Pregnancy Outcomes in Women Who Developed Elevated Blood Pressure and Stage I Hypertension after 20 Weeks Gestation.

OBJECTIVE: The American College of Obstetrics threshold for hypertension (≥140/90 mm Hg) differs from those of the American College of Cardiology (ACC) and the American Heart Association (AHA). It is unknown if ACC/AHA hypertension levels are associated with adverse pregnancy outcomes (APOs) after 20 weeks gestation. The purpose of this study is to analyze APOs in women with blood pressure (BP) in the elevated or stage 1 range after 20 weeks gestation. STUDY DESIGN: This was a secondary analysis of the nuMoM2b prospective cohort study of 10,038 nulliparous, singleton pregnancies between 2010 and 2014. BP was measured at three visits during the pregnancy using a standard protocol. Women without medical comorbidities, with normal BP by ACC/AHA guidelines (systolic BP [SBP] < 120 and diastolic BP [DBP] < 80 mm Hg) up to 22 weeks, were included. Exposure was BP between 22 and 29 weeks gestation: normal (SBP < 120 and DBP < 80 mm Hg), elevated (SBP: 120-129 and DBP < 80 mm Hg), and stage 1 (SBP: 130-139 or DBP: 80-89 mm Hg). The primary outcome was hypertensive disorder of pregnancy (HDP) at delivery. Secondary outcomes included fetal growth restriction (FGR), placental abruption, preterm delivery, and cesarean delivery. Multivariable-adjusted odds ratio (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. RESULTS: Of 4,460 patients that met inclusion criteria, 3,832 (85.9%) had BP in the normal range, 408 (9.1%) in elevated, and 220 (4.9%) in stage 1 range between 22 and 29 weeks. The likelihood of HDP was significantly higher in women with elevated BP (aOR 1.71, 95%CI: 1.18,2.48), and stage 1 BP (aOR: 2.79, 95%CI: 1.84,4.23) compared to normal BP (p < 0.001). Stage 1 BP had twice odds of FGR (aOR: 2.33, 95%CI: 1.22,4.47) and elevated BP had three times odds of placental abruption (aOR: 3.03; 95%CI: 1.24,7.39). CONCLUSION: Elevated or stage 1 BP >20 weeks of pregnancy are associated with HDP, FGR, and placental abruption. KEY POINTS: · Elevated and stage 1 BP increases risk for HDP.. · Elevated BP increases risk for placental abruption.. · Stage 1 BP increases risk for FGR..

Primary and Secondary Intracerebral Hemorrhage in Pregnant and Nonpregnant Young Adults by SMASH-UP Criteria.

BACKGROUND: Intracerebral hemorrhage (ICH) is a major cause of maternal morbidity, but its pathophysiology is poorly characterized. We investigated characteristics of pregnancy-associated ICH (P-ICH), compared with ICH in similar aged nonpregnant adults of both sexes. METHODS AND RESULTS: We performed a retrospective analysis of 134 adults aged 18 to 44 years admitted to our center with nontraumatic ICH from January 1, 2012, to December 31, 2021. We compared ICH characteristics among 3 groups: those with P-ICH (pregnant or within 12 months of end of pregnancy); nonpregnant women; and men. We categorized ICH pathogenesis according to a modified scheme, SMASH-UP (structural, medications, amyloid angiopathy, systemic, hypertension, undetermined, posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome), and calculated odds ratios and 95% CIs for primary (spontaneous small-vessel) ICH versus secondary ICH (structural lesions or coagulopathy related), using nonpregnant women as the reference. We also compared specific ICH pathogenesis by SMASH-UP criteria and functional outcomes between groups. Of 134 young adults with nontraumatic ICH, 25 (19%) had P-ICH, of which 60% occurred postpartum. Those with P-ICH had higher odds of primary ICH compared with nonpregnant women (adjusted odds ratio, 4.5 [95% CI, 1.4-14.7]). The odds of primary ICH did not differ between men and nonpregnant women. SMASH-UP pathogenesis for ICH differed significantly between groups (P<0.001). While the in-hospital mortality rate was lowest in the P-ICH group (4%) compared with nonpregnant women (13%) and men (24%), 1 in 4 patients with P-ICH were bedbound and dependent at the time of discharge. CONCLUSIONS: In our cohort of young adults with ICH, 1 in 5 was pregnancy related. P-ICH differed in pathogenesis compared with non-pregnancy-related ICH in young adults, suggesting unique pathophysiology.

