Tight vs liberal control of mild postpartum hypertension: a randomized controlled trial.

BACKGROUND: High-quality evidence to inform the management of postpartum hypertension, including the optimal blood pressure threshold to initiate therapy, is lacking. Randomized trials have been conducted in pregnancy, but there are no published trials to guide management in the postpartum period. OBJECTIVE: This study aimed to test the hypothesis that initiating antihypertensive therapy in the postpartum period at a threshold of 140/90 mm Hg would result in less maternal morbidity than initiating therapy at a threshold of 150/95 mm Hg. STUDY DESIGN: We performed a pragmatic multicenter randomized controlled trial of patients aged 18 to 55 years with postpartum hypertension. Patients with chronic hypertension, gestational hypertension, and preeclampsia without severe features were randomized to 1 of 2 blood pressure thresholds to initiate treatment: persistent blood pressure of ≥150/95 mm Hg (institutional standard or "liberal control" group) or ≥140/90 mm Hg (intervention or "tight control" group). Our primary outcome was composite maternal morbidity defined as: severe hypertension (blood pressure ≥160/110 mm Hg) or preeclampsia with severe features, the need for a second antihypertensive agent, postpartum hospitalization >4 days, and maternal adverse outcome secondary to hypertension as evidenced by pulmonary edema, acute kidney injury (creatinine level ≥1.1 mg/dL), cardiac dysfunction (eg, elevated brain natriuretic peptide level) or cardiomyopathy, posterior reversible encephalopathy syndrome, cerebrovascular accident, or admission to an intensive care unit. Secondary outcomes included hospital readmission for hypertension, persistence of hypertension beyond 14 days, medication side effects, and time to blood pressure control. We calculated that 256 women would provide 90% power to detect a relative 50% reduction in the primary outcome from 36% in the standard blood pressure threshold group to 18%, with a 2-sided alpha set at 0.05 for significance. Data were analyzed using R statistical software. RESULTS: A total of 256 patients were randomized, including 128 to the "tight control" group (140/90 mm Hg) and 128 to the "liberal control" group (150/95 mm Hg). Patients in the "tight control" group had a higher body mass index at delivery (37.1±9.4 vs 34.9±8.1; P=.04); other demographic and obstetrical characteristics were similar between groups. The rate of the primary outcome was similar between groups (8.6% vs 11.7%; P=.41; relative risk, 0.73; 95% confidence interval, 0.35-1.53). The rates of all secondary outcomes and the individual components of the primary and secondary outcome measures were also similar between groups. CONCLUSION: In the postpartum period, initiation of antihypertensive therapy at a lower blood pressure threshold of 140/90 mm Hg did not decrease maternal morbidity or improve outcomes compared with a threshold of 150/95 mm Hg.

Body composition in term neonates of mothers with hypertensive disorders of pregnancy.

BACKGROUND: Neonates of gravidas with hypertensive disorders of pregnancy (HDP) are at increased lifelong risk of cardiometabolic complications. Neonatal adiposity measured by body composition (BC) is a better surrogate of nutritional status than birth weight. Data comparing BC in term neonates of hypertensive and normotensive pregnant patients is lacking. Our objective was to compare body composition in both groups of neonates. METHODS: This was a retrospective cohort study from March 2018 to June 2019 at our tertiary institution where term neonatal BC are routinely measured. Neonates of patients with HDP and matched controls were included. Skin fold thickness (SFT) and percent body fat (PBF) were calculated using a validated anthropometric formula and compared using Mann-Whitney U and chi-square tests. RESULTS: One hundred and forty-two neonates of patients with HDP were compared to 150 controls. Demographic characteristics were similar except for higher pre-pregnancy BMI (29.7 ± 8.4 vs 26.75 ± 7.1, p = <0.01) in the HDP group. SFT was not significantly different (4.6 vs 4.4 mm, p = 0.09) but PBF was higher in the hypertensive group (13.15 vs 11.72, p = 0.01). CONCLUSIONS: PBF is higher in neonates of mothers with HDP, which may contribute to an increased risk of cardiometabolic complications later in life. IMPACT: Birth weight percentiles do not explain the predisposition to cardiovascular complications in offspring of hypertensive mothers. Body composition estimation may provide an explanation for this increased risk. Percent body fat is higher in term neonates of mothers with hypertensive disorders of pregnancy than neonates of normotensive mothers. Body composition is different in term neonates of mothers with hypertensive disorders of pregnancy.

