Oxytocin regimen used for induction of labor and pregnancy outcomes.

BACKGROUND: Following the results of the ARRIVE trial, which demonstrated a reduction in cesarean delivery with no increase in adverse perinatal outcomes after elective induction of labor (IOL) in low-risk nulliparous patients at 39 weeks' gestation compared with expectant management, the use of induction has increased. Current evidence is insufficient to recommend mid-high-dose over low-dose regimens for routine IOL. OBJECTIVE(S): We sought to evaluate the association of oxytocin regimen with cesarean delivery and an adverse perinatal composite outcome in low-risk nulliparous patients undergoing IOL at 39 weeks of gestation or greater. STUDY DESIGN: This is a secondary analysis of the NICHD Maternal-Fetal Medicine Units Network ARRIVE randomized trial. Patients induced with a mid-to high-dose oxytocin regimen (MHD; starting or incremental increase >2 mU/min) were compared with those receiving a low-dose oxytocin regimen (LD; starting and incremental increase ≤2 mU/min). The co-primary outcomes for this secondary analysis were 1) cesarean delivery and 2) composite of perinatal death or severe neonatal complications. Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) and 97.5% confidence intervals (CI) for the co-primary endpoints, 95% CI for binomial outcomes and multinomial logistic regression was used to estimate adjusted odds ratios (aOR) and 95% CIs for multinomial outcomes. RESULTS: Of 6,106 participants enrolled in the primary trial, 2,933 underwent induction with oxytocin: 861 in the MHD group and 2,072 in the LD group. The lower frequency of cesarean delivery in the MHD group compared with the LD group (20.3% vs. 25.2%, RR 0.81, 95%CI (0.69-0.94)) was not significant after adjustment (aRR 0.90, 97.5%CI (0.76-1.07)). The composite of perinatal death or severe neonatal complications was more frequent in the MHD group compared with the LD group (6.7% vs. 4.3%, RR 1.55, 95%CI (1.13-2.14)) and remained significant after adjustment (aRR 1.61, 97.5%CI (1.11-2.35)). The majority of the cases in the composite were from the respiratory support (5.2% vs. 3.1%) component with an increase in transient tachypnea of the newborn (3.8% vs. 2.5%, aRR 1.63, 95% CI (1.04-2.54)). The duration of neonatal respiratory support for one day was significantly higher in the MHD group compared with the LD group (3.5% vs. 1.4%, aRR 2.59, 95%CI (1.52-4.39)); however, support beyond one day was not different between the two groups. The MHD group, when compared with the LD group had a higher operative vaginal delivery rate (10.0% vs. 7.0%, aRR 1.54, 95%CI (1.18-2.00)) and shorter duration of time from start of oxytocin to delivery [crude median (interquartile range) 12 (8-17) vs. 13 (9-19) hours, adjusted median difference -2 (-2 to -1), p<0.001], respectively. CONCLUSION(S): Mid-high-dose oxytocin regimen use for IOL in nulliparas at ≥ 39 weeks' gestation was not associated with improved maternal or neonatal outcomes compared with low-dose regimens. Although mid-high-dose oxytocin regimen use was associated with a shorter duration of labor, there was an increase in self-limited neonatal respiratory support and no difference in cesarean rates. More evidence is needed to define the magnitude of potential maternal and neonatal benefits and risks associated with oxytocin regimens.

Implementation of a Standardized Protocol for Postpartum Anemia: A Prospective Cohort Study.

