Comprehensive appraisal of pregnancy and neonatal outcomes in singleton pregnancies conceived via in vitro fertilization in the USA (2016-2021).

OBJECTIVES: We set out to compare adverse pregnancy and neonatal outcomes in singleton gestations conceived via in vitro fertilization (IVF) to those conceived spontaneously. METHODS: Retrospective, population-based cohort using the CDC Natality Live Birth database (2016-2021). All singleton births were stratified into two groups: those conceived via IVF, and those conceived spontaneously. The incidence of several adverse pregnancy and neonatal outcomes was compared between the two groups using Pearson's chi-square test with Bonferroni adjustments. Multivariate logistic regression was used to adjust outcomes for potential confounders. RESULTS: Singleton live births conceived by IVF comprised 0.86 % of the cohort (179,987 of 20,930,668). Baseline characteristics varied significantly between the groups. After adjusting for confounding variables, pregnancies conceived via IVF were associated with an increased risk of several adverse pregnancy and neonatal outcomes compared to those conceived spontaneously. The maternal adverse outcomes with the highest risk in IVF pregnancies included maternal transfusion, unplanned hysterectomy, and maternal intensive care unit admission. Increased rates of hypertensive disorder of pregnancy, preterm birth (delivery <37 weeks of gestation), and cesarean delivery were also noted. The highest risk neonatal adverse outcomes associated with IVF included immediate and prolonged ventilation, neonatal seizures, and neonatal intensive care unit admissions, among others. CONCLUSIONS: Based on this large contemporary United States cohort, the risk of several adverse pregnancy and neonatal outcomes is increased in singleton pregnancies conceived via IVF compared to those conceived spontaneously. Obstetricians should be conscious of these associations while caring for and counseling pregnancies conceived via IVF.

Risk factors associated with third- and fourth-degree perineal lacerations in singleton vaginal deliveries: a comprehensive United States population analysis 2016-2020.

OBJECTIVES: Perineal lacerations are a common complication of vaginal birth, affecting approximately 85 % of patients. Third-and fourth-degree perineal lacerations (3/4PL) remain a significant cause of physical and emotional distress. We aimed to perform an extensive assessment of potential risk factors for 3/4PL based on a comprehensive and current US population database. METHODS: Retrospective population-based cohort analysis based on the US Centers for Disease Control and Prevention Natality Live Birth online database between 2016-2020. Baseline characteristics were compared between women with 3/4PL and without 3/4PL by using Pearson's Chi-squared test with statistical significance set at p<0.05. Bonferroni correction was used to account for multiple comparisons. Multivariable logistic regression was performed to evaluate the association between a variety of potential risk factors and the risk of 3/4P. RESULTS: Asians/Pacific Islanders had the highest risk of 3/4PL (2.6 %, aOR 1.74). Gestational hypertension and preeclampsia were associated with increased risk of 3/4PL (aOR 1.28 and 1.34, respectively), as were both pre-gestational and gestational diabetes (aOR 1.28 and 1.46, respectively). Chorioamnionitis was associated almost double the risk (aOR 1.86). Birth weight was a major risk factor (aOR 7.42 for greater than 4,000 g), as was nulliparity (aOR 9.89). CONCLUSIONS: We identified several maternal, fetal, and pregnancy conditions that are associated with an increased risk for 3/4PL. As expected, nulliparity and increased birth weight were associated with the highest risk. Moreover, pregestational and gestational diabetes, hypertensive disorders of pregnancy, Asian/Pacific Islander race, and chorioamnionitis were identified as novel risk factors.

Risk factors and adverse outcomes associated with syphilis infection during pregnancy.

