Prediction of metabolic syndrome following a first pregnancy.

BACKGROUND: The prevalence of metabolic syndrome is rapidly increasing in the United States. We hypothesized that prediction models using data obtained during pregnancy can accurately predict the future development of metabolic syndrome. OBJECTIVE: This study aimed to develop machine learning models to predict the development of metabolic syndrome using factors ascertained in nulliparous pregnant individuals. STUDY DESIGN: This was a secondary analysis of a prospective cohort study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study [nuMoM2b-HHS]). Data were collected from October 2010 to October 2020, and analyzed from July 2023 to October 2023. Participants had in-person visits 2 to 7 years after their first delivery. The primary outcome was metabolic syndrome, defined by the National Cholesterol Education Program Adult Treatment Panel III criteria, which was measured within 2 to 7 years after delivery. A total of 127 variables that were obtained during pregnancy were evaluated. The data set was randomly split into a training set (70%) and a test set (30%). We developed a random forest model and a lasso regression model using variables obtained during pregnancy. We compared the area under the receiver operating characteristic curve for both models. Using the model with the better area under the receiver operating characteristic curve, we developed models that included fewer variables based on SHAP (SHapley Additive exPlanations) values and compared them with the original model. The final model chosen would have fewer variables and noninferior areas under the receiver operating characteristic curve. RESULTS: A total of 4225 individuals met the inclusion criteria; the mean (standard deviation) age was 27.0 (5.6) years. Of these, 754 (17.8%) developed metabolic syndrome. The area under the receiver operating characteristic curve of the random forest model was 0.878 (95% confidence interval, 0.846-0.909), which was higher than the 0.850 of the lasso model (95% confidence interval, 0.811-0.888; P<.001). Therefore, random forest models using fewer variables were developed. The random forest model with the top 3 variables (high-density lipoprotein, insulin, and high-sensitivity C-reactive protein) was chosen as the final model because it had the area under the receiver operating characteristic curve of 0.867 (95% confidence interval, 0.839-0.895), which was not inferior to the original model (P=.08). The area under the receiver operating characteristic curve of the final model in the test set was 0.847 (95% confidence interval, 0.821-0.873). An online application of the final model was developed (https://kawakita.shinyapps.io/metabolic/). CONCLUSION: We developed a model that can accurately predict the development of metabolic syndrome in 2 to 7 years after delivery.

Point-of-Care Ultrasound in Critical Care Obstetrics: A Scoping Review of the Current Evidence.

OBJECTIVES: To synthesize the current evidence of maternal point-of-care ultrasound (POCUS) in obstetrics. A scoping review was conducted using PubMed, Clinicaltrials.gov, and the Cochrane library from inception through October 2023. METHODS: Studies were eligible for inclusion if they described the use of POCUS among obstetric or postpartum patients. Two authors independently screened all abstracts. Quantitative, qualitative, and mixed-methods studies were eligible for inclusion. Case reports of single cases, review articles, and expert opinion articles were excluded. Studies describing detailed maternal nonobstetric sonograms or maternal first trimester sonograms to confirm viability and rule out ectopic pregnancy were also excluded. Data were tabulated using Microsoft Excel and summarized using a narrative review and descriptive statistics. RESULTS: A total of 689 publications were identified through the search strategy and 12 studies met the inclusion criteria. Nine studies evaluated the use of lung POCUS in obstetrics in different clinical scenarios. Lung ultrasound (LUS) findings in preeclampsia showed an excellent ability to detect pulmonary edema (area under the receiver operating characteristic 0.961) and findings were correlated with clinical evidence of respiratory distress (21 of 57 [37%] versus 14 of 109 [13%]; P = .001). Three studies evaluated abdominal POCUS, two of the inferior vena cava (IVC) to predict postspinal anesthesia hypotension (PSAH) and fluid receptivity and one to assess the rate of ascites in patients with preeclampsia. Patients with PSAH had higher IVC collapsibility (area under the curve = 0.950, P < .001) and, in patients with severe preeclampsia, there is a high rate of ascites (52%) associated with increased risk of adverse outcomes. There were no studies on the use of subjective cardiac POCUS. CONCLUSION: POCUS use in the management of high-risk obstetrics has increased. LUS has been the most studied modality and appears to have a potential role in the setting of preeclampsia complicated by pulmonary edema. Cardiac and abdominal POCUS have not been well studied. Trials are needed to evaluate its clinical applicability, reliability, and technique standardization before widespread use.

Infant Mortality Categorized by Birth Weight Percentiles for Deliveries Between 22 and 28 Weeks of Gestation.

