Lidocaine Patches After Cesarean Sections: A Randomized Control Trial.

OBJECTIVES: Lidocaine patches are a common topical analgesic therapy but have not been thoroughly investigated in the surgical or obstetric literature. We sought to investigate the impact of adding topical lidocaine patches to routine post-cesarean pain management on patients' post-cesarean pain scores and opioid use. STUDY DESIGN: This is a prospective randomized subject blinded controlled trial of patients undergoing cesarean delivery at a single institution. Individuals were excluded if they had three or more cesarean sections, abdominoplasty, history of abdominal hernia repair with mesh, active polysubstance use, or history of opiate use disorder with current medication-assisted treatment. Patients were randomized via a 1:1 randomization scheme to a placebo patch or lidocaine patch. Baseline maternal characteristics were collected. The primary outcome was mean visual analog pain scores (0-10). Our secondary outcome was total morphine equivalents used over the post-operative hospital stay. Pre- and post-study surveys were performed to evaluate subject's prior analgesia use (including opioids) and patient experience in the study. RESULTS: A total of 100 patients were randomized and 93 had complete data for analysis (46 placebo group, 47 treatment group). Groups had similar baseline characteristics (age, BMI, ethnicity, surgical time, and estimated blood loss). Mean maximum post-operative pain score by visual analog scale did not differ between placebo or lidocaine patch groups on post-operative day 1 (p=0.3), day 2 (p=0.9), day 3 (p=0.07), or day 4 (p=0.09). Mean post-operative pain score by visual analog scale did not differ between placebo or lidocaine patch groups on post-operative day 1 (p=0.7), day 2 (p=0.6), day 3 (p=0.2), or day 4 (p=0.5). In the post-study survey, 0% of the respondents in the lidocaine patch group reported disruption of their care and 63% reported desired use of lidocaine patch in the future. CONCLUSIONS: The addition of lidocaine patches did not significantly decrease the maximum or average post-operative pain scores via visual analog scale after cesarean sections. More research is needed into non-opioid pain management strategies in the post-operative period in obstetric care.

The early COVID-19 pandemic period and associated gestational weight gain.

OBJECTIVES: The aim of this study was to investigate if gestational weight gain was altered during the early COVID-19 pandemic period. METHODS: This a retrospective cohort study evaluating gestational weight gain among individuals delivering during the early COVID-19 pandemic epoch (March 10-December 31, 2020) compared to temporally matched pre-pandemic (matched months in 2018 and 2019) controls using electronic medical record data from a large tertiary care hospital. The primary outcome was gestational weight gain defined as a categorical measure representing below, meeting, or above Institute of Medicine (IOM) criteria with further adjustment for gestational age at delivery. The early-pandemic exposure group was also categorized by gestational age at the start period (<14 weeks' and 14-20 weeks') to assess if duration of exposure affected gestational weight gain risks with the use of multinominal logistic regression. RESULTS: Among 5,377 individuals 3,619 (67.3 %) and 1,758 (32.7 %) were in the pre and early pandemic epochs respectively. Overall, 934 (17.4 %) individuals gained below recommended, 1,280 (23.8 %) met recommendations, and 3,163 (58.8 %) gained above IOM recommended gestational weight gain. Compared to the pre-pandemic epoch, the early pandemic period was not associated with weight gain below (OR 1.06, 95 % Cl 0.89-1.27) or above (OR 1.03, 95 % Cl 0.89-1.19) IOM recommendations. This was also true when the early pandemic group was stratified based on gestational age at the start of the early pandemic period (<14 weeks' and 14-20 weeks'). CONCLUSIONS: This study demonstrated no significant difference in maternal weight gain between pre and early COVID-19 pandemic periods.

Late-Onset Postpartum Hypertension After Normotensive Pregnancy.

To better inform efforts to improve and extend postpartum care, we sought to estimate the incidence of de novo hypertension up to 6 months postpartum in patients without evidence of hypertension during pregnancy or immediately postpartum. This retrospective cohort study included all patients delivering within an academic health care system. All blood pressure (BP) measurements from fertilization to 6 months postpartum were obtained from the electronic medical record and used to identify patients who remained normotensive throughout pregnancy and in the first 6 weeks postpartum. By 6 months postpartum, nearly one-fifth of this large, previously normotensive cohort had developed BP abnormalities per American College of Cardiology-American Heart Association criteria. These findings underscore the importance of optimizing the transition from obstetrics to primary care in the postpartum period.

