Intrapartum electronic fetal heart rate monitoring to predict acidemia at birth with the use of deep learning.

BACKGROUND: Electronic fetal monitoring is used in most US hospital births but has significant limitations in achieving its intended goal of preventing intrapartum hypoxic-ischemic injury. Novel deep learning techniques can improve complex data processing and pattern recognition in medicine. OBJECTIVE: This study aimed to apply deep learning approaches to develop and validate a model to predict fetal acidemia from electronic fetal monitoring data. STUDY DESIGN: The database was created using intrapartum electronic fetal monitoring data from 2006 to 2020 from a large, multisite academic health system. Data were divided into training and testing sets with equal distribution of acidemic cases. Several different deep learning architectures were explored. The primary outcome was umbilical artery acidemia, which was investigated at 4 clinically meaningful thresholds: 7.20, 7.15, 7.10, and 7.05, along with base excess. The receiver operating characteristic curves were generated with the area under the receiver operating characteristic assessed to determine the performance of the models. External validation was performed using a publicly available Czech database of electronic fetal monitoring data. RESULTS: A total of 124,777 electronic fetal monitoring files were available, of which 77,132 had <30% missingness in the last 60 minutes of the electronic fetal monitoring tracing. Of these, 21,041 were matched to a corresponding umbilical cord gas result, of which 10,182 were time-stamped within 30 minutes of the last electronic fetal monitoring reading and composed the final dataset. The prevalence rates of the outcomes in the data were 20.9% with a pH of <7.2, 9.1% with a pH of <7.15, 3.3% with a pH of <7.10, and 1.3% with a pH of <7.05. The best performing model achieved an area under the receiver operating characteristic of 0.85 at a pH threshold of <7.05. When predicting the joint outcome of both pH of <7.05 and base excess of less than -10 meq/L, an area under the receiver operating characteristic of 0.89 was achieved. When predicting both pH of <7.20 and base excess of less than -10 meq/L, an area under the receiver operating characteristic of 0.87 was achieved. At a pH of <7.15 and a positive predictive value of 30%, the model achieved a sensitivity of 90% and a specificity of 48%. CONCLUSION: The application of deep learning methods to intrapartum electronic fetal monitoring analysis achieves promising performance in predicting fetal acidemia. This technology could help improve the accuracy and consistency of electronic fetal monitoring interpretation.

Methods for the induction of labor: efficacy and safety.

This review assessed the efficacy and safety of pharmacologic agents (prostaglandins, oxytocin, mifepristone, hyaluronidase, and nitric oxide donors) and mechanical methods (single- and double-balloon catheters, laminaria, membrane stripping, and amniotomy) and those generally considered under the rubric of complementary medicine (castor oil, nipple stimulation, sexual intercourse, herbal medicine, and acupuncture). A substantial body of published reports, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PGE1) when used for cervical ripening and labor induction. Misoprostol administered vaginally at doses of 50 µg has the highest probability of achieving vaginal delivery within 24 hours. Regardless of dosing, route, and schedule of administration, when used for cervical ripening and labor induction, prostaglandin E2 seems to have similar efficacy in decreasing cesarean delivery rates. Globally, although oxytocin represents the most widely used pharmacologic agent for labor induction, its effectiveness is highly dependent on parity and cervical status. Oxytocin is more effective than expectant management in inducing labor, and the efficacy of oxytocin is enhanced when combined with amniotomy. However, prostaglandins administered vaginally or intracervically are more effective in inducing labor than oxytocin. A single 200-mg oral tablet of mifepristone seems to represent the lowest effective dose for cervical ripening. The bulk of the literature assessing relaxin suggests this agent has limited benefit when used for this indication. Although intracervical injection of hyaluronidase may cause cervical ripening, the need for intracervical administration has limited the use of this agent. Concerning the vaginal administration of nitric oxide donors, including isosorbide mononitrate, isosorbide, nitroglycerin, and sodium nitroprusside, the higher incidence of side effects with these agents has limited their use. A synthetic hygroscopic cervical dilator has been found to be effective for preinduction cervical ripening. Although a pharmacologic agent may be administered after the use of the synthetic hygroscopic dilator, in an attempt to reduce the interval to vaginal delivery, concomitant use of mechanical and pharmacologic methods is being explored. Combining the use of a single-balloon catheter with dinoprostone, misoprostol, or oxytocin enhances the efficacy of these pharmacologic agents in cervical ripening and labor induction. The efficacy of single- and double-balloon catheters in cervical ripening and labor induction seems similar. To date, the combination of misoprostol with an intracervical catheter seems to be the best approach when balancing delivery times with safety. Although complementary methods are occasionally used by patients, given the lack of data documenting their efficacy and safety, these methods are rarely used in hospital settings.

Clinical implications of crown-rump length discordance at 11 to 14 weeks in dichorionic twins.

