Interdependence of placenta and fetal cardiac development.

The placenta and fetal heart undergo development concurrently during early pregnancy, and, while human studies have reported associations between placental abnormalities and congenital heart disease (CHD), the nature of this relationship remains incompletely understood. Evidence from animal studies suggests a plausible cause and effect connection between placental abnormalities and fetal CHD. Biomechanical models demonstrate the influence of mechanical forces on cardiac development, whereas genetic models highlight the role of confined placental mutations that can cause some forms of CHD. Similar definitive studies in humans are lacking; however, placental pathologies such as maternal and fetal vascular malperfusion and chronic deciduitis are frequently observed in pregnancies complicated by CHD. Moreover, maternal conditions such as diabetes and pre-eclampsia, which affect placental function, are associated with increased risk of CHD in offspring. Bridging the gap between animal models and human studies is crucial to understanding how placental abnormalities may contribute to human fetal CHD. The next steps will require new methodologies and multidisciplinary approaches combining innovative imaging modalities, comprehensive genomic testing, and histopathology. These studies may eventually lead to preventative strategies for some forms of CHD by targeting placental influences on fetal heart development.

Traffic-related air pollution is associated with spontaneous extremely preterm birth and other adverse perinatal outcomes.

BACKGROUND: Although there is growing awareness of the relationship between air pollution and preterm birth, limited data exist regarding the relationship with spontaneous preterm birth and severe neonatal outcomes. OBJECTIVE: This study aimed to examine the association between traffic-associated air pollution exposure in pregnancy and adverse perinatal outcomes including extremes of preterm birth, neonatal intensive care unit admissions, low birthweight, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation. STUDY DESIGN: This was a retrospective cohort study of singleton pregnancies of patients residing in a metropolitan area in the southern United States. Using monitors strategically located across the region, average nitrogen dioxide concentrations were obtained from the Environmental Protection Agency Air Quality System database. For patients living within 10 miles of a monitoring station, average exposure to nitrogen dioxide was estimated for individual patients' pregnancy by trimester. Logistic regression models were used to assess the effect of pollutant exposure on gestational age at birth, indicated vs spontaneous delivery, and neonatal outcomes while adjusting for maternal age, self-reported race, parity, season of conception, diabetes mellitus, body mass index, registered Health Equity Index, and nitrogen dioxide monitor region. Adjusted odds ratios and 95% confidence intervals were calculated for an interquartile increase in average nitrogen dioxide exposure. RESULTS: Between January 1, 2013 and December 31, 2021, 93,164 patients delivered a singleton infant. Of these, 62,189 had measured nitrogen dioxide exposure during the pregnancy from a nearby monitoring station. Higher average nitrogen dioxide exposure throughout pregnancy was significantly associated with preterm birth (adjusted odds ratio, 1.94; 95% confidence interval, 1.77-2.12) and an increase in neonatal intensive care unit admissions, low birthweight infants, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation. This relationship persisted for nulliparous patients and spontaneous preterm birth, and had a greater association with earlier preterm birth. CONCLUSION: In a metropolitan area, increased exposure to the air pollutant nitrogen dioxide in pregnancy was associated with spontaneous preterm birth and had a greater association with extremely preterm birth. A greater association with neonatal intensive care unit admissions, low-birthweight infants, neonatal respiratory diagnosis, neonatal respiratory support, and neonatal sepsis evaluation was found even in term infants.

A comparison of criteria for defining metabolic acidemia in live-born neonates and its effect on predicting serious adverse neonatal outcomes.