Rate of clinically significant red blood cell antibody seroconversion in pregnancy.

OBJECTIVE: To determine the rate of clinically significant red blood cell (RBC) antibody seroconversion in pregnancy and associated risk factors and neonatal outcomes. METHODS: This is a retrospective cohort study of all deliveries within a large multi-hospital system from July 2016 to March 2023. Deliveries with a missing RBC antibody screen on admission for delivery were excluded, as were deliveries with a positive antibody screen on admission for delivery without a record of antecedent type and screen (T&S) in that pregnancy. Deliveries were categorized as 1) not possessing clinically significant antibodies (which includes those with a negative antibody screen, evidence of passive immunity solely due to Rh(D) immune globulin (RhIG), or possessing only non-clinically significant RBC antibodies); 2) previously alloimmunized (i.e. pregnancies that demonstrated clinically significant antibodies on the first T&S, regardless if they accrued additional antibodies throughout the pregnancy); or 3) seroconverted (i.e. no clinically significant antibodies on the first T&S with subsequent development of alloimmunization with clinically significant antibodies). For neonates born to seroconverted patients with clinically significant antibodies, neonatal outcomes such as initial hemoglobin, need for transfusion, and neonatal intensive care unit (NICU) admission were ascertained via chart abstraction. All records were linked with an existing validated database, inclusive of maternal characteristics and pregnancy outcomes, and comparisons were made between three categories based on antibody status with a sub-analysis of two categories. Bivariate analysis was performed with Chi-square for categorical and Wilcoxon rank-sum or Kruskal-Wallis test for continuous variables. RESULTS: There were 58,912 pregnant individuals with 71,384 eligible deliveries during the study period, with 67,570 deliveries remaining after data linkage. Of these, 67,209 (99.5%) deliveries had a negative or non-clinically significant antibody screen at delivery. Of the remaining 361 (0.53%) deliveries, 185 (0.27%) were previously alloimmunized and 176 (0.26%) seroconverted in pregnancy. Among pregnancies demonstrating seroconversion, the most common newly acquired antibodies were anti-E, anti-c, anti-JkA, anti-C, anti-D, anti-M, anti-K, and anti-S. Among the 176 pregnancies complicated by seroconversion, there were four unexplained fetal losses, none of which were attributable to HDFN. Among the 178 liveborn neonates born to the 176 pregnancies demonstrating seroconversion, three (1.7%) infants had initial hemoglobin <13.5 mg/dL, four (2.2%) required postnatal transfusion but all were unrelated to HDFN, and 34 (19.1%) required NICU admission. When comparing deliveries demonstrating seroconversion with those with a negative antibody screen at delivery, advanced maternal age and increasing gravidity and parity were most strongly associated with seroconversion. CONCLUSION: Development of new clinically significant RBC antibodies in pregnancy occurred at a rate of 0.26% in this large cohort study with no cases of stillbirth or neonatal demise attributable to RBC alloimmunization among pregnancies demonstrating seroconversion. Advanced maternal age and increasing gravidity and parity were most strongly associated with seroconversion in pregnancy. Routine third trimester prenatal assessment of maternal antibody status may not be indicated due to low likelihood for clinically significant seroconversion.

Association Between Intrapartum Nitrous Oxide for Labor Analgesia and Short-Term Neonatal Outcomes.

