Delivery Strategies for Postpartum Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the effects of postpartum health care-delivery strategies on health care utilization and maternal outcomes. DATA SOURCES: We searched Medline, EMBASE, CENTRAL, CINAHL, and ClinicalTrials.gov for studies in the United States or Canada from inception to November 16, 2022. METHODS OF STUDY SELECTION: We used duplicate screening for studies comparing health care-delivery strategies for routine postpartum care on health care utilization and maternal outcomes. We selected health care utilization, clinical, and harm outcomes prioritized by stakeholder panels. TABULATION, INTEGRATION, AND RESULTS: We found 64 eligible studies (50 randomized controlled trials, 14 nonrandomized comparative studies; N=543,480). For general postpartum care, care location (clinic, at home, by telephone) did not affect depression or anxiety symptoms (low strength of evidence), and care integration (by multiple types of health care professionals) did not affect depression symptoms or substance use (low strength of evidence). Providing contraceptive care earlier (compared with later) was associated with greater implant use at 6 months (summary effect size 1.36, 95% CI 1.13-1.64) (moderate strength of evidence). Location of breastfeeding care did not affect hospitalization, other unplanned care utilization, or mental health symptoms (all low strength of evidence). Peer support was associated with higher rates of any or exclusive breastfeeding at 1 month and any breastfeeding at 3-6 months (summary effect size 1.10-1.22) but not other breastfeeding measures (all moderate strength of evidence). Care by a lactation consultant was associated with higher breastfeeding rates at 6 months (summary effect size 1.43, 95% CI 1.07-1.91) but not exclusive breastfeeding (all moderate strength of evidence). Use and nonuse of information technology for breastfeeding care were associated with comparable rates of breastfeeding (moderate strength of evidence). Testing reminders for screening or preventive care were associated with greater adherence to oral glucose tolerance testing but not random glucose or hemoglobin A 1c testing (moderate strength of evidence). CONCLUSION: Various strategies have been shown to improve some aspects of postpartum care, but future research is needed on the most effective care delivery strategies to improve postpartum health. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022309756 .

Postpartum Home Blood Pressure Monitoring: A Systematic Review.

OBJECTIVE: To assess the effectiveness of postpartum home blood pressure (BP) monitoring compared with clinic-based follow-up and the comparative effectiveness of alternative home BP-monitoring regimens. DATA SOURCES: Search of Medline, Cochrane, EMBASE, CINAHL, and ClinicalTrials.gov from inception to December 1, 2022, searching for home BP monitoring in postpartum individuals. METHODS OF STUDY SELECTION: We included randomized controlled trials (RCTs), nonrandomized comparative studies, and single-arm studies that evaluated the effects of postpartum home BP monitoring (up to 1 year), with or without telemonitoring, on postpartum maternal and infant outcomes, health care utilization, and harm outcomes. After double screening, we extracted demographics and outcomes to SRDR+. TABULATION, INTEGRATION, AND RESULTS: Thirteen studies (three RCTs, two nonrandomized comparative studies, and eight single-arm studies) met eligibility criteria. All comparative studies enrolled participants with a diagnosis of hypertensive disorders of pregnancy. One RCT compared home BP monitoring with bidirectional text messaging with scheduled clinic-based BP visits, finding an increased likelihood that at least one BP measurement was ascertained during the first 10 days postpartum for participants in the home BP-monitoring arm (relative risk 2.11, 95% CI 1.68-2.65). One nonrandomized comparative study reported a similar effect (adjusted relative risk [aRR] 1.59, 95% CI 1.36-1.77). Home BP monitoring was not associated with the rate of BP treatment initiation (aRR 1.03, 95% CI 0.74-1.44) but was associated with reduced unplanned hypertension-related hospital admissions (aRR 0.12, 95% CI 0.01-0.96). Most patients (83.3-87.0%) were satisfied with management related to home BP monitoring. Home BP monitoring, compared with office-based follow-up, was associated with reduced racial disparities in BP ascertainment by approximately 50%. CONCLUSION: Home BP monitoring likely improves ascertainment of BP, which is necessary for early recognition of hypertension in postpartum individuals, and may compensate for racial disparities in office-based follow-up. There is insufficient evidence to conclude that home BP monitoring reduces severe maternal morbidity or mortality or reduces racial disparities in clinical outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022313075.

Health Insurance Coverage and Postpartum Outcomes in the US: A Systematic Review.

Importance: Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. Objective: To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum. Evidence Review: Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide. Findings: A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits. Conclusions and Relevance: The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines.