OBJECTIVE: Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves predelivery hemoglobin (Hb). However, this condition is often overlooked and inadequately treated in postpartum care settings. We aimed to determine if implementation of a standardized protocol for postpartum anemia increases postpartum IVFe use and affects clinical outcomes. STUDY DESIGN: We performed a prospective cohort study evaluating implementation of a standardized inpatient protocol for postpartum anemia. This protocol, implemented in December 2021, recommends (1) IVFe for postpartum Hb 7.0 to 8.9 g/dL and (2) oral iron for postpartum Hb 9.0 to 9.9 g/dL. We compared all postpartum inpatients at a single site from April 2021 (preimplementation period [PRE]) to April 2022 (postimplementation period [POST]). The primary outcome was any IVFe use. Secondary outcomes included number of IVFe doses, oral iron supplementation at discharge, postpartum complications, and length of stay. RESULTS: A total of 805 patients were included (PRE = 401; POST = 404). Patients in the PRE and POST groups differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p = 0.003). IVFe use significantly increased from PRE to POST (PRE: 6.0% vs. POST: 11.1%, p = 0.009) even when controlling for differences between groups (adjusted odds ratio: 2.48, 95% confidence interval: [1.08-5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared with patients receiving IVFe in the PRE group (POST: 29% vs. PRE: 4%, p = 0.04). Patients in the POST group had shorter lengths of stay than in the PRE group (POST: 1.69 days vs. PRE: 1.81 days, p < 0.001). There were no significant differences in blood transfusion, oral iron supplementation, or postpartum complications. CONCLUSION: Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay. KEY POINTS: · Postpartum anemia is associated with postpartum depression, fatigue, impaired cognition, and altered maternal-infant bonding.. · IVFe is more effective and better tolerated than oral iron.. · Implementation of standardized protocols for antepartum anemia has been shown to increase IVFe use.. · Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay..

Are Neonatal Birth Weights Reduced in Low-Risk Patients Diagnosed with COVID-19 during Pregnancy?

OBJECTIVE: Studies have shown that the 2019 novel coronavirus disease (COVID-19) may be associated with an increased risk of adverse pregnancy outcomes including preeclampsia, preterm birth, and stillbirth. However, the relationship between COVID-19 and abnormal fetal growth (i.e., low neonatal birth weight) has not been elucidated. Because other viruses affect fetal growth, obstetrical providers began to recommend ultrasound studies during the third trimester to assess fetal growth in patients with COVID-19 during pregnancy. The aim of this study was to determine if neonatal birth weight was different between low-risk patients diagnosed with COVID-19 during pregnancy and low-risk patients without COVID-19 in pregnancy, to ascertain if third trimester growth ultrasound is warranted in this patient population. STUDY DESIGN: We performed a retrospective cohort study of low-risk pregnant patients (who had no other indications for sonographic fetal surveillance during the third trimester) with and without COVID-19 during pregnancy. Patient demographics, gestational dating, neonatal birth weights, and corresponding Alexander growth curve birth weight percentiles were collected. The primary outcome was small-for-gestational age (SGA) neonates, defined as birth weight < 10th percentile for gestational age at delivery (SGA10). RESULTS: Our cohort (N = 513) included 248 COVID-19-exposed patients and 265 patients who did not have COVID-19 during pregnancy. Gestational age at delivery and average neonatal birth weights were similar in COVID-19-exposed (38 weeks 5 days, 3,266 g) and unexposed patients (38 weeks 4 days, 3,224 g; p = 0.434, 0.358). Rates of SGA10 neonates were similar in the COVID-19-exposed (22/248, 8.9%) and -unexposed (23/265, 8.7%, p = 0.939) groups. Timing and severity of COVID-19 during pregnancy also were not associated with rates of SGA neonates. CONCLUSION: In a cohort of low-risk patients, rates of SGA neonates were similar in patients with and without COVID-19 during pregnancy. These findings suggest that ultrasound surveillance to detect fetal growth restriction in low-risk patients with COVID-19 during pregnancy is not warranted. KEY POINTS: · COVID-19 may be associated with fetal growth restriction.. · There are normal infant weights in patients with COVID-19 in pregnancy.. · Growth ultrasound is not needed in patients with COVID-19..

