Abortion Restrictiveness and Infant Mortality: An Ecologic Study, 2014-2018.

INTRODUCTION: The U.S. has the highest infant mortality rate among peer countries. Restrictive abortion laws may contribute to poor infant health outcomes. This ecological study investigated the association between county-level infant mortality and state-level abortion access legislation in the U.S. from 2014 to 2018. METHODS: A multivariable regression analysis with the outcome of county-level infant mortality rates, controlling for the primary exposure of state-level abortion laws, and county-level factors, county-level distance to an abortion facility, and state Medicaid expansion status was performed. Incidence rate ratios and 95% CIs were reported. Analyses were conducted in 2022-2023. RESULTS: There were 113,397 infant deaths among 19,559,660 live births (infant mortality rate=5.79 deaths/1,000 live births; 95% CI=5.75, 5.82). Black infant mortality rate (10.69/1,000) was more than twice the White infant mortality rate (4.87/1,000). In the multivariable model, increased infant mortality rates were seen in states with ≥8 restrictive laws, with the most restrictive (11-12 laws) having a 16% increased infant mortality level (adjusted incidence rate ratios=1.162; 95% CI=1.103, 1.224). Increased infant mortality rates were associated with increased county-level Black race individuals (adjusted incidence rate ratios=1.031; 95% CI=1.026, 1.037), high school education (adjusted incidence rate ratios=1.018; 95% CI=1.008, 1.029), maternal smoking (adjusted incidence rate ratios=1.025; 95% CI=1.018, 1.033), and inadequate prenatal care (adjusted incidence rate ratios=1.045; 95% CI=1.036, 1.055). CONCLUSIONS: State-level abortion law restrictiveness is associated with higher county-level infant mortality rates. The Supreme Court decision on Dobbs versus Jackson and changes in state laws limiting abortion may affect future infant mortality.

Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review.

Maternal congenital heart disease is increasingly prevalent, and has been associated with a significantly increased risk of maternal, obstetric, and neonatal complications. For patients with CHD who require cardiac interventions during pregnancy, there is little evidence-based guidance with regard to optimal perioperative management. The periprocedural management of pregnant patients with congenital heart disease requires extensive planning and a multidisciplinary teams-based approach. Anesthesia providers must not only be facile in the management of adult congenital heart disease, but cognizant of the normal, but significant, physiologic changes of pregnancy.

Outcomes after treatment of breast cancer during pregnancy including taxanes and/or granulocyte colony-stimulating factor use: findings from a multi-institutional retrospective analysis.

BACKGROUND: Guidelines support comparable treatment for women diagnosed with breast cancer during pregnancy (PrBC) and nonpregnant women with limited case-specific modifications to ensure maternal-fetal safety. Experience during pregnancy with modern agents, such as taxanes or granulocyte colony-stimulating factors (GCSF), is limited. PATIENTS AND METHODS: We retrospectively identified a multi-institutional cohort of PrBC between 1996 and 2020. Propensity score analyses with multiple imputation for missing variables were applied to determine the associations between chemotherapy exposures during pregnancy, with or without taxanes or GCSF, and a compound maternal-fetal outcome including spontaneous preterm birth, preterm premature rupture of membranes, chorioamnionitis, small for gestational age newborns, congenital malformation, or 5-min Apgar score < 7. RESULTS: Among 139 PrBC pregnancies, 82 (59.0%) were exposed to chemotherapy, including 26 (31.7%) to taxane and 18 (22.0%) to GCSF. Chemotherapy use, in general, and inclusion of taxane and/or GCSF, specifically, increased over time. Pregnancies resulting in live singleton births (n = 123) and exposed to chemotherapy were as likely to reach term as those that were not (59.5% vs. 63.6%, respectively, punadjusted = 0.85). Among women treated with chemotherapy, propensity score-matched odds ratios (OR) for the composite maternal-fetal outcome were not significantly increased with taxane (OR 1.24, 95% CI 0.27-5.72) or GCSF (OR 2.11, 95% confidence interval (CI) 0.48-9.22) with similar effects in multiple imputation and sensitivity models. CONCLUSION: The judicious increased use of taxane chemotherapy and/or growth factor support during pregnancy was not associated with unfavorable short-term maternal-fetal outcomes. While these findings are reassuring, case numbers remain limited and continued surveillance of these patients and progeny is warranted.

