Breastfeeding Practices in Patients with Heart Disease Stratified by Area Deprivation Index

Objective: We sought to evaluate breastfeeding (BF) practices in patients with maternal cardiac disease (MCD) stratified by area deprivation index (ADI) to identity communities at risk. Study Design: Retrospective cohort of patients managed by the University of Alabama at Birmingham (UAB) Cardio-Obstetrics Program. Patients were included if they had ≥1 prenatal visit with the Cardio-Obstetrics team, delivered at UAB, and had a street address on file. The primary outcome was BF rate at hospital discharge. Secondary outcomes included BF intent on admission and BF at the postpartum (PP) visit. ADI reports socioeconomic disadvantage at the census tract level; 1 = least deprived and 100 = most deprived. Baseline characteristics and BF rates were compared by ADI categories: Low (ADI 1-33), medium (ADI 34-66), and high (ADI 67-100). Results: One hundred and forty-eight patients were included: 14 (10%) low, 42 (28%) medium, and 92 (62%) high ADI. Patients in the high ADI category were younger relative to those in the medium or low ADI (26 versus 28 versus 32 years; p < 0.01) and less likely to be married or living with a partner (30.4% versus 58.5% versus 71.4%; p < 0.01), There was no difference in BF intent between the lowest, medium, and highest ADI categories (85.7% versus 85.4% versus 81.6%; p = 0.38) or BF rates at hospital discharge (100% versus 92.7% versus 85.6%, p = 0.23). However, there was a significant difference in BF rates at the PP visit (90% versus 63.0% versus 38.6%; p < 0.01) even after controlling for differences in baseline characteristics (odds ratio = 0.11 (95% confidence interval [0.01-0.93]), p = 0.043). Conclusions: There was an association between living in a resource-poor community and early cessation of BF in our population of patients with MCD. Community-based interventions targeting mothers with heart disease living in high ADI communities may help these individuals achieve higher BF rates.

Racial Disparities in Breastfeeding Rates in Patients with Heart Disease

OBJECTIVE

To evaluate racial disparities in breastfeeding rates in patients with heart disease.

STUDY DESIGN

Retrospective cohort of pregnant patients with maternal cardiac disease managed by a Cardio-Obstetrics program. Patients self-identifying as Non-Hispanic Black (NHB) and Non-Hispanic White (NHW), who attended ≥ 1 prenatal visit at the Cardio-Obstetrics Program and delivered at the same hospital between March 2015 and June 2019 were included. The primary outcome was breastfeeding rate at discharge from the delivery-associated hospitalization. Secondary outcomes included breastfeeding intent on admission and breastfeeding rates at the postpartum visit among patients who initiated breastfeeding.

RESULTS

138 pregnant patients with cardiac disease were included: 58 (42%) NHB and 80 (58%) NHW patients. Parity, marital status and insurance were statistically different between groups. NHB patients were more likely to have government insurance compared to NHW patients (77.6% vs. 40%; p < 0.001). There was a significant difference in the intent to breastfeed upon admission for the delivery-associated hospitalization (74.2% NHB vs. NHW 91.3%; p = 0.01), but not at hospital discharge (84.5% NHB vs. 93.8% NHW; p = 0.08). However, breastfeeding rates were significantly lower among NHB patients at the postpartum visit among the entire cohort (38.2% in NHB vs. 61.1% in NHW women; p = 0.036) and among those who initiated breastfeeding (35.3% NHB vs. 61.1% NHW, p = 0.018).

CONCLUSIONS

Despite similar breastfeeding rates at hospital discharge, NHB patients with maternal cardiac disease were less likely to intend to breastfeed at admission and/or continue breastfeeding by the postpartum visits. Qualitative studies understanding these differences are crucial to improve breastfeeding rates, especially for NHB patients with maternal cardiac disease.

Adverse pregnancy outcomes and risk of type 2 diabetes in postmenopausal women

BACKGROUND

Although gestational diabetes mellitus and delivering high-birthweight infants are known to predict a higher risk of future type 2 diabetes mellitus, the association of hypertensive disorders of pregnancy and other adverse pregnancy outcomes with type 2 diabetes mellitus is not well established.

OBJECTIVE

This study aimed to examine the associations between different types of adverse pregnancy outcomes and incident type 2 diabetes mellitus among postmenopausal women.