OBJECTIVE: Our objective was to describe infant mortality within 1 year of life according to gestational age and birth weight percentile in infants delivered between 22 and 28 weeks of gestation. STUDY DESIGN: This study was a retrospective cohort study based on publicly available U.S. birth certificate data linked to infant death data between 2014 and 2020. Maternal-neonate pairs of singleton live births between 220/7 and 286/7 weeks' gestation (vaginal or cesarean) were evaluated. We excluded infants with major fetal anomalies, chromosomal disorders, and birth weight outliers. Our primary outcome was infant mortality within 1 year of life. Individuals were categorized into eight sex-specific birth weight percentiles categories: less than the 3rd, 3rd-less than the 10th, 10th-less than the 25th, 25th-to less than the 50th, 50th-less than the 75th, 75th-to less than the 90th, 90th-less than the 97th, and 97th or higher. RESULTS: Of 27,014,444 individuals with live births from January 2014 to December 2020, 151,677 individuals who gave birth at 22 to 28 weeks of gestation were included in the study population. The mortality rate ranged from 4.2% for the 50th-less than the 75th percentiles at 28 weeks to 80.3% for the 3rd-less than the 10th percentile at 22 weeks. Using the 50th-less than the 75th birth weight percentile at each gestational age as a reference group, birth weight less than the 50th percentile was associated with increased mortality at all gestational ages in a dose-dependent manner. From 22 to 25 weeks of gestation, higher birth weight percentiles were associated with lower mortality, while the 97th or higher birth weight percentile was associated with increased mortality compared with the 50th-less than the 75th birth weight percentile at 26 to 28 weeks of gestation. CONCLUSION: The lower birth weight percentiles were associated with higher mortality across all gestational ages, but the association between higher birth weight percentiles and infant mortality exhibited an opposite pattern at 22 to 25 weeks as compared to later gestational age. KEY POINTS: · Birth weight ≥97th percentile was associated with increased infant mortality at 26 to 28 weeks.. · Higher birth weight percentiles were associated with a lower risk of mortality at 22 to 25 weeks.. · Lower birth weight percentiles were associated with a higher risk of mortality at 22 to 28 weeks..

Trial of Labor versus Repeat Cesarean Delivery in Individuals with Morbid Obesity after Previous Cesarean Delivery.

OBJECTIVE: This study aimed to compare adverse neonatal outcomes associated with the trial of labor after cesarean (TOLAC) at term in pregnancies according to maternal prepregnancy body mass index (BMI; kg/m2) and the presence of previous vaginal delivery (VD). STUDY DESIGN: This was a repeated cross-sectional analysis of individuals with singleton, cephalic, and term deliveries with a history of one or two cesarean deliveries in the Linked Birth/Infant Death data from 2011 to 2020. Outcomes were examined according to the BMI category including BMI <30, 30 to 39.9, and 40 to 69.9 kg/m2. The primary outcome was a composite neonatal outcome, defined as any presence of neonatal death, neonatal intensive care unit admission, assisted ventilation, surfactant therapy, or seizures. Outcomes were compared between TOLAC and elective repeat cesarean delivery (eRCD) after stratifying by BMI category and previous VD. Log-binomial regression was performed to obtain adjusted relative risk (aRR) with 99% confidence intervals, controlling for covariates. RESULTS: Of 4,055,440 individuals, 2,627,131 had BMI <30 kg/m2, 1,108,278 had BMI 30 to 39.9 kg/m2, and 320,031 had BMI 40 to 69.9 kg/m2. In individuals with no previous VD, VD rates after TOLAC were 66.7, 57.2, and 48.1%, respectively. In individuals with previous VD, VD rates after TOLAC were 81.4, 74.7, and 67.3%, respectively. In individuals without previous VD, compared with those who had an eRCD, those who had TOLAC were more likely to experience composite neonatal outcomes in individuals with BMI < 30 kg/m2 (5.0 vs. 6.5%; aRR 1.33 [1.30-1.36]), BMI 30 to 39.9 kg/m2 (6.1 vs. 7.8%; aRR 1.29 [1.24-1.34]), and BMI 40 to 69.9 kg/m2 (8.2 vs. 9.0%; aRR 1.15 [1.07-1.23]). In individuals with previous VD, there was no difference in the composite neonatal outcomes in BMI < 30 kg/m2 (6.2 vs. 5.8%; aRR 0.98 [0.96-1.00]), BMI 30 to 39.9 kg/m2 (7.4 vs. 7.1%; aRR 0.99 [0.95-1.02]), and BMI 40 to 69.9 kg/m2 (9.4 vs. 8.7%; aRR 0.96 [0.91-1.02]). CONCLUSION: TOLAC among obese individuals could be offered in selected cases. KEY POINTS: · TOLAC among obese individuals could be offered selectively, despite their reduced likelihood of attempting or succeeding at it.. · Higher BMI individuals show decreased rates of both attempting and achieving successful TOLAC.. · Despite these trends, attempting TOLAC after a previous vaginal delivery does not heighten neonatal complications..

Impact of the ARRIVE Trial in Nulliparous Individuals with Morbid Obesity: Interrupted Time Series Analysis.

