Factors Associated With Persistent Bothersome Urinary Symptoms and Leakage After Pregnancy.

IMPORTANCE: Urinary incontinence is a common postpartum morbidity that negatively affects quality of life. OBJECTIVE: This study aimed to identify factors associated with persistent (ie, 12 months postpartum) bothersome urinary symptoms, including stress urinary incontinence (SUI) and urgency urinary incontinence (UUI), and explore their association with mental health in medically underserved communities. STUDY DESIGN: This was a cross-sectional analysis of a prospective study of individuals enrolled into "extending Maternal Care After Pregnancy," a program providing 12 months of postpartum care to individuals with health disparities. Patients were screened at 12 months for urinary dysfunction, anxiety, and depression using the Urinary Distress Index-6, Generalized Anxiety Disorder-7, and Edinburgh Postnatal Depression Scale, respectively. Bivariate and multivariable logistic regression analyses were performed for at-least-somewhat-bothersome SUI versus no-SUI, UUI versus no-UUI, and for bothersome versus asymptomatic urinary symptoms, using demographic and peripartum and postpartum variables as associated factors. RESULTS: Four hundred nineteen patients provided data at median 12 months postpartum. Patients were 77% Hispanic White and 22% non-Hispanic Black. After multivariable analysis, SUI (n = 136, 32.5%) was significantly associated with increasing body mass index at the time of delivery and greater depression screening scores. Fetal birthweight, mode of delivery, degree of laceration, and breastfeeding status were not associated. Urgency urinary incontinence (n = 69, 16.5%) was significantly associated with increasing parity and higher anxiety screening scores. Similarly, participants with urinary symptom bother had significantly greater parity and higher anxiety screening scores. CONCLUSIONS: At 12 months postpartum, bothersome urinary symptoms and incontinence were quite common. Since these are treatable, postpartum screening for urinary complaints-and associated anxiety and depression-is essential, as is assisting patients in achieving a healthy weight.

Area Deprivation and Postpartum Readmission Facility Location and Timing.

This cohort study evaluates the role that community-level socioeconomic status plays in hypertension-related hospital readmission within 12 weeks after delivery.

A personalized protocol for prescribing opioids after cesarean delivery: leveraging the electronic medical record to reduce outpatient opioid prescriptions.

BACKGROUND: Although cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have mostly focused on the immediate postpartum period when patients are still admitted to the hospital. At discharge, most providers prescribe a fixed number of opioid tablets. Most patients do not use all the opioids that they are prescribed at hospital discharge. This leads to an excess of opioids in the community, which can ultimately lead to misuse and diversion. OBJECTIVE: This study aimed to determine whether a transition from universal opioid prescribing to a personalized, patient-specific protocol decreases morphine milligram equivalents prescribed at hospital discharge after cesarean delivery while adequately controlling pain. STUDY DESIGN: This was a prospective cohort study of patients undergoing cesarean delivery before and after the implementation of a personalized opioid-prescribing practice at the time of hospital discharge. Each patient was prescribed scheduled ibuprofen and acetaminophen, with a prescription for oxycodone tablets equal to 5 times the morphine milligram equivalents used in the 24 hours before discharge, calculated via an electronic order set. The previous traditional cohorts were routinely prescribed 30 tablets of acetaminophen-codeine 300/30 mg. The primary outcome was morphine milligram equivalents prescribed at discharge. A hotline to address pain control issues after discharge was established, and calls, emergency department visits, and readmissions were examined. Statistical analyses was performed using chi-square and Wilcoxon rank-sum test, with a P value of <.05 considered statistically significant. RESULTS: Overall, 412 patients underwent cesarean delivery in the 6 weeks after initiation of the personalized prescribing protocol and were compared with 367 patients before the change. The median morphine milligram equivalents prescribed at discharge was lower with personalized prescribing (37.5 [interquartile range, 0-75] vs 135 [interquartile range, 135-135]; P<.001). Moreover, 176 patients (43%) were not prescribed opioids at discharge, which was a substantial change as all 367 patients in the traditional cohort received opioids at discharge (P<.001). Of note, 9 hotline phone calls were received; none required additional opioids after a 24-hour trial of scheduled ibuprofen, which none had taken before the call. In addition, 11 patients (2.7%) presented to the emergency department for pain evaluation, of which none required readmission or an outpatient prescription of opioids. CONCLUSION: A personalized protocol for opioid prescriptions after cesarean delivery decreased the total morphine milligram equivalents and the number of opioid tablets at discharge, without hospital readmissions or need for rescue opioid prescriptions after discharge. Opioids released into our community will be reduced by more than 90,000 tablets per year, without demonstrable adverse effect.

