Racial and ethnic disparities in short interval pregnancy following delivery in Catholic vs non-Catholic hospitals among California Medicaid enrollees.

OBJECTIVES: We examined the impact of Catholic hospital delivery on short interval pregnancy in the California 2010-2014 Medicaid population. STUDY DESIGN: We used Cox regression to estimate the association between hospital affiliation and short interval pregnancy, adjusting for patient factors. RESULTS: Catholic hospital delivery had increased the risk of pregnancy within 6 months for Black (hazard ratio [HR] 1.11, 95% CI 1.06, 1.17) and Hispanic (HR 1.07, 95% CI 1.05, 1.09) but not for White women (HR 1.02, 95% CI 0.98, 1.05). CONCLUSIONS: Among California women with Medicaid, Catholic hospital delivery was associated with short interval pregnancy only among women of color.

The association between a single abnormal glucose and fetal c-peptide.

AIM: We aimed to evaluated if fetuses of subjects with one elevated value on the 3-h GTT had a measurable physiologic difference in fetal C-peptide levels as compared to those with no elevated values on the GTT. METHODS: We performed a prospective cohort study to evaluate insulin levels in singleton non-anomalous fetuses of subjects with one elevated value on the GTT as compared to subjects with no elevated values on their GTT. Fetal insulin levels were measured by fetal C-peptide in cord blood. Distribution of data was assessed and outliers representing values > the 99th and < the 1st percentiles were excluded. Data were log transformed to achieve normal distribution and univariable analyses were performed to compare fetal C-peptide levels, baseline maternal characteristics and perinatal outcomes in subjects with one elevated value as compared those with no elevated values. RESULTS: Our analysis included 99 subjects, with 49 subjects in the one elevated value group and 50 subjects in the no elevated values group. Fetal C-peptide levels (picomoles per liters, pmol/L), were significantly higher in the elevated value group as compared to the no elevated value group (mean ± SD; 4.6 ± 0.8 vs. 4.3 ± 0.7, P = 0.046, respectively). In univariable analysis, there was no significant difference in maternal characteristics or adverse composite perinatal outcomes. CONCLUSION: Fetuses of subjects who had one elevated value on their GTT had a measurable physiologic difference in C-peptide levels as compared to fetuses of subjects with no elevated values on the GTT.

Human Immunodeficiency Virus in Pregnancy.

Approximately 5000 people living with human immunodeficiency virus (HIV) give birth each year. Perinatal transmission of HIV will occur in about 15% to 45% of pregnancies without treatment. With appropriate antiretroviral therapy for pregnant people as well as appropriate intrapartum and postpartum interventions, the rate of perinatal transmission can be reduced to less than 1%. Antiretroviral therapy will also reduce health risks for pregnant patients living with HIV. All pregnant people should be offered the opportunity to learn their HIV status and access treatment as needed.

Adherence to Sexually Transmitted Infection Screening in Pregnancy.

Objective: Professional guidelines and state law require screening for sexually transmitted infections (STI) during pregnancy. Our objective was to evaluate adherence to these recommendations. Methods: This is a retrospective cohort study of patients initiating prenatal care before 20 weeks' gestation. Demographic characteristics and STI screening were abstracted from prenatal records. Tests of interest included initial syphilis, human immunodeficiency virus (HIV), hepatitis B, chlamydia, and gonorrhea tests, as well as repeat (third trimester) syphilis and HIV tests. All patients were eligible for initial screening. Patients were eligible for analysis of whether they received adherent repeat third trimester screening for syphilis (mandated by state law) and HIV (institutional protocol) if they delivered at or after 32 weeks' gestation. Adherent screening was defined as performance of all recommended screening. Results: Of 2370 patients, 1816 (76.6%) received adherent initial STI screening and 181 (7.8% of 2308 patients who delivered at or after 32 weeks' gestation) received adherent repeat third trimester STI screening. After adjusting for covariates, private insurance (adjusted odds ratio [aOR] 1.45, confidence interval [95% CI] 1.12-1.95) was associated with adherent initial screening, whereas being non-Hispanic Black or Hispanic were associated with lower odds of adherent initial screening. Factors associated with adherent repeat third trimester STI screening were younger age (aOR 0.93, 95% CI 0.90-0.97) and non-Hispanic Black race (aOR 3.24, 95% CI 1.94-5.42). Those with private insurance (aOR 0.10, 95% CI 0.06-0.15) were less likely to receive adherent repeat third trimester screening. Conclusion: STI screening rates remain suboptimal. Multiple disparities exist in performance both of initial and repeat third trimester screening.

