Co-existing chronic hypertension and hypertensive disorders of pregnancy and associated adverse pregnancy outcomes.

OBJECTIVE: Chronic hypertension (CHTN) causes vascular damage and resistance in the pregnant person and malperfusion in the placenta which may worsen the endothelial dysfunction of hypertensive disorders of pregnancy (HDP). These conditions frequently co-exist. A cumulative effect has been inconsistently demonstrated in prior studies, and it is unclear how co-existing hypertensive conditions affect pregnancy outcomes. We sought to examine maternal and neonatal outcomes in pregnancies affected by co-existing CHTN and HDP and compare these outcomes to those of pregnancies which were unaffected or affected by either condition alone. METHODS: This is a retrospective cohort study of singleton deliveries at a single institution 1 October 2013 to 1 October 2021. Data were extracted from the electronic medical record using standardized definitions and billing and diagnosis codes. Pregnant people with no evidence of hypertensive condition were compared to those with CHTN only, HDP only, and co-existing CHTN and HDP. Demographics, baseline clinical data, and use of aspirin or antihypertensive medications were assessed. Maternal outcomes included cesarean delivery, critical range blood pressure, intensive care unit (ICU) admission, and death. Neonatal outcomes included preterm birth <37 weeks' gestation, small for gestational age (SGA) birthweight, ICU admission, and a morbidity composite. Bivariate tests of association were performed using Chi-square test. Crude and adjusted odds ratios (aORs) were calculated using logistic regression for three maternal and four neonatal outcomes. Descriptive statistics and multivariable analyses were performed. RESULTS: Of 40,840 eligible people, 1451 (3.6%) had CHTN only; 5213 (12.8%) had HDP only; and 1890 (4.6%) had co-existing CHTN and HDP. Though odds of adverse maternal and neonatal outcomes were significantly increased for all hypertensive groups relative to the unaffected referent group, co-existing CHTN and HDP had the highest odds of cesarean delivery (aOR 1.60; 95% confidence interval (CI) 1.45-1.77), critical blood pressure (OR 41.54; 95% CI 35.96-47.99), maternal ICU admission or death (aOR 3.52; 95% CI 2.65-4.67), preterm birth (aOR 2.76; 95% CI 2.41-3.16), and SGA birthweight (aOR 1.61; 95% CI 1.39-1.87). CONCLUSIONS: Hypertensive disorders of pregnancy in the setting of CHTN are associated with the highest odds of serious consequences on the pregnant person and neonate independent of maternal comorbidities and prematurity. Antihypertensive medication use lowers the odds of some adverse outcomes. Patients should be informed of heightened risks, but optimal management remains unclear.

The association between a low 50-gram, 1-hour glucose challenge test value and neonatal morbidity.

OBJECTIVE: To evaluate the association between a low 50-gram, 1-hour glucose challenge test (GCT) value and adverse maternal and neonatal outcomes among patients receiving care at a single center tertiary care academic hospital. METHODS: We performed a retrospective cohort study of pregnant patients with a documented result of a 50-gram, 1-hour GCT performed ≥24 weeks 0 days gestation at a single tertiary care academic hospital from 2013-2021. Patients with a low GCT value, defined as cohort specific ≤10th percentile (<82 mg/dL), were compared to patients with a GCT value ≥82 mg/dL who were not diagnosed with gestational diabetes (GDM) to examine adverse maternal and neonatal outcomes. Additionally, these comparisons were repeated across patients with low GCT (<82 mg/dL), those with a GCT ≥82 mg/dL without diagnosis of GDM (heretofore referred to as normal glycemic screening) and patients diagnosed with GDM. Our primary outcome was a composite neonatal morbidity variable, inclusive of stillbirth, neonatal death, neonatal hypoglycemia with neonatal intensive care unit (NICU) admission, neonatal hyperbilirubinemia with NICU admission, respiratory distress with NICU admission, and/or small for gestational age (SGA). Multivariable logistic regression modeling was used to examine the association of low GCT value and the composite neonatal morbidity outcome, compared to those with the normal glycemic screening. RESULTS: Of 36,342 eligible patients, 3,789 (10.4%) had a low GCT value of <82 mg/dL, 30,729 (84.6%) had a GCT value ≥82 mg/dL and were not diagnosed with GDM, and 1,824 (5.0%) had a diagnosis of GDM. Patients with a low GCT value were significantly less likely to be diagnosed with hypertensive disorder of pregnancy (HDP) (12.4% vs 16.3%, p < .01), undergo cesarean delivery (22.8% vs 29.9%, p < .01), or experience postpartum hemorrhage (7.8% vs 9.4%, p < .01) as compared to patients with normal glycemic screening. Compared to newborns whose mothers had normal glycemic screening, newborns of mothers with a low GCT value were significantly more likely to experience the composite morbidity outcome (OR 1.17; 95% CI 1.08-1.27); this persisted after adjusting for potential confounders (aOR 1.18; 95% CI 1.09-1.29). CONCLUSION: A low maternal GCT value after 24 weeks gestation is significantly associated with an increased risk of morbidity in the newborn, driven by higher rates of SGA. Patients with a low GCT value may have underlying maternal hypoglycemia or other glycemic dysregulation affecting fetal development and may benefit from enhanced antenatal surveillance.