OBJECTIVE: To evaluate the association between intrapartum nitrous oxide use and adverse short-term neonatal outcomes. METHODS: This was a retrospective cohort study of individuals with singleton gestations at 35 or more weeks who attempted labor and delivered at an academic hospital between June 1, 2015, and February 28, 2020. Data were extracted from the electronic medical record using billing and diagnostic codes. Patients were classified based on whether they received no intrapartum analgesia or received nitrous oxide only. Those who received other analgesia types were excluded. The primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included Apgar score less than 7 at 1 minute and 5 minutes, respiratory composite outcome (including meconium aspiration syndrome, neonatal bronchopulmonary disorders, neonatal transient tachypnea, and other neonatal respiratory distress that required NICU admission), hypoglycemia, and hyperbilirubinemia. Univariable and multivariable analyses were used to estimate the association between nitrous oxide exposure intrapartum and the selected outcomes. RESULTS: Of 6,047 included, 4,153 (68.7%) received no analgesia, and 1,894 (31.3%) received nitrous oxide only. In comparison with individuals who received no analgesia, those who received nitrous oxide were more likely to be nulliparous, be of Black racial identity, have noncommercial insurance, and be less likely to deliver by intrapartum cesarean. The reception of nitrous oxide, compared with the reception of no analgesia, was associated with a lower likelihood of NICU admission (6.4% vs 8.1%; adjusted odds ratio [aOR] 0.77, 95% CI, 0.62-0.96) and an increased likelihood of neonatal hyperbilirubinemia (aOR 1.23, 95% CI, 1.08-1.41). Inhaled nitrous oxide exposure, in comparison with the reception of no analgesia, was not associated with the other secondary outcomes, including Apgar score less than 7 at 1 minute (odds ratio [OR] 0.74, 95% CI, 0.50-1.10) or 5 minutes (OR 0.91, 95% CI, 0.32-2.60), respiratory composite outcome (OR 0.91, 95% CI, 0.70-1.17), and hypoglycemia (OR 0.82, 95% CI, 0.64-1.05). CONCLUSION: In this single-center retrospective cohort of low-risk patients, intrapartum inhaled nitrous oxide, compared with the reception of no analgesia, was associated with a decreased risk for NICU admission but with an increased risk for hyperbilirubinemia; other outcomes did not differ. These findings may be used to counsel patients when considering nitrous oxide for labor analgesia.

A Multidimensional and Longitudinal Exploratory Study of the Stability of Pregnancy Contexts in the United States.

Objective: Evaluate the longitudinal stability of six pregnancy contexts, including intention, in a diverse cohort of individuals experiencing delivery, abortion, or miscarriage. Methods: We enrolled individuals 16-44 years of age with pregnancies <24 weeks gestation in this longitudinal study between June 2014 and June 2015 in four US urban clinics. We assessed six pregnancy contexts (intention, wantedness, planning, timing, desirability, and happiness) at enrollment and 3-month follow-up. We constructed three-level categorical measures for each context defined as favorable, ambivalent, or unfavorable. We used Wilcoxon sign tests to evaluate changes in paired observations between pregnancy context measures over time and by pregnancy outcome. Results: Among 121 participants at median gestational age of 7 weeks and 3 days, we found intention, wantedness, planning, timing, and happiness remained unchanged from enrollment in early pregnancy to 3-month follow-up. Individuals demonstrated changes in desirability; pregnancy assessments shifted toward less desirable from enrollment to follow-up (p = 0.01) (i.e., desired to ambivalent, or ambivalent to undesired). Among participants choosing delivery (57%), assessments shifted toward more favorable planning (i.e., unplanned to ambivalent, or ambivalent to planned) (p < 0.01), and less favorable desirability (i.e., desired to ambivalent or ambivalent to undesired) (p < 0.01) at follow-up. Among participants choosing abortion (28%), assessments shifted toward more unfavorable planning (i.e., planned to ambivalent, or ambivalent to unplanned) at follow-up (p < 0.01). Conclusion: In multidimensional, longitudinal assessment, pregnant participants' perspectives on five of six pregnancy contexts remained unchanged between enrollment and 3-month follow-up; only desirability shifted. Pregnancy planning perspectives differed by pregnancy outcome.Human Research Subjects Protection Program: 1310012926.

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.

Effect of Educational Video on Patient Adherence and Completeness of Voiding Diaries: A Randomized Trial.