Maximum Dose Rate of Intrapartum Oxytocin Infusion and Associated Obstetric and Perinatal Outcomes.

OBJECTIVE: Despite lack of evidence for a safety threshold for oxytocin dose rate, many hospital protocols specify a maximum rate. We investigated whether exceeding 20 milliunits/min of oxytocin was associated with adverse outcomes. METHODS: This is a secondary analysis of a double-blind, single-center, randomized controlled trial of nulliparous patients with singleton gestations at 36 weeks of gestation or later who presented in spontaneous labor randomized 1:1 to either a high-dose oxytocin titration regimen (initial-incremental rate of 6 milliunits/min) or standard-dose titration regimen (initial-incremental rate of 2 milliunits/min) for labor augmentation. A maximum oxytocin dose rate limit was not specified in the study protocol. For this secondary analysis, outcomes of participants who received oxytocin and exceeded a dose rate of 20 milliunits/min at any point in labor were compared with those whose rate remained at 20 milliunits/min or less. In addition, the cumulative proportions of labor and birth outcomes were calculated for each maximum dose rate of oxytocin reached among this study cohort. RESULTS: Of the 1,003 participants in the parent trial, 955 (95.2%) received oxytocin, as planned, and were included, with 190 (19.9%) exceeding a maximum dose rate of 20 milliunits/min. Those who exceeded 20 milliunits/min were older and were more likely to have rupture of membranes as their trial entry indication, have hypertensive disorders of pregnancy, receive intrapartum magnesium sulfate infusion, and receive oxytocin for longer. Those whose maximum rates exceeded 20 milliunits/min underwent cesarean delivery more frequently, but the majority (74%) still delivered vaginally. In multivariable analyses, there were no significant associations between maximum oxytocin dose rates greater than 20 milliunits/min and cesarean delivery (adjusted odds ratio [aOR] 1.57, 95% CI 1.00-2.46), peripartum infection (aOR 0.69, 95% CI 0.41-1.19), postpartum hemorrhage (aOR 1.37, 95% CI 0.70-2.71), or neonatal intensive care unit (NICU) admission (aOR 1.72, 95% CI 0.89-3.31). Although 85% of spontaneous vaginal deliveries occurred at maximum oxytocin dose rates of 20 milliunits/min or less, vaginal deliveries continued to occur at higher maximum dose rates. The cumulative proportions of NICU admissions and composite severe neonatal morbidity and mortality cases increased with increasing oxytocin dose rates even with maximum oxytocin dose rates at 20 milliunits/min or less. CONCLUSION: In multivariable analyses, there are no significant differences in maternal or perinatal adverse outcomes based on exceeding 20 milliunits/min of oxytocin. These data suggest that oxytocin dosing should be individualized to each patient and not be based on arbitrary thresholds. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT02487797.

The Association between Maternal Body Mass Index and the Risk of Perinatal Depression.