Low-Dose Aspirin during Pregnancy and Postpartum Bleeding.

OBJECTIVE: This study aimed to investigate whether aspirin 81 mg daily for preeclampsia prevention is associated with increased risk of postpartum blood loss at the time of delivery. STUDY DESIGN: This is a retrospective cohort study performed at a tertiary hospital from January 2018 to April 2021. Data were extracted from the electronic medical record. Patients prescribed low-dose aspirin (LDA) were compared with patients who were not. The primary outcome was a composite of postpartum blood loss, defined as: estimated blood loss (EBL) >1,000 mL, documentation of International Classification of Diseases-9/-10 codes for postpartum hemorrhage (PPH), or red blood cell (RBC) transfusion. Bivariate analysis, and unadjusted and adjusted logistic regression modeling were performed. RESULTS: Among 16,980 deliveries, 1,922 (11.3%) were prescribed LDA. Patients prescribed LDA were more likely to be >35 years old, nulliparous, obese, taking other anticoagulants, or have diagnoses of diabetes, systemic lupus erythematosus, fibroids, or hypertensive disease of pregnancy. After adjusting for potential confounders, the significant association between LDA use and the composite did not persist (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 1.0-1.3) nor did the association between EBL > 1,000 mL (aOR: 1.0, 95% CI: 0.9-1.3) and RBC transfusion (aOR: 1.3, 95% CI: 0.9-1.7). The association between LDA and PPH remained significant (aOR: 1.3, 95% CI: 1.1-1.6). Patients who discontinued LDA <7 days prior to delivery had an increased risk of the postpartum blood loss composite compared discontinuation ≥7 days (15.0 vs. 9.3%; p = 0.03). CONCLUSION: There may be an association between LDA use and increased risk of postpartum bleeding. This suggests that use of LDA outside the recommended guidelines should be cautioned and further investigation is needed to determine its ideal dosing and timing of discontinuation. KEY POINTS: · There may be an association with LDA and an increased risk of postpartum bleeding.. · Patients who discontinued LDA less than 7 days prior to delivery had an increased rate of postpartum bleeding.. · Additional research is need to determine optimal LDA dose and timing of discontinuation..

Intravenous iron for treatment of iron deficiency anemia during pregnancy and associated maternal outcomes.

BACKGROUND: More than 40% of pregnant patients worldwide are anemic, with at least half resulting from iron deficiency anemia (IDA). Anemia in pregnancy is linked with adverse maternal and neonatal outcomes. Treatment for IDA is iron supplementation; however, the optimal route of administration remains unclear. We sought to investigate whether patients with IDA who received intravenous iron (IVI) had decreased odds of maternal morbidity compared to patients who did not. METHODS: This is a retrospective cohort study of pregnant patients with presumed IDA with term deliveries at a tertiary hospital from 2013-2021. Data were extracted from the hospital's electronic medical record using standardized definitions and billing codes. Patients who received antepartum IVI were compared to patients who did not. The primary outcome was a maternal morbidity composite inclusive of receipt of blood transfusion, hysterectomy, admission to the intensive care unit or death. Bivariate analyses and multivariable logistic regression modelling were performed adjusting for potential confounders. RESULTS: Of 45,345 pregnancies, 5054 (11.1%) met eligibility criteria. Of these, 944 (18.7%) patients received IVI while 4110 (81.3%) did not. Patients who received IVI had higher risk baseline characteristics. They experienced a greater increase in hematocrit from pregnancy nadir to delivery admission (4.5% vs. 3.3%, p < .01). Despite this, patients who received IVI had higher odds of the maternal morbidity composite (OR 1.47, 95%CI 1.11-1.95). This finding persisted after adjusting for potential confounders, although the strength of the association became attenuated (aOR 1.37, 95%CI 1.02-1.85). Odds of the morbidity composite were not elevated among patients who received a full IVI treatment course (OR 1.2, 95% CI 0.83-1.90). DISCUSSION: Odds of the maternal morbidity composite were increased among patients who received IVI despite greater increases in hematocrit. The effect was attenuated after adjusting for potential confounders and was not significant among patients who completed a full treatment course.