IMPORTANCE: Voiding diaries are clinically useful tools for elucidating the etiology of lower urinary tract symptoms. The utility of voiding diaries is challenged by low return rate and incomplete or inaccurate data entry. OBJECTIVE: The objective was to determine the effect of the use of an educational video on patient adherence, completeness of intake and voiding diaries, and patient satisfaction. STUDY DESIGN: In this trial, patients who were asked to complete an intake and voiding diary in a urogynecology clinic were randomized to receive standard education or enhanced education with an instructional video on how to complete the diary. Patients returned the diaries at their follow-up visits in the clinic. The primary outcome was the return rate of the diaries. Upon follow-up, patients filled out a survey reporting their satisfaction with instructions received. Diaries were graded by 3 blinded experts. RESULTS: Eighty-five patients were enrolled, 42 in the standardized instructions arm and 43 in the video arm. A total of 26 patients (30.6%) filled out and returned an intake and voiding diary. Between groups, there was no difference in the rate of return of the diaries ( P = 0.59) or in completeness of the returned voiding diaries ( P = 0.60). The educational video did not change satisfaction between the groups; patients reported identical satisfaction between groups. CONCLUSIONS: The addition of an instructional video on how to complete an intake and voiding diary did not increase patients' rate of return, completeness of diaries, or satisfaction with instructions provided to complete the diary.

Collaboration between maternal-fetal medicine and family planning: a survey of Northeast US academic medical centers.

OBJECTIVES: To explore how complex family planning (CFP) and maternal-fetal medicine (MFM) in Northeast academic medical centers work together to provide abortion care. METHODS: We distributed an exploratory cross-sectional online survey to CFP and MFM faculty and fellows at academic medical centers in the Northeast between July and September of 2020. The survey included demographic information, assessment of practice patterns, hospital/administration support and assessment of collaboration. Likert scale questions examined opinions about collaboration and an open-ended question solicited ideas for improvement. We performed bivariate analysis to examine the association between subspecialty and practice location regarding provision of abortion care and perceived barriers to care. RESULTS: The response rate was 31 % and was similar by specialty. Of the 69 respondents, 83 % were MFMs, 75 % were faculty, and 54 % practiced in New York. More than 85 % reported personal participation in some portion of abortion care. The two most common perceived barriers to care were "lack or reluctance of physicians/staff" and state laws prohibiting termination. Nearly all (95 %) stated there was a good working relationship between CFP and MFM divisions; however, almost one-third agreed with or were neutral to the statements "MFM and CFP are siloed in terms of work/patient care." CONCLUSIONS: Academic MFM and CFP providers in the Northeast collaborate well in providing abortion care, though our findings highlight areas that would benefit from improvement. Optimizing collaboration in the Northeast is important given its regional role for ensuring abortion access in the current national landscape. Improved education of all members of the patient care team on the importance of abortion access may also help provide optimal patient care where abortion services still legally exist.

Estimated National Cost of Pelvic Organ Prolapse Surgery in the United States.

OBJECTIVE: To estimate the national cost of pelvic organ prolapse (POP) surgery in the United States. METHODS: In this cross-sectional, population-based study, we used the 2016-2018 Healthcare Cost and Utilization Project National Inpatient Samples and National Ambulatory Surgery Samples to identify patients undergoing POP surgery using International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, ICD-10 procedural codes, and Current Procedural Terminology codes. Cost-to-charge ratios and weighted estimates were used to calculate nationwide costs. Descriptive analysis was used to identify the sociodemographic, clinical, and surgical characteristics of the population undergoing POP surgery. RESULTS: Between 2016 and 2018, there were 140,762 POP surgical cases annually with an annual national cost estimated at $1.523 billion per year. The median cost per procedure increased slightly from $8,837 in 2016 to $8,958 in 2018. Overall, 82.5% of the total surgeries and 78% of the total national costs associated with POP surgery came from the ambulatory setting over this time period. Of these surgeries, 44.7% included an apical repair, and 42.3% included a concomitant hysterectomy. The average age of the population was 62 years, and 20% of the total population receiving prolapse surgery were younger than age 50 years. CONCLUSION: The annual national cost associated with surgical correction of POP is substantial, and the majority of cases occur in an ambulatory setting. These findings will contribute to enhancing cost-effectiveness analyses and decision-making processes for both health care professionals and policymakers as the national population continues to age.

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.

Fetal growth restriction and small for gestational age as predictors of neonatal morbidity: which growth nomogram to use?

