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Minor KC, Liu J, Druzin ML, El-Sayed YY, Hintz SR, Bonifacio SL, Leonard SA, Lee HC, Profit J, Karakash SD. Magnesium sulfate and risk of hypoxic-ischemic encephalopathy in a high-risk cohort. Am J Obstet Gynecol 2024:S0002-9378(24)00478-2. [PMID: 38580044 DOI: 10.1016/j.ajog.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy contributes to morbidity and mortality among neonates ≥36 weeks of gestation. Evidence of preventative antenatal treatment is limited. Magnesium sulfate has neuroprotective properties among preterm fetuses. Hypertensive disorders of pregnancy are a risk factor for hypoxic-ischemic encephalopathy, and magnesium sulfate is recommended for maternal seizure prophylaxis among patients with preeclampsia with severe features. OBJECTIVE (1) Determine trends in the incidence of hypertensive disorders of pregnancy, antenatal magnesium sulfate, and hypoxic-ischemic encephalopathy; (2) evaluate the association between hypertensive disorders of pregnancy and hypoxic-ischemic encephalopathy; and (3) evaluate if, among patients with hypertensive disorders of pregnancy, the odds of hypoxic-ischemic encephalopathy is mitigated by receipt of antenatal magnesium sulfate. STUDY DESIGN We analyzed a prospective cohort of live births ≥36 weeks of gestation between 2012 and 2018 within the California Perinatal Quality Care Collaborative registry, linked with the California Department of Health Care Access and Information files. We used Cochran-Armitage tests to assess trends in hypertensive disorders, encephalopathy diagnoses, and magnesium sulfate utilization and compared demographic factors between patients with or without hypertensive disorders of pregnancy or treatment with magnesium sulfate. Hierarchical logistic regression models were built to explore if hypertensive disorders of pregnancy were associated with any severity and moderate/severe hypoxic-ischemic encephalopathy. Separate hierarchical logistic regression models were built among those with hypertensive disorders of pregnancy to evaluate the association of magnesium sulfate with hypoxic-ischemic encephalopathy. RESULTS Among 44,314 unique infants, the diagnosis of hypoxic-ischemic encephalopathy, maternal hypertensive disorders of pregnancy, and the use of magnesium sulfate increased over time. Compared with patients with hypertensive disorders of pregnancy alone, patients with hypertensive disorders treated with magnesium sulfate represented a high-risk population. They were more likely to be publicly insured, born between 36 and 38 weeks of gestation, be small for gestational age, have lower Apgar scores, require a higher level of resuscitation at delivery, have prolonged rupture of membranes, experience preterm labor and fetal distress, and undergo operative delivery (all P<.002). Hypertensive disorders of pregnancy were associated with hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.13-1.40]; P<.001) and specifically moderate/severe hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.11-1.42]; P<.001). Among patients with hypertensive disorders of pregnancy, treatment with magnesium sulfate was associated with 29% reduction in the odds of neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.71 [95% confidence interval, 0.52-0.97]; P=.03) and a 37% reduction in the odds of moderate/severe neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.63 [95% confidence interval, 0.42-0.94]; P=.03). CONCLUSION Hypertensive disorders of pregnancy are associated with hypoxic-ischemic encephalopathy and, specifically, moderate/severe disease. Among people with hypertensive disorders, receipt of antenatal magnesium sulfate is associated with a significant reduction in the odds of hypoxic-ischemic encephalopathy and moderate/severe disease in a neonatal cohort admitted to neonatal intensive care unit at ≥36 weeks of gestation. The findings of this observational study cannot prove causality and are intended to generate hypotheses for future clinical trials on magnesium sulfate in term infants.
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Affiliation(s)
- Kathleen C Minor
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA.
| | - Jessica Liu
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Maurice L Druzin
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Yasser Y El-Sayed
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Susan R Hintz
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Sonia L Bonifacio
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Stephanie A Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Henry C Lee
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Jochen Profit
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Scarlett D Karakash
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
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Jotwani AR, Lyell DJ, Butwick AJ, Rwigi W, Leonard SA. Validity of ICD-10 diagnosis codes for placenta accreta spectrum disorders. Paediatr Perinat Epidemiol 2024. [PMID: 38514907 DOI: 10.1111/ppe.13076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND The 10th revision of the International Classification of Diseases, Clinical Modification (ICD-10) includes diagnosis codes for placenta accreta spectrum for the first time. These codes could enable valuable research and surveillance of placenta accreta spectrum, a life-threatening pregnancy complication that is increasing in incidence. OBJECTIVE We sought to evaluate the validity of placenta accreta spectrum diagnosis codes that were introduced in ICD-10 and assess contributing factors to incorrect code assignments. METHODS We calculated sensitivity, specificity, positive predictive value and negative predictive value of the ICD-10 placenta accreta spectrum code assignments after reviewing medical records from October 2015 to March 2020 at a quaternary obstetric centre. Histopathologic diagnosis was considered the gold standard. RESULTS Among 22,345 patients, 104 (0.46%) had an ICD-10 code for placenta accreta spectrum and 51 (0.23%) had a histopathologic diagnosis. ICD-10 codes had a sensitivity of 0.71 (95% CI 0.56, 0.83), specificity of 0.98 (95% CI 0.93, 1.00), positive predictive value of 0.61 (95% CI 0.48, 0.72) and negative predictive value of 1.00 (95% CI 0.96, 1.00). The sensitivities of the ICD-10 codes for placenta accreta spectrum subtypes- accreta, increta and percreta-were 0.55 (95% CI 0.31, 0.78), 0.33 (95% CI 0.12, 0.62) and 0.56 (95% CI 0.31, 0.78), respectively. Cases with incorrect code assignment were less morbid than cases with correct code assignment, with a lower incidence of hysterectomy at delivery (17% vs 100%), blood transfusion (26% vs 75%) and admission to the intensive care unit (0% vs 53%). Primary reasons for code misassignment included code assigned to cases of occult placenta accreta (35%) or to cases with clinical evidence of placental adherence without histopatholic diagnostic (35%) features. CONCLUSION These findings from a quaternary obstetric centre suggest that ICD-10 codes may be useful for research and surveillance of placenta accreta spectrum, but researchers should be aware of likely substantial false positive cases.
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Affiliation(s)
- Anjali R Jotwani
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Deirdre J Lyell
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Wanjiru Rwigi
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
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Gemmill A, Passarella M, Phibbs CS, Main EK, Lorch SA, Kozhimannil KB, Carmichael SL, Leonard SA. Validity of Birth Certificate Data Compared With Hospital Discharge Data in Reporting Maternal Morbidity and Disparities. Obstet Gynecol 2024; 143:459-462. [PMID: 38176017 PMCID: PMC10922435 DOI: 10.1097/aog.0000000000005497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/09/2023] [Indexed: 01/06/2024]
Abstract
A growing number of studies are using birth certificate data, despite data-quality concerns, to study maternal morbidity and associated disparities. We examined whether conclusions about the incidence of maternal morbidity, including Black-White disparities, differ between birth certificate data and hospitalization data. Using linked birth certificate and hospitalization data from California and Michigan for 2018 (N=543,469), we found that maternal morbidity measures using birth certificate data alone are substantially underreported and have poor validity. Furthermore, the degree of underreporting in birth certificate data differs between Black and White individuals and results in erroneous inferences about disparities. Overall, Black-White disparities were more modest in the birth certificate data compared with the hospitalization data. Birth certificate data alone are inadequate for studies of maternal morbidity and associated racial disparities.
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Affiliation(s)
- Alison Gemmill
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Molly Passarella
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ciaran S. Phibbs
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Elliott K. Main
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Scott A. Lorch
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Katy B. Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
| | - Suzan L. Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Stephanie A. Leonard
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
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El Ayadi AM, Lyndon A, Kan P, Mujahid MS, Leonard SA, Main EK, Carmichael SL. Trends and Disparities in Severe Maternal Morbidity Indicator Categories during Childbirth Hospitalization in California from 1997 to 2017. Am J Perinatol 2024. [PMID: 38057087 DOI: 10.1055/a-2223-3520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. STUDY DESIGN We analyzed California birth cohort data on all live and stillbirths ≥ 20 weeks' gestation from 1997 to 2017 (n = 10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven nonmutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. RESULTS SMM occurred in 1.16% of births and nontransfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over 3-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717 and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, U.S.-born Hispanic, and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. CONCLUSION Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities, and potential needs for intervention. KEY POINTS · By SMM subgroup, trends and racial and ethnic disparities varied yet Black individuals consistently had highest rates.. · Hemorrhage, renal, respiratory, and sepsis SMM significantly increased over time.. · Disparities increased for respiratory SMM among Black, U.S.-born Hispanic and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals..
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Affiliation(s)
- Alison M El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Audrey Lyndon
- NYU Rory Meyers College of Nursing, New York, New York
| | - Peiyi Kan
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Dunlevie Maternal-Fetal Medicine Center, Stanford University School of Medicine, Stanford, California
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Dunlevie Maternal-Fetal Medicine Center, Stanford University School of Medicine, Stanford, California
| | - Suzan L Carmichael
- Department of Pediatrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, California
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Leonard SA, Phibbs CS, Main EK, Kozhimannil KB, Bateman BT. In Reply. Obstet Gynecol 2024; 143:e18-e19. [PMID: 38096558 DOI: 10.1097/aog.0000000000005457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California
| | - Ciaran S Phibbs
- Department of Pediatrics, Stanford University, Stanford, and Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California
| | | | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
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Main EK, Chang SC, Tucker CM, Sakowski C, Leonard SA, Rosenstein MG. Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates. Am J Obstet Gynecol MFM 2023; 5:101145. [PMID: 37648109 PMCID: PMC10873027 DOI: 10.1016/j.ajogmf.2023.101145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023]
Abstract
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.