Optimizing Opioid Prescription Quantity After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To test whether an individualized opioid-prescription protocol (IOPP) with a shared decision-making component can be used without compromising postcesarean pain management. METHODS: In this multicenter randomized controlled noninferiority trial, we compared IOPP with shared decision making with a fixed quantity of opioid tablets at hospital discharge. We recruited at 31 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Study participants had uncomplicated cesarean births. Follow-up occurred through 12 weeks postdischarge. Individuals with complicated cesarean births or history of opioid use in the pregnancy were excluded. Participants were randomized 1:1 to IOPP with shared decision making or fixed quantity (20 tablets of 5 mg oxycodone). In the IOPP group, we calculated recommended tablet quantity based on opioid use in the 24 hours before discharge. After an educational module and shared decision making, participants selected a quantity of discharge tablets (up to 20). The primary outcome was moderate to severe pain (score 4 or higher [possible range 0-10]) on the BPI (Brief Pain Inventory) at 1 week after discharge. A total sample size of 5,500 participants was planned to assess whether IOPP with shared decision making was not inferior to the fixed quantity of 20 tablets. RESULTS: From September 2020 to March 2022, 18,990 individuals were screened and 5,521 were enrolled (n=2,748 IOPP group, n=2,773 fixed-quantity group). For the primary outcome, IOPP with shared decision making was not inferior to fixed quantity (59.5% vs 60.1%, risk difference 0.67%; 95% CI, -2.03% to 3.37%, noninferiority margin -5.0) and resulted in significantly fewer tablets received (median 14 [interquartile range 4-20] vs 20, P <.001) through 90 days postpartum. CONCLUSION: Compared with fixed quantity, IOPP with shared decision making was noninferior for outpatient postcesarean analgesia at 1 week postdischarge and resulted in fewer prescribed opioid tablets at discharge. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04296396.

First and Second Stage Risk Factors Associated with Perineal Lacerations.

OBJECTIVE: To determine intrapartum factors associated with perineal laceration at delivery. METHODS: This was a planned secondary analysis of a multicenter randomized clinical trial of delayed versus immediate pushing among term nulliparous women in labor with neuraxial analgesia conducted in the United States. Intrapartum characteristics were extracted from the medical charts. The primary outcome was perineal laceration, defined as second degree or above, characterized at delivery in women participating in longer term pelvic floor assessments post-delivery. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, birth weight, and maternal age. RESULTS: Among the 941 women participating in the pelvic floor follow-up, 40.6% experienced a perineal laceration. No first stage labor characteristics were associated with perineal laceration, including type of labor or length of first stage. Receiving an amnioinfusion appeared protective of perineal laceration (adjusted odds ratio, 0.48; 95% confidence interval 0.26-0.91; P = 0.01). Second stage labor characteristics associated with injury were length of stage (2.01 h vs. 1.50 h; adjusted odds ratio, 1.36; 95% confidence interval 1.18-1.57; P < 0.01) and a prolonged second stage (adjusted odds ratio, 1.64; 95% confidence interval 1.06-2.56; P < 0.01). Operative vaginal delivery was strongly associated with perineal laceration (adjusted odds ratio, 3.57; 95% confidence interval 1.85-6.90; P < 0.01). CONCLUSION: Operative vaginal delivery is a modifiable risk factor associated with an increased risk of perineal laceration. Amnioinfusion appeared protective against injury, which could reflect a spurious finding, but may also represent true risk reduction similar to the mechanism of warm perineal compress.

Impact of the Duration of the Second Stage of Labor on Postpartum Pelvic Floor Symptoms.

IMPORTANCE: The associated effect of duration of the second stage of labor (SSL) on pelvic floor symptoms development is not well studied. OBJECTIVE: This study aimed to examine the association between duration of SSL and pelvic floor symptoms at 6 months postpartum among primiparous women. STUDY DESIGN: A planned secondary analysis of a multicenter randomized trial evaluating the impact of immediate versus delayed pushing on vaginal delivery rates, maternal morbidity, and neonatal outcomes was conducted between 2014 and 2018. For pelvic floor arm participants, demographic, pelvic examination, and validated questionnaire data were collected postpartum. Primary outcome was change in Pelvic Floor Distress Inventory 20 (PFDI-20) score from immediate to 6 months postpartum. Secondary outcomes included changes in the Pelvic Floor Impact Questionnaire, Fecal Incontinence Severity Index, Modified Manchester Health Questionnaire scores, and Pelvic Organ Prolapse Quantification measurements at 6 months postpartum. Participants were analyzed by SSL duration ≤60 minutes or >60 minutes. RESULTS: Of the 2,414 trial participants, 767 (32%) completed pelvic floor assessments at 6 months. Pelvic Floor Distress Inventory 20 scores significantly improved at 6 months in the ≤60 minutes SSL group compared with >60 minutes SSL (-14.3 ± 48.0 and -3.2 ± 45.3, respectively; P = 0.04). Changes from immediate postpartum in total and subscale scores for other questionnaires at 6 months did not differ between groups. Prolapse stage did not differ between groups. Perineal body was significantly shorter in the >60 minutes SSL group (3.7 ± 0.7, 3.5 ± 0.8; P = 0.03). CONCLUSIONS: Women with SSL >60 minutes experience less improvement in PFDI-20 scores at 6 months. Greater tissue and innervation trauma in those with SSL >60 minutes may explain persistently less improvement in PFDI-20 scores.