BACKGROUND: Crown-rump length discordance, defined as ≥10% discordance, has been investigated as an early sonographic marker of subsequent growth abnormalities and is associated with an increased risk of fetal loss in twin pregnancies. Previous studies have not investigated the prevalence of fetal aneuploidy or structural anomalies in twins with discordance or the independent association of crown-rump length discordance with adverse perinatal outcomes. Moreover, data are limited on cell-free DNA screening for aneuploidy in dichorionic twins with discordance. OBJECTIVE: This study aimed to evaluate whether crown-rump length discordance in dichorionic twins between 11 and 14 weeks of gestation is associated with a higher risk of aneuploidy, structural anomalies, or adverse perinatal outcomes and to assess the performance of cell-free DNA screening in dichorionic twin pregnancies with crown-rump length discordance. STUDY DESIGN: This was a secondary analysis of a multicenter retrospective cohort study that evaluated the performance of cell-free DNA screening for the common trisomies in twin pregnancies from December 2011 to February 2020. For this secondary analysis, we included live dichorionic pregnancies with crown-rump length measurements between 11 and 14 weeks of gestation. First, we compared twin pregnancies with discordant crown-rump lengths with twin pregnancies with concordant crown-rump lengths and analyzed the prevalence of aneuploidy and fetal structural anomalies in either twin. Second, we compared the prevalence of a composite adverse perinatal outcome, which included preterm birth at <34 weeks of gestation, hypertensive disorders of pregnancy, stillbirth or miscarriage, small-for-gestational-age birthweight, and birthweight discordance. Moreover, we assessed the performance of cell-free DNA screening in pregnancies with and without crown-rump length discordance. Outcomes were compared with multivariable regression to adjust for confounders. RESULTS: Of 987 dichorionic twins, 142 (14%) had crown-rump length discordance. The prevalence of aneuploidy was higher in twins with crown-rump length discordance than in twins with concordance (9.9% vs 3.9%, respectively; adjusted relative risk, 2.7; 95% confidence interval, 1.4-4.9). Similarly, structural anomalies (adjusted relative risk, 2.5; 95% confidence interval, 1.4-4.4]) and composite adverse perinatal outcomes (adjusted relative risk, 1.2; 95% confidence interval, 1.04-1.3) were significantly higher in twins with discordance. A stratified analysis demonstrated that even without other ultrasound markers, there were increased risks of aneuploidy (adjusted relative risk, 3.5; 95% confidence interval, 1.5-8.4) and structural anomalies (adjusted relative risk, 2.7; 95% confidence interval, 1.5-4.8) in twins with CRL discordance. Cell-free DNA screening had high negative predictive values for trisomy 21, trisomy 18, and trisomy 13, regardless of crown-rump length discordance, with 1 false-negative for trisomy 21 in a twin pregnancy with discordance. CONCLUSION: Crown-rump length discordance in dichorionic twins is associated with an increased risk of aneuploidy, structural anomalies, and adverse perinatal outcomes, even without other sonographic abnormalities. Cell-free DNA screening demonstrated high sensitivity and negative predictive values irrespective of crown-rump length discordance; however, 1 false-negative result illustrated that there is a role for diagnostic testing. These data may prove useful in identifying twin pregnancies that may benefit from increased screening and surveillance and are not ascertained by other early sonographic markers.

Socioeconomic Disadvantage in Pregnancy and Postpartum Risk of Cardiovascular Disease.

BACKGROUND: Pregnancy is an educable and actionable life stage to address social determinants of health (SDOH) and lifelong cardiovascular disease (CVD) prevention. But the link between a risk score that combines multiple neighborhood-level social determinants in pregnancy and the risk of long-term CVD remains to be evaluated. OBJECTIVE: To examine whether neighborhood-level socioeconomic disadvantage measured by the Area Deprivation Index (ADI) in early pregnancy is associated with a higher 30-year predicted risk of CVD postpartum, as measured by the Framingham Risk Score. METHODS: An analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be (nuMoM2b) Heart Health Study longitudinal cohort. Participant home addresses during early pregnancy were geocoded at the Census-block level. The exposure was neighborhood-level socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]) measured in the first trimester. Outcomes were the predicted 30-year risks of atherosclerotic CVD (ASCVD, composite of fatal and non-fatal coronary heart disease and stroke) and total CVD (composite of ASCVD plus coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication, and heart failure) using the Framingham Risk Score measured 2-to-7 years after delivery. These outcomes were assessed as continuous measures of absolute estimated risk in increments of 1%, and, secondarily, as categorical measures with high-risk defined as an estimated probability of CVD >10%. Multivariable linear regression and modified Poisson regression models adjusted for baseline age and individual-level social determinants, including health insurance, educational attainment, and household poverty. RESULTS: Among 4,309 nulliparous individuals at baseline, the median age was 27 years (IQR: 23-31) and the median ADI was 43 (IQR: 22-74). At 2-to-7 years postpartum (median: 3.1 years, IQR: 2.5, 3.7), the median 30-year risk of ASCVD was 2.3% (IQR: 1.5, 3.5) and of total CVD was 5.5% (IQR: 3.7, 7.9); 2.2% and 14.3% of individuals had predicted 30-year risk >10%, respectively. Individuals living in the highest ADI tertile had a higher predicted risk of 30-year ASCVD % (adj. ß: 0.41; 95% CI: 0.19, 0.63) compared with those in the lowest tertile; and those living in the top two ADI tertiles had higher absolute risks of 30-year total CVD % (T2: adj. ß: 0.37; 95% CI: 0.03, 0.72; T3: adj. ß: 0.74; 95% CI: 0.36, 1.13). Similarly, individuals living in neighborhoods in the highest ADI tertile were more likely to have a high 30-year predicted risk of ASCVD (aRR: 2.21; 95% CI: 1.21, 4.02) and total CVD ≥10% (aRR: 1.35; 95% CI: 1.08, 1.69). CONCLUSIONS: Neighborhood-level socioeconomic disadvantage in early pregnancy was associated with a higher estimated long-term risk of CVD postpartum. Incorporating aggregated SDOH into existing clinical workflows and future research in pregnancy could reduce disparities in maternal cardiovascular health across the lifespan, and requires further study.