Changes in prenatal testing during the COVID-19 pandemic.

Objective: The coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare delivery, including prenatal care. The study objective was to assess if timing of routine prenatal testing changed during the COVID-19 pandemic. Methods: Retrospective observational cohort study using claims data from a regional insurer (Highmark) and electronic health record data from two academic health systems (Penn Medicine and Yale New Haven) to compare prenatal testing timing in the pre-pandemic (03/10/2018-12/31/2018 and 03/10/2019-12/31/2019) and early COVID-19 pandemic (03/10/2020-12/31/2020) periods. Primary outcomes were second trimester fetal anatomy ultrasounds and gestational diabetes (GDM) testing. A secondary analysis examined first trimester ultrasounds. Results: The three datasets included 31,474 pregnant patients. Mean gestational age for second trimester anatomy ultrasounds increased from the pre-pandemic to COVID-19 period (Highmark 19.4 vs. 19.6 weeks; Penn: 20.1 vs. 20.4 weeks; Yale: 18.8 vs. 19.2 weeks, all p < 0.001). There was a detectable decrease in the proportion of patients who completed the anatomy survey <20 weeks' gestation across datasets, which did not persist at <23 weeks' gestation. There were no consistent changes in timing of GDM screening. There were significant reductions in the proportion of patients with first trimester ultrasounds in the academic institutions (Penn: 57.7% vs. 40.6% and Yale: 78.7% vs. 65.5%, both p < 0.001) but not Highmark. Findings were similar with multivariable adjustment. Conclusion: While some prenatal testing happened later in pregnancy during the pandemic, pregnant patients continued to receive appropriately timed testing. Despite disruptions in care delivery, prenatal screening remained a priority for patients and providers during the COVID-19 pandemic.

Changes in preterm birth during the COVID-19 pandemic by duration of exposure and race and ethnicity.

OBJECTIVE: We aimed to determine whether coronavirus-disease-2019 (COVID-19) pandemic exposure duration was associated with PTB and if the pandemic modified racial disparities. STUDY DESIGN: We analyzed Philadelphia births and replicated in New Haven. Compared to matched months in two prior years, we analyzed overall PTB, specific PTB phenotypes, and stillbirth. RESULTS: Overall, PTB was similar between periods with the following exceptions. Compared to pre-pandemic, early pregnancy (<14 weeks') pandemic exposure was associated with lower risk of PTB < 28 weeks' (aRR 0.60 [0.30-1.10]) and later exposure with higher risk (aRR 1.77 [0.78-3.97]) (interaction p = 0.04). PTB < 32 weeks' among White patients decreased during the pandemic, resulting in non-significant widening of the Black-White disparity from aRR 2.51 (95%CI: 1.53-4.16) to aRR 4.07 (95%CI: 1.56-12.01) (interaction P = 0.41). No findings replicated in New Haven. CONCLUSION: We detected no overall pandemic effects on PTB, but potential indirect benefits for some patients which could widen disparities remains possible.

Postpartum Length of Stay and Hospital Readmission Before and During the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: To compare postpartum hospitalization length of stay (LOS) and hospital readmission among obstetric patients before (March 2017-February 2020; prepandemic) and during the coronavirus disease 2019 (COVID-19) pandemic (March 2020-February 2021). METHODS: We conducted a retrospective cohort study, using Epic Systems' Cosmos research platform, of obstetric patients who delivered between March 1, 2017, and February 28, 2021, at 20-44 weeks of gestation and were discharged within 7 days of delivery. The primary outcome was short postpartum hospitalization LOS (less than two midnights for vaginal births and less than three midnights for cesarean births) and secondary outcome was hospital readmission within 6 weeks of postpartum hospitalization discharge. Analyses compared outcomes before and during the pandemic using standardized differences and Bayesian logistic mixed-effects models, among all births and stratified by mode of delivery. RESULTS: Of the 994,268 obstetric patients in the study cohort, 742,113 (74.6%) delivered prepandemic and 252,155 (25.4%) delivered during the COVID-19 pandemic. During the COVID-19 pandemic, the percentage of short postpartum hospitalizations increased among all births (28.7-44.5%), vaginal births (25.4-39.5%), and cesarean births (35.3-55.1%), which was consistent with the adjusted analysis (all births: adjusted odds ratio [aOR] 2.35, 99% credible interval 2.32-2.39; vaginal births: aOR 2.14, 99% credible interval 2.11-2.18; cesarean births aOR 2.90, 99% credible interval 2.83-2.98). Although short postpartum hospitalizations were more common during the COVID-19 pandemic, there was no change in readmission in the unadjusted (1.4% vs 1.6%, standardized difference=0.009) or adjusted (aOR 1.02, 99% credible interval 0.97-1.08) analyses for all births or when stratified by mode of delivery. CONCLUSION: Short postpartum hospitalization LOS was significantly more common during the COVID-19 pandemic for obstetric patients with no change in hospital readmissions within 6 weeks of postpartum hospitalization discharge. The COVID-19 pandemic created a natural experiment, suggesting shorter postpartum hospitalization may be reasonable for patients who are self-identified or health care professional-identified as appropriate for discharge.