Adverse delivery hospitalisation outcomes in 2020 during the COVID-19 pandemic.

OBJECTIVE: To evaluate risk for adverse obstetric outcomes associated with the coronavirus disease 2019 (COVID-19) pandemic period and with COVID-19 diagnoses. DESIGN: Serial cross-sectional study. SETTING: A national sample of US delivery hospitalisations before (1/2016 to 2/2020) and during the first 10 months of (3/2020 to 12/2020) the COVID-19 pandemic. POPULATION: All 2016-2020 US delivery hospitalisations in the National Inpatient Sample. METHODS: Delivery hospitalisations were identified and stratified into pre-pandemic and pandemic periods and the likelihood of adverse obstetric outcomes was compared using logistic regression models with adjusted odds ratios (aOR) with 95% confidence intervals (CI) as measures of association. Risk for adverse outcomes was also analysed specifically for 2020 deliveries with a COVID-19 diagnosis. MAIN OUTCOME MEASURE: Adverse maternal outcomes including respiratory complications and cardiac morbidity. RESULTS: Of an estimated 18.2 million deliveries, 2.9 million occurred during the pandemic. The proportion of delivery hospitalisations with a COVID-19 diagnosis increased from 0.1% in March 2020 to 3.1% in December. Comparing the pandemic period to the pre-pandemic period, there were higher adjusted odds of transfusion (aOR 1.12, 95% CI 1.05-1.19), a respiratory complication composite (aOR 1.37, 95% CI 1.29-1.46), cardiac severe maternal morbidity (aOR 1.30, 95% 1.20-1.39), postpartum haemorrhage (aOR 1.19, 95% CI 1.15-1.24), placental abruption/antepartum haemorrhage (OR 1.04, 95% CI 1.00-1.08), and hypertensive disorders of pregnancy (OR 1.23, 95% CI 1.21-1.26). These associations were similar to unadjusted analysis. Risk for these outcomes during the pandemic period was significantly higher in the presence of a COVID-19 diagnosis. CONCLUSIONS: In a national estimate of delivery hospitalisations, the odds of cardiac and respiratory outcomes were higher in 2020 compared with 2016-2019. COVID-19 diagnoses were specifically associated with a range of serious complications.

Trends in and outcomes of delivery hospitalizations with lupus and antiphospholipid syndrome.

OBJECTIVE: To assess trends and outcomes associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) during US delivery hospitalizations. STUDY DESIGN: The National Inpatient Sample from 2000 to 2019 was used for this repeated cross-sectional analysis. We identified delivery hospitalizations with and without SLE. Temporal trends in SLE during delivery hospitalizations were determined using joinpoint regression. Adjusted logistic regression models accounting for demographic, clinical, and hospital factors were used to determine adjusted odds ratios (aORs) for adverse outcomes based on the presence or absence of SLE. RESULTS: Of an estimated 76 698 775 delivery hospitalizations identified in the NIS, 79386 (0.10%) had an associated diagnosis of SLE. Over the study period, SLE increased from 6.7 to 14.6 cases per 10 000 delivery hospitalizations (average annual percent change 4.5%, 95% CI 4.0-5.1). Deliveries with SLE had greater odds of non-transfusion severe morbidity (aOR 2.21, 95% CI 2.00, 2.44) and underwent a larger absolute increase in morbidity risk over the study period. SLE was associated with a range of other adverse outcomes including preterm delivery, eclampsia, cesarean delivery, and blood transfusion. CONCLUSION: The proportion of deliveries to women with SLE has increased over time in the US, and SLE and APS are associated with a broad range of adverse outcomes.

Peripartum cardiomyopathy delivery hospitalization and postpartum readmission trends, risk factors, and outcomes.