BACKGROUND: Metabolic acidemia is a known risk factor for serious adverse neonatal outcomes in both preterm and term infants. OBJECTIVE: This study aimed to evaluate the clinical significance of delivery umbilical cord gas measurements with regard to serious adverse neonatal outcomes, and to determine if distinct thresholds for defining metabolic acidemia differ in their ability to predict such adverse neonatal complications. STUDY DESIGN: This is a retrospective cohort study of singleton live-born deliveries between January 2011 and December 2019. Stratification according to gestational age at birth (≥35 and <35 weeks of gestation) was performed, and comparisons of maternal characteristics, obstetrical complications, intrapartum events, and adverse neonatal outcomes were made between neonates with metabolic acidemia and those without. Metabolic acidemia (based on delivery umbilical cord gas analyses) was defined using both American College of Obstetricians and Gynecologists and Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria. The primary outcome of interest was hypoxic-ischemic encephalopathy requiring whole-body hypothermia. RESULTS: A total of 91,694 neonates born at ≥35 weeks of gestation met the inclusion criteria. By American College of Obstetricians and Gynecologists criteria, 2659 (2.9%) infants had metabolic acidemia. Neonates with metabolic acidemia were at markedly increased risk for neonatal intensive care unit admission, seizures, need for respiratory support, sepsis, and neonatal death. Metabolic acidemia by American College of Obstetricians and Gynecologists criteria was associated with an almost 100-fold increased risk of hypoxic-ischemic encephalopathy requiring whole-body hypothermia (relative risk, 92.69; 95% confidence interval, 64.42-133.35) in neonates born at ≥35 weeks of gestation. Diabetes mellitus, hypertensive disorders of pregnancy, postterm deliveries, prolonged second stages, chorioamnionitis, operative vaginal deliveries, placental abruption and cesarean deliveries were associated with metabolic acidemia in neonates born ≥ 35 weeks of gestation. The highest relative risk was in those diagnosed with placental abruption (relative risk, 9.07; 95% confidence interval, 7.25-11.36). The neonatal cohort born <35 weeks of gestation had similar findings. When comparing those infants born ≥ 35 weeks of gestation with metabolic acidemia by American College of Obstetricians and Gynecologists criteria vs Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria, the Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria identified more neonates at risk for serious adverse neonatal outcomes. In particular, 4.9% more neonates were diagnosed with metabolic acidemia, and 16 more term neonates were identified as requiring whole-body hypothermia. Mean 1-minute and 5-minute Apgar scores were similar and reassuring among neonates born at ≥35 weeks of gestation with and without metabolic acidemia as defined by both American College of Obstetricians and Gynecologists and Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria (8 vs 8 and 9 vs 9, respectively; P<.001). Sensitivity and specificity were 86.7% and 92.2%, respectively, with the Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria, and 74.2% and 97.2% with the American College of Obstetricians and Gynecologists criteria. CONCLUSION: Infants with metabolic acidemia identified on cord gas collection at delivery are at considerably greater risk of serious adverse neonatal outcomes, including an almost 100-fold increased risk of hypoxic-ischemic encephalopathy requiring whole-body hypothermia. Use of the more sensitive Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria for defining metabolic acidemia identifies more neonates born at ≥35 weeks of gestation at risk for adverse neonatal outcomes, including hypoxic-ischemic encephalopathy requiring whole-body hypothermia.

Longitudinal assessment of placental perfusion in normal and hypertensive pregnancies using pseudo-continuous arterial spin-labeled MRI: preliminary experience.

OBJECTIVES: To evaluate longitudinal placental perfusion using pseudo-continuous arterial spin-labeled (pCASL) MRI in normal pregnancies and in pregnancies affected by chronic hypertension (cHTN), who are at the greatest risk for placental-mediated disease conditions. METHODS: Eighteen normal and 23 pregnant subjects with cHTN requiring antihypertensive therapy were scanned at 3 T using free-breathing pCASL-MRI at 16-20 and 24-28 weeks of gestational age. RESULTS: Mean placental perfusion was 103.1 ± 48.0 and 71.4 ± 18.3 mL/100 g/min at 16-20 and 24-28 weeks respectively in normal pregnancies and 79.4 ± 27.4 and 74.9 ± 26.6 mL/100 g/min in cHTN pregnancies. There was a significant decrease in perfusion between the first and second scans in normal pregnancies (p = 0.004), which was not observed in cHTN pregnancies (p = 0.36). The mean perfusion was not statistically different between normal and cHTN pregnancies at both scans, but the absolute change in perfusion per week was statistically different between these groups (p = 0.044). Furthermore, placental perfusion was significantly lower at both time points (p = 0.027 and 0.044 respectively) in the four pregnant subjects with cHTN who went on to have infants that were small for gestational age (52.7 ± 20.4 and 50.4 ± 20.9 mL/100 g/min) versus those who did not (85 ± 25.6 and 80.0 ± 25.1 mL/100 g/min). CONCLUSION: pCASL-MRI enables longitudinal assessment of placental perfusion in pregnant subjects. Placental perfusion in the second trimester declined in normal pregnancies whereas it remained unchanged in cHTN pregnancies, consistent with alterations due to vascular disease pathology. Perfusion was significantly lower in those with small for gestational age infants, indicating that pCASL-MRI-measured perfusion may be an effective imaging biomarker for placental insufficiency. CLINICAL RELEVANCE STATEMENT: pCASL-MRI enables longitudinal assessment of placental perfusion without administering exogenous contrast agent and can identify placental insufficiency in pregnant subjects with chronic hypertension that can lead to earlier interventions. KEY POINTS: • Arterial spin-labeled (ASL) magnetic resonance imaging (MRI) enables longitudinal assessment of placental perfusion without administering exogenous contrast agent. • ASL-MRI-measured placental perfusion decreased significantly between 16-20 week and 24-28 week gestational age in normal pregnancies, while it remained relatively constant in hypertensive pregnancies, attributed to vascular disease pathology. • ASL-MRI-measured placental perfusion was significantly lower in subjects with hypertension who had a small for gestational age infant at 16-20-week gestation, indicating perfusion as an effective biomarker of placental insufficiency.

The Cesarean Scar of Pregnancy: Ultrasound Findings and Expectant Management Outcomes.