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Affiliation(s)
- Elliott K Main
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Main and Leonard).
| | - Shen-Chih Chang
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA (Drs Chang and Tucker and Ms Sakowski)
| | - Curisa M Tucker
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA (Drs Chang and Tucker and Ms Sakowski)
| | - Christa Sakowski
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA (Drs Chang and Tucker and Ms Sakowski)
| | - Stephanie A Leonard
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Main and Leonard)
| | - Melissa G Rosenstein
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, CA (Dr Rosenstein)
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Igbinosa II, Leonard SA, Noelette F, Davies-Balch S, Carmichael SL, Main E, Lyell DJ. Racial and Ethnic Disparities in Anemia and Severe Maternal Morbidity. Obstet Gynecol 2023; 142:845-854. [PMID: 37678935 PMCID: PMC10510811 DOI: 10.1097/aog.0000000000005325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To evaluate antepartum anemia prevalence by race and ethnicity, to assess whether such differences contribute to severe maternal morbidity (SMM), and to estimate the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity. METHODS We conducted a population-based cohort study using linked vital record and birth hospitalization data for singleton births at or after 20 weeks of gestation in California from 2011 through 2020. Pregnant patients with hereditary anemias, out-of-hospital births, unlinked records, and missing variables of interest were excluded. Antepartum anemia prevalence and trends were estimated by race and ethnicity. Centers for Disease Control and Prevention criteria were used for SMM and nontransfusion SMM indicators. Multivariable logistic regression modeling was used to estimate risk ratios (RRs) for SMM and nontransfusion SMM by race and ethnicity after sequential adjustment for social determinants, parity, obstetric comorbidities, delivery, and antepartum anemia. Population attributable risk percentages were calculated to assess the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity. RESULTS In total, 3,863,594 births in California were included. In 2020, Black pregnant patients had the highest incidence of antepartum anemia (21.5%), followed by Pacific Islander (18.2%), American Indian-Alaska Native (14.1%), multiracial (14.0%), Hispanic (12.6%), Asian (10.6%), and White pregnant patients (9.6%). From 2011 to 2020, the prevalence of anemia increased more than100% among Black patients, and there was a persistent gap in prevalence among Black compared with White patients. Compared with White patients, the adjusted risk for SMM was high among most racial and ethnic groups; adjustment for anemia after sequential modeling for known confounders decreased SMM risk most for Black pregnant patients (approximated RR 1.47, 95% CI 1.42-1.53 to approximated RR 1.27, 95% CI 1.22-1.37). Compared with White patients, the full adjusted nontransfusion SMM risk remained high for most groups except Hispanic and multiracial patients. Within each racial and ethnic group, the population attributable risk percentage for antepartum anemia and SMM was highest for multiracial patients (21.4%, 95% CI 17.5-25.0%), followed by Black (20.9%, 95% CI 18.1-23.4%) and Hispanic (20.9%, 95% CI 19.9-22.1%) patients. The nontransfusion SMM population attributable risk percentages for Asian, Black, and White pregnant patients were less than 8%. CONCLUSION Antepartum anemia, most prevalent among Black pregnant patients, contributed to disparities in SMM by race and ethnicity. Nearly one in five to six SMM cases among Black, Hispanic, American Indian-Alaska Native, Pacific Islander, and multiracial pregnant patients is attributable in part to antepartum anemia.
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Affiliation(s)
- Irogue I Igbinosa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, and the Department of Pediatrics, School of Medicine, Stanford University, Stanford, and the BLACK Wellness & Prosperity Center, Fresno, California
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Leonard SA, Formanowski BL, Phibbs CS, Lorch S, Main EK, Kozhimannil KB, Passarella M, Bateman BT. Chronic Hypertension in Pregnancy and Racial-Ethnic Disparities in Complications. Obstet Gynecol 2023; 142:862-871. [PMID: 37678888 PMCID: PMC10510794 DOI: 10.1097/aog.0000000000005342] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To evaluate whether there are individual- and population-level associations between chronic hypertension and pregnancy complications, and to assess differences across seven racial-ethnic groups. METHODS This population-based study used linked vital statistics and hospitalization discharge data from all live and stillbirths in California (2008-2018), Michigan (2008-2020), Oregon (2008-2020), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used multivariable log-binomial regression models to estimate risk ratios (RRs) and population attributable risk (PAR) percentages with 95% CIs for associations between chronic hypertension and several obstetric and neonatal outcomes, selected based on prior evidence and pathologic pathways. We adjusted models for demographic factors (race and ethnicity, payment method, educational attainment), age, body mass index, obstetric history, delivery year, and state, and conducted analyses stratified across seven racial-ethnic groups. RESULTS The study included 7,955,713 pregnancies, of which 168,972 (2.1%) were complicated by chronic hypertension. Chronic hypertension was associated with several adverse obstetric and neonatal outcomes, with the largest adjusted PAR percentages observed for preeclampsia with severe features or eclampsia (22.4; 95% CI 22.2-22.6), acute renal failure (13.6; 95% CI 12.6-14.6), and pulmonary edema (10.7; 95% CI 8.9-12.6). Estimated RRs overall were similar across racial-ethnic groups, but PAR percentages varied. The adjusted PAR percentages (95% CI) for severe maternal morbidity-a widely used composite of acute severe events-for people who were American Indian or Alaska Native, Asian, Black, Latino, Native Hawaiian or Other Pacific Islander, White, and Multiracial or Other were 5.0 (1.1-8.8), 3.7 (3.0-4.3), 9.0 (8.2-9.8), 3.9 (3.6-4.3), 11.6 (6.4-16.5), 3.2 (2.9-3.5), and 5.5 (4.2-6.9), respectively. CONCLUSION Chronic hypertension accounts for a substantial fraction of obstetric and neonatal morbidity and contributes to higher complication rates, particularly for people who are Black or Native Hawaiian or Other Pacific Islander.
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Affiliation(s)
- Stephanie A Leonard
- Department of Obstetrics and Gynecology, the Department of Pediatrics, and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, and the Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California; the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and the Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota
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Handley SC, Formanowski B, Passarella M, Kozhimannil KB, Leonard SA, Main EK, Phibbs CS, Lorch SA. Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole. Health Aff (Millwood) 2023; 42:1266-1274. [PMID: 37669487 PMCID: PMC10901240 DOI: 10.1377/hlthaff.2023.00398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.
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Affiliation(s)
- Sara C Handley
- Sara C. Handley , Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Ciaran S Phibbs
- Ciaran S. Phibbs, Palo Alto Veterans Affairs Medical Center, Menlo Park, California; and Stanford University
| | - Scott A Lorch
- Scott A. Lorch, Children's Hospital of Philadelphia and University of Pennsylvania
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Miller HE, Fraz F, Zhang J, Henkel A, Leonard SA, Maskatia SA, El-Sayed YY, Blumenfeld YJ. Abortion Bans and Resource Utilization for Congenital Heart Disease: A Decision Analysis. Obstet Gynecol 2023; 142:652-659. [PMID: 37535962 DOI: 10.1097/aog.0000000000005291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/01/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To investigate the implications of potential national abortion ban scenarios on the incidence of neonatal single-ventricle cardiac defects. METHODS A decision tree model was developed to predict the incidence of neonatal single-ventricle cardiac defects and related outcomes in the United States under four theoretical national abortion bans: 1) abortion restrictions in existence immediately before the June 2022 Dobbs v Jackson Women's Health Organization Supreme Court decision, 2) 20 weeks of gestation, 3) 13 weeks of gestation, and 4) a complete abortion ban. The model included incidence of live births of neonates with single-ventricle cardiac defects, neonatal heart surgery (including heart transplant and extracorporeal membrane oxygenation [ECMO]), and neonatal death. Cohort size was based on national pregnancy incidence and different algorithm decision point probabilities were aggregated from the existing literature. Monte Carlo simulations were conducted with 10,000 iterations per model. RESULTS In the scenario before the Dobbs decision, an estimated 6,369,000 annual pregnancies in the United States resulted in 1,006 annual cases of single-ventricle cardiac defects. Under a complete abortion ban, the model predicted a 53.7% increase in single-ventricle cardiac defects, or an additional 9 cases per 100,000 live births. This increase would result in an additional 531 neonatal heart surgeries, 16 heart transplants, 77 ECMO utilizations, and 102 neonatal deaths annually. More restrictive gestational age-based bans are predicted to confer increases in cases of neonatal single-ventricle cardiac defects and related adverse outcomes as well. CONCLUSION Universal abortion bans are estimated to increase the incidence of neonatal single-ventricle cardiac defects, associated morbidity, and resource utilization. States considering limiting abortion should consider the implications on the resources required to care for increasing number of children that will be born with significant and complex medical needs, including those with congenital heart disease.