Birthweight and Chemotherapy Exposure in Women Diagnosed with Breast Cancer during Pregnancy.

OBJECTIVE: Breast cancer is one of the most frequently diagnosed cancers in pregnancy and is commonly treated with chemotherapy. To date, studies examining effects of chemotherapy during pregnancy on fetal growth have yielded conflicting results, and most are limited by small sample sizes or are nonspecific with respect to cytotoxic regimen or type of cancer treated. We sought to evaluate the effect of chemotherapy for breast cancer in pregnancy on birthweight and small for gestational age infants. STUDY DESIGN: This is a retrospective cohort study of 74 women diagnosed with pathologically confirmed breast cancer during pregnancy between 1997 and 2018 at one of three academic medical centers, who had a singleton birth with known birthweight. Forty-nine received chemotherapy and 25 did not receive chemotherapy. Linear regression modeling was used to compare birthweight (by gestational age and sex-specific z-score) by chemotherapy exposure. Subanalyses of specific chemotherapy regimen and duration of chemotherapy exposure were also performed. Placental, neonatal, and maternal outcomes were also analyzed by chemotherapy exposure. RESULTS: In the adjusted model, chemotherapy exposure was associated with lower birthweight (Δ z-score = -0.49, p = 0.03), but similar rates of small for gestational age (defined as birthweight <10th percentile for gestational age) infants (8.2 vs. 8.0%, p = 1.0; Fisher's exact test). Each additional week of chemotherapy (Δ z-score = -0.05, p = 0.03) was associated with decreased birthweight, although no association was found with specific chemotherapy regimen. Chemotherapy exposure was associated with lower median placental weight percentile by gestational age (9th vs. 75th, p < 0.05). Secondary maternal outcomes were similar between the group that did and did not receive chemotherapy. CONCLUSION: Chemotherapy for breast cancer in pregnancy in this cohort is associated with lower birthweight but no difference in the rate of small for gestational age infants. KEY POINTS: · Chemotherapy for breast cancer in pregnancy is associated with decreased birthweight but similar rates of small for gestational age infants.. · Birthweight did not differ according to chemotherapy regimen.. · There is no difference in the rate of small for gestational age infants..

Bleeding and thrombotic risk in pregnant women with Fontan physiology.

BACKGROUND/OBJECTIVES: Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan. METHODS: We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors. RESULTS: We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096). CONCLUSIONS: Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.

Planned vaginal delivery and cardiovascular morbidity in pregnant women with heart disease.