Temporal Association Between Interracial Couples and Odds of Low Birth Weight Infants: Trends in National Vital Statistics Data from 1971 to 2016.

Our study explores the temporal association between low birth weight (LBW) infants and the increasing population prevalence of interracial relationships. Our hypothesis was that the odds of LBW would decrease as the population prevalence of interracial relationships increased. National Center for Health Statistics Natality data for 1971-2016 was analyzed. LBW was defined as birth weight less than 2500 gm. We restricted our analyses to singleton births by White and Black mothers with reported White or Black partners of the neonate. Logistic regression was used to calculate the odds ratios of LBW, both unadjusted and adjusted for maternal education and parental ages. The proportion of couples coded as interracial increased annually from 0.36% in 1971 to 3.86% in 2016 for White mothers and 0.59% to 8.63% for Black mothers during the same period. In each year the odds ratio of LBW was significant. As the proportion of White mothers with Black partners increased, their odds of LBW declined (OR1.75 to 1.30, p < 0.001). The odds ratio of LBW among Black mothers with White partners did not change and remained stable between 0.70 and 0.80 (p = 0.22) over the same time period. As the annual proportion of White mothers with Black partners increased, their odds of LBW decreased when compared to White couples. Black mothers with White partners did not exhibit a similar change when compared to Black couples, with the odds ratio of LBW remaining stable.

Comparing Two Testing Strategies: Universal versus Symptomatic SARS-CoV-2 Testing in Obstetric Patients.

OBJECTIVE: To compare universal severe acute respiratory syndrome coronvirus-2 (SARS-CoV-2) testing to symptomatic testing at two large academic centers. STUDY DESIGN: We performed a retrospective cohort study comparing the approach to testing at two academic centers in Northeast Ohio. The study period started with the inception of symptomatic testing for SARS-CoV-2 at both institutions in March 2020. Women younger than 18 years were excluded. The primary outcome was the SARS-CoV-2 positivity rate in symptomatic pregnant patients at both institutions. Our coprimary outcome was the additional positivity rate obtained from universal testing at the University Hospitals. The secondary outcome of interest was the percentage of SARS-CoV-2 screen positive mothers with screen positive neonates. Data were analyzed using Mann-Whitney U test for continuous variables with chi-square and Fisher's exact tests for proportions. RESULTS: During the study period, 144 pregnant women with symptoms of coronavirus disease 2019 (COVID-19) were tested at MetroHealth of which 27 resulted as positive for SARS-CoV-2 (18.7% positivity rate). University Hospitals tested 392 pregnant women with symptoms of COVID-19 of which 67 resulted as positive for SARS-CoV-2 (positivity rate 17.0%). In the universal testing program at University Hospitals, an additional 2,870 tests were performed on asymptomatic pregnant women of which 30 were positive for SARS-CoV-2 (1.0% positivity rate).There were no SARS-CoV-2 positive infants in our cohort, and all cases of maternal critical illness occurred in symptomatic patients. CONCLUSION: Universal and symptomatic testing approaches demonstrated similar clinical performance within a single geographic region in obstetric patients. KEY POINTS: · There is a lack of data to recommend an optimal approach to SARS-CoV-2 testing in obstetric patients.. · Universal testing detected few additional cases of SARS-CoV-2.. · Maternal and neonatal outcomes were unaffected by testing strategy..

Is a Fetal Echocardiography Necessary in IVF-ICSI Pregnancies After Anatomic Survey?

PURPOSE: In vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) is generally regarded as an indication for fetal echocardiography due to a reported increased risk of congenital abnormalities including cardiac anomalies. In this study we evaluated the utility of fetal echocardiography after anatomic survey in an experienced center. METHODS: This was a retrospective case review of in vitro fertilization with intracytoplasmic sperm injection pregnancies who had echocardiography in our institution from January 1996 to October 2010. RESULTS: Records from 85 mothers and 110 fetuses were identified. During anatomic survey, six cardiac anomalies were identified, including four ventricular septal defects, one pulmonary-aortic disproportion, and one post-valvular pulmonary artery dilatation. At fetal echocardiography, two of the four ventricular septal defects were confirmed and an additional three were identified. The most common cardiac anomaly seen in our population of IVF-ICSI pregnancies was ventricular septal defect, which was identified in 3.6% of all cases in the neonatal period. Of ventricular septal defects identified in the prenatal period, 71% resolved before birth. CONCLUSION: In experienced centers, a fetal echocardiography may not be necessary if the 3 vessels tracheal view of the heart is evaluated and the heart is evaluated carefully for a ventricular septal defect.