Communication and Birth Experiences Among Black Birthing People Who Experienced Preterm Birth.

PURPOSE: Physically or psychologically distressing birth experiences can influence postpartum health, parenting efficacy, and future pregnancy plans. Communication deficits contribute to negative birth experiences. This qualitative analysis explored themes related to communication and negative birth experiences among Black birthing people who experienced preterm birth. METHODS: We conducted qualitative interviews with non-Hispanic Black, English language-proficient birthing people with Medicaid-insured preterm infants. Interviews were designed to explore experiences with health care access and well-being after birth. Interviews were audio recorded, transcribed, and coded following an integrated approach where we applied a priori codes and captured emergent themes from the data. RESULTS: We interviewed 30 participants from October 2018 to July 2021. Median gestational age at birth was 30 weeks (range 22-36 weeks). Interviews occurred a median of 7 months postpartum (range 2-34 months). Themes emerged related to negative birth experiences and communication: (1) communication gaps during urgent or emergent intrapartum procedures contributed to negative birth experiences; (2) postpartum opportunities to share birth experiences, particularly with peers, sometimes mitigated the psychological consequences of negative birth experiences; (3) participants did not consistently discuss concerns about future pregnancy risk related to negative birth experiences with clinical teams. CONCLUSIONS: Themes from this sample of Black birthing people who experienced preterm birth suggest 3 ways health systems might intervene to improve communication to mitigate the consequences of negative birth experiences. Improvement efforts in these areas may improve postpartum health, future pregnancy outcomes, and long-term health.

Acceptability of Dyad Care Management After Preterm Birth: A Qualitative Study.

OBJECTIVES: Care management programs for medically complex infants interact with parents after complicated pregnancies, when gaps in maternal health care are well documented. These care managers may have the relationships and skills to promote postpartum and interconception health and health care access. It is unknown whether expanding these care management models to address maternal needs would be acceptable. METHODS: We conducted qualitative interviews with women with a history of preterm birth and clinicians. For women with a history of preterm birth, additional inclusion criteria were Medicaid-insured infant in one health system and English proficiency. We purposively oversampled women whose infants received care management. Clinicians worked in two geographically adjacent health systems. Interviews explored priorities after preterm birth and perceived acceptability of mother-infant dyad care management. Interviews were audio recorded, transcribed, and coded following an integrated approach in which we applied a priori codes and captured emergent themes. RESULTS: We interviewed 33 women (10/2018-7/2021) and 24 clinicians (3/2021-8/2021). Women were predominantly non-Hispanic Black, and 15 had infants receiving care management. Clinicians included physicians, nurses, and social workers from Pediatrics, Obstetrics, and Family Medicine. Subgroups converged thematically, finding care management acceptable. Tailoring programs to address stress and sleep, emphasizing care managers with strong interpersonal skills and shared experiences with care management users, and program flexibility would contribute to acceptability. CONCLUSIONS FOR PRACTICE: Dyad care management after preterm birth is acceptable to potential program end-users and clinicians. Dyad health promotion may contribute to improved birth outcomes, infant, and parent health.

Using Longitudinal Twitter Data for Digital Epidemiology of Childhood Health Outcomes: An Annotated Data Set and Deep Neural Network Classifiers.

We manually annotated 9734 tweets that were posted by users who reported their pregnancy on Twitter, and used them to train, evaluate, and deploy deep neural network classifiers (F1-score=0.93) to detect tweets that report having a child with attention-deficit/hyperactivity disorder (678 users), autism spectrum disorders (1744 users), delayed speech (902 users), or asthma (1255 users), demonstrating the potential of Twitter as a complementary resource for assessing associations between pregnancy exposures and childhood health outcomes on a large scale.

The Relationship between Gestational Weight Gain and Cesarean Delivery among Patients undergoing Induction of Labor.

OBJECTIVE: This study aimed to determine the impact of pregnancy weight gain above National Academy of Medicine (NAM) guidelines on cesarean delivery rates following induction. STUDY DESIGN: This is a secondary analysis of a prospective cohort study of patients who underwent induction at a single tertiary care center between July 2017 and July 2019. Included in the primary study were patients undergoing term (≥37 weeks) labor induction with a singleton gestation, intact membranes, and unfavorable cervical examination (Bishop score of ≤6 and cervical dilation ≤ 2 cm). Eligibility for this analysis was limited to patients with a documented prenatal body mass index (BMI) < 20 weeks' gestation. The primary exposure was gestational weight gain greater than NAM guidelines (WGGG) for a patient's initial BMI category. The primary outcome was cesarean delivery for any indication. RESULTS: Of 1,610 patients included in the original cohort, 1,174 (72.9%) met inclusion criteria for this analysis and 517 (44.0%) of these had weight gain above NAM guidelines. Of the entire cohort, 60.0% were Black and 52.7% had private insurance. In total, 160 patients (31%) with WGGG underwent cesarean compared with 127 patients (19.3%) without WGGG (p < 0.001), which equates to a 59% increased odds of cesarean when controlling for initial BMI category, parity, gestational diabetes, and indication for induction (Adjusted Odds Ratio [aOR] 1.58, 95% confidence interval [CI] 1.17-2.12). Among only nulliparous patients, WGGG was associated with an increased odds of cesarean (26.4 vs. 38.2%, aOR 1.50, 95% CI 1.07-2.10). In multiparous patients, however, there was no difference in cesarean between those with and without WGGG (8.8 vs. 14.1%, aOR 1.85, 95% CI 0.96-3.58). CONCLUSION: This study demonstrates that weight gain above NAM guidelines is associated with more than a 50% increased odds of cesarean. Patients should be informed of this association as gestational weight gain may be a modifiable risk factor for cesarean delivery. KEY POINTS: · Weight gain above NAM guidelines was associated with a 59% increased odds of cesarean delivery.. · Nulliparous patients with weight gain above NAM guidelines are at higher risk of cesarean delivery.. · No difference in cesarean delivery among multiparous patients regardless of gestational weight gain..