Birth Hospital Length of Stay and Rehospitalization During COVID-19.

OBJECTIVES: To determine if birth hospitalization length of stay (LOS) and infant rehospitalization changed during the coronavirus disease 2019 (COVID-19) era among healthy, term infants. METHODS: Retrospective cohort study using Epic's Cosmos data from 35 health systems of term infants discharged ≤5 days of birth. Short birth hospitalization LOS (vaginal birth <2 midnights; cesarean birth <3 midnights) and, secondarily, infant rehospitalization ≤7 days after birth hospitalization discharge were compared between the COVID-19 (March 1 to August 31, 2020) and prepandemic eras (March 1 to August 31, 2017, 2018, 2019). Mixed-effects models were used to estimate adjusted odds ratios (aORs) comparing the eras. RESULTS: Among 202 385 infants (57 110 from the COVID-19 era), short birth hospitalization LOS increased from 28.5% to 43.0% for all births (vaginal: 25.6% to 39.3%, cesarean: 40.1% to 61.0%) during the pandemic and persisted after multivariable adjustment (all: aOR 2.30, 95% confidence interval [CI] 2.25-2.36; vaginal: aOR 2.12, 95% CI 2.06-2.18; cesarean: aOR 3.01, 95% CI 2.87-3.15). Despite shorter LOS, infant rehospitalizations decreased slightly during the pandemic (1.2% to 1.1%); results were similar in adjusted analysis (all: aOR 0.83, 95% CI 0.76-0.92; vaginal: aOR 0.82, 95% CI 0.74-0.91; cesarean: aOR 0.87, 95% CI 0.69-1.10). There was no change in the proportion of rehospitalization diagnoses between eras. CONCLUSIONS: Short infant LOS was 51% more common in the COVID-19 era, yet infant rehospitalization within a week did not increase. This natural experiment suggests shorter birth hospitalization LOS among family- and clinician-selected, healthy term infants may be safe with respect to infant rehospitalization, although examination of additional outcomes is needed.

Coronavirus Disease 2019 (COVID-19) Pandemic and Pregnancy Outcomes in a U.S. Population.

OBJECTIVE: To examine whether the coronavirus disease 2019 (COVID-19) pandemic altered risk of adverse pregnancy-related outcomes and whether there were differences by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection status among pregnant women. METHODS: In this retrospective cohort study using Epic's Cosmos research platform, women who delivered during the pandemic (March-December 2020) were compared with those who delivered prepandemic (matched months 2017-2019). Within the pandemic epoch, those who tested positive for SARS-CoV-2 infection were compared with those with negative test results or no SARS-CoV-2 diagnosis. Comparisons were performed using standardized differences, with a value greater than 0.1 indicating meaningful differences between groups. RESULTS: Among 838,489 women (225,225 who delivered during the pandemic), baseline characteristics were similar between epochs. There were no significant differences in adverse pregnancy outcomes between epochs (standardized difference<0.10). In the pandemic epoch, 108,067 (48.0%) women had SARS-CoV-2 testing available; of those, 7,432 (6.9%) had positive test results. Compared with women classified as negative for SARS-CoV-2 infection, those who tested positive for SARS-CoV-2 infection were less likely to be non-Hispanic White or Asian or to reside in the Midwest and more likely to be Hispanic, have public insurance, be obese, and reside in the South or in high social vulnerability ZIP codes. There were no significant differences in the frequency of preterm birth (8.5% vs 7.6%, standardized difference=0.032), stillbirth (0.4% vs 0.4%, standardized difference=-0.002), small for gestational age (6.4% vs 6.5%, standardized difference=-0.002), large for gestational age (7.7% vs 7.7%, standardized difference=-0.001), hypertensive disorders of pregnancy (16.3% vs 15.8%, standardized difference=0.014), placental abruption (0.5% vs 0.4%, standardized difference=0.007), cesarean birth (31.2% vs 29.4%, standardized difference=0.039), or postpartum hemorrhage (3.4% vs 3.1%, standardized difference=0.019) between those who tested positive for SARS-CoV-2 infection and those classified as testing negative. CONCLUSION: In a geographically diverse U.S. cohort, the frequency of adverse pregnancy-related outcomes did not differ between those delivering before compared with during the pandemic, nor between those classified as positive compared with negative for SARS-CoV-2 infection during pregnancy.

