Society for Maternal-Fetal Medicine Position Statement: Access to abortion care.

POSITION: The Society for Maternal-Fetal Medicine supports the right of all individuals to access the full spectrum of reproductive health services, including abortion care. Reproductive health decisions are best made by each individual with guidance and support from their healthcare providers. The Society opposes legislation and policies that limit access to abortion care or criminalize abortion care and self-managed abortion. In addition, the Society opposes policies that compromise the patient-healthcare provider relationship by limiting a healthcare provider's ability to counsel patients and provide evidence-based, medically appropriate treatment.

Cardiometabolic Health in Pregnancy and Postpartum: Findings From a Prospective Cohort Study in South Africa.

Background: The cardiometabolic impact of HIV infection and treatment with antiretroviral therapy (ART) in pregnancy and the postpartum period remains unclear. Methods: We enrolled pregnant persons with (PHIV) and without HIV in Cape Town, South Africa, who were ≥18 years old at 24-28 weeks' gestation and followed them up to 32 months postpartum. We estimated associations between HIV status and cardiometabolic risk including body mass index (BMI), obesity (BMI ≥30 kg/m2), blood pressure (BP; elevated systolic BP ≥130 and/or diastolic ≥85 mmHg), lipid levels, and metabolic syndrome according to the Joint Interim Statement criteria using multivariable log binomial or linear regression models. Subgroup analyses compared PHIV on efavirenz (EFV)- vs dolutegravir (DTG)-based ART. Results: Among 400 participants (n = 200 without HIV, n = 200 PHIV), 52% had prepregnancy obesity and 9% had elevated BP. Postpartum, 57% were classified with obesity, 31% had elevated BP, and 29% had metabolic syndrome. In multivariable analyses, HIV was associated with a lower BMI prepregnancy but not postpartum; however, mean indices were in the obese range regardless of HIV status. Neither BMI nor obesity prepregnancy or postpartum differed by ART regimen. Among PHIV, participants on DTG had higher levels of elevated BP in pregnancy and postpartum, compared with PHIV on EFV. Conclusions: We observed high levels of obesity, elevated BP, and metabolic syndrome in the perinatal period but few differences by HIV status. Participants on DTG may be more likely to have elevated BP in pregnancy and postpartum. Monitoring of cardiometabolic health for pregnant persons on DTG is warranted.

Association of maternal pre-pregnancy or first trimester body mass index with neurodevelopmental impairment or death in extremely low gestational age neonates.

OBJECTIVE: To compare the rates of death or survival with severe neurodevelopmental impairment (sNDI) at 2 years among extremely preterm infants in relation to pre-pregnancy or first-trimester maternal body mass index (BMI). METHODS: This retrospective cohort study included extremely preterm infants (gestational age 220/7-266/7 weeks). The study was conducted at National Institute of Child Health and Human Development Neonatal Research Network sites. The primary outcome was death or sNDI at 2 years. RESULTS: Data on the primary outcome were available for 1208 children. Death or sNDI was not different among the three groups: 54.9% in normal, 56.1% in overweight, and 53.4% in obese group (p = 0.39). There was no significant difference in mortality, sNDI, moderate/severe cerebral palsy, Bayley Scales of Infant Development (BSID)-III cognitive composite score <70, BSID-III language composite score <70 in adjusted models. CONCLUSION: Neurodevelopmental outcome was not significantly associated with maternal pre-pregnancy BMI among extreme preterm infants.

Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People with Gestational Diabetes.