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Affiliation(s)
- Hayley E Miller
- Division of Maternal-Fetal Medicine and Obstetrics and the Division of Family Planning Services and Research, Department of Obstetrics and Gynecology, and the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, and the Department of Obstetrics and Gynecology, Stanford University, Stanford, California
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Suharwardy S, Ramachandran M, Leonard SA, Gunaseelan A, Lyell DJ, Darcy A, Robinson A, Judy A. Feasibility and impact of a mental health chatbot on postpartum mental health: a randomized controlled trial. AJOG Glob Rep 2023; 3:100165. [PMID: 37560011 PMCID: PMC10407813 DOI: 10.1016/j.xagr.2023.100165] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Perinatal mood disorders are common yet underdiagnosed and un- or undertreated. Barriers exist to accessing perinatal mental health services, including limited availability, time, and cost. Automated conversational agents (chatbots) can deliver evidence-based cognitive behavioral therapy content through text message-based conversations and reduce depression and anxiety symptoms in select populations. Such digital mental health technologies are poised to overcome barriers to mental health care access but need to be evaluated for efficacy, as well as for preliminary feasibility and acceptability among perinatal populations. OBJECTIVE To evaluate the acceptability and preliminary efficacy of a mental health chatbot for mood management in a general postpartum population. STUDY DESIGN An unblinded randomized controlled trial was conducted at a tertiary academic center. English-speaking postpartum women aged 18 years or above with a live birth and access to a smartphone were eligible for enrollment prior to discharge from delivery hospitalization. Baseline surveys were administered to all participants prior to randomization to a mental health chatbot intervention or to usual care only. The intervention group downloaded the mental health chatbot smartphone application with perinatal-specific content, in addition to continuing usual care. Usual care consisted of routine postpartum follow up and mental health care as dictated by the patient's obstetric provider. Surveys were administered during delivery hospitalization (baseline) and at 2-, 4-, and 6-weeks postpartum to assess depression and anxiety symptoms. The primary outcome was a change in depression symptoms at 6-weeks as measured using two depression screening tools: Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale. Secondary outcomes included anxiety symptoms measured using Generalized Anxiety Disorder-7, and satisfaction and acceptability using validated scales. Based on a prior study, we estimated a sample size of 130 would have sufficient (80%) power to detect a moderate effect size (d=.4) in between group difference on the Patient Health Questionnaire-9. RESULTS A total of 192 women were randomized equally 1:1 to the chatbot or usual care; of these, 152 women completed the 6-week survey (n=68 chatbot, n=84 usual care) and were included in the final analysis. Mean baseline mental health assessment scores were below positive screening thresholds. At 6-weeks, there was a greater decrease in Patient Health Questionnaire-9 scores among the chatbot group compared to the usual care group (mean decrease=1.32, standard deviation=3.4 vs mean decrease=0.13, standard deviation=3.01, respectively). 6-week mean Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores did not differ between groups and were similar to baseline. 91% (n=62) of the chatbot users were satisfied or highly satisfied with the chatbot, and 74% (n=50) of the intervention group reported use of the chatbot at least once in 2 weeks prior to the 6-week survey. 80% of study participants reported being comfortable with the use of a mobile smartphone application for mood management. CONCLUSION Use of a chatbot was acceptable to women in the early postpartum period. The sample did not screen positive for depression at baseline and thus the potential of the chatbot to reduce depressive symptoms in this population was limited. This study was conducted in a general obstetric population. Future studies of longer duration in high-risk postpartum populations who screen positive for depression are needed to further understand the utility and efficacy of such digital therapeutics for that population.
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Affiliation(s)
- Sanaa Suharwardy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Obstetrics, Stanford University, Stanford, CA (Dr. Suharwardy, Dr. Ramachandran, Dr. Leonard, Dr Gunaseelan, Dr Lyell, and Dr Judy)
| | - Maya Ramachandran
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Obstetrics, Stanford University, Stanford, CA (Dr. Suharwardy, Dr. Ramachandran, Dr. Leonard, Dr Gunaseelan, Dr Lyell, and Dr Judy)
| | - Stephanie A. Leonard
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Obstetrics, Stanford University, Stanford, CA (Dr. Suharwardy, Dr. Ramachandran, Dr. Leonard, Dr Gunaseelan, Dr Lyell, and Dr Judy)
| | - Anita Gunaseelan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Obstetrics, Stanford University, Stanford, CA (Dr. Suharwardy, Dr. Ramachandran, Dr. Leonard, Dr Gunaseelan, Dr Lyell, and Dr Judy)
| | - Deirdre J. Lyell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Obstetrics, Stanford University, Stanford, CA (Dr. Suharwardy, Dr. Ramachandran, Dr. Leonard, Dr Gunaseelan, Dr Lyell, and Dr Judy)
| | - Alison Darcy
- Woebot Health, San Francisco, CA (Drs Darcy and Robinson)
| | | | - Amy Judy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Obstetrics, Stanford University, Stanford, CA (Dr. Suharwardy, Dr. Ramachandran, Dr. Leonard, Dr Gunaseelan, Dr Lyell, and Dr Judy)
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Kozhimannil KB, Leonard SA, Handley SC, Passarella M, Main EK, Lorch SA, Phibbs CS. Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals. JAMA Health Forum 2023; 4:e232110. [PMID: 37354537 DOI: 10.1001/jamahealthforum.2023.2110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2023] Open
Abstract
Importance Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts. Objective To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients. Design, Setting, and Participants This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023. Exposures Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties. Main Outcome and Measures The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity. Results Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients. Conclusions and Relevance In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.
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Affiliation(s)
- Katy Backes Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Stephanie A Leonard
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
- California Maternal Quality Care Collaborative, Stanford
| | - Sara C Handley
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Molly Passarella
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elliott K Main
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
- California Maternal Quality Care Collaborative, Stanford
| | - Scott A Lorch
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Ciaran S Phibbs
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California
- Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, California
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Panelli DM, Leonard SA, Joudi N, Judy AE, Bianco K, Gilbert WM, Main EK, El-Sayed YY, Lyell DJ. Clinical and Physician Factors Associated With Failed Operative Vaginal Delivery. Obstet Gynecol 2023; 141:1181-1189. [PMID: 37141591 PMCID: PMC10440297 DOI: 10.1097/aog.0000000000005181] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/02/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births. METHODS This was a retrospective cohort study of individuals with NTSV live births with an attempted operative vaginal delivery by a physician between 2016 and 2020 in California. The primary outcome was cesarean birth after failed operative vaginal delivery, identified using linked diagnosis codes, birth certificates, and physician licensing board data stratified by device type (vacuum or forceps). Clinical and physician-level exposures were selected a priori, defined using validated indices, and compared between successful and failed operative vaginal delivery attempts. Physician experience with operative vaginal delivery was estimated by calculating the number of operative vaginal delivery attempts made per physician during the study period. Multivariable mixed effects Poisson regression models with robust standard errors were used to estimate risk ratios of failed operative vaginal delivery for each exposure, adjusted for potential confounders. RESULTS Of 47,973 eligible operative vaginal delivery attempts, 93.2% used vacuum and 6.8% used forceps. Of all operative vaginal delivery attempts, 1,820 (3.8%) failed; the success rate was 97.3% for vacuum attempts and 82.4% for forceps attempts. Failed operative vaginal deliveries were more likely with older patient age, higher body mass index, obstructed labor, and neonatal birth weight more than 4,000 g. Between 2016 and 2020, physicians who attempted more operative vaginal deliveries were less likely to fail. When vacuum attempts were successful, physicians who conducted them had a median of 45 vacuum attempts during the study period, compared with 27 attempts when vacuum attempts were unsuccessful (adjusted risk ratio [aRR] 0.95, 95% CI 0.93-0.96). When forceps attempts were successful, physicians who conducted them had a median of 19 forceps attempts, compared with 11 attempts when forceps attempts were unsuccessful (aRR 0.76, 95% CI 0.64-0.91). CONCLUSION In this large, contemporary cohort with NTSV births, several clinical factors were associated with operative vaginal delivery failure. Physician experience was associated with operative vaginal delivery success, more notably for forceps attempts. These results may provide guidance for physician training in maintenance of operative vaginal delivery skills.
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Affiliation(s)
- Danielle M Panelli
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, the Department of Obstetrics and Gynecology, Sutter Medical Center, Sacramento, and the California Maternal Quality Care Collaborative, Palo Alto, California
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Leonard SA, Girsen A, Trepman P, Carmichael SL, Darmawan K, Butwick A, Gibbs R. Early postpartum hospital encounters among patients with genitourinary and wound infections during hospitalization for birth. Am J Perinatol 2023. [PMID: 37216972 DOI: 10.1055/a-2097-1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To assess the associations between genitourinary and wound infections during the birth hospitalization and early postpartum hospital encounters, and to evaluate clinical risk factors for early postpartum hospital encounters among patients with a genitourinary or wound infection during the birth hospitalization. STUDY DESIGN We conducted a population-based cohort study of births in California during 2016-2018 and postpartum hospital encounters. We identified genitourinary and wound infections using diagnosis codes. Our main outcome was early postpartum hospital encounter, defined as a readmission or ED visit within 3 days after discharge from the birth hospitalization. We evaluated the association of genitourinary and wound infections (overall and subtypes) with early postpartum hospital encounter using logistic regression, adjusting for sociodemographic factors and comorbidities and stratified by mode of birth. We then evaluated factors associated with early postpartum hospital encounter among patients with genitourinary and wound infections. RESULTS Among 1,217,803 birth hospitalizations, 5.5% were complicated by genitourinary and wound infections and 1.8% resulted in an early postpartum hospital encounter. Genitourinary or wound infection was associated with an early postpartum hospital encounter among patients with both vaginal births (aRR 1.26, 95% CI 1.17, 1.36) and cesarean births (aRR 1.23, 95% CI 1.15, 1.32). Major puerperal infection, followed by wound infection, among patients with a cesarean birth conferred the highest risk of an early postpartum hospital encounter (6.4% and 4.3%, respectively). Among patients with genitourinary and wound infections at birth hospitalization, factors associated with an early postpartum hospital encounter included severe maternal morbidity, major mental health condition, prolonged postpartum hospital stay, and, among cesarean births, postpartum hemorrhage (P-value < 0.05). CONCLUSIONS Genitourinary and wound infections during hospitalization for birth may increase risk of a readmission or ED visit within the first few days after discharge, particularly among patients who have a major puerperal infection or wound infection.