STUDY DESIGN

The Women's Health Initiative, a nationwide cohort of postmenopausal women, collected self-reported history of adverse pregnancy outcomes, including gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm birth, and delivering low- birthweight (<2500 g) or high-birthweight (>4500 g) infants. Participants were followed up annually for self-reported incident type 2 diabetes mellitus treated with medication from baseline (1993-1998) to March 2021. This study used logistic regression to examine the associations of any and individual adverse pregnancy outcomes with diabetes mellitus. Stratified analyses were performed to assess effect modification by body mass index, race and ethnicity, education, parity, breastfeeding, and age at first birth.

RESULTS

This analysis included 49,717 women without a history of diabetes mellitus at enrollment who had a least 1 pregnancy and responded to the questionnaire about adverse pregnancy outcomes. After adjusting for body mass index, demographic, lifestyle, and reproductive factors, gestational diabetes mellitus (odds ratio, 2.26; 95% confidence interval, 1.94-2.63), high birthweight (odds ratio, 1.30; 95% confidence interval, 1.18-1.44), and hypertensive disorders of pregnancy (odds ratio, 1.18; 95% confidence interval, 1.08-1.30) were independently associated with higher odds of type 2 diabetes mellitus, whereas preterm birth and low birthweight were not associated with diabetes mellitus risk. A history of ≥2 adverse pregnancy outcomes was associated with higher odds of type 2 diabetes mellitus (odds ratio, 1.55; 95% confidence interval, 1.28-1.88). This study further observed higher odds of type 2 diabetes mellitus (odds ratio, 3.69; 95% confidence interval, 2.38-5.70) among women with a history of both gestational diabetes mellitus and hypertensive disorders of pregnancy than those without any adverse pregnancy outcomes.

CONCLUSION

Postmenopausal women with a history of gestational diabetes mellitus, those delivering high-birthweight infants, or those with hypertensive disorders of pregnancy are at risk of future type 2 diabetes mellitus. In addition, women with ≥2 conditions had an augmented risk and might be prioritized for screening and prevention efforts for type 2 diabetes mellitus.

Breastfeeding practices among patients managed by a comprehensive cardio-obstetrics program

Objective: To evaluate breastfeeding intent, rates at discharge, and continued breastfeeding at follow-up in patients managed in a comprehensive cardio-obstetrics program stratified by severity of maternal cardiac disease.Study Design: Retrospective cohort of patients managed by a comprehensive cardio-obstetrics program at the University of Alabama at Birmingham (UAB). Patients were included if they had ≥1 prenatal visit with the Cardio-Obstetrics team and delivered at UAB. The primary outcome was the breastfeeding rate on discharge from the delivery-associated hospitalization. Secondary outcomes included intent to breastfeed on admission and breastfeeding at the postpartum visit. Baseline characteristics and rates were compared between patients with less severe (mWHO I - II/III) vs. more severe (mWHO III - IV) maternal cardiac disease.Results: 147 patients were included: 85 (57.8%) mWHO class I - II and 62 (42.2%) mWHO class III-IV. Patients with more severe maternal cardiac disease had higher rates of chronic hypertension (22.6% vs. 9.4%; p = 0.027), lower gestational age at delivery (36.4 vs 37.7 weeks; p = 0.008), and higher rates of NICU admission (31.2% vs. 14.1%; p = 0.013). There were no significant differences between mWHO class I-II vs. mWHO class III-IV in intent to breastfeed upon admission to the delivery-associated hospitalization (84.7% vs. 82.3%; p = 0.67), breastfeeding rates upon discharge from the delivery-associated hospitalization (90.6% vs. 87.1%; p = 0.50), or breastfeeding rates at the postpartum visit (54.1% vs. 48.5%; p = 0.60).Conclusions: Despite potential barriers in this high-risk population, over 85% of patients breastfed upon discharge from the delivery-associated hospitalization. However, breastfeeding rates dropped by 40% at the postpartum visit. Strategies to support breastfeeding in the post-partum period in patients with maternal cardiac disease are imperative.

