (EMRs). The aim was to advance the learning health system as a platform for automating information extraction from EMRs and to uncover the prevalence of common morbidities during pregnancy and their association with pregnancy-related complications.

Methods

This study included 48 502 pregnant women attending Monash Health maternity hospitals from 2016 to 2021. Natural language processing (NLP) was used to extract morbidities from semi-structured text in EMRs. Chi-squared tests were used to assess the association between morbidities of gestational diabetes mellitus (GDM) and other pregnancy complications. The k-means clustering algorithm identified clusters of comorbid conditions associated with GDM.

Results

The most common comorbidities during pregnancy were vitamin deficiency (14 019; 28.9%), overweight (13 918; 28.7%), obesity (11 026; 22.7%), anemia and other blood-related disorders (4821; 9.9%), mental health disorders (4314; 9.8%), asthma (4126; 8.5%), thyroid diseases (3576; 7.4%), endometrial disease (1927; 3.9%), cardiovascular disease (1525; 3.1%), and polycystic ovary syndrome (PCOS) (1464; 3.0%). While 22.5% of women had no medical conditions, 77.5% had one or more. Multimorbidity was associated with conditions including overweight, obesity, vitamin deficiency, thyroid disease, substance use, PCOS, GDM, and endometrial diseases. On cluster analysis, aged 35 years or older, overweight, vitamin deficiency, obesity, thyroid disease, asthma, uterine disease, other blood disorders, mental disorders, and PCOS were associated with GDM.

Conclusions

More than three-quarters of pregnant women in the Australian urban setting experienced one or more morbidities during pregnancy, which can be associated with adverse pregnancy outcomes. This project contributes to developing a learning health system infrastructure to deliver high-value maternal health care while reducing costs.

Hereditary Hemorrhagic Telangiectasia: Pregnancy and Delivery-Specific Considerations and Outcomes

Prior studies have evaluated maternal outcomes in patients with hereditary hemorrhagic telangiectasia (HHT), yet pregnancy- and delivery-specific data remain limited. This study aims to evaluate pregnancy and delivery outcomes in patients with HHT.This retrospective cohort study used the Nationwide Readmissions Database to identify patients with HHT diagnosis on delivery between 2010 and 2021. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included nontransfusion SMM, preterm birth, stillbirth, prelabor rupture of membranes or preterm prelabor rupture of membranes, cesarean delivery, respiratory bleeding, cerebrovascular complications, patient disposition, and length of stay. Trends in the prevalence of HHT at delivery were assessed with logistic regression. Logistic regression analyses, adjusting for age, payer, zip code income, hospital size, and teaching status, were also used to produce adjusted relationships between HHT status and outcomes.The cohort of 21,698,861 delivered pregnancies corresponded to a national estimate of 44,325,599. Of those, 612 (national estimate: 1,265; 2.8 per 100,000) had a diagnosis of HHT. A steady rise in the HHT diagnosis rate during pregnancy from 2010 to 2021 (1.7 per 100,000 in 2010, 3.8 per 100,000 in 2021, p < 0.001 for trend) was seen. Patients with HHT were significantly more likely to experience SMM compared with patients without HHT (7.8 vs. 1.7%, adjusted relative risk [aRR]: 4.49 [95% confidence interval, CI: 3.06, 6.58]). Rates of preterm birth (14.2 vs. 8.5%, aRR: 1.57 [95% CI: 1.22, 2.03]), cesarean delivery (41.0 vs. 32.9%, aRR: 1.23 [95% CI: 1.07, 1.41]), respiratory bleeding (2.1 vs. <0.1%, aRR: 94.44 [56.64, 157.46]), and cerebrovascular complications (0.9 vs. <0.1%, aRR: 22.89 [9.89, 52.96]) were higher in patients with HHT than non-HHT patients. There was no difference in stillbirth rates between groups.Patients with HHT have higher rates of SMM and adverse delivery outcomes when compared with the baseline population. · There was a steady rise in the rates of HHT during pregnancy from 2010 to 2021.. · Patients with HHT are more likely to experience SMM.. · Patients with HHT are more likely to have a preterm delivery and cesarean delivery..

Pregnancy and birth complications among women undergoing bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass

BACKGROUND

Metabolic bariatric surgery is the most effective therapy for severe obesity, which affects the health of millions, most of whom are women of child-bearing age. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most common bariatric procedures and are associated with durable weight loss and comorbidity resolution. Although obstetric outcomes broadly improve, the safety profile comparing the impact of RYGB and SG on obstetric outcomes is underexplored.

OBJECTIVES

To compare obstetric outcomes in women who gave birth post-RYGB versus SG to determine whether there are differences in perinatal outcomes.

SETTING

United States, all patients within commercial, Medicare, Medicaid, government, and cash payor systems.

METHODS

The PearlDiver-Mariner database was used to identify women aged 18-52 years who underwent RYGB or SG between 2010 and 2020 and became pregnant within 2 years of surgery. Outcomes were defined by the presence of 1 or more pregnancy-related complications including gestational diabetes, preeclampsia, and hysterectomy. A 1:1 propensity-matched analysis was performed.

RESULTS

In total, 16,911 individuals, 10,675 (63.1%) and 6236 (36.9%) underwent SG and RYGB, respectively. Obstetric complication rates were 28.3% in the SG versus 32.1% in the RYGB group (P < .01). The RYGB group had an increased relative odds of experiencing an obstetric complication compared with the SG group (odds ratio 1.26; 95% confidence interval 1.14-1.38).

CONCLUSIONS

Although both are safe, RYGB was associated with a greater obstetric complication rate than SG. These findings can help women and surgeons decide which procedure to pursue and inform discussions regarding the timing of pregnancy after surgery.

How much can we reduce delivery-related medical costs associated with maternal mortality? A nationwide cohort study from 2003 to 2021

Objective

This study aims to examine the association between maternal mortality and childbirth-related medical costs using both unadjusted and adjusted models and to assess the potential reduction in delivery-related medical costs associated with maternal mortality in South Korea.

Methods

This retrospective cohort study used data from the National Health Insurance Service Delivery Cohort Database of South Korea. A total of 7,171,578 participants were included. The outcome measured was delivery-related medical costs associated with maternal mortality. A Generalized Estimating Equation model with a log link and gamma distribution was used to estimate delivery-related medical costs.

Results

The maternal death rates were 9.7 per 100,000 births. The adjusted mean delivery-related medical costs were approximately six times higher in cases with maternal death than in those without ($2,802 vs. $480, p < 0.0001). The total delivery-related medical costs for all women with maternal mortality were approximately $2 million, accounting for 0.06% of total delivery-related medical costs. Although this proportion is relatively small, 83% of the direct medical costs associated with maternal mortality among South Korean women were potentially reducible.

Conclusion

This study found that maternal mortality is associated with significantly higher delivery-related medical costs, nearly six times those of non-maternal mortality cases. Therefore, policymakers should consider reducing costs and improving maternal health outcomes, expanding access to prenatal care for early risk detection and strengthen nationwide maternal health monitoring systems.

Risk Factors, Trends, and Outcomes Associated with Rural Delivery Hospitalizations Complicated by Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy (HDP) may account for a considerable and growing clinical burden at rural hospitals which have been providing fewer obstetric services over the past two decades. The objectives of this analysis were to evaluate trends, risk factors, and outcomes associated with HDP during delivery hospitalizations at rural hospitals in the United States.The 2000 to 2020 National Inpatient Sample was used for this repeated-cross sectional analysis. Delivery hospitalizations at rural hospitals to women 15 to 54 years of age with and without HDP (including preeclampsia and gestational hypertension) were identified. Trends in HDP were characterized with joinpoint regression and estimated as the average annual percent change (AAPC) with 95% confidence intervals (CIs). The associations between (i) HDP risk factors and HDP and (ii) HDP and adverse maternal outcomes were estimated with adjusted logistic regression models.Among 8,885,683 deliveries that occurred at rural hospitals, the proportion with a HDP diagnosis increased significantly from 6.0% in 2000 to 11.1% in 2020 (AAPC: 3.1%; 95% CI: 2.8 and 3.4%). Preeclampsia with severe features (AAPC: 5.5%; 95% CI: 4.8 and 6.2%) and superimposed preeclampsia (AAPC: 6.5%; 95% CI: 5.6 and 7.5%) underwent the largest relative increases over the study period. Obesity, pregestational diabetes, chronic hypertension, multiple gestation, and chronic kidney disease were all associated with increased adjusted odds of HDP. HDP diagnoses were significantly associated with severe maternal morbidity (SMM), transfusion, stroke, and disseminated intravascular coagulation. The proportion of overall delivery SMM associated with HDP more than doubled from 11.3% in 2000 to 24.7% in 2020.Among delivery hospitalizations at rural hospitals, HDP, and associated risk factors increased significantly over the study period. Deliveries with HDP accounted for an increasing proportion of population-level SMM. HDP is a major, growing contributor to maternal risk and adverse outcomes during deliveries at rural hospitals. · Hypertensive disorders accounted for an increasing proportion of population-level severe morbidity.. · Hypertensive disorders increased among rural delivery hospitalizations.. · Risk factors associated with hypertensive disorders increased among rural delivery hospitalizations..

Reduced odds of severe maternal morbidity associated with the US Affordable Care Act dependent coverage provision

BACKGROUND

Continuous perinatal health insurance coverage is a policy intervention that may help reduce severe maternal morbidity (SMM) and racial and ethnic disparities in SMM in the United States. The Affordable Care Act Dependent Coverage Provision (DCP) allowed young adults to remain on their parent's private health insurance plan until their 26th birthday but its effectiveness in reducing SMM has not been evaluated.