OBJECTIVE: We aimed to evaluate uptake of the glucose tolerance test performed during delivery hospitalization as part of routine clinical care. STUDY DESIGN: This is a retrospective cohort study of people with GDM at a tertiary center. We collected 9 months of postimplementation data after the in-hospital ("early") glucose tolerance test was adopted as a routine screening option. Adherence was compared between those who elected early glucose tolerance testing versus those who deferred testing to the standard postpartum period. Bivariable statistics including demographics, care team, and postpartum testing/visit attendance were compared between those who received early testing and those who did not using chi-square, Fisher's exact, and t-tests. RESULTS: A total of 681 patients with GDM delivered during the study period. Of those who had an early glucose tolerance test ordered (n = 408), 340 (83.3%) completed the test. Among those who did not complete an early glucose tolerance test (ordered and not completed or never ordered), only 104/341 (30.5%) completed any postpartum glucose testing in the first 12 months of postpartum. There were significant differences in characteristics in terms of race/ethnicity, insurance, type of gestational diabetes (A1GDM vs. A2GDM), diabetes medications, obstetric care provider, and delivery mode. Among those who completed early testing, 43.7% of participants had impaired glucose metabolism and 6.5% had values concerning for overt diabetes mellitus. Among those who deferred testing to the standard 6- to 12-week period, 24.0% had impaired glucose metabolism and none had overt diabetes. Those who completed an early glucose tolerance test had a lower rate of postpartum visit attendance compared with those who deferred (75.6 vs. 91.5%, p < 0.01). CONCLUSION: In this cohort, when the early glucose tolerance test is offered in clinical practice, adherence rates are higher than when the test is deferred until the postpartum visit. KEY POINTS: · Adherence rates with the early glucose tolerance test (GTT) are higher than if the testing is deferred.. · Those who completed an early GTT had a lower rate of postpartum visit attendance compared with those who deferred.. · Offering an in-hospital postpartum GTT can help address low rates of glucose testing postpartum..

Early-Pregnancy Resilience Characteristics Before Versus During the COVID-19 Pandemic.

OBJECTIVE: Resilience is associated with mental and somatic health benefits. Given the social, physical, and mental health toll of the coronavirus disease 2019 (COVID-19) pandemic, we examined whether the COVID-19 pandemic was associated with population-level changes in resilience among pregnant people. STUDY DESIGN: Secondary analysis of a prospective cohort of nulliparous pregnant people <20 weeks' gestation from a single hospital. Participants completed baseline assessments of resilience characteristics, including dispositional optimism (DO), mindfulness, and proactive coping. For this analysis, participants recruited before the COVID-19 pandemic were compared with those recruited during the pandemic. The primary outcome was DO, assessed as a continuous score on the validated Revised Life Orientation Test. Secondary outcomes included continuous scores on mindfulness and proactive coping assessments. Bivariable analyses were completed using chi-squared and Mann-Whitney U tests. Multivariable linear regression compared resilience scores by recruitment time frame, controlling for confounders selected a priori: maternal age, education, and marital status. RESULTS: Of the 300 participants, 152 (50.7%) were recruited prior to the pandemic. Demographic and pregnancy characteristics differed between groups: the during-pandemic group was older, had higher levels of education, and were more likely to be married/partnered. There were no significant differences in any of the resilience characteristics before versus during the pandemic in bivariable or multivariable analyses. CONCLUSION: In this cohort, there were no differences in early pregnancy resilience characteristics before versus during the COVID-19 pandemic. This affirms that on a population level, resilience is a stable metric, even in the setting of a global pandemic. KEY POINTS: · Resilience is associated with mental and somatic health benefits.. · No difference in early-pregnancy resilience in those recruited before versus during the pandemic.. · Consistent with conceptualization of resilience as an innate characteristic..

Food, nutrition, and fertility: from soil to fork.

Food and nutrition-related factors, including foods and nutrients consumed, dietary patterns, use of dietary supplements, adiposity, and exposure to food-related environmental contaminants, have the potential to impact semen quality and male and female fertility; obstetric, fetal, and birth outcomes; and the health of future generations, but gaps in evidence remain. On 9 November 2022, Tufts University's Friedman School of Nutrition Science and Policy and the school's Food and Nutrition Innovation Institute hosted a 1-d meeting to explore the evidence and evidence gaps regarding the relationships between food, nutrition, and fertility. Topics addressed included male fertility, female fertility and gestation, and intergenerational effects. This meeting report summarizes the presentations and deliberations from the meeting. Regarding male fertility, a positive association exists with a healthy dietary pattern, with high-quality evidence for semen quality and lower quality evidence for clinical outcomes. Folic acid and zinc supplementation have been found to not impact male fertility. In females, body weight status and other nutrition-related factors are linked to nearly half of all ovulation disorders, a leading cause of female infertility. Females with obesity have worse fertility treatment, pregnancy-related, and birth outcomes. Environmental contaminants found in food, water, or its packaging, including lead, perfluorinated alkyl substances, phthalates, and phenols, adversely impact female reproductive outcomes. Epigenetic research has found that maternal and paternal dietary-related factors can impact outcomes for future generations. Priority evidence gaps identified by meeting participants relate to the effects of nutrition and dietary patterns on fertility, gaps in communication regarding fertility optimization through changes in nutritional and environmental exposures, and interventions impacting germ cell mechanisms through dietary effects. Participants developed research proposals to address the priority evidence gaps. The workshop findings serve as a foundation for future prioritization of scientific research to address evidence gaps related to food, nutrition, and fertility.