OBJECTIVE: The aim of this study was to evaluate whether the risk of perinatal depression is associated with body mass index (BMI) category. STUDY DESIGN: We performed a retrospective cohort study of women who completed an Edinburgh Postnatal Depression Scale (EPDS) questionnaire during the antepartum period at an integrated health system from January 2003 to May 2018. Risk of perinatal depression was defined as a score of ≥10 on the EPDS or an affirmative response to thoughts of self-harm. Risk of perinatal depression was compared by first trimester BMI category, defined as underweight (BMI: <18.5 kg/m2), normal weight (BMI: 18.5-24.9 kg/m2), overweight (BMI: 25.0-29.9 kg/m2), or obese (BMI: ≥30.0 kg/m2). Univariable analyses were performed using χ 2, Fisher's exact test, analysis of variance, Kruskal-Wallis, and Wilcoxon rank-sum tests as appropriate to evaluate the association between maternal BMI category, demographic and clinical characteristics, and risk of perinatal depression. Logistic multivariable regression models were performed to adjust for potential confounders identified as variables with p < 0.10 in univariable analysis. RESULTS: Our analysis included 3,420 obese women, 3,839 overweight women, 5,949 normal weight women, and 1,203 underweight women. The overall median gestational age at EPDS administration was 27 weeks (interquartile range: 23-29). Overweight and obese women were more likely to be non-Hispanic Black, Hispanic, multiparous, to have public insurance, prepregnancy diabetes, and chronic hypertension as compared with normal or underweight women (p < 0.001). In univariable analysis, the risk of perinatal depression was not significantly different among underweight (10.8%, odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.79-1.18) or overweight women (12%, OR: 0.96, 95% CI: 0.79-1.18); however, the risk was higher among obese women (14.7%, 95% CI: 1.21-1.55) compared with normal weight women (11.2%). In multivariable analysis, obesity remained associated with an increased risk of perinatal depression (adjusted OR: 1.19, 95% CI: 1.04-1.35). CONCLUSION: Obesity is associated with an increased risk of perinatal depression as compared with women of normal weight. KEY POINTS: · Maternal obesity is associated with an increased risk of perinatal depression.. · Maternal BMI is associated with increased risk of perinatal depression.. · Maternal obesity is an independent risk factor for perinatal depression..

Interpregnancy Body Mass Index Change and Offspring Mortality Risk following the Second Pregnancy.

OBJECTIVE: The aim of the study is to examine the impact of maternal interpregnancy body mass index (BMI) change on subsequent offspring mortality risk. STUDY DESIGN: This is a retrospective cohort study of women who had two consecutive live singleton deliveries of at least 20 weeks' gestation from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from the date of first delivery to the conception date of subsequent pregnancy. We categorized BMI change as: < - 1, -1 to 0, 0 to <1 (reference), 1 to 2, 2 to 4, ≥4 kg/m2. Our primary outcome was all-cause age-specific mortality during four time periods: neonatal (≤28 days), infant (29 days to <1 year old), childhood ((≥1 to <5 years old), and late childhood (5 to <18 years old). We also examined mortality specifically attributed to congenital anomalies. Analyses used Cox proportional hazard models stratified by full term (≥37 weeks) and preterm (<37 weeks) deliveries. All models were adjusted for relevant confounders. RESULTS: Of 266,752 women, among full-term deliveries, women with a BMI increase of 4 kg/m2 or more had an increased risk of neonatal mortality in their subsequent pregnancy (hazard ratio or HR = 1.72, 95% confidence interval or CI: 1.23-2.41) Women who lost 1 kg/m2 or more between deliveries also had increased neonatal mortality (HR = 1.46, 95% CI: 1.04-2.05). There were no differences in infant, early, or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy interval weight loss of 1 kg/m2 or more and weight gain of ≥4 kg/m2 also had increased risk of mortality associated with congenital anomalies or conditions arising during the neonatal period following their subsequent delivery. CONCLUSION: Women with significant interpregnancy weight gain and modest weight loss have a significant increased risk of neonatal mortality following their subsequent pregnancy. KEY POINTS: · Significant weight gain between deliveries increases the risk of neonatal death.. · Modest weight loss between deliveries increases the risk of neonatal death.. · This risk may be partially explained by increased risk of congenital malformations..

Neonatal outcomes in trial of vaginal birth versus repeat caesarean delivery in preterm pregnancies: A prospective cohort study.

