Recurrence of Severe Maternal Morbidity and Transfusion During Delivery Hospitalisations: A Retrospective Cohort Study.

OBJECTIVE: To determine risks for non-transfusion severe maternal morbidity and transfusion during a second delivery hospitalisation based on clinical risk factors and obstetric complications from an index, first delivery hospitalisation. DESIGN: Retrospective cohort. POPULATION: Delivery hospitalisations in the 2010-2017 New York State Inpatient Database. METHODS: Patients with a first index delivery hospitalisation followed by a second delivery hospitalisation during the study period were included. Clinical risk factors and obstetric complications were obtained from the first index delivery hospitalisation. Adjusted logistic regression models for non-transfusion severe maternal morbidity during the second delivery were performed with adjusted (aORs) odds ratios as measures of effect. These analyses were then repeated for the outcome of transfusion. RESULTS: Of 624 500 paired delivery hospitalisations to 312 250 women, severe maternal morbidity occurred among 0.85% of second deliveries (n = 2672). When adjusted analysis was performed, several clinical factors were associated with severe maternal morbidity in a subsequent pregnancy, including severe maternal morbidity during the index pregnancy (aOR 8.4, 95% CI 7.0, 9.9), transfusion (aOR 2.0, 95% CI 1.6, 2.4) and pregestational diabetes (aOR 2.2, 95% 1.6, 2.9). When analyses were repeated for transfusion, several factors were associated with increased risk, including severe maternal morbidity (aOR 1.5, 95% CI 1.2, 1.8), index transfusion (aOR 6.3, 95% CI 5.6, 7.0), chronic heart disease (aOR 1.6, 95% 1.4, 1.9) and pregestational diabetes (aOR 1.7, 95% 1.3, 2.2). CONCLUSION: Many obstetric complications and chronic conditions identified during an index delivery hospitalisation are associated with severe morbidity during a second, subsequent delivery. Index severe maternal morbidity is associated with the highest odds. These findings may be of use in patient counselling and risk stratification.

Risk of postpartum hemorrhage according to the planned mode of delivery among twin pregnancies with previous cesarean delivery.

INTRODUCTION: Both twin pregnancies and previous cesarean delivery are situations with increased risk of failed vaginal delivery. Cesarean delivery after a trial of labor is associated with an increased risk of postpartum hemorrhage Therefore, in twin pregnancies with a previous cesarean delivery, planned vaginal delivery could lead to an increased risk of postpartum hemorrhage due to an important rate of cesarean delivery after a trial of labor. Our objective was to evaluate the association between the planned mode of delivery and postpartum hemorrhage in women with twin pregnancies and a previous cesarean delivery. METHODS: We conducted a secondary analysis of the JUMODA French population-based prospective cohort study of twin pregnancies (n=8823). We included women with one previous cesarean and without contraindication to vaginal birth. The primary outcome was postpartum hemorrhage. RESULTS: Among the 735 women included, 187 women (25.4%) had planned vaginal delivery and 548 (74.6%) had planned cesarean delivery. Among women with planned vaginal delivery, 125 (66.8%) had a successful vaginal delivery. The incidence of PPH was 8.2% in the planned cesarean group and 9.1% in the planned vaginal delivery group(p=0.709). After adjustment for confounders, the planned mode of delivery was not associated with the risk of postpartum hemorrhage (adjusted relative risk 0.94, 95% CI 0.56-1.60). There were only 2 uterine ruptures, both in the planned cesarean delivery group. CONCLUSION: In women with a twin pregnancy and a previous cesarean delivery, there is no overall association between the planned mode of delivery and the risk of postpartum hemorrhage.

Severe Maternal Morbidity: The Impact of Race on Tricare Beneficiaries.

Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate impact on women of color. While numerous factors contribute to the inequities in pregnancy-related mortality, access to health insurance is among the most significant. Military Tricare models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzed maternal delivery outcomes for all women with Tricare coverage, including deliveries in the civilian sector. We analyzed data from 6.2 million births in the Centers for Disease Control (CDC) Wide-ranging Online Data for Epidemiology Research (WONDER) Linked Birth/Infant Death Records for 2017-2019. Data included all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and ICU admissions), severe maternal morbidity (SMM) excluding lacerations, and SMM excluding transfusion. Risk ratios were calculated by comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race. In conclusion, there is an increased risk for women identifying as racial minorities for SMM and SMM excluding transfusion. While Tricare coverage seems to decrease the risk, the decrease is not significant and disparities in outcomes persist among women identifying as minorities. The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.