OBJECTIVE: We aimed to examine rates of induction of labor at 39 weeks and cesarean delivery before and after the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial stratified by body mass index (BMI; kg/m2) category. STUDY DESIGN: This was a repeated cross-sectional analysis of publicly available U.S. birth certificate data from 2015 to 2021. We limited analyses to nulliparous individuals with a singleton pregnancy, cephalic presentation, without chronic hypertension, diabetes (gestational or pregestational), and fetal anomaly who delivered between 39 and 42 weeks' gestation. The pre-ARRIVE period spanned from August 2016 to July 2018 and the post-ARRIVE period spanned from January 2019 to December 2020. The dissemination period of the ARRIVE trial was from August 2018 to December 2018. Our co-primary outcomes were induction at 39 weeks and cesarean delivery. Our secondary outcomes were overall induction of labor and preeclampsia. We conducted an interrupted time series analysis after stratifying by prepregnancy BMI (<40 or ≥40). Negative binomial regression was used to calculate adjusted incident rate ratios with 95% confidence intervals. RESULTS: Of 2,122,267 individuals that were included, 2,051,050 had BMI <40 and 71,217 had BMI ≥40. In individuals with BMI <40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, a decreased rate of cesarean delivery, and an increased rate of overall induction of labor. In individuals with BMI ≥40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, an increased rate of overall induction of labor and a decreased rate of preeclampsia; however, the decrease in the rate of cesarean delivery was not significant. CONCLUSION: An increase in induction of labor at 39 weeks' gestation in individuals with BMI ≥40 was not associated with a decrease in the cesarean delivery rate. KEY POINTS: · The ARRIVE trial increased 39-week labor inductions in BMI <40 and ≥40.. · BMI <40 had fewer cesareans; BMI ≥40 showed no significant decrease.. · Offering labor induction is reasonable as cesarean rates didn't increase..

Outcomes of Ultrasound or Physical Examination-Indicated Cerclage according to the Degree of Cervical Dilation.

OBJECTIVE: Pregnancy outcomes of individuals receiving cervical cerclage when the cervix is dilated are not well known. We sought to examine preterm birth rates after ultrasound or physical examination-indicated cerclage placement according to the degree of cervical dilation. STUDY DESIGN: This was a retrospective cohort study of individuals with singleton pregnancies undergoing ultrasound or physical examination-indicated cerclage before 240/7 weeks of gestation from 2004 to 2018. Individuals were categorized based on the degree of cervical dilation at the time of cerclage. Our primary outcome was preterm delivery at less than 37 weeks of gestation. Multivariable logistic regression was performed to calculate adjusted odds ratios (aOR) with 95th confidence intervals (95% CI), controlling for predefined covariates. RESULTS: Of 147 individuals undergoing ultrasound or physical examination-indicated cerclage, 90/147 (61%) had a closed or 0.5 cm dilated cervix at the time of cerclage placement, 45/147 (31%) had a cervical dilation of 1 to 2.5 cm, and 12/147 (8%) had a cervical dilation of 3 to 4 cm at the time of placement. Individuals with a cervical dilation of 1 to 2.5 cm compared with those who had a closed cervix did not have increased odds of preterm delivery (58 vs. 42%; aOR: 1.95; 95% CI: 0.93-4.07). However, individuals with a cervical dilation of 3 to 4 cm compared with individuals who had a closed cervix had significantly increased odds of preterm delivery (75 vs. 42%; aOR: 4.33; 95% CI: 1.05-17.77). CONCLUSION: The rate of preterm birth increases with increasing cervical dilation at the time of cerclage placement. However, individuals who have a cerclage placed when the cervix is 1 to 2.5 cm can achieve an outcome that is not significantly different from those who had a cerclage placed when the cervix is closed. KEY POINTS: · Time from cerclage placement to delivery decreases as cervical dilation increases.. · Individuals 1 to 2.5 cm dilated at the time of cerclage can achieve a favorable outcome.. · A cervical dilation of ≥3 cm at cerclage placement was associated with extreme prematurity..

Temporal Trend in Maternal Morbidity and Comorbidity.

OBJECTIVE: This study aimed to examine the temporal trends of severe maternal morbidity (SMM) in the U.S. population in relation to trends in maternal comorbidity. STUDY DESIGN: We performed a repeated cross-sectional analysis of data from individuals at 20 weeks' gestation or greater using U.S. birth certificate data from 2011 to 2021. Our primary outcome was SMM defined as the occurrence of intensive care unit admission, eclampsia, hysterectomy, uterine rupture, and blood product transfusion. We also examined the proportions of maternal comorbidity. Outcomes of the adjusted incidence rate ratio (IRR) with 99% confidence intervals (99% CIs) for 2021 m12 compared with 2011 m1 were calculated using negative binomial regression, controlling for predefined confounders. RESULTS: There were 42,504,125 births included in the analysis. From 2011 m1 to 2021 m12, there was a significant increase in the prevalence of advanced maternal age (35-39 [45%], 40-44 [29%], and ≥45 [43%] years), morbid obesity (body mass index 40-49.9 [66%], 50-59.9 [91%], and 60-69.9 [98%]), previous cesarean delivery (14%), chronic hypertension (104%), pregestational diabetes (64%), pregnancy-associated hypertension (240%), gestational diabetes (74%), and preterm delivery at 34 to 36 weeks (12%). There was a significant decrease in the incidence of multiple gestation (9%), preterm delivery at 22 to 27 weeks (9%), and preterm delivery at 20 to 21 weeks (22%). From 2011 m1 to 2021 m12, the incidence of SMM increased from 0.7 to 1.0% (crude IRR 1.60 [99% CI 1.54-1.66]). However, the trend was no longer statistically significant after controlling for confounders (adjusted IRR 1.01 [95% CI 0.81-1.27]). The main comorbidity that was associated with the increase in SMM was pregnancy-associated hypertension. CONCLUSION: The rise in the prevalence of comorbidity in pregnancy seems to fuel the rise in SMM. Interventions to prevent SMM should include the management and prevention of pregnancy-associated hypertension. KEY POINTS: · The rise in maternal mortality is related to morbidity.. · Pregnancy-associated hypertension increases morbidity.. · There were increasing trends in age, body mass index, and medical conditions..