BACKGROUND: The prevalence of syphilis infection in pregnancy is increasing at an alarming rate. OBJECTIVE: This study aimed to evaluate sociodemographic risk factors and adverse pregnancy outcomes associated with syphilis infection during pregnancy in a current US population of live births. STUDY DESIGN: This was a retrospective analysis of the Centers for Disease Control and Prevention, Natality Live Birth database for the years 2016 to 2019. All live births were eligible for inclusion. Deliveries with missing data on syphilis infection were excluded. We analyzed the database comparing pregnancies complicated by maternal infection with syphilis with those without infection. Several maternal sociodemographic factors and adverse pregnancy and neonatal outcomes were compared between the 2 groups. Multivariable logistic regression was performed to evaluate the association of these factors with syphilis infection in pregnancy, and adverse pregnancy and neonatal outcomes while adjusting for potential confounders. Data were presented as adjusted odds ratios with 95% confidence intervals. RESULTS: Of the 15,341,868 births included, 17,408 (0.11%) were complicated by maternal infection with syphilis. Concurrent infection with gonorrhea was associated with the highest risk of syphilis in pregnancy (adjusted odds ratio, 7.24; 95% confidence interval, 6.79-7.72). Low educational attainment (less than high school: adjusted odds ratio, 4.40; 95% confidence interval, 3.93-4.92), non-Hispanic Black race/ethnicity (adjusted odds ratio, 3.81; 95% confidence interval, 3.65-3.98), and Medicaid insurance (adjusted odds ratio, 2.13; 95% confidence interval, 2.03-2.23) were also associated with a significantly increased risk of infection. Syphilis infection was associated with an increased risk for preterm birth (<37 weeks: adjusted odds ratio, 1.25; 95% confidence interval, 1.20-1.31; <32 weeks: adjusted odds ratio, 1.26; 95% confidence interval, 1.16-13.7), low birthweight (adjusted odds ratio, 1.34; 95% confidence interval, 1.28-1.40), congenital malformations (adjusted odds ratio, 1.43; 95% confidence interval, 1.14-1.78), low 5-minute Apgar scores (adjusted odds ratio, 1.29; 95% confidence interval, 1.19-1.41), neonatal intensive care unit admission (adjusted odds ratio, 2.19; 95% confidence interval, 2.11-2.28), immediate ventilation (adjusted odds ratio, 1.48; 95% confidence interval, 1.39-1.57), and prolonged ventilation (adjusted odds ratio, 1.58; 95% confidence interval, 1.44-1.73). CONCLUSION: We identified several risk factors and adverse pregnancy outcomes associated with syphilis infection in pregnancy. Given the concerning rise in prevalence of pregnancy infections, public health strategies aimed at infection prevention and access to timely screening and treatment to reduce associated adverse pregnancy outcomes are urgently needed.

Cervical cerclage for short cervix at 24 to 26 weeks of gestation: systematic review and meta-analysis of randomized controlled trials using individual patient-level data.

OBJECTIVE: This study aimed to determine whether cervical cerclage for a transvaginal ultrasound-detected short cervical length after 24 weeks of gestation in singleton pregnancies reduces the risk for preterm birth. DATA SOURCES: Ovid MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were searched using the following terms: "cerclage, cervical," "uterine cervical incompetence," "obstetrical surgical procedures," "cervix uteri," "randomized controlled trial," and "controlled clinical trial." STUDY ELIGIBILITY CRITERIA: All randomized controlled trials comparing cerclage placement with no cerclage in singleton gestations with a transvaginal ultrasound-detected short cervical length ≤25 mm between 24+0/7 and 29+6/7 weeks of gestation were eligible for inclusion. METHODS: Individual patient-level data from each trial were collected. If an eligible trial included patients with both multiple and singleton gestations with a short cervical length detected either before or after 24+0/7 weeks of gestation, only singletons who presented at or after 24+0/7 weeks were included. The primary outcome was preterm birth <37 weeks' gestation. Secondary outcomes included preterm birth <34, <32, and <28 weeks' gestation, gestational age at delivery, latency, preterm prelabor rupture of membranes, chorioamnionitis, and adverse neonatal outcomes. Individual patient-level data from each trial were analyzed using a 2-stage approach. Pooled relative risks or mean differences with 95% confidence intervals were calculated as appropriate. RESULTS: Data from the 4 eligible randomized controlled trials were included. A total of 131 singletons presented at 24+0/7 to 26+6/7 weeks of gestation and were further analyzed; there were no data on patients with a cerclage at 27+0/7 weeks' gestation or later. Of those included, 66 (50.4%) were in the cerclage group and 65 (49.6%) were in the no cerclage group. The rate of preterm birth <37 weeks' gestation was similar between patients who were randomized to the cerclage group and those who were randomized to the no cerclage group (27.3% vs 38.5%; relative risk, 0.78; 95% confidence interval, 0.37-1.28). Secondary outcomes including preterm birth <34, <32, and <28 weeks' gestation, gestational age at delivery, time interval from randomization to delivery, preterm prelabor rupture of membranes, and adverse neonatal outcomes such as low birthweight, very low birthweight, and perinatal death were similar between the 2 groups. Planned subgroup analyses revealed no statistically significant differences in the rate of preterm birth <37 weeks' gestation between the 2 groups when compared based on cervical length measurement (≤15 mm or ≤10 mm), gestational age at randomization (24+0/7 to 24+6/7 weeks or 25+0/7 to 26+6/7 weeks), or history of preterm birth. CONCLUSION: Cervical cerclage did not reduce or increase the rate of preterm birth among singleton pregnancies with a short cervical length detected after 24 weeks of gestation. Because there was a 22% nonsignificant decrease in preterm birth associated with cerclage, which is a similar amount of risk reduction often associated with ultrasound-indicated cerclage before 24 weeks' gestation, further randomized controlled trials in this patient population are warranted.

Hidden in plain sight in the delivery room - the Apgar score is biased.