OBJECTIVE: To characterise neonatal morbidity following preterm trial of labour (TOL) in comparison with elective repeat caesarean section (eRCS) specifically among patients without a previous vaginal delivery who may have a lower success rate of vaginal birth after caesarean. DESIGN: This is a secondary analysis of a multicentre prospective database. SETTING/POPULATION: Maternal and Fetal Medicine Unit Cesarean Section Registry. POPULATION: Singleton pregnancies in women without a previous vaginal delivery who delivered at 24+0  weeks to 36+6  weeks gestation. METHODS: Neonatal outcomes were compared between those with a TOL and those undergoing eRCS. Logistic regression was used to control for confounders, including gestational age at delivery. MAIN OUTCOME MEASURES: Composite neonatal morbidity. RESULTS: A total of 1906 patients were included, 985 with TOL and 921 with no TOL. The TOL success rate was 63.1%. The rate of uterine rupture was low, at 0.10% in the TOL group and 0.11% in the eRCS group (p = 0.32). After adjustment, neonates born to women undergoing a TOL had no statistically significant difference in outcomes including composite neonatal outcome (adjusted odds ratio 0.86, 95% CI 0.68-1.09), neonatal intensive care unit admission, respiratory distress syndrome, necrotising enterocolitis, hypoxic ischaemic encephalopathy, seizures, transient tachypnoea of the newborn, compared with patients who underwent eRCS, with the exception of decreased risk of proven/suspected sepsis (adjusted odds ratio 0.68, 95% CI 0.52-0.87) CONCLUSION: A TOL in preterm patients without a previous vaginal delivery was not found to have a statistically significant association with increased neonatal morbidity.

Preconception care and severe maternal morbidity in the United States.

BACKGROUND: In the United States, approximately 52,000 women per year (accounting for 1.46% of births) experience severe maternal morbidity, which is defined as a complication that causes significant maternal harm or risk of death. It disproportionately affects women from racial or ethnic minorities, people with chronic diseases, and those with Medicaid or no insurance. Preconception care has been hailed as a strategy to improve pregnancy outcomes and reduce disparities, but its broad benefits for maternal outcomes have not been demonstrated. OBJECTIVE: Our objective was to measure the association between preconception care and the odds of severe maternal morbidity among women with Medicaid. STUDY DESIGN: This is a secondary analysis of Medicaid claims using the Medicaid Analytic Extract files (2010-2012). We used the International Classification of Diseases, Ninth Revision codes, published by the US Office of Population Affairs' Quality Family Planning program to define 7 domains of preconception care. The primary outcome was maternal death within 12 weeks of delivery or severe maternal morbidity during birth hospitalization, defined by the presence of any diagnosis or procedure on the severe maternal morbidity International Classification of Diseases, Ninth Revision code list from the Centers for Disease Control and Prevention. Because this list may overestimate severe maternal morbidity by counting any blood transfusion, our secondary outcome used the same code list but without transfusion. We reviewed care in the year before conception and used logistic regression to estimate the association between each domain and severe maternal morbidity for all births to women enrolled in Medicaid and aged 15 to 45 years with births during 2012. We performed a subgroup analysis for women with chronic disease (kidney disease, hypertension, or diabetes). RESULTS: Severe maternal morbidity or death occurred in 26,285 births (1.74%) when including blood transfusions and 9,481 births (0.63%) when excluding transfusions. Receiving contraceptive services in the year before conception was associated with decreased odds of severe maternal morbidity (adjusted odds ratio, 0.92; 95% confidence interval, 0.88-0.95) and pregnancy test services were associated with increased odds (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.14). In the primary analysis, no significant associations were observed for other preconception care domains. Among those women with at least 1 chronic disease, contraceptive care (adjusted odds ratio, 0.84; 95% confidence interval, 0.75-0.95) and routine physical or gynecologic exams (adjusted odds ratio, 0.79; 95% confidence interval, 0.71-0.88) were associated with decreased odds of severe maternal morbidity. Similar associations were found for severe maternal morbidity when excluding blood transfusion. CONCLUSIONS: Contraceptive services in the year before conception and routine exams for women with chronic disease are associated with decreased odds of severe maternal morbidity or death for Medicaid enrollees.

History of respiratory problems in prior infant and respiratory morbidity in subsequent pregnancy.