Predicting Spontaneous Labor beyond 39 Weeks among Low-Risk Expectantly Managed Pregnant Patients

OBJECTIVES

The aim of the study was to identify the characteristics associated with spontaneous labor onset in pregnant patients undergoing expectant management at greater than 39 weeks' gestation and delineate perinatal outcomes associated with spontaneous labor compared with labor induction.

STUDY DESIGN

This was a retrospective cohort study of singleton pregnancies at ≥390/7 weeks' gestation delivered at a single center in 2013. The exclusion criteria were elective induction, cesarean delivery or presence of a medical indication for delivery at 39 weeks, more than one prior cesarean delivery, and fetal anomaly or demise. We evaluated prenatally available maternal characteristics as potential predictors of the primary outcome-spontaneous labor onset. Multivariable logistic regression was used to generate two parsimonious models: one with and one without third trimester cervical dilation. We also performed sensitivity analysis by parity and timing of cervical examination, and compared the mode of delivery and other secondary outcomes between patients who went into spontaneous labor and those who did not.

RESULTS

Of 707 eligible patients, 536 (75.8%) attained spontaneous labor and 171 (24.2%) did not. In the first model, maternal body mass index (BMI), parity, and substance use were identified as the most predictive factors. Overall, the model did not predict spontaneous labor (area under the curve [AUC]: 0.65; 95% confidence interval [CI]: 0.61-0.70) with high accuracy. The addition of third trimester cervical dilation in the second model did not significantly improve labor prediction (AUC: 0.66; 95% CI: 0.61-0.70; p = 0.76). These results did not differ by timing of cervical examination or parity. Patients admitted in spontaneous labor had lower odds of cesarean delivery (odds ratio [OR]: 0.33; 95% CI: 0.21-0.53) and neonatal intensive care unit (NICU) admission (OR: 0.38; 95% CI: 0.15-0.94). Other perinatal outcomes were similar between the groups.

CONCLUSION

Maternal characteristics did not predict spontaneous labor onset at ≥39 weeks' gestation with high accuracy. Patients should be counseled on the challenges of labor prediction regardless of parity and cervical examination, outcomes if spontaneous labor does not occur, and benefits of labor induction.

KEY POINTS

· Majority of patients will attain spontaneous labor at ≥39 weeks.. · Maternal characteristics do not predict labor at ≥39 weeks.. · Spontaneous labor has associated lower perinatal risks.. · A shared decision model should be utilized in counseling patients who may choose expectant management..

Two pregnancies in a patient following pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

Pregnancies complicated by pulmonary hypertension are associated with a high rate of maternal morbidity and mortality. Pulmonary endarterectomy is a curative treatment for pulmonary hypertension in select patients with chronic thromboembolic pulmonary hypertension. Limited data exist regarding the maternal and perinatal outcomes following pulmonary endarterectomy.We present the case of a patient in her 20s with antiphospholipid antibody syndrome and chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy and subsequently carried two pregnancies. Her cardiopulmonary status remained stable throughout both pregnancies. Her first pregnancy was complicated by HELLP syndrome requiring induction of labour at 30 weeks, and her second child was born at term. In summary, this patient's course provides cautious optimism that a curative pulmonary endarterectomy may allow a patient to avoid complications of pulmonary hypertension during pregnancy.

Community and Systems Contributors and Strategies to Reduce Racial Inequities in Maternal Health in the Deep South: Provider Perspectives

Purpose

Black pregnant individuals in Alabama are disproportionately affected by severe maternal morbidity and mortality (SMM). To understand why racial disparities in maternal health outcomes persist and identify potential strategies to reduce these inequities, we sought perspectives from obstetric health care providers, health administrators, and members of local organizations who provide pregnancy, delivery, and postpartum care services in Alabama.

Methods

We conducted qualitative in-depth interviews with stakeholders (n=20), purposively recruited from community-based organizations, clinical settings, government organizations, and academic institutions. Interview guides were based on Howell's conceptual model of pathways to racial disparities in maternal mortality. Data were coded using a modified framework theory approach and analyzed thematically.

Results

Racism, unjust laws and policies, and poverty/lack of infrastructure in communities emerged as major themes contributing to racial disparities in maternal health at the community and systems levels. Inadequate health insurance coverage was described as a strong driver of the disparities. Service providers suggested strategies for Alabama should be community focused, evidence based, and culturally sensitive. These should include Medicaid expansion, expanded parental leave, and removal of laws restricting choice. Community- and systems-level interventions should include community infrastructure improvements, choice in maternity services, and provision of digital communication options.