Are Racial Disparities in Cesarean Due to Differences in Labor Induction Management?

OBJECTIVE: While there are known racial disparities in cesarean delivery (CD) rates, the exact etiologies for these disparities are multifaceted. We aimed to determine if differences in induction of labor (IOL) management contribute to these disparities. STUDY DESIGN: This retrospective cohort study evaluated all nulliparous patients with an unfavorable cervix and intact membranes who underwent IOL of a term, singleton gestation at a single institution from October 1, 2018, to September 30, 2020. IOL management was at clinician discretion. Patients were classified as Black, Indigenous, and People of Color (BIPOC) or White based on self-report. Overall rates of CD were compared for BIPOC versus White race. Chart review then evaluated various IOL management strategies as possible contributors to differences in CD by race. RESULTS: Of 1,261 eligible patients, 915 (72.6%) identified as BIPOC and 346 (27.4%) as White. BIPOC patients were more likely to be younger (26 years interquartile range (IQR) [22-30] vs. 32 years IQR [30-35], p < 0.001) and publicly insured (59.1 vs. 9.9%, p < 0.001). Indication for IOL and modified Bishop score also differed by race (p < 0.001; p = 0.006). There was 40% increased risk of CD for BIPOC patients, even when controlling for confounders (30.7 vs. 21.7%, p = 0.001; adjusted relative risk (aRR) 1.41, 95% confidence interval (CI) [1.06-1.86]). Despite this difference in CD, there were no identifiable differences in IOL management prior to decision for CD by race. Specifically, there were no differences in choice of cervical ripening agent, cervical dilation at or time to amniotomy, use and maximum dose of oxytocin, or dilation at CD. However, BIPOC patients were more likely to undergo CD for fetal indications and failed IOL. CONCLUSION: BIPOC nulliparas are 40% more likely to undergo CD during IOL than White patients within our institution. These data suggest that the disparity is not explained by differences in IOL management prior to cesarean, indicating that biases outside of induction management may be important to target to reduce CD disparities. KEY POINTS: · The etiologies for racial disparities in cesarean are likely multifaceted.. · In this work, there were no differences by race in measures of labor induction management.. · Biases outside of induction management during labor may be targeted to reduce CD disparities..

Association between Group B Streptococcus and Clinical Chorioamnionitis by Gestational Week at Delivery-A Multicenter Cohort Study.

OBJECTIVE: In the era of group B Streptococcus (GBS) screening and intrapartum antibiotic prophylaxis (IAP), GBS colonization has been associated with a lower risk of chorioamnionitis, possibly due to a protective effect of IAP. We sought to confirm this finding and assess whether this association varies by gestational week at delivery. STUDY DESIGN: We performed a retrospective cohort study of term (37.0-42.6 weeks), singleton parturients with known GBS status who delivered from 2005 to 2021 at two academic medical centers in Israel. We excluded patients who underwent planned cesarean, out of hospital birth, or had a fetal demise. Patients received GBS screening and IAP for GBS positivity as routine clinical care. The primary outcome was a diagnosis of clinical chorioamnionitis as determined by the International Classification of Diseases 10th Revision code, compared between GBS-positive and -negative groups, and assessed by gestational week at delivery. RESULTS: Of 292,126 deliveries, 155,255 met inclusion criteria. In total, 30.1% were GBS positive and 69.9% were negative. GBS-positive patients were 21% less likely to be diagnosed with clinical chorioamnionitis than GBS-negative patients, even after controlling for confounders (1.5 vs. 2.2%, adjusted odds ratio: 0.79, 95% confidence interval: 0.68-0.92). When assessed by gestational week at delivery, there was a significantly greater difference in rates of clinical chorioamnionitis between GBS-positive versus GBS-negative groups with advancing gestational age: 1.5-fold difference at 38 to 40 weeks, but a twofold difference at 42 weeks. The risk of clinical chorioamnionitis remained stable in the GBS-positive group, but increased significantly in the GBS-negative group at 41- and 42-week gestation (2.0 vs. 2.9%, p < 0.01 at 41 weeks; up to 3.9% at 42 weeks, p < 0.01). CONCLUSION: In a large multicenter cohort with universal GBS screening and IAP, GBS positivity was associated with a lower risk of chorioamnionitis, driven by an increasing rate of chorioamnionitis among GBS-negative patients after 40 weeks. KEY POINTS: · GBS positivity and IAP may be associated with lower risk of chorioamnionitis.. · GBS-positive patients were less likely to be diagnosed with chorioamnionitis.. · This difference increased with advancing gestational age after 40 weeks..