OBJECTIVE: To evaluate risk for peripartum cardiomyopathy during delivery and postpartum hospitalizations, and analyze associated trends, risk factors, and clinical outcomes. METHODS: The 2010-2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations along with postpartum readmissions occurring within five months of delivery discharge were analyzed. Risk factors associated with peripartum cardiomyopathy were analyzed with unadjusted and adjusted logistic regression models with odds ratios as measures of effect. Risk for severe adverse outcomes associated with peripartum cardiomyopathy was analyzed. Trends were analyzed with joinpoint regression. RESULTS: Of 39,790,772 delivery hospitalizations identified, 9,210 were complicated by a diagnosis of peripartum cardiomyopathy (2.3 per 10,000). Risk for a 5-month readmission with a peripartum cardiomyopathy diagnosis was 4.8 per 10,000. Factors associated with peripartum cardiomyopathy during deliveries included preeclampsia with severe features (OR 18.9, 95 % CI 17.2, 20.7), preeclampsia without severe features (OR 6.9, 95 % CI 6.1, 7.8), multiple gestation (OR 4.7, 95 % CI 4.1, 5.3), chronic hypertension (OR 10.1, 95 % CI 8.9, 11.3), and older maternal age. Associations were attenuated but retained significance in adjusted models. Similar estimates were found when evaluating associations with postpartum readmissions. Peripartum cardiomyopathy readmissions were associated with 10 % of overall postpartum deaths, 21 % of cardiac arrest/ventricular fibrillation diagnoses, 18 % of extracorporeal membrane oxygenation cases, and 40 % of cardiogenic shock. In joinpoint analysis, peripartum cardiomyopathy increased significantly during delivery hospitalizations (average annual percent change [AAPC] 2.2 %, 95 % CI 1.0 %, 3.4 %) but not postpartum readmissions (AAPC 0.0 %, 95 % CI -1.6 %, 1.6 %). CONCLUSION: Risk for peripartum cardiomyopathy increased during delivery hospitalizations over the study period. Obstetric conditions such as preeclampsia and chronic medical conditions that are increasing in prevalence in the obstetric population were associated with the highest odds of peripartum cardiomyopathy.

Outcomes associated with peripartum hysterectomy in the setting of placenta accreta spectrum disorder.

BACKGROUND: Although peripartum hysterectomy for placenta accreta spectrum disorder is known to be associated with complications at the time of delivery, there are limited data on postpartum outcomes and readmission risk in this population. OBJECTIVE: This study aimed to analyze risks for adverse outcomes and postpartum readmissions in the setting of peripartum hysterectomy for placenta accreta spectrum disorder by severity of placenta accreta spectrum disorder subcategory. STUDY DESIGN: Using the 2016-2020 Nationwide Readmissions Database, this retrospective cohort study identified peripartum hysterectomies with a diagnosis of placenta accreta spectrum disorder. The primary exposure was placenta accreta spectrum disorder, subcategorized as placenta accreta vs increta/percreta. The primary outcome was readmission rate and delivery complications. Complications evaluated included the following: (1) nontransfusion severe maternal morbidity (ntSMM), (2) venous thromboembolism, (3) reoperation, (4) intraoperative complications, (5) hemorrhage, (6) sepsis, and (7) surgical site complications. We additionally evaluated delivery hospitalization and readmission mean length of stay, and hospital costs. Unadjusted and adjusted logistic regression models were fit for outcomes adjusting for clinical, demographic, and hospital factors. The association measures were expressed as unadjusted and adjusted odds ratios with 95% confidence intervals. RESULTS: Between 2016 and 2020, 7864 hysterectomies during a delivery hospitalization with a diagnosis of placenta accreta spectrum disorder were identified (66.5% with placenta accreta and 33.5% with placenta increta/percreta diagnoses). The overall 60-day all-cause readmission rate was 7.3%. Most readmissions (57.2%) occurred within 10 days of hospital discharge. Compared with peripartum hysterectomy with a diagnosis of placenta accreta, hysterectomies with placenta increta/percreta diagnoses carried significantly increased risk of 60-day readmission (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.71), inpatient mortality (odds ratio, 13.23; 95% confidence interval, 3.35-52.30), nontransfusion severe maternal morbidity (adjusted odds ratio, 1.43; 95% confidence interval, 1.20-1.71), intraoperative complications (adjusted odds ratio, 2.31; 95% confidence interval, 1.93-2.77), and surgical site complications (adjusted odds ratio, 1.55; 95% confidence interval, 1.23-1.95). The median length of stay during delivery hospitalization was longer for placenta increta/percreta (5.8 days; 95% confidence interval, 5.4-6.1) than for placenta accreta (4.2 days; 95% confidence interval, 4.1-4.3; P<.05). In addition, delivery hospitalization costs were higher in cases of placenta increta/percreta (median, $30,686; 95% confidence interval, $28,922-$32,449) than placenta accreta (median, $21,321; 95% confidence interval, $20,480-$22,163). CONCLUSION: Complication and readmission risks after peripartum hysterectomy with placenta accreta spectrum disorder are high. Compared with patients with placenta accreta, patients with placenta increta/percreta had increased risk for delivery and postoperative complications and postpartum readmission, and increased costs and length of stay.