Buccal Versus Vaginal Misoprostol Combined with a Foley Catheter among Individuals with Obesity Undergoing Induction.

BACKGROUND: Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied. OBJECTIVE: Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population. STUDY DESIGN: This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 µg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m2) was stratified. The primary outcome was time to delivery. RESULTS: A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m2 (vaginal misoprostol-FC: 21.3 hours vs. buccal misoprostol-FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1-1.7). There were no significant differences in maternal and neonatal outcomes. CONCLUSION: We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population. KEY POINTS: · Vaginal misoprostol was superior to buccal route among patients with obesity.. · There was no difference in the cesarean delivery rate between the two groups.. · Vaginal misoprostol should be the preferred route of administration among patients with obesity..

Neonatal Outcomes among Fetuses with an Abdominal Circumference <3rd %ile and Estimated Fetal Weight 3rd to 9th %ile Compared to Fetuses with an EFW <3rd %ile.

OBJECTIVE: Fetal growth restriction (FGR) is defined as an estimated fetal weight (EFW) or abdominal circumference (AC) <10th percentile (%ile) for gestational age (GA). An EFW <3rd %ile for GA is considered severe FGR (sFGR). It remains unknown if fetuses with isolated AC <3rd %ile should be considered sFGR. Our primary objective was to assess composite neonatal outcomes in fetuses with an AC <3rd %ile and overall EFW 3rd to 9th %ile compared with those with an EFW <3rd %ile. STUDY DESIGN: This retrospective cohort study was undertaken at a tertiary academic center from January 2016 to December 2021. Inclusion criteria were singleton fetuses with an EFW <3rd %ile (Group 1) or AC <3rd %ile with EFW 3rd to 9th %ile (Group 2) at 28 weeks' gestation or greater. Exclusion criteria were multiple gestations, presence of a major fetal anomaly, resolution of FGR, genetic syndrome, or infection. Composite neonatal outcome was defined by any of the following: neonatal intensive care unit admission >48 hours, necrotizing enterocolitis, sepsis, respiratory distress syndrome, mechanical ventilation, retinopathy of prematurity, seizures, intraventricular hemorrhage, stillbirth, or death before discharge. Small for gestational age (SGA) was defined as birth weight <10th %ile for GA. RESULTS: A total of 743 patients fulfilled our study criteria, with 489 in Group 1 and 254 in Group 2. The composite neonatal outcome occurred in 281 (57.5%) neonates in Group 1 and 53 (20.9%) in Group 2 (p < 0.01). The rates of SGA at birth were 94.9 and 75.6% for Group 1 and Group 2, respectively (OR 5.99, 95% confidence interval 3.65-9.82). CONCLUSION: Although AC <3rd %ile with EFW 3rd to 9th %ile is associated with a lower frequency of SGA and neonatal morbidity than EFW <3 %ile, fetuses with AC <3 %ile still exhibited moderate rates of these adverse perinatal outcomes. Consideration should be given to inclusion of an AC <3rd %ile with EFW 3rd to 9th %ile as a criterion for sFGR. However, prospective studies comparing delivery at 37 versus 38 to 39 weeks' gestation are needed to ensure improved outcomes before widespread adaptation in clinical practice. KEY POINTS: · The composite neonatal outcome occurred in 57.5% of fetuses with an overall EFW <3rd %ile and 20.9% of fetuses with an AC <3rd %ile but EFW 3rd to 9th %ile.. · Both groups demonstrated a high positive predictive value for SGA birth weight.. · Consideration should be given to inclusion of an AC <3rd %ile as a criterion for sFGR..

Factors Associated with Refractory Severe Hypertension in Patients with Preeclampsia.

OBJECTIVE: This study aimed to identify factors associated with refractory severe hypertension that does not resolve after an initial dose of antihypertensive medication in patients with preeclampsia. STUDY DESIGN: This was a retrospective study of all pregnant and postpartum individuals with a diagnosis of preeclampsia, superimposed preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome, or eclampsia who delivered at 22 weeks or greater at a single academic institution from 2010 to 2020. Inclusion criteria were patients with preeclampsia who developed severe hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥110 mm Hg) and received antihypertensive medications for acute severe hypertension. We defined refractory severe hypertension as a systolic blood pressure of ≥160 mm Hg or a diastolic blood pressure of ≥110 mm Hg that did not improve after receiving the initial treatment. To evaluate for factors associated with refractory severe hypertension, we developed multivariable modified Poisson regression using all variables with p-value <0.1 on bivariable analysis and calculated adjusted relative risks (aRRs) with 95% confidence intervals (95% CIs). RESULTS: Of 850, 386 (45.4%) had refractory severe hypertension and 464 (54.6%) responded to the initial antihypertensive medications. Factors associated with refractory severe hypertension included higher body mass index (BMI), chronic hypertension, and higher systolic pressure. Every 5 kg/m2 increase in BMI was associated with a 7% increased risk of refractory severe hypertension (aRR = 1.07; 95% CI: 1.02-1.12). Every 10 mm Hg increase in systolic blood pressure was associated with a 10% increased risk of refractory severe hypertension (aRR = 1.10; 95% CI: 1.04-1.17). Chronic hypertension was associated with a 25% increased risk of refractory severe hypertension (aRR = 1.25; 95% CI: 1.01-1.56) in the diastolic pressure model. CONCLUSION: Refractory severe hypertension was associated with elevated BMI, chronic hypertension, and higher systolic blood pressure. KEY POINTS: · Risk factors for refractory severe hypertension are not well-known.. · Almost half of the patients had refractory severe hypertension.. · Higher BMI, chronic hypertension, and higher systolic pressure were the risk factors.. · These patients would require closer follow-up and prompt response to vital signs..