OBJECTIVE

To assess the association of the DCP with SMM during delivery hospitalization.

STUDY DESIGN

Difference-in-differences analysis of US delivery hospitalizations from January 2006 to September 2015, stratified according to maternal race and ethnicity. The outcome was SMM exclusive of blood transfusion only, as defined by the Centers for Disease Control and Prevention criteria. The exposure was maternal age categorized into 21 to 25 years (covered by the DCP) and 27 to 31 years (not covered the DCP). The intervention was the DCP categorized into pre- and post-DCP periods (January 2006-September 2010 and October 2010-September 2015, respectively).

RESULTS

Of the 4,007,937 delivery hospitalizations in the sample, 22,540 (56.2 per 10,000) recorded SMM. For birthing people aged 21 to 25 years (covered by the DCP), the mean SMM rate was 48.9 per 10,000 during the pre-DCP period and 58.2 per 10,000 during the post-DCP period (crude difference: 9.3 per 10,000). For birthing people aged 27 to 31 years (not covered the DCP), the mean SMM rate was 53.4 per 10,000 during the pre-DCP period and 63.6 per 10,000 during the post-DCP period (crude difference: 10.2 per 10,000). Implementation of DCP was associated with a 1.2% (95% CI: -3.6, 1.3) relative decrease in the mean SMM rate (adjusted odds ratio (aOR): 0.988; 95% CI: 0.964, 1.013). For non-Hispanic White people, the DCP was associated with a 10.7% (95% CI: 7.1, 14.2) relative decrease in the mean SMM rate (aOR: 0.893; 95% CI: 0.858, 0.929). The DCP was associated with an increase in the proportion of privately insured (aOR: 1.225; 95% CI: 1.220, 1.231), a decrease in the proportion of Medicaid beneficiaries (aOR: 0.853; 95% CI: 0.849, 0.856), and a decrease in the proportion of uninsured (aOR: 0.807; 95% CI: 0.798, 0.816).

CONCLUSIONS

Maternal health benefit of the DCP appears to be limited to non-Hispanic White birthing people.

Severe maternal morbidity in the high income setting: a systematic review of composite definitions

Background

Severe maternal morbidity (SMM) is an important indicator for the improvement of maternity care. Measurement of SMM varies, limiting global comparisons. To promote concordance we studied how SMM has been defined in epidemiological practice.

Methods

Comprehensive composite definitions of SMM in pregnancy or up to 6 weeks postnatal that captured both obstetric and non-obstetric processes in high-income settings were identified through a prospectively registered (PROSPERO CRD42023421377) systematic search of PubMed, Embase, and Google Scholar 01/01/1993-31/08/2024. Clinical concepts, diagnostic and procedural codes captured by definitions of SMM were compared and the variation between definitions was described.

Findings

The initial search identified 7852 records and 40 studies were included: 28 studies that reported 32 definitions of SMM for use with administrative data, with median incidence of 11.4/1000, and 13 studies that reported 13 definitions for use with the primary medical record, with median SMM incidence of 6.7/1000. The majority of definitions included cardiac, respiratory, and renal dysfunction or failure; haemorrhagic, thrombotic or infective morbidity; and critical interventions. Up to 75% of cases of SMM under some definitions involved transfusion. The main source of variation between definitions was the selection and definition of common obstetric diagnoses. Variation in the sources of additional routine data required to construct a definition also limited comparability.

Interpretation

Despite common approaches to defining SMM, there are opportunities to improve comparability. No two definitions for use with administrative data in different settings involved a similar incidence and set of components and involved a similar distribution of components among cases. Harmonization of the purpose, constituent codes, and sources of data would facilitate comparisons between maternity systems.

Funding

This work was supported by the Medical Research Council [MR/X006115/1] as well as the National Institute for Health Research [NIHR204430].

Trends of childbirth and cesarean section among women with epilepsy in Korea

PURPOSE

This study aims to investigate trends in birth and cesarean section (CS) rates among women with epilepsy (WWE) in Korea.

METHODS

We conducted a nationwide, population-based, repeated cross-sectional study using data from the Korean National Health Insurance Service database. We evaluated the annual childbirth rate and proportion of CS among all deliveries for WWE and the entire female population aged 15-49 years from 2004 to 2019.

RESULTS

The annual childbirth rates declined more sharply for WWE than those for the general population, with an average annual percent change (AAPC) of -3.5 % for WWE compared to -1.3 % for general women. The CS rate was higher in WWE (51.2 %) than in general population (38.9 %), with increasing trends observed in both groups (AAPC = 2.2 % for WWE vs. AAPC = 1.8 % for general women). Among WWE under monotherapy, without emergency room visits related to epilepsy, and without both central nervous system and psychiatric diseases, the CS rates were 47.8%, 50.6%, and 48.3%, respectively. After adjusting for age and obstetric comorbidities, factors associated with increased CS risk included the use of four or more antiseizure medications (adjusted odds ratio (aOR) 1.74 [1.06-2.87]), emergency room visits (aOR 5.64 [2.83-11.24]), and an Epilepsy-Specific Comorbidity Index of ≥2 (aOR 1.45 [1.05-2.01]).

CONCLUSIONS

The annual decline in childbirth and increase in CS rates were more prominent in WWE. While epilepsy severity and comorbidities were associated with CS deliveries, the persistently high CS rates in WWE even under favorable maternal conditions suggest the potential for unnecessary CS procedures.

A Latent Class Analysis of Pre-Pregnancy Multimorbidity Patterns in a Delivery Cohort at a Safety-Net Hospital

Background: Multimorbidity affects approximately 1 in 3 adults and is associated with adverse health outcomes. However, there is a paucity of information describing patterns of multimorbidity among the birthing population. The objective of this study was to describe the clustering of pre-pregnancy chronic conditions in the birthing population by age, race and ethnicity, insurance status, and parity using latent class analysis (LCA). Study design: We conducted a retrospective cohort study of deliveries using medical record data between 2015 and 2019. Multimorbidity was defined as having at least two chronic conditions before the start of the index pregnancy, using adapted versions of obstetric comorbidity indices. The final LCA model was selected based on clinical interpretability and statistical fit. We also compared the distribution of sociodemographic factors across classes. Results: Of 6,455 deliveries, 1,870 (29%) deliveries were to patients with multimorbidity. LCA resulted in a 3-class model: Class 1 (45% of individuals with multimorbidity) was characterized by mood/anxiety and substance use disorders; class 2 (39%) was defined by body mass index ≥30 kg/m2 and chronic hypertension; and class 3 (16%) was characterized by reproductive conditions and infertility. Individuals who were <25 years or non-Hispanic White were more frequently in class 1; individuals who were ≥35 years or non-Hispanic Black were disproportionately in class 2. Nulliparas and individuals with private insurance were more frequently in class 3. Conclusion: Multimorbidity is prevalent in pregnancy and distinct chronic condition clusters vary across sociodemographic sub-groups, demonstrating the need for integrative approaches to periconceptional care for birthing individuals with multimorbidity.

PregMedNet: Multifaceted Maternal Medication Impacts on Neonatal Complications

While medication intake is common among pregnant women, medication safety remains underexplored, leading to unclear guidance for patients and healthcare professionals. PregMedNet addresses this gap by providing a multifaceted maternal medication safety framework based on systematic analysis of 1.19 million mother-baby dyads from U.S. claims databases. A novel confounding adjustment pipeline was applied to systematically control confounders for multiple medication-disease pairs, robustly identifying both known and novel maternal medication effects. Notably, one of the newly discovered associations was experimentally validated, demonstrating the reliability of claims data and machine learning for perinatal medication safety studies. Additionally, potential biological mechanisms of newly identified associations were generated using a graph learning method. These findings highlight PregMedNet's value in promoting safer medication use during pregnancy and maternal-neonatal outcomes.

Prospective transitions in hemoglobin A1c following gestational diabetes using multistate Markov models

We characterized the state-to-state transitions in postpartum hemoglobin A1c levels after gestational diabetes, including remaining in a state of normoglycemia or transitions between prediabetes or diabetes states of varying severity. We used data from the APPLE Cohort, a postpartum population-based cohort of individuals with gestational diabetes between 2009 and 2011, and linked A1c data with up to 9 years of follow-up (n = 34 171). We examined maternal sociodemographic and perinatal characteristics as predictors of transitions in A1c progression using Markov multistate models. In the first year postpartum following gestational diabetes, 45.1% of people had no diabetes, 43.1% had prediabetes, 4.6% had controlled diabetes, and 7.2% had uncontrolled diabetes. Roughly two-thirds of individuals remained in the same state in the next year. Black individuals were more likely to transition from prediabetes to uncontrolled diabetes (adjusted hazard ratio [aHR] = 2.32; 95% CI, 1.21-4.47) than White persons. Perinatal risk factors were associated with disease progression and a lower likelihood of improvement. For example, hypertensive disorders of pregnancy were associated with a stronger transition (aHR = 2.06; 95% CI, 1.39-3.05) from prediabetes to uncontrolled diabetes. We illustrate factors associated with adverse transitions in incremental A1c stages and describe patient profiles that may warrant enhanced postpartum monitoring.

Association of in vitro fertilization with severe maternal morbidity in low-risk patients without comorbidities

OBJECTIVE

To determine whether an association exists between in vitro fertilization (IVF) and severe maternal morbidity among low-risk pregnant patients.

DESIGN

Retrospective cohort study.

SUBJECTS

Low-risk pregnant patients who delivered between January 2019 and December 2022. Low-risk was defined as having an obstetric comorbidity index score of 0.

EXPOSURE

In vitro fertilization.