Early pregnancy dispositional optimism and pregnancy outcomes among nulliparous people.

BACKGROUND: Dispositional optimism, the expectation of positive outcomes after personal challenges, is a resilience factor associated with widespread health benefits. However, the data on pregnancy-related outcomes are more limited. OBJECTIVE: This study aimed to assess the association of early pregnancy dispositional optimism with adverse perinatal outcomes. STUDY DESIGN: This was a prospective cohort study completed between May 2019 and February 2022 at a single, large tertiary medical center. Nulliparous pregnant people were recruited from outpatient obstetrical care sites. Participants completed a validated assessment of dispositional optimism at <20 weeks of gestation and were followed up until delivery. The primary outcome was an adverse maternal outcome composite that included gestational diabetes mellitus, hypertensive disorders of pregnancy, and/or cesarean delivery. The secondary outcomes included individual composite components and a neonatal morbidity composite. Bivariate analyses compared characteristics and primary and secondary outcomes by dispositional optimism score quartile. Multivariable logistic regression compared outcomes by dispositional optimism score quartile with the highest quartile serving as the referent, controlling for confounders determined a priori. RESULTS: Overall, 491 pregnant people were approached for participation, and 135 pregnant people (27.5%) declined participation. Among the 284 individuals who enrolled and had complete outcome data, the median dispositional optimism score was 16.0 (interquartile range, 14-18), and 47.9% of individuals experienced at least 1 adverse maternal outcome 135 (47.9%). After adjusting for confounders, the odds of adverse maternal outcomes were significantly higher in the lowest 2 optimism quartiles: quartile 1 (adjusted odds ratio, 3.33; 95% confidence interval, 1.57-7.36) and quartile 2 (adjusted odds ratio, 2.22; 95% confidence interval, 1.05-4.79) than the highest quartile. This was driven by significantly higher rates of hypertension (quartile 1: adjusted odds ratio, 2.62; 95% confidence interval, 1.12-6.29) and cesarean delivery (quartile 1: adjusted odds ratio, 2.75; 95% confidence interval, 1.20-6.55). There was no difference noted when quartile 3 was compared with quartile 4. CONCLUSION: Lower early pregnancy dispositional optimism was associated with significantly higher odds of adverse maternal outcomes. Interventions targeting improvements in optimism may be a novel mechanism for reducing perinatal morbidity.

Experiences of stigma, psychological distress, and facilitative coping among pregnant people with gestational diabetes mellitus.

BACKGROUND: Gestational diabetes mellitus (GDM) has been rising in the United States, and it poses significant health risks to pregnant individuals and their infants. Prior research has shown that individuals with GDM also experience prevalent stress and mental health issues, which can further contribute to glucose regulation difficulties. Stigma associated with GDM may contribute to these mental health challenges, yet there is a lack of focused research on GDM-related stigma, its impact on psychological health, and effective coping mechanisms. Thus, this qualitative study aims to understand individuals' experiences related to GDM stigma, mental health, and facilitative coping. METHODS: In-depth, semi-structured interviews were conducted with 14 individuals with a current or recent (within the last year) diagnosis of GDM. Thematic analysis was employed to guide data analysis. RESULTS: Four themes emerged from data analysis: (1) experience of distal GDM stigma including stigmatizing provider interactions, stigma from non-medical spaces, and intersecting stigma with weight, (2) internalized GDM stigma, such as shame, guilt, and self-blame, (3) psychological distress, which included experiences of stress and overwhelm, excessive worry and fear, and loneliness and isolation, and (4) facilitative coping mechanisms, which included diagnosis acceptance, internet-based GDM community, active participation in GDM management, social and familial support, and time for oneself. CONCLUSIONS: Findings demonstrate the relevance of GDM stigma in mental health among people with GDM and the need for addressing GDM stigma and psychological health in this population. Interventions that can reduce GDM stigma, improve psychological wellness, and enhance positive coping may facilitate successful GDM management and healthy birth outcomes. Future quantitative, theory-driven research is needed to understand the prevalence of GDM stigma experiences and mechanisms identified in the current study, as well as among marginalized populations (e.g., individuals of color, sexual and gender minorities).