Complications of lymphangioleiomyomatosis in pregnancy: a case report and review of the literature.

Lymphangioleiomyomatosis is a rare cystic lung disease primarily affecting premenopausal females and may be exacerbated by pregnancy. We conducted a literature review of lymphangioleiomyomatosis during pregnancy with a specific focus on related maternal morbidity and obstetrical outcomes. We also report a case of lymphangioleiomyomatosis that presented as an acute spontaneous pneumothorax in the third trimester of pregnancy, followed by significant maternal morbidity. A 37-year-old primigravid woman who presented at 29 weeks 5 days gestation with chest pain was diagnosed with spontaneous pneumothorax. Further imaging demonstrated cystic lung lesions and renal angiomyolipomas. She developed severe abdominal pain concerning for placental abruption that led to an urgent cesarean delivery at 30 weeks 2 days gestation. Her course was complicated by recurrent pneumothorax, superimposed preeclampsia, and significant ileus and bowel dilation complicated by bowel perforation. For patients with a clinical suspicion of lymphangioleiomyomatosis in pregnancy, prompt recognition, diagnosis, and referral to appropriate multidisciplinary subspecialists is critical to mitigate complications and optimize outcomes both during and after pregnancy.

Frequency of Prenatal Care Visits: A Core Outcome Set for Prenatal Care Schedules.

Objective: The aim of this study is to develop a core outcome set for the frequency and modality of prenatal care visits. Material and Methods: A consensus development study was conducted in the United States with participants, including 31 health care professionals, 12 public policy members or public health payers, and 18 public members, representing 24 states. A modified Delphi method and modified nominal group technique were utilized. Results: Twenty-one potential core outcomes were developed by combining the outcomes reported in three systematic reviews that evaluated the frequency of prenatal care visits or modality of prenatal visit type (e.g., in person, telemedicine, or hybrids of both). Eighteen consensus outcomes were identified from the Delphi process, following which 10 maternal and 4 neonatal outcomes were agreed at the consensus development meeting. Maternal core outcomes include maternal quality of life; maternal mental health outcomes; the experience of maternity care; lost time; attendance of recommended visits; unplanned care utilization; completion of the American College of Obstetricians and Gynecologists-recommended services; diagnosis of obstetric complications-proportion and timing; disparities in care outcomes; and severe maternal morbidity or mortality. Neonatal core outcomes include gestational age at birth, birth weight, stillbirth or perinatal death, and neonatal intensive care unit admissions. Conclusions: The core outcome set for the frequency and modality of prenatal visits should be utilized in forthcoming randomized controlled trials and systematic reviews. Such application will warrant that in future research, consistent reporting will enrich care and improve outcomes. Clinical Trial Registration number: 2021.

Racial disparities in low-risk cesarean birth rates across hospitals.