Community-engaged implementation of a safety bundle for pregnancy-related severe hypertension in the outpatient setting: protocol for a type 3 hybrid study with a multiple baseline design.

BACKGROUND: Hypertensive disorders of pregnancy are among the leading causes of maternal mortality and morbidity in the U.S., with rates highest among birthing people who are Black, rural residents, and/or have low-income. Severe hypertension, in particular, increases risk of stroke and other serious pregnancy complications. To promote early detection and treatment of severe hypertension, the Alliance for Innovation on Maternal Health developed the Severe Hypertension During Pregnancy and Postpartum Period Safety Bundle (HTN Bundle). Multiple studies have demonstrated the HTN Bundle's effectiveness in the inpatient setting. With funding from the National Heart, Lung, and Blood Institute, we engaged community partners to adapt the HTN Bundle for the outpatient setting (i.e., O-HTN Bundle) and planned for its implementation. In this paper, we describe the protocol for a study evaluating O-HTN Bundle implementation in 20 outpatient clinics serving Black, rural, and/or low-income populations. METHODS: This study is a hybrid type 3 effectiveness-implementation trial with a multiple baseline design. We will implement the O-HTN Bundle in three successive cohorts of clinics using a multicomponent implementation strategy to engage community partners (coalition, patient workgroup) and support clinics (training, facilitation, education materials, and simulations of severe hypertension events). To test the strategy, we will compare clinic fidelity to evidence-based guidelines for (a) patient education on hypertension and (b) blood pressure measurement technique, with repeated measures occurring before and after strategy receipt. We will also observe strategy effects on community- and clinic-level intermediate outcomes (community engagement, organizational readiness), implementation outcomes (reach, adoption, fidelity, maintenance), and effectiveness outcomes (receipt of guideline concordant care). Analyses will address whether outcomes are equitable across Black, rural, and/or low-income subgroups. Guided by the Consolidated Framework for Implementation Research 2.0, we will use mixed methods to identify adaptations and other determinants of implementation success. DISCUSSION: This study integrates community engagement and implementation science to promote equitable and timely response to severe HTN in the outpatient setting during pregnancy and postpartum. This is one of the first studies to implement an outpatient HTN Bundle and to use simulation as a strategy to reinforce team-based delivery of guideline concordant care. TRIAL REGISTRATION: This study was registered with ClinicalTrials.gov as "Testing Implementation Strategies to Support Clinic Fidelity to an Outpatient Hypertension Bundle (AC3HIEVE)." Registration number NCT06002165, August 21, 2023: https://clinicaltrials.gov/study/NCT06002165 .

Comparison of maternal and neonatal morbidity in transvaginal versus transabdominal cerclage patients: A retrospective study from two tertiary hospitals.

OBJECTIVE: To compare the maternal and neonatal morbidity in patients with transvaginal (TVC) versus transabdominal (TAC) cerclage. MATERIALS AND METHODS: Retrospective analysis of patients who received cervical cerclage and terminated the pregnancy in the second trimester or third trimester in two tertiary hospitals. Data on basic clinical characteristics, predelivery maternal morbidity, intrapartum morbidity, postpartum morbidity and neonatal morbidity of TVC patients and TAC patients were analysed and compared. RESULTS: Seventy-two TVC patients and 120 TAC patients were included. The rates of abnormal fetal presentation and placental disorders were significantly higher in TAC patients than that in TVC patients (21.67% vs 5.56% and 18.33% vs 4.17%, respectively). The rates of premature rupture of membranes and intrauterine infection were significantly higher in TVC patients than that in TAC patients (25.00% vs 2.50% and 11.23% vs 3.33%, respectively). Compared with TVC patients, the rates of estimated intrapartum hemorrhage ≥500 ml, uterine rupture and cesarean delivery in the third trimester were significantly higher in TAC patients than in TVC patients. Gestational age at delivery and neonatal morbidity were comparable between TVC patients and TAC patients. CONCLUSION: Compared with TVC patients, TAC patients were associated with a significantly higher incidence of maternal morbidity in placental disorders, abnormal fetal presentation, intrapartum hemorrhage ≥500 ml and uterine rupture.