OBJECTIVE: The nomenclature has evolved from low implantation to cesarean scar pregnancy (CSP) and criteria are recommended for identification and management. Management guidelines include pregnancy termination due to life-threatening complications. This article applies ultrasound (US) parameters recommended by the Society for Maternal Fetal Medicine (SMFM) in women who were expectantly managed. STUDY DESIGN: Pregnancies were identified between March 1, 2013 and December 31, 2020. Inclusion criteria were women with CSP or low implantation identified on US. Studies were reviewed for niche, smallest myometrial thickness (SMT), and location of basalis blinded to clinical data. Clinical outcomes, pregnancy outcome, need for intervention, hysterectomy, transfusion, pathologic findings, and morbidities were obtained by chart review. RESULTS: Of 101 pregnancies with low implantation, 43 met the SMFM criteria at < 10 weeks and 28 at 10 to 14 weeks. At < 10 weeks, SMFM criteria identified 45out of 76 women; of these 13 required hysterectomy; there were 6 who required hysterectomy but did not meet the SMFM criteria. At 10 to < 14 weeks, SMFM criteria identified 28 out of 42 women; of these 15 required hysterectomy. US parameters yielded significant differences in women requiring hysterectomy, at < 10 weeks and 10 to < 14 weeks' gestational age epochs, but the sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of these US parameters have limitations in identifying invasion to determine management. Of the 101 pregnancies, 46 (46%) failed < 20 weeks, 16 (35%) required medical/surgical management including 6 hysterectomies, and 30 (65%) required no intervention. There were 55 pregnancies (55%) that progressed beyond 20 weeks. Of these, 16 required hysterectomy (29%) while 39 (71%) did not. In the overall cohort of 101, 22 (21.8%) required hysterectomy and an additional16 (15.8%) required some type of intervention, while 66.7% required no intervention. CONCLUSION: SMFM US criteria for CSP have limitations for discerning clinical management due to lack of discriminatory threshold. KEY POINTS: · The SMFM US criteria for CSP at <10 or <14 weeks have limitations for clinical management.. · The sensitivity and specificity of the ultrasound findings limit the utility for management. · The SMT of <1 mm is more discriminating than <3 mm for hysterectomy..

Neuraxial Anesthesia during the COVID-19 Pandemic: Report from a Large Academic Medical Center.

OBJECTIVE: Three primary neuraxial techniques reduce labor pain: epidural, dural puncture epidural (DPE), and combined spinal-epidural (CSE). This study aims to determine whether neuraxial analgesia techniques changed after the onset of the coronavirus disease 2019 (COVID-19) pandemic. Given that a dural puncture confirms neuraxial placement, we hypothesized that DPE was more frequent in women with concerns for COVID-19. STUDY DESIGN: A single-center retrospective cohort study comparing neuraxial analgesia techniques for labor and delivery pain management before and after the onset of the COVID-19 pandemic and in patients with and without SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) at a maternity hospital in Dallas, Texas, with a large delivery service. Statistical analyses included the Chi-square test for categorical and Kruskal-Wallis test for nonparametric ordinal comparisons. The Cochran-Mantel-Haenszel test was used to assess the association between neuraxial technique and accidental dural puncture or postdural puncture headache. RESULTS: Of 10,971 patients who received neuraxial analgesia for labor, 5,528 were delivered in 2019 and 5,443 in 2020. Epidural analgesia was the most common neuraxial technique for labor pain in 2019 and 2020. There was no difference in the frequency of neuraxial analgesia techniques or the rates of accidental dural puncture or postdural puncture headaches comparing all deliveries in 2019 to 2020. Despite a significant increase in DPEs relative to epidurals in the SARS-CoV-2-positive group compared with the SARS-CoV-2-negative group in 2020, there was no significant difference in postdural puncture headaches or accidental dural punctures. CONCLUSION: The advantages of a DPE, specifically the ability to confirm epidural placement using a small gauge spinal needle, likely led to an increase in the placement of this neuraxial in SARS-CoV-2-positive patients. There was no effect on the frequency of postdural puncture headaches or accidental dural punctures within the same period. KEY POINTS: · Epidural analgesia was the most common neuraxial technique for labor pain management.. · Dural puncture epidural placements increased in SARS-CoV-2-positive patients.. · Rates of postdural puncture headaches and accidental dural puncture after neuraxial placement did not change..

Prenatal Ultrasound Findings of Circumvallate Placenta and Pregnancy Outcomes.