Conclusions

Providers shared perspectives on community and structural areas of intervention to reduce racial inequities in SMM. These results can inform discussions with health system and community partners about Alabama and other Deep South initiatives to improve maternal health outcomes in black communities.

Associations of maternal preterm birth with subsequent risk for type 2 diabetes in women from the women's health initiative

Preterm birth has been associated with insulin resistance and beta-cell dysfunction, a hallmark characteristic of type 2 diabetes. However, studies investigating the relationship between a personal history of being born preterm and type 2 diabetes are sparse. We sought to investigate the potential association between a personal history of being born preterm and risk for type 2 diabetes in a racially and ethnically diverse population. Baseline and incident data (>16 years of follow-up) from the Women's Health Initiative (n = 85,356) were used to examine the association between personal history of being born preterm (born 1910-1940s) and prevalent (baseline enrollment; cross-sectional) or incident (prospective cohort) cases of type 2 diabetes. Logistic and Cox proportional hazards regression models were used to estimate odds and hazards ratios. Being born preterm was significantly, positively associated with odds for prevalent type 2 diabetes at enrollment (adjOR = 1.79, 95% CI 1.43-2.24; P < 0.0001). Stratified regression models suggested the positive associations at baseline were consistent across race and ethnicity groups. However, being born preterm was not significantly associated with risk for incident type 2 diabetes. Regression models stratified by age at enrollment suggest the relationship between being born preterm and type 2 diabetes persists only among younger age groups. Preterm birth was associated with higher risk of type 2 diabetes but only in those diagnosed with type 2 diabetes prior to study enrollment, suggesting the association between preterm birth and type 2 diabetes may exist at earlier age of diagnosis but wane over time.

Validation of a Remote Monitoring Blood Pressure Device in Pregnancy

BACKGROUND

The Ideal Life Blood Pressure Manager measures blood pressure (BP) and automatically transmits results to the patient's medical record independent of internet access, but has not been validated. Our objective was to conduct a validation study of the Ideal Life BP Manager in pregnant women using a validation protocol.

METHODS

Pregnant participants were enrolled into three subgroups per the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization protocol: normotensive (systolic blood pressure (SBP) < 140 and diastolic blood pressure (DBP) < 90), hypertensive without proteinuria (SBP ≥ 140 or DBP ≥ 90), and preeclampsia (SBP ≥ 140 or DBP ≥ 90 with proteinuria). Two trained research staff used a mercury sphygmomanometer to validate the device, alternating sphygmomanometer, and device readings for a total of 9 measurements.

RESULTS

Among 51 participants, the mean SBP and DBP differences and standard deviations between the device and the mean staff measurements for all participants were 1.7 ± 7.1 and 1.5 ± 7.0 mm Hg, respectively. The standard deviations of the individual participant's paired device and mean staff SBP and DBP measurements were 6.0 and 6.4 mm Hg, respectively. The device was more likely to overestimate rather than underestimate BP (SBP: mean difference = 1.67, 95% CI [-12.15 to 15.49]; DBP: mean difference = 1.51, 95% CI [-12.26 to 15.28]). Most paired readings had a difference of less than 10 mm Hg across averaged paired readings.

CONCLUSION

The Ideal Life BP Manager met internationally recognized validity criteria in this sample of pregnant women.

Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

OBJECTIVE

Approximately one-third of maternal deaths occur postpartum. Little is known about the intersection between the postpartum period, emergency department (ED) use, and opportunities to reduce maternal mortality. The primary objectives of this systematic review are to explore the incidence of postpartum ED use, identify postpartum disease states that are evaluated in the ED, and summarize postpartum ED use by race/ethnicity and payor source.

STUDY DESIGN

We searched PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, Cochrane CENTRAL, Social Services Abstracts, and Scopus from inception to September 19, 2019. Each identified abstract was screened by two authors; the full-text manuscripts of all studies deemed to be potential candidates were then reviewed by the same two authors and included if they were full-text, peer-reviewed articles in the English language with primary patient data reporting care of a female in the ED in the postpartum period, defined as up to 1 year after the end of pregnancy.