Decision and economic evaluation of abortion availability in the United States military.

BACKGROUND: Active-duty service women rely on the civilian sector for most abortion care due to limits on federal funding for abortion. Abortion is now banned in many states with large military presences. The Department of Defense has implemented policies to assist active-duty service women in accessing abortion, but there is debate to reverse this support. OBJECTIVE: Our goal was to compare the cost-effectiveness and incidence of adverse maternal and neonatal outcomes of a hypothetical cohort of active-duty service women living in abortion-restricted states comparing restricted abortion access (abortion not available cohort) to abortion available with Department of Defense travel support (abortion available cohort). STUDY DESIGN: We developed a decision tree model to compare abortion not available and abortion available cohorts for active-duty service women living in abortion-restricted states. Our cohorts were subdivided into normal pregnancies and those with a major fetal anomaly. Cost estimates, probabilities, and disability weights of various health conditions associated with abortion and pregnancy were obtained and derived from the literature. Effectiveness was expressed in disability-adjusted life years and the willingness-to-pay threshold was set to $100,000 per disability-adjusted life year gained or averted. We completed probabilistic sensitivity analyses with 10,000 simulations to test the robustness of our results. Secondary outcomes included numbers of stillbirths, neonatal deaths, neonatal intensive care unit admissions, maternal deaths, severe maternal morbidities, and first and second trimester abortions. RESULTS: The abortion not available cohort had a higher annual cost to the military ($299.1 million, 95% confidence interval 239.2-386.6, vs $226.0 million, 95% confidence interval 181.9-288.5) and was associated with 203 more disability-adjusted life years compared to the abortion available cohort. The incremental cost-effectiveness ratio was dominant for abortion available. Abortion not available resulted in an annual additional 7 stillbirths, 1 neonatal death, 112 neonatal intensive care unit admissions, 0.016 maternal deaths, 24 severe maternal morbidities, 27 less second trimester abortions, and 602 less first trimester abortions. Probabilistic sensitivity analysis revealed that the chance of the abortion available cohort being the more cost-effective strategy was greater than 95%. CONCLUSION: Limiting active-duty service women's access to abortion care increases costs to the military, even with costs of travel support, and increases adverse maternal and neonatal outcomes. This analysis provides important information for policymakers about economic and health burdens associated with barriers to abortion care in the military.

What is the best mode of delivery in nulliparous, singleton, term, vertex pregnancies.

With approximately 145 million births occurring worldwide each year-over 30 million by cesarean delivery (CD), the need for evaluation of maternal and perinatal outcomes in different delivery scenarios is more pressing than ever. Recently, in a meta-analysis of the available randomized controlled trials, planned CD was associated with significantly decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery (VD). Among singleton pregnancies, planned CD was associated with a significantly lower rate of perinatal death. For mothers, planned CD was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1 to 2 years. Conversely, planned VD has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned CD. Nonetheless, several risk factors for CD are increasing-such as older maternal age, obesity, diabetes, excessive gestational weight gain, and birth weight-while maternal pelvises are getting smaller. Concerns about the potential long-term risks of multiple cesarean deliveries, such as placenta accreta spectrum disorders, highlight the need for a balanced evaluation of both delivery modes. However, the total fertility rate is decreasing in the US and around the world, with many people wanting two or fewer babies, which decreases future risk of placenta accreta incurred by multiple cesarean deliveries in these individuals. Furthermore, one in four obstetricians-gynecologists has undergone a CD on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and CD rates less than about 19% have been associated with higher perinatal and maternal mortality. Thus, we propose that it is imperative that we prioritize conducting randomized trials to compare planned cesarean to planned VD for NSTV pregnancies. Such trials would need to include 8000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including nonbiologic outcomes such as patient satisfaction, postpartum depression, breastfeeding rates, mother-infant bonding, post-traumatic stress, and cost-effectiveness. The time for such a trial is now, as it holds the potential to inform and improve obstetrical care practices globally.

Sepsis as a driver of excess severe maternal morbidity and mortality in the rural United States.