OBJECTIVE: Circumvallate placenta has a suggested association with adverse pregnancy outcomes (antenatal bleeding, placental abruption, preterm birth, emergency cesarean, small for gestational age infants, and stillbirth). The aim was to determine if prenatal diagnosis of circumvallate placenta is associated with these adverse pregnancy outcomes. STUDY DESIGN: Pregnancies with a singleton gestation prenatally diagnosed with circumvallate placenta between January 1, 2012 and March 31, 2021 were identified. Adverse pregnancy outcomes were obtained. Rates of adverse pregnancy outcomes were compared among those with prenatally diagnosed circumvallate placentas to those without this prenatal diagnosis with a 4:1 control matched group. Pregnancies with known fetal anomalies or other placental abnormalities were excluded. Statistical analyses included Student's t-test and Χ 2 with p < 0.05 considered significant. RESULTS: Prenatal ultrasound findings of circumvallate placenta were seen in 179 pregnant people (0.20% of all anatomic US studies and 0.17% of all deliveries). Diagnosis was made at a mean gestational age of 19.8 ± 2.4 weeks. Adverse pregnancy outcomes were similar between groups. CONCLUSION: Prenatal ultrasound findings of circumvallate placenta do not correlate with adverse pregnancy outcomes. Given overall good prognosis, prenatal diagnosis of circumvallate placenta may not warrant additional surveillance during pregnancy. KEY POINTS: · The risk of prenatally diagnosed circumvallate placenta was previously unclear.. · Prenatally diagnosed circumvallate placenta is not associated with adverse pregnancy outcomes.. · No change in management may be necessary with prenatally diagnosed circumvallate placenta..

A Prospective Study of Social Needs Associated with Mental Health among Postpartum Patients Living in Underserved Communities.

OBJECTIVE: Given the rising rates of maternal morbidity and mortality in the United States and the contribution of mental illness, especially among individuals living in underresourced communities, the objective was to evaluate the prevalence of unmet health-related social needs and their impact on perinatal mental health outcomes. STUDY DESIGN: This was a prospective observational study of postpartum patients residing within regions with increased rates of poor perinatal outcomes and sociodemographic disparities. Patients were enrolled in a multidisciplinary public health initiative "extending Maternal Care After Pregnancy (eMCAP)" between October 1, 2020 and October 31, 2021. Unmet health-related social needs were assessed at delivery. Symptoms of postpartum depression and anxiety were evaluated at 1 month postpartum utilizing the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder-7 (GAD7) screening tools, respectively. Mean EPDS and GAD7 scores and odds of screening positive (scoring ≥ 10) were compared among individuals with and without unmet health-related social needs with p < 0.05 considered significant. RESULTS: Of participants enrolled in eMCAP, 603 completed at least one EPDS or GAD7 at 1 month. Most had at least one social need, most commonly dependence on social programs for food (n = 413/603; 68%). Individuals lacking transportation to medical (odds ratio [OR]: 4.0, 95% confidence interval [CI]: 1.2-13.32) and nonmedical appointments (OR: 4.17, 95% CI: 1.08-16.03) had significantly higher odds of screening positive on EPDS while participants lacking transportation to medical appointments (OR: 2.73, 95% CI: 0.97-7.70) had significantly higher odds of screening positive on GAD7. CONCLUSION: Among postpartum individuals in underserved communities, social needs correlate with higher depression and anxiety screening scores. This highlights the need to address social needs to improve maternal mental health. KEY POINTS: · Social needs are prevalent among underserved patients.. · Needs can be assessed in a structured or freeform manner.. · Unmet needs correlate with poor mental health outcomes.. · Similar needs correlate with depression and anxiety..

Placental vascular malperfusion lesions in fetal congenital heart disease.

BACKGROUND: Fetuses with congenital heart disease are at increased risk of perinatal morbidity and mortality, which is highly influenced by their prenatal health. Placental function is vital for the health of the fetus, but increased rates of pathologic lesions of the placenta have been observed in pregnancies complicated by fetal congenital heart disease. OBJECTIVE: This study aimed to determine the prevalence of both gross and histologic placental pathologies in a cohort of pregnancies complicated by fetal congenital heart disease vs healthy controls using the Amsterdam Placental Workshop Group Consensus Statement sampling and definitions of placental lesions. STUDY DESIGN: This single-center retrospective cohort study included placental examinations from pregnancies diagnosed prenatally with fetal congenital heart disease between 2010 and 2019; moreover, control placentas were collected from pregnancies without maternal or fetal complications. Placentas were sampled and evaluated according to the Amsterdam Placental Workshop Group Consensus Statement and gross and histopathologic diagnoses determined. RESULTS: Approximately 80% of fetuses diagnosed with congenital heart disease (n=305) had a placental examination for comparison with controls (n=40). Of note, 239 placentas (78%) in the group with fetal congenital heart disease had at least 1 gross or histopathologic lesion compared with 11 placentas (28%) in the control group (P<.01). One-third of placentas complicated by fetal congenital heart disease met the criteria for small for gestational age, and 48% of placentas had one or more chronic lesions, including maternal vascular malperfusion (23% vs 0%; P<.01), villitis of unknown etiology (22% vs 0%; P<.01), fetal vascular malperfusion (20% vs 0%; P<.01), and other chronic lesions (16% vs 0%; P<.01). Acute inflammation was equally present in both the group with fetal congenital heart disease and the control group (28% vs 28%; P=1.00). Although gestational age and birthweight z score were similar between the 2 groups, birth head circumference was 1.5 cm less in pregnancies complicated by fetal congenital heart disease with a significantly lower z score compared with the control group (-0.52±1.22 vs 0.06±0.69; P<.01). CONCLUSION: Vascular malperfusion lesions and chronic forms of inflammation occur at markedly higher rates in placentas complicated by fetal congenital heart disease, which may contribute to the decreased head circumference at birth. Further work in neuroplacentology is needed to explore connections among cardiac defects, placental vascular malperfusion lesions, and fetal brain development.