BACKGROUND: Although consensus guidelines on the management of cardiovascular disease in pregnancy reserve cesarean delivery for obstetric indications, there is a paucity of data to support this approach. OBJECTIVE: The objective of the study was to compare cardiovascular and obstetric morbidity in women with cardiovascular disease according to the plan for vaginal birth or cesarean delivery. STUDY DESIGN: We assembled a prospective cohort of women delivering at an academic tertiary care center with a protocolized multidisciplinary approach to management of cardiovascular disease between September 2011 and December 2016. Our practice is to encourage vaginal birth in women with cardiovascular disease unless there is an obstetric indication for cesarean delivery. We allow women attempting vaginal birth a trial of Valsalva in the second stage with the ability to provide operative vaginal delivery if pushing leads to changes in hemodynamics or symptoms. Women were classified according to planned mode of delivery: either vaginal birth or cesarean delivery. We then used univariate analysis to compare adverse outcomes according to planned mode of delivery. The primary composite cardiac outcome of interest included sustained arrhythmia, heart failure, cardiac arrest, cerebral vascular accident, need for cardiac surgery or intervention, or death. Secondary obstetric and neonatal outcomes were also considered. RESULTS: We included 276 consenting women with congenital heart disease (68.5%), arrhythmias (11.2%), connective tissue disease (9.1%), cardiomyopathy (8.0%), valvular disease (1.4%), or vascular heart disease (1.8%) at or beyond 24 weeks' gestation. Seventy-six percent (n = 210) planned vaginal birth and 24% (n = 66) planned cesarean delivery. Women planning vaginal birth had lower rates of left ventricular outflow tract obstruction, multiparity, and preterm delivery. All women attempting vaginal birth were allowed Valsalva. Among planned vaginal deliveries 86.2% (n = 181) were successful, with a 9.5% operative vaginal delivery rate. Five women underwent operative vaginal delivery for the indication of cardiovascular disease without another obstetric indication at the discretion of the delivering provider. Four of these patients tolerated trials of Valsalva ranging from 15 to 75 minutes prior to delivery. Adverse cardiac outcomes were similar between planned vaginal birth and cesarean delivery groups (4.3% vs 3.0%, P = 1.00). Rates of postpartum hemorrhage (1.9% vs 10.6%, P < .01) and transfusion (1.9% vs 9.1%, P = .01) were lower in the planned vaginal birth group. There were no differences in adverse cardiac, obstetric, or neonatal outcomes in the cohort overall or the subset of women with high-risk cardiovascular disease or a high burden of obstetric comorbidity. CONCLUSION: These findings suggest that cesarean delivery does not reduce adverse cardiovascular outcomes and lend support to a planned vaginal birth for the majority of women with cardiovascular disease including those with high-risk disease.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association.

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

Immediate breast reconstruction following mastectomy in pregnant women with breast cancer.

BACKGROUND: Surgical management of breast cancer in pregnancy (BCP) requires balancing benefits of therapy with potential risks to the developing fetus. Minimal data describe outcomes after mastectomy with immediate breast reconstruction (IR) in pregnant patients. METHODS: Retrospective review was performed of patients who underwent IR after mastectomy within a BCP cohort. Parameters included intra- and post-operative complications, short-term maternal/fetal outcomes, surgery duration, and delayed reconstruction in non-IR cohort. RESULTS: Of 82 patients with BCP, 29 (35%) had mastectomy during pregnancy: 10 (34%) had IR, 19(66%) did not. All IR utilized tissue expander (TE) placement. Mean gestational age (GA) at IR was 16.2 weeks. Mean surgery duration was 198 min with IR versus 157 min without IR. Those with IR delivered at, or close to, term infants of normal birthweight. No fetal or major obstetrical complications were seen. Post-mastectomy radiation (PMRT) was provided after pregnancy in 2 (20%) patients in the IR cohort and 12 (63%) in the non-IR cohort. All patients in the IR cohort successfully transitioned to permanent implant. CONCLUSIONS: This report represents one of the largest series describing IR during BCP. IR after mastectomy increased surgery duration, but was not associated with adverse obstetrical or fetal outcomes. IR with TE may preserve reconstructive options when PMRT is indicated. J. Surg. Oncol. 2016;114:140-143. © 2016 Wiley Periodicals, Inc.