OBJECTIVE: To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. DESIGN: Comparative study. SETTING: High-resource countries. POPULATION: Women with PPH. METHODS: Systematic comparison of guidance on PPH from eight high-income countries. MAIN OUTCOME MEASURES: Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. CONCLUSIONS: Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. RESULTS: Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.

Feasibility of establishing a Canadian Obstetric Survey System (CanOSS) for severe maternal morbidity: a study protocol.

INTRODUCTION: Severe maternal morbidity (SMM)-an unexpected pregnancy-associated maternal outcome resulting in severe illness, prolonged hospitalisation or long-term disability-is recognised by many, as the preferred indicator of the quality of maternity care, especially in high-income countries. Obtaining comprehensive details on events and circumstances leading to SMM, obtained through maternity units, could complement data from large epidemiological studies and enable targeted interventions to improve maternal health. The aim of this study is to assess the feasibility of gathering such data from maternity units across Canadian provinces and territories, with the goal of establishing a national obstetric survey system for SMM in Canada. METHODS AND ANALYSIS: We propose a sequential explanatory mixed-methods study. We will first distribute a cross-sectional survey to leads of all maternity units across Canada to gather information on (1) Whether the unit has a system for reviewing SMM and the nature and format of this system, (2) Willingness to share anonymised data on SMM by direct entry using a web-based platform and (3) Respondents' perception on the definition and leading causes of SMM at a local level. This will be followed by semistructured interviews with respondent groups defined a priori, to identify barriers and facilitators for data sharing. We will perform an integrated analysis to determine feasibility outcomes, a narrative description of barriers and facilitators for data-sharing and resource implications for data acquisition on an annual basis, and variations in top-5 causes of SMM. ETHICS AND DISSEMINATION: The study has been approved by the Mount Sinai and Hamilton Integrated Research Ethics Boards. The study findings will be presented at annual scientific meetings of the Society of Obstetricians and Gynaecologists of Canada, North American Society of Obstetric Medicine, and International Network of Obstetric Survey Systems and published in an open-access peer-reviewed Obstetrics and Gynaecology or General Internal Medicine journal.

Dermatology in a multidisciplinary approach with infectious disease and obstetric medicine against COVID-19.

The care for patients infected with COVID-19 requires a team approach, and dermatologists may collaborate with other specialties, especially infectious disease (ID) medicine and obstetrics and gynecology (ObGyn), at every stage of the infection process. A broad spectrum of cutaneous manifestations may occur early in COVID-19 infection, making appropriate dermatologic identification critical for an early diagnosis. There is prognostic value in appropriately identifying different types of COVID-19-associated skin manifestations, which have been linked to disease severity. Such observations emanated from dermatology research, especially large series and international registries of cutaneous manifestations relating to COVID-19, and impact COVID-19 care provided by most health care providers. Also, research based on international registries of skin reactions from the COVID-19 vaccines has an impact across disciplines. An increased risk for severe illness from COVID-19 is encountered during pregnancy, and dermatologists' role is to urge ObGyn and other clinicians to monitor and educate pregnant patients about the potential for eruptions as a manifestation of COVID-19. ID and ObGyn experts indicate that teledermatology enhanced the interaction among health care providers and improved COVID-19 care. More than 40% of all dermatology consultations at a tertiary care hospital were done via teledermatology. Future collaborative research involving dermatology and specialties, such as ID and ObGyn, could help delineate guidelines for dermatology consultations in patients infected with COVID-19 and determine cases appropriate for teledermatology.

Primary Nephrotic Syndrome and Risks of ESKD, Cardiovascular Events, and Death: The Kaiser Permanente Nephrotic Syndrome Study.

BACKGROUND: Little population-based data exist about adults with primary nephrotic syndrome. METHODS: To evaluate kidney, cardiovascular, and mortality outcomes in adults with primary nephrotic syndrome, we identified adults within an integrated health care delivery system (Kaiser Permanente Northern California) with nephrotic-range proteinuria or diagnosed nephrotic syndrome between 1996 and 2012. Nephrologists reviewed medical records for clinical presentation, laboratory findings, and biopsy results to confirm primary nephrotic syndrome and assigned etiology. We identified a 1:100 time-matched cohort of adults without diabetes, diagnosed nephrotic syndrome, or proteinuria as controls to compare rates of ESKD, cardiovascular outcomes, and death through 2014, using multivariable Cox regression. RESULTS: We confirmed 907 patients with primary nephrotic syndrome (655 definite and 252 presumed patients with FSGS [40%], membranous nephropathy [40%], and minimal change disease [20%]). Mean age was 49 years; 43% were women. Adults with primary nephrotic syndrome had higher adjusted rates of ESKD (adjusted hazard ratio [aHR], 19.63; 95% confidence interval [95% CI], 12.76 to 30.20), acute coronary syndrome (aHR, 2.58; 95% CI, 1.89 to 3.52), heart failure (aHR, 3.01; 95% CI, 2.16 to 4.19), ischemic stroke (aHR, 1.80; 95% CI, 1.06 to 3.05), venous thromboembolism (aHR, 2.56; 95% CI, 1.35 to 4.85), and death (aHR, 1.34; 95% CI, 1.09 to 1.64) versus controls. Excess ESKD risk was significantly higher for FSGS and membranous nephropathy than for presumed minimal change disease. The three etiologies of primary nephrotic syndrome did not differ significantly in terms of cardiovascular outcomes and death. CONCLUSIONS: Adults with primary nephrotic syndrome experience higher adjusted rates of ESKD, cardiovascular outcomes, and death, with significant variation by underlying etiology in the risk for developing ESKD.