Neuroplacentology in congenital heart disease: placental connections to neurodevelopmental outcomes.

Children with congenital heart disease (CHD) are living longer due to effective medical and surgical management. However, the majority have neurodevelopmental delays or disorders. The role of the placenta in fetal brain development is unclear and is the focus of an emerging field known as neuroplacentology. In this review, we summarize neurodevelopmental outcomes in CHD and their brain imaging correlates both in utero and postnatally. We review differences in the structure and function of the placenta in pregnancies complicated by fetal CHD and introduce the concept of a placental inefficiency phenotype that occurs in severe forms of fetal CHD, characterized by a myriad of pathologies. We propose that in CHD placental dysfunction contributes to decreased fetal cerebral oxygen delivery resulting in poor brain growth, brain abnormalities, and impaired neurodevelopment. We conclude the review with key areas for future research in neuroplacentology in the fetal CHD population, including (1) differences in structure and function of the CHD placenta, (2) modifiable and nonmodifiable factors that impact the hemodynamic balance between placental and cerebral circulations, (3) interventions to improve placental function and protect brain development in utero, and (4) the role of genetic and epigenetic influences on the placenta-heart-brain connection. IMPACT: Neuroplacentology seeks to understand placental connections to fetal brain development. In fetuses with CHD, brain growth abnormalities begin in utero. Placental microstructure as well as perfusion and function are abnormal in fetal CHD.

Acute Kidney Injury in Pregnancies Complicated by Late-Onset Preeclampsia with Severe Features.

OBJECTIVE: Acute kidney injury (AKI)-complicating pregnancy is used as a marker of severe maternal morbidity (SMM) and frequently associated with obstetric hypertensive disorders. We examined AKI in pregnancies complicated by late-onset preeclampsia with severe features (SPE) using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We compared outcomes of pregnancies with and without AKI and stratified by stage of disease. We further differentiated renal dysfunction at the time of admission and compared outcomes to those who developed AKI after admission. STUDY DESIGN: This was a retrospective cohort study of women with care established before 20 weeks and diagnosed with preeclampsia with severe features with delivery at ≥34 weeks. Women with chronic hypertension or suspected underlying renal dysfunction were excluded. KDIGO criteria were applied to stratify staging of renal disease. Demographics and perinatal outcomes were compared using Chi-square analysis and Wilcoxon's rank-sum test with p < 0.05 considered significant. RESULTS: From January 2015 through December 2019, a total of 3,515 women meeting study criteria were delivered. Of these, 517 (15%) women met KDIGO criteria for AKI at delivery with 248 (48%) having AKI at the time of admission and the remaining 269 (52%) after admission. Stratified by severity, 412 (80%) had stage 1 disease, 89 (17%) had stage II, and 16 (3%) had stage III. Women with AKI had higher rates of cesarean delivery (risk ratio [RR] = 1.3; 95% confidence interval [CI]: 1.17-1.44), postpartum hemorrhage (RR = 1.46; 95% CI: 1.29-1.66), and longer lengths of stay. Other associated outcomes included NICU admission (RR = 1.72; 95% CI: 1.19-2.48), 5-minute Apgar score ≤ 3 (RR = 5.11; 95% CI: 1.98-13.18), and infant length of stay. CONCLUSION: Of women with late preterm SPE, 15% were found to have AKI by KDIGO criteria. The majority (80%) of AKI was stage I disease, and approximately half of the cases were present by the time of admission. KEY POINTS: · AKI was found in 15% of our cohort with 80% stage I disease.. · Half of the cases of AKI were present on admission.. · Few adverse perinatal outcomes are associated with AKI..

The safety of asthma medications during pregnancy and lactation: Clinical management and research priorities.

Asthma is one of the most common underlying diseases in women of reproductive age that can lead to potentially serious medical problems during pregnancy and lactation. A group of key stakeholders across multiple relevant disciplines was invited to take part in an effort to prioritize, strategize, and mobilize action steps to fill important gaps in knowledge regarding asthma medication safety in pregnancy and lactation. The stakeholders identified substantial gaps in the literature on the safety of asthma medications used during pregnancy and lactation and prioritized strategies to fill those gaps. Short-term action steps included linking data from existing complementary study designs (US and international claims data, single drug pregnancy registries, case-control studies, and coordinated systematic data systems). Long-term action steps included creating an asthma disease registry, incorporating the disease registry into electronic health record systems, and coordinating care across disciplines. The stakeholders also prioritized establishing new infrastructures/collaborations to perform research in pregnant and lactating women and to include patient perspectives throughout the process. To address the evidence gaps, and aid in populating product labels with data that inform clinical decision making, the consortium developed a plan to systematically obtain necessary data in the most efficient and timely manner.