Sentinel lymph node biopsy in pregnant women with breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SNB) in pregnant women with breast cancer is uncommonly pursued given concern for fetal harm. This study evaluated efficacy and safety outcomes in pregnant breast cancer patients undergoing SNB. METHODS: Patients who underwent SNB while pregnant were identified from a retrospective parent cohort of women diagnosed with breast cancer during pregnancy. Chart review was performed to tabulate patient/tumor characteristics, method/outcome of SNB, and short-term maternal/fetal outcomes. RESULTS: Within a cohort of 81, 47 clinically node-negative patients had surgery while pregnant: 25 (53.2 %) SNB, 20 (42.6 %) upfront axillary lymph node dissection, and 2 (4.3 %) no lymph node surgery. Of SNB patients, 8, 9, and 8 had SNB in the first, second, and third trimesters, respectively. 99 m-Technetium (99-Tc) alone was used in 16 patients, methylene blue dye alone in 7 patients, and 2 patients had unknown mapping method. Mapping was successful in all patients. There were no SNB-associated complications. At a median of 2.5 years from diagnosis, there was one locoregional recurrence, one new primary contralateral tumor, three distant recurrences, and one breast cancer death. Among patients who underwent SNB, there were 25 liveborn infants, of whom 24 were healthy, and 1 had cleft palate (in the setting of other maternal risk factors). CONCLUSIONS: SNB in pregnant breast cancer patients appears to be safe and accurate using either methylene blue or 99-Tc. This is one of the largest reported experiences of SNB during pregnancy; however, numbers remain limited. SNB rates in this cohort were lower than in non-pregnant breast cancer patients.

Contemporary multidisciplinary treatment of pregnancy-associated breast cancer.

Breast cancer diagnosed during pregnancy poses unique challenges. Application of standard treatment algorithms is limited by lack of level I evidence from randomized trials. This study describes contemporary multidisciplinary treatment of pregnancy-associated breast cancer (PABC) in an academic setting and explores early maternal and fetal outcomes. A search of the Dana-Farber/Harvard Cancer Center clinical databases was performed to identify PABC cases. Sociodemographic, disease, pregnancy, and treatment information, as well as data on short-term maternal and fetal outcomes, were collected through retrospective chart review. 74 patients were identified, the majority with early-stage breast cancer. Most (73.5%) underwent surgical resection during pregnancy, including 40% with sentinel lymph node biopsy and 32% with immediate reconstruction. A total of 36 patients received anthracycline-based chemotherapy during pregnancy; of those, almost 20% were on a dose-dense schedule and 8.3% also received paclitaxel. 68 patients delivered liveborn infants; over half were delivered preterm (< 37 weeks), most scheduled to allow further maternal cancer therapy. For the infants with available data, all had normal Apgar scores and over 90% had birth weight >10(th) percentile. The rate of fetal malformations (4.4%) was not different than expected population rate. Within a multidisciplinary academic setting, PABC treatment followed contemporary algorithms without apparent increase in maternal or fetal adverse outcomes. A considerable number of preterm deliveries were observed, the majority planned to facilitate cancer therapy. Continued attention to maternal and fetal outcomes after PABC is required to determine the benefit of this delivery strategy.

Hematologic disease in pregnancy: the obstetrician's perspective.

Pregnancy can be a time of significantly increased morbidity and mortality in women with hematologic disease. With careful planning and preparation, most women can be cared for safely, resulting in a healthy mother and child. Management concerns in each trimester are reviewed, with a particular focus on labor and delivery planning and common obstetric complications. Diagnostic testing and the use of medications in pregnancy and lactation are discussed in detail.

Obstetric complications of fibroids.

The effect of uterine fibroids on fecundity and pregnancy outcome is difficult to determine with any degree of accuracy; this is due, in large part, to the lack of adequate large clinical trials. In general, the literature tends to underestimate the prevalence of fibroids in pregnancy and overestimate the complications that are attributed to them. In contrast to popular opinion, most fibroids do not exhibit a significant change in volume during pregnancy, although those that do increase in size tend to do so primarily in the first trimester. Although most pregnancies are unaffected by the presence of uterine fibroids, large submucosal and retro-placental fibroids seem to impart a greater risk for complications, including pain (degeneration), vaginal bleeding, placental abruption, IUGR, and preterm labor and birth. Preconception myomectomy to improve reproductive outcome can be considered on an individual basis, but likely has a place only in women who have recurrent pregnancy loss, large submucosal fibroids, and no other identifiable cause for recurrent miscarriage. Antepartum myomectomy should be reserved for women who have subserosal or pedunculated fibroids and intractable fibroid pain that are unresponsive to medical therapy and who are in the first or second trimester of pregnancy. Myomectomy at the time of cesarean delivery is associated with significant morbidity (hemorrhage) and should be pursued with caution and only in select patients.