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People.

Importance: Postpartum transfusion is the most common indicator of severe maternal morbidity in the US. Higher rates of anemia are associated with a higher blood transfusion rate. Objective: To determine if providing, rather than recommending, supplements with iron at prenatal visits in a medically underserved community is associated with improved hematologic indices and reduced blood transfusion. Design, Setting, and Participants: In this quality improvement study, patients who delivered between May 13 and December 13, 2020, and thus were provided a prenatal supplement with iron throughout pregnancy were compared with those who delivered between January 1 and August 1, 2019, before supplements were dispensed. The study was conducted at Parkland Health, a safety net hospital in Dallas, Texas, with a 95% Medicaid-funded or self-pay population and included all patients who delivered at our institution during the study period with available hematologic data. Exposures: In the earlier cohort, all patients were recommended to obtain and take iron supplements. In the later cohort, prenatal supplements with iron were dispensed via clinic pharmacy to all patients during prenatal visits. Main Outcomes and Measures: Maternal hematocrit levels (28-32 weeks, delivery admission, and discharge), rates of anemia (hematocrit <30%), and postpartum transfusion for acute blood loss anemia were compared using χ2 and analysis of variance methods with P < .05 considered significant. The analysis took place in July of 2022. Results: Overall, 13 910 patients (98%) met inclusion criteria (mean age [SD], 27.9 [6.5] and 27.6 [6.5] years, mean [SD] body mass index at first visit, 29.2 [6.6] and 29.3 [6.6]). Mosty of the patients in both cohorts were of Hispanic ethnicity (76%). Providing iron-containing prenatal supplements was associated with higher average hematocrit levels at all time points including a mean difference of 1.27% (95% CI, 1.13%-1.42%) on admission for delivery, when compared with those who were not directly dispensed iron. Among patients prior to providing supplements, 18% had anemia on admission compared with 11% with iron-containing supplements dispensed (risk ratio [RR], 0.61; 95% CI, 0.56-0.66). Postpartum transfusion for acute blood loss anemia was reduced by one-third in patients after program implementation from 10 per 1000 to 6.6 per 1000 (RR, 0.62; 95% CI, 0.43-0.91). Conclusions and Relevance: In this quality improvement study, providing supplements with iron to patients at prenatal visits was associated with improved hematocrit levels, rates of anemia, and reduced transfusions unrelated to obstetric catastrophes among a predominantly Medicaid population.

Transfusion and hematologic indices in cases of stillbirth due to placental abruption.