Delivery Outcomes and Postpartum Readmissions Associated with Ehlers-Danlos Syndrome.

OBJECTIVE: Given that updated estimates of Ehlers-Danlos syndrome and risks for obstetric complications including postpartum readmission may be of public health significance, we sought to analyze associated obstetric trends and outcomes in a nationally representative population. STUDY DESIGN: The 2016 to 2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations to women aged 15 to 54 with and without Ehlers-Danlos syndrome were identified. Temporal trends in Ehlers-Danlos syndrome diagnoses during delivery hospitalizations were analyzed using joinpoint regression to estimate the average annual percent change with 95% confidence intervals (CIs). To determine whether adverse obstetric outcomes during the delivery were associated with Ehlers-Danlos syndrome, unadjusted and adjusted logistic regression models were fit with unadjusted (odds ratio [OR]) and adjusted ORs with 95% CIs as measures of association. In addition to analyzing adverse delivery outcomes, risk for 60-day postpartum readmission was analyzed. RESULTS: An estimated 18,214,542 delivery hospitalizations were included of which 7,378 (4.1 per 10,000) had an associated diagnosis of Ehlers-Danlos syndrome. Ehlers-Danlos syndrome diagnosis increased from 2.7 to 5.2 per 10,000 delivery hospitalization from 2016 to 2020 (average annual percent change increase of 16.1%, 95% CI: 9.4%, 23.1%). Ehlers-Danlos syndrome was associated with increased odds of nontransfusion severe maternal morbidity (OR: 1.84, 95% CI: 1.38, 2.45), cervical insufficiency (OR: 2.14, 95% CI: 1.46, 3.13), postpartum hemorrhage (OR: 1.41, 95% CI: 1.17, 1.68), cesarean delivery (OR: 1.26, 95% CI: 1.17, 1.36), and preterm delivery (OR: 1.35, 95% CI: 1.16, 1.56). Estimates for transfusion, placental abruption, and placenta previa did not differ significantly. Risk for 60-day postpartum readmission was 3.0% among deliveries with Ehlers-Danlos (OR: 1.76, 95% CI: 1.37, 2.25). CONCLUSION: Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period and was associated with a range of adverse obstetric outcomes and complications during delivery hospitalizations as well as risk for postpartum readmission. KEY POINTS: · Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period.. · Ehlers-Danlos was associated with a range of adverse obstetric outcomes.. · Ehlers-Danlos was associated with increased readmission risk..

Dynamic cerebral autoregulation in postpartum individuals with and without preeclampsia.

