Factors associated with persistent sexual dysfunction and pain 12 months postpartum.

OBJECTIVE: Identify factors associated with persistent sexual dysfunction and pain 12-months postpartum in an underserved population. METHODS: Extending Maternal Care After Pregnancy (eMCAP) is a program addressing health needs/disparities of patients at risk for worse perinatal outcomes. Participants completed the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and Urinary Distress Index (UDI-6) 12-months postpartum. The PISQ-12 was dichotomized with scores < 32.5 indicating sexual dysfunction. Urinary incontinence (UI) was defined as at-least-somewhat bothersome (vs. none or not-at-all bothersome) urgency urinary incontinence (UUI) or stress urinary incontinence (SUI). Screening for anxiety and depression was completed using Generalized Anxiety Disorder-7 (GAD-7) and Edinburgh Postnatal Depression Scale (EPDS). Bivariate and multivariable logistic regression analyses were performed for sexual dysfunction vs. normal-function, and pain vs. no-pain, using demographic, peri/postpartum, and social-determinant-of-health variables as correlating factors. RESULTS: 328 sexually active patients provided data. On bivariate analysis, sexual dysfunction (n = 31, 9.5%) vs. normal function (n = 297, 90.5%) groups showed no differences in age, BMI, parity, mode of delivery, episiotomy/laceration types, or breastfeeding. Sexual dysfunction was significantly associatedwith both UUI and SUI: 12 (39%) vs. 46 (15%) had UUI, p = 0.001, and 20 (65%) vs. 97 (33%) had SUI, P < 0.001; the dysfunction group also had higher GAD-7 and EPDS scores and greater overall stress levels. On multivariable analysis, SUI and stress remained significantly associated: OR (95% CI) 2.45 (1.02-6.03) and 1.81 (1.32-2.49), respectively. Comparing pain (n = 45, 13.7%) vs. no-pain (n = 283, 86.2%), dyspareunia patients endorsed greater stress levels. CONCLUSION: The interplay between sexual health, incontinence, and mental health deserves further study, and all three should be routinely addressed in postpartum care.

Factors Associated With Persistent Bothersome Urinary Symptoms and Leakage After Pregnancy.

IMPORTANCE: Urinary incontinence is a common postpartum morbidity that negatively affects quality of life. OBJECTIVE: This study aimed to identify factors associated with persistent (ie, 12 months postpartum) bothersome urinary symptoms, including stress urinary incontinence (SUI) and urgency urinary incontinence (UUI), and explore their association with mental health in medically underserved communities. STUDY DESIGN: This was a cross-sectional analysis of a prospective study of individuals enrolled into "extending Maternal Care After Pregnancy," a program providing 12 months of postpartum care to individuals with health disparities. Patients were screened at 12 months for urinary dysfunction, anxiety, and depression using the Urinary Distress Index-6, Generalized Anxiety Disorder-7, and Edinburgh Postnatal Depression Scale, respectively. Bivariate and multivariable logistic regression analyses were performed for at-least-somewhat-bothersome SUI versus no-SUI, UUI versus no-UUI, and for bothersome versus asymptomatic urinary symptoms, using demographic and peripartum and postpartum variables as associated factors. RESULTS: Four hundred nineteen patients provided data at median 12 months postpartum. Patients were 77% Hispanic White and 22% non-Hispanic Black. After multivariable analysis, SUI (n = 136, 32.5%) was significantly associated with increasing body mass index at the time of delivery and greater depression screening scores. Fetal birthweight, mode of delivery, degree of laceration, and breastfeeding status were not associated. Urgency urinary incontinence (n = 69, 16.5%) was significantly associated with increasing parity and higher anxiety screening scores. Similarly, participants with urinary symptom bother had significantly greater parity and higher anxiety screening scores. CONCLUSIONS: At 12 months postpartum, bothersome urinary symptoms and incontinence were quite common. Since these are treatable, postpartum screening for urinary complaints-and associated anxiety and depression-is essential, as is assisting patients in achieving a healthy weight.

Interdependence of placenta and fetal cardiac development.