Obstetric sepsis is a leading cause of preventable maternal morbidity and mortality. Pregnant and postpartum patients in rural settings experience disproportionate rates of sepsis and other forms of severe maternal morbidity. Although there have been recent advances in addressing preventable morbidity and mortality from sepsis in the general adult population, combating excess rates of sepsis in the obstetric population, particularly among rural patients, will require targeted clinical and policy interventions.

Navigating the Complexities: A Rare Case of Intrahepatic Cholestasis of Pregnancy With Placenta Previa Manifesting With Seizures.

Intrahepatic cholestasis of pregnancy (ICP) is a prevalent and reversible liver disorder that occurs during pregnancy. It is primarily characterized by itching, especially on the palms and soles, and elevated levels of transaminases and bile acids. Some patients may also exhibit hyperbilirubinemia. This condition generally has a good maternal prognosis. The patient, in this case, presented with severe itching, elevated liver enzymes and bile acids, and an ultrasound indicated placenta previa. Uniquely, she experienced an episode of seizure and high blood pressure following surgery. This case report underscores the need for vigilant monitoring of patients with ICP, not only during pregnancy due to the risk of adverse perinatal outcomes but also for antenatal and postpartum complications.

Maternal morbidity in postpartum severe preeclampsia by obstetric delivery volume.

BACKGROUND: Pre-eclampsia is a leading cause of maternal morbidity and mortality in the United States. Emerging data suggests that postpartum pre-eclampsia may be associated with a higher incidence of maternal morbidity compared to hypertensive disorders of pregnancy (HDP) diagnosed antenatally. Understanding postpartum maternal risk across facilities with a spectrum of obstetric services is critical with the rising rates of pre-eclampsia in all healthcare settings. OBJECTIVES: We investigated the relationship between facility delivery volume and rates of non-transfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features. STUDY DESIGN: This is a retrospective cohort study using the Nationwide Readmissions Database (2015-2019) of postpartum patients readmitted for pre-eclampsia with severe features. Our primary outcome was non-transfusion SMM during readmission, defined per U.S. Centers for Disease Control and Prevention criteria. We also evaluated SMM, cardiac SMM, and individual morbidities. The exposure variable was the number of annual deliveries at the readmitting facility. Restricted cubic splines with 4 knots were used to assess the functional form of the relationship between obstetric delivery volume and non-transfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, non-transfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery. RESULTS: The cohort included 29,472 patients readmitted with postpartum pre-eclampsia with severe features. The primary payer was 55% private and 42% governmental. Median age was 31.4 years. Most patients did not have prior HDP (65%) or chronic hypertension (86%) diagnosis antenatally. The median interval from delivery hospitalization to readmission was 3.9 days (25th percentile-75th percentile: 2.2-6.5). Non-transfusion SMM occurred in 7% of patients readmitted to facilities with >2,000 deliveries compared to 9% with 1-2,000 deliveries, and 52% without any delivery hospitalizations. The most common SMM was pulmonary edema and heart failure, observed in 4% of readmissions. We observed that for every increase in 1,000 deliveries, the odds of a non-transfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99) CONCLUSIONS: Non-transfusion SMM for postpartum readmissions with pre-eclampsia with severe features was inversely associated with readmitting hospital delivery volume. This information may guide risk-reducing initiatives for identifying strategies to optimize postpartum care at facilities with lower or no delivery volume.

Utilizing Maternal Morbidity as a Novel Screening (MMS) Tool for Predicting Peripartum Morbidity at a Rural Tertiary Care Teaching Hospital in Central India.

Background The majority of complications and deaths related to childbirth are concentrated in developing and disadvantaged nations, where the rates are unacceptably elevated. These incidents predominantly occur in the vicinity during the intrapartum period and immediately after childbirth. The peripartum period is especially critical for expectant mothers, as it represents the time when a significant number of complications and deaths occur. This study aimed to develop, validate, and assess the efficacy of the maternal morbidity screening (MMS) tool for predicting peripartum morbidity. Methodology The study was conducted in two phases: Phase one involved developing, validating, and piloting the MMS tool, while Phase two focused on evaluating and comparing the MMS tool with the modified early obstetric warning system (MEOWS) chart for predicting peripartum morbidity. An observational analytical clinical study design was utilized. Result In Phase one, the MMS tool was developed and validated by subject experts, resulting in a reliability score of 0.90. Therefore, the tool was deemed reliable and valid. Phase two results revealed that obstetric morbidity in the maternal morbidity group was 66.66%, higher than the 32% observed with the MEOWS chart. The MMS tool demonstrated significantly higher sensitivity at 95.24%, specificity at 89.50%, and predictive value at 98.50%, yielding an overall accuracy of 90.50%. In comparison, the MEOWS chart exhibited a sensitivity of 70.51%, specificity of 86.81%, predictive value of 92.94%, and accuracy of 83.71%. Conclusion The occurrence of maternal morbidity in the trigger zone was significantly higher than in the non-trigger zone in the MMS tool. The MMS tool was significantly more effective as a predictor of peripartum morbidity compared to the MEOWS chart.