Prolonged labor and adverse cardiac outcomes in pregnant patients with congenital heart disease.

BACKGROUND: Patients with congenital heart disease are at high risk for peripartum cardiac morbidity, yet data on the impact of duration of labor on cardiac outcomes are limited. Prolonged labor is a known risk factor for maternal morbidity, but the impact of prolonged labor on cardiac outcomes in patients with congenital heart disease has not been evaluated. OBJECTIVE: This study aimed to evaluate the association between prolonged labor (≥24 hours) and adverse peripartum maternal cardiac outcomes in pregnant patients with congenital heart disease. STUDY DESIGN: This was a retrospective cohort study of pregnant patients ≥18 years with congenital heart disease who received prenatal care and delivered at an academic institution between 1998 and 2020 with a singleton gestation. Pregnancies that ended <20 weeks' gestation and patients who underwent an outright cesarean delivery without exposure to labor were excluded. The primary outcome was a composite adverse maternal cardiac outcome that occurred intrapartum or up to 6 weeks postpartum, defined as the occurrence of 1 or more of the following events: heart failure or clinical volume overload requiring diuresis, pulmonary edema, arrhythmia requiring treatment, thromboembolic complications including deep vein thrombosis or pulmonary embolism, transient ischemic attack, stroke, endocarditis, myocardial infarction, aortic dissection, cardiac arrest, or cardiac death. Outcomes were compared between patients with prolonged labor (≥24 hours) and those without prolonged labor (<24 hours). An interaction between prolonged labor and cesarean delivery was evaluated. RESULTS: A total of 229 patients were included. The median duration of labor was 14 hours, and 18% of patients labored for ≥24 hours. Overall, 11.8% experienced the composite cardiac outcome with a significantly higher rate in the prolonged labor group (22% vs 9.6%; P=.03). After adjusting for confounders, including nulliparity, labor induction, gestational age, and World Health Organization class, there was a 2.7-fold increase in the odds of the composite cardiac outcome for patients who experienced prolonged labor (adjusted odds ratio, 2.7; 95% confidence interval, 1.1-7.1). There was no significant difference in cardiac outcome between those who had a vaginal delivery and those who had a cesarean delivery during labor (10.0% vs 16.1%; P=.18). There was, however, a significant interaction between prolonged labor and cesarean delivery; after adjustment for confounders, patients who underwent a cesarean delivery after prolonged labor had a 6.8-fold increase in the odds of experiencing the composite cardiac outcome when compared with those who underwent a cesarean delivery without prolonged labor (30.8% vs 7.1%; adjusted odds ratio, 6.8; 95% confidence interval, 1.4-32.5), most commonly, heart failure or volume overload requiring diuresis. CONCLUSION: In a cohort of pregnant patients with congenital heart disease, prolonged duration of labor ≥24 hours was significantly associated with an increased risk for an adverse peripartum cardiac outcome, especially among those who underwent a cesarean delivery after that time. These findings suggest that close attention should be paid to the duration of labor, and those who require a cesarean delivery after a prolonged labor should be monitored closely for signs of volume overload and other adverse cardiac events.

Association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis among patients undergoing induction of labor at term.

BACKGROUND: Rectovaginal colonization with Group B Streptococcus during pregnancy has historically been shown to be associated with an increased risk of clinical chorioamnionitis and peripartum infectious morbidity. OBJECTIVE: Newer observational data in the era of intrapartum antibiotic prophylaxis suggest a possible reversal of this association; however, it is unclear if this is related to differences in labor management for those with and without Group B Streptococcus colonization. We therefore sought to assess the association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis within the context of a randomized induction of labor trial with a standardized labor protocol. STUDY DESIGN: We performed an exploratory secondary analysis of a randomized trial of patients undergoing term induction at a tertiary care center. Patients received third trimester Group B Streptococcus screening and intrapartum antibiotic prophylaxis as routine care. Group B Streptococcus detection was performed using a carrot broth-enhanced subculture to Group B Streptococcus Detect approach (Hardy Diagnostics, Santa Maria, CA). Labor management was protocolized per the trial. Patients with unknown Group B Streptococcus status or who did not receive intrapartum antibiotic prophylaxis, if indicated, were excluded. The primary outcome was diagnosis of clinical chorioamnionitis, compared between patients who received intrapartum antibiotic prophylaxis for known Group B Streptococcus positive status (by culture, history, or Group B Streptococcus bacteriuria) and those who were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis. Secondary outcomes included postpartum endometritis, wound infection, a composite maternal peripartum infectious morbidity, and neonatal outcomes. RESULTS: A total of 491 patients were enrolled in the trial. Of these, 466 had a known Group B Streptococcus status and received or did not receive intrapartum antibiotic prophylaxis accordingly and were included in this analysis: 292 (62.7%) were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis, and 174 (37.3%) were Group B Streptococcus positive and received intrapartum antibiotic prophylaxis. The majority of patients were Non-Hispanic Black (78.1%) and nulliparous (59.7%). There were no differences in demographic, clinical, induction or labor characteristics between groups. Patients who were Group B Streptococcus positive had a 49% lower rate of clinical chorioamnionitis (8.1% vs 14.7%, odds ratio, 0.51; P=.03) and a lower rate of peripartum infectious morbidity (8.1% vs 15.8%, odds ratio, 0.47; P=.02) compared to those who were Group B Streptococcus negative. Infants born to patients who were Group B Streptococcus positive were significantly less likely to be admitted to the neonatal intensive care unit (3.4% vs 15.1%, P<.001). CONCLUSION: Although Group B Streptococcus colonization has historically been considered a risk factor for clinical chorioamnionitis, in the era of universal antibiotic prophylaxis for Group B Streptococcus positive patients, our findings support the point that intrapartum antibiotic prophylaxis for Group B Streptococcus positivity is associated with lower rates of clinical chorioamnionitis and peripartum infectious morbidity among patients undergoing induction with protocolized labor management. These findings demonstrate that intrapartum antibiotic prophylaxis for Group B Streptococcus may protect against perinatal infectious morbidity, a phenomenon that warrants further investigation.