The placenta and fetal heart undergo development concurrently during early pregnancy, and, while human studies have reported associations between placental abnormalities and congenital heart disease (CHD), the nature of this relationship remains incompletely understood. Evidence from animal studies suggests a plausible cause and effect connection between placental abnormalities and fetal CHD. Biomechanical models demonstrate the influence of mechanical forces on cardiac development, whereas genetic models highlight the role of confined placental mutations that can cause some forms of CHD. Similar definitive studies in humans are lacking; however, placental pathologies such as maternal and fetal vascular malperfusion and chronic deciduitis are frequently observed in pregnancies complicated by CHD. Moreover, maternal conditions such as diabetes and pre-eclampsia, which affect placental function, are associated with increased risk of CHD in offspring. Bridging the gap between animal models and human studies is crucial to understanding how placental abnormalities may contribute to human fetal CHD. The next steps will require new methodologies and multidisciplinary approaches combining innovative imaging modalities, comprehensive genomic testing, and histopathology. These studies may eventually lead to preventative strategies for some forms of CHD by targeting placental influences on fetal heart development.

Area Deprivation and Postpartum Readmission Facility Location and Timing.

This cohort study evaluates the role that community-level socioeconomic status plays in hypertension-related hospital readmission within 12 weeks after delivery.

Magnetic resonance imaging improves diagnosis of placenta accreta spectrum requiring hysterectomy compared to ultrasound.

BACKGROUND: Magnetic resonance imaging has been used increasingly as an adjunct for ultrasound imaging for placenta accreta spectrum assessment and preoperative surgical planning, but its value has not been established yet. The ultrasound-based placenta accreta index is a well-validated standardized approach for placenta accreta spectrum evaluation. Placenta accreta spectrum-magnetic resonance imaging markers have been outlined in a joint guideline from the Society of Abdominal Radiology and the European Society of Urogenital Radiology. OBJECTIVE: This study aimed to compare placenta accreta spectrum-magnetic resonance imaging parameters with the ultrasound-based placenta accreta index in pregnancies at high risk for placenta accreta spectrum and to assess the additional diagnostic value of magnetic resonance imaging for placenta accreta spectrum that requires a cesarean hysterectomy. STUDY DESIGN: This was a single-center, retrospective study of pregnant patients who underwent magnetic resonance imaging, in addition to ultrasonography, because of suspected placenta accreta spectrum. The ultrasound-based placenta accreta index and placenta accreta spectrum-magnetic resonance imaging parameters were obtained. Student's t test and Fisher's exact test were used to compare the groups in terms of the primary outcome (hysterectomy vs no hysterectomy). The diagnostic performance of magnetic resonance imaging and the ultrasound-based placenta accreta index was assessed using multivariable logistic regressions, receiver operating characteristics curves, the DeLong test, McNemar test, and the relative predictive value test. RESULTS: A total of 82 patients were included in the study, 41 of whom required a hysterectomy. All patients who underwent a hysterectomy met the International Federation of Gynecology and Obstetrics clinical evidence of placenta accreta spectrum at the time of delivery. Multiple parameters of the ultrasound-based placenta accreta index and placenta accreta spectrum-magnetic resonance imaging were able to predict hysterectomy, and the parameter of greatest dimension of invasion by magnetic resonance imaging was the best quantitative predictor. At 96% sensitivity for hysterectomy, the cutoff values were 3.5 for the ultrasound-based placenta accreta index and 2.5 cm for the greatest dimension of invasion by magnetic resonance imaging. Using this sensitivity, the parameter of greatest dimension of invasion measured by magnetic resonance imaging had higher specificity (P=.0016) and a higher positive predictive value (P=.0018) than the ultrasound-based placenta accreta index, indicating an improved diagnostic threshold. CONCLUSION: In a suspected high-risk group for placenta accreta spectrum, magnetic resonance imaging identified more patients who will not need a hysterectomy than when using the ultrasound-based placenta accrete index only. Magnetic resonance imaging has the potential to aid patient counseling, surgical planning, and delivery timing, including preterm delivery decisions for patients with placenta accreta spectrum requiring hysterectomy.

Vaginal Compared With Oral Misoprostol Induction at Term: A Cluster Randomized Controlled Trial.