Cost-effectiveness of history-indicated cerclage vs cervical length assessment for prevention of preterm birth.

BACKGROUND: Preterm birth is one of the major causes of neonatal morbidity and mortality. Preterm delivery is a large burden to our health care system, and a history of preterm birth is one of the most common risk factors for subsequent preterm birth. OBJECTIVE: We sought to examine the cost-effectiveness of the history-indicated cerclage strategy compared with the transvaginal ultrasound cervical length assessment strategy in individuals with a history of preterm birth. STUDY DESIGN: We developed a decision analysis model to compare history-indicated cerclage and cervical length assessment. The primary outcome was the net monetary benefit from a maternal and neonatal perspective of both strategies, defined as the value of an intervention with a known willingness to pay threshold for a unit of benefit. The time horizon was set to be a lifetime. Costs (in 2022 USD) included those for the cerclage, serial transvaginal ultrasounds, maternal care for admission, neonatal care, and severe disability. Probabilities, utilities, and costs were derived from the literature. A cost-effectiveness threshold was set at $100,000 per QALY (quality-adjusted life year). We first conducted 1-way sensitivity analyses with associated variables as sensitivity analyses. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation with 1000 trials to test the robustness of the results in the setting of simultaneous changes in probabilities, costs, and utilities. RESULTS: In our base-case analysis, the history-indicated cerclage strategy compared to transvaginal ultrasound cervical length assessment was associated with more cost ($85,038 vs $70,155), with slightly less effectiveness from the maternal perspective (26.74 QALY vs 26.78 QALY) and from the neonatal perspective (28.91 QALY vs 29.06 QALY), and with less maternal and neonatal net monetary benefit. Therefore, the history-indicated cerclage strategy was dominated. With the 1000 trials of Monte Carlo simulation, transvaginal ultrasound cervical length assessment was the preferred strategy 84% and 88% of the time from the maternal and neonatal perspectives, respectively. CONCLUSION: The history-indicated cerclage strategy was more expensive and slightly less effective than the transvaginal ultrasound cervical length assessment strategy with a lower net monetary benefit.

Longitudinal Ultrasound Evaluation of Dilapan-S During Cervical Ripening.

OBJECTIVE: To assess the diameter change of hygroscopic rod dilation during 12 hours of cervical ripening. METHODS: This was an observational, prospective study of term women undergoing labor induction with a bishop score ≤ 6. Women were allocated into two groups (soaked gauze or no gauze) stratified by parity. Using transvaginal ultrasound, maximal rod diameters were obtained in a longitudinal plane. Measurements were taken at four pre-specified time points (3, 6, 8, and 12 hours). All rods were removed at 12 hours from insertion. Patient satisfaction scores between the groups were assessed. To evaluate if measures were significantly different among the four time points, a generalized linear model was used. Independent t-tests were used to compare mean rod diameter values and pain measures between the two groups. Fisher Exact tests were used to evaluate categorical satisfaction measures. RESULTS: Forty-four women were recruited with a total of 178 hygroscopic rods placed. Mean rod diameters (mm) were significantly different among the four time periods (3 hour: 7.9 mm [SD 0.9]; 6 hour: 9.4 mm [SD 0.9]; 8 hour: 10.0 mm [SD 0.9]; 12 hour: 10.9 mm [SD 0.8]; P-value <.001). After stratifying by the use of gauze, there was no difference in rod diameters at 3, 6, 8, and 12 hours respectively. There was no difference in patient satisfaction scores between the two groups. CONCLUSION: The majority of hygroscopic rod dilation occurs within the first 8 hours of cervical ripening. Placement of saturated gauze does not accelerate rod dilation.

An Externally Validated Model to Predict Prolonged Induction of Labor with an Unfavorable Cervix.

OBJECTIVE: To develop and externally validate a prediction model to calculate the likelihood of prolonged induction of labor (induction start to delivery time > 36 hours). STUDY DESIGN: This was a retrospective cohort study of all nulliparous women with singleton pregnancies and vertex presentation at term who underwent induction of labor and had a vaginal delivery at a single academic center. Women with contraindications for vaginal delivery were excluded. Analyses were limited to women with unfavorable cervix (both simplified Bishop score [dilation, station, and effacement: range 0-9] <6 and cervical dilation <3 cm). Prolonged induction of labor was defined as the duration of induction (induction start time to delivery) longer than 36 hours. A backward stepwise logistic regression analysis was used to identify the factors associated with prolonged induction of labor by considering maternal characteristics and comorbidities as well as fetal conditions. The final model was validated using an external dataset of the Consortium on Safe Labor after applying the same inclusion and exclusion criteria. We developed a receiver observer characteristic curve with area under the curve (AUC) in validation cohorts. RESULTS: Of 2,118 women, 364 (17%) had prolonged induction of labor. Factors associated with prolonged induction of labor included body mass index at admission, hypertension, fetal conditions, and epidural. Factors including younger maternal age, prelabor rupture of membranes, and a more favorable simplified Bishop score were associated with a decreased likelihood of prolonged induction of labor. In the external validation cohort, 4,418 women were analyzed, of whom 188 (4%) had prolonged induction of labor. The AUC of the final model was 0.76 (95% confidence interval: 0.73-0.80) for the external validation cohort. The online calculator was created and is available at: https://medstarapps.org/obstetricriskcalculator. CONCLUSION: Our externally validated model was efficient in predicting prolonged induction of labor with an unfavorable cervix. KEY POINTS: · The number of inductions of labor at 39 weeks' gestation and beyond has been increasing.. · Our model had a good prediction of prolonged induction of labor.. · An online calculator has been created and available..