Associations of HIV and antiretroviral therapy with gestational diabetes in South Africa.

OBJECTIVE: To estimate associations of HIV status and antiretroviral (ART) regimen with gestational diabetes (GDM) and postpartum glucose metabolism. DESIGN: Prospective cohort study. METHODS: We enrolled pregnant persons with HIV (PWH) and without HIV in Cape Town, South Africa who were at least 18 years of age at 24-28 weeks' gestation and followed up to 26 months postpartum. Participants were tested for GDM in pregnancy and for diabetes postpartum using a 75 g 2 h oral glucose tolerance test (OGTT) and diagnosed via WHO criteria. We estimated associations of HIV status and ART regime [efavirenz (EFV) versus dolutegravir (DTG)] with GDM and postpartum impaired glucose metabolism using multivariable log binomial or linear regression models. RESULTS: Among 397 participants [median age 30 (interquartile range (IQR) 25-34; n  = 198 without HIV, n  = 199 PWH], the prevalence of GDM was 6% (9 PWH versus 3% without HIV). In multivariable analyses, PWH were at higher risk of GDM [risk ratio (RR) 3.9, 95% confidence interval (CI) 1.4-10.7] after adjustment for prepregnancy BMI and other confounders. GDM risk did not differ by ART regimen (unadjusted prevalence 8.1% DTG versus 5.6% EFV, adjusted RR 1.1, 95% CI 0.2-6.6). Few participants had diabetes, impaired glucose tolerance (IGT), or impaired fasting glucose postpartum ( n  = 13, 6%) with no differences by HIV or ART status. CONCLUSION: In a setting of universal GDM testing, PWH had an increased risk of impaired glucose metabolism during pregnancy but not postpartum. Among PWH, GDM risk was similar regardless of EFV or DTG use. Given concerns about DTG and weight gain, diabetes risk should continue to be monitored.

Variation in Outpatient Postpartum Care Use in the United States: A Latent Class Analysis.

INTRODUCTION: Despite efforts to improve postpartum health care in the United States, little is known about patterns of postpartum care beyond routine postpartum visit attendance. This study aimed to describe variation in outpatient postpartum care patterns. METHODS: In this longitudinal cohort study of national commercial claims data, we used latent class analysis to identify subgroups of patients (classes) with similar outpatient postpartum care patterns (defined by the number of preventive, problem, and emergency department outpatient visits in the 60 days after birth). We also compared classes in terms of maternal sociodemographics and clinical characteristics measured at childbirth, as well as total health spending and rates of adverse events (all-cause hospitalizations and severe maternal morbidity) measured from childbirth to the late postpartum period (61-365 days after birth). RESULTS: The study cohort included 250,048 patients hospitalized for childbirth in 2016. We identified six classes with distinct outpatient postpartum care patterns in the 60 days after birth, which we classified into three broad groups: no care (class 1 [32.4% of the total sample]); preventive care only (class 2 [18.3%]); and problem care (classes 3-6 [49.3%]). The prevalence of clinical risk factors at childbirth increased progressively from class 1 to class 6; for example, 6.7% of class 1 patients had any chronic disease compared with 15.5% of class 5 patients. Severe maternal morbidity was highest among the high problem care classes (classes 5 and 6): 1.5% of class 6 patients experienced severe maternal morbidity in the postpartum period and 0.5% in the late postpartum period, compared with less than 0.1% of patients in classes 1 and 2. CONCLUSIONS: Efforts to redesign and measure postpartum care should reflect the current heterogeneity in care patterns and clinical risks in the postpartum population.

Predicting primary cesarean delivery in pregnancies complicated by gestational diabetes mellitus.

