Performance Characteristics of Sepsis Screening Tools During Antepartum and Postpartum Admissions

OBJECTIVE

To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions.

METHODS

This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion.

RESULTS

We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum.

CONCLUSION

For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.

Performance Characteristics of Sepsis Screening Tools During Delivery Admissions

OBJECTIVE

To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions.

METHODS

This was a case-control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis-endometritis, and cohort 2, which included those patients.

RESULTS

Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis-endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis-endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC.

CONCLUSION

During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis-endometritis.

Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates

BACKGROUND

Nationally, rates of cesarean delivery are highest among Black patients compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean delivery rates among Black patients were lower than average), indicating an opportunity to narrow the gap. Cesarean delivery rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate.

OBJECTIVE

This study aimed to explore reasons for the current large Black-White disparity in first-birth cesarean delivery rates by first examining the hospital-level variation in first-birth cesarean delivery rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean delivery rates among Black patients and compared them with hospitals with high rates. We sought to identify differences in facility or patient characteristics that could explain the racial disparity.

STUDY DESIGN

A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk and 95% confidence intervals for first-birth cesarean delivery comparing 2019 with 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals with first-birth cesarean delivery rates <23.9% for Black patients and hospitals with rates ≥23.9% for Black patients.

RESULTS

Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic, and White patients each were identified. Black patients had a very different distribution, with a significantly higher rate (28.4%) and wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<.01). A total of 29 hospitals with a low first-birth cesarean delivery rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared with 106 hospitals with higher rates. The low-rate group had a cesarean delivery rate of 19.9%, as opposed to 30.7% in the higher-rate group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, neonatal level of care, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, body mass index, hypertension, diabetes mellitus). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for White patients with a mean rate of 21.4%. In the same hospitals, the mean rate for Black patients was 29.5%. Among Black patients in the group that did not meet the 23.9% target, there were significantly higher rates of all cesarean delivery indications: labor dystocia, fetal concern (spontaneous labor), and no labor (eg, macrosomia), which are all indications with a high degree of subjectivity.

CONCLUSION

The statewide cesarean delivery rate of Black patients is significantly higher and has substantially greater hospital variation compared with other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean delivery rates among Black patients and those with high rates suggests that unconscious bias and structural racism potentially play important roles in creating these racial differences.

Improving the Rate of Delayed Cord Clamping in Preterm Infants: A Quality Improvement Project

OBJECTIVE

Delayed cord clamping (DCC) provides many benefits for preterm infants. The aim of this quality improvement project was to increase the rate of DCC by 25% within 12 months for neonates <34 weeks' gestation born at a tertiary care hospital.

METHOD

A multidisciplinary team investigated key drivers and developed targeted interventions to improve DCC rates. The primary outcome measure was the rate of DCC for infants <34 weeks' gestation. Process measures were adherence to the DCC protocol and the rate of births with an experienced neonatology provider present at the bedside. Balancing measures included the degree of neonatal resuscitation, initial infant temperature, and maternal blood loss. Data were collected from chart review and a perinatal research database and then analyzed on control charts. The preintervention period was from July 2019 to June 2020 and the postintervention period was from July 2020 to December 2021.

RESULTS

322 inborn neonates born at <34 weeks' met inclusion criteria (137 preintervention and 185 postintervention). The rate of DCC increased by 63%, from a baseline of 40% to 65% (P <.001), with sustained improvement over 18 months. Significant improvement occurred for all process measures without a significant change in balancing measures.

CONCLUSION

Using core quality improvement methodology, a multidisciplinary team implemented a series of targeted interventions which was associated with an increased rate of DCC in early preterm infants.