Transvaginal Color Mapping Ultrasound in the First Trimester Predicts Placenta Accreta Spectrum: A Retrospective Cohort Study.

OBJECTIVES: Ultrasound (US) prediction of placenta accreta spectrum (PAS) in the first trimester may be aided by postprocessing mechanisms employing color pixel quantification near the bladder-uterine serosal interface. Our objective was to create a postprocessing algorithm of color images to identify findings associated with PAS and compare quantification to sonologist impression in prospectively obtained cine US images. METHODS: Transverse transvaginal (TV) US color cines obtained in the first trimester as part of a prospective study were reviewed. Investigators blinded to clinical outcomes reviewed anonymized cines that were archived and labeled the bladder-uterine serosal interface. Color pixels within 2 cm of the defined bladder-uterine serosal interface were ascertained using a Python-based plugin in the Horos open-source DICOM viewer. A sonologist classified the findings as suspicious for invasion, indeterminate, or normal. Statistical analysis was performed using Wilcoxon rank-sum test, Cochran-Armitage trend test, and calculation of receiver-operating characteristic (ROC) curves. RESULTS: Fifty-four studies met inclusion criteria. Of those, six (11%) required hysterectomy with pathologic confirmation of PAS. Women requiring hysterectomy had a significantly higher color Doppler pixel area than those not requiring hysterectomy (P = .0205). A significant trend was identified in the sonologist impression of invasion (P = .0003). ROC's comparing sonologist impression to Doppler color imaging areas were comparable (P = .054). CONCLUSIONS: Color Doppler mapping in the first trimester showed an increase in color pixel area near the bladder-uterine serosal interface in women requiring cesarean hysterectomy with histologically confirmed PAS at time of delivery, compared to women without hysterectomy or pathologic evidence of PAS.

Predicting Placenta Accreta Spectrum: Validation of the Placenta Accreta Index.

OBJECTIVES: The placenta accreta spectrum (PAS) incidence has risen substantially over the past century, paralleling a rise in cesarean delivery (CD) rates. Prenatal diagnosis of PAS improves maternal outcomes. The Placenta Accreta Index (PAI) is a standardized approach to prenatal diagnosis of PAS incorporating clinical risk and ultrasound (US) findings suggestive of placental invasion. We sought to validate the PAI for prediction of PAS in pregnancies with prior CD. METHODS: This work was a retrospective cohort study of pregnancies with 1 or more prior CDs that received a US diagnosis of placenta previa or low-lying placenta in the third trimester. Images of third-trimester US with a complete placental evaluation were read by 2 blinded physicians, and the PAI was applied. Surgical outcomes and pathologic findings were reviewed. Placenta accreta spectrum was diagnosed if clinical evidence of invasion was seen at time of delivery or if any placental invasion was identified histologically. International Federation of Gynecology and Obstetrics criteria were used. RESULTS: A total of 194 women met inclusion criteria. Cesarean hysterectomy was performed in 92 (47%), CD in 97 (50%), and vaginal delivery in 5 (3%). Of those who underwent hysterectomy, PAS was histologically confirmed in 79 (85%) pregnancies. Of the remaining 13 who underwent hysterectomy, all met International Federation of Gynecology and Obstetrics grade 1 clinical criteria for PAS. With a threshold of greater than 4, the PAI has a sensitivity of 87%, specificity of 77%, positive predictive value of 72%, and negative predictive value of 90% for PAS diagnosis. CONCLUSIONS: Contemporaneous application of the PAI, a standardized approach to US diagnosis, is useful in the prenatal prediction of PAS.

Perinatal Outcomes among Women Identified by a Community Health Needs Assessment.