OBJECTIVES: The objective of this study was to compare the maximum 5-min Apgar score of 10 among different U.S. races and Hispanic ethnicity. METHODS: Retrospective population-based cohort study from the National Center for Health Statistics (NCHS), and Division of Vital Statistics natality online database. We included only deliveries where the race and Hispanic ethnicity of the father and mother were listed as either Black, White, Chinese, or Asian Indian and as Hispanic or Latino origin or other. Proportions of 5-Minute Apgar scores of 10 were compared among different races and Hispanic ethnicity for six groups each for mother and father: Non-Hispanic or Latino White, Hispanic or Latino White, Non-Hispanic or Latino Black, Hispanic or Latino Black, Chinese, and Asian Indian. RESULTS: The study population consists of 9,710,066 mothers and 8,138,475 fathers from the US natality birth data 2016-2019. Black newborns had a less than 50% chance of having a 5-min Apgar score of 10 when compared to white newborns (OR 0.47 for Black mother and Black father; p<0.001). White babies (non-Hispanic and Hispanic) had the highest proportion of Apgar scores of 10 across all races and ethnicities. CONCLUSIONS: The Apgar score introduces a bias by systematically lowering the score in people of color. Embedding skin color scoring into basic data and decisions of health care propagates race-based medicine. By removing the skin color portion of the Apgar score and with it's racial and ethnic bias, we will provide more accuracy and equity when evaluating newborn babies worldwide.

Time interval to delivery in asymptomatic twin pregnancies with a short cervix at 23-28 weeks' gestation.

OBJECTIVES: To evaluate the risk and timing of spontaneous preterm birth (PTB) in asymptomatic twin pregnancies with a short cervical length (CL≤25 mm) at 23-28 weeks of gestation. METHODS: Multicenter retrospective cohort study of asymptomatic twin pregnancies with a short CL between 23 and 28 weeks' gestation within a university health system from 1/2012 to 12/2019. Cases were divided into 4 groups based on CL measurement (≤10 mm, 11-15 mm, 16-20 mm, and 21-25 mm). The primary outcome was time interval from presentation to delivery. Secondary outcomes included delivery within one and two weeks of presentation, and delivery prior to 32, 34, and 37 weeks, respectively. RESULTS: 104 patients were included. The time interval from presentation to delivery was significantly different among the four groups (p<0.001), with the CL≤10 mm group having the shortest time interval to delivery. Regardless of the CL measurement, spontaneous PTB within one and two weeks was extremely uncommon and occurred in only one patient within the study cohort (1/104, 1.0%). The risk of spontaneous PTB was highest in the shortest CL group (CL ≤ 10 mm; 53.8% PTB<32 weeks, 61.5% PTB<34 weeks, 92.3% PTB<37 weeks). CONCLUSIONS: Asymptomatic twin pregnancies with a CL ≤ 10 mm had the shortest time interval to delivery and thus represent a specifically high risk group for sPTB. Although all patients were at high risk of sPTB, only one delivered within 1 or 2 weeks of presentation.

Maternal race/ethnicity impacts the success rates of external cephalic version (ECV) in the United States.

OBJECTIVES: Racial and ethnic disparities in obstetrics are prevalent in the United States (US). We aimed to assess whether the success rate of external cephalic version (ECV) is affected by maternal race/ethnicity. METHODS: We conducted a retrospective analysis based on the CDC Natality Live Birth database for 2016-2018. We compared the success rates of ECV across US pregnant women of different racial/ethnic groups (non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic Asians, and Hispanics) using the Pearson chi-square test and used multivariate logistic regression to control for confounding variables. Statistical signiciance was determined as p<0.05 and results were displayed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Of the 11,150,527 births, 26,255 women underwent an ECV and met inclusion criteria. The overall ECV success rate was 52.75% (13,850 women). Non-Hispanic Blacks had the highest ECV success rate (64.52%), followed by Hispanics (59.21%) and non-Hispanic Asians (55.51%). These rates were significantly higher than those of non-Hispanic Whites (49.27%, p<0.001). Non-Hispanic Blacks were associated with the highest success rate compared to non-Hispanic Whites (adjusted OR 1.95, 95% CI 1.77-2.15). CONCLUSIONS: The success rate of ECV varies among different maternal racial/ethnic groups. Non-Hispanic White women have the lowest ECV success rate, while non-Hispanic Black women have the highest ECV success rate.

Maternal education and racial/ethnic disparities in nulliparous, term, singleton, vertex cesarean deliveries in the United States.