Data-driven longitudinal characterization of neonatal health and morbidity

Although prematurity is the single largest cause of death in children under 5 years of age, the current definition of prematurity, based on gestational age, lacks the precision needed for guiding care decisions. Here, we propose a longitudinal risk assessment for adverse neonatal outcomes in newborns based on a deep learning model that uses electronic health records (EHRs) to predict a wide range of outcomes over a period starting shortly before conception and ending months after birth. By linking the EHRs of the Lucile Packard Children's Hospital and the Stanford Healthcare Adult Hospital, we developed a cohort of 22,104 mother-newborn dyads delivered between 2014 and 2018. Maternal and newborn EHRs were extracted and used to train a multi-input multitask deep learning model, featuring a long short-term memory neural network, to predict 24 different neonatal outcomes. An additional cohort of 10,250 mother-newborn dyads delivered at the same Stanford Hospitals from 2019 to September 2020 was used to validate the model. Areas under the receiver operating characteristic curve at delivery exceeded 0.9 for 10 of the 24 neonatal outcomes considered and were between 0.8 and 0.9 for 7 additional outcomes. Moreover, comprehensive association analysis identified multiple known associations between various maternal and neonatal features and specific neonatal outcomes. This study used linked EHRs from more than 30,000 mother-newborn dyads and would serve as a resource for the investigation and prediction of neonatal outcomes. An interactive website is available for independent investigators to leverage this unique dataset: https://maternal-child-health-associations.shinyapps.io/shiny_app/.

Patient Decisions Regarding Fetal Monitoring in the Periviable Period and Perinatal and Maternal Outcomes

OBJECTIVE

Management of delivery at periviable gestation requires complex counseling and decision making, including difficult choices about monitoring and potential cesarean delivery (CD) for fetal benefit. Our objective was to characterize decisions that patients make regarding fetal monitoring and potential CD for fetal benefit when delivering in the periviable period, and associations with perinatal and obstetric outcomes. We hypothesize that a significant number of patients forgo monitoring and potential CD for fetal benefit in the periviable period when offered the opportunity to do so.

STUDY DESIGN

Retrospective cohort study of nonanomalous singleton pregnancies delivering between 23^0/7 and 25^6/7 weeks at a tertiary care center from 2015 to 2020 as based on our institutional clinical practice. Since 2015, these patients are offered the ability to accept or decline fetal monitoring, potential CD for fetal benefit, and active resuscitation of a liveborn neonate. The frequency of patients desiring potential CD for fetal benefit was identified, and associations with CD and intrapartum demise were analyzed.

RESULTS

Fifty subjects were included. Seventy-eight percent (n = 39) desired monitoring and potential CD for fetal benefit, and 84% (n = 42) desired resuscitation if the neonate was born alive. This varied by gestational age: 55% (6/11) of patients delivering between 23^0/7 and 23^6/7 weeks desired fetal monitoring and potential CD for fetal benefit, while 90% (19/21) of patients delivering between 25^0/7 and 25^6/7 weeks desired fetal monitoring and potential CD for fetal benefit (p = 0.02). Sixty-nine percent of pregnancies in which potential CD for fetal benefit was desired resulted in CD (27/39), of which 85% were classical (23/27). Intrapartum fetal demise occurred in 45% (5/11) of pregnancies in which monitoring was not performed.

CONCLUSION

While a majority of patients delivering between 23^0/7 and 25^6/7 weeks desired monitoring and potential CD for fetal benefit, this varied significantly by gestational age. The decision to perform monitoring and potential CD for fetal benefit was associated with a high frequency of CD, while the decision to forgo monitoring was associated with high frequency of intrapartum demise.

KEY POINTS

· Patients desires vary in the setting of periviable delivery.. · Periviable monitoring is associated with cesarean delivery.. · Forgoing monitoring is associated with intrapartum demise..

External cephalic version: Success rates with and without nitrous oxide

BACKGROUND

External cephalic version (ECV) is a technique used to reduce the incidence of cesarean deliveries due to malpresentation. Nitrous oxide is an inhaled analgesic that may be used for pain relief for women undergoing external cephalic version.

OBJECTIVE

To compare the conversion rate of non-cephalic to cephalic presentation in ECV with and without nitrous oxide.

STUDY DESIGN

A retrospective cohort analysis was performed including all singleton, term gestation ECVs between January 2016 and June 2017 at a single institution. Multivariable logistic regression was used to compare women who had ECV with nitrous oxide versus ECV without nitrous oxide. The primary outcome was successful rate of conversion to cephalic presentation and the secondary outcome was the rate of vaginal delivery.