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Affiliation(s)
- Stephanie A Leonard
- Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, United States
| | - Anna Girsen
- Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, United States
| | - Paula Trepman
- University of Washington School of Medicine, Seattle, United States
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, United States
| | - Kelly Darmawan
- Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, United States
| | - Alexander Butwick
- Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, United States
| | - Ronald Gibbs
- Stanford University School of Medicine, Stanford, United States
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15
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Phibbs CM, Kristensen-Cabrera A, Kozhimannil KB, Leonard SA, Lorch SA, Main EK, Schmitt SK, Phibbs CS. Racial/ethnic disparities in costs, length of stay, and severity of severe maternal morbidity. Am J Obstet Gynecol MFM 2023; 5:100917. [PMID: 36882126 PMCID: PMC10121928 DOI: 10.1016/j.ajogmf.2023.100917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/01/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND In contrast to other high-resource countries, the United States has experienced increases in the rates of severe maternal morbidity. In addition, the United States has pronounced racial and ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people. OBJECTIVE This study aimed to examine whether the racial and ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity. STUDY DESIGN This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009 to 2011. Of the 1.5 million linked records, 250,000 were excluded because of incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnosis-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days after delivery. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial or ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race and ethnicity with costs and length of stay. RESULTS Asian or Pacific Islander, Non-Hispanic Black, Hispanic, and other race or ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio, 1.61; P<.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (P<.001) higher costs (marginal effect of $5023) and 24% (P<.001) longer hospital stays (marginal effect of 1.4 days) than non-Hispanic White patients. These effects changed when cases, such as cases where a blood transfusion was the only indication of severe maternal morbidity, were excluded, with 29% higher costs (P<.001) and 15% longer length of stay (P<.001). For other racial and ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significantly different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients; however, Hispanic patients had significantly lower costs and length of stay than non-Hispanic White patients. CONCLUSION There were racial and ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; in addition, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity support greater case severity in that population. These findings suggest that efforts to address racial and ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.
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Affiliation(s)
| | - Alexandria Kristensen-Cabrera
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN (Ms Kristensen-Cabrera and Dr Kozhimannil)
| | - Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN (Ms Kristensen-Cabrera and Dr Kozhimannil)
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Leonard and Main); California Maternal Quality Care Collaborative, Stanford, CA (Drs Leonard and Main)
| | - Scott A Lorch
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Lorch); Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA (Dr Lorch)
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Leonard and Main); California Maternal Quality Care Collaborative, Stanford, CA (Drs Leonard and Main)
| | - Susan K Schmitt
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA (Drs Schmitt and Phibbs); Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, CA (Drs Schmitt and Phibbs)
| | - Ciaran S Phibbs
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA (Drs Schmitt and Phibbs); Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, CA (Drs Schmitt and Phibbs)
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Tsur A, Leonard SA, Kan P, Datoc I, Girsen A, Shaw GM, Stevenson DK, El-Sayed YY, Druzin ML, Blumenfeld YJ. Vaginal Progesterone is Associated with Intrahepatic Cholestasis of Pregnancy. Am J Perinatol 2023. [PMID: 37100422 DOI: 10.1055/a-2081-2573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
Background The frequency of intrahepatic cholestasis of pregnancy peaks during the third trimester of pregnancy when plasma progesterone levels are highest. Furthermore, twin pregnancies are characterized by higher progesterone levels than singletons, and have a higher frequency of cholestasis. Therefore, we hypothesized that exogenous progestogens administered for reducing the risk of spontaneous preterm birth may increase the risk of cholestasis. Objectives Utilizing the large IBM MarketScan® Commercial Claims and Encounters Database, we investigated the frequency of cholestasis in patients treated with vaginal progesterone or intramuscular 17α-hydroxyprogesterone caproate for the prevention of preterm birth. Study design We identified 1,776,092 live-born singleton pregnancies between 2010-2014. We confirmed 2nd and 3rd trimester administration of progestogens by cross-referencing the dates of progesterone prescriptions with the dates of scheduled pregnancy events such as nuchal translucency scan, fetal anatomy scan, glucose challenge test, and Tdap vaccination. We excluded pregnancies with missing data regarding timing of scheduled pregnancy events, or progesterone treatment prescribed only during the 1st trimester. Cholestasis of pregnancy was identified based on prescriptions for ursodeoxycholic acid. We used multivariable logistic regression to estimate adjusted (for maternal age) odds ratios for cholestasis in patients treated with vaginal progesterone, and in patients treated with 17α-hydroxyprogesterone caproate compared to those not treated with any type of progestogen (the reference group). Results The final cohort consisted of 870,599 pregnancies. Among patients treated with vaginal progesterone during the 2nd and 3rd trimester, the frequency of cholestasis was significantly higher than the reference group (0.75% vs 0.23%, aOR 3.16, 95% CI 2.23-4.49). In contrast, there was no significant association between 17α-hydroxyprogesterone caproate and cholestasis (0.27%, aOR 1.12, 95% CI 0.58-2.16) Conclusions Using a robust dataset, we observed that vaginal progesterone but not intramuscular 17α-hydroxyprogesterone caproate was associated with an increased risk for intrahepatic cholestasis of pregnancy.
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Affiliation(s)
- Abraham Tsur
- Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Stephanie A Leonard
- Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, United States
| | - Peiyi Kan
- Department of Pediatrics, Stanford University School of Medicine, Stanford, United States
| | - Imee Datoc
- Department of Pediatrics, Stanford University School of Medicine, Stanford, United States
| | - Anna Girsen
- Obstetrics & Gynecology, Stanford University, Stanford, United States
| | - Gary M Shaw
- Pediatrics, Stanford University School of Medicine, Stanford, United States
| | - David K Stevenson
- Pediatrics, Stanford university school of medicine, stanford, United States
| | - Yasser Y El-Sayed
- Obstetrics and Gynecology, Stanford University, Stanford, United States
| | - Maurice L Druzin
- Obstetrics and Gynecology, Stanford University, Stanford, United States
| | - Yair J Blumenfeld
- Obstetrics & Gynecology, Stanford University, Stanford, United States
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Sperling MM, Leonard SA, Blumenfeld YJ, Carmichael SL, Chueh J. Prepregnancy body mass index and gestational diabetes mellitus across Asian and Pacific Islander subgroups in California. AJOG Glob Rep 2023; 3:100148. [PMID: 36632428 PMCID: PMC9826825 DOI: 10.1016/j.xagr.2022.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists recommends early screening for gestational diabetes mellitus among pregnant Asian people with a prepregnancy body mass index ≥23.0 kg/m2, in contrast with the recommended screening at a body mass index ≥25 kg/m2 for other races and ethnicities. However, there is significant heterogeneity within Asian and Pacific Islander populations, and gestational diabetes mellitus and its association with body mass index among Asian and Pacific Islander subgroups may not be uniform across all groups. OBJECTIVE This study aimed to analyze the association between body mass index and gestational diabetes mellitus among Asian and Pacific Islander subgroups in California, specifically gestational diabetes mellitus rates among those with a body mass index above vs below 23 kg/m2, which is the cutoff point for the designation of being overweight among Asians populations. STUDY DESIGN Using a linked delivery hospitalization discharge and vital records database, we identified patients who gave birth in California between 2007 and 2017 and who self-reported to be 1 of 13 Asian and Pacific Islander subgroups, which was collected from birth and fetal death certificates. In each subgroup, we evaluated the association between body mass index and gestational diabetes mellitus using multivariable logistic regression models adjusted for age, education, parity, payment method, the trimester in which prenatal care was initiated, and nativity. We fit body mass index nonlinearly with splines and categorized body mass index as being above or below 23 kg/m2. Predicted probabilities of gestational diabetes mellitus with 95% confidence intervals were calculated across body mass index values using the nonlinear regression models. RESULTS The overall prevalence of gestational diabetes mellitus was 14.3% (83,400/584,032), ranging between 8.4% and 17.1% across subgroups. The highest prevalence was among Indian (17.1%), Filipino (16.7%), and Vietnamese (15.5%) subgroups. In these subgroups, gestational diabetes mellitus was diagnosed in 10% to 13% of those with a body mass index <23.0 kg/m2 and in 22% of those with a body mass index ≥23 kg/m2. Gestational diabetes mellitus was least common among Korean (8.4%), Japanese (9.0%), and Samoan (9.8%) subgroups with a gestational diabetes mellitus rate of 5% to 7% among those with a body mass index <23.0 kg/m2 and in 10% to 15% among those with a body mass index ≥23 kg/m2. Although Samoan patients had the highest rate of obesity, defined as body mass index ≥30 kg/m2 (57.4%), they had the third lowest prevalence of gestational diabetes mellitus. Conversely, Vietnamese patients had the second lowest rate of obesity (2.4%) but the highest rate of gestational diabetes mellitus at a body mass index of ≥23 kg/m2 (22.3%). CONCLUSION Gestational diabetes mellitus and its association with body mass index varied among Asian subgroups but increased as body mass index increased. Subgroups with the lowest prevalence of obesity trended toward a higher prevalence of gestational diabetes mellitus and those with a higher prevalence of obesity trended toward a lower prevalence of gestational diabetes mellitus.