Prediction of Postoperative Day 1 Hemoglobin Level after Cesarean Delivery.

OBJECTIVE: To create a prediction model for postoperative hemoglobin levels after cesarean delivery, which could reduce routine use of postoperative laboratory test. STUDY DESIGN: This was a secondary analysis of a retrospective cohort study of all women who underwent cesarean delivery (primary or repeat) at or more than 23 weeks' gestation at a single academic center. The cohort was randomly divided into a training cohort to develop a prediction model and a validation cohort to test the model in a 2:1 ratio. Variables with p-value <0.10 were considered for the mixed multivariable linear regression model in a backward stepwise fashion. We obtained the best cut-off point of the predicted hemoglobin level to detect severe anemia (postoperative hemoglobin level less than 7.0 g/dL) in the training cohort. A receiver operating characteristic curve with the area under a curve was created. We calculated the sensitivity and specificity of the model in the validation cohort using the best cut-off point obtained in the training cohort as well as postoperative hemoglobin of 10.0 g/dL. RESULTS: Of 2,930 women, 1,954 (66.6%) and 976 (33.3%) were randomly allocated to training and validation cohorts. The final model included preoperative hemoglobin level, preoperative platelet level, quantitative blood loss, height, weight, magnesium administration, labor, and general anesthesia. The best cut-off to predict severe anemia was predicted hemoglobin level of 8.57 g/dL in the training cohort. Using this cut-off, the sensitivity and specificity in the validation cohort were 77% (95% confidence interval [CI]: 56-91%) and 87% (95% CI: 85-89%), respectively. The use of postpartum hemorrhage yielded the sensitivity of 58% (95% CI: 37-77%) and specificity 79% (95% CI: 76-81%), respectively. CONCLUSION: We developed a validated model to predict the postoperative day 1 hemoglobin levels after cesarean delivery that could assist with identifying women who may not need postoperative laboratory tests. KEY POINTS: · Postoperative laboratory tests are routine.. · A prediction model may allow reduce routine tests.. · We developed an accurate mathematical model..

Term Neonatal Outcomes after Maternal Magnesium Sulfate Treatment for Seizure Prophylaxis.

OBJECTIVE: This study aimed to evaluate term neonatal outcomes after maternal magnesium sulfate (MgSO4) treatment for seizure prophylaxis. STUDY DESIGN: This was a single-site retrospective cohort study of all women with term singleton gestation requiring MgSO4 treatment for seizure prophylaxis and their respective neonatal outcomes from January 2013 through December 2020. Our primary outcome was neonatal intensive care unit (NICU) admission. We compared outcomes between women treated with MgSO4 for 24 hours or more and women treated with MgSO4 for less than 24 hours prior to delivery. Multivariable logistic regression was performed to calculate adjusted odds ratio (aOR) and 95% confidence interval (95% CI), controlling for variables with a p < 0.05 based on bivariable analysis. RESULTS: Of 834 women analyzed, 173 (20.7%) neonates were admitted to the NICU. Women treated with MgSO4 for 24 hours or more compared with women treated with MgSO4 for less than 24 hours were more likely to have neonates admitted to the NICU during their hospitalization (27.3 vs. 18.9%; p = 0.01), neonates requiring immediate NICU admission (24.6 vs. 18.3%; p < 0.01), and NICU admission for neonatal lethargy. After adjusting for covariates, only NICU admission due to neonatal lethargy remained statistically significant (aOR: 4.78 [95% CI: 1.50-15.21]). CONCLUSION: Prolonged MgSO4 treatment for 24 hours or more was associated with increased odds of term NICU admission due to neonatal lethargy. KEY POINTS: · NICU admission rose with longer magnesium treatment.. · Nulliparous patients had more magnesium sulfate exposure.. · Obese patients had longer magnesium sulfate exposure..

Pregnancy Outcomes in Women with Arrhythmias following Surgical Repair of Cardiac Defects.