MAIN OUTCOME MEASURE(S)

The primary outcome (dependent variable) was any severe maternal morbidity. The secondary outcome was the need for a cesarean delivery. A modified Poisson regression with robust error variance was used to model the probability of severe maternal morbidity as a function of IVF. Risk ratios and their associated 95% confidence intervals (CIs) were computed. An α value of 0.05 was considered statistically significant.

RESULT(S)

A total of 39,668 pregnancies were included for analysis, and 454 (1.1%) were conceived by IVF. The overall severe maternal morbidity rate was 2.4% (n = 949), with the most common indicator being blood transfusion. The overall cesarean delivery rate was 18.8% (n = 7,459). On modified Poisson regression, IVF-conceived pregnancies were associated with 2.56 times the risk of severe maternal morbidity (95% CI, 1.73-3.79) and 1.54 times the risk of having a cesarean delivery (95% CI, 1.37-1.74) compared with non-IVF pregnancies.

CONCLUSION(S)

In vitro fertilization is associated with higher rates of severe maternal morbidity, primarily the need for a blood transfusion, and cesarean delivery in low-risk pregnancies without major comorbidities. Recognizing this association allows healthcare providers to implement proactive measures for better monitoring and tailored postpartum care.

Validity of a Classification System for the Levels of Maternal Care

OBJECTIVE

To assess the content validity of the classification of maternal level of care of the American Hospital Association Database for research use.

METHODS

This was a secondary data analysis where we classified the maternal level of care in the 2018 American Hospital Association Database and linked this to birth hospitalizations from five states in the 2016 and 2017 State Inpatient Databases: Delaware, Florida, Kentucky, Maryland, and Washington. We compared maternal level of care classification with birth volume quartiles, hospital size quartiles, and teaching status to predict the birth hospital for women with high OCI (Obstetric Comorbidity Index) scores and hospital-to-hospital transfers. We calculated the odds of birth at the highest-level hospital, controlling for maternal race, rural residence, primary payer, and state.

RESULTS

People with high OCI scores and hospital-to-hospital transfer had increased odds of birth at hospitals classified as maternal level III or IV, large hospitals, and teaching hospitals. The probability of birth at the highest-level hospital for people with high OCI scores was increased 4.9% for a level III or IV hospital, 2.6% for a large hospital, and 1.2% for a teaching hospital. The probability of birth at the highest-level hospital for people with hospital transfer was increased 5.2% for a level III or IV hospital, 1.4% for a large hospital, and 14.4% for a teaching hospital.

CONCLUSION

Researchers can classify the maternal level of care using the American Hospital Association Database to study maternal risk-appropriate care.

Effect of Social Vulnerability Index on Betamethasone Timing in Patients at Risk of Preterm Birth

Background/Objectives: Several social vulnerability index (SVI) components have been associated with adverse obstetrical outcomes and provider bias. The objective of this study is to assess whether betamethasone administration timing among patients at risk for preterm birth differs by social vulnerability index. Methods: A multicenter retrospective cohort study of pregnant people at a large academic healthcare system between January 2019 and January 2023. Patients with live singleton gestations at risk for preterm birth who received at least one dose of intramuscular betamethasone for fetal lung maturity from 22 to 34 weeks were included. Patients aged less than 18, who received late-preterm corticosteroids and/or had scheduled delivery at 34 weeks were excluded. We analyzed the association between patient SVI quartile and maternal demographic factors on betamethasone timing, with optimal timing defined as the receipt of two doses of betamethasone within 2 to 7 days of delivery. Results: 1686 patients met the inclusion criteria. Only 22.4% of patients had optimally timed betamethasone administration. Among those who did not receive optimal betamethasone timing, 360 patients delivered less than 48 h from the first dose and 948 delivered greater than 7 days from the first dose. Optimal betamethasone timing within 2 to 7 days of delivery was more common in patients with higher SVI values. Patients with lower social vulnerability were more likely to deliver greater than one week from betamethasone administration. Conclusions: Patients in higher SVI quartiles are more likely to have optimally timed betamethasone. This is likely attributed to overtreatment with betamethasone of less socially vulnerable populations.

Pregnancy Outcomes and Maternal Characteristics in Women with Pregestational and Gestational Diabetes: A Population-Based Study in Spain, 2016-2022

Background/Objectives: The objective of this study was to compare trends in the incidence of deliveries and in obstetric interventions and outcomes in women with and without type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM). Methods: This was an observational study using the Spanish National Hospital Discharge Database (2016-2022). Results: A total of 1,995,953 deliveries were recorded between 2016 and 2022 (6495 mothers with T1DM, 5449 with T2DM, and 124,172 with GDM). The incidence of T1DM and GDM increased over time, although it remained stable in women with T2DM. Women with T2DM were more likely to have obstetric comorbid conditions (72.93%) than women with GDM (63.04%), women with T1DM (59.62%), and women who did not have diabetes (45.3%). Pre-eclampsia, previous cesarean delivery, and arterial hypertension were the most prevalent conditions in all types of diabetes. The highest frequency of cesarean delivery was recorded for women with T1DM (55.04%), followed by women with T2DM (44.94%), and those with GDM (28.13%). The probability of cesarean delivery was 2.38, 1.79, and 1.19 times greater for T1DM, T2DM, and GDM, respectively, than for women who did not have diabetes. The adjusted rate for severe maternal morbidity was significantly higher for women with T1DM (RR 2.31; 95%CI 2.02-2.63) and T2DM (RR 1.58; 95%CI 1.34-1.87) than for women without diabetes. Conclusions: The incidence of deliveries in women with T2DM remained unchanged between 2016 and 2022; the incidence of deliveries increased in women with T1DM and GDM. The prevalence of comorbidity and obstetric factors increased over time in women with T1DM and GDM.

Association of General Anesthesia for Cesarean Delivery with Postpartum Depression and Suicidality

BACKGROUND

Compared to neuraxial anesthesia, general anesthesia (GA) for cesarean delivery is associated with an increased risk of postpartum depression (PPD) requiring hospitalization. However, obstetric complications occurring during childbirth (eg, stillbirth) are associated with both increased use of GA and increased risk of PPD, and may account for the reported association between GA and PPD. This study assessed the association of GA for cesarean delivery with PPD requiring hospitalization, outpatient visit, or emergency department (ED) visit, accounting for obstetric complications.

METHODS

This retrospective cohort study included women who underwent a cesarean delivery in New York State between January 2009 and December 2017. Women were followed for 1 year after discharge for readmission, outpatient visit, or ED visit. The primary outcome was PPD requiring readmission, outpatient visit, or ED visit. The 2 secondary outcomes were (1) PPD requiring readmission, and (2) suicidality. Obstetric complications included severe maternal morbidity, blood transfusion, postpartum hemorrhage, preterm birth, and stillbirth. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of PPD, PPD requiring readmission, and suicidality associated with GA were estimated using the propensity score matching and the overlap propensity score weighting methods.

RESULTS

Of the 325,840 women included, 19,513 received GA (6.0%; 95% CI, 5.9-6.1). Complications occurred in 43,432 women (13.3%) and the GA rate for these women was 9.7% (95% CI, 9.4-10.0). The incidence rate of PPD was 12.8 per 1000 person-years, with 24.5% requiring hospital readmission, and was higher when an obstetric complication occurred (17.1 per 1000 person-years). After matching, the incidence rate of PPD was 15.5 per 1000 person-years for women who received neuraxial anesthesia and 17.5 per 1000 person-years for women who received GA, yielding an aHR of 1.12 (95% CI, 0.97-1.30). Use of GA was associated with a 38% increased risk of PPD requiring hospitalization (aHR: 1.38; 95% CI, 1.07-1.77) and with a 45% increased risk of suicidality (aHR 1.45; 95% CI, 1.02-2.05). Results were consistent when using the overlap propensity score weighting.

CONCLUSIONS

Use of GA for cesarean delivery is independently associated with a significantly increased risk of PPD requiring hospitalization and suicidality. It underscores the need to avoid using GA whenever appropriate and to address the potential mental health issues of patients after GA use, specifically by screening for PPD and providing referrals to accessible mental health providers as needed.

Burden of Medical Costs Associated with Severe Maternal Morbidity in South Korea

BACKGROUND

Adverse maternal health outcomes lead to health loss and unnecessary medical costs. However, few have explored how severe maternal morbidity (SMM) affects medical costs separately from blood transfusion. Therefore, the aim of this study was to evaluate the delivery-related costs of healthcare services in patients with and without SMM as well as blood transfusion.

METHODS

This retrospective cohort study used the National Health Insurance Service (NHIS) Delivery Cohort database in South Korea. We included all delivering mothers in South Korea from 2016 to 2021, except those with incomplete data, totaling 1,517,773 participants. The measured outcomes included delivery-related medical costs associated with SMM. A generalized estimating equation model with a log link, gamma distribution, and robust standard errors was used to estimate the mean delivery-related medical costs of SMM.

RESULTS

SMM occurred in 2.2% of the cohort. The adjusted mean delivery-related medical costs were approximately 2.1- and 1.4-fold higher in cases with SMM without blood transfusion and only blood transfusion than in those without SMM, respectively ($2005, 95% CI: $1934-2078 and $1339, 95% CI: 1325-1354, respectively). The adjusted mean delivery-related medical costs were 1.5-fold higher in cases with SMM with blood transfusion than in those without SMM (SMM $1539, 95% CI: $1513-$1565).

CONCLUSIONS

Medical costs associated with delivery-related SMM with or without blood transfusion were significantly higher than those of normal deliveries, with excess costs varying according to existing healthcare policies. Policymakers should consider supporting programs to prevent high medical costs by improving maternal health.