BACKGROUND: Changes in dynamic cerebral autoregulation (DCA) may contribute to postpartum maternal cerebrovascular complications after preeclampsia. We hypothesized that DCA is impaired in the first week postpartum after diagnosis of preeclampsia with severe features (PSF), compared with normotensive postpartum individuals and healthy non-pregnant female volunteers. METHODS: We measured DCA within seven days after delivery in individuals with and without PSF, using transcranial Doppler and continuous arterial blood pressure monitoring with finger plethysmography. Historical data from 28 healthy female non-pregnant volunteers, collected using the same methods, were used for comparison. We used generalized harmonic wavelets to estimate autoregulation parameters (phase shift and gain) in very low frequency and low frequency bands, with lower phase shift and higher gain indicating impaired DCA function. We compared DCA parameters between the three groups using the Kruskal Wallis test. RESULTS: A total of 69 postpartum participants contributed data, of whom 49 had preeclampsia with severe features. Median phase shifts in both postpartum groups were higher compared with historical controls across all frequency ranges (p = 0.001), indicating faster autoregulatory response. Gain was higher in both postpartum groups than in historical controls across all frequency ranges (p = 0.04), indicating impaired dampening effect. CONCLUSION: We found that postpartum individuals, regardless of preeclampsia diagnosis, had higher phase shifts and higher gain than healthy non-pregnant/postpartum female volunteers. Our results suggest hyperdynamic DCA with impaired dampening effect in the first week postpartum, regardless of preeclampsia diagnosis.

Postpartum psychosis during delivery hospitalizations and postpartum readmissions, 2016-2019.

BACKGROUND: Up-to-date data on population-level risk factors for postpartum psychosis is limited, although increasing substance use disorders, psychiatric disorders, autoimmune disorders, and other medical comorbidities in the obstetrical population may be contributing to the increased baseline risk of postpartum psychosis. OBJECTIVE: This study aimed to determine trends in and risk factors for postpartum psychosis during delivery hospitalizations and postpartum readmissions. STUDY DESIGN: Analyzing the 2016-2019 Nationwide Readmission Database, this repeated cross-sectional study identified diagnoses of postpartum psychosis during delivery hospitalizations and postpartum readmissions within 60 days of discharge. The relationship among demographic, clinical, and hospital-level factors present at delivery and postpartum psychosis was analyzed with logistic regression models with adjusted odds ratios with 95% confidence intervals as measures of association. Separate models were created for postpartum psychosis diagnoses at delivery and during postpartum readmission. Temporal trends in diagnoses were analyzed with Joinpoint regression to determine the average annual percent change with 95% confidence intervals. RESULTS: Of 12,334,506 deliveries in the analysis, 13,894 (1.1 per 1000) had a diagnosis of postpartum psychosis during the delivery hospitalization, and 7128 (0.6 per 1000) had a 60-day postpartum readmission with postpartum psychosis. Readmissions with postpartum psychosis increased significantly during the study period (P=.046). Most readmissions with a postpartum psychosis diagnosis occurred in 0 to 10 days (43% of readmissions) or 11 to 20 days (18% of readmissions) after discharge. Clinical factors with the highest adjusted odds for postpartum psychosis readmission included delivery postpartum psychosis (adjusted odds ratio, 5.8; 95% confidence interval, 4.2-8.0), depression disorder (adjusted odds ratio, 3.7; 95% confidence interval, 3.3-4.2), bipolar spectrum disorder (odds ratio, 2.9; 95% confidence interval, 2.3-3.5), and schizophrenia spectrum disorder (adjusted odds ratio, 2.9; 95% confidence interval, 2.1-4.0). In models analyzing postpartum psychosis diagnoses at delivery, risk factors associated with the highest odds included anxiety disorder (adjusted odds ratio, 3.9; 95% confidence interval, 3.5-4.2), schizophrenia spectrum disorder (adjusted odds ratio, 2.5; 95% confidence interval, 1.9-3.4), bipolar disorder (adjusted odds ratio, 1.8; 95% confidence interval, 1.6-2.1), stillbirth (odds ratio, 3.6; 95% confidence interval, 3.1-4.2), and substance use disorder (odds ratio, 1.7; 95% confidence interval, 1.6-1.9). In addition, chronic conditions, such as pregestational diabetes mellitus, obesity, and substance use, were associated with delivery and readmission postpartum psychosis. CONCLUSION: This study determined that postpartum psychosis is increasing during postpartum readmissions and is associated with a wide range of obstetrical and medical comorbidities. Close follow-up care after delivery for other medical and obstetrical diagnoses may represent an opportunity to identify postpartum psychiatric conditions, including postpartum psychosis.