RESULTS

During the study period, 167 women underwent ECV: 77 with nitrous oxide and 90 without nitrous oxide. Of the 77 women who used nitrous oxide, 25 (32.5%) were successful and 17 of these women delivered vaginally (68%). Of the women who underwent ECV without nitrous oxide, 29 (32.2%) successfully converted and 21 of these delivered vaginally (72%). After controlling for confounders, the use of nitrous oxide had no clinically or statistically significant difference on ECV success rates (OR 1.08, 95% CI 0.52-2.23).

CONCLUSION

Nitrous oxide does not seem to affect conversion rate to cephalic presentation in ECV. Further studies are needed to determine the impact of nitrous oxide on women's decision to undergo ECV and on patient satisfaction and tolerability.

Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California

IMPORTANCE

Safe reduction of the cesarean delivery rate is a national priority.

OBJECTIVE

To evaluate the rates of cesarean delivery for nulliparous, term, singleton, vertex (NTSV) births in California in the context of a statewide multifaceted intervention designed to reduce the rates of cesarean delivery.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of cesarean delivery rates from 2014 to 2019 among 7 574 889 NTSV births in the US and at 238 nonmilitary hospitals providing maternity services in California. From 2016 to 2019, California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019.

EXPOSURES

Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in cesarean delivery rates for NTSV births in California and a difference-in-differences analysis was performed to compare cesarean delivery rates for NTSV births in California vs the rates in the rest of the US. A mixed multivariable logistic regression model that adjusted for patient-level and hospital-level confounders also was used to assess the collaborative and the external statewide actions. The cesarean delivery rates for NTSV births at hospitals participating in the collaborative were compared with the rates from the nonparticipating hospitals and the rates in the participating hospitals prior to participation in the collaborative.

RESULTS

A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]).

CONCLUSIONS AND RELEVANCE

In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.

Is Preimplantation Genetic Testing Associated with Increased Risk of Abnormal Placentation After Frozen Embryo Transfer?

OBJECTIVE

This study aimed to assess the association of preimplantation genetic testing (PGT) with abnormal placentation among a cohort of pregnancies conceived after frozen embryo transfer (FET).

STUDY DESIGN

This is a retrospective cohort study of women who conceived via FET at the University of California, San Francisco from 2012 to 2016 with resultant delivery at the same institution. The primary outcome was abnormal placentation, including placenta accreta, retained placenta, abruption, placenta previa, vasa previa, marginal or velamentous cord insertion, circumvallate placenta, circummarginate placenta, placenta membranacea, bipartite placenta, and placenta succenturiata. Diagnosis was confirmed by reviewing imaging, delivery, and pathology reports. Our secondary outcome was hypertensive disease of pregnancy.

RESULTS

A total of 311 pregnancies were included in analysis; 158 (50.8%) underwent PGT. Baseline demographic characteristics were similar between groups except for age at conception and infertility diagnosis. Women with PGT were more likely to undergo single embryo transfer (82.3 vs. 64.1%, p < 0.001). There were no statistically significant differences in the rate of the primary outcome (26.6 vs. 27.4%, p = 0.86) or hypertensive disorders of pregnancy (33.5 vs. 33.3%, p = 0.97), which remained true after multivariate analysis was performed.

CONCLUSION

Among pregnancies conceived after FET, PGT is not associated with a statistically significant increased risk of abnormal placentation or hypertensive disorders of pregnancy.

KEY POINTS

· In pregnancies conceived by FET, PGT is not associated with increased risk of abnormal placentation.. · In pregnancies conceived by FET, PGT is not associated with increased risk of hypertensive disorders.. · Differences in outcomes of PGT pregnancies may be related to FET rather than trophectoderm biopsy..

Development and validation of a machine-learning model for prediction of shoulder dystocia

OBJECTIVES

To develop a machine-learning (ML) model for prediction of shoulder dystocia (ShD) and to externally validate the model's predictive accuracy and potential clinical efficacy in optimizing the use of Cesarean delivery in the context of suspected macrosomia.