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Affiliation(s)
- Meryl M. Sperling
- Departments of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Sperling, Leonard, Blumenfeld, Carmichael, and Chueh)
| | - Stephanie A. Leonard
- Departments of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Sperling, Leonard, Blumenfeld, Carmichael, and Chueh)
| | - Yair J. Blumenfeld
- Departments of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Sperling, Leonard, Blumenfeld, Carmichael, and Chueh)
| | - Suzan L. Carmichael
- Departments of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Sperling, Leonard, Blumenfeld, Carmichael, and Chueh)
- Pediatrics (Dr Carmichael), Stanford University School of Medicine, Stanford, CA
| | - Jane Chueh
- Departments of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Sperling, Leonard, Blumenfeld, Carmichael, and Chueh)
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Leonard SA, Panelli DM. Quasi-experimental study designs can inform pandemic effects on nutrition and weight gain in pregnancy. Am J Clin Nutr 2023; 117:216-217. [PMID: 36863821 PMCID: PMC9972863 DOI: 10.1016/j.ajcnut.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 03/04/2023] Open
Affiliation(s)
- Stephanie A Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA, USA.
| | - Danielle M Panelli
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA, USA
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Sperling MM, Leonard SA, Miller SE, Hurtado J, El-Sayed YY, Herrero T, Faig J, Carter S, Blumenfeld YJ. Fasting Compared With Fed and Oral Intake Before the 1-Hour Oral Glucose Tolerance Test: A Randomized Controlled Trial. Obstet Gynecol 2023; 141:126-133. [PMID: 36701613 DOI: 10.1097/aog.0000000000005013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the effect of fasting compared with eating before the 1-hour oral glucose tolerance test (OGTT) on gestational diabetes mellitus (GDM) screening results. METHODS In a single-center, prospective randomized trial, participants were randomized to: 1) fasting for 6 or more hours or 2) oral intake ("fed") within 2 hours of the 50-g, 1-hour OGTT. The 1-hour OGTT was administered after 24 weeks of gestation. A positive screen result was defined as a serum glucose level of 140 mg/dL or higher. Protocol adherence was assessed by a survey administered immediately after the OGTT. We planned to enroll 100 participants in each group to detect an absolute difference of 20 percentage points or more on the 1-hour OGTT screen-positive rate using Fisher exact test, assuming an estimated screen-positive rate of 45% in the fasting and 25% in the fed group and 10% attrition, with a two-sided α=0.05, power=0.8. The primary outcome was the 1-hour OGTT screen-positive rate. Secondary outcomes included mean 1-hour OGTT glucose values, GDM diagnosis, maternal and neonatal outcomes, and patient perceptions regarding the 1-hour OGTT. RESULTS From November 2020 through April 2021, 200 participants were randomized. One hundred ninety-five completed the 1-hour OGTT (97 fasting, 98 fed). Participant surveys confirmed 97.9% (n=95) adherence to the fasting and 91.8% (n=90) adherence to the fed groups. The screen-positive rate was significantly higher in the fasting than the fed group (32.0% vs 13.3%, respectively, P=.002), as was the mean glucose value (127.7 mg/dL vs 113.3 mg/dL, P=.002). The incidence of GDM in the fasting group was 12.4% (n=12) and in the fed group was 5.1% (n=5) (P=.08). There were no significant differences in maternal or neonatal outcomes. CONCLUSION Fasting for 6 or more hours doubled the incidence of a positive 1-hour OGTT result when compared with eating within 2 hours of the test. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04547023.
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Affiliation(s)
- Meryl M Sperling
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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Leonard SA, Xu X, Davies-Balch S, Main E, Bateman BT, Rehkopf D, Lee HC, Illuzzi J, Igbinosa I, Iwekaogwu I, Lyell DJ. Hospital intrapartum practices and disparities in severe maternal and neonatal morbidity. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Panelli DM, Esmaeili A, Joyce V, Chan C, Gujral K, Schmitt S, Murphy N, Kimerling R, Leonard SA, Shaw JG, Phibbs CS. Impact of psychiatric conditions on the risk of severe maternal morbidity in veterans. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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22
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Darmawan KF, Leonard SA, Meador K, McElrath TF, Carmichael SL, Lyell DJ, El-Sayed YY, Herrero T, Druzin ML, Panelli DM. Increased primary cesarean delivery rate among people with epilepsy: Risks, drivers and future directions. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Minor KC, Mayo JA, Bianco K, Judy A, Abir G, Lee HC, Leonard SA, Sie L, Ayotte S, Daniels KI. A novel virtual simulation training improves providers’ knowledge and confidence to manage obstetric emergencies. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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24
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Darmawan KF, Leonard SA, Meador K, McElrath TF, Carmichael SL, Lyell DJ, El-Sayed YY, Herrero T, Druzin ML, Panelli DM. Increased rates of postpartum emergency department visits and inpatient readmissions in people with epilepsy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Waldrop AR, Blumenfeld YJ, Mayo JA, Panelli DM, Heft-Neal S, Burke M, Leonard SA, Shaw GM. Antenatal wildfire smoke exposure and hypertensive disorders of pregnancy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Waldrop AR, Zhang J, Flentje A, Lunn MR, Lubensky ME, Leonard SA, Dastur Z, Obedin-Maliver J. Factors contributing to delay in family building among sexual/gender minority people in the COVID-19 pandemic. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Miller HE, Henkel A, Zhang J, Leonard SA, Quirin AP, Maskatia SA, El Sayed YY, Blumenfeld YJ. Abortion restriction impact on burden of neonatal single ventricle congenital heart disease: a decision-analytic model. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Darmawan KF, Panelli DM, Mayo JA, Leonard SA, Girsen A, Carmichael SL, Bianco K. Severe maternal morbidity among people with cardiac disease: getting to the heart of the problem. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Sun T, Cruz GI, Mousavi N, Marić I, Brewer A, Wong RJ, Aghaeepour N, Sayed N, Wu JC, Stevenson DK, Leonard SA, Gymrek M, Winn VD. HMOX1 Genetic Polymorphisms Display Ancestral Diversity and May Be Linked to Hypertensive Disorders in Pregnancy. Reprod Sci 2022; 29:3465-3476. [PMID: 35697922 PMCID: PMC9734242 DOI: 10.1007/s43032-022-01001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 06/02/2022] [Indexed: 12/14/2022]
Abstract
Racial disparity exists for hypertensive disorders in pregnancy (HDP), which leads to disparate morbidity and mortality worldwide. The enzyme heme oxygenase-1 (HO-1) is encoded by HMOX1, which has genetic polymorphisms in its regulatory region that impact its expression and activity and have been associated with various diseases. However, studies of these genetic variants in HDP have been limited. The objective of this study was to examine HMOX1 as a potential genetic contributor of ancestral disparity seen in HDP. First, the 1000 Genomes Project (1 KG) phase 3 was utilized to compare the frequencies of alleles, genotypes, and estimated haplotypes of guanidine thymidine repeats (GTn; containing rs3074372) and A/T SNP (rs2071746) among females from five ancestral populations (Africa, the Americas, Europe, East Asia, and South Asia, N = 1271). Then, using genomic DNA from women with a history of HDP, we explored the possibility of HMOX1 variants predisposing women to HDP (N = 178) compared with an equivalent ancestral group from 1 KG (N = 263). Both HMOX1 variants were distributed differently across ancestries, with African women having a distinct distribution and an overall higher prevalence of the variants previously associated with lower HO-1 expression. The two HMOX1 variants display linkage disequilibrium in all but the African group, and within EUR cohort, LL and AA individuals have a higher prevalence in HDP. HMOX1 variants demonstrate ancestral differences that may contribute to racial disparity in HDP. Understanding maternal genetic contribution to HDP will help improve prediction and facilitate personalized approaches to care for HDP.
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Affiliation(s)
- Tianyanxin Sun
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Giovanna I Cruz
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Nima Mousavi
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA, USA
| | - Ivana Marić
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Alina Brewer
- Preeclampsia Foundation, Juneau Biosciences, LLC, Salt Lake City, UT, USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Nima Aghaeepour
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Nazish Sayed
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph C Wu
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - David K Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Melissa Gymrek
- Department of Medicine, Department of Computer Science and Engineering, University of California San Diego, La Jolla, CA, USA
| | - Virginia D Winn
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
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Panelli DM, Diwan M, Cruz GI, Leonard SA, Chueh J, Gotlib IH, Bianco K. An exploratory analysis of leukocyte telomere length among pregnant and non-pregnant people. Brain Behav Immun Health 2022; 25:100506. [PMID: 36110146 PMCID: PMC9467886 DOI: 10.1016/j.bbih.2022.100506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/15/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022] Open
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Leonard SA, Ogawa Y, Jedrzejewski PT, Maleki SJ, Chapman MD, Tilles SA, Du Toit G, Mustafa SS, Vickery BP. Manufacturing processes of peanut ( Arachis hypogaea) allergen powder-dnfp. Front Allergy 2022; 3:1004056. [PMID: 36304076 PMCID: PMC9592818 DOI: 10.3389/falgy.2022.1004056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022] Open
Abstract
Background Important components of drug safety, efficacy, and acceptability involve manufacturing and testing of the drug substance and drug product. Peanut flour sourcing/processing and manufacturing processes may affect final drug product allergen potency and contamination level, possibly impacting drug safety, quality, and efficacy. We describe key steps in the manufacturing processes of peanut (Arachis hypogaea) allergen powder-dnfp (PTAH; Palforzia®), a drug used in oral immunotherapy (OIT) for the treatment of peanut allergy. Methods Established criteria for source material must be met for manufacturing PTAH drug product. Degree of roasting was determined with a Hunter colorimeter. Protein/allergen content, identity, potency, safety, and quality of each batch of PTAH drug substance were assessed with a combustion analyzer, allergen-specific Western blot (immunoblotting), ELISA, and HPLC. Contaminants (ie, aflatoxin) were measured by UPLC. Results Roasting degree beyond "light roast" was associated with variable degrees of protein allergen degradation, or potentially aggregation. Relative potency and amounts of protein allergens showed variability due in part to seasonal/manufacturing variability. Proportion of lots not meeting aflatoxin limits has increased in recent years. Up to 60% of peanut flour source material failed to meet screening selection acceptance criteria for proceeding to drug substance testing, mostly because of failure to meet potency acceptance criteria. Other lots were rejected due to safety (ie, aflatoxin) and quality. Influence of potency variation, within specification parameters, on safety/tolerability observed in trials was considered low, in part due to stringent controls placed at each step of manufacturing. Conclusions Extensive variability in allergen potency is a critical issue during immunotherapy, particularly during OIT initial dose escalation and up-dosing, as it may result in lack of efficacy or avoidable adverse allergic reactions. Based on EU and US regulatory requirements, the production of PTAH includes manufacturing controls to ensure drug product safety, potency, and quality. For example, although PTAH contains all peanut allergens, each lot has met strict criteria ensuring consistent allergenic potency of Ara h 1, Ara h 2, and Ara h 6. The rigor of PTAH's manufacturing process ensures reliable dose consistency and stability throughout its shelf life.