Factors associated with appropriate treatment of acute-onset severe obstetrical hypertension.

BACKGROUND: The American College of Obstetricians and Gynecologists recommends that pregnant patients receive expeditious treatment with first-line antihypertensive agents within 1 hour of confirmed severe hypertension to reduce the risk for maternal stroke. However, it is unknown how often this guideline is followed and what factors influence a patient's likelihood of receiving guideline-concordant care. OBJECTIVE: We aimed to identify factors associated with receiving guideline-concordant treatment for an obstetrical hypertensive emergency. STUDY DESIGN: We present a case-control study of all pregnant and postpartum patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, or both within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from October 1, 2013, to August 31, 2020. Data were extracted from the hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined receipt of the recommended treatment as administration of a first-line antihypertensive agent (intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine) within 60 minutes of the first or second severe-range blood pressure measurement during their delivery hospitalization. Delayed treatment was defined as the administration of a first-line agent >60 minutes after the second elevated blood pressure measurement. Patients were considered untreated if a first-line agent was never administered. Maternal sociodemographic, clinical and pregnancy factors, and time and day of the week of the hypertensive emergency were compared among patients who received the recommended treatment, those who received delayed treatment, and those who were untreated. Bivariate analyses were performed, and multinomial and multivariable logistic regression models were used to adjust for potential confounders. RESULTS: Of the 39,918 deliveries in the cohort, 1987 (5.0%) were complicated by severe, persistent obstetrical hypertension. Of these patients, 532 (26.8%) received the recommended treatment, 356 (17.9%) received delayed treatment, and 1099 (55.3%) did not receive any first-line antihypertensive therapy. The multinomial regression models that were used to compare these 3 groups indicated that patients who received the recommended treatment were more likely to be Black (adjusted odds ratio, 1.85; 95% confidence interval, 1.36-2.51), Hispanic (adjusted odds ratio, 1.77; 95% confidence interval, 1.28-2.52), or pregnant and at <37 weeks of gestation (adjusted odds ratio, 6.65; 95% confidence interval, 5.08-8.72). Treatment was less likely if the severe obstetrical hypertension emergency occurred overnight (7:00 PM to 6:59 AM) (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.97) or during the postpartum period (adjusted odds ratio, 0.66; 95% confidence interval, 0.51-0.86). CONCLUSION: Approximately half of obstetrical patients with at least 2 documented severely elevated blood pressure measurements did not receive the recommended antihypertensive treatment. Of those who did receive treatment, about 40% had delayed treatment. Black and Hispanic race and preterm gestation were associated with an increased likelihood of receiving the recommended treatment when compared with White race and term pregnancies. Patients whose severe obstetrical hypertension emergency occurred overnight and those who were postpartum were less likely to receive any first-line antihypertensive treatment. Overall, patients without sociodemographic and clinical risk factors for severe obstetrical hypertension or other pregnancy complications were less likely to be treated. However, treatment improved significantly over time with the implementation of targeted quality measures and specific institutional policies based on the American College of Obstetricians and Gynecologists' latest severe obstetrical hypertension management guidelines.

Cytokine profiling: variation in immune modulation with preterm birth vs. uncomplicated term birth identifies pivotal signals in pathogenesis of preterm birth.