METHODS

We used electronic health records (EHR) from the Sheba Medical Center in Israel to develop the model (derivation cohort) and EHR from the University of California San Francisco Medical Center to validate the model's accuracy and clinical efficacy (validation cohort). Subsequent to application of inclusion and exclusion criteria, the derivation cohort included 686 singleton vaginal deliveries, of which 131 were complicated by ShD, and the validation cohort included 2584 deliveries, of which 31 were complicated by ShD. For each of these deliveries, we collected maternal and neonatal delivery outcomes coupled with maternal demographics, obstetric clinical data and sonographic fetal biometry. Biometric measurements and their derived estimated fetal weight were adjusted (aEFW) according to gestational age at delivery. A ML pipeline was utilized to develop the model.

RESULTS

In the derivation cohort, the ML model provided significantly better prediction than did the current clinical paradigm based on fetal weight and maternal diabetes: using nested cross-validation, the area under the receiver-operating-characteristics curve (AUC) of the model was 0.793 ± 0.041, outperforming aEFW combined with diabetes (AUC = 0.745 ± 0.044, P = 1e^-16 ). The following risk modifiers had a positive beta that was > 0.02, i.e. they increased the risk of ShD: aEFW (beta = 0.164), pregestational diabetes (beta = 0.047), prior ShD (beta = 0.04), female fetal sex (beta = 0.04) and adjusted abdominal circumference (beta = 0.03). The following risk modifiers had a negative beta that was < -0.02, i.e. they were protective of ShD: adjusted biparietal diameter (beta = -0.08) and maternal height (beta = -0.03). In the validation cohort, the model outperformed aEFW combined with diabetes (AUC = 0.866 vs 0.784, P = 0.00007). Additionally, in the validation cohort, among the subgroup of 273 women carrying a fetus with aEFW ≥ 4000 g, the aEFW had no predictive power (AUC = 0.548), and the model performed significantly better (0.775, P = 0.0002). A risk-score threshold of 0.5 stratified 42.9% of deliveries to the high-risk group, which included 90.9% of ShD cases and all cases accompanied by maternal or newborn complications. A more specific threshold of 0.7 stratified only 27.5% of the deliveries to the high-risk group, which included 63.6% of ShD cases and all those accompanied by newborn complications.

CONCLUSION

We developed a ML model for prediction of ShD and, in a different cohort, externally validated its performance. The model predicted ShD better than did estimated fetal weight either alone or combined with maternal diabetes, and was able to stratify the risk of ShD and neonatal injury in the context of suspected macrosomia. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Implementation of Evidence-Based Cervical Ripening Protocol: Outcomes and Next Steps

Objective  A prominent randomized controlled trial demonstrated that low-dose misoprostol with the concurrent cervical Foley shortened the median time to delivery when compared with either method alone. Our study aims to address implementation of this protocol and evaluate its impact on time to delivery. Study Design  This was a retrospective before-and-after study of nulliparous women who delivered nonanomalous, term, singletons at the University of California San Francisco (UCSF) in two separate 2-year periods before and after changes in UCSF's cervical ripening protocol. The primary outcome was time from first misoprostol dose to delivery. Results  A total of 1,496 women met inclusion criteria, with 698 in the preimplementation group and 798 in the postimplementation group. There were no statistically significant differences in time to delivery (29 vs. 30 hours, p  = 0.69), rate of cesarean delivery (30 vs. 26%, p  = 0.09), or cesarean delivery for fetal indications (11 vs. 8%, p  = 0.15) between the groups. Conclusion  Implementing evidence-based low-dose misoprostol with the concurrent cervical Foley did not change the time to delivery, time to vaginal-delivery, or likelihood of vaginal delivery in our population. This may be due to differences in labor management practices and incomplete fidelity to the protocol. Real-world effectiveness of these interventions will vary and should be considered when choosing an induction method.