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Affiliation(s)
- Stephanie A. Leonard
- Division of Pediatric Allergy / Immunology, University of California San Diego, Rady Children's Hospital, San Diego, CA, United States
| | - Yasushi Ogawa
- Medical Affairs, Aimmune Therapeutics, a Nestlé Health Science company, Brisbane, CA, United States
| | - Paul T. Jedrzejewski
- Medical Affairs, Aimmune Therapeutics, a Nestlé Health Science company, Brisbane, CA, United States
| | - Soheila J. Maleki
- United States Department of Agriculture, Agricultural Research Service, New Orleans, LA, United States
| | | | - Stephen A. Tilles
- Medical Affairs, Aimmune Therapeutics, a Nestlé Health Science company, Brisbane, CA, United States,Correspondence: Stephen A. Tilles
| | - George Du Toit
- Department of Pediatrics, Guy's and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - S. Shahzad Mustafa
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Brian P. Vickery
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
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Sperling MM, Sie L, Leonard SA, Girsen AI, Lee HC, Gibbs RS. Effect of gestational age at first delivery and interpregnancy interval on the recurrence of clinical chorioamnionitis. AJOG Glob Rep 2022; 2:100116. [PMID: 36316994 PMCID: PMC9617201 DOI: 10.1016/j.xagr.2022.100116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND There is an increased odds of having a recurrence of clinical chorioamnionitis in patients with a diagnosis of clinical chorioamnionitis compared with those without clinical chorioamnionitis in a previous pregnancy. However, it is unclear how gestational age at delivery of the first pregnancy or interpregnancy interval may contribute to this increased risk. OBJECTIVE This study aimed to evaluate how gestational age of delivery in a first pregnancy and interpregnancy interval affect the odds of recurrent clinical chorioamnionitis. STUDY DESIGN Using maternally linked birth record files, Nulliparous patients from California with at least 2 consecutive deliveries between the gestational ages of 20 and 44 weeks from 2007 to 2012 were identified. The rates of clinical chorioamnionitis in the second pregnancy for patients with clinical chorioamnionitis vs those without clinical chorioamnionitis in the first pregnancy, stratified by the gestational age at delivery of the first pregnancy were determined. As a secondary analysis, the analysis by interpregnancy interval (<18 months vs ≥18 months) was stratified. Corresponding crude and adjusted odds ratios for each stratum were calculated to assess the association of clinical chorioamnionitis in the first and second pregnancies. RESULTS Among 31,571 nulliparous patients with clinical chorioamnionitis in the first pregnancy, the frequency of clinical chorioamnionitis in the next pregnancy was 4.0% (1257 cases). This was in comparison with the 1.0% (9177 of 896,154) of nulliparous patients without clinical chorioamnionitis in the first pregnancy who were diagnosed with clinical chorioamnionitis in the next pregnancy (adjusted odds ratio, 2.78; 95% confidence interval, 2.61-2.96). The absolute frequency of recurrence was the highest (54 cases [8.2%]) in those who delivered at 20 to 24 weeks of gestation in the first pregnancy with the diagnosis of clinical chorioamnionitis (adjusted odds ratio, 1.76; 95% confidence interval, 1.25-2.48). For pregnancies delivered at term in the first pregnancy, the frequency of clinical chorioamnionitis in the next pregnancy was higher in those diagnosed with clinical chorioamnionitis in the first pregnancy than in those without clinical chorioamnionitis in the first pregnancy (4.0% vs 1.0%; adjusted odds ratio, 2.85; 95% confidence interval, 2.66-3.05). An interpregnancy interval of <18 months was not associated with increased odds of recurrent clinical chorioamnionitis. CONCLUSION The odds of recurrence of clinical chorioamnionitis were the strongest when a patient delivered in the term to postterm period in the first pregnancy, with the absolute risk being the highest when the first pregnancy was delivered in the periviable period (20-24 weeks of gestation). The interpregnancy interval did not seem to modify the risk of recurrent clinical chorioamnionitis.
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Affiliation(s)
- Meryl M. Sperling
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA (Drs Sperling, Leonard, Girsen, and Gibbs),Corresponding author: Meryl M. Sperling, MD, MA.
| | - Lillian Sie
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA (Ms Sie and Dr Lee)
| | - Stephanie A. Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA (Ms Sie and Dr Lee)
| | - Anna I. Girsen
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA (Drs Sperling, Leonard, Girsen, and Gibbs)
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA (Ms Sie and Dr Lee)
| | - Ronald S. Gibbs
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA (Drs Sperling, Leonard, Girsen, and Gibbs)
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Gemmill A, Leonard SA. Risk of Adverse Pregnancy Outcomes Among US Individuals With Gestational Diabetes by Race and Ethnicity. JAMA 2022; 328:397. [PMID: 35881129 DOI: 10.1001/jama.2022.9412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alison Gemmill
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, California
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Berrahou IK, Leonard SA, Zhang A, Main EK, Obedin-Maliver J. Sexual and/or gender minority parental structures among California births from 2016 to 2020. Am J Obstet Gynecol MFM 2022; 4:100653. [PMID: 35462057 DOI: 10.1016/j.ajogmf.2022.100653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/06/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Sexual and/or gender minority people account for roughly 7.1% of the US population, and an estimated one-third are parents. Little is known about sexual and/or gender minority people who become pregnant, despite this population having documented healthcare disparities that may affect pregnancy. OBJECTIVE Our objective was to describe parental structures among birth parents and the prepregnancy characteristics of parents giving birth in likely sexual and/or gender minority parental structures from California birth certificates. STUDY DESIGN We conducted a population-based study using birth certificate data from all live births in California from 2016 through 2020 (n=2,257,974). The state amended its birth certificate in 2016 to enable the recording of more diverse parental roles. Now, parents on birth certificates are classified as "parent giving birth" and "parent not giving birth" and people in either role can identify as "mother," "father," or "parent." We examined all potential combinations of parenting roles, and grouped parental structures of "mother-mother" and those designating a "father" as the "parent giving birth" into likely sexual and/or gender minority groups. We assessed the distribution of prepregnancy characteristics across parental structure groups ("mother-father," "sexual and/or gender minority," "mother only," "unclassified," and "missing both parental roles"). RESULTS Sexual and/or gender minority parents accounted for 6802 (0.3%) of live births in California over the 5-year study period. The most common sexual and/or gender minority parental structures were "mother-mother" (n=4310; 63% of the group) and "father-father" (n=1486; 22% of the group). Compared with "parents giving birth" in the "mother-father" structure (n=2,055,038; 91%), a higher proportion of "parents giving birth" in the "sexual and/or gender minority" group were aged ≥35 years, White, college-educated, and had commercial health insurance. In addition, a higher proportion had a high prepregnancy body mass index. Although likely underreported overall, the proportion of those who used assisted reproductive technology was much higher in the "sexual and/or gender minority" group (1.4%) than in the "mother-father" group (0.05%). Cigarette smoking in the 3 months before pregnancy was similar in both groups. CONCLUSION Changes to the California birth certificate have revealed a multiplicity of parental structures. Our findings suggest that sexual and/or gender minority parents differ from other parental structures and from the general sexual and/or gender minority population and warrant further research.
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Affiliation(s)
- Iman K Berrahou
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA (Dr Berrahou).
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA (Drs Leonard, Main, and Obedin-Maliver)
| | - Adary Zhang
- Stanford University School of Medicine, Stanford, CA (Mx. Zhang)
| | - Elliott K Main
- California Maternal Quality Care Collaborative, Palo Alto, CA (Drs Leonard and Main)
| | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA (Drs Leonard, Main, and Obedin-Maliver); Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA (Dr Obedin-Maliver)
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Leonard SA, Berrahou I, Zhang A, Monseur B, Main EK, Obedin-Maliver J. Sexual and/or gender minority disparities in obstetrical and birth outcomes. Am J Obstet Gynecol 2022; 226:846.e1-846.e14. [PMID: 35358492 DOI: 10.1016/j.ajog.2022.02.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than those who are not sexual and/or gender minority individuals. OBJECTIVE To evaluate obstetrical and birth outcomes comparing couples who are likely sexual and/or gender minority patients compared with those who are not likely to be sexual and/or gender minority patients. STUDY DESIGN We performed a population-based cohort study of live birth hospitalizations during 2016 to 2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields such as "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate the risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. The models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated the analyses after excluding multifetal gestations. RESULTS In the final birthing patient sample, 1,483,119 were mothers with father partners, 2572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (adjusted risk ratio, 3.9; 95% confidence interval, 3.4-4.4), labor induction (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3), postpartum hemorrhage (adjusted risk ratio, 1.4; 95% confidence interval, 1.3-1.6), severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2-1.8), and nontransfusion severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean delivery, preterm birth (<37 weeks' gestation), low birthweight (<2500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in the multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, though the risk of multifetal gestation was nonsignificantly higher (adjusted risk ratio, 1.5; 95% confidence interval, 0.9-2.7). The adjusted risk ratios for the outcomes were similar after restriction to singleton gestations. CONCLUSION Birthing mothers with mother partners experienced disparities in several obstetrical and birth outcomes independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at a significantly elevated risk of any adverse obstetrical or birth outcome considered in this study.