OBJECTIVE: To evaluate efficacy in achieving vaginal delivery with a standardized vaginal compared with oral misoprostol regimen for labor induction at term. METHODS: In this single-center, cluster randomized trial, we randomized induction method by week among individuals with gestational age of 37 weeks or more, cervical dilation of 2 cm or less, intact membranes, and indication for delivery to either oral (100 micrograms every 4 hours for up to two doses), or vaginal (25 micrograms every 3 hours for up to five doses) misoprostol regimens, followed by a standardized oxytocin protocol. Individuals with an antepartum stillbirth, major fetal anomalies, malpresentation, ruptured membranes, nonreassuring fetal status, or contraindication to prostaglandin were excluded. The primary outcome was vaginal delivery at first induction attempt. Secondary outcomes included time to delivery, need for oxytocin, chorioamnionitis, and adverse maternal and neonatal outcomes. Outcomes were recorded at the individual level and adjusted for clustering, with analysis by intention to treat. RESULTS: Between May 24, 2021, to September 19, 2022, 1,322 women were randomized to vaginal misoprostol in 33 clusters and 1,224 to oral misoprostol in 37 clusters. Demographic characteristics or initial cervical dilation did not differ between groups. The primary outcome did not differ between induction regimens and occurred in 1,032 (78.1%) of the vaginal misoprostol arm and 945 (77.2%) of the oral misoprostol arm (adjusted relative risk [RR] 1.01, 95% CI, 0.97-1.05). Tachysystole with fetal heart rate changes occurred less frequently with vaginal compared with oral misoprostol (3.5% vs 5.9%, adjusted RR 0.59, 95% CI, 0.40-0.87). Time to delivery did not differ between groups. Oxytocin was less frequently required before delivery in the vaginal misoprostol group (68.8% vs 78.4%, adjusted RR 0.88, 95% CI, 0.84-0.92). CONCLUSION: Induction of labor with vaginal compared with oral misoprostol protocols did not increase the frequency of vaginal delivery at term but did reduce the need for oxytocin use before delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04755218.

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People.

Importance: Postpartum transfusion is the most common indicator of severe maternal morbidity in the US. Higher rates of anemia are associated with a higher blood transfusion rate. Objective: To determine if providing, rather than recommending, supplements with iron at prenatal visits in a medically underserved community is associated with improved hematologic indices and reduced blood transfusion. Design, Setting, and Participants: In this quality improvement study, patients who delivered between May 13 and December 13, 2020, and thus were provided a prenatal supplement with iron throughout pregnancy were compared with those who delivered between January 1 and August 1, 2019, before supplements were dispensed. The study was conducted at Parkland Health, a safety net hospital in Dallas, Texas, with a 95% Medicaid-funded or self-pay population and included all patients who delivered at our institution during the study period with available hematologic data. Exposures: In the earlier cohort, all patients were recommended to obtain and take iron supplements. In the later cohort, prenatal supplements with iron were dispensed via clinic pharmacy to all patients during prenatal visits. Main Outcomes and Measures: Maternal hematocrit levels (28-32 weeks, delivery admission, and discharge), rates of anemia (hematocrit <30%), and postpartum transfusion for acute blood loss anemia were compared using χ2 and analysis of variance methods with P < .05 considered significant. The analysis took place in July of 2022. Results: Overall, 13 910 patients (98%) met inclusion criteria (mean age [SD], 27.9 [6.5] and 27.6 [6.5] years, mean [SD] body mass index at first visit, 29.2 [6.6] and 29.3 [6.6]). Mosty of the patients in both cohorts were of Hispanic ethnicity (76%). Providing iron-containing prenatal supplements was associated with higher average hematocrit levels at all time points including a mean difference of 1.27% (95% CI, 1.13%-1.42%) on admission for delivery, when compared with those who were not directly dispensed iron. Among patients prior to providing supplements, 18% had anemia on admission compared with 11% with iron-containing supplements dispensed (risk ratio [RR], 0.61; 95% CI, 0.56-0.66). Postpartum transfusion for acute blood loss anemia was reduced by one-third in patients after program implementation from 10 per 1000 to 6.6 per 1000 (RR, 0.62; 95% CI, 0.43-0.91). Conclusions and Relevance: In this quality improvement study, providing supplements with iron to patients at prenatal visits was associated with improved hematocrit levels, rates of anemia, and reduced transfusions unrelated to obstetric catastrophes among a predominantly Medicaid population.

The human placenta project: Funded studies, imaging technologies, and future directions.

The placenta plays a critical role in fetal development. It serves as a multi-functional organ that protects and nurtures the fetus during pregnancy. However, despite its importance, the intricacies of placental structure and function in normal and diseased states have remained largely unexplored. Thus, in 2014, the National Institute of Child Health and Human Development launched the Human Placenta Project (HPP). As of May 2023, the HPP has awarded over $101 million in research funds, resulting in 41 funded studies and 459 publications. We conducted a comprehensive review of these studies and publications to identify areas of funded research, advances in those areas, limitations of current research, and continued areas of need. This paper will specifically review the funded studies by the HPP, followed by an in-depth discussion on advances and gaps within placental-focused imaging. We highlight the progress within magnetic reasonance imaging and ultrasound, including development of tools for the assessment of placental function and structure.