BACKGROUND: We compared low-risk cesarean birth rates for Black and White women across hospitals serving increasing proportions of Black women and identified hospitals where Black women had low-risk cesarean rates less than or equal to White women. METHODS: In this cross-sectional analysis of secondary data from four states, we categorized hospitals by their proportion of Black women giving birth from "low" to "high". We analyzed the odds of low-risk cesarean for Black and White women across hospital categories. RESULTS: Our sample comprised 493 hospitals and the 65,524 Black and 251,426 White women at low risk for cesarean who birthed in them. The mean low-risk cesarean rate was significantly higher for Black, compared with White, women in the low (20.1% vs. 15.9%) and medium (18.1% vs. 16.9%) hospital categories. In regression models, no hospital structural characteristics were significantly associated with the odds of a Black woman having a low-risk cesarean. For White women, birthing in a hospital serving the highest proportion of Black women was associated with a 21% (95% CI: 1.01-1.44) increase in the odds of having a low-risk cesarean. DISCUSSION: Black women had higher odds of a low-risk cesarean than White women and were more likely to access care in hospitals with higher low-risk cesarean rates. The existence of hospitals where low-risk cesarean rates for Black women were less than or equal to those of White women was notable, given a predominant focus on hospitals where Black women have poorer outcomes. Efforts to decrease the low-risk cesarean rate should focus on (1) improving intrapartum care for Black women and (2) identifying differentiating organizational factors in hospitals where cesarean birth rates are optimally low and equivalent among racial groups as a basis for system-level policy efforts to improve equity and reduce cesarean birth rates.

Alternative Payment Models in Pregnancy to Improve Outcomes and Advance Equity.

This Viewpoint reviews the state of alternative payment models (APMs) applied to pregnancy and proposes clinical and policy objectives that could guide model design going forward.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

The Heart Rhythm Society (HRS) has developed expert consensus documents that have guided clinical care in the management of cardiac arrhythmias since 1996. This HRSled expert consensus statement was developed in collaboration with the American College of Cardiology (ACC), the American College of Obstetricians and Gynecologists (ACOG), the American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), the European Heart Rhythm Association (EHRA), the Latin American Heart Rhythm Society (LAHRS), the Pediatric and Congenital Electrophysiology Society (PACES), and the Society for Maternal-Fetal Medicine (SMFM). This clinical practice document is intended to provide comprehensive guidance to cardiac electrophysiologists, cardiologists, and other health care professionals on the management of cardiac arrhythmias in pregnant patients, including arrhythmias that occur in the mother and in the fetus.

An innovative sequential mixed-methods approach to evaluating clinician acceptability during implementation of a standardized labor induction protocol.

BACKGROUND: Implementation outcomes, including acceptability, are of critical importance in both implementation research and practice. The gold standard measure of acceptability, Acceptability of Intervention Measure (AIM), skews positively with a limited range. In an ongoing hybrid effectiveness-implementation trial, we aimed to evaluate clinician acceptability of induction standardization. Here, we describe an innovative mixed-methods approach to maximize the interpretability of the AIM using a case study in maternal health. METHODS: In this explanatory sequential mixed methods study, we distributed the validated, 4-question AIM (total 4-20) to labor and delivery clinicians 6 months post-implementation at 2 sites (Site 1: 3/2021; Site 2: 6/2021). Respondents were grouped by total score into tertiles. The top ("High" Acceptability) and bottom ("Low" Acceptability) tertiles were invited to participate in a 30-minute semi-structured qualitative interview from 6/2021 to 10/2021 until thematic saturation was reached in each acceptability group. Participants were purposively sampled by role and site. Interviews were coded using an integrated approach, incorporating a priori attributes (Consolidated Framework for Implementation Research constructs) into a modified content analysis approach. RESULTS: 104 clinicians completed the initial survey; 24 were interviewed (12 "High" and 12 "Low" Acceptability). Median total AIM scores were 20/20 IQR[20-20] in the High and 12.5/20 IQR[11-14] in the Low Acceptability groups. In both groups, clinicians were enthusiastic about efforts to standardize labor induction, believing it reduces inter-clinician variability and improves equitable, evidence-based care. In the Low Acceptability group, clinicians stated the need for flexibility and consideration for patient uniqueness. Rarely, clinicians felt labor induction could not or should not be standardized, citing discomfort with medicalization of labor, and concerns with "bulldozing" the patient with interventions. Suggested strategies for overcoming negative sentiment included comprehensive clinician education, as well as involving patients as active participants in the protocol prenatally. CONCLUSIONS: This study utilized AIM in an innovative sequential mixed-methods approach to characterize clinician acceptability, which may be generalizable across implementation endeavors. By performing this work during a hybrid trial, implementation strategies to improve acceptability emerged (clinician education focusing on respect for flexibility; involving patients as active participants prenatally) for year 2, which will inform future multi-site work.