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Affiliation(s)
- Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA; California Maternal Quality Care Collaborative, Palo Alto, CA.
| | - Iman Berrahou
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA
| | - Adary Zhang
- Department of Medicine, Stanford University, Stanford, CA
| | - Brent Monseur
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA; California Maternal Quality Care Collaborative, Palo Alto, CA
| | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA
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Panelli DM, Leonard SA, Wong RJ, Becker M, Mayo JA, Wu E, Girsen AI, Gotlib IH, Aghaeepour N, Druzin ML, Shaw GM, Stevenson DK, Bianco K. Leukocyte telomere dynamics across gestation in uncomplicated pregnancies and associations with stress. BMC Pregnancy Childbirth 2022; 22:381. [PMID: 35501726 PMCID: PMC9063069 DOI: 10.1186/s12884-022-04693-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Short leukocyte telomere length is a biomarker associated with stress and morbidity in non-pregnant adults. Little is known, however, about maternal telomere dynamics in pregnancy. To address this, we examined changes in maternal leukocyte telomere length (LTL) during uncomplicated pregnancies and explored correlations with perceived stress. METHODS In this pilot study, maternal LTL was measured in blood collected from nulliparas who delivered live, term, singleton infants between 2012 and 2018 at a single institution. Participants were excluded if they had diabetes or hypertensive disease. Samples were collected over the course of pregnancy and divided into three time periods: < 200/7 weeks (Timepoint 1); 201/7 to 366/7 weeks (Timepoint 2); and 370/7 to 9-weeks postpartum (Timepoint 3). All participants also completed a survey assessing a multivariate profile of perceived stress at the time of enrollment in the first trimester. LTL was measured using quantitative polymerase chain reaction (PCR). Wilcoxon signed-rank tests were used to compare LTL differences within participants across all timepoint intervals. To determine whether mode of delivery affected LTL, we compared postpartum Timepoint 3 LTLs between participants who had vaginal versus cesarean birth. Secondarily, we evaluated the association of the assessed multivariate stress profile and LTL using machine learning analysis. RESULTS A total of 115 samples from 46 patients were analyzed. LTL (mean ± SD), expressed as telomere to single copy gene (T/S) ratios, were: 1.15 ± 0.26, 1.13 ± 0.23, and 1.07 ± 0.21 for Timepoints 1, 2, and 3, respectively. There were no significant differences in LTL between Timepoints 1 and 2 (LTL T/S change - 0.03 ± 0.26, p = 0.39); 2 and 3 (- 0.07 ± 0.29, p = 0.38) or Timepoints 1 and 3 (- 0.07 ± 0.21, p = 0.06). Participants who underwent cesareans had significantly shorter postpartum LTLs than those who delivered vaginally (T/S ratio: 0.94 ± 0.12 cesarean versus 1.12 ± 0.21 vaginal, p = 0.01). In secondary analysis, poor sleep quality was the main stress construct associated with shorter Timepoint 1 LTLs (p = 0.02) and shorter mean LTLs (p = 0.03). CONCLUSIONS In this cohort of healthy pregnancies, maternal LTLs did not significantly change across gestation and postpartum LTLs were shorter after cesarean than after vaginal birth. Significant associations between sleep quality and short LTLs warrant further investigation.
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Affiliation(s)
- Danielle M Panelli
- Department of Obstetrics and Gynecology, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Martin Becker
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Jonathan A Mayo
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Erica Wu
- Department of Obstetrics and Gynecology, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA
| | - Anna I Girsen
- Department of Obstetrics and Gynecology, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA
| | - Ian H Gotlib
- Department of Psychology, Stanford University, Stanford, CA, USA
| | - Nima Aghaeepour
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Maurice L Druzin
- Department of Obstetrics and Gynecology, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Katherine Bianco
- Department of Obstetrics and Gynecology, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA
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Abrams BF, Leonard SA, Kan P, Lyell DJ, Carmichael SL. Interpregnancy weight change: associations with severe maternal morbidity and neonatal outcomes. Am J Obstet Gynecol MFM 2022; 4:100596. [PMID: 35181513 PMCID: PMC10960247 DOI: 10.1016/j.ajogmf.2022.100596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/04/2022] [Accepted: 02/10/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Prepregnancy body mass index and gestational weight gain have been linked with severe maternal morbidity, suggesting that weight change between pregnancies may also play a role, as it does for neonatal outcomes. OBJECTIVE This study assessed the association of changes in prepregnancy body mass index between 2 consecutive singleton pregnancies with the outcomes of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants in the subsequent pregnancy. STUDY DESIGN This observational study was based on birth records from 1,111,032 consecutive pregnancies linked to hospital discharge records in California (2007-2017). Interpregnancy body mass index change between the beginning of an index pregnancy and the beginning of the subsequent pregnancy was calculated from self-reported weight and height. Severe maternal morbidity was defined based on the Centers for Disease Control and Prevention index, including and excluding transfusion-only cases. We used multivariable log-binomial regression models to estimate adjusted risks, overall and stratified by prepregnancy body mass index at index birth. RESULTS Substantial interpregnancy body mass index gain (≥4 kg/m2) was associated with severe maternal morbidity in crude but not adjusted analyses. Substantial interpregnancy body mass index loss (>2 kg/m2) was associated with increased risk of severe maternal morbidity (adjusted relative risk, 1.13; 95% confidence interval (1.07-1.19), and both substantial loss (adjusted relative risk, 1.11 [1.02-1.19]) and gain (≥4 kg/m2; adjusted relative risk, 1.09 [1.02-1.17]) were associated with nontransfusion severe maternal morbidity. Substantial loss (adjusted relative risk, 1.17 [1.05-1.31]) and gain (1.26 [1.14-1.40]) were associated with stillbirth. Body mass index gain was positively associated with large-for-gestational-age infants and inversely associated with small-for-gestational-age infants. CONCLUSION Substantial interpregnancy body mass index changes were associated with modestly increased risk of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants.
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Affiliation(s)
- Barbara F Abrams
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA (XX Abrams)
| | - Stephanie A Leonard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (XX Leonard, XX Lyell, and Dr Carmichael)
| | - Peiyi Kan
- Division of Neonatology and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford University School of Medicine, Stanford, CA (XX Kan and Dr Carmichael)
| | - Deirdre J Lyell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (XX Leonard, XX Lyell, and Dr Carmichael)
| | - Suzan L Carmichael
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (XX Leonard, XX Lyell, and Dr Carmichael); Division of Neonatology and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford University School of Medicine, Stanford, CA (XX Kan and Dr Carmichael).
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Leonard SA, Main EK, Lyell DJ, Carmichael SL, Kennedy CJ, Johnson C, Mujahid MS. Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups. Am J Obstet Gynecol MFM 2022; 4:100530. [PMID: 34798329 PMCID: PMC10980357 DOI: 10.1016/j.ajogmf.2021.100530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/30/2021] [Accepted: 11/10/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND A recently developed obstetrical comorbidity scoring system enables the comparison of severe maternal morbidity rates independent of health status at the time of birth hospitalization. However, the scoring system has not been evaluated in racial-ethnic and socioeconomic groups or used to assess disparities in severe maternal morbidity. OBJECTIVE This study aimed to evaluate the performance of an obstetrical comorbidity scoring system when applied across racial-ethnic and socioeconomic groups and to determine the effect of comorbidity score risk adjustment on disparities in severe maternal morbidity. STUDY DESIGN We analyzed a population-based cohort of live births that occurred in California during 2011 through 2017 with linked birth certificates and birth hospitalization discharge data (n=3,308,554). We updated a previously developed comorbidity scoring system to include the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modifications diagnosis codes and applied the scoring system to subpopulations (groups) defined by race-ethnicity, nativity, payment method, and educational attainment. We then calculated the risk-adjusted rates of severe maternal morbidity (including and excluding blood transfusion-only cases) for each group and estimated the disparities for these outcomes before and after adjustment for the comorbidity score using logistic regression. RESULTS The obstetric comorbidity scores performed consistently across groups (C-statistics ranged from 0.68 to 0.76; calibration curves demonstrated overall excellent prediction of absolute risk). All non-White groups had significantly elevated rates of severe maternal morbidity before and after risk adjustment for comorbidities when compared with the White group (1.3% before, 1.3% after) (American Indian-Alaska Native: 2.1% before, 1.8% after; Asian: 1.5% before, 1.7% after; Black: 2.5% before, 2.0% after; Latinx: 1.6% before, 1.7% after; Pacific Islander: 2.2% before, 1.9% after; and multi-race groups: 1.7% before, 1.6% after). Risk adjustment also modestly increased disparities for the foreign-born group and government insurance groups. Higher educational attainment was associated with decreased severe maternal morbidity rates, which was largely unaffected by comorbidity risk adjustment. The pattern of results was the same whether or not transfusion-only cases were included as severe maternal morbidity. CONCLUSION These results support the use of an updated comorbidity scoring system to assess disparities in severe maternal morbidity. Disparities in severe maternal morbidity decreased in magnitude for some racial-ethnic and socioeconomic groups and increased in magnitude for other groups after adjustment for the comorbidity score.
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Affiliation(s)
- Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA; California Maternal Quality Care Collaborative, Stanford University, Stanford, CA.