BACKGROUND: Stillbirth because of placental abruption is often associated with maternal hemorrhage and coagulopathy. OBJECTIVE: This study aimed to describe blood product requirements, hematologic indices, and the overall clinical picture of patients experiencing abruption demise. STUDY DESIGN: This retrospective cohort included patients with abruption demise at an urban hospital from 2010 to 2020. Outcome data from patients who delivered stillborn infants ≥500 g or with gestational age of ≥24 weeks were included. Abruption was a clinical diagnosis made by a multidisciplinary stillbirth review committee. The overall number and type of blood products given were analyzed. Patients with a stillbirth who required blood transfusion were compared with those that did not. In addition, the hematologic indices of these 2 populations were analyzed and compared with one another. Finally, the overall clinical characteristics of the 2 populations were analyzed. The analysis of data included chi-square, t test, and logistic and negative binomial regression models. RESULTS: Of 128,252 deliveries, 615 patients (0.48%) experienced a stillbirth, with 76 cases (12%) caused by abruption. Of note, 42 patients (55.2%) required blood transfusion; all received either packed red blood cells or whole blood with a median 3.5 units (2.0-5.5) received. The total units ranged from 1 to 59, with 12 of 42 patients (29%) requiring ≥10 units. Maternal age, gestational age, and mode of delivery were not different, with most (61/76 [80%]) delivering vaginally. Hematocrit level on arrival (odds ratio, 0.80; 95% confidence interval, 0.68-0.91; P=.002) and vaginal bleeding on arrival (odds ratio, 3.73; 95% confidence interval, 1.15-13.40; P=.033) were associated with blood transfusion, as was a diagnosis of preeclampsia (odds ratio, 8.40; 95% confidence interval, 2.49-33.41; P=.001). Those that required a blood transfusion often presented with lower hematologic indices and were more likely to develop disseminated intravascular coagulation (28% vs 0%; P<.001). CONCLUSION: Most patients experiencing stillbirth because of abruption required blood transfusion, with almost 1 in 3 of those patients consuming ≥10 units of blood products. Hematocrit level on arrival, vaginal bleeding, and preeclampsia were all predictors of the need for blood transfusion. Those requiring blood transfusion were more likely to develop disseminated intravascular coagulation. Blood transfusion should be prioritized when abruption demise is suspected.

Extending Maternal Care After Pregnancy: An Initiative to Address Health Care Disparities and Enhance Access to Care After Delivery.

PROBLEM DEFINITION: A substantial proportion of maternal morbidity and mortality occurs after birth. However, little is known about the optimal design of programs to improve outcomes and decrease disparities during this period. CONTEXT: Parkland Health is a tax-supported health system in Dallas that delivers more than 11,000 patients annually. A community needs assessment identified substantial health disparities in this community. The proportion of women in this region with diabetes mellitus (DM) and chronic hypertension (CHTN) during pregnancy is higher than surrounding regions, but access to care in the area is difficult because of the limited availability of ambulatory care. INITIAL APPROACH: The authors created extending Maternal Care After Pregnancy (eMCAP), a community-based program, to address health care disparities and enhance access to care for the 12 months after birth. The team also evaluated the ability of Z codes (ICD-10 codes for social determinants of health) to identify patients with health-related social needs. KEY INSIGHTS AND SURPRISES: The eMCAP program demonstrated improvement in attendance and quality of postpartum care for women living in underserved areas with CHTN and DM. For both CHTN and DM, eMCAP patients were matched 1:2 to controls outside of the eMCAP target region with similar comorbidities for maternal age ± 4 years, Black race, and delivery date ± 45 days. Compared to matched controls who were provided standard referrals, follow-up postpartum attendance for eMCAP women with CHTN was significantly better at 2 weeks and 1, 3, 6, 9, and 12 months (all p < 0.001). Similarly, eMCAP women with DM had significantly better follow-up at 2 weeks (p = 0.04), 1 month (p = 0.002), and 3 months (p = 0.049), resulting in HbA1c values for DM being significantly lower (p < 0.05) throughout the postpartum period. Despite the health system leading in reporting of Z codes, nearly 99% of applicable Z codes were not recorded, underscoring a public health opportunity. Through the eMCAP program, this initiative has demonstrated improved clinical performance for health care outcomes relevant to postpartum patients that can be deployed elsewhere to improve maternal health in underserved communities.

A Randomized Trial of the Effects of Ambient Operating Room Temperature on Neonatal Morbidity.