BACKGROUND: Fetal growth nomograms were developed to screen for fetal growth restriction and guide clinical care to improve perinatal outcomes; however, existing literature remains inconclusive regarding which nomogram is the gold standard. OBJECTIVE: This study aimed to compare the ability of 4 commonly used nomograms (Hadlock, International Fetal and Newborn Growth Consortium for the 21st Century, Eunice Kennedy Shriver National Institute of Child Health and Human Development-unified standard, and World Health Organization fetal growth charts) and 1 institution-specific reference to predict small for gestational age and poor neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of all nonanomalous singleton pregnancies undergoing ultrasound at ≥20 weeks of gestation between 2013 and 2020 and delivering at a single academic center. Using random selection methods, the study sample was restricted to 1 pregnancy per patient and 1 ultrasound per pregnancy completed at ≥22 weeks of gestation. Fetal biometry data were used to calculate estimated fetal weight and percentiles according to the aforementioned 5 nomograms. Maternal and neonatal data were extracted from electronic medical records. Logistic regression was used to estimate the association between estimated fetal weight of <10th and <3rd percentiles compared with estimated fetal weight of 10th to 90th percentile as the reference group for small for gestational age and the neonatal composite outcomes (perinatal mortality, hypoxic-ischemic encephalopathy or seizures, respiratory morbidity, intraventricular hemorrhage, necrotizing enterocolitis, hyperbilirubinemia or hypoglycemia requiring neonatal intensive care unit admission, and retinopathy of prematurity). Receiver operating characteristic curve contrast estimation (primary analysis) and test characteristics were calculated for all nomograms and the prediction of small for gestational age and the neonatal composite outcomes. We restricted the sample to ultrasounds performed within 28 days of delivery; moreover, similar analyses were completed to assess the prediction of small for gestational age and neonatal composite outcomes. RESULTS: Among 10,045 participants, the proportion of fetuses classified as <10th percentile varied across nomograms from 4.9% to 9.7%. Fetuses with an estimated fetal weight of <10th percentile had an increased risk of small for gestational age (odds ratio, 9.9 [95% confidence interval, 8.5-11.5] to 12.8 [95% confidence interval, 10.9-15.0]). In addition, the estimated fetal weight of <10th and <3rd percentile was associated with increased risk of the neonatal composite outcome (odds ratio, 2.4 [95% confidence interval, 2.0-2.8] to 3.5 [95% confidence interval, 2.9-4.3] and 5.7 [95% confidence interval, 4.5-7.2] to 8.8 [95% confidence interval, 6.6-11.8], respectively). The prediction of small for gestational age with an estimated fetal weight of <10th percentile had a positive likelihood ratio of 6.3 to 8.5 and an area under the curve of 0.62 to 0.67. Similarly, the prediction of the neonatal composite outcome with an estimated fetal weight of <10th percentile had a positive likelihood ratio of 2.1 to 3.1 and an area under the curve of 0.55 to 0.57. When analyses were restricted to ultrasound within 4 weeks of delivery, among fetuses with an estimated fetal weight of <10th percentile, the risk of small for gestational age increased across all nomograms (odds ratio, 16.7 [95% confidence interval, 12.6-22.3] to 25.1 [95% confidence interval, 17.0-37.0]), and prediction improved (positive likelihood ratio, 8.3-15.0; area under the curve, 0.69-0.75). Similarly, the risk of neonatal composite outcome increased (odds ratio, 3.2 [95% confidence interval, 2.4-4.2] to 5.2 [95% confidence interval, 3.8-7.2]), and prediction marginally improved (positive likelihood ratio, 2.4-4.1; area under the curve, 0.60-0.62). Importantly, the risk of both being small for gestational age and having the neonatal composite outcome further increased (odds ratio, 21.4 [95% confidence interval, 13.6-33.6] to 28.7 (95% confidence interval, 18.6-44.3]), and the prediction of concurrent small for gestational age and neonatal composite outcome greatly improved (positive likelihood ratio, 6.0-10.0; area under the curve, 0.80-0.83). CONCLUSION: In this large cohort, Hadlock, recent fetal growth nomograms, and a local population-derived fetal growth reference performed comparably in the prediction of small for gestational age and neonatal composite outcomes.

Pregnant Patients with a Documented History of Penicillin Allergy and Associated Maternal and Neonatal Outcomes at a Tertiary Care Center.