Management of primary headaches during pregnancy, postpartum, and breastfeeding: A systematic review.

BACKGROUND: Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to best and most safely manage them. OBJECTIVE: We conducted a systematic review (SR) of interventions to prevent or treat primary headaches in women who are pregnant, attempting to become pregnant, postpartum, or breastfeeding. METHODS: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Database of SRs, and Epistemonikos for primary studies of pregnant women with primary headache and existing SRs of harms in pregnant women regardless of indication. No date or language restrictions were applied. We assessed strength of evidence (SoE) using standard methods. RESULTS: We screened 8549 citations for studies and 2788 citations for SRs. Sixteen studies (mostly high risk of bias) comprising 14,185 patients (total) and 26 SRs met the criteria. For prevention, we found no evidence addressing effectiveness. Antiepileptics, venlafaxine, tricyclic antidepressants, benzodiazepines, ß-blockers, prednisolone, and oral magnesium may be associated with fetal/child adverse effects, but calcium channel blockers and antihistamines may not be (1 single-group study and 11 SRs; low-to-moderate SoE). For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache (1 randomized controlled trial; low SoE). Triptans may not be associated with fetal/child adverse effects (8 nonrandomized comparative studies; low SoE). Acetaminophen, prednisolone, indomethacin, ondansetron, antipsychotics, and intravenous magnesium may be associated with fetal/child adverse effects, but low-dose aspirin may not be (indirect evidence; low-to-moderate SoE). We found insufficient evidence regarding non-pharmacologic treatments. CONCLUSIONS: For prevention of primary headache, calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects. For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine. Triptans and low-dose aspirin may not be associated with fetal/child adverse effects. Future research should identify effective and safe interventions in pregnancy and postpartum.

Diffuse Large B-Cell Lymphoma During Third-Trimester Pregnancy and Lactation.

BACKGROUND: Diffuse large B-cell lymphoma is the most common type of non-Hodgkin's lymphoma affecting pregnancy. These tumors may be aggressive and rapidly growing in pregnancy. Management is based on the balance of risks and benefits to both the pregnant patient and the fetus. CASE: We present a case of diffuse large B-cell lymphoma diagnosed in the third trimester of pregnancy. The patient underwent labor induction at 34 weeks of gestation, started a standard chemotherapy protocol postpartum, and breastfed following a timed lactation protocol. CONCLUSION: Management of lymphoma during pregnancy highlights the need to consider all aspects of proposed oncologic and obstetric care as well as neonatal risks. Considerations highlighted in this case include staging methods, administration of antenatal steroids, timing of delivery, and lactation during chemotherapy.

Maternal monitoring and safety considerations during antiarrhythmic treatment for fetal supraventricular tachycardia.

Fetal tachycardia is a rare complication during pregnancy. After exclusion of maternal and fetal conditions that can result in a secondary fetal tachycardia, supraventricular tachycardia is the most common cause of a primary sustained fetal tachyarrhythmia. In cases of sustained fetal supraventricular tachycardia, maternal administration of digoxin, flecainide, sotalol, and more rarely amiodarone, is considered. As these medications have the potential to cause significant adverse effects, we sought to examine maternal safety during transplacental treatment of fetal supraventricular tachycardia. In this narrative review we summarize the literature addressing pharmacologic properties, monitoring, and adverse reactions associated with medications most commonly prescribed for transplacental therapy of fetal supraventricular tachycardia. We also describe maternal monitoring practices and adverse events currently reported in the literature. In light of our findings, we provide clinicians with a suggested maternal monitoring protocol aimed at optimizing safety.

Obstetric medical care in the United States of America.