Routine Prenatal Care.

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

Association of a Remote Blood Pressure Monitoring Program With Postpartum Adverse Outcomes.

OBJECTIVE: To use administrative claims data to evaluate the association of a remote blood pressure monitoring program with adverse postpartum clinical outcomes in patients with a hypertensive disorder of pregnancy. METHODS: This was a retrospective cohort study of Independence Blue Cross members with a hypertensive disorder of pregnancy diagnosis across three obstetric hospitals from 2017 to 2021. Patients who were enrolled in twice-daily text-based blood pressure monitoring for 10 days postpartum were compared with two propensity-score matched cohorts of patients who met the program criteria: an asynchronous cohort (cohort A), consisting of patients at any of the three participating hospitals before remote monitoring program implementation, and a contemporaneous cohort (cohort C), consisting of patients at other hospitals during the same time period as clinical use of the program. Patients with less than 16 months of continuous insurance enrollment before delivery were excluded. Claims for adverse clinical outcomes after delivery discharge were evaluated. Health care service utilization and total medical costs were evaluated. RESULTS: The 1,700 patients in remote blood pressure monitoring program were matched to 1,021 patients in cohort A and 1,276 in cohort C. Within the first 6 months after delivery, patients enrolled in remote monitoring were less likely to have the composite adverse outcome than those in cohort A (2.9% vs 4.7%; OR 0.61, 95% CI 0.40-0.98). There was no statistically significant difference relative to cohort C (3.2% vs 4.5%; OR 0.71, 95% CI 0.47-1.07). The remote monitoring group had more cardiology visits and fewer postnatal emergency department (ED) visits and readmissions compared with both comparison cohorts. Reductions in ED visits and readmissions drove overall lower total medical costs for the program cohort. CONCLUSION: Patients enrolled in a remote blood pressure monitoring program were less likely to experience an adverse outcome in the first 6 months after delivery. Reductions in ED visits and readmissions resulted in lower postpartum total medical costs compared with both control cohorts. Broad implementation of evidence-based remote monitoring programs may reduce postpartum adverse outcomes, thereby reducing morbidity and mortality in populations such as the one studied here.

Maternal and Delivery Characteristics and Self-Reported Perceived Control During Labor.

OBJECTIVE: To evaluate the association between maternal and delivery characteristics and self-reported perceived control during childbirth. METHODS: A secondary analysis of a multicenter randomized trial was conducted to compare labor induction at 39 weeks of gestation with expectant management in low-risk nulliparous people. Six to 96 hours after delivery, participants who experienced labor completed the Labor Agentry Scale, a validated self-administered questionnaire to ascertain perceived control during childbirth. Scores range from 29 to 203, with higher scores indicating a sense of greater control. Multivariable linear regression was used to determine which maternal and delivery characteristics were associated with the Labor Agentry Scale score. Eligible characteristics included age, self-reported race and ethnicity, marital status, employment status, type of insurance, previous pregnancy loss before 20 weeks of gestation, body mass index (BMI), smoking, alcohol use, mode of delivery, labor pain (0-10 points), and a composite of perinatal death or severe neonatal complications. Significant variables ( P <.05) were retained in the final multivariable model, and adjusted mean differences (95% CIs) between groups were estimated. RESULTS: Of 6,106 people enrolled in the trial, 6,038 experienced labor, of whom 5,750 (95.2%) completed the Labor Agentry Scale and were included in this analysis. Mean [95% CI] adjusted Labor Agentry Scale scores were significantly lower among those who identified as Asian (-6.4 [-10.5 to -2.3]) or Hispanic (-3.7 [-5.7 to -1.7]) compared with White, smoked compared with did not smoke (-2.8 [-5.5 to -0.1]), had BMIs of 35 or higher compared with less than 30 (-2.0 [-3.8 to -0.2]), were unemployed (-3.15 [-4.76 to -1.55]), did not have private health insurance (-2.61 [-4.47 to -0.76]), underwent operative vaginal (-5.1 [-7.7 to -2.6]) or cesarean (-14.4 [-16.1 to -12.6]) delivery compared with spontaneous vaginal delivery, and reported greater labor pain score of 8 or higher compared with less than 8 (-11.9 [-13.4 to -10.4]). Mean [95% CI] adjusted Labor Agentry Scale scores were significantly higher among people who were employed compared with unemployed (3.2 [1.6-4.8]) and had private compared with nonprivate insurance (2.6 [0.76-4.5]). CONCLUSION: In nulliparous people at low risk, unemployment, lack of private health insurance, Asian race, Hispanic ethnicity, smoking, operative delivery, and more labor pain were associated with lower perceived control during labor. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT01990612.