OBJECTIVE: Pregnant individuals are likely to need antibiotics during the peripartum period. For pregnant individuals who report a history of penicillin allergy, non-ß-lactam antibiotics are often administered. Compared with first-line ß-lactam antibiotics, alternative antibiotics can be less effective, more toxic, and more costly. It remains unclear if being labeled with a penicillin allergy is associated with adverse maternal and neonatal outcomes. STUDY DESIGN: We conducted a retrospective cohort study of all pregnant patients who delivered a viable singleton between 24 and 42 weeks of gestation at a large academic hospital from 2013 to 2021. We compared patients who had a documented penicillin allergy history in their electronic medical record versus those who did not and examined whether there were significant differences in maternal outcomes and neonatal outcomes. Bivariable and multivariable analyses were performed. RESULTS: Of 41,943 eligible deliveries included in the analysis, 4,705 (11.2%) patients had a penicillin allergy history documented in their electronic medical record and 37,238 (88.8%) did not. Even after adjusting for potential confounders, patients with a documented penicillin allergy had a higher risk of postpartum endometritis (adjusted odds ratio [aOR]: 1.46; 95% confidence interval [CI]: 1.01-2.11) and a higher risk of their neonates having a postnatal hospital stay lasting more than 72 hours (aOR: 1.10; 95% CI: 1.02-1.18). There were no significant differences seen in the other maternal and neonatal outcomes in both bivariable and multivariable analyses. CONCLUSION: Pregnant patients who are labeled as having a penicillin allergy are more likely to have postpartum endometritis, and neonates born to mothers who are labeled as having a penicillin allergy are more likely to have a postnatal hospital stay lasting more than 72 hours. There were no other significant differences seen in pregnant patients and their newborns whether they were labeled as having a penicillin allergy history or not. However, pregnant individuals with a penicillin allergy documented in their medical record were significantly more likely to receive alternative non-ß lactam antibiotics, and may have benefitted from having more details of their allergy history available as well as proper allergy verification with testing. KEY POINTS: · It is unclear whether pregnant individuals labeled with penicillin allergies have worse obstetric outcomes.. · These individuals were significantly more likely to have endometritis and their newborns hospitalized for >72 hours.. · They were significantly more likely to receive alternative non-ß lactam antibiotics than those without documented allergies..

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..

Severe Maternal Morbidity Review and Preventability Assessment in a Large Academic Center.

With the goal of identifying factors contributing to severe maternal morbidity (SMM) at our institution, we established a formal SMM review process. We performed a retrospective cohort study including all SMM cases as defined by American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine consensus criteria that were managed at Yale-New Haven Hospital over a 4-year period. Overall, 156 cases were reviewed. The SMM rate was 0.49% (95% CI 0.40-0.58). The leading causes of SMM were hemorrhage (44.9%) and nonintrauterine infection (14.1%). Two thirds of the cases were deemed to be preventable. Preventability was mostly associated with health care professional-level (79.4%) and system-level (58.8%) factors that could coexist. Detailed case review allowed for identification of preventable causes of SMM, revealed gaps in care, and allowed for implementation of practice changes targeting health care professional-level and system-level factors.

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.

Use of family history of cardiovascular disease or chronic hypertension to better identify who needs postpartum cardiovascular risk screening.

BACKGROUND: Individuals with pregnancies complicated by hypertensive disorders of pregnancy are at increased risk of cardiovascular disease. However, not all who have hypertensive disorders of pregnancy are at risk, and not all who have uncomplicated pregnancies are without risk. OBJECTIVE: This study aimed to determine if use of first-degree family history of cardiovascular disease or chronic hypertension better identifies individuals who need postpartum cardiovascular risk screening. STUDY DESIGN: Participants were included if they had pregnancies complicated by hypertensive disorders of pregnancy or uncomplicated, term pregnancies. Individuals with a first-degree relative with chronic hypertension, myocardial infarction, or stroke were deemed to have a positive family history and were thus included. RESULTS: Four groups were considered: 302 individuals with hypertensive disorders of pregnancy who had a positive family history, 218 individuals with hypertensive disorders of pregnancy with no family history, 39 control individuals with a positive family history, and 63 control individuals with no family history. Among individuals with hypertensive disorders of pregnancy, those with a positive family history were more likely to be diagnosed with chronic hypertension, and to have elevated 30-year lipid, 30-year body mass index, and lifetime cardiovascular disease risk score (all P<.05). Among individuals with uncomplicated pregnancies, those with a positive family history were more likely to be diagnosed with chronic hypertension (P<.05) and meet criteria for metabolic syndrome (P<.05). CONCLUSION: First-degree family history of cardiovascular disease and/or chronic hypertension can be used to reliably identify individuals without pregnancy complications who should have postpartum cardiovascular risk screening, and may better determine which individuals who have a pregnancy complicated by hypertensive disorders of pregnancy would most benefit from postpartum cardiovascular risk screening.