The current models of obstetric medical care utilized in the United States, how those models fit in with the overall care system, and ways to increase the role of obstetric internists will be reviewed.

Enhanced cellular uptake of size-separated lipophilic silicon nanoparticles.

Specific size, shape and surface chemistry influence the biological activity of nanoparticles. In the case of lipophilic nanoparticles, which are widely used in consumer products, there is evidence that particle size and formulation influences skin permeability and that lipophilic particles smaller than 6 nm can embed in lipid bilayers. Since most nanoparticle synthetic procedures result in mixtures of different particles, post-synthetic purification promises to provide insights into nanostructure-function relationships. Here we used size-selective precipitation to separate lipophilic allyl-benzyl-capped silicon nanoparticles into monodisperse fractions within the range of 1 nm to 5 nm. We measured liposomal encapsulation and cellular uptake of the monodisperse particles and found them to have generally low cytotoxicities in Hela cells. However, specific fractions showed reproducibly higher cytotoxicity than other fractions as well as the unseparated ensemble. Measurements indicate that the cytotoxicity mechanism involves oxidative stress and the differential cytotoxicity is due to enhanced cellular uptake by specific fractions. The results indicate that specific particles, with enhanced suitability for incorporation into lipophilic regions of liposomes and subsequent in vitro delivery to cells, are enriched in certain fractions.

Cationic Silicon Nanocrystals with Colloidal Stability, pH-Independent Positive Surface Charge and Size Tunable Photoluminescence in the Near-Infrared to Red Spectral Range.

In this report, the synthesis of a novel class of cationic quaternary ammonium-surface-functionalized silicon nanocrystals (ncSi) using a novel and highly versatile terminal alkyl halide-surface-functionalized ncSi synthon is described. The distinctive features of these cationic ncSi include colloidal stability, pH-independent positive surface charge, and size-tunable photoluminescence (PL) in the biologically relevant near-infrared-to-red spectral region. These cationic ncSi are characterized via a combination of high-resolution scanning transmission electron microscopy with energy-dispersive X-ray analysis, Fourier transform infrared, X-ray photoelectron, and photoluminescence spectroscopies, and zeta potential measurements.

Skin disease in pregnancy: The approach of the obstetric medicine physician.

This review presents the approach of the obstetric medicine physician to skin disease in pregnancy. It elaborates on common skin-related problems during gestation, such as pruritus, with or without eruption, and drug eruptions. An algorithmic approach to the differential diagnosis of pruritus in pregnancy is outlined. Also, the review focuses on how to diagnose promptly endocrinopathies presenting with skin manifestations in pregnancy, such as Addison disease, diabetes, and hyperthyroidism. The prompt diagnosis of endocrine disorders can help to optimize management and improve outcomes. Finally, the authors outline their approach to minimizing maternal and fetal risks associated with skin disease. The risks associated with obstetric cholestasis, pemphigoid gestationis, and impetigo herpetiformis are discussed. Prompt diagnosis helps to minimize the serious risks associated with certain infections. Preconception counseling and a multidisciplinary approach are crucial to preventing risks associated with rheumatic skin disease and genodermatoses. Challenging, real-life obstetric medicine cases are discussed.

Neonatal thyroid function: effect of a single exposure to iodinated contrast medium in utero.

PURPOSE: To evaluate the effect of in utero exposure to a single dose of water-soluble intravenous iodinated contrast medium on thyroid function at birth. MATERIALS AND METHODS: This study was approved by the institutional review board, with waiver of consent, and was HIPAA compliant. Maternal and newborn records were retrospectively reviewed. All pregnant women who underwent multidetector pulmonary computed tomographic angiography because they were suspected of having pulmonary embolism between 2004 and 2008 and newborns resulting from the index pregnancy were included. In all examinations, iohexol was used as the contrast agent. Dose and amount of contrast agent and gestational age at the time of administration of the contrast agent were collected, and thyroxine (T(4)) and thyroid-stimulating hormone (TSH) levels were measured at birth. A total of 344 maternal and 343 newborn records were reviewed. A descriptive analysis was performed, and means, standard deviations, and confidence intervals were reported. RESULTS: Mean gestational age at the time of administration of the contrast material was 27.8 weeks +/- 7.4. The mean dose of total iodine administered was 45,000 mg/L +/- 7321. All newborns had a normal T(4) level at birth; only one newborn had a transiently abnormal TSH level at birth, which normalized at day 6 of life. This newborn was born to a mother who had many drug exposures during pregnancy. CONCLUSION: A single, high-dose in utero exposure to water-soluble, low-osmolar, iodinated intravenous products, such as iohexol, is unlikely to have a clinically important effect on thyroid function at birth.