Maternal pulmonary hypertension and cardiopulmonary outcomes during delivery hospitalization in the United States: A nationwide study from 2016-2020

BACKGROUND

Maternal pulmonary hypertension can pose substantial morbidity and mortality risks, particularly during labor and delivery. Although maternal pulmonary hypertension is conventionally considered a contraindication to pregnancy, advances in the management of pH may contribute to improving outcomes.

OBJECTIVES

In this nationwide study, we aim to characterize the prevalence of maternal pulmonary hypertension in the United States and its association with adverse cardiopulmonary outcomes during delivery hospitalizations.

STUDY DESIGN

In this cross-sectional cohort study, we analyzed delivery hospitalizations in the National Inpatient Sample from 2016 to 2020. The primary exposure was maternal pulmonary hypertension. The primary outcome was a composite of maternal cardiopulmonary morbidity events during the delivery hospitalization including: death, heart failure, intraoperative heart failure, pulmonary edema, cardiac arrest, myocardial infarction, ventricular fibrillation, respiratory failure, pneumonia, acute kidney injury, and cardiac conversion. Propensity score matching was used to estimate the association between maternal pulmonary hypertension and adverse cardiopulmonary outcomes, adjusting for sociodemographic variables and validated clinical comorbidities as covariates. Secondary outcomes included mechanical circulatory support utilization, length of stay, and total hospitalization costs.

RESULTS

Among 18,161,315 delivery hospitalizations, 4,630 patients had pulmonary hypertension, yielding a maternal pulmonary hypertension prevalence of 25 per 100,000 delivery hospitalizations with a yearly trend of increasing prevalence (odds ratio = 1.06, 95 % CI 1.01 to 1.11, P = 0.028). After propensity score matching to create well-balanced groups, 4,560 patients with pulmonary hypertension were compared to 4,560 patients without pulmonary hypertension. In this confounder-adjusted analysis, the primary composite outcome of cardiopulmonary morbidity and mortality occurred in 41.1 % of the PH group compared to 14.4 % in the no PH group (adjusted odds ratio = 4.16, 95 % CI 3.32 to 5.23, P < 0.001). Additionally, patients with PH had a higher incidence of mechanical circulatory support use (adjusted odds ratio = 9.08, 95 % CI 1.14 to 71.81, P = 0.037), longer length of stay (length of stay ratio = 2.82, 95 % CI 2.74 to 2.9, P < 0.001) and higher total hospitalization costs (total cost ratio = 1.67, 95 % CI 1.52 to 1.85, P < 0.001).

CONCLUSIONS

Maternal pulmonary hypertension is increasing in prevalence and is strongly associated with adverse cardiopulmonary outcomes in the United States, with 41.1% of pH patients experiencing a composite outcome of cardiopulmonary morbidity and mortality during delivery hospitalization. Our findings emphasize the importance of caring for patients with maternal pulmonary hypertension in a multidisciplinary setting at high-acuity centers to ensure appropriate management of cardiopulmonary complications that arise during labor and delivery.

Association between hospital procedure volume, socioeconomic status, comorbidities, and adverse events related to surgical abortion: a nationwide population-based cohort study

BACKGROUND

Limited evidence exists on the influence of hospital procedure volume, socioeconomic status, and comorbidities on surgical abortion outcomes.

OBJECTIVE

Our study aimed to assess the association between hospital procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events.

STUDY DESIGN

A nationwide population-based cohort study of all women hospitalized for surgical abortion was conducted from January 1, 2018 to December 31, 2019 in France. Annual hospital procedure volume was categorized into 4 levels based on spline function visualization: very low (<80), low ([80-300]), high ([300-650]), and very high-volume (≥650) centers. The primary outcome was the occurrence of at least one surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, and admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery.

RESULTS

Of the 112,842 hospital stays, 4951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multivariate analysis showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.34, 95% CI [0.29-0.39], P<.001), high-volume (4.24%, aOR=0.61, 95% CI [0.55-0.69], P<.001), and low-volume (4.69%, aOR=0.81, 95% CI [0.75-0.88], P<.001) wh en compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.69, 95% CI [1.47-1.94], P<.001), neighborhood deprivation (aOR=1.31, 95% CI [1.22-1.39], P<.001), and comorbidities (aOR=1.79, 95% CI [1.35-2.38], P<.001) were associated with surgical-related adverse events. Conversely, the multivariate analysis of general adverse events did not reveal any volume-outcome relationship.

CONCLUSION

The presence of a volume-outcome relationship underscores the need for enhanced safety standards in low-volume centers to ensure equity in women's safety during surgical abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic status and comorbidities that policymakers must consider.

The obstetrics comorbidity index as a predictive tool for risk-appropriate maternal care

BACKGROUND

The aim of this study was to assess the correlation between obstetric co-morbidity index (OBCMI) and severe maternal morbidity (SMM) in antepartum obstetrics transfers. By utilizing a population of transfers to a level IV maternal care facility, we hope to demonstrate validity for the use of OBCMI in the triage of transfer to provide risk-appropriate maternal care.

METHODS

Antepartum obstetrics transfers to a single level IV maternal care facility from 1/1/2016 to 12/31/2020 that resulted in delivery during the same encounter were included in this retrospective study. The components of the OBCMI score were retrospectively collected by manual chart review of transfer and admission notes in the electronic medical record (EMR). SMM was determined via ICD-10 and CPT code extraction from time of transfer through six weeks postpartum and confirmed by the same reviewer. Mode of delivery, length of stay, ICU admission, readmission and reoperation were obtained via institutional databases and manual EMR review.

RESULTS

Among 561 transfers meeting the inclusion criteria, the median OBCMI was significantly higher for transfers with a maternal-only indication (n = 232) compared to fetal-only( n = 282) (median [IQR], 6 [4-8], 5 [4-6], and 1 [0-2] for maternal-only, maternal-fetal combined (n = 47), and fetal-only; p < 0.001). The prevalence of SMM was 16.8% (39/232), 27.7% (13/47), 2.1% (6/282), p < 0.0001 for those transferred for maternal, fetal and maternal, and fetal only indications respectively. The median (IQR) OBCMI score was 5 (4-8) and 3 (1-5) for those with versus without SMM. A cut-off OBCMI score of ≥ 4 was identified with 81% sensitivity (95% CI 68.6-90.1%) in predicting SMM (P = < .0001) and was noted to be significantly associated with operative delivery, blood transfusion, ICU admission, prolonged hospitalization, and reoperation. Using a cut-off OBCMI score of ≥ 4 on the population transferred for maternal and maternal-fetal combined indications only (279) yielded a specificity of 90.4% and sensitivity of 23.8% (p = 0.024).

CONCLUSION

OBCMI was demonstrated to discriminate for SMM in a population of obstetrics transfers to a Level IV maternal care facility. When stratifying for maternal indicated transfers, the ability of OBCMI as a predictive tool decreased. The obtained cutoff OBCMI value of ≥ 4 had high specificity but may miss a significant population that would benefit from transfer. Use of the OBCMI may be too crude of a measure to provide a comprehensive risk assessment to predict SMM and adverse obstetrics outcomes. Further studies that may include newer tools such as machine learning may be necessary to develop a more clinically useful tool.

Development and Validation of a Predictive Model for Maternal Cardiovascular Morbidity Events in Patients With Hypertensive Disorders of Pregnancy

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are a major contributor to maternal morbidity, mortality, and accelerated cardiovascular (CV) disease. Comorbid conditions are likely important predictors of CV risk in pregnant people. Currently, there is no way to predict which people with HDP are at risk of acute CV complications. We developed and validated a predictive model for all CV events and for heart failure, renal failure, and cerebrovascular events specifically after HDP.

METHODS

Models were created using the Premier Healthcare Database. The inclusion criteria for the model dataset were delivery with an HDP with discharge from October 1, 2015 to December 31, 2020. Machine learning methods were used to derive predictive models of CV events occurring during delivery hospitalization (Index Model) or during readmission (Readmission Model) using a training set (60%) to estimate model parameters, a validation set (20%) to tune model hyperparameters and select a final model, and a test set (20%) to evaluate final model performance.

RESULTS

The total model cohort consisted of 553,658 deliveries with an HDP. A CV event occurred in 6501 (1.2%) of the delivery hospitalizations. Multilabel neural networks were selected for the Index Model and Readmission Model due to favorable performance compared to alternatives. This approach is designed for prediction of multiple events that share risk factors and may cooccur. The Index Model predicted all CV events with area under the receiver operating curve (AUROC) 0.878 and average precision (AP) 0.239 (cerebrovascular events: AUROC 0.941, heart failure: AUROC 0.898, and renal failure: AUROC 0.885). With a positivity threshold set to achieve ≥90% sensitivity, model specificity was 65.0%, 83.5%, 68.6%, and 65.6% for predicting all CV events, cerebrovascular events, heart failure, and renal failure, respectively. CV events within 1 year of delivery occurred in 3018 (0.6%) individuals. The Readmission Model predicted all CV events with AUROC 0.717 and AP 0.022 (renal failure: AUROC 0.748, heart failure: AUROC 0.734, and cerebrovascular events AUROC 0.698). Feature importance analysis indicated that the presence of chronic renal disease, cardiac disease, pulmonary hypertension, and preeclampsia with severe features had the greatest effect on the prediction of CV events.

CONCLUSIONS

Among individuals with HDP, our multilabel neural network model predicted CV events at delivery admission with good classification and events within 1 year of delivery with fair classification.

Incidence of pregnancy related pulmonary embolism in Spain 2016-2021: an observational population-based retrospective study

OBJECTIVE

This study aimed to estimate the overall and annual age-standardized incidence of pregnancy-related pulmonary embolism (PE) in Spain from 2016 to 2021, explore the distribution of PE events during pregnancy and the postpartum period, identify potential risk factors, and estimate mortality rates during hospital admission.