OBJECTIVES: To assess deviations in longitudinally measured cytokines with preterm birth (PTB). METHODS: Prospective longitudinal study targeting 80 subjects. Phlebotomy specimens for broad panel of cytokine analysis were obtained at three time (T) intervals: first trimester (T1: 8-14 weeks' gestation), second trimester (T2: 18-22 weeks' gestation), and third trimester (T3: 28-32 weeks' gestation). Important demographics and outcomes were tracked. Data were stratified and the target groups were analyzed as follows: "Uncomplicated" (delivered ≥37 weeks) or "Preterm Birth" (<37 weeks). Generalized Linear Modeling determined rate of change T1-T3 by outcome. RESULTS: Complete data replete with phlebotomy at all three visits were obtained on 80 women. Birth outcomes were as follows: 11 Uncomplicated Term Birth (UTB), 28 PTB, 4 low birth weight (LBW), 16 OB complications (OBC), 11 current infections (IFN), and 10 mixed complications (MC=2 or more of the above). 28 PTB were compared to 11 uncomplicated term deliveries. In both groups, T helper type 1 (TH1) cytokine (IL-1ß), pleiotrophic pro-inflammatory cytokine (IL-6), and counter-regulatory cytokine (IL-10) responses decreased over gestation, but rates of change in IL-1ß, IL-6, and IL-10 were significantly different. Stratification of women by smoking status additionally demonstrated significant variance in immune status over the course of pregnancy. CONCLUSIONS: Women delivering PTB demonstrated significant differences in cytokine trajectory over pregnancy; these data further validate key role played by immune regulation in directing pregnancy outcome. Likewise, smoking impacts longitudinal trajectory of cytokines over pregnancy.

Perinatal outcomes in women with elevated blood pressure and stage 1 hypertension.

BACKGROUND: Hypertension was redefined in 2017 with lower diagnostic thresholds; elevated blood pressure is defined as systolic blood pressure of 120 to 129 mm Hg with diastolic blood pressure of <80 mm Hg and stage 1 hypertension as systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg. These guidelines did not include pregnant women. There is limited information on stage 1 hypertension and pregnancy outcomes. OBJECTIVE: This study aimed to determine whether elevated blood pressure and stage 1 hypertension as newly defined by the 2017 American College of Cardiology and the American Heart Association guidelines are associated with an increased risk of hypertensive disorders of pregnancy and other adverse maternal and neonatal outcomes. STUDY DESIGN: In this retrospective cohort study, 18,801 women with singletons from 2013 to 2019 were categorized as normotensive, prehypertensive (elevated blood pressure), stage 1 hypertensive, or chronic hypertensive. Women with ≥2 systolic blood pressures of 120 to 129 mm Hg before 20 weeks' gestation were classified into the elevated blood pressure group. Women with ≥2 systolic blood pressures of 130 to 139 mm Hg or ≥2 diastolic blood pressures of 80 to 89 mm Hg before 20 weeks' gestation were assigned to the stage 1 hypertension group. Women were classified as chronic hypertensives if they had any of the following: ≥2 systolic blood pressure of ≥140 mm Hg or ≥2 diastolic blood pressure of ≥90 mm Hg before 20 weeks' gestation, a history of chronic hypertension, or antihypertensive medication use before 20 weeks' gestation. Women with pregestational diabetes, lupus, or <2 blood pressures before 20 weeks' gestation were excluded. The association of stage 1 hypertension with the risk of developing hypertensive disorders of pregnancy was estimated using multivariate logistic regression controlling for maternal sociodemographic characteristics, gestational weight gain by prepregnancy body mass index, parity, and aspirin use. Secondary outcomes included subgroups of hypertensive disorders (gestational hypertension, preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome), gestational diabetes, placental abruption, intrauterine growth restriction, preterm birth, neonatal intensive care unit admission, stillbirth and neonatal death, and maternal intensive care unit admission. All outcomes were adjusted for potential confounders. RESULTS: Of the 18,801 women, 13,478 (71.7%) were normotensive, 2659 (14.1%) had elevated blood pressure, 1384 (7.4%) were stage 1 hypertensive, and 1280 (6.8%) were chronic hypertensive. A dose-response relationship was observed: the risk of hypertensive disorders of pregnancy increased from 4.2% in normotensive women to 6.7% (adjusted odds ratio, 1.50; 95% confidence interval, 1.26-1.79) in women with elevated blood pressure, to 10.9% (adjusted odds ratio, 2.54; 95% confidence interval, 2.09-3.08) in women with stage 1 hypertension, and 28.4% (adjusted odds ratio, 7.14; 95% confidence interval, 6.06-8.40) in women with chronic hypertension. Compared with normotensive women, women with stage 1 hypertension had an increased risk of neonatal intensive care unit admissions (15.8% vs 13.0%; adjusted odds ratio, 1.21; 95% confidence interval, 1.03-1.42), preterm birth at <37 weeks' gestation (7.2% vs 5.2%; adjusted odds ratio, 1.45; 95% confidence interval, 1.16-1.81), and gestational diabetes (14.8% vs 6.8%; adjusted odds ratio, 2.68; 95% confidence interval, 2.27-3.17). CONCLUSION: Our study demonstrates that elevated blood pressure and stage 1 hypertension, using the 2017 American College of Cardiology and the American Heart Association guideline definition, are associated with increased maternal and neonatal risk. This group of women warrants further investigation to determine whether pregnancy management can be altered to reduce maternal and neonatal morbidity.