OBJECTIVE: Newborn hypothermia has been implicated in neonatal morbidity without randomized evidence that it compromises the infant. Our objective was to determine if a difference in operating room temperature at cesarean birth impacts neonatal morbidity. STUDY DESIGN: Women undergoing cesarean delivery of a liveborn infant without major malformations were included. The institutional preexisting operating room temperature of 20°C (67°F) was compared with an experimental group of 24°C (75°F) by cluster randomization assigned on a weekly basis. Newborn hypothermia was defined as axillary temperature on arrival to the nursery of less than 36.5°C (<97.7°F). The primary outcome was a composite of neonatal morbidity including respiratory support, sepsis, hypoglycemia, and neonatal death. RESULTS: Between November 2016 and May 2018, 5,221 women had cesarean deliveries at Parkland Hospital with 2,817 randomized to the standard care group and 2,404 to the experimental group. The rate of neonatal composite morbidity did not differ between the groups: standard care 398 (14%) versus experimental 378 (16%), p = 0.11. This was despite a significant decrease in the rate of neonatal hypothermia: standard care 1,195 (43%) versus experimental 414 (18%), p < 0.001. There was no difference in the composite outcome for preterm infants (<37 wk) between the groups: standard care 194 (49%) versus experimental 185 (54%), p = 0.25. CONCLUSION: An 8°F increase in operating room temperature was significantly associated with a reduced rate of neonatal hypothermia, although this decrease was not associated with a significant improvement in neonatal morbidity. However, the increase in operating room temperature was met with resistance from obstetricians and operating room personnel. This trial is registered (registration no.: NCT03008577).

The Association between Placenta Accreta Spectrum Severity and Incidence of Small for Gestational Age Neonates.

OBJECTIVE: The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight. STUDY DESIGN: This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal-Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients. RESULTS: Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36-1.10 for increta and aRR = 0.72, 95% CI: 0.45-1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203). CONCLUSION: There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period. KEY POINTS: · PAS severity is not associated with SGA in the preterm period.. · PAS severity is not associated with LGA.. · Placenta previa does not affect the incidence of SGA in women with PAS..

Tranexamic acid for prevention of hemorrhage in elective repeat cesarean delivery-a randomized study.

BACKGROUND: The American College of Obstetricians and Gynecologists states that the current data are insufficient to recommend tranexamic acid prophylaxis for postpartum hemorrhage. OBJECTIVE: This study's objective was to evaluate if prophylactic tranexamic acid treatment reduces the calculated blood loss when compared with a placebo in women undergoing an elective repeat cesarean delivery. STUDY DESIGN: This was a double-blind, randomized, placebo-controlled trial in which the calculated blood loss was determined after administration of prophylactic doses of 1 g of tranexamic acid before skin incision and after placental delivery and standard uterotonics in women with singleton pregnancies at ≥37 weeks' gestation presenting for their second or third cesarean delivery under neuraxial anesthesia. The primary outcome was calculated blood loss at 24 hours. The calculation was based on each participant's height, weight, and the difference in hematocrit before the start of surgery and 24 hours after delivery. Prespecified secondary outcomes were quantification of maternal coagulation activity during the perioperative course. A sample size of 50 women per group was planned (N=100) based on a meta-analysis of mean reduction in blood loss after tranexamic acid. RESULTS: A total of 723 women were screened, and 110 women were randomized as follows: 55 to the tranexamic acid group and 55 to the placebo group. The primary outcome of mean calculated blood loss was 2274±469 mL for the tranexamic acid group and 2407±388 mL for the placebo group (P>.05). For the secondary outcomes, D-dimer levels were lower in the tranexamic acid group than in the placebo group 24 hours after delivery (2.1±1.2 µg/mL vs 4.3±2.4 µg/mL; P<.001). CONCLUSION: Prophylactic tranexamic acid treatment did not decrease the mean calculated blood loss. Significantly less participants had a calculated blood loss >2000 mL in the tranexamic acid group than in the placebo group and had lower levels of D-dimer at 24 hours.

A comparison of acute pain management strategies after cesarean delivery.

BACKGROUND: There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited. OBJECTIVE: To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain. STUDY DESIGN: This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant. RESULTS: During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001). CONCLUSION: Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

The effect of normal saline on renal function and electrolytes in women with preeclampsia.