BACKGROUND: Racial and ethnic disparities in obstetrical and neonatal outcomes are prevalent in the United States. Such racial or ethnic disparities have also been documented in the prevalence of cesarean deliveries. OBJECTIVE: We aimed to evaluate the impact of maternal education on racial or ethnic disparities in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States. STUDY DESIGN: This is a retrospective analysis of the Centers for Disease Control and Prevention live births database (2016-2019). Nulliparous, term, singleton, vertex births from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. Pregnancies complicated by gestational or pregestational diabetes mellitus and hypertensive disorders were excluded. Data were analyzed on the basis of the level of maternal education (less than high school graduate, high school graduate, college graduate, and advanced degree). We compared the prevalence of cesarean deliveries among the different racial or ethnic groups within each education level using Pearson chi-square test with Bonferroni adjustment. Multivariate logistic regression was performed to assess the association between cesarean deliveries and maternal race/ethnicity, maternal education, and the interaction between maternal race or ethnicity and education level, while controlling for potential confounders. To demonstrate the effect of the interaction, separate logistic regression models with similar covariates were performed for each education level and for each race/ethnicity group. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios with 95% confidence intervals. RESULTS: The overall prevalence of cesarean deliveries during the study period was 23.4% (695,214 of 2,969,207 births). All racial or ethnic minority groups had higher rates of cesarean deliveries than non-Hispanic White women (non-Hispanic Black, 27.4%; non-Hispanic Asian, 25.6%; Hispanic, 23.0%; and non-Hispanic White, 22.4%; [P<.001 for all comparisons]). Similar racial or ethnic differences in cesarean delivery rates were detected among all education levels. Higher levels of education were associated with a lower likelihood of cesarean delivery (adjusted odds ratio, 0.88; [95% confidence interval, 0.87-0.89]) in women with advanced degrees than in women who did not graduate from high school. However, although maternal education was associated with a protective effect in non-Hispanic White and non-Hispanic Asian women (adjusted odds ratio, 0.83 [95% confidence interval, 0.81-0.85] and adjusted odds ratio, 0.81 [95% confidence interval, 0.77-0.86], respectively, for women with advanced degrees), it had a smaller protective effect in non-Hispanic Black women (adjusted odds ratio, 0.93 [95% confidence interval, 0.89-0.97]) and no protective effect in Hispanic women (adjusted odds ratio, 0.98 [95% confidence interval, 0.96-1.01]). CONCLUSION: We document a significant racial/ethnic disparity in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States. Furthermore, our findings suggest that although a higher level of maternal education is associated with a lower likelihood of cesarean delivery, this protective effect varies among racial or ethnic groups. Further research is needed to investigate the underlying causes for this racial/ethnic disparity.

Adverse outcomes associated with twin pregnancies conceived via in vitro fertilization.

OBJECTIVE: To compare adverse pregnancy and neonatal outcomes in twin pregnancies conceived by in vitro fertilization (IVF) to those conceived spontaneously. METHODS: Retrospective analysis of the Centers for Disease Control and Prevention, Natality Live Birth database for the years 2016-2019. All twin live births were included and stratified into two groups: those from pregnancies conceived via IVF and those from pregnancies conceived spontaneously. The incidence of several adverse pregnancy and neonatal outcomes were compared between the two groups. Statistical analysis included multivariable logistic regression to adjust for the following potential confounders: maternal age, race/ethnicity, body mass index, education level, type of medical insurance, chronic hypertension, pregestational diabetes, and prior preterm birth. Data were presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Twin live births from pregnancies conceived via IVF comprised 9.5% of the study cohort (39,356 of 415,560). Baseline characteristics varied significantly between IVF and spontaneously conceived twins. After adjusting for these variables, IVF in twins was associated with an increased risk of multiple adverse outcomes including gestational diabetes (aOR = 1.35, 95% CI = 1.30-1.39), hypertensive disorders of pregnancy (aOR = 1.70, 95% CI = 1.65-1.75), preterm birth prior to 28 weeks (aOR = 1.53, 95% CI = 1.43-1.63), maternal intensive care unit admission (aOR = 2.03, 95% CI = 1.79-2.31), maternal blood transfusion (aOR = 2.97, 95% CI = 2.75-3.20), unplanned hysterectomy (aOR = 3.37, 95% CI = 2.73-4.16), and prolonged ventilation in newborns (aOR = 1.76, 95% CI = 1.69-1.82), compared to spontaneously conceived twin pregnancies. CONCLUSIONS: Based on this large United States population-based cohort, twin pregnancies conceived via IVF represent a subgroup of twins that have an increased risk for several adverse pregnancy and neonatal outcomes, compared to those conceived spontaneously. With increased contemporary utilization of IVF, obstetricians should consider these risks while caring for patients with twin pregnancies conceived via IVF.

Sociodemographic Factors Associated With Gonorrhea and Chlamydia Infection in Pregnancy.