OBJECTIVE: The aim of the study is to compare perinatal outcomes for women with greater social needs, as identified by the Community Health Needs Assessment, to those of women living in other areas of the county. STUDY DESIGN: This was a retrospective cohort study of pregnant women delivering at a large inner-city county hospital. Perinatal outcomes were analyzed for women living within a target area with substantial health disparities and social needs, and compared with those women living outside the target area. Statistical analysis included student's t-test, Chi square, and logistic regression. RESULTS: Between January 2015 and July 2020, 66,936 women delivered at Parkland hospital. Of these, 7,585 (11%) resided within the target area. These women were younger (26.8 ± 6.5 vs. 27.9 ± 6.4 years, p < 0.001), more likely to be black (37 vs. 13%, p < 0.001), and had a higher body mass index or BMI (33.3 ± 7.0 vs. 32.6 ± 6.4 kg/m2, p < 0.001). All women were likely to access prenatal care, with 7,320 (96.5%) in the target area and 57,677 (97.2%) outside the area attending at least one visit. Adverse perinatal outcomes were increased for women living within the target area, which persisted after adjustment for age, race, and BMI. This included an increased risk of preeclampsia (adjusted risk ratio [aRR] 1.1, 95% confidence interval or CI [1.03, 1.2]) and abruption (aRR 1.3, 95% CI [1.1, 1.7]), as well as preterm birth before both 34 weeks (aRR 1.3, 95% CI [1.2, 1.5]) and 28 weeks (aRR 1.3, 95% CI [1.02,1.7]). It follows that neonatal ICU admission (aRR 2.1, 95% CI [1.3, 3.4]) and neonatal death (aRR 1.2, 95% CI [1.1, 1.3]) were increased within the target area. Interestingly, rate of postpartum visit attendance was higher in the target area (57 vs. 48%), p < 0.001. CONCLUSION: Even among vulnerable populations, women in areas with worse health disparities and social needs are at greater risk of adverse perinatal outcomes. Efforts to achieve health equity will need to address social disparities. KEY POINTS: · At a county hospital, 97% of women accessed prenatal care.. · Greater social needs were associated with adverse perinatal outcomes.. · Differences persisted with adjustment for age, race, and BMI..

Episiotomy: Evolution of a Common Obstetric Practice at a Public Hospital.

OBJECTIVE: This study aimed to evaluate the rate and impact of episiotomy on maternal and newborn outcomes before and after restricted use of episiotomy. STUDY DESIGN: This population-based observational study used an obstetric database of all deliveries since 1990 that has been maintained with quality checks. Inclusion criteria were vaginal deliveries at ≥37 weeks. Exclusion criteria included fetal malformations, multifetal gestations, or fetal deaths known on arrival to Labor and Delivery. The primary outcomes of interest were episiotomy, perineal lacerations, and newborn outcomes. To evaluate the impact of restrictive episiotomy, data from 1990 to 1997 (35% overall episiotomy rate) were compared with data from 2010 to 2017 (2.5% overall episiotomy rate). Univariable analysis of maternal and infant outcomes were performed comparing the two-time epochs with the Pearson's Chi-squared test. RESULTS: Overall, 268,415 women met inclusion criteria and 49,089 (18.2%) had an episiotomy. The rate of episiotomy decreased from 37% of deliveries in 1990 to 2% in 2017. A total of 82,082 deliveries occurred in the 1990 to 1997 epoch and 57,183 in 2010 to 2017. Indicated use of episiotomy was associated with a significant decrease in third and fourth degree lacerations. Immediate newborn condition (5-minute Apgar's score ≤3 and umbilical artery pH <7.1) and neonatal outcomes (intraventricular hemorrhage [IVH] grade 3/4, positive culture sepsis, neonatal seizures, and neonatal demise) were not significantly different. CONCLUSION: Selective, indicated use of episiotomy compared with routine was associated with lower rates of third/fourth-degree lacerations with no change in neonatal outcomes. The common obstetric practice of routinely performing episiotomy, presumably to prevent perineal trauma, proved untrue when analyzed over almost three decades. KEY POINTS: · Episiotomy use decreased overtime at our institution.. · Decreased episiotomy use was associated with significant improvement in maternal outcomes.. · Neonatal outcomes were unchanged suggesting no deleterious effects with restricted episiotomy..

Timing of Emergency Postpartum Hospital Visits in the Fourth Trimester.

OBJECTIVE: The concept of the "fourth trimester" emphasizes the importance of individualized postpartum follow-up. Women seek care for urgent issues during this critical time period. Our objective was to evaluate trends in presenting complaints and admissions in an emergency setting over the first 42 days following delivery. STUDY DESIGN: Postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were studied. Demographic information, delivery route, and emergent hospital encounter details were obtained from the electronic medical record. The postpartum encounters were analyzed by week of presentation. Statistical analysis included Student's t-test and Mantel-Haenszel test with p <0.05 considered significant. RESULTS: Of the 8,589 deliveries, 491 (5.7%) were complicated by an emergent hospital presentation within 42 days of delivery resulting in 576 hospital encounters. 35.9% of these visits occurred in the first week and 75.5% occurred within the first 3 weeks. Women presenting to the hospital were more commonly African American, higher body mass index, and delivered via cesarean. The most common chief complaints were fever, headache, abdominal pain, vaginal bleeding, hypertension, and wound concerns with temporal trends noted. 72% of admissions occur within 14 days of delivery and drop dramatically thereafter (p = 0.001). The most common diagnoses were hypertension/preeclampsia with severe features, vaginal bleeding/delayed postpartum hemorrhage, and wound infection. CONCLUSION: We observed important trends in presenting complaints and admission diagnoses of emergency postpartum visits in the first 42 days. The majority of hospital visits and admissions occur within the first 2 weeks postpartum. Understanding maternal conditions and reasons for accessing care through an emergency setting allows for tailoring of routine postpartum follow-up. KEY POINTS: · Women presenting in the postpartum period most commonly seek care within 3 weeks of delivery.. · Postpartum presentations requiring admission most frequently occur within 2 weeks of delivery.. · The most common diagnoses on presentation were hypentension, vaginal bleeding, and wound infections..