INTRODUCTION: Due to a nationwide shortage of Ringer's lactate, normal saline became the intravenous fluid of choice at our institution in May 2018. Recent studies have shown that the administration of normal saline in critically ill patients may have adverse renal effects. OBJECTIVE: Our objective was to evaluate the renal function effects; if any, of normal saline administered to women with preeclampsia receiving magnesium sulfate. MATERIALS AND METHODS: This is a prospective observational study of women identified with preeclampsia with severe features, requiring magnesium sulfate prophylaxis. The amount of normal saline administered was calculated and a basic metabolic panel was surveyed 12 h after initiation of magnesium sulfate prophylaxis. Laboratory analytes were examined according to the volume of intravenous normal saline received, including a comparison to those women who did not receive normal saline, to determine the impact of parameters after 12 h of magnesium sulfate prophylaxis. RESULTS: From May 2018 to November 2018, a total of 233 patients receiving magnesium sulfate were identified, 184 of which had received intravenous normal saline. No differences were identified at 12 h in serum chloride or creatinine between those patients who received intravenous normal saline and those who did not. This finding persisted when serum chloride and creatinine were analyzed across quartiles of normal saline received. Interestingly, serum calcium was found to decrease with increasing serum magnesium (p < .001). This association was also dependent upon the amount of intravenous fluids received (p < .001) when controlling for serum magnesium. CONCLUSION: Renal function indices were preserved despite the introduction of normal saline with oxytocin into routine practice. No dose-response relationship was identified when serum chloride and creatinine were analyzed across quartiles of normal saline received. Interestingly, serum calcium levels were noted to decline with both the amount of intravenous fluid received as well as with increasing serum magnesium levels.

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..

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..

Comparison Between In-Person and Audio-Only Virtual Prenatal Visits and Perinatal Outcomes.

Importance: Ensuring access to prenatal care services in the US is challenging, and implementation of telehealth options was limited before the COVID-19 pandemic, especially in vulnerable populations, given the regulatory requirements for video visit technology. Objective: To explore the association of audio-only virtual prenatal care with perinatal outcomes. Design, Setting, and Participants: This cohort study compared perinatal outcomes of women who delivered between May 1 and October 31, 2019 (n = 6559), and received in-person prenatal visits only with those who delivered between May 1 and October 31, 2020 (n = 6048), when audio-only virtual visits were integrated into prenatal care during the COVID-19 pandemic, as feasible based on pregnancy complications. Parkland Health and Hospital System in Dallas, Texas, provides care to the vulnerable obstetric population of the county via a high-volume prenatal clinic system and public maternity hospital. All deliveries of infants weighing more than 500 g, whether live or stillborn, were included. Exposures: Prenatal care incorporating audio-only prenatal care visits. Main Outcomes and Measures: The primary outcome was a composite of placental abruption, stillbirth, neonatal intensive care unit admission in a full-term (≥37 weeks) infant, and umbilical cord blood pH less than 7.0. Visit data, maternal characteristics, and other perinatal outcomes were also examined. Results: The mean (SD) age of the 6559 women who delivered in 2019 was 27.8 (6.4) years, and the age of the 6048 women who delivered in 2020 was 27.7 (6.5) years (P = .38). Of women delivering in 2020, 1090 (18.0%) were non-Hispanic Black compared with 1067 (16.3%) in 2019 (P = .04). In the 2020 cohort, 4067 women (67.2%) attended at least 1 and 1216 women (20.1%) attended at least 3 audio-only virtual prenatal visits. Women who delivered in 2020 attended a greater mean (SD) number of prenatal visits compared with women who delivered in 2019 (9.8 [3.4] vs 9.4 [3.8] visits; P < .001). In the 2020 cohort, 173 women (2.9%) experienced the composite outcome, which was not significantly different than the 195 women (3.0%) in 2019 (P = .71). In addition, the rate of the composite outcome did not differ substantially when examined according to the number of audio-only virtual visits attended. Conclusions and Relevance: Implementation of audio-only virtual prenatal visits was not associated with changes in perinatal outcomes and increased prenatal visit attendance in a vulnerable population during the COVID-19 pandemic when used in a risk-appropriate model.

Fetal Anomaly Detection in Pregnancies With Pregestational Diabetes.

