Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association.

Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.

Who's Haywood? Path to Leadership: I Am NO Jackie Robinson.

Having been afforded many opportunities throughout my academic career, I took on the challenges that chronicled my path to leadership. In many instances, I was the first person of color to enter that educational and leadership environment. I am grateful to many mentors who have guided and supported me over the 4 decades since the time of my residency through fellowships and the various institutions to which I have been affiliated. It continues to be a great journey, making a contribution to the Ob Gyn academic community and advocating for quality and equitable women's health care.

Maternal Weight Gain and Infant Birth Weight in Women with Class III Obesity.

OBJECTIVE: The aim of this study is to describe the impact of maternal weight gain on infant birth weight among women with Class III obesity. STUDY DESIGN: Retrospective cohort of women with body mass index (BMI) ≥40 kg/m2 at initial prenatal visit, delivered from July 2013 to December 2017. Women presenting 14/0 weeks of gestational age (GA), delivering preterm, or had multiples or major fetal anomalies excluded. Maternal demographics and complications, intrapartum events, and neonatal outcomes abstracted. Primary outcomes were delivery of large for gestational age or small for gestational age (SGA) infant. Bivariate statistics used to compare women gaining less than Institute of Medicine (IOM) recommendations (LTR) and women gaining within recommendations (11-20 pounds/5-9.1 kg) (at recommended [AR]). Regression models used to estimate odds of primary outcomes. RESULTS: Of included women (n = 230), 129 (56%) gained LTR and 101 (44%) gained AR. In sum, 71 (31%) infants were LGA and 2 (0.8%) were SGA. Women gaining LTR had higher median entry BMI (46 vs. 43, p < 0.01); other demographics did not differ. LTR women were equally likely to deliver an LGA infant (29 vs. 34%, p = 0.5) but not more likely to deliver an SGA infant (0.8 vs. 1%, p > 0.99). After controlling for confounders, the AOR of an LGA baby for LTR women was 0.79 (95% CI: 0.4-1.4). CONCLUSION: In this cohort of morbidly obese women, gaining less than IOM recommendations did not impact risk of having an LGA infant, without increasing risk of an SGA infant.

Postpartum Weight Loss in Women with Class-III Obesity: Do They Lose What They Gain?

OBJECTIVE: Excessive gestational weight gain (GWG) increases risk of postpartum weight retention in normal and overweight women but little is known about weight retention in morbidly obese women. We evaluated the impact of GWG on postpartum weight retention in women with class-III obesity. STUDY DESIGN: This is a retrospective cohort of pregnancies at a single institution from July 2013 to December 2017 complicated by body mass index (BMI) ≥ 40 at entry to care. Women were classified as GWG within (WITHIN), less than (LESS), or greater than (MORE) Institute of Medicine's (IOM) recommendations. Women were excluded for multiples, late prenatal care, preterm birth, fetal anomalies, intrauterine demise, weight loss, and missing data. Primary outcome was achievement of intake weight at the postpartum visit. Logistic regression was used to adjust for confounding factors. RESULTS: Among 338 women, 93 (28%) gained WITHIN, 129 (38%) LESS, and 144 (43%) MORE. Women in the MORE group were less likely to achieve their intake weight at the postpartum visit (adjusted odds ratio [AOR] = 0.09 95% confidence interval [CI]: 0.05-0.17, p < 0.01). Women gaining MORE were the only group who did not lose weight from intake to postpartum (Median weight change [LESS: -14 lbs (IQR: -20 to -7)] vs. [WITHIN: -7 lbs (IQR: -13 to -1)] vs. [MORE: 5 lbs (IQR: 0-15)]; p < 0.01). CONCLUSION: Excessive GWG in women with class-III obesity is associated with postpartum weight retention.

Gestational Weight Gain and Postpartum Depression in Women with Class III Obesity.