OBJECTIVE: The goal of this study was to investigate whether preexisting cardiac arrhythmias are associated with adverse obstetrical outcomes in women with a history of open cardiac surgery. STUDY DESIGN: This was a retrospective cohort study of women with a history of open cardiac surgery who delivered at MedStar Washington Hospital Center (Washington, DC) from January 2007 through December 2018. Women with the isolated percutaneous cardiac surgical repair were excluded. Maternal and neonatal outcomes were compared between patients with preexisting cardiac arrhythmias and patients without preexisting cardiac arrhythmias. Maternal outcomes studied were intensive care unit admission, postpartum blood loss greater than 1,000 mL, congestive heart failure development, preeclampsia with severe features, postpartum readmission, postpartum cardiac events, and postpartum length of stay >5 days. Neonatal outcomes investigated were low birth weight <2,500 g, Apgar's scores <7 at 5 minutes, and neonatal intensive care unit admission. Multivariate logistic regression model was used to calculate the adjusted odds ratio (aOR) and 95% confidence intervals. RESULTS: The outcomes for 69 deliveries from 56 women with a history of open cardiac surgery were examined. Thirty-three women (48%) had arrhythmias after cardiac surgery with fourteen (20%) requiring implantable cardioverted defibrillators. Two women (6%) with preexisting arrhythmias after cardiac surgery developed postpartum volume overload requiring readmission (p = 0.06). After controlling for age, gestational age at delivery, and BMI, preeclampsia with severe features (p = 0.02) and low birth weight neonates (p = 0.02, aOR = 2.26 [0.56-9.03]) remained statistically more like to occur in patients with preexisting cardiac arrhythmias than in patients without preexisting arrhythmias. CONCLUSION: Women with a history of open cardiac surgery and preexisting cardiac arrhythmias prior to pregnancy are more likely to develop preeclampsia with severe features and have low birth weight neonates compared with women with a history of open cardiac surgery without preexisting cardiac arrhythmias. KEY POINTS: · Preexisting arrhythmias after cardiac surgery was associated with a risk of preeclampsia.. · Neonates of women with preexisting cardiac arrhythmias are more likely to be low birth weight.. · Forty-seven percent of women with open cardiac surgery developed subsequent arrhythmias..

The Association between Fetal Growth Restriction and Maternal Morbidity.

OBJECTIVE: This study aimed to compare adverse maternal outcomes between pregnancies complicated by fetal growth restriction (FGR) and those without FGR. STUDY DESIGN: This was a secondary analysis of the data from the Consortium on Safe Labor, which was conducted from 2002 to 2008 in 12 clinical centers with 19 hospitals across 9 American College of Obstetricians and Gynecologists districts. We included singleton pregnancies without any maternal comorbidities or placenta abnormalities. We compared the outcomes of individuals with FGR with individuals without FGR. Our primary outcome was severe maternal morbidity. Our secondary outcome included various adverse maternal and neonatal outcomes. Multivariable logistic regression was performed to obtain adjusted odds ratios (aOR) and 95% confidence intervals (95% CI), adjusting for confounders. Missing values for maternal age and body mass index were imputed. RESULTS: Of 199,611 individuals, 4,554 (2.3%) had FGR and 195,057 (97.7%) did not have FGR. Compared with the individuals without FGR, individuals with FGR had increased odds of severe maternal morbidity (0.6 vs. 1.3%; aOR: 1.97 [95% CI: 1.51-2.57]), cesarean delivery (27.7 vs. 41.2%; aOR: 2.31 [95% CI: 2.16-2.48]), pregnancy-associated hypertension (8.3 vs. 19.2%; aOR: 2.76 [95% CI: 2.55-2.99]), preeclampsia without severe features (3.2 vs. 4.7%; aOR: 1.45 [95% CI: 1.26-1.68]), preeclampsia with severe features (1.4 vs. 8.6%; aOR: 6.04 [95% CI: 5.39-6.76]), superimposed preeclampsia (18.3 vs. 30.2%; aOR: 1.99 [95% CI: 1.53-2.59]), neonatal intensive care unit admission (9.7 vs. 28.4%; aOR: 3.53 [95% CI: 3.28-3.8]), respiratory distress syndrome (2.2 vs. 7.7%; aOR: 3.57 [95% CI: 3.15-4.04]), transient tachypnea of the newborn (3.3 vs. 5.4%; aOR: 1.62 [95% CI: 1.40-1.87]), and neonatal sepsis (2.1 vs. 5.5%; aOR: 2.43 [95% CI: 2.10-2.80]). CONCLUSION: FGR was associated with increased odds of severe maternal outcomes in addition to adverse neonatal outcomes. KEY POINTS: · FGR is associated with cesarean section.. · FGR is not associated with severe maternal morbidity.. · FGR is related to pregnancy-associated hypertension.. · FGR is associated with neonatal morbidity..

Effect of Calcium Channel Blocker on Labor Curve in Pregnant Individuals with Chronic Hypertension.

OBJECTIVE: This study aimed to compare the labor progress between individuals who received calcium channel blocker (CCB) and those who did not receive CCB during labor. STUDY DESIGN: This was a secondary analysis of a retrospective cohort study of individuals with chronic hypertension who underwent vaginal delivery at a tertiary care center from January 2010 to December 2020. We excluded individuals with prior uterine surgeries and a 5-minute Apgar score of less than 5. We used a repeated-measures regression with a third-order polynomial function to compare the average labor curves according to antihypertensive medication. Estimates of the median (5th-95th percentile) traverse times between two dilations were computed using interval-censored regression. RESULTS: Of 285 individuals with chronic hypertension, 88 (30.9%) received CCB. Individuals who received CCB during labor compared with those who did not were more likely to deliver at earlier gestational age and to have pregestational diabetes and superimposed preeclampsia (p < 0.01). The progress of labor in the latent phase was not found to be significantly different between both groups (median: 11.51 vs. 8.74 hours; p = 0.08). However, after stratification by parity, nulliparous individuals who received CCB during labor were more likely to have a longer latent phase of labor (median: 14.4 vs. 8.5 hours; p = 0.03) CONCLUSION: A calcium channel blocker may slow the latent phase of labor in individuals with chronic hypertension. Aiming to minimize intrapartum iatrogenic interventions, allowing adequate time for pregnant individuals during the latent phase of labor is especially important if individuals are on a calcium channel blocker. KEY POINTS: · Calcium channel blockers seem to be associated with a longer latent phase of labor.. · The effect of calcium channel blocker on labor was not observed in multiparous individuals.. · Allowing adequate labor time for individuals taking calcium channel blocker is important..