BACKGROUND: We explored the impact of maternal sociodemographic parameters on the prevalence of chlamydial and gonorrheal infection in pregnancy in a large United States population of live births. METHODS: Retrospective analysis of the Centers for Disease Control and Prevention Natality Live Birth database (2016-2019). We compared pregnancies complicated by maternal infection with either gonorrhea or chlamydia to those without gonorrheal or chlamydial infection, separately. Both analyses included assessment of multiple maternal sociodemographic factors, which were compared between the 2 groups. Multivariable logistic regression was performed to evaluate the association of these factors with gonorrheal or chlamydial infection in pregnancy. RESULTS: Of the 15,341,868 included live births, 45,639 (0.30%) were from patients who had gonorrheal infection, and 282,065 (1.84%) were from patients who had chlamydial infection during pregnancy. Concurrent infection with chlamydia and gonorrhea was associated with the highest risk of gonorrhea and chalmydia in pregnancy (adjusted odds ratio, 26.28; 95% confidence interval, 25.74-26.83, and adjusted odds ratio, 26.03; 95% confidence interval, 25.50-26.58, respectively). Young maternal age, low educational attainment, non-Hispanic Black race/ethnicity, concurrent infection with syphilis, and tobacco use were also associated with a substantial increase in the risk of gonorrheal and chlamydial infection in pregnancy. CONCLUSIONS: Several sociodemographic factors including young maternal age, low educational attainment, Medicaid insurance, and non-Hispanic Black race/ethnicity, are associated with a marked increase in the risk for gonorrheal and chlamydial infection in current US pregnancies. These data may be used to better screen, educate, and treat pregnancies of vulnerable populations at risk for such infections.

Antenatal corticosteroids and neonatal outcomes in preterm birth in the United States.

OBJECTIVES: To determine the impact of antenatal corticosteroids (ACS) on neonatal outcomes in a large United States population of preterm births. METHODS: Retrospective cohort study utilizing the United States Natality Live Birth database from the Centers for Disease Control and Prevention (2016-2017). Women with singleton preterm births were eligible for inclusion. Out-of-hospital births, fetal anomalies, and cases where ACS exposure was unknown were excluded. Neonates from reported live births were divided into two groups based on whether the mother received ACS before delivery or not. The incidence of several reported neonatal outcomes were compared between the two groups at each gestational week. Subsequently, comparisons between three gestational age groups (23 0/7 to 27 6/7, 28 0/7 to 33 6/7, and 34 to 36 6/7 weeks) were performed. Statistical analysis included use of Chi-squared test and multivariate logistic regression. RESULTS: Of the 588,077 live births included, 121,151 (20.6%) had been exposed to ACS. ACS use was associated with a significantly decreased odds of neonatal mortality and 5-min Apgar score <7, but an increased rate of several neonatal outcomes such as surfactant replacement therapy, prolonged ventilation, antibiotics for suspected neonatal sepsis, and neonatal intensive care unit (NICU) admissions. CONCLUSIONS: ACS administration prior to preterm birth is associated with a decrease in neonatal mortality and low Apgar scores, and increased odds of several adverse neonatal outcomes.

Maternal and Neonatal Complications in Teen Pregnancies: A Comprehensive Study of 661,062 Patients.

PURPOSE: To provide a comprehensive assessment of maternal and neonatal complications associated with teen pregnancies in the United States. METHODS: Retrospective analysis of the Centers for Disease Control and Prevention natality live births database (2016-2019). Singleton births to women younger than 35 years from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. The risks of various complications were compared between teen patients (<20 years old) and nonteen patients (20-35 years old) using Pearson's chi-square test with the Bonferroni correction. Multivariate logistic regressions were used to adjust outcomes for potential confounders, including body mass index, race/ethnicity, payment method, prenatal care, parity, and the presence of chronic comorbidities. RESULTS: Teen pregnancies comprised approximately 6% of the study population (661,062 of 11,038,489). Teen pregnancies were associated with increased odds of several maternal complications, such as hypertensive disorders of pregnancy, eclampsia, preterm birth, blood transfusion, and chlamydial and gonorrheal infections. Teen pregnancies were also associated with increased odds of several neonatal complications, including congenital birth defects, low 5-minute Apgar score, suspected neonatal sepsis, and assisted ventilation. Conversely, teen pregnancies were associated with decreased odds of gestational diabetes, unplanned hysterectomy, macrosomia, low birth weight, and neonatal intensive care unit admission. DISCUSSION: Teen pregnancies in the United States are associated with increased risks of multiple adverse outcomes. This information should inform clinicians and policy makers about the unique risks of this highly vulnerable patient population and provide further knowledge for the important efforts to reduce teen birth rates in the United States.

Adverse perinatal outcomes of chlamydia infections: an ongoing challenge.

OBJECTIVES: Chlamydia trachomatis is one of the most common sexually transmitted diseases in the world, but there are limited data on its impact on perinatal outcomes. Our objective was to investigate the association between chlamydia infections and adverse perinatal outcomes. METHODS: This is a retrospective analysis of the United States Centers for Disease Control and Prevention natality live birth database for the years 2016-2019. The rates of adverse perinatal outcomes were compared between patients with a chlamydia infection during pregnancy and patients without such infection, using Pearson's chi-square test with the Bonferroni adjustment. A multivariate logistic regression was then used to adjust outcomes for potential confounders. RESULTS: Chlamydia infections were associated with small, but statistically significant, increased odds of preterm birth (<37 weeks), early preterm birth (<32 weeks), low birthweight (<2,500 g), congenital anomalies, low 5-min Apgar score (<7), neonatal intensive care unit admission, immediate neonatal ventilation, prolonged (>6 h) neonatal ventilation, and neonatal antibiotic treatment for suspected sepsis. CONCLUSIONS: Chlamydia infections during pregnancy are associated with adverse perinatal outcomes. These results call for increased education regarding the potential risks of pregnancies with a chlamydia infection, as well as for increased antenatal surveillance and post-natal pediatric assessment in these pregnancies.