OBJECTIVES: To evaluate fetal anomaly detection in pregnancies with pregestational diabetes, according to the gestational age at the time of specialized sonography, use of follow-up sonography, maternal body mass index, and organ system(s) involved. METHODS: Women with pregestational diabetes who received prenatal care and delivered a live-born or stillborn neonate at our hospital from October 2011 through April 2017 were ascertained. We included all pregnancies with at least 1 confirmed structural anomaly (EUROCAT classification) who had detailed sonography at 18 weeks' gestation or later. We analyzed detection of anomalous fetuses at the initial detailed sonogram and, if no abnormality was identified, during any follow-up sonograms. Statistical analyses were performed with the χ2 test and Mantel-Haenszel χ2 test for trend. RESULTS: Seventy-two anomalous neonates (72 of 1060 [6.8%]) were born. Overall detection was 55 of 72 (76%); 49 of 72 (68%) were detected at the initial detailed sonogram, compared to 6 of 15 (40%) of follow-up examinations (P = .04). Recognition at the initial or follow-up examination was not dependent on gestational age or body mass index category (all P > .05). Of individual organ system anomalies, 67 of 89 (75%) were identified. Detection exceeded 85% for central nervous system, genitourinary, and musculoskeletal abnormalities and 43% for craniofacial anomalies. Sixty-five percent of cardiac anomalies were detected, and 14 of 17 (82%) requiring specialized care in the immediate neonatal period were recognized. CONCLUSIONS: Approximately three-fourths of anomalous fetuses were identified, with greater detection at the initial detailed examination. Fetuses with central nervous system, genitourinary, musculoskeletal abnormalities and those with cardiac anomalies requiring specialized cardiac care were more likely to come to attention.

Sonography interval and the diagnosis of twin-twin transfusion syndrome.

OBJECTIVE: To evaluate the relationship between sonography surveillance interval and Quintero stage at diagnosis. METHODS: This was a retrospective cohort study of monochorionic diamniotic pregnancies diagnosed with twin-twin transfusion syndrome (TTTS) and followed with serial sonography between 1997 and 2013. Women were divided into three cohorts: diagnosis at initial second-trimester sonogram, at a sonogram within 14 d of the prior exam, and at a sonogram greater than 14 d from the prior exam. Isolated amniotic fluid abnormalities were also recorded. RESULTS: TTTS was identified in 48 pregnancies, with 50% of cases diagnosed at the initial sonogram, 21% within 14 d of a prior sonogram, and 29% more than 14 d from a prior sonogram. There was no association between interval and TTTS stage at diagnosis. Of 24 cases diagnosed during a follow-up sonogram, 46% had an isolated amniotic fluid abnormality preceding diagnosis. When isolated oligohydramnios (29%) or hydramnios (17%) was present, the sonography interval was significantly shorter (p = 0.003), but no difference in TTTS stage at diagnosis was found. CONCLUSIONS: Although frequent surveillance of monochorionic diamniotic pregnancies is prudent, when close follow-up of isolated fluid abnormalities was practiced, we were unable to demonstrate an effect of surveillance interval on stage of TTTS at diagnosis.

The FL/AC ratio for prediction of shoulder dystocia in women with gestational diabetes.

PURPOSE: To determine if sonographic variables, including fetal femur length to abdominal circumference (FL/AC) ratio, are associated with shoulder dystocia in women with gestational diabetes. METHODS: This was a retrospective cohort study of women with gestational diabetes who delivered singleton infants at Parkland Hospital from 1997 to 2015. Diagnosis and treatment of gestational diabetes were uniform including sonography at 32-36 weeks. Biometric calculations were evaluated for correlation with shoulder dystocia. RESULTS: During the study period, 6952 women with gestational diabetes underwent a sonogram at a mean gestation of 34.8 ± 1.8 weeks. Of 4183 vaginal deliveries, 66 experienced shoulder dystocia (16/1000). The FL/AC was associated with shoulder dystocia (p < 0.001) with an AUC of 0.70 (95% CI: 0.64-0.77). This was similar to age-adjusted AC and head circumference to AC ratio (HC/AC) (both with an AUC of 0.72). All other measurements, including estimated fetal weight, were inferior. When examining the 257 women with multiple sonograms after 32 weeks' gestation, FL/AC was stable with advancing gestational age (p = 0.54) whereas age-adjusted AC and HC/AC were not (p < 0.001). CONCLUSIONS: The FL/AC is associated with shoulder dystocia in women with gestational diabetes. Additionally, it is a simple ratio that is independent of the reference used and remains stable, unlike age-adjusted AC and HC/AC ratio.