OBJECTIVE: Respiratory distress syndrome (RDS) is a common cause of morbidity in preterm neonates. Late preterm births (34 0/7 to 36 6/7 weeks of gestation) account for three-quarters of preterm births. Delivery in the late preterm period is a well-established risk factor for RDS.1 Whether history of a neonate with respiratory morbidity at birth relates to respiratory morbidity in a subsequent pregnancy is not well characterized. In this research letter, we have described how maternally reported respiratory morbidity in a neonate in a previous pregnancy is associated with respiratory morbidity in a neonate in a subsequent pregnancy. STUDY DESIGN: This was a secondary analysis of a randomized controlled study of antenatal corticosteroids in the late preterm period (antenatal betamethasone for women at risk for late preterm delivery).2 Multiparous patients with a singleton pregnancy were included. The institutional review board at The University of Chicago (approval number IRB 21-0141) deemed this study exempt. Respiratory morbidity of a previous infant was maternally reported in a questionnaire specifying any "respiratory problems at birth" in their live neonates (yes or no). Major respiratory morbidity (MRM) in the current pregnancy was defined as any of the following: continuous positive airway pressure or high-flow nasal cannula for ≥12 hours in the first 72 hours of life, ventilator use in the first 72 hours of life, extracorporeal membrane oxygenation, oxygen requirement of FiO2 of ≥0.3 for ≥24 total hours in the first 72 hours of life, or stillbirth or neonatal death at <72 hours of age. This was abstracted from maternal and neonatal medical records. The presence of any respiratory morbidity (MRM, RDS, or transient tachypnea of the newborn [TTN]) was compared by history of a previous infant with any respiratory morbidity. Chi-square and Wilcoxon rank-sum tests were used for bivariable analyses, and logistic regression was performed to adjust for confounders. The analysis was repeated, stratified by any betamethasone use. RESULTS: We included 1412 multiparous patients, 195 with a previous infant with maternally reported respiratory morbidity and 1217 without. RDS, MRM, and a composite of RDS, TTN, and apnea were more likely among those who had a sibling with respiratory morbidity, per maternal report (adjusted odds ratio [aOR] of RDS, 2.17 [95% confidence interval (CI), 1.28-3.70]; aOR of MRM, 1.9 [95% CI, 1.20-3.02]; aOR of RDS, TTN, and apnea, 1.85 [95% CI, 1.22-2.70]). When stratified by administration of betamethasone, the risk of MRM was only persistent in those without betamethasone use (aOR, 1.84; 95% CI, 1.00-3.39). Similarly, the risk of RDS and a composite risk of RDS, TTN, and apnea were only persistent in those without betamethasone use (aOR, 2.37 [95% CI, 1.16-4.84]; aOR, 1.82 [95% CI, 1.05-3.17]) Tables 1 and 2. CONCLUSION: A maternally reported history of respiratory morbidity in a previous late preterm or term infant was independently associated with respiratory morbidity, including RDS, in a subsequent infant. When stratified by betamethasone use, the risk of respiratory morbidity was only persistent in those neonates without betamethasone exposure during the late preterm period.

The association of immediate postpartum glucose values with persistent insulin resistance in patients with gestational diabetes.