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA; California Maternal Quality Care Collaborative, Stanford University, Stanford, CA
| | - Deirdre J Lyell
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA; California Maternal Quality Care Collaborative, Stanford University, Stanford, CA
| | - Suzan L Carmichael
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA; Department of Pediatrics, Stanford University, Stanford, CA
| | - Chris J Kennedy
- Department of Biomedical Informatics, Harvard University, Boston, MA
| | - Christina Johnson
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Mahasin S Mujahid
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA
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Murugappan G, Leonard SA, Farland LV, Lau ES, Shadyab AH, Wild RA, Schnatz P, Carmichael SL, Stefanick ML, Parikh NI. Association of infertility with atherosclerotic cardiovascular disease among postmenopausal participants in the Women’s Health Initiative. Fertil Steril 2022; 117:1038-1046. [PMID: 35305814 PMCID: PMC9081220 DOI: 10.1016/j.fertnstert.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the association of infertility with atherosclerotic cardiovascular disease (ASCVD) among postmenopausal participants in the Women's Health Initiative (WHI). We hypothesized that nulliparity and pregnancy loss may reveal more extreme phenotypes of infertility, enabling further understanding of the association of infertility with ASCVD. DESIGN Prospective cohort study. SETTING Forty clinical centers in the United States. PATIENT(S) A total of 158,787 postmenopausal participants in the Women's Health Initiative cohort. INTERVENTION(S) Infertility, parity, and pregnancy loss. MAIN OUTCOME MEASURE(S) The primary outcome was risk of ASCVD among women with and without a history of infertility, stratified by history of live birth and pregnancy loss. Cox proportional-hazards models were adjusted for demographics and risk factors for ASCVD. RESULT(S) Among 158,787 women, 25,933 (16.3%) reported a history of infertility; 20,427 (80%) had at least 1 live birth; and 9,062 (35%) had at least 1 pregnancy loss. There was a moderate overall association between infertility and ASCVD (adjusted hazard ratio, 1.02; 95% confidence interval [CI], 0.99-1.06) over 19 years of follow-up. Among nulliparous women, infertility was associated with a 13% higher risk of ASCVD (95% CI, 1.04-1.23). Among nulliparous women who had a pregnancy loss, infertility was associated with a 36% higher risk of ASCVD (95% CI, 1.09-1.71). CONCLUSION(S) Women with a history of infertility overall had a moderately higher risk of ASCVD compared with women without a history of infertility. Atherosclerotic cardiovascular disease risk was much higher among nulliparous infertile women and among nulliparous infertile women who also had a pregnancy loss, suggesting that in these more extreme phenotypes, infertility may be associated with ASCVD risk.
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Affiliation(s)
- Gayathree Murugappan
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California.
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Obstetrics and Gynecology, College of Medicine-Tucson, University of Arizona, Tucson, Arizona
| | - Emily S Lau
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Robert A Wild
- Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Peter Schnatz
- Department of Obstetrics and Gynecology and Internal Medicine, Reading Hospital, Reading, Pennsylvania
| | - Suzan L Carmichael
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California; Department of Pediatrics, Stanford University Medical Center, Stanford, California
| | - Marcia L Stefanick
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California; Department of Medicine, Stanford Prevention Research Center, Stanford, California
| | - Nisha I Parikh
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
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Smith KL, Shipchandler F, Kudumu M, Davies-Balch S, Leonard SA. "Ignored and Invisible": Perspectives from Black Women, Clinicians, and Community-Based Organizations for Reducing Preterm Birth. Matern Child Health J 2022; 26:726-735. [PMID: 35072869 DOI: 10.1007/s10995-021-03367-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The preterm birth rate for Black women in the U.S. is consistently higher than other racial groups. The crisis of preterm birth and adverse birth outcomes among Black people is a historical, systematic confluence of racism, stressors, and an unsupportive and hostile healthcare system. To inform the development of preterm birth risk reduction interventions, this study aimed to collect and synthesize the experiences of Black women who gave birth preterm along with clinicians and community-based organizations who serve them. METHODS A qualitative study design was employed whereby nine focus groups and 17 key informant interviews that included Black women, clinicians, and representatives from community-based organizations were facilitated in Los Angeles County from March 2019 to March 2020. Participants were recruited through the organizations and the focus groups took place virtually and in person. The process of thematic analysis was employed to analyze the focus group and interview transcripts. RESULTS Five overarching themes emerged from the data. Black women experience chronic and pregnancy-related stress, and have lasting trauma from adverse maternal health experiences. These issues are exacerbated by racism and cultural incongruence within healthcare and social services systems. Black women have relied on self-education and self-advocacy to endure the barriers related to racism, mistreatment, and their experiences with preterm birth. CONCLUSIONS FOR PRACTICE Healthcare and social service providers must offer more holistic care that prioritizes, rather than ignores, the racial components of health, placing increased importance on implementing inclusive and culturally-appropriate patient education, attentiveness to patient needs, respectful care, and support for Black women.
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Affiliation(s)
| | - Fatema Shipchandler
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | | | | | - Stephanie A Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, School of Medicine, Stanford University, Stanford, CA, USA
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Phibbs CM, Kozhimannil KB, Leonard SA, Lorch SA, Main EK, Schmitt SK, Phibbs CS. A Comprehensive Analysis of the Costs of Severe Maternal Morbidity. Womens Health Issues 2022; 32:362-368. [PMID: 35031196 DOI: 10.1016/j.whi.2021.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases. METHODS California linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS. RESULTS Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days]). CONCLUSIONS Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.
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Affiliation(s)
| | - Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Stephanie A Leonard
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Palo Alto, California; California Maternal Quality Care Collaborative, Palo Alto, California
| | - Scott A Lorch
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elliott K Main
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Palo Alto, California; California Maternal Quality Care Collaborative, Palo Alto, California
| | - Susan K Schmitt
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California; Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Ciaran S Phibbs
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California; Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.
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Miller SE, Sperling M, Cruz G, Schulkin J, Leonard SA, Lyell DJ, Herrero T, Blumenfeld YJ. Provider utilization of gestational diabetes screening methods – Have practices changed since the HAPO trial? Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Miller HE, Sie L, Minor KC, Bianco K, Druzin ML, Lee HC, Leonard SA. Preterm twin gestation: The association between severity of small for gestational age and neonatal outcomes. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Girsen A, Leonard SA, Carmichael SL, Gibbs RS, Butwick A. Hospital Readmissions after Postpartum Emergency Department Visit. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Leonard SA, Berrahou I, Zhang A, Main EK, Obedin-Maliver J. Obstetric and birth outcomes among sexual and/or gender minority patients, California, 2016-2019. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Callahan A, Murugappan G, Main EK, Leonard SA. Constructing a cohort of nulliparous, term, singleton, vertex births from electronic health records. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Panelli DM, Sherwin EB, Lee CJ, Leonard SA, Miller SE, Miller HE, Tolani AT, Hoover V, Ansari JR, Khandelwal A, Bianco K. Clinical factors associated with a positive postpartum depression screen in people with cardiac disease during pregnancy. Curr Res Psychiatry 2022; 2:25-29. [PMID: 36570491 PMCID: PMC9788649 DOI: 10.46439/psychiatry.2.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background While people with cardiac disease are known to be at increased lifetime risk of depression, little is known about postpartum depression rates in this population. Describing rates of positive postpartum depression screens and identifying risk factors that are unique to cardiac patients may help inform risk reduction strategies. Methods This retrospective cohort study included pregnant patients with congenital and/or acquired cardiac disease who delivered at a single institution between 2014 and 2020. The primary outcome was a positive postpartum depression screen, defined as Edinburgh Postpartum Depression Score (EPDS) ≥10. Potential exposures were selected a priori and compared between patients with and without a positive postpartum depression screen using Wilcoxon rank-sum and Fisher's exact tests. Secondary outcomes were responses to a longitudinal follow-up survey sent to English-speaking patients evaluating cardiac status, mental health, and infant development. Results Of 126 eligible cardiac patients, 23 (18.3%) had a positive postpartum depression screen. Patients with a positive postpartum depression screen were more likely to have had antepartum anticoagulation with heparin or enoxaparin (56.5% versus 26.2%, p=0.007), blood transfusion during delivery (8.7% versus 0%, p=0.032), and maternal-infant separation postpartum (52.2% versus 28.2%, p=0.047) compared to patients with a negative screen. Among 29 patients with a positive screen who responded to the follow up survey, 50% reported being formally diagnosed with anxiety or depression and 33.3% reported child development problems. Conclusions Our results highlight the importance of screening for postpartum depression in patients with cardiac disease, especially those requiring antepartum anticoagulation or maternal-infant separation postpartum.
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Affiliation(s)
- Danielle M. Panelli
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA,Author for correspondence:
| | - Elizabeth B. Sherwin
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine J. Lee
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie A. Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah E. Miller
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Hayley E. Miller
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Alisha T. Tolani
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Valerie Hoover
- Department of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jessica R. Ansari
- Division of Obstetric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Abha Khandelwal
- Department of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Katherine Bianco
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Sperling M, Leonard SA, Miller SE, El-Sayed YY, Herrero T, Faig J, Carter S, Blumenfeld YJ. Ketonuria is associated with a positive 1-hour oral glucose tolerance test. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Miller SE, Sperling M, Cruz G, Schulkin J, Leonard SA, Lyell DJ, Herrero T, Blumenfeld YJ. To Eat or not to Eat? Provider Recommendations Surrounding Oral Intake Before the 50g OGTT. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Minor KC, Liu J, El-Sayed YY, Druzin ML, Profit J, Hintz S, Bonifacio S, Leonard SA, Karakash S. Does magnesium sulfate for hypertensive disease reduce the risk of neonatal hypoxic ischemic encephalopathy? Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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