Trends in and outcomes associated with obstructive sleep apnea during deliveries in the United States, 2000-2019.

BACKGROUND: Population-level data on obstructive sleep apnea among pregnant women in the United States and associated risk for adverse outcomes during delivery may be of clinical importance and public health significance. OBJECTIVE: This study aimed to assess trends in and outcomes associated with obstructive sleep apnea during delivery hospitalizations. STUDY DESIGN: This repeated cross-sectional study analyzed delivery hospitalizations using the National Inpatient Sample. Temporal trends in obstructive sleep apnea were analyzed using joinpoint regression to estimate the average annual percentage change with 95% confidence intervals. Survey-adjusted logistic regression models were fit to assess the association between obstructive sleep apnea and mechanical ventilation or tracheostomy, acute respiratory distress syndrome, hypertensive disorders of pregnancy, peripartum hysterectomy, pulmonary edema/heart failure, stillbirth, and preterm birth. RESULTS: From 2000 to 2019, an estimated 76,753,013 delivery hospitalizations were identified, of which 54,238 (0.07%) had a diagnosis of obstructive sleep apnea. During the study period, the presence of obstructive sleep apnea during delivery hospitalizations increased from 0.4 to 20.5 cases per 10,000 delivery hospitalizations (average annual percentage change, 20.6%; 95% confidence interval, 19.1-22.2). Clinical factors associated with obstructive sleep apnea included obesity (4.3% of women without and 57.7% with obstructive sleep apnea), asthma (3.2% of women without and 25.3% with obstructive sleep apnea), chronic hypertension (2.0% of women without and 24.5% with obstructive sleep apnea), and pregestational diabetes mellitus (0.9% of women without and 10.9% with obstructive sleep apnea). In adjusted analyses accounting for obesity, other clinical factors, demographics, and hospital characteristics, obstructive sleep apnea was associated with increased odds of mechanical ventilation or tracheostomy (adjusted odds ratio, 21.9; 95% confidence interval, 18.0-26.7), acute respiratory distress syndrome (adjusted odds ratio, 5.9; 95% confidence interval, 5.4-6.5), hypertensive disorders of pregnancy (adjusted odds ratio, 1.6; 95% confidence interval, 1.6-1.7), stillbirth (adjusted odds ratio, 1.2; 95% confidence interval, 1.0-1.4), pulmonary edema/heart failure (adjusted odds ratio, 3.7; 95% confidence interval, 2.9-4.7), peripartum hysterectomy (adjusted odds ratio, 1.66; 95% confidence interval, 1.23-2.23), and preterm birth (adjusted odds ratio, 1.2; 95% confidence interval, 1.1-1.2). CONCLUSION: Obstructive sleep apnea diagnoses are increasingly common in the obstetrical population and are associated with a range of adverse obstetrical outcomes during delivery hospitalizations.

Postpartum stroke trends, risk factors, and associated adverse outcomes.