Exploratory study of race- or ethnicity-based discrimination among patients receiving procedural abortion care.

OBJECTIVE: Explore relationships of race and ethnicity with experiences of race- or ethnicity-based discrimination during abortion care. STUDY DESIGN: English- or Spanish-speaking individuals aged 18 to 50 completed cross-sectional, self-administered online surveys within 30 days of procedural abortion at 5 Northeastern U.S. reproductive health clinics from June 2020 toFebruary 2021. We considered any affirmative response on the Discrimination in Medical Settings (DMS) scale evidence of race- or ethnicity-based discrimination. We performed bivariate analyses and logistic regression examining discrimination among Black non-Latinx, Latinx any race, Other race non-Latinx compared to White non-Latinx participants. We assessed associations between discrimination and healthcare quality and satisfaction. RESULTS: Participants (n = 163) averaged 27(±6) years and self-identified as Black non-Latinx (36.2%), White non-Latinx (28.8%), Latinx of any race (27.0%), and Other non-Latinx (8.0%). Most were publicly insured (52.8%) and <14 weeks gestation (90.8%).Overall, 15.3% reported race- or ethnicity-based discrimination during abortion care with Black non-Latinx more likely to report discrimination (23.7%; OR 7.00, 95% CI 1.50-32.59), while Latinx any race (15.9%, OR 4.26, 95% CI 0.83-21.74) and Other race non-Latinx participants (15.4%, OR 4.09, 95% CI 0.52-32.35) demonstrated statistically nonsignificant trend toward increased odds of discrimination compared to White non-Latinx (4.3%). Discrimination was associated with negative perceptions of: time with physician (p = 0.03), patient care involvement (p < 0.05), physician communication (p = 0.01), care quality (p = 0.02), and care satisfaction (p < 0.01). CONCLUSION: Racially minoritized participants were more likely to report race- or ethnicity-based discrimination during abortion care; Black non-Latinx reported highest odds of discrimination compared to White non-Latinx. Discrimination was associated with unfavorable healthcare quality measures. IMPLICATIONS: Race- or ethnicity-based discrimination during abortion care is disproportionately reported by racially minoritized populations, especially Black individuals, compared to White non-Latinx individuals. Discrimination is significantly associated with negative experiences of care. Future work should verify findings in different regions and larger studies, and design and test discrimination-reduction interventions.

Optimizing menstrual health and hygiene management in the U.S.: A mixed-methods study of the barriers and the role of healthcare professionals.

OBJECTIVE: Menstrual health (MH) practices have been understudied in the U.S. This study aimed to assess patient and medical staff views of MH. METHODS: The mixed-methods approach included medical staff and patient surveys, and patient interviews on MH experiences. Quantitative survey data generated descriptive statistics. Thematic content analysis (TCA) evaluated qualitative interviews. Convergent Parallel Triangulation Analysis (CPTA) evaluated both datasets in tandem. RESULTS: The medical staff survey's response rate was 72% (54 participants/75 invited staff). Only 7% (4/54) of staff consistently asked patients about menstrual products (MP), while 54% (29/54) were concerned about patients affording MP. The patient survey's response rate was 90% (186/207); 22% (40/186) of respondents showed MH insecurity, which was associated with annual income <$30,000 (p < 0.01); 45% (85/186) missed commitments during menses; 53% (98/186) never discussed MP with healthcare providers. To reach thematic saturation 10/17 invited patients were interviewed. Five themes were identified through TCA: menstruation as a social barrier; menstrual education comes from a variety of sources; MP choice is a balance of comfort, cost, and convenience; patients value relationships with their providers; adolescence is the window for establishing MH. Three threads were identified through CPTA: MH insecurity is common; MH screening and education are limited; menstruation impacts patients' ability to engage in daily activities. CONCLUSION: A holistic approach toward MH is needed; education and screening are inconsistent. Comprehensive MH can enhance a patient's understanding of and capacity to advocate for their health. These findings are specific to this population and may not be generalizable.