An interactive childbirth education platform to improve pregnancy-related anxiety: a randomized trial.

BACKGROUND: Perinatal anxiety is one of the most common conditions during pregnancy and is associated with adverse maternal and neonatal outcomes. Interventions that are focused on childbirth education and health literacy have been shown to help decrease pregnancy-related anxiety. These programs, however, have limitations. Transportation, childcare, and work conflicts pose barriers to patients. In addition, many of these programs have not been studied in high-risk patients, who are most at risk for pregnancy-related anxiety. Thus, it is uncertain whether an online childbirth education course can help to improve outcomes in a high-risk patient population. OBJECTIVE: This study aimed to compare an interactive online platform for childbirth education (Birthly) with usual prenatal education on anxiety, emergency healthcare utilization, and delivery outcomes for high-risk pregnancies. STUDY DESIGN: We performed a randomized trial comparing an interactive online childbirth education platform combined with usual prenatal education (intervention) with usual prenatal education alone (usual care). Nulliparous, English-speaking patients with internet access and a high-risk pregnancy (medical or mental health disorders) were included. Patients in 2 urban clinics that serve underresourced patients were enrolled at <20 weeks of gestation. The intervention included 3 interactive courses (prenatal bootcamp, breastfeeding, newborn care) and access to a clinician-moderated online community. Pregnancy-related Anxiety Scale questionnaires were administered at randomization and at 34 to 40 weeks. The primary outcome was third-trimester Pregnancy-related Anxiety Scale score. Secondary outcomes included change in Pregnancy-related Anxiety Scale score, unscheduled emergency visits, delivery, and postpartum outcomes. To demonstrate a 15% decrease in Pregnancy-related Anxiety Scale score, 37 patients would be needed per group. Accounting for a 20% loss to follow-up rate, we planned to recruit 90 total patients or 45 per group. RESULTS: A total of 90 patients were randomized with no differences in demographics or baseline Pregnancy-related Anxiety Scale scores. Most patients self-identified as Black and were publicly insured. More than 60% of patients (62.2%) in the intervention arm completed at least 1 Birthly course. Patients in the intervention arm had significantly lower third-trimester Pregnancy-related Anxiety Scale scores (indicating lower anxiety) compared with those receiving usual care (44.6±7.3 vs 53.9±13.8; P<.01), with a decrease in score of 8.3 points vs 0.7 for usual care (P<.01). Patients in the intervention arm also had fewer emergency visits (1 [0-2] vs 2 [1-3]; P=.003). There were no differences in delivery outcomes. Patients in the intervention arm were more likely to breastfeed at delivery, although this was not different by the postpartum visit. Finally, patients who received the intervention were more likely to be satisfied with their childbirth education (94.6% vs 64.9%; P<.01). CONCLUSION: An interactive online childbirth education platform can reduce pregnancy-related anxiety and emergency healthcare utilization while improving satisfaction in a high-risk patient population.

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

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

Can allostatic load in pregnancy explain the association between race and subsequent cardiovascular disease risk: A cohort study.

OBJECTIVE: To assess the relationship between allostatic load, a measure of cumulative chronic stress in early pregnancy and cardiovascular disease risk, 2-7 years postpartum, and pathways contributing to racial disparities in cardiovascular disease risk. DESIGN: Secondary analysis of a prospective cohort study. SETTING MULTICENTER POPULATION: Pregnant women. METHODS: Our primary exposure was high allostatic load in the first trimester, defined as at least 4 of 12 biomarkers (systolic blood pressure, diastolic blood pressure, body mass index, cholesterol, low-density lipoprotein, high-density lipoprotein, high-sensitivity C-reactive protein, triglycerides, insulin, glucose, creatinine and albumin) in the unfavourable quartile. Logistic regression was used to test the association between high allostatic load and main outcome adjusted for confounders: time from index pregnancy and follow up, age, education, smoking, gravidity, bleeding in the first trimester, index adverse pregnancy outcomes, and health insurance. Each main outcome component and allostatic load were analysed secondarily. Mediation and moderation analyses assessed the role of high allostatic load in racial disparities of cardiovascular disease risk. MAIN OUTCOME MEASURE: Incident cardiovascular disease risk: hypertension, or metabolic disorders. RESULTS: Cardiovascular disease risk was identified in 1462/4022 individuals (hypertension: 36.6%, metabolic disorder: 15.4%). After adjustment, allostatic load was associated with cardiovascular disease risk (adjusted odds ratio [aOR] 2.0, 95% CI 1.8-2.3), hypertension (aOR 2.1, 95% CI 1.8-2.4) and metabolic disorder (aOR 1.7, 95% CI 1.5-2.1). Allostatic load was a partial mediator between race and cardiovascular disease risk. Race did not significantly moderate this relationship. CONCLUSIONS: High allostatic load during pregnancy is associated with cardiovascular disease risk. The relationships between stress, subsequent cardiovascular risk and race warrant further study.