Frequency of Prenatal Care Visits: Protocol to Develop a Core Outcome Set for Prenatal Care Schedules.

BACKGROUND: Prenatal care, one of the most common preventive care services in the United States, endeavors to improve pregnancy outcomes through evidence-based screenings and interventions. Despite the prevalence of prenatal care and its importance to maternal and infant health, there are several debates about the best methods of prenatal care delivery, including the most appropriate schedule frequency and content of prenatal visits. Current US national guidelines recommend that low-risk individuals receive a standard schedule of 12 to 14 in-office visits, a care delivery model that has remained unchanged for almost a century. OBJECTIVE: In early 2020, to mitigate individuals' exposure to the SARS-CoV-2 virus, prenatal care providers implemented new paradigms that altered the schedule frequency, interval, and modality (eg, telemedicine) of how prenatal care services were offered. In this paper, we describe the development of a core outcome set (COS) that can be used to evaluate the effect of the frequency of prenatal care schedules on maternal and infant outcomes. METHODS: We will systematically review the literature to identify previously reported outcomes important to individuals who receive prenatal care and the people who care for them. Stakeholders with expertise in prenatal care delivery (ie, patients or family members, health care providers, and public health professionals and policy makers) will rate the importance of identified outcomes in a web-based survey using a 3-round Delphi process. A digital consensus meeting will be held for a group of stakeholder representatives to discuss and vote on the outcomes to include in the final COS. RESULTS: The Delphi survey was initiated in July 2022 with invited 71 stakeholders. A digital consensus conference was conducted on October 11, 2022. Data are currently under analysis with plans to submit them in a subsequent manuscript. CONCLUSIONS: More research about the optimal schedule frequency and modality for prenatal care delivery is needed. Standardizing outcomes that are measured and reported in evaluations of the recommended prenatal care schedules will assist evidence synthesis and results reported in systematic reviews and meta-analyses. Overall, this COS will expand the consistency and patient-centeredness of reported outcomes for various prenatal care delivery schedules and modalities, hopefully improving the overall efficacy of recommended care delivery for pregnant people and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43962.

Electronic Reminder to Transition Care After Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: Scalable interventions are needed to improve preventive care for those with increased cardiovascular disease (CVD) risk identified during pregnancy. We hypothesized that an automated reminder message for clinicians (nudge) would increase counseling at the postpartum visit on patient transitions of care. METHODS: We conducted a single-center, randomized controlled trial including birthing people with a hypertensive disorder of pregnancy evaluating a nudge compared with usual care. The nudge, including counseling phrases and patient-specific information on hypertensive diagnosis, was sent to the obstetric clinician through the electronic medical record up to 7 days before the postpartum visit. The primary outcome was documentation of counseling on transitions of care to primary care or cardiology. Secondary outcomes were documentation of CVD risk, use of counseling phrases, and preventive care visit within 6 months. A sample size of 94 per group (n=188) was planned to compare the nudge intervention with usual care; given the anticipated loss to follow-up, the sample size was increased to 222. Intention-to-treat analyses were performed, with P <.05 considered significant. RESULTS: From February to June 2021, 392 patients were screened, and 222 were randomized and analyzed. Of these, 205 (92.3%) attended a postpartum visit. Groups were similar, but more women in the usual care group had diabetes (16.1% vs 6.7%, P =.03). After adjustment for diabetes, patients in the nudge group were more likely to have documented counseling on transitions of care (38.8% vs 26.2%, adjusted relative risk [aRR] 1.53, 95% CI 1.02-2.31), CVD risk (21.4% vs 8.4%, aRR 2.57, 95% CI 1.20-5.49), and use of aspirin in a future pregnancy (14.3% vs 1.9%, aRR 7.49, 95% CI 1.66-33.93). Counseling phrases were used more often in the nudge group (11.2% vs 0.9%, aRR 12.27, 95% CI 1.50-100.28). Preventive care visit attendance did not differ by group (22.1% vs 24.6%, aRR 0.91, 95% CI 0.57-1.47). CONCLUSION: A timely electronic reminder to obstetric clinicians improved counseling about transitions of care after hypertensive disorders of pregnancy but did not result in increased preventive care visit attendance. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04660032.