OBJECTIVE: We investigated the association between gestational weight gain (GWG) and postpartum depression (PPD) in women with class III obesity. STUDY DESIGN: This is a retrospective cohort of women with body mass index (BMI) ≥ 40 kg/m2 at entry to care, first prenatal visit ≤14 weeks gestation, with singleton, nonanomalous pregnancies who delivered at term from July 2013 to December 2017. Women missing data regarding PPD were excluded. Primary outcome was PPD; classified as Edinburgh Postnatal Depression Scale (EPDS) score >13/30 or provider's report of depression. Participants were classified, according to Institute of Medicine GWG guidelines (11-20 pounds), as either less than 11 pounds (LT11) or at/more than 11 pounds (GT11). Bivariate statistics compared demographics and pregnancy characteristics. Logistic regression used to estimate odds of primary outcome. RESULTS: Of 275 women, 96 (34.9%) gained LT11 and 179 (65.1%) gained GT11 during pregnancy. The rate of PPD was 8.7% (n = 24), 9 (9.4%) in the LT11 group and 15 (8.4%) in the GT11 group (p = 0.82, odds ratio: 1.13, 95% confidence interval [CI]: 0.48, 2.69). When controlling for entry BMI and multiparity, adjusted odds of PPD was 1.07 (95% CI: 0.44, 2.63). No correlation was found between GWG and EPDS. CONCLUSION: A relationship between GWG and PPD in class III obese women was not found in this cohort.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

SMFM Special Report: Putting the "M" back in MFM: Addressing education about disparities in maternal outcomes and care.

At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them.

Quality measures in high-risk pregnancies: Executive Summary of a Cooperative Workshop of the Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists.

Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change.

Quality and Safety in Obstetrics and Gynecology.

The discipline of obstetrics and gynecology has been a leader for quality and safety in women's health for decades. Obstetrics is the leading cause for admissions, triage, and hospital discharge with over 4 million hospitalizations for births annually. Appropriately, safety initiatives and use of quality measures particularly relevant to obstetrics and gynecology are essential to patient satisfaction, safe and efficient evidence-based care.

Infant Mortality Lessons Learned from a Fetal and Infant Mortality Review Program.

Objective To review fetal and infant deaths from women enrolled in Indianapolis Healthy Start using the National Fetal and Infant Mortality Review (FIMR) methods to provide strategies for prevention. METHODS: Marion County Public Health Department (MCPHD) FIMR staff identified and reviewed 22 fetal and infant deaths to Indianapolis Healthy Start program participants between 2005 and 2012. Trained FIMR nurses completed 13 of 20 maternal interviews and compiled case summaries of all deaths from the MCPHD FIMR database.. Results Case review teams identified a total of 349 family strengths, 219 contributing factors, and made 220 recommendations for future pregnancies. FIMR deliberation values for Healthy Start program participant deaths were similar to other infant deaths in Marion County during the same time period. Common themes that emerged from the reviews included lack of social support, absence of paternal involvement, substance abuse, non-compliance, and poor health behaviors leading to chronic health conditions that complicated many pregnancies. Conclusions A number of the infant deaths in this review could have been prevented with preconception and inter-conception education and by improving the quality and content of prenatal care.

Perinatal implications of motor vehicle accident trauma during pregnancy: identifying populations at risk.

OBJECTIVE: The purpose of this study was to examine the association between restraint use, race, and perinatal outcome after motor vehicle accidents (MVAs) during pregnancy. STUDY DESIGN: The Duke Trauma Registry and medical records were searched for information on pregnant women at >14 weeks' gestation who were involved in an MVA and who received care through the Emergency Department and the Obstetric Units. Between January 1994 and December 31, 2010, 126 women were identified. Variables that were collected included type of trauma, gestational age at presentation, and delivery outcomes. A prognostic study was performed that evaluated the associations between maternal demographics, details of the accident that included restraint use, and maternal treatment that was related to the accident in relationship to perinatal outcome. RESULTS: There was no difference in the mean age or median gravidity or parity by race among pregnant women who were cared for after an MVA. There was no difference in mean age or racial distribution between women who were restrained compared with women who were unrestrained; unrestrained women were more likely to be nulliparous. Unrestrained women were more likely to require nonobstetric surgery that was related to the trauma. The overall rate of placental abruption was 6%. There were 6 intrauterine fetal deaths, 3 each in the unrestrained (25%) and restrained groups (3.5%; P = .018). Airbags deployed in 17 accidents. Among the 7 women with placenta abruption, 4 women (57%) experienced air bag deployment. CONCLUSION: Lack of restraint use during pregnancy is associated with an increased risk of fetal death.

Predictors of failed trial of labor among women with an extremely obese body mass index.