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism in the Third Trimester of Pregnancy

A 37-year-old woman presented with chest pain and shortness of breath in the third trimester of pregnancy. Diagnostic imaging demonstrated a saddle pulmonary embolism, severe impairment of right ventricular function, and an extensive deep venous thrombus. She underwent catheter-directed thrombolysis with tissue plasminogen activator and delivered a healthy infant at term. (Level of Difficulty: Intermediate.).

Does the 1-step method of gestational diabetes mellitus screening improve pregnancy outcomes?

BACKGROUND

Despite considerate debate, the best method of diagnosing gestational diabetes mellitus remains unknown. A commonly used method of gestational diabetes mellitus screening in the United States is the 2-step method, which includes screening with a 50-gram, 1-hour glucose challenge followed by a 100-gram, 3-hour diagnostic oral glucose tolerance test. The International Association of Diabetes and Pregnancy Study Group has recommended the 1-step method using a 75-gram, 2-hour oral glucose tolerance test. The International Association of Diabetes and Pregnancy Study Group thresholds have been predicted to increase the rates of gestational diabetes mellitus, yet little is known about the effect on pregnancy outcomes, especially in the United States.

OBJECTIVE

This study aimed to determine whether adoption of the 1-step method of gestational diabetes mellitus screening leads to improved obstetrical outcomes at a single academic institution.

STUDY DESIGN

This is a retrospective cohort study of patients who delivered before and after a switch from the 2-step method to the 1-step International Association of Diabetes and Pregnancy Study Group method in July 2015. Women with a due date of January 1, 2012 through October 1, 2015 were diagnosed with gestational diabetes mellitus using the 2-step method with Carpenter and Coustan criteria. After a 6-month transition period, outcomes from women with a due date of May 1, 2016 through February 1, 2018, when the 1-step International Association of Diabetes and Pregnancy Study Group criteria were used to diagnose gestational diabetes mellitus, were evaluated. Women with gestational diabetes mellitus were managed similarly throughout the study period. The primary outcome was the incidence of primary cesarean delivery. Maternal and neonatal outcomes were compared using chi-square and t tests, and multivariable logistic regression was used to control for changes in the population.

RESULTS

With the adoption of the International Association of Diabetes and Pregnancy Study Group method, the rates of gestational diabetes mellitus more than doubled, to 23.3% from 9.2% (P<.001). The rates of primary cesarean delivery increased with the International Association of Diabetes and Pregnancy Study Group criteria (22.2% vs 19.4%, P=.001), and the incidence of shoulder dystocia was not significantly different (1.1% vs 0.8%, P=.07). The rate of preeclampsia decreased during the time the 1-step method was in use (8.2% vs 10.9%, P<.001). The rate of macrosomia was not different using a definition of ≥4500 g (0.99% vs 0.86%, P=.5) but was reduced when using a definition of ≥4000 g (8.0% vs 6.0%, P<.001). The rate of neonatal intensive care unit admission did not change significantly. Controlling for maternal age, body mass index, race or ethnicity, chronic hypertension, and parity, the adjusted odds of a diagnosis of gestational diabetes mellitus increased 3-fold (adjusted odds ratio, 3.3; 95% confidence interval, 2.90-3.66) with 1-step testing, the adjusted odds of a shoulder dystocia increased (adjusted odds ratio, 1.48; 95% confidence interval, 0.97-2.25), and the adjusted odds of preeclampsia decreased (adjusted odds ratio, 0.64; 95% confidence interval, 0.55-0.74). There was no change in the adjusted odds of primary cesarean delivery (adjusted odds ratio, 1.05; 95% confidence interval, 0.94-1.17).

CONCLUSION

Although the rates of gestational diabetes mellitus increased 3-fold with the adoption of the International Association of Diabetes and Pregnancy Study Group method, the rates of primary cesarean delivery, shoulder dystocia, and birthweight ≥4500 g did not decrease in our population. The incidence of preeclampsia decreased; our analysis suggests that this was not because of the increased diagnosis of gestational diabetes mellitus. In our patient population, a large increase in the rates of gestational diabetes mellitus did not lead to an improvement in several clinically meaningful obstetrical outcomes.