METHODS

In a retrospective, observational, population-based study, data from the Spanish National Hospital Discharge Database were analyzed to identify women with hospital episodes of pregnancy-related-PE. The primary outcome was the overall and annual age-standardized incidence of pregnancy-related-PE, with secondary aims including the distribution of events during pregnancy and postpartum and the calculation of age-standardized mortality rates during admission.

RESULTS

Among 2,178,805 births from 2016 to 2021, 522 women were diagnosed with pregnancy-related PE, yielding an overall age-standardized incidence of 2.83 cases per 10,000 births. A non-significant increasing trend was observed from 2.43 to 4.18 cases per 10,000 births (p = 0.06). Comorbidities were low, with a notable association between PE and SARS-CoV-2 infection during the last two years. The mortality rate among women with pregnancy-related PE was 2.8%, with a higher incidence of PE reported during the postpartum period.

CONCLUSION

The incidence of pregnancy-related-PE in Spain exhibits a non-significant increasing trend, with a significant risk of mortality. The association with SARS-CoV-2 infection underscores the importance of vigilant monitoring and management of pregnant women, particularly during pandemics. This study contributes specific data on the incidence and characteristics of pregnancy-related-PE in Spain, emphasizing the need to consider PE in the differential diagnosis and management strategies for pregnant and postpartum women.

Impact of the 2017 revised Japanese obstetric hemorrhage management guidelines on tranexamic acid use in patients undergoing cesarean delivery: an interrupted time series analysis

BACKGROUND

Tranexamic acid is one component of a complex management algorithm for postpartum hemorrhage. In Japan, the 2010 obstetric hemorrhage management guidelines was revised in 2017, adding the recommendation for the administration of tranexamic acid for postpartum hemorrhage. This research aims to delineate the temporal trends in tranexamic acid administration in patients undergoing cesarean deliveries and to examine the impact of the obstetric hemorrhage management guidelines implementation.

METHODS

An interrupted time series analysis was conducted on data from patients who underwent cesarean deliveries from April 2012 to August 2021, sourced from Japan's nationwide health insurance claims database. We examined the trends of tranexamic acid usage and blood transfusion use before and after the implementation of the revised guidelines in 2017.

RESULTS

The study cohort comprised 91 166 cesarean deliveries. Prior to the guideline implementation, the rate of tranexamic acid usage decreased. Post-guidelines implementation, there was a statistically significant increase in the rate of tranexamic acid use, with a quarterly percentage change of 0.48% (95% confidence interval: 0.36 to 0.60; P < 0.001). The guidelines implementation in 2017 was not significantly associated with a change in the rate of transfusions.

CONCLUSIONS

This interrupted time series analysis demonstrated a significant increase in the rate of tranexamic acid administration following the implementation of the revised guidelines, reversing the previously observed downward trend. Our findings could reflect the impact of the revised guideline on the use of tranexamic acid for postpartum hemorrhage, but this did not translate to fewer blood transfusions.

Accelerating adverse pregnancy outcomes research amidst rising medication use: parallel retrospective cohort analyses for signal prioritization

BACKGROUND

Pregnant women are significantly underrepresented in clinical trials, yet most of them take medication during pregnancy despite the limited safety data. The objective of this study was to characterize medication use during pregnancy and apply propensity score matching method at scale on patient records to accelerate and prioritize the drug effect signal detection associated with the risk of preterm birth and other adverse pregnancy outcomes.

METHODS

This was a retrospective study on continuously enrolled women who delivered live births between 2013/01/01 and 2022/12/31 (n = 365,075) at Providence St. Joseph Health. Our exposures of interest were all outpatient medications prescribed during pregnancy. We limited our analyses to medication that met the minimal sample size (n = 600). The primary outcome of interest was preterm birth. Secondary outcomes of interest were small for gestational age and low birth weight. We used propensity score matching at scale to evaluate the risk of these adverse pregnancy outcomes associated with drug exposure after adjusting for demographics, pregnancy characteristics, and comorbidities.

RESULTS

The total medication prescription rate increased from 58.5 to 75.3% (P < 0.0001) from 2013 to 2022. The prevalence rate of preterm birth was 7.7%. One hundred seventy-five out of 1329 prenatally prescribed outpatient medications met the minimum sample size. We identified 58 medications statistically significantly associated with the risk of preterm birth (P ≤ 0.1; decreased: 12, increased: 46).

CONCLUSIONS

Most pregnant women are prescribed medication during pregnancy. This highlights the need to utilize existing real-world data to enhance our knowledge of the safety of medications in pregnancy. We narrowed down from 1329 to 58 medications that showed statistically significant association with the risk of preterm birth even after addressing numerous covariates through propensity score matching. This data-driven approach demonstrated that multiple testable hypotheses in pregnancy pharmacology can be prioritized at scale and lays the foundation for application in other pregnancy outcomes.

Emergency Care Use During Pregnancy and Severe Maternal Morbidity

Importance

Pregnant individuals who repeatedly use emergency care during pregnancy represent a population who could be disproportionately vulnerable to harm, including severe maternal morbidity (SMM).

Objective

To explore patterns of unscheduled care visits during pregnancy and ascertain its association with SMM at the time of birth.

Design, Setting, and Participants

This cohort study used data from a statewide database that linked hospital records to births and fetal deaths occurring between October 1, 2002, and March 31, 2020, in Massachusetts. Pregnant individuals experiencing births or fetal deaths during the study period were included. Data analysis was conducted from June 2022 to September 2024.

Exposure

The exposure was 4 or more cases of emergency use, defined as either an emergency department visit or observational stay during pregnancy not resulting in hospital admission. Pregnancy episode was ascertained by subtracting the gestational age at birth from the date of birth.

Main Outcomes and Measures

The outcome of interest was the odds ratio (OR) for SMM at the time of birth. The algorithm includes 20 conditions or procedures (excluding transfusion) identified through International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes across the study period.

Results

A total of 774 092 pregnant individuals (mean [SD] age, 31.2 [5.8] years; 16.8% Hispanic, 9.3% non-Hispanic Asian or Pacific Islander, 9.5% non-Hispanic Black, 63.1% non-Hispanic White) with emergency care visits during the pregnancy were included; 31.3% of these individuals had at least 1 visit. Overall, 18.1% had 1 visit and 3.3% had 4 or more visits. Four or more unscheduled visits were common among those younger than age 25 years (8.7%), with Hispanic (5.7%) or non-Hispanic Black (4.9%) race and ethnicity, with public insurance (6.5%), or with a comorbidity (19.0%) or an opioid use-related hospitalization (26.8%) in the year prior to pregnancy. Of those with 4 or more unscheduled visits, 43.8% visited more than 1 hospital during pregnancy. In a multivariable analysis of the likelihood of SMM, those with 4 or more unscheduled visits had an adjusted OR of 1.46 (95% CI, 1.29-1.66) compared with those with 0 visits.

Conclusions and Relevance

This cohort study found that high emergency care use during pregnancy was associated with an increased risk for SMM. With a significant proportion of those with frequent unscheduled visits also using multiple hospitals, solutions that are community-based and integrated across health systems may be most beneficial.

Infection and Sepsis Trends during United States' Delivery Hospitalizations from 2000 to 2020

OBJECTIVE

 This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States.

STUDY DESIGN

 The 2000-2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association.

RESULTS

 An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection.

CONCLUSION

 Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity.

KEY POINTS

· Sepsis increased over the study period for deliveries with and without chronic condition diagnoses.. · Endometritis and wound infection decreased over the study period.. · Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes..

Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores

OBJECTIVE

 Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity.

STUDY DESIGN

 Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to "low-risk" term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots.

RESULTS

 A total of 14,497 maternal-neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated.

CONCLUSION

 A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries.

KEY POINTS

· EOCS had moderate discrimination for Apgar <7.. · Predictive performance declined when limited to low-risk term singletons.. · Relationship between EOCS and Apgar <7 was likely driven by prematurity..

Tools used to measure the impact of comorbidities on surgical outcomes in children with complex chronic conditions: A scoping review

AIM

To identify and describe assessment tools used to measure the impact of comorbidities on postoperative outcomes in children with complex chronic conditions (CCC).

METHOD

This was a scoping review using five electronic databases. The search was conducted in March 2022 by a medical librarian. There were no date or language restrictions. Included studies were full-text articles published in peer-reviewed journals that described a tool used to measure the impact of comorbidities in children with CCC to assess postoperative outcomes. A standardized data charting tool was used.

RESULTS

A total of 2157 articles were retrieved. Five studies reporting on six comorbidity measures met inclusion criteria. All were cohort studies and were secondary analyses of data from an administrative database (n = 4) or a patient registry (n = 1). Sample sizes ranged from 645 to 25 747 participants. One paper described the assessment of reliability. Only one form of validity - predictive validity - was assessed in three papers for five measures.

INTERPRETATION

Findings from this scoping review revealed a paucity of comorbidity assessment tools validated for use with children with CCC; significant conceptual and measurement challenges exist in the current scientific literature.

WHAT THIS PAPER ADDS

Five studies used formal risk assessment approaches to evaluate postoperative outcomes in children with complex chronic conditions. Conceptual and methodological differences between comorbidity indexes and risk prediction models are explicated. Further development of prediction science is needed for determining postoperative outcomes. Enhanced preoperative comorbidity assessment will identify children at risk of poor outcomes.

External validation and comparison of four prediction scores for severe maternal morbidity

BACKGROUND

Severe maternal morbidity (SMM) is increasing in the United States. Several tools and scores exist to stratify an individual's risk of SMM.

OBJECTIVE

We sought to examine and compare the validity of four scoring systems for predicting SMM.