OBJECTIVE: Gestational diabetes (GDM) affects approximately 6% of pregnancies and has critical maternal and neonatal implications.1 About 20-33% of these patients have insulin resistance or type 2 diabetes when evaluated at 6 to 12 weeks postpartum, however only approximately half of the affected patients return for postpartum testing.2-5 Fasting glucose during delivery hospitalization is correlated with fasting glucose on oral glucose tolerance testing (OGTT) at 4 to 12 weeks postpartum, but there is limited data on the utility of this value to identify the patients at an increased risk for postpartum insulin resistance.3 We aimed to evaluate if higher fasting glucose values on postpartum day 1 (PPD1) are correlated with an increased risk of persistent insulin resistance at 4 to 12 weeks postpartum diagnosed on OGTT. STUDY DESIGN: We conducted a retrospective cohort study of patients with GDM who delivered from 2009 to 2019 at 2 suburban hospitals. Eligible patients had a singleton pregnancy affected by GDM with complete data on PPD1 fasting glucose and OGTT at 4 to 12 weeks postpartum. GDM was diagnosed by a 50 gram, 1-hour OGTT value of ≥200 mg/dL or a 3-hour glucose tolerance test with ≥2 values exceeding defined thresholds (Carpenter-Coustan criteria). Postpartum impaired fasting glucose was defined as a fasting glucose ≥100 mg/dL, and impaired glucose tolerance was defined as a 2-hour glucose ≥140 mg/dL on postpartum glucose tolerance testing. PPD1 fasting glucose values were divided into 3 categories (<95, ≥95 to 109, and ≥110 mg/dL) for analyses. Univariate analyses were performed using chi-squared, analysis of variance, and Wilcoxon rank-sum tests as appropriate to evaluate the association between an abnormal postpartum OGTT and demographic variables, clinical characteristics, and PPD1 glucose by glucose category. Logistic regression models were performed to adjust for variables that were determined a priori and those found to be significant (P<.05) in univariate analyses. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using descriptive statistics. RESULTS: Our analysis included 367 patients (Figure), of which 69.5% (255/367) had a PPD1 glucose <95 mg/dL, 19.9% (73/367) had a PPD1 glucose of 95 to 109 mg/dL, and 10.6% (39/367) had a PPD1 glucose ≥110 mg/dL. In multivariate analysis, compared with PPD1 <95 mg/dL, there was no significant association between postpartum glucose categories and abnormal postpartum OGTT results (PPD1 glucose ≥95 to 109 mg/dL: aOR [adjusted odds ratio], 1.10; 95% CI [confidence interval], 0.58-2.07; P=.77; PPD1 glucose ≥110 mg/dL: aOR, 1.01; 95% CI, 0.44-2.30; P=.99, Table). Fasting glucose on PPD1 of 95 mg/dL had a sensitivity of 20.1% (95% CI, 13.8-27.8%), specificity of 81.2% (95% CI, 76.4-85.4%), positive predictive value of 32.2% (95% CI, 22.6-43.1%), and negative predictive value of 69.7% (95% CI, 64.7-74.3%) to identify patients with impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes postpartum. In identifying patients with type 2 diabetes at 4 to 12 weeks postpartum, fasting glucose of 95 mg/dL on PPD1 had a sensitivity of 1.79% (95% CI, 0.2-6.3%), specificity of 98.4% (95% CI, 96.0-99.6%), positive predictive value 33.3% (95% CI, 4.3-77.7%), and negative predictive value of 69.6% (95% CI, 64.6-74.3%). CONCLUSION: Fasting glucose on PPD1 was not associated with persistent insulin resistance at 4 to 12 weeks postpartum.

Neonatal hypoglycemia after antenatal late preterm steroids in individuals with diabetes.

OBJECTIVE: To establish whether administration of antenatal late preterm steroids to pregnant people with diabetes resulted in higher risk of neonatal hypoglycemia. STUDY DESIGN: This is a retrospective cohort study of individuals with pre-gestational or gestational diabetes admitted between 34 0/7-36 6/7 weeks' gestation before and after introduction of an antenatal late preterm steroids protocol. The primary outcome was any neonatal blood glucose ≤ 60 mg/dL in the first 24 h of life. RESULTS: Of 123 mother-neonate pairs, 52.8% (N = 65) delivered during the post-protocol period; 75.4% of those (N = 49) received late preterm steroids. 59.7% (N = 34) of the pre-protocol neonates and 81.5% (N = 53) of the post-protocol neonates had hypoglycemia (p = 0.008). After controlling for gestational age at delivery and mode of delivery, neonates in the post-protocol group had increased odds of hypoglycemia (adjusted odds ratio 2.96, 95% confidence interval 1.29-6.82). CONCLUSION: Neonates born to mothers with diabetes who received late preterm corticosteroids experienced greater odds of hypoglycemia.

Society for Maternal-Fetal Medicine Consult Series #58: Use of antenatal corticosteroids for individuals at risk for late preterm delivery: Replaces SMFM Statement #4, Implementation of the use of antenatal corticosteroids in the late preterm birth period in women at risk for preterm delivery, August 2016.