BACKGROUND: Management of postpartum stroke has been the focus of several quality improvement efforts in the past decade. However, there is little recent national trends data for postpartum stroke readmissions. OBJECTIVE: This study aimed to determine trends, risk factors, and complications associated with postpartum stroke readmission. STUDY DESIGN: The 2013 to 2019 Nationwide Readmissions Database was used to perform a retrospective cohort study that evaluated the risk for readmission for stroke within 60 days of delivery hospitalization discharge. Temporal trends in readmissions were analyzed using the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. Stratified trends were analyzed for hemorrhage stroke, ischemic stroke, and stroke readmissions at 1 to 10, 11 to 30, and 31 to 60 days after delivery discharge. Risk factors for stroke were analyzed using unadjusted and adjusted logistic regression models with odds ratios and 95% confidence intervals as measures of association. The risk for stroke complications, including mechanical ventilation, seizures, death, and a prolonged stay ≥14 days, was analyzed. RESULTS: Of an estimated 21,754,603 delivery hospitalizations, 5006 were complicated by a 60-day postpartum readmission with a diagnosis of stroke. The average annual percent change for all stroke readmissions over the study period was not significant (average annual percent change, 0.1%; 95% confidence interval, -2.2% to 2.4%). When the trends in readmission for ischemic and hemorrhagic stroke were analyzed, the results were similar, as were the stratified analyses by readmission timing. Risk factors associated with increased odds included superimposed preeclampsia (odds ratio, 4.8; 95% confidence interval, 3.9-5.9), preeclampsia with severe features (odds ratio, 3.7; 95% confidence interval, 3.0-4.4), maternal cardiac disease (odds ratio, 3.0; 95% confidence interval, 2.5-3.7), chronic kidney disease (odds ratio, 5.0; 95% confidence interval, 3.4-7.5), and lupus (odds ratio, 7.0; 95% confidence interval, 4.9-10.2). Risk was retained in adjusted analyses. Common stroke-related complications included a prolonged hospital stay ≥14 days (12.1 per 1000 stroke-related readmissions), seizures (9.9 per 1000 stroke-related readmissions), and mechanical ventilation (6.6 per 1000 stroke-related readmissions). CONCLUSION: This analysis of nationally representative data demonstrated no change in the rate of 60-day postpartum hospitalizations for stroke from 2013 to 2019. Further clinical research is indicated to optimize risk reduction for stroke after delivery hospitalization discharge.

Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum.

BACKGROUND: The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE: In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN: This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS: A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION: The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.

Quantitative activity levels and gestational age at delivery: a prospective cohort study among nulliparous women.

OBJECTIVE: Despite the knowledge that bed rest does not reduce the risk of preterm birth (PTB), it continues to be recommended by many providers worldwide. This is because there are no quantitative data assessing the relationship between PTB and physical activity in pregnancy.1-3 We designed a prospective cohort study using a Fitbit activity tracker to quantitatively explore the association between baseline physical activity in pregnancy in steps/day and the risk of PTB (<37 weeks). STUDY DESIGN: This was a prospective cohort study assessing the association between the risk of PTB and physical activity in healthy nulliparous women from 10 to 24 weeks to delivery. The physical activity (San Francisco, California) was measured from the time of entry into the study until the day before admission for delivery using the Fitbit Flex 2. The participants wore the faceless device 24/7 without modifying their activity. The primary exposure was steps/day in low- (<5000 steps/d) and high-level (≥5000 steps/d) activity groups. The primary outcome was the rate of PTB (<37 weeks). An additional unplanned secondary analysis was performed using a 3500 steps/d cutoff. The secondary outcomes included peripartum complications and median steps/day in term vs preterm groups. Adjusted analyses were performed to account for possible confounders. RESULTS: A total of 134 women were enrolled, of which 25 (19%) and 109 (81%) were in the low- and high-level activity groups, respectively. Overall, 11 (8.2%) women delivered preterm. The high-level activity group was older, partnered, employed, and had a higher education level. The PTB did not differ between the groups (adjusted risk ratio, 0.99; 95% confidence interval [CI], 0.99-1.00) (Table). There was no difference in the median steps/d between preterm and term deliveries (7767 interquartile range, [5188-10,387] vs 6986 [5412-8528]); percentile difference, -442; (95% CI, -2233 to 1507) steps. Using a 3500 steps/d cutoff, there was a 75% reduction in the PTB risk (29% vs 7%, respectively; risk ratio, 0.25; 95% CI, 0.05-2.35) (Table). CONCLUSION: This prospective study of nulliparous women showed no difference in the risk of PTB between low- vs high-activity groups using a cutoff of 5000 steps/d. The gestational age at delivery was similar between the groups. No significant difference in the number of steps/d was observed between women who delivered preterm compared with term. The women who were prescribed activity restriction (AR) had a marked reduction in their median number of steps/d after AR was prescribed. However, their median number of steps per day (>5000) reflected that they remained active despite this instruction. An additional analysis using 3500 steps/d as a cutoff for exposure groups showed a significantly increased risk of PTB in the <3500 steps/d group than the ≥3500 steps/d group. It is therefore plausible that activity levels <3500 steps/d are associated with an increased risk of PTB.

OBGYN practice patterns regarding combination therapy for prevention of preterm birth: A national survey.