Pre-oxygenation using high flow humidified nasal oxygen or face mask oxygen in pregnant people - a prospective randomised controlled crossover non-inferiority study (The HINOP2 study).

BACKGROUND: Airway guidelines recommend pre-oxygenation of obstetric patients to an end tidal oxygen concentration (etO2) ≥90%. High flow nasal oxygen (HFNO) achieves this in 60% of pregnant people. However face mask (FM) pre-oxygenation also may not achieve this target in all patients. In this study we determined whether HFNO pre-oxygenation is non-inferior to FM pre-oxygenation. METHODS: This randomised controlled crossover non-inferiority trial was conducted on healthy participants of gestational age ≥37 weeks in a simulated environment. Participants underwent pre-oxygenation for three minutes with HFNO and FM oxygen in randomised order. HFNO was delivered at a maximal flow of 70 l.min-1 and FM oxygen at 10 l.min-1. The primary outcome was etO2 on first expired breath after pre-oxygenation. Non-inferiority was defined as a mean difference in first etO2 between groups of ≤5%. RESULTS: Seventy participants were randomised with 62 analysed. Age (mean (SD)), gestation (median (IQR)), and body mass index (median (IQR)), were 34.7 (4.6) years, 39 (38.4, 39.4) weeks, 29 (26.6, 32.4) kg.m-2 respectively. First etO2 after HFNO pre-oxygenation was greater than after FM pre-oxygenation (HFNO pre-oxygenation mean (SD) 90.2 (3.9)% versus FM pre-oxygenation 88.7 (3.0)%; mean difference = 1.45%, 95% CI 0.19 to 2.72%; p = 0.025. Forty-four (71%) participants achieved ≥90% first etO2 concentration after HFNO pre-oxygenation versus 27 (44%) after FM pre-oxygenation (p = 0.002). CONCLUSIONS: In this cohort of pregnant people at term in a simulated environment, pre-oxygenation with HFNO was not inferior to FM pre-oxygenation. FM pre-oxygenation did not achieve pre-oxygenation targets in over 50% of participants.

Preeclampsia in the Context of COVID-19: Mechanisms, Pathophysiology, and Clinical Outcomes.

The emergence of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to the global COVID-19 pandemic, significantly impacting the health of pregnant women. Obstetric populations, already vulnerable, face increased morbidity and mortality related to COVID-19, aggravated by preexisting comorbidities. Recent studies have shed light on the potential correlation between COVID-19 and preeclampsia (PE), a leading cause of maternal and perinatal morbidity worldwide, emphasizing the significance of exploring the relationship between these two conditions. Here, we review the pathophysiological similarities that PE shares with COVID-19, with a particular focus on severe COVID-19 cases and in PE-like syndrome cases related with SARS-CoV-2 infection. We highlight cellular and molecular mechanistic inter-connectivity between these two conditions, for example, regulation of renin-angiotensin system, tight junction and barrier integrity, and the complement system. Finally, we discuss how COVID-19 pandemic dynamics, including the emergence of variants and vaccination efforts, has shaped the clinical scenario and influenced the severity and management of both COVID-19 and PE. Continued research on the mechanisms of SARS-CoV-2 infection during pregnancy and the potential risk of developing PE from previous infections is warranted to delineate the complexities of COVID-19 and PE interactions and to improve clinical management of both conditions.

External validation and comparison of four prediction scores for severe maternal morbidity.