RESULTS

A total of 620 were screened, 354 records were excluded and 266 full-text articles were reviewed. Of the 266 full-text articles, 178 were included in the systematic review; of these, 108 were case reports. Incidence of ED use by postpartum females varied from 4.8 to 12.2% in the general population. Infection was the most common reason for postpartum ED evaluation. Young females of minority race and those with public insurance were more likely than whites and those with private insurance to use the ED.

CONCLUSION

As many as 12% of postpartum women seek care in the ED. Young minority women of lower socioeconomic status are more likely to use the ED. Since approximately one-third of maternal deaths occur in the postpartum period, successful efforts to reduce maternal mortality must include ED stakeholders. This study is registered with the Systematic Review Registration (identifier: CRD42020151126).

KEY POINTS

· Up to 12% of postpartum women seek care in the ED.. · One-third of maternal deaths occur postpartum.. · Maternal mortality reduction efforts should include ED stakeholders..

Analytical approaches to evaluating hypertensive disorders of pregnancy

BACKGROUND

Data from the A Randomized Trial of Induction Versus Expectant Management study suggested that low-risk pregnant patients randomized to expectant management at term had a higher risk for developing hypertensive disorders of pregnancy than pregnant patients randomized to elective induction at 39 weeks. In addition, hypertensive disorders of pregnancy were reported to decrease with advancing gestational age when comparing outcomes by gestational age at delivery.

OBJECTIVE

This study aimed to verify these contrasting findings by evaluating the relationship between hypertensive disorders of pregnancy at term and gestational age at delivery.

STUDY DESIGN

This was a secondary analysis of a multicenter, prospective cohort study of nulliparous pregnant patients with singleton gestations (from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be). Pregnant patients who delivered ≥37+0 weeks' gestation were included. Patients were excluded if they did not provide consent for data release in subsequent studies or if they had missing outcome data. The primary outcome was hypertensive disorders of pregnancy, defined as gestational hypertension or preeclampsia with or without severe features according to the American College of Obstetricians and Gynecologists guidelines. Descriptive statistics were used to evaluate hypertensive disorders of pregnancy in the following 2 ways: analysis (1), incidence of hypertensive disorders of pregnancy by gestational age week among all ongoing pregnancies and analysis (2), the incidence of hypertensive disorders of pregnancy by gestational age week among deliveries at that gestational age week. It was assumed that hypertensive disorders of pregnancy were not expectantly managed at term.

RESULTS

Of the 8011 pregnant patients included in this analysis, 1003 (12.5%) had hypertensive disorders of pregnancy: 162 (24.5%) delivered at 37+0 to 37+6 weeks' gestation, 232 (18%) delivered at 38+0 to 38+6 weeks, 310 (12.1%) delivered at 39+0 to 39+6 weeks, 207 (8.7%) delivered at 40+0 to 40+6 weeks, and 92 (8.1%) delivered at ≥41+0 weeks. In analysis 1, the incidence of hypertensive disorders of pregnancy increased with advancing gestational age among all ongoing pregnancies with a hypertensive disorder of pregnancy (2.0% at 37 weeks and 8.1% at 41 weeks). In analysis 2, the incidence of hypertensive disorders of pregnancy decreased with advancing gestational age among deliveries at that gestational age week alone (24.5% at 37 weeks and 8.1% at 41 weeks).

CONCLUSION

Our results confirm the findings from the A Randomized Trial of Induction Versus Expectant Management study showing that the risk for hypertensive disorders of pregnancy increases with advancing gestational age, but hypertensive disorders of pregnancy is more common among deliveries at earlier gestational ages. These key differences illustrate how important the study design and analytical approach are to accurately interpret results and apply findings clinically.

Uterine myomas: effect of prior myomectomy on pregnancy outcomes

OBJECTIVE

Reproductive aged women with fibroids must weigh the risks and benefits of preconception myomectomy. Women with fibroids may have higher rates of fetal growth restriction (FGR) and stillbirth; however, there is a paucity of data on the impact of myomectomy on pregnancy outcomes. We compared perinatal outcomes in women with prior myomectomy versus those with no prior myomectomy and at least one fibroid ≥ 5 cm.