STUDY DESIGN

This was a retrospective cohort study of all individuals in the Consortium on Safe Labor dataset, which was conducted from 2002 to 2008. Individuals were excluded if they had missing information on risk factors. SMM was defined based on the Centers for Disease Control and Prevention excluding blood transfusion. Blood transfusion was excluded due to concerns regarding the specificity of International Classification of Diseases codes for this indicator and its variable clinical significance. Risk scores were calculated for each participant using the Assessment of Perinatal Excellence (APEX), California Maternal Quality Care Collaborative (CMQCC), Obstetric Comorbidity Index (OB-CMI), and modified OB-CMI. We calculated the probability of SMM according to the risk scores. The discriminative performance of the prediction score was examined by the areas under receiver operating characteristic curves and their 95% confidence intervals (95% CI). The area under the curve for each score was compared using the bootstrap resampling. Calibration plots were developed for each score to examine the goodness-of-fit. The concordance probability method was used to define an optimal cutoff point for the best-performing score.

RESULTS

Of 153, 463 individuals, 1115 (0.7%) had SMM. The CMQCC scoring system had a significantly higher area under the curve (95% CI) (0.78 [0.77-0.80]) compared to the APEX scoring system, OB-CMI, and modified OB-CMI scoring systems (0.75 [0.73-0.76], 0.67 [0.65-0.68], 0.66 [0.70-0.73]; P<.001). Calibration plots showed excellent concordance between the predicted and actual SMM for the APEX scoring system and OB-CMI (both Hosmer-Lemeshow test P values=1.00, suggesting goodness-of-fit).

CONCLUSION

This study validated four risk-scoring systems to predict SMM. Both CMQCC and APEX scoring systems had good discrimination to predict SMM. The APEX score and the OB-CMI had goodness-of-fit. At ideal calculated cut-off points, the APEX score had the highest sensitivity of the four scores at 71%, indicating that better scoring systems are still needed for predicting SMM.

Temporal Trend in Maternal Morbidity and Comorbidity

OBJECTIVE

 This study aimed to examine the temporal trends of severe maternal morbidity (SMM) in the U.S. population in relation to trends in maternal comorbidity.

STUDY DESIGN

 We performed a repeated cross-sectional analysis of data from individuals at 20 weeks' gestation or greater using U.S. birth certificate data from 2011 to 2021. Our primary outcome was SMM defined as the occurrence of intensive care unit admission, eclampsia, hysterectomy, uterine rupture, and blood product transfusion. We also examined the proportions of maternal comorbidity. Outcomes of the adjusted incidence rate ratio (IRR) with 99% confidence intervals (99% CIs) for 2021 m12 compared with 2011 m1 were calculated using negative binomial regression, controlling for predefined confounders.

RESULTS

 There were 42,504,125 births included in the analysis. From 2011 m1 to 2021 m12, there was a significant increase in the prevalence of advanced maternal age (35-39 [45%], 40-44 [29%], and ≥45 [43%] years), morbid obesity (body mass index 40-49.9 [66%], 50-59.9 [91%], and 60-69.9 [98%]), previous cesarean delivery (14%), chronic hypertension (104%), pregestational diabetes (64%), pregnancy-associated hypertension (240%), gestational diabetes (74%), and preterm delivery at 34 to 36 weeks (12%). There was a significant decrease in the incidence of multiple gestation (9%), preterm delivery at 22 to 27 weeks (9%), and preterm delivery at 20 to 21 weeks (22%). From 2011 m1 to 2021 m12, the incidence of SMM increased from 0.7 to 1.0% (crude IRR 1.60 [99% CI 1.54-1.66]). However, the trend was no longer statistically significant after controlling for confounders (adjusted IRR 1.01 [95% CI 0.81-1.27]). The main comorbidity that was associated with the increase in SMM was pregnancy-associated hypertension.

CONCLUSION

 The rise in the prevalence of comorbidity in pregnancy seems to fuel the rise in SMM. Interventions to prevent SMM should include the management and prevention of pregnancy-associated hypertension.

KEY POINTS

· The rise in maternal mortality is related to morbidity.. · Pregnancy-associated hypertension increases morbidity.. · There were increasing trends in age, body mass index, and medical conditions..

Comparative Safety of In Utero Exposure to Buprenorphine Combined With Naloxone vs Buprenorphine Alone

Importance

Buprenorphine combined with naloxone is commonly used to treat opioid use disorders outside of pregnancy. In pregnancy, buprenorphine alone is generally recommended because of limited perinatal safety data on the combination product.

Objective

To compare perinatal outcomes following prenatal exposure to buprenorphine with naloxone vs buprenorphine alone.

Design, Settings, and Participants

Population-based cohort study using health care utilization data from Medicaid-insured beneficiaries in the US from 2000 to 2018. The cohort was restricted to pregnant individuals linked to their liveborn infants, with maternal Medicaid enrollment from 3 months before pregnancy to 1 month after delivery and infant enrollment for the first 3 months after birth, unless they died sooner.

Exposure

Use of buprenorphine with naloxone vs buprenorphine alone during the first trimester based on outpatient dispensings.

Main Outcomes and Measures

Outcomes included major congenital malformations, low birth weight, neonatal abstinence syndrome, neonatal intensive care unit admission, preterm birth, respiratory symptoms, small for gestational age, cesarean delivery, and maternal morbidity. Confounder-adjusted risk ratios were calculated using propensity score overlap weights.

Results

This study identified 3369 pregnant individuals exposed to buprenorphine with naloxone during the first trimester (mean [SD] age, 28.8 [4.6] years) and 5326 exposed to buprenorphine alone or who switched from the combination to buprenorphine alone by the end of the first trimester (mean [SD] age, 28.3 [4.5] years). When comparing buprenorphine combined with naloxone with buprenorphine alone, a lower risk for neonatal abstinence syndrome (absolute risk, 37.4% vs 55.8%; weighted relative risk, 0.77 [95% CI, 0.70-0.84]) and a modestly lower risk for neonatal intensive care unit admission (absolute risk, 30.6% vs 34.9%; weighted relative risk, 0.91 [95% CI, 0.85-0.98]) and small for gestational age (absolute risk, 10.0% vs 12.4%; weighted relative risk, 0.86 [95% CI, 0.75-0.98]) was observed. For maternal morbidity, the comparative rates were 2.6% vs 2.9%, respectively, and the weighted relative risk was 0.90 (95% CI, 0.68-1.19). No differences were observed with respect to major congenital malformations overall, low birth weight, preterm birth, respiratory symptoms, or cesarean delivery. Results were consistent across sensitivity analyses.

Conclusions and Relevance

There were similar and, in some instances, more favorable neonatal and maternal outcomes for pregnancies exposed to buprenorphine combined with naloxone compared with buprenorphine alone. For the outcomes assessed, compared with buprenorphine alone, buprenorphine with naloxone during pregnancy appears to be a safe treatment option. This supports the view that both formulations are reasonable options for the treatment of opioid use disorder in pregnancy, affirming flexibility in collaborative treatment decision-making.

Preconception HbA1c Levels in Adolescents and Young Adults and Adverse Birth Outcomes

Importance

Subclinical hyperglycemia before pregnancy may be associated with the likelihood of maternal morbidity but is understudied among young people.

Objective

To explore the association of preconception hemoglobin A1c (HbA1c) levels among adolescents and young adults with risk of gestational diabetes at first live birth.

Design, Setting, and Participants

This retrospective cohort study used linked 2009 to 2017 birth registry, hospital discharge, and New York City Department of Health A1C Registry data for birthing individuals aged 10 to 24 years with no history of diabetes and at least 1 preconception HbA1c test in New York, New York. Statistical analysis was performed from August to November 2022.

Exposure

Preconception HbA1c values categorized as no diabetes (HbA1c <5.7%) or prediabetes (HbA1c ≥5.7% to <6.5%).

Main Outcomes and Measures

The primary outcome was gestational diabetes at first birth. Secondary outcomes included hypertensive disorders of pregnancy, preterm birth, cesarean delivery, and macrosomia. Log binomial regression was used to estimate the relative risk (RR) of gestational diabetes at first birth by preconception HbA1c level, adjusting for prepregnancy characteristics. The optimal HbA1c threshold for gestational diabetes was examined using receiver operating curve regression.

Results

A total of 14 302 individuals (mean [SD] age, 22.10 [1.55] years) met study eligibility criteria. Of these, 5896 (41.0%) were Hispanic, 4149 (29.0%) were Black, 2583 (18.1%) were White, 1516 (10.6%) were Asian, and 185 (1.3%) had other or unknown race and ethnicity. Most (11 407 individuals [79.7%]) had normoglycemia before pregnancy, and 2895 individuals (20.2%) had prediabetes. Adjusting for prepregnancy characteristics, those with preconception prediabetes had more than twice the risk of gestational diabetes vs those with normoglycemia (adjusted RR [aRR], 2.21; 95% CI, 1.91-2.56). Preconception prediabetes was associated with small increases in the likelihood of a hypertensive disorder of pregnancy (aRR, 1.18; 95% CI, 1.03-1.35) and preterm delivery (aRR, 1.18; 95% CI, 1.02-1.37). The aRRs for cesarean delivery (aRR, 1.09; 95% CI, 0.99-1.20) and macrosomia (aRR, 1.13; 95% CI, 0.93-1.37) were increased but not statistically significant. The optimal HbA1c threshold to identify gestational diabetes among adolescents and young adults was 5.6%. The threshold did not vary by obesity status but was slightly lower among Hispanic individuals (HbA1c of 5.5%).

Conclusions and Relevance

In this study of adolescents and young adults with at least 1 preconception HbA1c test, prediabetes was associated with increased likelihood of maternal cardiometabolic morbidity at first birth. Efforts to optimize cardiometabolic health before pregnancy may avert excess maternal risk.