Congenital Malformation Risk According to Hemoglobin A1c Values in a Contemporary Cohort with Pregestational Diabetes.

OBJECTIVE: The study aimed to evaluate the association between hemoglobin A1c values and likelihood of fetal anomalies in women with pregestational diabetes. STUDY DESIGN: Women with pregestational diabetes who delivered at a single institution that serves a nonreferred population from May 1, 2009 to December 31, 2018 were ascertained. Hemoglobin A1c values were obtained at the first prenatal visit. Women who delivered a singleton live- or stillborn infant with a major malformation as defined by European Surveillance of Congenital Anomalies criteria were identified. In infants with multiple system anomalies, each malformation was considered separately. Hemoglobin A1c values were analyzed categorically by using Mantel-Haenszel method and continuously with linear regression for trend for fetal anomalies. RESULTS: A total of 1,676 deliveries to women with pregestational diabetes were delivered at our institution, and hemoglobin A1c was assessed in 1,573 deliveries (94%). There were 129 deliveries of an infant with at least one major malformation, an overall anomaly rate of approximately 8%. Mean hemoglobin A1c concentration was significantly higher in pregnancies with anomalous infants, 9.3 ± 2.1% versus 8.0 ± 2.1%, and p <0.001. There was no difference in gestational age at the time hemoglobin A1c was obtained, 13 ± 8.3 versus 14 ± 8.7 weeks. Hemoglobin A1c was associated with increased probability of a congenital malformation. This reached 10% with a hemoglobin A1c concentration of 10%, and 20% with a hemoglobin A1c of 13%. Similar trends were seen when examining risk of anomalies by organ system with increasing hemoglobin A1c levels, with the greatest increase in probability for both cardiac and genitourinary anomalies. CONCLUSION: In women with pregestational diabetes, hemoglobin A1c is strongly associated with fetal anomaly risk. Data from a contemporary cohort may facilitate counseling and also highlight the need for preconceptual care and glycemic optimization prior to entry to obstetric care. KEY POINTS: · Infants of diabetic mothers had an 8% major anomaly rate.. · HbA1c of 10% in pregnancy associated with 10% anomaly rate.. · HbA1c of 13% in pregnancy associated with 20% anomaly rate.. · Preconceptual care is important to reduce prevalence..

A Gap in Care? Postpartum Women Presenting to the Emergency Room and Getting Readmitted.

OBJECTIVE: Emergent postpartum hospital encounters in the first 42 days after birth are estimated to complicate 5 to 12% of births. Approximately 2% of these visits result in admission. Data on emergent visits and admissions are critically needed to address the current maternal morbidity crisis. Our objective is to characterize trends in emergent postpartum hospital encounters and readmissions through chief complaints and admission diagnoses over a 4.5-year period. STUDY DESIGN: All postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were included. We reviewed demographic information, antepartum, intrapartum, and postpartum care and postpartum hospital encounters. Trends in hospital presentation and admission over the study period were analyzed. Comparisons between women who were admitted to those managed outpatient were performed. Statistical analysis included Chi-square, student's t-test, and Mantel-Haenszel test for trend and ANOVA, as appropriate. A p-value <0.05 considered significant. RESULTS: Among 8,589 deliveries, 491 (5.7%) presented emergently to the hospital within 42 days of delivery, resulting in 576 hospital encounters. From 2015 to 2019, annual rates of presentation were stable, ranging from 5.0 to 6.4% (p = 0.09). Of the 576 hospital encounters, 224 (38.9%) resulted in an admission with increasing rates from 2.0% in 2015 to 3.4% in 2019 (p = 0.005). Primiparous women with higher body mass index, cesarean delivery, and blood loss ≥1, 000 mL during delivery were significantly more likely to be admitted to the hospital. Women with psychiatric illnesses increasingly utilized the emergency room in the postpartum period (6.7-17.2%, p = 0.03). The most common presenting complaints were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and high blood pressure. Admitting diagnoses were predominantly hypertensive disorder (22.9%), wound complications (12.8%), endometritis (9.6%), headache (6.9%), and delayed postpartum hemorrhage (5.6%). CONCLUSION: The average proportion of women presenting for an emergent hospital encounter in the immediate 42-day postpartum period is 5.7%. Nearly 40% of emergent hospital encounters resulted in admission and the rate increased from to 2.0 to 3.4% over the study period. The most common reasons for presentation were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and hypertension. Hypertension, wound complications, and endometritis accounted for the top three admission diagnoses.