The administration of antenatal corticosteroids has been widely adopted as the standard of care in the management of pregnancies at risk for preterm delivery before 37 weeks of gestation, with the primary goal of reducing neonatal morbidity. However, the long-term risks associated with antenatal corticosteroid use remain uncertain. The purpose of this Consult is to review the current literature on the benefits and risks of antenatal corticosteroid use in the late preterm period and to provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend offering a single course of antenatal corticosteroids (2 doses of 12 mg of intramuscular betamethasone 24 hours apart) to patients who meet the inclusion criteria of the Antenatal Late Preterm Steroids trial, ie, those with a singleton pregnancy between 34 0/7 and 36 6/7 weeks of gestation who are at high risk of preterm birth within the next 7 days and before 37 weeks of gestation (GRADE 1A); (2) we suggest consideration for the use of antenatal corticosteroids in select populations not included in the original Antenatal Late Preterm Steroids trial, such as patients with multiple gestations reduced to a singleton gestation on or after 14 0/7 weeks of gestation, patients with fetal anomalies, or those who are expected to deliver in <12 hours (GRADE 2C); (3) we recommend against the use of antenatal corticosteroids for fetal lung maturity in pregnant patients with a low likelihood of delivery before 37 weeks of gestation (GRADE 1B); (4) we recommend against the use of late preterm corticosteroids in pregnant patients with pregestational diabetes mellitus, given the risk of worsening neonatal hypoglycemia (GRADE 1C); (5) we recommend that patients at risk for late preterm delivery be thoroughly counseled regarding the potential risks and benefits of antenatal corticosteroid administration and be advised that the long-term risks remain uncertain (GRADE 1C).

The association between persistent maternal hypotension and small for gestational age neonates.

BACKGROUND: The association between maternal hypotension and poor fetal growth has not been well studied. OBJECTIVE: We hypothesized that the presence of persistent maternal hypotension will reflect a chronic reduction of uteroplacental blood flow, leading to placental hypoperfusion and subsequent poor fetal growth. We aimed to evaluate whether persistent hypotension is associated with the risk of having a small for gestational age neonate. A secondary aim was to evaluate whether transient hypotension is associated with the same risk of having a small for gestational age neonate. STUDY DESIGN: We performed a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be data, a large prospective cohort study of nulliparous women. The inclusion criteria included delivery of subjects with singleton pregnancies at ≥24 weeks' gestation who had systolic and diastolic blood pressure data at 3 antenatal visits between 6 0/7 and 29 6/7 weeks' gestation. Univariable analyses were performed to evaluate the association among persistent hypotension (systolic blood pressure of <100 mm Hg and or diastolic blood pressure of <60 mm Hg at 3 antenatal visits), transient hypotension (systolic blood pressure <100 mm Hg and diastolic blood pressure <60 mm Hg at any 1 of 3 aforementioned visits but not all 3), maternal characteristics and small for gestational age neonates. Variables found to be significant (P<.05) were included in multivariable logistic regression. RESULTS: Here, 164 of 7233 participants (2.3%) had persistent hypotension. In univariable analyses, subjects with persistent hypotension compared with those without were significantly more likely to have small for gestational age neonates (21.3% vs 11.6%; P<.001). When adjusting for confounders, persistent hypotension remained significantly associated with an increased risk of having a small for gestational age neonate (adjusted odds ratio, 1.65; 95% confidence interval, 1.11-2.44). In multivariable analysis, transient hypotension was not associated with an increased risk of having a small for gestational age neonate. CONCLUSION: Persistent hypotension was significantly associated with small for gestational age among neonates born to low-risk nulliparous women.

Elevated Glucose Challenge Test in a Nondiabetic Index Pregnancy and Gestational Diabetes in a Subsequent Pregnancy.