Pregnancy outcomes in women with congenital heart disease.

BACKGROUND: Pregnant women with congenital heart disease are at increased risk for cardiac and neonatal complications, yet risk factors for adverse outcomes are not fully defined. METHODS AND RESULTS: Between January 1998 and September 2004, 90 pregnancies at age 27.7+/-6.1 years were followed in 53 women with congenital heart disease. Spontaneous abortions occurred in 11 pregnancies at 10.8+/-3.7 weeks, and 7 underwent elective pregnancy termination. There were no maternal deaths. Primary maternal cardiac events complicated 19.4% of ongoing pregnancies, with pulmonary edema in 16.7% and sustained arrhythmias in 2.8%. Univariate risk factors included prior history of heart failure (odds ratio [OR], 15.5), NYHA functional class > or =2 (OR, 5.4), and decreased subpulmonary ventricular ejection fraction (OR, 7.7). Independent predictors were decreased subpulmonary ventricular ejection fraction and/or severe pulmonary regurgitation (OR, 9.0) and smoking history (OR, 27.2). Adverse neonatal outcomes occurred in 27.8% of ongoing pregnancies and included preterm delivery (20.8%), small for gestational age (8.3%), respiratory distress syndrome (8.3%), intraventricular hemorrhage (1.4%), intrauterine fetal demise (2.8%), and neonatal death (1.4%). A subaortic ventricular outflow tract gradient >30 mm Hg independently predicted an adverse neonatal outcome (OR, 7.5). Cardiac risk assessment was improved by including decreased subpulmonary ventricular systolic function and/or severe pulmonary regurgitation (OR, 10.3) in a previously proposed risk index developed in pregnant women with acquired and congenital heart disease. CONCLUSIONS: Maternal cardiac and neonatal complication rates are considerable in pregnant women with congenital heart disease. Patients with impaired subpulmonary ventricular systolic function and/or severe pulmonary regurgitation are at increased risk for adverse cardiac outcomes.

A comparison of MRI and laparoscopy in detecting pelvic structures in cases of vaginal agenesis.

OBJECTIVE: To determine whether laparoscopy improves detection of uterine structures over MRI in cases of vaginal agenesis. DESIGN: Prospective case series. SETTING: Ambulatory pediatric gynecology clinic in a tertiary care children's hospital. PARTICIPANTS: Subjects with vaginal agenesis who had an MRI to detect uterine structures. MAIN OUTCOME MEASURES: A chart review identified subjects with vaginal agenesis who had an MRI to assess müllerian structures. The MRI findings were correlated with physical exam, presenting symptoms, and operative findings. We assessed degree of agreement between laparoscopy and MRI in patients both with and without pelvic pain to determine sensitivity and specificity of MRI in predicting uterine structures confirmed on laparoscopy. RESULTS: Twenty-two subjects with vaginal agenesis were identified and 14 had both an MRI and laparoscopic evaluation. MRI successfully predicted uterine anomalies in six cases (43%) and lack of uterine structures in one case (8%). MRI diagnosis did not correlate with laparoscopic findings in the remaining seven cases (50%). Among subjects presenting with no complaints of pelvic pain (n = 6), three had negative MR imaging but positive laparoscopy. Using laparoscopy as a gold standard, MRI had a sensitivity of 53% for accurately detecting uterine anomalies confirmed on laparoscopy. CONCLUSION: Laparoscopy improves detection of uterine structures over MRI alone in women with vaginal agenesis.