Uses of antiseizure medication among pregnant women with epilepsy and risk of adverse obstetric outcomes: A group-based trajectory analysis

OBJECTIVE

This study was undertaken to examine the association between different patterns of antiseizure medication (ASM) use during pregnancy and adverse obstetric outcomes (preterm birth, low birth weight [LBW], and small for gestational age [SGA]).

METHODS

This retrospective cohort study used the Birth Certificate Application and National Health Insurance data in Taiwan (January 1, 2004 through December 31, 2018). We retrieved weekly ASM among pregnant women with epilepsy who were prepregnancy chronic users and used group-based trajectory modeling to identify distinct patterns of use. Logistic regressions were adopted to examine the association between patterns of ASM use and risk of preterm birth, LBW, and SGA. In addition, we revealed postnatal ASM utilization pattern among these prepregnancy chronic users as an exploratory study.

RESULTS

Of 2175 pregnant women with epilepsy, we identified four patterns of ASM use during pregnancy: frequent and continuous (64.87%), frequent but discontinuous (7.08%), intermittent (19.72%), and intermittent and discontinuous users (8.32%). Compared to frequent and continuous users, the adjusted odds ratios for preterm birth in frequent but discontinuous, intermittent, and intermittent and discontinuous users were .83 (95% confidence interval [CI] = .47-1.48), .71 (95% CI = .47-1.05), and .88 (95% CI = .52-1.49), respectively. Similar results were observed for LBW and SGA. In the exploratory study, we found that most of our study subjects maintained the same patterns before and after delivery.

SIGNIFICANCE

After considering duration and timing of exposure, our study did not find an association between four distinct patterns of ASM use and adverse obstetric outcomes among women with epilepsy. The findings suggested that optimal seizure control could be received for pregnant women with epilepsy after evaluating the risks and benefits.

Racial/ethnic differences in pre-pregnancy conditions and adverse maternal outcomes in the nuMoM2b cohort: A population-based cohort study

OBJECTIVES

To determine how pre-existing conditions contribute to racial disparities in adverse maternal outcomes and incorporate these conditions into models to improve risk prediction for racial minority subgroups.

STUDY DESIGN

We used data from the "Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b)" observational cohort study. We defined multimorbidity as the co-occurrence of two or more pre-pregnancy conditions. The primary outcomes of interest were severe preeclampsia, postpartum readmission, and blood transfusion during pregnancy or up to 14 days postpartum. We used weighted Poisson regression with robust variance to estimate adjusted risk ratios and 95% confidence intervals, and we used mediation analysis to evaluate the contribution of the combined effects of pre-pregnancy conditions to racial/ethnic disparities. We also evaluated the predictive performance of our regression models by racial subgroup using the area under the receiver operating characteristic curve (AUC) metric.

RESULTS

In the nuMoM2b cohort (n = 8729), accounting for pre-existing conditions attenuated the association between non-Hispanic Black race/ethnicity and risk of severe preeclampsia. Cardiovascular and kidney conditions were associated with risk for severe preeclampsia among all women (aRR, 1.77; CI, 1.61-1.96, and aRR, 1.27; CI, 1.03-1.56 respectively). The mediation analysis results were not statistically significant; however, cardiovascular conditions explained 36.6% of the association between non-Hispanic Black race/ethnicity and severe preeclampsia (p = 0.07). The addition of pre-pregnancy conditions increased model performance for the prediction of severe preeclampsia.

CONCLUSIONS

Pre-existing conditions may explain some of the association between non-Hispanic Black race/ethnicity and severe preeclampsia. Specific pre-pregnancy conditions were associated with adverse maternal outcomes and the incorporation of comorbidities improved the performance of most risk prediction models.

Predictors and a scoring model for maternal near-miss and maternal death in Southern Thailand: a case-control study

PURPOSE

To identify predictors and develop a scoring model to predict maternal near-miss (MNM) and maternal mortality.

METHODS

A case-control study of 1,420 women delivered between 2014 and 2020 was conducted. Cases were women with MNM or maternal death, controls were women who had uneventful deliveries directly after women in the cases group. Antenatal characteristics and complications were reviewed. Multivariate logistic regression and Akaike information criterion were used to identify predictors and develop a risk score for MNM and maternal mortality.

RESULTS

Predictors for MNM and maternal mortality (aOR and score for predictive model) were advanced age (aOR 1.73, 95% CI 1.25-2.39, 1), obesity (aOR 2.03, 95% CI 1.22-3.39, 1), parity ≥ 3 (aOR 1.75, 95% CI 1.27-2.41, 1), history of uterine curettage (aOR 5.13, 95% CI 2.47-10.66, 3), history of postpartum hemorrhage (PPH) (aOR 13.55, 95% CI 1.40-130.99, 5), anemia (aOR 5.53, 95% CI 3.65-8.38, 3), pregestational diabetes (aOR 5.29, 95% CI 1.27-21.99, 3), heart disease (aOR 13.40, 95%CI 4.42-40.61, 5), multiple pregnancy (aOR 5.57, 95% CI 2.00-15.50, 3), placenta previa and/or placenta-accreta spectrum (aOR 48.19, 95% CI 22.75-102.09, 8), gestational hypertension/preeclampsia without severe features (aOR 5.95, 95% CI 2.64-13.45, 4), and with severe features (aOR 16.64, 95% CI 9.17-30.19, 6), preterm delivery <37 weeks (aOR 1.65, 95%CI 1.06-2.58, 1) and < 34 weeks (aOR 2.71, 95% CI 1.59-4.62, 2). A cut-off score of ≥4 gave the highest chance of correctly classified women into high risk group with 74.4% sensitivity and 90.4% specificity.

CONCLUSIONS

We identified predictors and proposed a scoring model to predict MNM and maternal mortality with acceptable predictive performance.

Postpartum Access to Health Care and Opioid Use Treatment: An Evaluation of a Medicaid Population

Background

In this study, we aimed to examine postpartum health care utilization and identify gaps in care among a postpartum Medicaid population of patients diagnosed with opioid use disorder (OUD) during pregnancy.

Methods

We queried North Carolina Medicaid medical and pharmacy claims to identify individuals with a live delivery and evidence of OUD during pregnancy from 2015 to 2019. We examined any evidence of postpartum health care utilization and evidence of medications for OUD (MOUD) during postpartum. We also determined the impact that 4 factors may have had on these outcomes: type of Medicaid coverage (Medicaid for Pregnant Women as compared to other types of Medicaid coverage), rurality, race, and the prenatal use of MOUD. Descriptive statistics, Kaplan-Meier curves with log-rank tests, and negative binomial regression were used.

Results

Of the 6,186 individuals in the study, 84.5% were White, 29.6% lived in rural areas, and 35.0% had MPW coverage. Of the sample, 77.4% sought health care services during the postpartum period. In the multiple negative binomial regression model, individuals who were MPW beneficiaries, non-White, lived in rural areas, and had no evidence of prenatal MOUD all had significantly lower rates of postpartum health care utilization. Of the sample, 53.6% had evidence of MOUD utilization during the postpartum period. We found that patients with MPW continued MOUD at much lower rates compared to patients with other forms of Medicaid (86% versus 93% at 60 days; 57% versus 78% at 180 days, respectively).

Limitations

Limitations to this analysis are inherent to administrative claims data, such as misclassification of outcomes and covariates, as well as loss to follow-up.

Conclusions

Significant gaps in health care use remain across type of Medicaid coverage, race, geographic setting, and prenatal care access.

Perinatal Psychotherapy Use and Costs Before and After Federally Mandated Health Insurance Coverage

Importance

Insurance coverage affects health care access for many delivering women diagnosed with perinatal mood and anxiety disorders (PMADs). The Mental Health Parity and Addiction Equity Act (MHPAEA; passed in 2008) and the Patient Protection and Affordable Care Act (ACA; passed in 2010) aimed to improve health care access.

Objective

To assess associations between MHPAEA and ACA implementation and psychotherapy use and costs among delivering women overall and with PMADs.

Design, Setting, and Participants

This cross-sectional study conducted interrupted time series analyses of private insurance data from January 1, 2007, to December 31, 2019, for delivering women aged 15 to 44 years, including those with PMADs, to assess changes in psychotherapy visits in the year before and the year after delivery. It estimated changes in any psychotherapy use and per-visit out-of-pocket costs (OOPCs) for psychotherapy associated with MHPAEA (January 2010) and ACA (January 2014) implementation. Data analyses were performed from August 2022 to May 2023.

Exposures

Implementation of the MHPAEA and ACA.

Main Outcomes and Measures

Any psychotherapy use and per-visit OOPCs for psychotherapy standardized to 2019 dollars.

Results

The study included 837 316 overall deliveries among 716 052 women (mean [SD] age, 31.2 [5.4] years; 7.6% Asian, 8.8% Black, 12.8% Hispanic, 64.1% White, and 6.7% unknown race and ethnicity). In the overall cohort, a nonsignificant step change was found in the delivering women who received psychotherapy after MHPAEA implementation of 0.09% (95% CI, -0.04% to 0.21%; P = .16) and a nonsignificant slope change of delivering women who received psychotherapy of 0.00% per month (95% CI, -0.02% to 0.01%; P = .69). A nonsignificant step change was found in delivering individuals who received psychotherapy after ACA implementation of 0.11% (95% CI, -0.01% to 0.22%; P = .07) and a significantly increased slope change of delivering individuals who received psychotherapy of 0.03% per month (95% CI, 0.00% to 0.05%; P = .02). Among those with PMADs, the MHPAEA was associated with an immediate increase (0.72%; 95% CI, 0.26% to 1.18%; P = .002) then sustained decrease (-0.05%; -0.09% to -0.02%; P = .001) in psychotherapy receipt; the ACA was associated with immediate (0.77%; 95% CI, 0.26% to 1.27%; P = .003) and sustained (0.07%; 95% CI, 0.02% to 0.12%; P = .005) monthly increases. In both populations, per-visit monthly psychotherapy OOPCs decreased (-$0.15; 95% CI, -$0.24 to -$0.07; P < .001 for overall and -$0.22; -$0.32 to -$0.12; P < .001 for the PMAD population) after MHPAEA passage with an immediate increase ($3.14 [95% CI, $1.56-$4.73]; P < .001 and $2.54 [95% CI, $0.54-$4.54]; P = .01) and steady monthly increase ($0.07 [95% CI, $0.02-$0.12]; P = .006 and $0.10 [95% CI, $0.03-$0.17]; P = .004) after ACA passage.