OBJECTIVE: The aim of this study was to evaluate whether a 1-hour glucose challenge test (GCT) ≥140 mg/dL in a nondiabetic index pregnancy is associated with the development of gestational diabetes mellitus (GDM) in a subsequent pregnancy. STUDY DESIGN: We performed a retrospective cohort study from a single institution from June 2009 to December 2018. Women with a nondiabetic index singleton gestation who underwent a 1-hour GCT at 24 to 28 weeks and had a successive singleton delivery were included. GDM was defined by a 1-hour GCT of ≥ 200 mg/dL, ≥2 of 4 elevated values on a 3-hour GCT, or a diagnosis of GDM defined by International Classification of Disease codes in the electronic medical record. Univariable analyses were performed to evaluate the associations between an elevated 1-hour GCT result in the index pregnancy, maternal characteristics, and the development of GDM in the subsequent pregnancy. Variables found to be significant (p < 0.05) were included in multivariable analysis. RESULTS: A total of 2,423 women were included. Of these, 340 (14.0%) had an elevated 1-hour GCT in the index pregnancy. Women with an elevated 1-hour GCT in the index pregnancy compared with those without were significantly more likely to be older, married, privately insured, of Hispanic ethnicity or Asian race, chronically hypertensive, have a higher body mass index (BMI), have a shorter inter-pregnancy interval, and to develop GDM in the subsequent pregnancy (14.4 vs. 3.3%, p < 0.001). In multivariable analysis, an elevated 1-hour GCT (adjusted odds ratio [aOR]: 4.54, 95% confidence interval [CI]: 3.02-6.81), first-trimester BMI ≥30 kg/m2 in the index pregnancy (aOR: 3.10, 95% CI: 2.03-4.71), Asian race (aOR: 2.96, 95% CI: 1.70-5.12), Hispanic ethnicity (aOR: 2.11, 95% CI: 1.12-4.00), and increasing age (aOR: 1.07, 95% CI: 1.02-1.12) were significantly associated with an increased risk of GDM in the subsequent pregnancy. CONCLUSION: An elevated 1-hour GCT in a nondiabetic index pregnancy is associated with a fourfold increased risk of GDM in a subsequent pregnancy. KEY POINTS: · An abnormal 1 hour GCT in an index pregnancy is associated with GDM in a subsequent pregnancy.. · An abnormal 1 hour GCT may be an independent risk factor for GDM in a subsequent pregnancy.. · An abnormal 1 hour GCT is associated with a 4 fold increased risk of GDM in a subsequent pregnancy..

Periconception glycemic control and congenital anomalies in women with pregestational diabetes.

INTRODUCTION: To assess the relationship between periconception glycemic control and congenital anomalies in a contemporary, diverse population of women with pregestational diabetes. RESEARCH DESIGN AND METHODS: This is a retrospective cohort study of all pregnant women with pregestational diabetes at a single institution (2003-2017) in the USA. The primary outcome was frequency of major or minor congenital anomalies. Glycemic control was assessed by periconception glycosylated hemoglobin (HbA1c). The association of periconception HbA1c with pregnancy outcomes was assessed using bivariable and multivariable analyses. RESULTS: Our sample included 351 women, of which 63.8% had type 2 diabetes. Our study cohort is racially and ethnically diverse, with approximately equal numbers of women identifying as white non-Hispanic, black non-Hispanic and Hispanic, with 3.4% identifying as Asian. Of these 351 women, 52 (14.8%) had a fetus with a congenital anomaly, of whom the majority (n=43) had a major anomaly. Over half (51.1%) of all major anomalies were cardiovascular. Compared with the group with the best glycemic control (HbA1c ≤7.4%), which had an anomaly frequency of 10.2%, the frequency of congenital anomalies increased significantly with each category of worsening glycemic control (HbA1c 7.5%-9.4%: 20.6%, adjusted OR (aOR) 2.35, 95% confidence interval (CI) 1.08 to 5.13; HbA1c 9.5% to 11.4%: 25.8%, aOR 2.86, 95% CI 1.08 to 7.59; HbA1c ≥11.5%: 37.5%, aOR 7.66, 95% CI 2.27 to 25.9). CONCLUSION: In a diverse cohort of women with pregestational diabetes, higher periconception HbA1c, especially HbA1c >9.5, was significantly associated with major congenital fetal anomalies. Our study sample is reflective of the current population of pregnant women with diabetes, including women with type 2 diabetes and from racial and ethnic minorities.