Sex Vulnerabilities to Hypoxia-Ischemia at Birth.

This cross-sectional study examines the incidence of hypoxic ischemic encephalopathy in male vs female neonates.

Longitudinal assessment of placental perfusion in normal and hypertensive pregnancies using pseudo-continuous arterial spin-labeled MRI: preliminary experience.

OBJECTIVES: To evaluate longitudinal placental perfusion using pseudo-continuous arterial spin-labeled (pCASL) MRI in normal pregnancies and in pregnancies affected by chronic hypertension (cHTN), who are at the greatest risk for placental-mediated disease conditions. METHODS: Eighteen normal and 23 pregnant subjects with cHTN requiring antihypertensive therapy were scanned at 3 T using free-breathing pCASL-MRI at 16-20 and 24-28 weeks of gestational age. RESULTS: Mean placental perfusion was 103.1 ± 48.0 and 71.4 ± 18.3 mL/100 g/min at 16-20 and 24-28 weeks respectively in normal pregnancies and 79.4 ± 27.4 and 74.9 ± 26.6 mL/100 g/min in cHTN pregnancies. There was a significant decrease in perfusion between the first and second scans in normal pregnancies (p = 0.004), which was not observed in cHTN pregnancies (p = 0.36). The mean perfusion was not statistically different between normal and cHTN pregnancies at both scans, but the absolute change in perfusion per week was statistically different between these groups (p = 0.044). Furthermore, placental perfusion was significantly lower at both time points (p = 0.027 and 0.044 respectively) in the four pregnant subjects with cHTN who went on to have infants that were small for gestational age (52.7 ± 20.4 and 50.4 ± 20.9 mL/100 g/min) versus those who did not (85 ± 25.6 and 80.0 ± 25.1 mL/100 g/min). CONCLUSION: pCASL-MRI enables longitudinal assessment of placental perfusion in pregnant subjects. Placental perfusion in the second trimester declined in normal pregnancies whereas it remained unchanged in cHTN pregnancies, consistent with alterations due to vascular disease pathology. Perfusion was significantly lower in those with small for gestational age infants, indicating that pCASL-MRI-measured perfusion may be an effective imaging biomarker for placental insufficiency. CLINICAL RELEVANCE STATEMENT: pCASL-MRI enables longitudinal assessment of placental perfusion without administering exogenous contrast agent and can identify placental insufficiency in pregnant subjects with chronic hypertension that can lead to earlier interventions. KEY POINTS: • Arterial spin-labeled (ASL) magnetic resonance imaging (MRI) enables longitudinal assessment of placental perfusion without administering exogenous contrast agent. • ASL-MRI-measured placental perfusion decreased significantly between 16-20 week and 24-28 week gestational age in normal pregnancies, while it remained relatively constant in hypertensive pregnancies, attributed to vascular disease pathology. • ASL-MRI-measured placental perfusion was significantly lower in subjects with hypertension who had a small for gestational age infant at 16-20-week gestation, indicating perfusion as an effective biomarker of placental insufficiency.

Traffic-related air pollution is associated with spontaneous extremely preterm birth and other adverse perinatal outcomes.

BACKGROUND: Although there is growing awareness of the relationship between air pollution and preterm birth, limited data exist regarding the relationship with spontaneous preterm birth and severe neonatal outcomes. OBJECTIVE: This study aimed to examine the association between traffic-associated air pollution exposure in pregnancy and adverse perinatal outcomes including extremes of preterm birth, neonatal intensive care unit admissions, low birthweight, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation. STUDY DESIGN: This was a retrospective cohort study of singleton pregnancies of patients residing in a metropolitan area in the southern United States. Using monitors strategically located across the region, average nitrogen dioxide concentrations were obtained from the Environmental Protection Agency Air Quality System database. For patients living within 10 miles of a monitoring station, average exposure to nitrogen dioxide was estimated for individual patients' pregnancy by trimester. Logistic regression models were used to assess the effect of pollutant exposure on gestational age at birth, indicated vs spontaneous delivery, and neonatal outcomes while adjusting for maternal age, self-reported race, parity, season of conception, diabetes mellitus, body mass index, registered Health Equity Index, and nitrogen dioxide monitor region. Adjusted odds ratios and 95% confidence intervals were calculated for an interquartile increase in average nitrogen dioxide exposure. RESULTS: Between January 1, 2013 and December 31, 2021, 93,164 patients delivered a singleton infant. Of these, 62,189 had measured nitrogen dioxide exposure during the pregnancy from a nearby monitoring station. Higher average nitrogen dioxide exposure throughout pregnancy was significantly associated with preterm birth (adjusted odds ratio, 1.94; 95% confidence interval, 1.77-2.12) and an increase in neonatal intensive care unit admissions, low birthweight infants, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation. This relationship persisted for nulliparous patients and spontaneous preterm birth, and had a greater association with earlier preterm birth. CONCLUSION: In a metropolitan area, increased exposure to the air pollutant nitrogen dioxide in pregnancy was associated with spontaneous preterm birth and had a greater association with extremely preterm birth. A greater association with neonatal intensive care unit admissions, low-birthweight infants, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation was found even in term infants.