Conclusions and Relevance

This study found complementary and complex associations between passage of the MHPAEA and ACA and access to psychotherapy among delivering individuals. These findings indicate the value of continuing efforts to improve access to mental health treatment for this population.

Concomitant use of antidepressants and benzodiazepines during pregnancy and associated risk of congenital malformations: a population-based cohort study in Taiwan

BACKGROUND

Despite the frequent co-administration of antidepressants and benzodiazepines, the association between such concomitant use during pregnancy and the risk of congenital malformations remains inadequately explored. This study aims to examine the association between concomitant use of antidepressants and benzodiazepines during the first trimester and organ-specific congenital malformations.

METHODS

We conducted a population-based cohort study using Taiwan's National Birth Certificate Application database, the Maternal and Child Health database, and Taiwan's National Health Insurance database. Pregnant people aged 15-50 years with singleton births between Jan 1, 2004, and Dec 31, 2018, were included. Use of antidepressants and benzodiazepines was defined as at least one prescription during the first trimester, and concomitant use was defined as the overlapping prescription of both drugs with an overlapping prescription period. The primary outcomes were overall congenital malformations and eight organ-specific malformations, consisting of the nervous system, heart, respiratory system, oral cleft, digestive system, urinary system, genital system, and limb malformations. Logistic regression models with propensity score fine stratification weighting approach were used to control for measured confounders. Analyses controlling for confounding by indication and sibling comparison analyses were done to address unmeasured confounders. No individuals with lived experience participated in the research or writing process.

FINDINGS

The cohort included 2 634 021 singleton pregnancies, and 8599 (0·3%) individuals were concomitant users of antidepressants and benzodiazepines during the first trimester (mean age at delivery was 31·8 years [SD 5·2] for pregnancies with exposure to antidepressants and benzodiazepines vs 30·7 years [SD 4·9] for pregnancies without exposure). All study participants were female, and information about ethnicity was not available. Absolute risk of overall malformations was 3·81 per 100 pregnancies with exposure, compared with 2·87 per 100 pregnancies without exposure. The propensity score-weighted odds ratios (weighted ORs) did not suggest an increased risk for overall malformations (weighted OR 1·10, 95% CI 0·94-1·28), heart defects (1·01, 0·83-1·23), or any of the other organ-specific malformations, except for digestive system malformations, for which the weighted OR remained statistically significant after adjustment (1·63, 1·06-2·51). The absence of an increased risk for overall congenital malformations associated with concomitant use of antidepressants and benzodiazepines was supported by the analyses controlling for confounding by indication and sibling-matched comparisons.

INTERPRETATION

The findings of this study suggest that the concomitant use of antidepressants and benzodiazepines during the first trimester is not associated with a substantial increase in risk for most malformation subtypes. However, considering other potential adverse effects of using both medications concomitantly, a thorough assessment of the risks and benefits is crucial for clinical decision making.

FUNDING

National Science and Technology Council.

The HOPE cohort: cohort profile and evaluation of selection bias

The HOPE cohort is a Danish nationwide cohort with ongoing follow-up, holding information on postpartum depression (PPD) symptoms and diagnoses on 170,218 childbirths (142,795 unique mothers). These data have been linked with extensive register data on health and socioeconomic information on the mothers, their partners, parents, and children. This cohort profile aimed to provide an overview of the data collection and content, describe characteristics, and evaluate potential selection bias. PPD screenings, using the Edinburgh Postnatal Depression Scale, were collected from 67 of the 98 Danish municipalities, covering the period January 2015 to December 2021. This data was linked with register data on PPD diagnoses (identified through medication prescriptions and hospital contacts) as well as background information. Cohort characteristics were compared to the source population, defined as all childbirths by women residing in Denmark during the same period (452,207 childbirths). Potential selection bias was evaluated by comparing odds ratios of five well-established associations between the cohort and the source population. The HOPE cohort holds information on 170,218 childbirths (38% of the source population) involving 142,795 unique mothers. The HOPE cohort only differed slightly from the source population on most characteristics examined, but larger differences were observed on specific characteristics with an underrepresentation of the youngest and oldest age groups, women with more than three children or twins/triplets, and women born outside Denmark. Similar associations were identified across the two populations within the five well-established associations. There was no indication of selection bias on the five examined associations, and the HOPE cohort is representative of the source population on important perinatal characteristics.

Disparities in postpartum readmission by patient- and hospital-level social risk factors in the United States: a retrospective multistate analysis, 2015-2020

BACKGROUND

Postpartum readmission is an area of focus for improving obstetric care and reducing costs. We examined disparities in all-cause 30-day postpartum readmission by patient- and hospital-level factors in the United States.

METHODS

We conducted a retrospective cohort study using 2015-2020 records from the State Inpatient Databases from four states. Generalized linear mixed models were constructed to estimate the effects of individual patient- and hospital-level factors on adjusted odds of 30-day readmission after controlling for confounders. Stratified analyses by delivery and anesthesia type (New York only) and interaction models were performed.

RESULTS

Black mothers were more likely than White mothers to be readmitted within 30-days postpartum (aOR 1.57, 95% CI 1.52 to 1.61). Mothers with public insurance had increased odds of readmission compared with those with private insurance (Medicare: aOR 2.13, 95% CI 1.95 to 2.32; Medicaid: aOR 1.14, 95% CI 1.11 to 1.17). Compared with mothers in the lowest income quartile, those in the highest quartile experienced a 14% lower odds of readmission (aOR 0.86, 95% CI 0.83 to 0.89). There were no significant associations between hospital-level characteristics and readmission. Black mothers were more likely to be readmitted regardless of delivery type and most combinations of delivery and anesthesia type. Black mothers from the highest income quartile were more likely to be readmitted than White mothers from the lowest income quartile.

CONCLUSION

Substantial disparities in 30-day postpartum readmissions by patient-level social factors were observed, particularly amongst Black mothers. Action is needed to address and mitigate disparities in postpartum readmission.

Perinatal and Postpartum Health Among People With Intellectual and Developmental Disabilities

Importance

Small, geographically limited studies report that people with intellectual and developmental disabilities (IDD) have increased risk for serious pregnancy-related and birth-related challenges, including preeclampsia, preterm birth, and increased anxiety and depression, than their peers. United States-based population-level data among people with IDD are lacking.

Objectives

To identify perinatal and postpartum outcomes among a national, longitudinal sample of people with IDD enrolled in public health insurance, compare subgroups of people with IDD, and compare outcomes among people with IDD with those of peers without IDD.

Design, Setting, and Participants

This retrospective cohort study used national Medicaid claims from January 1, 2008, to December 31, 2019, for 55 440 birthing people with IDD and a random sample of 438 557 birthing people without IDD. Medicaid funds almost half of all births and is the largest behavioral health insurer in the US, covering a robust array of services for people with IDD. Statistical analysis was performed from July 2023 to June 2024.

Exposure

People who had a documented birth in Medicaid during the study years.

Main Outcome and Measures

Perinatal outcomes were compared across groups using univariate and multivariate logistic regression. The probability of postpartum anxiety and depression was estimated using Kaplan-Meier and Cox proportional hazards regression.

Results

The study sample included 55 440 birthing people with IDD (including 41 854 with intellectual disabilities [ID] and 13 586 with autism; mean [SD] age at first delivery, 24.9 [6.7] years) and a random sample of 438 557 birthing people without IDD (mean [SD] age at first delivery, 26.4 [6.3] years). People with IDD were younger at first observed delivery, had a lower prevalence of live births (66.6% vs 76.7%), and higher rates of obstetric conditions (gestational diabetes, 10.3% vs 9.9%; gestational hypertension, 8.7% vs 6.1%; preeclampsia, 6.1% vs 4.4%) and co-occurring physical conditions (heart failure, 1.4% vs 0.4%; hyperlipidemia, 5.3% vs 1.7%; ischemic heart disease, 1.5% vs 0.4%; obesity, 16.3% vs 7.4%) and mental health conditions (anxiety disorders, 27.9% vs 6.5%; depressive disorders, 32.1% vs 7.5%; posttraumatic stress disorder, 9.5% vs 1.2%) than people without IDD. The probability of postpartum anxiety (adjusted hazard ratio [AHR], 3.2 [95% CI, 2.9-3.4]) and postpartum depression (AHR, 2.4 [95% CI, 2.3-2.6]) was significantly higher among autistic people compared with people with ID only and people without IDD.

Conclusions and Relevance

In this retrospective cohort study, people with IDD had a younger mean age at first delivery, had lower prevalence of live births, and had poor obstetric, mental health, and medical outcomes compared with people without IDD, pointing toward a need for clinician training and timely delivery of maternal health care. Results highlight needed reproductive health education, increasing clinician knowledge, and expanding Medicaid to ensure access to care for people with IDD.