Sleep-disordered Breathing in Pregnancy and after Delivery: Associations with Cardiometabolic Health.

Rationale: Knowledge gaps exist regarding health implications of sleep-disordered breathing (SDB) identified in pregnancy and/or after delivery. Objectives: To determine whether SDB in pregnancy and/or after delivery is associated with hypertension (HTN) and metabolic syndrome (MS). Methods: nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be Heart Health Study) (N = 4,508) followed participants initially recruited during their first pregnancy. Participants returned for a visit 2-7 years after pregnancy. This study examined a subgroup who underwent SDB assessments during their first pregnancy (n = 1,964) and a repeat SDB assessment after delivery (n = 1,222). Two SDB definitions were considered: 1) apnea-hypopnea index (AHI) ⩾ 5 and 2) oxygen desaturation index (ODI) ⩾ 5. Associations between SDB and incident HTN and MS were evaluated with adjusted risk ratios (aRRs). Measurements and Main Results: The aRR for MS given an AHI ⩾ 5 during pregnancy was 1.44 (95% confidence interval [CI], 1.08-1.93), but no association with HTN was found. ODI ⩾ 5 in pregnancy was associated with both an increased risk for HTN (aRR, 2.02; 95% CI, 1.30-3.14) and MS (aRR, 1.53; 95% CI, 1.19-1.97). Participants with an AHI ⩾ 5 in pregnancy that persisted after delivery were at higher risk for both HTN (aRR, 3.77; 95% CI, 1.84-7.73) and MS (aRR, 2.46; 95% CI, 1.59-3.76). Similar associations were observed for persistent ODI ⩾ 5 after delivery. Conclusions: An AHI ⩾ 5 in pregnancy was associated with an increased risk of MS. An ODI ⩾ 5 in pregnancy was significantly associated with both HTN and MS. Participants with persistent elevations in AHI and ODI during pregnancy and at 2-7 years after delivery were at the highest risk for HTN and MS. Clinical trial registered with www.clinicaltrials.gov (NCT02231398).

Standardized Cesarean Risk Counseling with Induction: Impact on Racial Disparities in Birth Satisfaction.

OBJECTIVE: Our prior work demonstrated decreased birth satisfaction for Black women undergoing labor induction. We aimed to determine if implementation of standardized counseling around calculated cesarean risk during labor induction could reduce racial disparities in birth satisfaction. STUDY DESIGN: We implemented use of a validated calculator that provides an individual cesarean risk score for women undergoing induction into routine care. This prospective cohort study compared satisfaction surveys for 6 months prior to implementation (preperiod: January 2018-June 2018) to 1 year after (postperiod: July 2018-June 2019). Women with full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix undergoing induction were included. In the postperiod, providers counseled patients on individual cesarean risk at the beginning of induction using standardized scripts. This information was incorporated into care at patient-provider discretion. The validated 10-question Birth Satisfaction Scale-Revised (BSS-R) subdivided into three domains was administered throughout the study. Patients were determined to be "satisfied" or "unsatisfied" if total BSS-R score was above or below the median, respectively. In multivariable analysis, interaction terms evaluated the differential impact of the calculator on birth satisfaction by race (Black vs. non-Black women). RESULTS: A total of 1,008 of 1,236 (81.6%) eligible women completed the BSS-R (preperiod: 330 [79.7%] versus postperiod: 678 [82.5%], p = 0.23), 63.8% of whom self-identified as Black. In the preperiod, Black women were 50% less likely to be satisfied than non-Black women, even when controlling for differences in parity (Black: 39.0% satisfied vs. non-Black: 53.9%, adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI]: 0.30-0.79). In the postperiod, there was no difference in satisfaction by race (Black: 43.7% satisfied vs. non-Black: 44.0%, aOR = 0.97. 95% CI: 0.71-1.33). Therefore, disparities in birth satisfaction were no longer present at postimplementation (interaction p = 0.03). CONCLUSION: Implementation of standardized counseling with a validated calculator to predict cesarean risk after labor induction is associated with a decrease in racial disparities in birth satisfaction. KEY POINTS: · Preintervention, Black women were less likely to have above-median birth satisfaction.. · We implemented standardized counseling around cesarean risk with labor induction.. · Implementation was associated with reduced racial disparities in birth satisfaction scores..

Genetic and Phenotypic Landscape of Peripartum Cardiomyopathy.