BACKGROUND: Severe maternal morbidity (SMM) is increasing in the United States. Several tools and scores exist to stratify an individual's risk of SMM. OBJECTIVE: We sought to examine and compare the validity of four scoring systems for predicting SMM. STUDY DESIGN: This was a retrospective cohort study of all individuals in the Consortium on Safe Labor dataset, which was conducted from 2002 to 2008. Individuals were excluded if they had missing information on risk factors. SMM was defined based on the Centers for Disease Control and Prevention excluding blood transfusion. Blood transfusion was excluded due to concerns regarding the specificity of International Classification of Diseases codes for this indicator and its variable clinical significance. Risk scores were calculated for each participant using the Assessment of Perinatal Excellence (APEX), California Maternal Quality Care Collaborative (CMQCC), Obstetric Comorbidity Index (OB-CMI), and modified OB-CMI. We calculated the probability of SMM according to the risk scores. The discriminative performance of the prediction score was examined by the areas under receiver operating characteristic curves and their 95% confidence intervals (95% CI). The area under the curve for each score was compared using the bootstrap resampling. Calibration plots were developed for each score to examine the goodness-of-fit. The concordance probability method was used to define an optimal cutoff point for the best-performing score. RESULTS: Of 153, 463 individuals, 1115 (0.7%) had SMM. The CMQCC scoring system had a significantly higher area under the curve (95% CI) (0.78 [0.77-0.80]) compared to the APEX scoring system, OB-CMI, and modified OB-CMI scoring systems (0.75 [0.73-0.76], 0.67 [0.65-0.68], 0.66 [0.70-0.73]; P<.001). Calibration plots showed excellent concordance between the predicted and actual SMM for the APEX scoring system and OB-CMI (both Hosmer-Lemeshow test P values=1.00, suggesting goodness-of-fit). CONCLUSION: This study validated four risk-scoring systems to predict SMM. Both CMQCC and APEX scoring systems had good discrimination to predict SMM. The APEX score and the OB-CMI had goodness-of-fit. At ideal calculated cut-off points, the APEX score had the highest sensitivity of the four scores at 71%, indicating that better scoring systems are still needed for predicting SMM.

Diversity, Equity, and Inclusion: Obstetrics and Gynecologist Hospitalists' Impact on Maternal Mortality.

Obstetrics and gynecology hospitalists play a vital role in reducing maternal morbidity and mortality by providing immediate access to obstetric care, especially in emergencies. Their presence in hospitals ensures timely interventions and expert management, contributing to better outcomes for mothers and babies. This proactive approach can extend beyond hospital walls through education, advocacy, and community outreach initiatives aimed at improving maternal health across diverse settings.

Racial/ethnic disparity in severe maternal morbidity among women who conceived by in vitro fertilization.

Background: In vitro fertilization (IVF) as a fertility treatment is associated with adverse perinatal outcomes. Racial/ethnic disparity in severe maternal morbidity (SMM) in women who conceived by IVF is understudied. Objective: To examine differences in the association between race/ethnicity and SMM between women who conceived spontaneously and those who conceived using IVF. Methods: We included all singleton live births and stillbirths in the United States, 2016-2021; data were obtained from the National Center for Health Statistics. Maternal race/ethnicity included non-Hispanic White (NHW), non-Hispanic Black (NHB), American Indian and Alaska Native (AIAN), Asian, Pacific Islander (PI), Hispanic, and mixed-race categories. The SMM composite outcome included eclampsia, uterine rupture, peripartum hysterectomy, blood transfusion, and intensive care unit (ICU) admission. We used logistic regression to adjust for potential confounders (such as age, education, parity, prepregnancy body mass index, smoking during pregnancy, chronic hypertension, and preexisting diabetes) and to assess modification of the association between race/ethnicity and SMM by IVF. Results: The study population included 21,585,015 women: 52% were NHW, 15% NHB, 0.8% AIAN, 6% Asian, 0.2% PI, 24% Hispanic, and 2% were of mixed race. IVF was used by 183,662 (0.85%) women; the rate of the SMM composite outcome was 18.5 per 1000 deliveries and 7.9 per 1000 deliveries in the IVF and spontaneous conception groups, respectively (unadjusted rate ratio 2.34, 95% confidence interval [CI] 2.26-2.43). In women with spontaneous conception, NHB, Asian and mixed-race women had elevated odds of SMM compared with NHW women (adjusted odds ratio [aOR]=1.39, 95% CI 1.37-1.41; aOR=1.04, 95% CI 1.02-1.07; and aOR=1.42, 95% CI 1.38-1.46, respectively). Racial/ethnic disparities in SMM and its components were not different between the IVF and spontaneous conception groups for the mixed-race category. NHB and Hispanic women had significantly higher aORs for uterine rupture/intrapartum hysterectomy compared with NHW women in the IVF group, while Asian women had a higher aOR for ICU admission compared with NHW women in the IVF group. Conclusion: Women who conceived by IVF have a greater than two-fold higher risk of SMM and this higher risk is evident across all racial/ethnic groups. However, NHB and Hispanic women who conceived by IVF had a higher risk of uterine rupture/hysterectomy, and Asian women who conceived by IVF had a higher risk of ICU admission. Our results warrant further investigation examining pregnancy and postpartum care issues among racial/ethnic minority women who conceive using IVF.