Transfer of monoclonal antibodies into breastmilk in neurologic and non-neurologic diseases

Objective

To review currently available data on the transfer of monoclonal antibodies (mAbs) in the breastmilk of women receiving treatment for neurologic and non-neurologic diseases.

Methods

We systematically searched the medical literature for studies referring to 19 selected mAb therapies frequently used in neurologic conditions and “breastmilk,” “breast milk,” “breastfeeding,” or “lactation.” From an initial list of 288 unique references, 29 distinct full-text studies met the eligibility criteria. One additional study was added after the literature search based on expert knowledge of an additional article. These 30 studies were reviewed. These assessed the presence of our selected mAbs in human breastmilk in samples collected from a total of 155 individual women.

Results

Drug concentrations were typically low in breastmilk and tended to peak within 48 hours, although maximum levels could occur up to 14 days from infusion. Most studies did not evaluate the breastmilk to maternal serum drug concentration ratio, but in those evaluating this, the highest ratio was 1:20 for infliximab. Relative infant dose, a metric comparing the infant with maternal drug dose (<10% is generally considered safe), was evaluated for certolizumab (<1%), rituximab (<1%), and natalizumab (maximum of 5.3%; cumulative effects of monthly dosing are anticipated). Importantly, a total of 368 infants were followed for ≥6 months after exposure to breastmilk of mothers treated with mAbs; none experienced reported developmental delay or serious infections.

Conclusions

The current data are reassuring for low mAb drug transfer to breastmilk, but further studies are needed, including of longer-term effects on infant immunity and childhood development.

Prolonged second stage of labor and risk of subsequent spontaneous preterm birth

BACKGROUND

Preterm birth is the leading cause of neonatal morbidity and death in the United States. Although many risk factors for spontaneous preterm birth have been elucidated, some women with a previous term delivery experience spontaneous preterm birth in the absence of any identifiable risk factors. Cervical trauma during a prolonged second stage of labor has been postulated as a potential contributor to subsequent spontaneous preterm birth.

OBJECTIVE

This study was designed to examine the relationship between the length of the second stage of labor in the first pregnancy and the risk of spontaneous preterm birth in the subsequent pregnancy.

STUDY DESIGN

This was a retrospective cohort study of all women with 2 consecutive singleton deliveries at a single institution between July 2012 and June 2018, with the first delivery occurring ≥37 weeks of gestation. Multiparous women and those women who did not reach the second stage of labor in the first pregnancy were excluded. Prolonged second stage of labor was defined as ≥4 hours, based on the 75th percentile for this cohort and on recommendations from the National Institute of Child Health and Human Development. Very prolonged second stage of labor was defined as ≥7 hours, based on the 95th percentile for this cohort. The primary outcome was spontaneous preterm birth <37 weeks of gestation in the subsequent pregnancy. The Kruskal-Wallis test compared median values for nonparametric continuous variables; Fisher's exact tests compared proportions for categoric variables, and logistic regression generated odds ratios.

RESULTS

A total of 1032 women met criteria for study inclusion, with an overall subsequent spontaneous preterm birth rate of 3.1%. Prolonged second stage of labor of ≥4 hours was identified in 24.4% (252/1032 women) of the cohort, with 70.6% (178/252 women) of this group delivering vaginally. There was no statistically significant difference in rate of spontaneous preterm birth in those with and without prolonged second stage of labor (4.4% [11/252 women] with prolonged labor vs 2.7% [21/780 women] without prolonged labor; P=.21; odds ratio, 1.6; 95% confidence interval, 0.8-3.5). Very prolonged second stage of labor of ≥7 hours was identified in 4.3% (44/1032 women) of the cohort, with 45.4% (20/44 women) of this group delivering vaginally. There was a significantly higher rate of spontaneous preterm birth in those with very prolonged second stage of labor compared with those without prolonged labor (9.1% [4/44 women] with prolonged labor vs 2.8% [28/988 women] without prolonged labor; P=.04; odds ratio, 3.4; 95% confidence interval, 1.1-10.2), although this finding did not persist after we controlled for the mode of first delivery (adjusted odds ratio, 1.55; 95% confidence interval, 0.65-3.73). Spontaneous preterm birth after very prolonged second stage of labor was identified in only 4 patients, all of whom had a cesarean delivery with the first pregnancy.