BACKGROUND: Peripartum cardiomyopathy (PPCM) occurs in ≈1:2000 deliveries in the United States and worldwide. The genetic underpinnings of PPCM remain poorly defined. Approximately 10% of women with PPCM harbor truncating variants in TTN (TTNtvs). Whether mutations in other genes can predispose to PPCM is not known. It is also not known if the presence of TTNtvs predicts clinical presentation or outcomes. Nor is it known if the prevalence of TTNtvs differs in women with PPCM and preeclampsia, the strongest risk factor for PPCM. METHODS: Women with PPCM were retrospectively identified from several US and international academic centers, and clinical information and DNA samples were acquired. Next-generation sequencing was performed on 67 genes, including TTN, and evaluated for burden of truncating and missense variants. The impact of TTNtvs on the severity of clinical presentation, and on clinical outcomes, was evaluated. RESULTS: Four hundred sixty-nine women met inclusion criteria. Of the women with PPCM, 10.4% bore TTNtvs (odds ratio=9.4 compared with 1.2% in the reference population; Bonferroni-corrected P [P*]=1.2×10-46). We additionally identified overrepresentation of truncating variants in FLNC (odds ratio=24.8, P*=7.0×10-8), DSP (odds ratio=14.9, P*=1.0×10-8), and BAG3 (odds ratio=53.1, P*=0.02), genes not previously associated with PPCM. This profile is highly similar to that found in nonischemic dilated cardiomyopathy. Women with TTNtvs had lower left ventricular ejection fraction on presentation than did women without TTNtvs (23.5% versus 29%, P=2.5×10-4), but did not differ significantly in timing of presentation after delivery, in prevalence of preeclampsia, or in rates of clinical recovery. CONCLUSIONS: This study provides the first extensive genetic and phenotypic landscape of PPCM and demonstrates that predisposition to heart failure is an important risk factor for PPCM. The work reveals a degree of genetic similarity between PPCM and dilated cardiomyopathy, suggesting that gene-specific therapeutic approaches being developed for dilated cardiomyopathy may also apply to PPCM, and that approaches to genetic testing in PPCM should mirror those taken in dilated cardiomyopathy. Last, the clarification of genotype/phenotype associations has important implications for genetic counseling.

Screening Echocardiogram in High-Risk Women with Class III Obesity to Predict the Risk of Preeclampsia.

OBJECTIVE: Women with obesity and other comorbidities such as hypertension and diabetes are at an increased risk of preeclampsia and perinatal morbidity. This study evaluates whether screening echocardiogram can identify women with obesity at a higher risk of preeclampsia. METHODS: We conducted a retrospective cohort study of women with class III obesity (body mass index [BMI] ≥40 kg/m2) and one or more medical comorbidities associated with an increased risk of preeclampsia (such as diabetes, hypertension, and rheumatologic disease) undergoing screening echocardiogram. Abnormal findings were defined as the presence of one or more of the following: diastolic dysfunction, ejection fraction of ≤45%, or cardiac chamber enlargement or hypertrophy. Multivariable logistic regression was used to estimate the odds ratio (OR) of gestational hypertension/mild preeclampsia, severe preeclampsia, and any preterm delivery <37 weeks associated with abnormal echocardiographic findings when controlling for potential confounders. RESULTS: Of 267 eligible women, 174 (64%) underwent screening echocardiograms. Sixty-nine women (40%) had abnormal echocardiograms. Maternal clinical characteristics were similar between women with normal echocardiographic findings and women with abnormal findings. Women with abnormal echocardiograms were more likely to have chronic hypertension (78 vs. 62%, p = 0.04) and a history of preeclampsia (27 vs. 10%, p = 0.02). After controlling for confounders, women with abnormal echocardiogram were at an increased risk of hypertensive disorders of pregnancy, OR 6.80 (95% confidence interval [CI] 3.32-13.93, p = 0.01), and in particular severe preeclampsia, OR 8.77 (95% CI 3.90-19.74, p = 0.01). CONCLUSION: Among pregnant women with class III obesity and medical comorbidities, screening echocardiogram may help identify a subset of women at the highest risk of developing preeclampsia. KEY POINTS: · Women with obesity and comorbid conditions are at a high risk of abnormal echocardiogram.. · Women with obesity, medical comorbid conditions, and abnormal echo are at a high risk of preeclampsia.. · Screening echocardiogram can help identify obese women at the highest risk of severe preeclampsia..

Neighborhood education status drives racial disparities in clinical outcomes in PPCM.

BACKGROUND: Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry. Additionally, clinical outcomes are worse in this subpopulation compared to White women with PPCM.  The extent to which socioeconomic parameters contribute to these racial disparities is not known. METHODS: We aimed to quantify the association between area-based proxies of socioeconomic status (SES) and clinical outcomes in PPCM, and to determine the potential contribution of these factors to racial disparities in outcomes. A retrospective cohort study was performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of Black individuals. The cohort included 220 women with PPCM, 55% of whom were Black or African American. Available data included clinical and demographic characteristics as well as residential address georeferenced to US Census-derived block group measures of SES. Rates of sustained cardiac dysfunction (defined as persistent LVEF <50%, LVAD placement, transplant, or death) were compared by race and block group-level measures of SES, and a composite neighborhood concentrated disadvantage index (NDI). The contributions of area-based socioeconomic parameters to the association between race and sustained cardiac dysfunction were quantified. RESULTS: Black race and higher NDI were both independently associated with sustained cardiac dysfunction (relative risk [RR] 1.63, confidence interval [CI] 1.13-2.36; and RR 1.29, CI 1.08-1.53, respectively). Following multivariable adjustment, effect size for NDI remained statistically significant, but effect size for Black race did not. The impact of low neighborhood education on racial disparities in outcomes was stronger than that of low neighborhood income (explaining 45% and 0% of the association with black race, respectively). After multivariate adjustment, only low area-based education persisted as significantly correlating with sustained cardiac dysfunction (RR 1.49; CI 1.02-2.17). CONCLUSIONS: Both Black race and NDI independently associate with adverse outcomes in women with PPCM in a single center study. Of the specific components of NDI, neighborhood low education was most strongly associated with clinical outcome and partially explained differences in race. These results suggest interventions targeting social determinants of health in disadvantaged communities may help to mitigate outcome disparities.