Maternal and Fetal Outcomes after Multiple Cesarean Deliveries.

Background/Objectives: Cesarean delivery (CD) is a common procedure, but it can be associated with some increasing risks as the number of previous CD increases. Although women undergoing multiple CDs is very unusual in Spain, our center serves pregnant women with a history of three or more previous CDs with some frequency. We aimed to assess whether women who undergo multiple CDs (≥4) have more risks than those who undergo a third CD. Material and Methods: A retrospective cohort study was conducted with 161 pregnant women who had undergone ≥ 2 previous CDs and were monitored during their next pregnancy. The primary endpoint was to evaluate the obstetric hemorrhage rate in the multiple CD group and compare it with that in the third CD group. Secondary outcomes regarding maternal and neonatal complications were also analyzed. Results: Hemorrhage (7% and 10%; p = 0.522) and transfusion (3% and 8%; p = 0.141) rates were similar in both groups. The risk of dehiscence of the uterine segment (6% and 24%; p < 0.006), as well as hysterectomy (0 and 6.6%, p = 0.019), difficult abdominal opening (49% and 82%; p = 0.001), peritoneal adhesions (3% and 22%; p < 0.001), and difficult bladder separation (36% and 73%; p < 0.001), was higher in the multiple CD group. No uterine rupture or maternal-neonatal mortality was observed in either of the groups. Conclusions: Since undergoing multiple CD is uncommon, our study may be the largest sample in our environment. Our findings suggest that despite the potential risks of undergoing multiple CDs, maternal and neonatal outcomes are overall favorable.

Outcomes in term breech birth according to intended mode of delivery-A Swedish prospective single-center experience of a dedicated breech birth team.

INTRODUCTION: The appropriate mode of delivery for breech babies is a topic of ongoing debate. After the publication of the Term Breech Trial in 2000, the proportion of breech babies delivered vaginally in Sweden rapidly dropped to 7% from 26%. In 2015, international guidelines changed to once again recommend offering vaginal breech deliveries in select cases. In 2017, a Swedish hospital established a dedicated Breech Team to provide safe vaginal breech deliveries according to the new guidelines. The aim of this study is to compare neonatal morbidity in the group planned for cesarean breech delivery with the group planned for vaginal breech delivery treated in accordance with the new guidelines. The study adds to the literature by providing insights into the consequences of reintroducing vaginal breech births in a high-resource health-care setting. MATERIAL AND METHODS: A prospective observational study was conducted at Södersjukhuset's maternity ward with 1067 women who gave birth to a single breech fetus at term. Outcomes were compared between the planned vaginal and planned cesarean delivery groups using intention-to-treat analysis and multivariate analysis to control for confounders. RESULTS: Out of the 1067 women, 78.9% were planned for cesarean delivery and 21.1% were planned for vaginal delivery. The planned vaginal group had a significantly greater risk for neonatal morbidity compared to the planned cesarean group (3.1% vs. 0.7%; OR 4.44, 95% CI 1.48-13.34). The risk difference remained significant after controlling for confounders. CONCLUSIONS: Planned vaginal breech delivery was associated with an increased risk of neonatal mortality and short-term morbidity compared to planned cesarean breech delivery in accordance with the new guidelines. The potential risks and benefits of planned vaginal breech delivery should be carefully weighed against those of planned cesarean delivery.