Comparison of Adverse Maternal Outcomes between Early- and Late-Onset Superimposed Preeclampsia.

OBJECTIVE: Superimposed preeclampsia (SIPE), defined as preeclampsia in individuals with chronic hypertension, is one of the most common complications, accounting for 13 to 40% of pregnancies with chronic hypertension. However, there are limited data regarding maternal outcomes of early- and late-onset SIPE in individuals with chronic hypertension. We hypothesized that early-onset SIPE was associated with increased odds of adverse maternal outcomes compared with late-onset SIPE. Therefore, we aimed to compare adverse maternal outcomes between individuals with early-onset SIPE and those with late-onset SIPE. STUDY DESIGN: This was a retrospective cohort study of pregnant individuals with SIPE who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as the onset of SIPE before 34 weeks' gestation. Late-onset SIPE was defined as the onset of SIPE at or after 34 weeks' gestation. Our primary outcome was a composite of eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, maternal death, placental abruption, pulmonary edema, SIPE with severe features, and thromboembolic disease. Maternal outcomes were compared between early- and late-onset SIPE. We used simple and multivariate logistic regression models to calculate crude and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Of 311 individuals, 157 (50.5%) had early-onset SIPE, 154 (49.5%) had late-onset SIPE. There were significant differences in the proportions of obstetric complications, including the primary outcome, HELLP syndrome, SIPE with severe features, fetal growth restriction (FGR), and cesarean delivery between early- and late-onset SIPE. Compared with individuals with late-onset SIPE, those with early-onset SIPE had increased odds of the primary outcome (aOR: 3.28; 95% CI: 1.42-7.59), SIPE with severe features (aOR: 2.72; 95% CI: 1.25-5.90), FGR (aOR: 6.07; 95% CI: 3.25-11.36), and cesarean delivery (aOR 3.42; 95% CI: 2.03-5.75). CONCLUSION: Individuals with early-onset SIPE had higher odds of adverse maternal outcomes compared with those with late-onset SIPE. KEY POINTS: · We revealed the incidence of maternal outcomes in early- and late-onset SIPE.. · Severe features were common in individuals with SIPE.. · Early-onset SIPE was associated with increased adverse maternal outcomes compared with late-onset SIPE..

Risk Factors for Early- and Late-Onset Superimposed Preeclampsia.

OBJECTIVE: Risk factors of early- and late-onset preeclampsia among pregnant individuals with chronic hypertension are not well described in the literature. We hypothesized that early- and late-onset superimposed preeclampsia (SIPE) have different risk factors. Therefore, we aimed to examine the risk factors of early- and late-onset SIPE among individuals with chronic hypertension. STUDY DESIGN: This was a retrospective case-control study of pregnant individuals with chronic hypertension who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as SIPE diagnosed before 34 weeks' gestation. To identify risk factors, we compared individuals' characteristics between individuals who developed early- and late-onset SIPE and those who did not. We then compared characteristics between individuals who developed early-onset SIPE and late-onset SIPE. Characteristics with p-values of less than 0.05 by bivariable variables were analyzed by simple and multivariable logistic regression models to calculate crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Missing values were imputed with multiple imputation. RESULTS: Of 839 individuals, 156 (18.6%) had early-onset, 154 (18.4%) had late-onset SIPE and 529 (63.1%) did not have SIPE. The multivariate logistic regression model showed that serum creatinine ≥ 0.7 mg/dL compared to less than 0.7 mg/dL (aOR: 2.89 [95% CI: 1.63-5.13]), increase of creatinine (1.33 [1.16-1.53]), nulliparity compared to multiparity (1.77 [1.21-2.60]), and pregestational diabetes (1.70 [1.11-2.62]) were risk factors for early-onset SIPE. The multivariate logistic regression model showed that nulliparity compared to multiparity (1.53 [1.05-2.22]) and pregestational diabetes (1.74 [1.14-2.64]) was a risk factor for late-onset SIPE. Serum creatinine ≥ 0.7 mg/dL (2.90 [1.36-6.15]) and increase of creatinine (1.33 [1.10-1.60]) were significantly associated with early-onset SIPE compared to late-onset SIPE. CONCLUSION: Kidney dysfunction seemed to be associated with the pathophysiology of early-onset SIPE. Nulliparity and pregestational diabetes were common risk factors for both early- and late-onset SIPE. KEY POINTS: · Serum creatinine level was positively associated with early-onset superimposed preeclampsia (SIPE).. · Pregestational diabetes and nulliparity were associated with both early- and late-onset SIPE.. · The identification of risk factors may provide an opportunity to decrease the rates of SIPE..