Prenatal Ultrasound Findings of Circumvallate Placenta and Pregnancy Outcomes.

OBJECTIVE: Circumvallate placenta has a suggested association with adverse pregnancy outcomes (antenatal bleeding, placental abruption, preterm birth, emergency cesarean, small for gestational age infants, and stillbirth). The aim was to determine if prenatal diagnosis of circumvallate placenta is associated with these adverse pregnancy outcomes. STUDY DESIGN: Pregnancies with a singleton gestation prenatally diagnosed with circumvallate placenta between January 1, 2012 and March 31, 2021 were identified. Adverse pregnancy outcomes were obtained. Rates of adverse pregnancy outcomes were compared among those with prenatally diagnosed circumvallate placentas to those without this prenatal diagnosis with a 4:1 control matched group. Pregnancies with known fetal anomalies or other placental abnormalities were excluded. Statistical analyses included Student's t-test and Χ 2 with p < 0.05 considered significant. RESULTS: Prenatal ultrasound findings of circumvallate placenta were seen in 179 pregnant people (0.20% of all anatomic US studies and 0.17% of all deliveries). Diagnosis was made at a mean gestational age of 19.8 ± 2.4 weeks. Adverse pregnancy outcomes were similar between groups. CONCLUSION: Prenatal ultrasound findings of circumvallate placenta do not correlate with adverse pregnancy outcomes. Given overall good prognosis, prenatal diagnosis of circumvallate placenta may not warrant additional surveillance during pregnancy. KEY POINTS: · The risk of prenatally diagnosed circumvallate placenta was previously unclear.. · Prenatally diagnosed circumvallate placenta is not associated with adverse pregnancy outcomes.. · No change in management may be necessary with prenatally diagnosed circumvallate placenta..

A Prospective Study of Social Needs Associated with Mental Health among Postpartum Patients Living in Underserved Communities.

OBJECTIVE: Given the rising rates of maternal morbidity and mortality in the United States and the contribution of mental illness, especially among individuals living in underresourced communities, the objective was to evaluate the prevalence of unmet health-related social needs and their impact on perinatal mental health outcomes. STUDY DESIGN: This was a prospective observational study of postpartum patients residing within regions with increased rates of poor perinatal outcomes and sociodemographic disparities. Patients were enrolled in a multidisciplinary public health initiative "extending Maternal Care After Pregnancy (eMCAP)" between October 1, 2020 and October 31, 2021. Unmet health-related social needs were assessed at delivery. Symptoms of postpartum depression and anxiety were evaluated at 1 month postpartum utilizing the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder-7 (GAD7) screening tools, respectively. Mean EPDS and GAD7 scores and odds of screening positive (scoring ≥ 10) were compared among individuals with and without unmet health-related social needs with p < 0.05 considered significant. RESULTS: Of participants enrolled in eMCAP, 603 completed at least one EPDS or GAD7 at 1 month. Most had at least one social need, most commonly dependence on social programs for food (n = 413/603; 68%). Individuals lacking transportation to medical (odds ratio [OR]: 4.0, 95% confidence interval [CI]: 1.2-13.32) and nonmedical appointments (OR: 4.17, 95% CI: 1.08-16.03) had significantly higher odds of screening positive on EPDS while participants lacking transportation to medical appointments (OR: 2.73, 95% CI: 0.97-7.70) had significantly higher odds of screening positive on GAD7. CONCLUSION: Among postpartum individuals in underserved communities, social needs correlate with higher depression and anxiety screening scores. This highlights the need to address social needs to improve maternal mental health. KEY POINTS: · Social needs are prevalent among underserved patients.. · Needs can be assessed in a structured or freeform manner.. · Unmet needs correlate with poor mental health outcomes.. · Similar needs correlate with depression and anxiety..