Neonatal outcomes of births in freestanding birth centers and hospitals in the United States, 2016-2019.

BACKGROUND: Births in freestanding birth centers have more than doubled between 2007 and 2019. Although birthing centers, which are defined by the American College of Obstetricians and Gynecologists as ". . . freestanding facilities that are not hospitals," are being promoted as offering women fewer interventions than hospitals, there are limited recent data available on neonatal outcomes in these settings. OBJECTIVE: To compare several important measures of neonatal safety between 2 United States birth settings and birth attendants: deliveries in freestanding birth centers and hospital deliveries by midwives and physicians. STUDY DESIGN: This is a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, and Division of Vital Statistics natality online database for the years 2016 to 2019. All term, singleton, low-risk births were eligible for inclusion. The study outcomes were several neonatal outcomes including neonatal death, neonatal seizures, 5-minute Apgar scores of <4 and <7, and neonatal death in nulliparous and in multiparous women. Outcomes were compared between the following 3 groups: births in freestanding birth centers, in-hospital births by a physician, and in-hospital births by a midwife. The prevalence of each neonatal outcome among the different groups was compared using Pearson chi-squared test, with the in-hospital midwife births being the reference group. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index, maternal weight gain, parity, gestational weeks, and neonatal birthweight and calculated as adjusted odds ratio. RESULTS: The study population consisted of 9,894,978 births; 8,689,467 births (87.82%) were in-hospital births by MDs and DOs, 1,131,398 (11.43%) were in-hospital births by midwives, and 74,113 (0.75%) were births in freestanding birth centers. Freestanding birth center deliveries were less likely to be to non-Hispanic Black or Hispanic, less likely to women with public insurance, less likely to be women with their first pregnancy, and more likely to be women with advanced education and to have pregnancies at ≥40 weeks' gestation. Births in freestanding birth center had a 4-fold increase in neonatal deaths (3.64 vs 0.95 per 10,000 births: adjusted odds ratio, 4.00; 95% confidence interval, 2.62-6.1), a more than 7-fold increase in neonatal deaths for nulliparous patients (6.8 vs 0.92 per 10,000 births: adjusted odds ratio, 7.7; 95% confidence interval, 4.42-13.76), a more than 2-fold increase in neonatal seizures (3.91 vs 1.94 per 10,000 births: adjusted odds ratio, 2.19; 95% confidence interval, 1.48-3.22), and a more than 7-fold increase of a 5-minute Apgar score of <4 (194.84 vs 28.5 per 10,000 births: adjusted odds ratio, 7.46; 95% confidence interval, 7-7.95). Compared with hospital midwife deliveries, hospital physician deliveries had significantly higher adverse neonatal outcomes (P<0.001). CONCLUSION: Births in United States freestanding birth centers are associated with an increased risk of adverse neonatal outcomes such as neonatal deaths, seizures, and low 5-minute Apgar scores. Therefore, when counseling women about the location of birth, it should be conveyed that births in freestanding birth centers are not among the safest birth settings for neonates compared with hospital births attended by either midwives or physicians.

The Risk of Readmission after Early Postpartum Discharge during the COVID-19 Pandemic.

OBJECTIVE: To determine whether early postpartum discharge during the coronavirus disease 2019 (COVID-19) pandemic was associated with a change in the odds of maternal postpartum readmissions. STUDY DESIGN: This is a retrospective analysis of uncomplicated postpartum low-risk women in seven obstetrical units within a large New York health system. We compared the rate of postpartum readmissions within 6 weeks of delivery between two groups: low-risk women who had early postpartum discharge as part of our protocol during the COVID-19 pandemic (April 1-June 15, 2020) and similar low-risk patients with routine postpartum discharge from the same study centers 1 year prior. Statistical analysis included the use of Wilcoxon's rank-sum and chi-squared tests, Nelson-Aalen cumulative hazard curves, and multivariate logistic regression. RESULTS: Of the 8,206 patients included, 4,038 (49.2%) were patients who had early postpartum discharge during the COVID-19 pandemic and 4,168 (50.8%) were patients with routine postpartum discharge prior to the COVID-19 pandemic. The rates of postpartum readmissions after vaginal delivery (1.0 vs. 0.9%; adjusted odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.39-1.45) and cesarean delivery (1.5 vs. 1.9%; adjusted OR: 0.65, 95% CI: 0.29-1.45) were similar between the two groups. Demographic risk factors for postpartum readmission included Medicaid insurance and obesity. CONCLUSION: Early postpartum discharge during the COVID-19 pandemic was associated with no change in the odds of maternal postpartum readmissions after low-risk vaginal or cesarean deliveries. Early postpartum discharge for low-risk patients to shorten hospital length of stay should be considered in the face of public health crises. KEY POINTS: · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after vaginal delivery.. · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after cesarean delivery.. · Early postpartum discharge for low-risk patients should be considered during a public health crisis..