METHODS

Retrospective cohort study of women at a single center who delivered between 2008 and 2017 with a viable intrauterine pregnancy at initial ultrasound scan and either prior myomectomy, or, in the no-myomectomy cohort, at least one fibroid ≥ 5 cm on a prenatal scan performed at < 21 weeks' gestation (wga). Pregnancies complicated by major congenital anomalies were excluded. Primary outcome was preterm birth (PTB) < 37wga. Secondary outcomes included rates of spontaneous loss, cesarean delivery (CD), abnormal placentation, malpresentation, FGR, birthweight, birthweight percentile, estimated blood loss (EBL), blood transfusion, and neonatal survival to discharge.

RESULTS

A total of 290 women met inclusion criteria: 70 had a prior myomectomy, 220 women had ≥1 fibroid ≥5cm. Women with prior myomectomy were older, more likely to have private insurance, and more likely used artificial reproductive technology to conceive; 20% with prior myomectomy still had at least one ≥ 5 cm myoma on their obstetric scan. Rates of spontaneous loss were lower in the prior myomectomy group (1.4% vs 7.3%; p = .08). Of the 273 pregnancies continuing beyond 20 weeks, women with prior myomectomy had significantly more PTBs (35% vs. 21%, p = .02) and significantly different primary birth indications (p < .0001). However, after controlling for late preterm, prelabor cesareans recommended by providers in the myomectomy cohort, the difference in PTB rates was not significant (p = .13). The myomectomy group had more CDs (88% vs. 53%, p < .0001), higher EBL (1250 mL vs. 811 mL, p = .04), and a trend toward more blood transfusions (16% vs 8%, p = .05). Other selected outcomes were similar, including rates of FGR.

CONCLUSIONS

Women with prior myomectomy had significantly more PTBs, due in part to more preterm, prelabor cesareans in the late preterm period. Otherwise, prior myomectomy did not confer appreciable obstetric or perinatal benefits, as patients had more CDs, and higher EBL. Recommendations to perform preterm prelabor cesareans in this population may explain some of the PTB disparity. The effect of prior myomectomy on early pregnancy loss and infertility requires further study.

Delivery timing for the opioid-exposed infant

BACKGROUND

The prevalence of opioid use disorder and medication-assisted treatment in pregnancy is increasing. Compared with term infants, preterm infants have a lower incidence of neonatal opioid withdrawal syndrome. It is unknown whether early term delivery compared with full or late-term delivery decreases the risk of neonatal opioid withdrawal syndrome.

OBJECTIVE

This study aimed to compare the neonatal outcomes among opioid-exposed infants born in the early, full, and late-term periods.

STUDY DESIGN

This was a retrospective cohort study of opioid-exposed pregnancies delivering at a single center from 2010 to 2017 at ≥37 weeks gestation. Participants with multiple gestations or fetal anomalies were excluded. Maternal opioid exposure was defined as prescription (including medication-assisted treatment) or nonprescription opioid use or a positive urine drug screen in pregnancy for opiates. The primary outcome was a neonatal composite of respiratory distress syndrome, neonatal sepsis, neonatal seizures, hypoxic ischemic encephalopathy, jaundice requiring treatment, 5-minute Apgar <5, neonatal intensive care unit admission, neonatal opioid withdrawal syndrome, or neonatal death. The secondary outcomes included individual components of the primary outcome, birthweight, need for and length of neonatal opioid withdrawal syndrome treatment, length of hospital admission, and maximum Finnegan scores. Early (37-<39), full (39-<41), and late (41-<42 weeks) term groups were defined by the American College of Obstetricians and Gynecologists.

RESULTS

Of 399 infants, 136 (34.1%), 229 (57.4%), and 34 (8.5%) were born in the early, full, and late-term periods, respectively. Two hundred and seventy patients (67.7%) received medication-assisted treatment for opioid use disorder, and the baseline characteristics were similar in all the groups except for history of intranasal heroin use, positive urine toxicology screen for heroin or any opiates, and delivery indication (P<.05). The primary composite outcome occurred in 313 (78.4%) neonates, and 296 (74.2%) neonates had neonatal opioid withdrawal syndrome. More than half (219 [54.9%]) of opioid-exposed neonates were admitted to the neonatal intensive care unit, and 160 (40.1%) required pharmacologic neonatal opioid withdrawal syndrome treatment for a mean duration of almost 3 weeks (19.0±16.1 days). There were no significant differences in the primary composite outcome, incidence of neonatal opioid withdrawal syndrome, or other secondary outcomes (except birthweight) between neonates born in the early, full, or late-term periods.