OBJECTIVE: The purpose of this study was to examine predictors associated with cesarean delivery (CD) among extremely obese women undergoing a trial of labor (TOL). STUDY DESIGN: Using a delivery database, we identified all pregnant women delivering at our institution from Jan. 1, 2008, through July 31, 2010, weighing >275 lb at the time of delivery who attempted a TOL with a singleton gestation >34 weeks' gestation. Demographic and obstetrical factors were compared for those having a successful vaginal delivery to those having a CD. RESULTS: During the study period, there were 357 pregnant women who weighed >275 lb (all with body mass index [BMI] >40 kg/m(2)), and among these, 248 (69.5%) attempted a TOL. Women having a CD had a greater BMI (51.6 vs 49.9 kg/m(2), P = .038), were less likely to be parous (32.2% vs 65.8%, P < .0001), and were more likely to be induced (80.5% vs 57.8%) compared to those having a vaginal delivery. Using a multivariable logistic regression model, among nulliparous women, maternal age, parity, and cervical dilation at time of admission were independent predictors for CD. Furthermore, an increase in BMI of 10 kg/m(2) was associated with a 3.5 increased odds (P = .002) for CD. CONCLUSION: Among nulliparous extremely obese women attempting a TOL, BMI was an independent predictor of CD, with the rate of CD increasing further with increasing BMI. The underlying mechanisms for failed TOL in the setting of maternal obesity remain largely unknown.

Putting the "M" back in maternal-fetal medicine.

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Smoking and marijuana use in pregnancy.

The obstetrical, neonatal, and childhood risk associated with prenatal smoking are well known. Prenatal smoking has been implicated in up to 25% of low birth weight infants primarily from preterm birth and fetal growth restriction and up to 10% of all infant mortality. The relationship between prenatal marijuana smoking and obstetrical and infant outcomes is less clear. Marijuana is the most commonly used illicit drug during pregnancy. Neither exposure to cigarette nor marijuana smoke has evidence for teratogenicity, but both have been implicated in developmental and hyperactivity disorders in children. Pregnant women should be counseled on the risk of both cigarette and marijuana smoking.

Fathers' Perspectives on Fatherhood and Paternal Involvement During Pregnancy and Childbirth.

There is limited research that specifically explores paternal involvement during pregnancy and childbirth. To address this gap, we completed a series of focus groups with fathers to examine social, cultural, and environmental factors that influence behaviors among new fathers while also providing community perspectives on men's experiences seeking care pre- and postdelivery. We used a phenomenological thematic approach to analyze data from 10 focus groups from five of the six Alliance for Innovation on Maternal Health-Community Care Initiative pilot sites collected between November 2021 and April 2022. The average age of fathers was 33.9 years (range = 24-61 years). The majority (86.25%) of men were African American, and approximately one sixth of focus group participants (16.25%) were Hispanic or Latino. Four key themes emerged: the importance and meaning of fatherhood, accessibility during pregnancy and childbirth, engagement during pregnancy and childbirth, and responsibility of fathers during pregnancy and childbirth. These fathers not only understood and embraced the awesome responsibility they had for their unborn child, but they also recognized and were invested in being present, accessible, engaged, and responsible to the pregnant woman during the pregnancy. Practitioners and policy makers should work to engage fathers as early in the pregnancy as possible; monitor father's mental health and financial stress; provide resources to educate fathers on maternal health, pregnancy, and childbirth; and emphasize fathers' rights, roles, and responsibilities.

The impact of prenatal education on behavioral changes toward breast feeding and smoking cessation in a healthy start population.

PURPOSE: To evaluate the impact of prenatal education by case managers on 2 social determinants of health behaviors-breast feeding and smoking cessation-among participants enrolled in Indianapolis Healthy Start (IHS). METHOD: Birth and death data up to 1 year for IHS clients were collected from Marion County vital records for births 20 weeks or greater. Case managers provide education on the health benefits for mothers and infants on breast feeding and smoking cessation to all clients. Data were analyzed for differences between the IHS participants and other Marion County births. RESULTS: Most participants (63%) were non-Hispanic blacks aged less than 25 years (56%), without a high school diploma or general education development (53%), and enrolled in Medicaid (91%). Program participants were more likely to initiate breast feeding than nonparticipants (OR, 1.33; 95% CI, 1.10-1.61), and 22% continued to breast feed for 6 months. Hispanic women were more likely to breast feed for at least 6 months (OR, 4.71; 95% CI, 2.32-9.58). Women with advanced education were more likely to have quit smoking, as were women who were breast feeding at hospital discharge. After controlling for education, IHS clients tended to be less likely to continue to smoke during the third trimester (OR, 0.76, 95% CI, 0.49-1.16), as were those with a first pregnancy (OR, 0.32; 95% CI, 0.10, 0.98) and no other smokers in the home (OR, 0.25; 95% CI, 0.08, 0.74). CONCLUSION: Breast feeding and smoking cessation are modifiable risk factors that were impacted by behavioral interventions through case management education.