CONCLUSION

A second stage of labor of ≥4 hours in the first pregnancy was not associated with an increased risk of subsequent spontaneous preterm birth and was associated with a high rate (>70%) of vaginal birth. A second stage of labor of ≥7 hours did not appear to be associated with an increased risk of preterm birth, when we adjusted for mode of first delivery. There was a nonsignificant increase in the risk of preterm birth in those who delivered via cesarean section after a second stage of labor of ≥7 hours.

Hospital bans on trial of labor after cesarean and antepartum transfer of care

BACKGROUND

Hospital policies restricting access to trial of labor after cesarean (TOLAC) are prevalent. Many women with a previous cesarean birth are affected by these bans, but there are limited data on the effect of these bans and whether women would consider changing delivery hospitals in the setting of a real or hypothetical TOLAC ban.

METHODS

This was a survey of TOLAC-eligible women receiving prenatal care at four hospitals where TOLAC is available, and 1 non-TOLAC site. Participants were asked about their likelihood of switching hospitals to pursue TOLAC if it were unavailable. Women at the non-TOLAC site had their medical records reviewed to ascertain final location and approach to delivery.

RESULTS

A total of 297 women were interviewed, 48 from the non-TOLAC site. 162 (54%) participants indicated they would transfer care if TOLAC were unavailable. Among women at the non-TOLAC site, 57% who indicated an intention to switch hospitals did so. In a multivariable logistic regression model, variables associated with transferring care included race/ethnicity other than Latina (aOR 25.20 [95% CI 2.23-284.26]), being unaware of the TOLAC ban (19.81 [1.99-196.64]), and perceiving that a close friend/relative thought they should undergo TOLAC (17.31 [1.70-176.06]).

CONCLUSIONS

More than half of women with prior cesarean would consider transferring care if TOLAC became unavailable, and more than 1 of 3 of women at a non-TOLAC site transferred care. More research is needed on the impact of TOLAC bans and how to facilitate transfer for those who desire TOLAC.

The mortality risk of expectant management compared with delivery stratified by gestational age and race and ethnicity

OBJECTIVE

The objective of the study was to compare the mortality risk of expectant management with the risk of delivery at each week of term pregnancy in 4 racial/ethnic groups.

STUDY DESIGN

This was a retrospective cohort study of all nonanomalous, term deliveries in California from 1997 to 2006 among white, black, Hispanic, and Asian women. In each racial/ethnic group, we compared the risk of infant death at each week with a composite risk representing the mortality risk of 1 week of expectant management.

RESULTS

The risk of stillbirth and infant death is highest in black women (stillbirth risk: 18.0 per 10,000, infant death: 24.4 per 10,000, compared with 9.4 per 10,000 and 10.8 per 10,000 in white women, respectively; P < .001). Although absolute risks differ by race/ethnicity, the composite risk of expectant management does not surpass the risk of delivery until 39 weeks in any group. At 39 weeks these absolute risk differences are low, however, with a number needed to deliver to prevent 1 death ranging from 751 (among black women) to 2587 (among Asian women).

CONCLUSION

The mortality risk of expectant management exceeds the risk of delivery at 39 weeks in all racial/ethnic groups, despite variation in absolute risks.

The risk of stillbirth and infant death by each additional week of expectant management stratified by maternal age

OBJECTIVE

The objective of the study was to examine fetal/infant mortality by gestational age at term stratified by maternal age.

STUDY DESIGN

A retrospective cohort study was conducted using 2005 US national birth certificate data. For each week of term gestation, the risk of mortality associated with delivery was compared with composite mortality risk of expectant management. The expectant management measure included stillbirth and infant death. This expectant management risk was calculated to estimate the composite mortality risk with remaining pregnant an additional week by combining the risk of stillbirth during the additional week of pregnancy and infant death risk following delivery at the next week. Maternal age was stratified by 35 years or more compared with women younger than 35 years as well as subgroup analyses of younger than 20, 20-34, 35-39, or 40 years old or older.