The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial.

BACKGROUND: Neonatal hypothermia is common at the time of cesarean delivery and has been associated with a constellation of morbidities in addition to increased neonatal mortality. Additionally, maternal hypothermia is often uncomfortable for the surgical patient and has been associated with intraoperative and postoperative complications. Various methods to decrease the rates of neonatal and maternal hypothermia have been examined and found to have varying levels of success. OBJECTIVE: We sought to determine whether an increase in operating room temperature at cesarean delivery results in a decrease in the rate of neonatal hypothermia and associated morbidities. STUDY DESIGN: In this single-center randomized trial, operating room temperatures were adjusted weekly according to a cluster randomization schedule to either 20°C (67°F), which was the standard at our institution, or 23°C (73°F), which was the maximum temperature allowable per hospital policy. Neonatal hypothermia was defined as core body temperature <36.5°C (97.7°F) per World Health Organization criteria. The primary study outcome was neonatal hypothermia on arrival to the admitting nursery. Measures of neonatal morbidity potentially associated with hypothermia were examined. RESULTS: From February through July 2015, 791 women who underwent cesarean deliveries were enrolled, resulting in 410 infants in the 20°C standard management group and 399 in the 23°C study group. The rate of neonatal hypothermia on arrival to the admitting nursery was lower in the study group as compared to the standard management group: 35% vs 50%, P < .001. Moderate to severe hypothermia was infrequent when the operating room temperature was 23°C (5%); in contrast such hypothermia occurred in 19% of the standard management group, P < .001. Additionally, neonatal temperature in the operating room immediately following delivery and stabilization was also higher in the study group, 37.1 ± 0.6°C vs 36.9 ± 0.6°C, P < .001. We found no difference in rates of intubation, ventilator use, hypoglycemia, metabolic acidemia, or intraventricular hemorrhage. Fever (temperature >38.0°C or 100.4°F) on arrival to the admitting unit was uncommon and did not differ between the study groups. Maternal temperature on arrival to the operating room was not different between the 2 groups, however by delivery it was significantly lower in the standard management group, 36.2 ± 0.6°C vs 36.4 ± 0.6°C, P < .001. This effect persisted, as maternal temperature on arrival to the postoperative care area was lower in the standard management group, 36.1 ± 0.6°C vs 36.2 ± 0.6°C, P < .001, and the rate of hypothermia was higher, 77% vs 69%, P = .008. CONCLUSION: A modest increase in operating room temperature at the time of cesarean reduces the rate of neonatal and maternal hypothermia. We did not detect a decrease in neonatal morbidity, but the power to detect a small change in these outcomes was limited.

The natural history of twin-twin transfusion syndrome stratified by Quintero stage.

OBJECTIVE: To describe the natural history of expectantly managed twin-twin transfusion syndrome (TTTS) specific to disease stage. METHODS: This was a retrospective study of monochorionic diamniotic pregnancies diagnosed with TTTS and delivered between 1997 and 2013. Staging was based on Quintero's criteria, with sonogram images reviewed to confirm findings specific to stage. Progression and outcomes were evaluated in pregnancies that did not receive any form of therapy. RESULTS: Thirty-eight pregnancies were diagnosed with TTTS and delivered at our institution, representing 1.6 per 10 000 births. Twenty were expectantly managed, of which 50% were stage I at presentation. Progression occurred in 45% of pregnancies, including 50% initially diagnosed with stage I TTTS. Seventy percent of pregnancies experienced survival of at least one twin, with no stillbirths or neonatal deaths if TTTS resolved. Pregnancies in which TTTS was either stable or improved had higher overall survival, compared with pregnancies that experienced progression, 86% versus 22%, p < 0.001, as well as more frequent survival of one or both twins, 91% versus 44%, p = 0.02. CONCLUSIONS: Among expectantly managed pregnancies with TTTS, most had early disease at diagnosis. Although 45% of cases progressed, which conferred poor prognosis, the majority experienced disease stabilization or improvement.