Maternal weight gain and neonatal outcomes in women with class III obesity.

OBJECTIVE: Obesity in the USA continues to be a prominent medical and public health concern. Due to increasing rates of maternal obesity, the current Institute of Medicine (IOM) guidelines recommend 11-20 pounds of total weight gain during pregnancy in women with a BMI ≥30 kg/m2. The impact of maternal obesity on adverse perinatal outcomes has been well documented however, there is minimal data on the effect of gestational weight gain on neonatal outcomes. In this study, we assessed the association between gestational weight gain (GWG) and neonatal outcomes at term in women with class III obesity. STUDY DESIGN: A retrospective cohort of women delivering at a tertiary care institution between July 2013 and December 2017 with a first-trimester baseline BMI ≥40 kg/m2 was studied. Pregnancies complicated by multiple gestations, preterm delivery, fetal anomalies, intrauterine fetal demise or with missing data were excluded. The primary outcome was a composite of adverse neonatal outcomes including 5 min Apgar <7, neonatal intubation, grade 3 or 4 intraventricular hemorrhage (IVH), confirmed neonatal sepsis or Neonatal Intensive Care Unit (NICU) admission. Secondary outcomes included individual components of composite and NICU admission for >7 days. Demographic, pregnancy complications & delivery characteristics of women who gained more than IOM guidelines (>20 lbs.) were compared to women who gained at or less than IOM guidelines (≤20 lbs.) using bivariate statistics. Stepwise backward regression was used to estimate the odds of outcomes as appropriate. RESULTS: Of 374 women included, 144 (39.5%) gained more than guidelines. Women who gained above IOM recommendations were less likely to be multiparous and use tobacco. Additional demographic, obstetric and delivery characteristics, including BMI at the entry to care, did not differ. The neonatal composite occurred in 30 (8.0%) of all neonates; corresponding to 11.1% of women who gained more than IOM recommendations and 6.1% of those who gained at or below recommendations (p = .12, OR = 1.71, 95%CI 0.74-3.96). Additionally, neonates born to women gaining more than IOM recommendations were more likely to be admitted to the NICU (10.4 vs. 4.3%, p = .03) and have a NICU length of stay >7 days (6.9 vs. 2.2%, p = .03). When adjusted for mode of delivery, delivery BMI, tobacco use, and chorioamnionitis, women who gained more were not more likely to have an adverse neonatal outcome (1.54, 95%CI 0.62-3.80), they were 3.6 times more likely to have a neonate admitted to the NICU for more than 7 days (95%CI 1.00-13.42). CONCLUSIONS: In women with class III obesity, excess gestational weight gain was associated with increased odds of NICU stay >7 days, with trends toward increased NICU admission risk, further emphasizing the importance of appropriate weight gain counseling in this population at risk.

The impact of excessive gestational weight gain timing on neonatal outcomes in women with class III obesity.

OBJECTIVE: This study evaluated the influence of early gestational weight gain (GWG) on neonatal outcomes among women with class III obesity. STUDY DESIGN: Retrospective cohort of women with class III obesity who gained more than the Institute of Medicine (IOM) guidelines (>20lbs). Women gaining ≥75% of total gestational weight prior to 28 weeks (EWG) were compared to women gaining <75% of their total weight prior to 28 weeks (SWG). The primary outcome was a neonatal composite morbidity and mortality. Secondary outcomes included individual components of composite and LGA. RESULTS: Of 144 women identified, 42 (29.2%) had EWG and 102 (70.8%) had SWG. Though 11% of the total population had composite neonatal morbidity, this did not differ between groups (p = .4). LGA was nearly twice as common in the SWG group (41% vs 26%, p = .13). EWG was associated with decreased risk of LGA (AOR 0.25 95% CI 0.08, 0.78) and lower median birth weight (AOR -312 g 95% CI -534.7, -90.2). CONCLUSION: Though adverse neonatal outcomes were common in this population, timing of gestational weight gain was not correlated. Increased rates of LGA and higher median birth weight in the SWG group suggests excessive GWG continuing in the third trimester of pregnancy may be of import for neonatal size.