State restrictions on abortion are associated with fewer abortions in patients with high-risk cardiovascular conditions.

OBJECTIVES: Patients with modified World Health Organization (mWHO) class IV cardiovascular conditions are at high risk of severe maternal morbidity and mortality in pregnancy and are advised to avoid pregnancy or consider abortion if they become pregnant. We aimed to determine if state-level abortion policy is associated with receiving an abortion in this high-risk population. STUDY DESIGN: We conducted a descriptive retrospective cross-sectional study of abortion among people 15-44 years of age with mWHO class IV cardiovascular conditionsstate policy on abortion using US claims data from United health Group from 2017 to 2020. RESULTS: There was a statistically significant association between restrictive abortion policy at that state level and lower number of pregnancies ending in abortions in this high-risk group. CONCLUSIONS: States with the most restrictive abortion policy have the lowest proportion of pregnancies ending in abortion among patients with mWHO class IV cardiovascular conditions. IMPLICATIONS: Variation in receiving abortion by state of residence among patients with mWHO class IV cardiovascular conditions may indicate an impending rise in severe maternal morbidity and mortality related to cardiovascular disease in pregnancy, and the risk factor is where a person lives. This trend may be exacerbated by the Supreme Court Decision Dobbs v Jackson Women's Health.

Risk Factors and Risk for Severe Maternal Morbidity in Severe Preeclampsia Complicated by Pulmonary Edema: A Case-Control Study.

OBJECTIVE: The objective of this study is to examine risk factors and adverse outcomes related to preeclampsia with severe features complicated by pulmonary edema. STUDY DESIGN: This is a nested case-control study of all patients with preeclampsia with severe features who delivered in a tertiary, urban, academic medical center over a 1-year period. The primary exposure was pulmonary edema and the primary outcome was a composite of severe maternal morbidity (SMM), defined according to the Centers for Disease Control and Prevention and based on International Classification of Diseases, 10th revision, Clinical Modification codes. Secondary outcomes included postpartum length of stay, maternal intensive care unit admission, 30-day readmission, and discharge on antihypertensive medication. A multivariable logistic regression model adjusting for clinical characteristics related to the primary outcome was used to determine adjusted odds ratios (aOR) as measures of effect. RESULTS: Of 340 patients with severe preeclampsia, there were seven cases of pulmonary edema (2.1%). Pulmonary edema was associated with lower parity, autoimmune disease, earlier gestational age at diagnosis of preeclampsia and at delivery, and cesarean section. Patients with pulmonary edema demonstrated increased odds of SMM (aOR: 10.11, 95% confidence interval [CI]: 2.13-47.90), extended postpartum length of stay (aOR: 32.56, 95% CI: 3.95-268.45), and intensive care unit admission (aOR: 102.85, 95% CI: 7.43-1422.92) compared with those without pulmonary edema. CONCLUSION: Pulmonary edema is associated with adverse maternal outcomes among patients with severe preeclampsia, and is more likely to affect patients who are nulliparous, have an autoimmune disease, and are diagnosed preterm. KEY POINTS: · Pulmonary edema increases odds of severe maternal morbidity in preeclamptics.. · Pulmonary edema prolongs postpartum and intensive care unit stay in preeclamptics.. · Risk factors for pulmonary edema include nulliparity and autoimmune disease.. · Earlier diagnosis of severe preeclampsia increases risk of pulmonary edema..