Race and ethnicity are among the predisposing factors for fetal malpresentation at term.

OBJECTIVE: Fetal malpresentation complicates approximately 3% to 4% of all term births. It requires special considerations for delivery and exposes the mother and neonate to obstetrical interventions and potential adverse outcomes, such as umbilical cord prolapse, head entrapment and birth trauma, hypoxic ischemic encephalopathy, cesarean delivery, and cesarean delivery-related complications. We set out to explore the maternal and fetal factors associated with noncephalic malpresentation at term, with specific interest on the impact of maternal race and ethnicity on fetal malpresentation. STUDY DESIGN: This was a retrospective analysis of the Centers for Disease Control and Prevention Natality Live Birth database for the years from 2016 through 2018. All term, singleton deliveries for the following racial and ethnic groups were included: non-Hispanic White, non-Hispanic Black, Asian, and Hispanic. Race and ethnicity were assigned based on self-identification and individuals with >1 racial category were excluded from the analysis. Malpresentation was defined as a noncephalic presentation at term and included breech and transverse presentations. The malpresentation group included all noncephalic births and cephalic births that occurred following successful external cephalic version, whereas all other cephalic births served as controls. A multivariable logistic regression analysis was used to assess the rate of malpresentation, with adjustment for potential confounders including maternal age, race and ethnicity, parity, birthweight, fetal malformations, malformations of the central nervous system (CNS), and chromosomal anomalies. The results are displayed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Statistical significance was set at a P value of <.05. Institutional review board approval was not required because the de-identified data are publicly available through a data use agreement. RESULTS: There were 9,692,203 term, singleton births during the study period. The malpresentation group included 354,689 births (3.66% of the total). The Table shows the rate of malpresentation for various maternal and fetal factors. We found a substantial racial and ethnic disparity in the malpresentation rates. Non-Hispanic White women had the highest malpresentation risk, whereas non-Hispanic Black women had the lowest risk (3.93% vs 2.81%; aOR, 1.38; 95% CI, 1.36-1.39). Hispanic and Asian women were also at increased risk for malpresentation when compared with non-Hispanic Black women (aOR, 1.30; 95% CI, 1.29-1.32 and aOR, 1.12; 95% CI, 1.10-1.14, respectively). In addition, several maternal and fetal conditions were noted to be associated with an increased risk for malpresentation at term, including older maternal age (aOR, 2.81; 95% CI, 2.74-2.88; for patients >40 years), nulliparity (aOR, 1.50; 95% CI, 1.48-1.51), low birthweight (aOR, 1.80; 95% CI, 1.77-1.83 for birthweight under 2500 g), and fetal malformations of the CNS and chromosomal anomalies (aOR, 3.53; 95% CI, 3.06-4.06 and aOR, 2.32; 95% CI, 2.05-2.63, respectively). CONCLUSION: Based on a large US population database, we identified several maternal, fetal, and racial and ethnic factors that are associated with an increased rate of noncephalic malpresentation at term. Specifically, fetal CNS malformations, congenital or chromosomal anomalies, advanced maternal age, low birthweight, and nulliparity are risk factors for noncephalic presentation. Interestingly, non-Hispanic White women have the highest risk for malpresentation, whereas non-Hispanic Black women have the lowest risk. Previous publications found that low birthweight, advanced maternal age, nulliparity, and congenital fetal malformations are risk factors for malpresentation.1-3 Nonetheless, the current data available on race and ethnicity are sporadic, with limited reports suggesting that sub-Saharan ethnicity is associated with a lower rate of malpresentation2 and that White race is associated with a higher rate.4 We present a large-scale, nationwide US-based study to confirm the racial and ethnic disparity regarding malpresentation in the United States. This may be explained by the known variation in the shape of the bony birth canal in different racial and ethnic groups and populations from different geographic locations.5 Further investigation is needed to explore the racial and ethnic disparity described.

Time interval from late preterm antenatal corticosteroid administration to delivery and the impact on neonatal outcomes.