Lessons learned from the Philadelphia Collaborative Preterm Prevention Project: the prevalence of risk factors and program participation rates among women in the intervention group.

BACKGROUND: Women who deliver preterm infants are at a much greater risk for repeating a preterm birth (PTB), compared to women without a history of PTB. However, little is known about the prevalence of the risk factors which account for this markedly increased risk. Moreover, little or nothing is known about the feasibility of providing treatments and services to these women, outside of the context of prenatal care, during the inter-conception period, which provides the best opportunity for successful risk-reduction interventions. METHODS: The Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large randomized control trial designed to identify and reduce six major risk factors for a repeat preterm birth among women immediately following the delivering of a preterm infant. For the women assigned to the PCPPP treatment group, we calculated the prevalence of the six risk factors in question, the percentages of women who agreed to receive high quality risk-appropriate treatments or services, and the of rates of participation among those who were offered and eligible for these treatments or services. RESULTS: Urogenital tract infections were identified in 57% of the women, while 59% were found to have periodontal disease. More than 39% were active smokers, and 17% were assessed with clinical depression. Low literacy, and housing instability were identified in, 22 and 83% of the study sample, respectively. Among women eligible for intervention, the percentages who accepted and at least minimally participated in treatment ranged from a low of 28% for smoking, to a high of 85% for urogenital tract infection. Most PCPPP enrollees (57%) had three or more major risk factors. Participation rates associated with the PCPPP treatments or services varied markedly, and were quite low in some cases, despite considerable efforts to reduce the barriers to receiving care. CONCLUSION: The efficacy of individual level risk-reduction efforts designed to prevent preterm/repeat preterm in the pre- or inter-conception period may be limited if participation rates associated with interventions to reduce major risk factors for PTB are low. Achieving adequate participation may require identifying, better understanding, and eliminating barriers to access, beyond those associated with cost, transportation, childcare, and service location or hours of operation. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT01117922 ).

Variation in birth outcomes by mother's country of birth among non-Hispanic black women in the United States.

Rates of prematurity (PTB) and small-for-gestational age (SGA) were compared between US-born and foreign-born non-Hispanic black women. Comparisons were also made between Sub-Saharan African-born and Caribbean-born black women and by maternal country of birth within the two regions. Comparisons were adjusted for sociodemographic, health behavioral and medical risk factors available on the birth record. Birth record data (2008) from all states (n = 27) where mother's country of birth was recorded were used. These data comprised 58 % of all singleton births to non-Hispanic black women in that year. Pearson Chi square and logistic regression were used to investigate variation in the rates of PTB and SGA by maternal nativity. Foreign-born non-Hispanic black women had significantly lower rates of PTB (OR 0.727; CI 0. 726, 0.727) and SGA (OR 0.742; CI 0.739-0.745) compared to US-born non-Hispanic black women in a fully adjusted model. Sub-Saharan African-born black women compared to Caribbean-born black women had significantly lower rates of PTB and SGA. Within each region, the rates of PTB and SGA varied by mother's country of birth. These differences could not be explained by adjustment for known risk factors obtained from vital records. Considerable heterogeneity in rates of PTB and SGA among non-Hispanic black women in the US by maternal nativity was documented and remained unexplained after adjustment for known risk factors.

Institutional racism, neighborhood factors, stress, and preterm birth.

OBJECTIVE: Racial/ethnic disparities in the risk of preterm birth may be explained by various factors, and previous studies are limited in examining the role of institutional racism. This study focused on the following questions: what is the association between preterm birth and institutional racism as measured by residential racial segregation (geographic separation by race) and redlining (black-white disparity in mortgage loan denial); and what is the association between preterm birth and reported stress, discrimination, and neighborhood quality. DESIGN: We used data from a clinic-based sample of pregnant women (n = 3462) participating in a stress and pregnancy study conducted from 1999 to 2004 in Philadelphia, PA (USA). We linked data from the 2000 US Census and Home Mortgage Disclosure Act (HMDA) data from 1999 to 2004 and developed measures of residential redlining and segregation. RESULTS: Among the entire population, there was an increased risk for preterm birth among women who were older, unmarried, tobacco users, higher number of previous births, high levels of experiences of everyday discrimination, owned their homes, lived in nonredlined areas, and areas with high levels of segregation measured by the isolation index. Among black women, living in a redlined area (where blacks were more likely to be denied mortgage loans compared to whites) was moderately associated with a decreased risk of preterm birth (aRR = 0.8, 95% CI: 0.6, 0.99). CONCLUSION: Residential redlining as a form institutional racism and neighborhood characteristic may be important for understanding racial/ethnic disparities in pregnancy and preterm birth.