CONCLUSION

Although neonatal morbidity was frequent among opioid-exposed neonates, the incidence and severity of neonatal opioid withdrawal syndrome or other neonatal outcomes were not different between neonates delivered in the early, full, and late-term periods, suggesting that opioid-exposed infants may not benefit from early term delivery.

Relationship Between Neighborhood Socioeconomic Disadvantage and Severe Maternal Morbidity and Maternal Mortality

Background

Rates of severe maternal morbidity and maternal mortality (SMM/MM) in the United States are rising. Disparities in SMM/MM persist by race, ethnicity and geography, and could partially be attributed to social determinants of health.

Purpose

Utilizing data from the largest, statewide referral hospital in Alabama, we investigated the relationship between residence in disadvantaged neighborhoods and SMM/MM.

Methods

Data on all pregnancies between 2010 and 2020 were included; SMM/MM cases were identified using CDC definitions. Area deprivation index (ADI) available at the census-block group was geographically linked to individual records and categorized using quintile cutoffs; higher ADI score indicated higher socioeconomic disadvantage. Generalized estimating equation models were used to adjust for spatial autocorrelation and ORs were computed to evaluate the relationship between ADI and SMM/MM, adjusted for covariates including age, race, insurance, residence in medically underserved areas/population (MUAP), and urban/rural residence.

Results

Overall, 32,909 live-birth deliveries were identified, with a prevalence of 9.8% deliveries with SMM/MM with blood transfusion and 5.3% without blood transfusion, respectively. Increased levels of ADI were associated with increased odds of SMM/MM. Compared to women in the lowest quintile, the adjusted OR for SMM/MM among women in highest quintile was 1.78 (95%CI, 1.22-2.59, P=.0027); increasing age, non-Hispanic Black, government insurance and residence in MUAP were also significantly associated with increased odds of SMM/MM.

Conclusion

Our results suggest that residence within disadvantaged neighborhoods may contribute to SMM/MM even after adjusting for patient-level factors. Measures such as ADI can help identify the most vulnerable populations and provide points to intervene.

Universal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Testing for Obstetric Inpatient Units Across the United States

BACKGROUND

The purpose of this study was to estimate prevalence of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates.

METHODS

A cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1-3-month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis.

RESULTS

Data were collected from 9 health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient units. A total of 10 147 SARS-CoV-2 tests were administered, of which 124 were positive (1.2%). Positivity rates varied by site, ranging from 0-3.2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (P=.003, r=.782) and state (P=.007, r=.708).

CONCLUSIONS

Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2-related healthcare resource utilization in obstetric inpatient units may be best informed by surrounding community infection rates.

Barriers and solutions to developing and maintaining research networks during a pandemic: An example from the iELEVATE perinatal network

Introduction

To improve maternal health outcomes, increased diversity is needed among pregnant people in research studies and community surveillance. To expand the pool, we sought to develop a network encompassing academic and community obstetrics clinics. Typical challenges in developing a network include site identification, contracting, onboarding sites, staff engagement, participant recruitment, funding, and institutional review board approvals. While not insurmountable, these challenges became magnified as we built a research network during a global pandemic. Our objective is to describe the framework utilized to resolve pandemic-related issues.

Methods

We developed a framework for site-specific adaptation of the generalized study protocol. Twice monthly video meetings were held between the lead academic sites to identify local challenges and to generate ideas for solutions. We identified site and participant recruitment challenges and then implemented solutions tailored to the local workflow. These solutions included the use of an electronic consent and videoconferences with local clinic leadership and staff. The processes for network development and maintenance changed to address issues related to the COVID-19 pandemic. However, aspects of the sample processing/storage and data collection elements were held constant between sites.

Results

Adapting our consenting approach enabled maintaining study enrollment during the pandemic. The pandemic amplified issues related to contracting, onboarding, and IRB approval. Maintaining continuity in sample management and clinical data collection allowed for pooling of information between sites.