BACKGROUND: Although administration of antenatal corticosteroids has been shown to decrease neonatal respiratory morbidity when given to women at risk for late preterm birth, the time interval from antenatal corticosteroid administration to delivery that is associated with the greatest neonatal benefit remains unknown. OBJECTIVE: This study aimed to evaluate whether the time interval from administration of late preterm antenatal corticosteroids to delivery is associated with a change in the likelihood of transient tachypnea of the newborn, respiratory distress syndrome, and hypoglycemia. STUDY DESIGN: This was a retrospective cohort study of all singleton neonates who were exposed to 1 or 2 doses of antenatal corticosteroids in the late preterm period (34+0 to 36+6 weeks' gestation) within a large healthcare system between November 2017 and March 2020. Neonates exposed to antenatal corticosteroids before 34 weeks' gestation and those with major fetal structural malformations and chromosomal disorders were excluded. Cases were stratified into the following groups based on the time interval from the first dose of antenatal corticosteroid administration to delivery: <2 days, 2 to 7 days, and >7 days. The primary outcome of transient tachypnea of the newborn was compared among the 3 groups. Secondary outcomes included respiratory distress syndrome and hypoglycemia. A multivariable logistic regression was performed to evaluate the association between the time interval and neonatal outcomes while adjusting for potential confounders. For each outcome, delivery within 2 to 7 days from the first dose of betamethasone administration was defined as the reference group. Data were presented as adjusted odds ratios with 95% confidence intervals, and statistical significance was defined as P < .05. RESULTS: The study cohort comprised 1248 neonates. Of those, 649 (52%) were exposed to 1 dose of antenatal corticosteroids. There were statistically significant differences in the maternal characteristics such as nulliparity, pregnancies complicated by hypertensive disorders and fetal growth restriction, gestational age at antenatal corticosteroid administration, gestational age at delivery, and mode of delivery among the 3 groups. There was a significantly increased risk for transient tachypnea of the newborn (adjusted odds ratio, 4.81; 95% confidence interval, 1.72-12.92) and respiratory distress syndrome (adjusted odds ratio, 9.86; 95% confidence interval, 1.15-84.24) associated with delivery <2 days of antenatal corticosteroid administration. The risk for hypoglycemia was highest in the delivery <2 days group (adjusted odds ratio, 3.44; 95% confidence interval, 2.10-5.63) and decreased as the time interval from antenatal corticosteroid administration to delivery increased (adjusted odds ratio, 0.32; 95% confidence interval, 0.20-0.51 for delivery >7 days). CONCLUSION: Adverse neonatal outcomes such as transient tachypnea of the newborn, respiratory distress syndrome, and hypoglycemia are more common when late preterm birth occurs <2 days after antenatal corticosteroid administration when compared with birth 2 to 7 days after administration. In addition, delivery >7 days after antenatal corticosteroid administration is associated with a decreased risk for hypoglycemia. Understanding the impact of antenatal corticosteroid timing on neonatal outcomes is essential in caring for patients at risk for late preterm birth.

Practice patterns in the administration of late preterm antenatal corticosteroids.

BACKGROUND: Given the unpredictable nature of preterm birth and the short-term impact of antenatal corticosteroids on neonatal outcomes, optimal timing of antenatal corticosteroid administration (2-7 days from expected birth) remains challenging. OBJECTIVE: We set out to evaluate the likelihood of delivery between 2 and 7 days after antenatal corticosteroid administration in the late preterm period and whether this differs based on the indication for corticosteroid administration. STUDY DESIGN: Retrospective cohort of all singletons that received antenatal corticosteroids in the late preterm period (34 0/7 to 36 6/7 weeks' gestation) and delivered within a large health system between November 2017 and March 2020. Women who received antenatal corticosteroids before the late preterm period, major fetal structural malformations, and cases with missing data were excluded. Cases were stratified on the basis of the indication for antenatal corticosteroid administration, that is, anticipated spontaneous late preterm birth or medically indicated late preterm birth. The primary outcome was delivery between 2 and 7 days after the administration of the first dose of antenatal corticosteroids. Secondary outcomes included time interval from antenatal corticosteroid administration to delivery and delivery during the first 2 days or later than 7 days after antenatal corticosteroid administration. Multivariable logistic regression was performed to evaluate factors associated with optimal timing while adjusting for potential confounders. RESULTS: Of the 1238 patients included in the study, 656 (53%) delivered within the first day after antenatal corticosteroid administration and thus received only the first of 2 doses. Regardless of the indication for late preterm antenatal corticosteroid administration, the likelihood of delivery between 2 and 7 days later was 13.3% (165 of 1238). Moreover, it was more common (23.4% vs 5.0%; P≤.001) (Table 2) and more likely (adjusted odds ratio, 5.88; 95% confidence interval, 4.00-9.09) in women at risk of medically indicated preterm birth than in those with anticipated spontaneous preterm birth. Furthermore, women with anticipated spontaneous preterm birth had a shorter time interval from antenatal corticosteroid administration to delivery (10.7 vs 49.71 hour; P≤.001). CONCLUSION: Regardless of the indication for late preterm antenatal corticosteroid administration, the likelihood of delivery between 2 and 7 days later was low. Nevertheless, our data suggested that delivery within the desired time interval of antenatal corticosteroid administration is more common in women at risk of medically indicated late preterm birth compared with those at risk of spontaneous late preterm birth.

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage.

Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system's post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.