RESULTS

The fetal/infant mortality risk of expectant management is greater than the risk of infant death at 39 weeks' gestation in women 35 years old or older (15.2 vs 10.9 of 10,000, P < .05). In women younger than 35 years old, the risk of expectant management also exceeded that of infant death at 39 weeks (21.3 vs 18.8 of 10,000, P < .05). For women younger than 35 years old, the overall expectant management risk is influenced by higher infant death risk and does not rise significantly until 41 weeks compared with women 35 years old or older in which it increased at 40 weeks.

CONCLUSION

Risk varies by maternal age, and delivery at 39 weeks minimizes fetal/infant mortality for both groups, although the magnitude of the risk reduction is greater in older women.

Maternal-fetal medicine subspecialists' provision of second-trimester termination services

OBJECTIVE

Most abortions for pregnancy complications occur in the second trimester. Little is known about whether maternal-fetal medicine subspecialists (MFMs) perform terminations for these women.

STUDY DESIGN

We surveyed all members of Society of Maternal Fetal Medicine by e-mail or mail regarding second-trimester abortion provision. We conducted analyses of whether MFMs perform abortions, by what method, and how frequently.

RESULTS

Our response rate was 32.4% (689/2,125). Over two-thirds of respondents perform either dilation and evacuation (D&E) or induction; 31% perform D&Es. Male gender, frequent chorionic villus sampling provision, and being trained in D&E during fellowship are associated with performing D&Es. Nonprovision of any second-trimester abortion is significantly associated with age over 50, nonacademic practice setting, and less supportive abortion attitudes (p < 0.001). A nonsignificant trend toward association between south/southeast region and nonprovision of any second-trimester abortion is seen (p = 0.09).

CONCLUSION

Many MFMs include D&E and induction termination services in their practice. Supporting current D&E providers and expanding training options for MFMs may optimize care for women diagnosed with serious pregnancy complications.

The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes

OBJECTIVE

We sought to compare the different mortality risks between delivery and expectant management in women with gestational diabetes mellitus (GDM).

STUDY DESIGN

This is a retrospective cohort study that included singleton pregnancies of women diagnosed with GDM delivering at 36-42 weeks' gestational age in California from 1997 through 2006. A composite mortality rate was developed to estimate the risk of expectant management at each gestational age incorporating the stillbirth risk during the week of continuing pregnancy plus the infant mortality risk at the gestational age 1 week hence.

RESULTS

In women with GDM, the risk of expectant management is lower than the risk of delivery at 36 weeks (17.4 vs 19.3/10,000), but at 39 weeks, the risk of expectant management exceeds that of delivery (relative risk, 1.8; 95% confidence interval, 1.2-2.6).

CONCLUSION

In women with GDM, infant mortality rates at 39 weeks are lower than the overall mortality risk of expectant management for 1 week; absolute risks of stillbirth and infant death are low.

Maternal Mortality in Argentina: A Closer Look at Women Who Die Outside of the Health System

OBJECTIVES

To assess maternal mortality among women who died outside health institutions. To use the technique of verbal autopsy to identify maternal deaths and to obtain qualitative information about the determinants of maternal death using the "three delays" model.

METHODS

Subjects were women aged 10-49 who died outside of a health institution during 2002 in five Argentine provinces with maternal mortality ratios above the national average. Cases were identified through the national and provincial registries, and data were collected using verbal autopsies, where the relatives of the deceased are interviewed.

RESULTS

Of 252 completed verbal autopsies, 15 maternal deaths and five late maternal deaths were found. Hemorrhage was the most common cause of maternal death. Seventy-nine percentage of women who died of maternal causes experienced at least one delay in accessing care, with delays in seeking assistance as the most common, followed by delays in accessing and receiving quality care.

CONCLUSIONS

Maternal causes of death are equally prevalent among women who die outside the health system as among those who die within it, but avoidable deaths are still a problem. Interventions to improve understanding of "alarm signals" (serious symptoms) and improved access and quality of care are necessary to reduce maternal mortality.