OBJECTIVE: Our objective was to examine if US obstetrician-gynecologists (OBGYNs) practice outside of evidenced-based guidelines and use a combination of interventions to prevent spontaneous preterm birth (sPTB). STUDY DESIGN: An electronic survey was distributed to members of the Pregnancy-Related Care Research Network (PRCRN), and also to members of the Society of Maternal-Fetal Medicine (SMFM). The survey consisted of questions regarding physician demographics, and the use of interventions to prevent sPTB in women with 1) a prior sPTB, 2) an incidental short cervix (no prior sPTB), and 3) a history of cervical insufficiency. RESULTS: The PRCRN response rate was 58.6% (283/483) with an additional 143 responses from SMFM members. Among PRCRN responders, 82.7% were general OBGYNs and 17.3% were Maternal-Fetal Medicine subspecialists. Respondents were from all geographic regions of the country; most practiced in a group private practice (42.6%) or academic institution (31.4%). In women with prior sPTB, 45.2% of respondents would consider combination therapy, most commonly weekly intramuscular progesterone (IM-P) and serial cervical length (CL) measurements. If the patient then develops a short cervix, 33.7% would consider adding an ultrasound-indicated cerclage. In women with an incidental short cervix, 66.8% of respondents were likely to recommend single therapy with daily vaginal progesterone (VP). If a patient developed an incidentally dilated cervix, 40.8% of PRCRN respondents would recommend dual therapy, most commonly cerclage + VP, whereas 64.3% of SMFM respondents were likely to continue with VP only. In women with a history of cervical insufficiency, 47% of PRCRN respondents indicated they would consider a combination of IM-P, history-indicated cerclage and serial CL measurements. CONCLUSION: Although not currently supported by evidence-based medicine, combination therapy is commonly being used by U.S. OBGYNs to prevent sPTB in women with risk factors such as prior sPTB, short or dilated cervix or more than one of these risks.

Cardiovascular and cerebrovascular health after pre-eclampsia: the Motherhealth prospective cohort study protocol.

INTRODUCTION: Cardiovascular and cerebrovascular diseases (CCVDs) are the leading cause of maternal mortality in the first year after delivery. Women whose pregnancies were complicated by pre-eclampsia are at particularly high risk for adverse events. In addition, women with a history of pre-eclampsia have higher risk of CCVD later in life. The physiological mechanisms that contribute to increased CCVD risk in these women are not well understood, and the optimal clinical pathways for postpartum CCVD risk reduction are not yet defined. METHODS AND ANALYSIS: The Motherhealth Study (MHS) is a prospective cohort study at Columbia University Irving Medical Center (CUIMC), a quaternary care academic medical centre serving a multiethnic population in New York City. MHS began recruitment on 28 September 2018 and will enrol 60 women diagnosed with pre-eclampsia with severe features in the antepartum or postpartum period, and 40 normotensive pregnant women as a comparison cohort. Clinical data, biospecimens and measures of vascular function will be collected from all participants at the time of enrolment. Women in the pre-eclampsia group will complete an additional three postpartum study visits over 12-24 months. Visits will include additional detailed cardiovascular and cerebrovascular phenotyping. As this is an exploratory, observational pilot study, only descriptive statistics are planned. Data will be used to inform power calculations for future planned interventional studies. ETHICS AND DISSEMINATION: The CUIMC Institutional Review Board approved this study prior to initiation of recruitment. All participants signed informed consent prior to enrolment. Results will be disseminated to the clinical and research community, along with the public, on completion of analyses. Data will be shared on reasonable request.

Hypertensive Disorders of Pregnancy.

"Pregnancy-induced hypertension" (HDP) describes a spectrum of disorders, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Each of these disease processes can progress to a more pathologic case with worsening hypertensive disease, end-organ damage, and concerning clinical sequelae. Risk factors for HDP include nulliparity, a prior pregnancy complicated by hypertension, and obesity. Close blood pressure monitoring, serologic and urine testing, and prompt clinical follow-up remain the gold standard for antenatal diagnosis and surveillance. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multidisciplinary team-based approach, and referral to an experienced provider for cases with advanced pathology.