The impact of social disadvantage on preconception health, illness, and well-being: an intersectional analysis.

PURPOSE: To understand how social and structural contexts shape individual risk, vulnerability, and interconception health-related behaviors of African-American women. APPROACH OR DESIGN: A longitudinal ethnographic study was conducted. SETTING: The study was conducted in Philadelphia, Pennsylvania. PARTICIPANTS: The sample included 19 African-American women who were participants in the intervention group of a randomized clinical trial of interconceptional care. METHOD: Data were collected through interaction with participants over a period of 6 to 12 months. Participant observation , structured and unstructured interviews, and Photovoice were used to obtain data; grounded theory was used for analysis. The analysis was guided by intersectional theory. RESULTS: Social disadvantage influenced health and health care-seeking behaviors of African-American women, and the disadvantage centered on the experience of racism. The authors identify seven experiences grounded in the interactions among the forces of racism, class, gender, and history that may influence women's participation in and the effectiveness of preconception and interconception health care. CONCLUSION: African-American women's health and wellness behaviors are influenced by an experience of racism structurally embedded and made more virulent by its intersection with class, gender, and history. These intersecting forces create what may be a unique exposure that contributes significantly to the proximal determinants of health inequities for African-American women. Health promotion approaches that focus on the individual as the locus of intervention must concomitantly unravel and address the intertwining structural forces that shape individual circumstance in order to improve women's interconceptional health and to reduce disparities.

Stress during pregnancy: the role of institutional racism.

Institutional racism, also known as structural racism, can be defined as differential access to resources and opportunities by race as well as policies, laws, and practices that reinforce racial inequity. This study examines how institutional racism in the form of residential redlining (neighbourhood-level racial inequities in mortgage lending) and segregation (geographic separation of groups by race) is associated with self-reported stress among a diverse cohort of pregnant women. Institutional racism was measured by a residential redlining index using Home Mortgage Disclosure Act data and residential segregation using 2000 US Census data. These redlining and segregation indices were linked with data from a pregnancy cohort study (n = 4652), which included individual measures of reported stress. We ran multilevel linear regression models to examine the association between redlining, segregation and reported stress. Hispanic women compared with all other women were slightly more likely to report stress. There was no significant relationship between redlining and stress among this population. However, higher neighbourhood percentage black was inversely associated with stress. This study suggests that some forms of segregation may be associated with reported stress. Future studies should consider how redlining and segregation may provide an understanding of how institutional racism and the neighbourhood context may influence stress and health of populations.

Small-for-gestational-age births in pregnant women with HIV, due to severity of HIV disease, not antiretroviral therapy.

OBJECTIVES: To determine rate and factors associated with small-for-gestational-age (SGA) births to women with HIV. METHODS: Prospective data were collected from 183 pregnant women with HIV in an urban HIV prenatal clinic, 2000-2011. An SGA birth was defined as less than the 10th or 3rd percentile of birth weight distribution based upon cut points developed using national vital record data. Bivariate analysis utilized chi-squared and t-tests, and multiple logistic regression analyses were used. RESULTS: The prevalence of SGA was 31.2% at the 10th and 12.6% at the 3rd percentile. SGA at the 10th (OR 2.77; 95% CI, 1.28-5.97) and 3rd (OR 3.64; 95% CI, 1.12-11.76) percentiles was associated with cigarette smoking. Women with CD4 count>200 cells/mm3 at the first prenatal visit were less likely to have an SGA birth at the 3rd percentile (OR 0.29; 95% CI, 0.10-0.86). Women taking NNRTI were less likely to have an SGA infant at the 10th (OR 0.28; 95% CI, 0.10-0.75) and 3rd (OR 0.16; 95% CI, 0.03-0.91) percentiles compared to those women on PIs. CONCLUSIONS: In this cohort with high rates of SGA, severity of HIV disease, not ART, was associated with SGA births after adjusting for sociodemographic, medication, and disease severity.