Conclusions

Adaptability is key to maintaining network sites. Rapidly changing guidelines for beginning and continuing research during the pandemic required frequent intra- and inter-institutional communication to navigate.

Preeclampsia-Pathophysiology and Clinical Presentations: JACC State-of-the-Art Review

Preeclampsia is a hypertensive disorder of pregnancy. It affects 2% to 8% of pregnancies worldwide and causes significant maternal and perinatal morbidity and mortality. Hypertension and proteinuria are the cornerstone of the disease, though systemic organ dysfunction may ensue. The clinical syndrome begins with abnormal placentation with subsequent release of antiangiogenic markers, mediated primarily by soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng). High levels of sFlt-1 and sEng result in endothelial dysfunction, vasoconstriction, and immune dysregulation, which can negatively impact every maternal organ system and the fetus. This review comprehensively examines the pathogenesis of preeclampsia with a specific focus on the mechanisms underlying the clinical features. Delivery is the only definitive treatment. Low-dose aspirin is recommended for prophylaxis in high-risk populations. Other treatment options are limited. Additional research is needed to clarify the pathophysiology, and thus, identify potential therapeutic targets for improved treatment and, ultimately, outcomes of this prevalent disease.

Risk factors for Cesarean delivery in pregnancy with small-for-gestational-age fetus undergoing induction of labor

OBJECTIVES

To identify risk factors for Cesarean delivery and non-reassuring fetal heart tracing (NRFHT) in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor and to design and validate a prediction model, combining antenatal and intrapartum variables known at the time of labor induction, to identify pregnancies at increased risk of Cesarean delivery.

METHODS

This was a retrospective cohort study of non-anomalous, singleton gestations with a SGA fetus that underwent induction of labor, delivered in a single tertiary referral center between January 2011 and December 2016. SGA was defined as estimated fetal weight (EFW) < 10^th percentile. The primary outcome was to identify risk factors associated with Cesarean delivery. The secondary outcome was to identify risk factors associated with NRFHT. Univariate and multivariate analyses were used to determine which clinical characteristics, available at the time of admission, had the strongest association with Cesarean delivery and NRFHT during labor induction. The predictive value of the final models was assessed by the area under the receiver-operating-characteristics curve (AUC). Sensitivity and specificity of the models were also assessed. Internal validation of the models was performed using 10 000 bootstrap replicates of the original cohort. The adequacy of the models was evaluated using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

A total of 594 pregnancies were included. Cesarean delivery was performed in 243 (40.9%) pregnancies. Significant risk factors associated with Cesarean delivery, and included in the final model, were maternal age, gestational age at delivery and initial method of labor induction. The bootstrap estimate of the AUC of the final prediction model for Cesarean delivery was 0.82 (95% CI, 0.78-0.86). The model had sensitivity of 64.2%, specificity of 86.9%, positive likelihood ratio (LR) of 4.9 and negative LR of 0.41. The model had good fit (P = 0.617). NRFHT complicated 117 (19.7%) pregnancies. Significant risk factors for NRFHT included EFW < 5^th percentile, abnormal umbilical artery Doppler studies (pulsatility index > 95^th percentile or absent/reversed end-diastolic flow) and gestational age at delivery. The final prediction model for NRFHT had an AUC of 0.69 (95% CI, 0.63-0.75) and specificity of 97.0%.

CONCLUSION

We identified several significant risk factors for Cesarean delivery and NRFHT among SGA pregnancies undergoing induction of labor. Clinicians may use these risk factors to guide patient counseling and to help anticipate the potential need for operative delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Did a shared thioredoxin-reductase gene mutation lead to maternal peripartum cardiomyopathy and fatal dilated cardiomyopathy in her son? A case report

Peripartum cardiomyopathy (PPCM) is characterized by development of left ventricular systolic dysfunction and heart failure that occurs towards the end of pregnancy or in the postpartum period in the absence of structural heart disease. A complex interplay of pathophysiological mechanisms likely contributes to the PPCM phenotype. Mutations in the mitochondrial thioredoxin reductase gene (TXNRD2) have been identified as a cause of dilated cardiomyopathy. We report a case of a shared, inherited genetic mutation in the TXNRD2 gene in a mother with PPCM and her infant son who died of dilated cardiomyopathy.

Management of reproductive health in patients with pulmonary hypertension

Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.