BACKGROUND: Prediction models have shown promise in helping clinicians and patients engage in shared decision-making by providing quantitative estimates of individual risk of important clinical outcomes. Gestational diabetes mellitus is a common complication of pregnancy, which places patients at higher risk of primary CD. Suspected fetal macrosomia diagnosed on prenatal ultrasound is a well-known risk factor for primary CD in patients with gestational diabetes mellitus, but tools incorporating multiple risk factors to provide more accurate CD risk are lacking. Such tools could help facilitate shared decision-making and risk reduction by identifying patients with both high and low chances of intrapartum primary CD. OBJECTIVE: This study aimed to develop and internally validate a multivariable model to estimate the risk of intrapartum primary CD in pregnancies complicated by gestational diabetes mellitus undergoing a trial of labor. STUDY DESIGN: This study identified a cohort of patients with gestational diabetes mellitus derived from a large, National Institutes of Health-funded medical record abstraction study who delivered singleton live-born infants at ≥34 weeks of gestation at a large tertiary care center between January 2002 and March 2013. The exclusion criteria included previous CD, contraindications to vaginal delivery, scheduled primary CD, and known fetal anomalies. Candidate predictors were clinical variables routinely available to a practitioner in the third trimester of pregnancy found to be associated with an increased risk of CD in gestational diabetes mellitus. Stepwise backward elimination was used to build the logistic regression model. The Hosmer-Lemeshow test was used to demonstrate goodness of fit. Model discrimination was evaluated via the concordance index and displayed as the area under the receiver operating characteristic curve. Internal model validation was performed with bootstrapping of the original dataset. Random resampling with replacement was performed for 1000 replications to assess predictive ability. An additional analysis was performed in which the population was stratified by parity to evaluate the model's predictive ability among nulliparous and multiparous individuals. RESULTS: Of the 3570 pregnancies meeting the study criteria, 987 (28%) had a primary CD. Of note, 8 variables were included in the final model, all significantly associated with CD. They included large for gestational age, polyhydramnios, older maternal age, early pregnancy body mass index, first hemoglobin A1C recorded in pregnancy, nulliparity, insulin treatment, and preeclampsia. Model calibration and discrimination were satisfactory with the Hosmer-Lemeshow test (P=.862) and an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.74-0.77). Internal validation demonstrated similar discriminatory ability. Stratification by parity demonstrated that the model worked well among both nulliparous and multiparous patients. CONCLUSION: Using information routinely available in the third trimester of pregnancy, a clinically pragmatic model can predict intrapartum primary CD risk with reasonable reliability in pregnancies complicated by gestational diabetes mellitus and may provide quantitative data to guide patients in understanding their individual primary CD risk based on preexisting and acquired risk factors.

How Close Are You to Gestational Diabetes Mellitus?

The objective of this study is to evaluate if proximity to food sources, rather than density, is associated with gestational diabetes mellitus (GDM) risk. Rhode Island birth certificate data from 2015-2016 were utilized. A proximity analysis was used to determine the distance from each pregnant person's home address to the closest food source (fast food restaurant, supermarket, and farmers market/community garden). Multivariable logistic regression was used to examine the association between distance to food source and the risk of GDM. Of the 20,129 births meeting inclusion criteria, 7.2% (1,447) had GDM. Distance to food sources differed by insurance type, educational background, and race/ethnicity. There was no statistically significant association between distance to any of the food sources and GDM in the adjusted model. Other factors need to be examined to improve interventions, influence policy, and impact neonatal and maternal outcomes.

Waterpipe Tobacco (Hookah) Use in Pregnancy: Associations with Nausea and Vomiting of Pregnancy.

OBJECTIVE: Waterpipe tobacco (WPT) use is common among reproductive age patients and is often perceived as safer than cigarette use. Prior studies have shown a decrease in nausea and vomiting symptoms among pregnant women who use cigarettes, but no studies to date have examined these symptoms in pregnant women who use WPT. This study was aimed to investigate the extent of symptoms of nausea/vomiting of pregnancy among participants who self-reported WPT use during pregnancy. STUDY DESIGN: Secondary analysis of a prospective cohort study examining WPT use during pregnancy. Participants completed the Pregnancy-Unique Quantification of Emesis (PUQE) during first and third trimesters. Medical conditions were determined by medical record review. Participants were evaluated by sole WPT use versus dual/polysubstance WPT use and frequency of WPT use. RESULTS: Ninety-nine (100%) participants completed the PUQE questionnaire during first trimester and 82 (82.8%) completed the PUQE during third trimester. Almost all (91.9%) participants reported moderate nausea/vomiting symptoms at both assessments. There was no difference in frequency of WPT use in pregnancy or rates of dual/polysubstance WPT use in participants with all levels of the PUQE questionnaire. There was also no difference in rates of WPT use or PUQE scores between sole WPT users and dual/polysubstance users. When comparing low and high WPT use, those who were in the higher frequency use group had higher waterpipe dependence scale scores (7.2 vs. 5.3, p < 0.02). With regard to maternal medical comorbidities, the only difference between groups was that sole WPT users were more likely to have a diagnosis of asthma than dual/polysubstance users (36.8 vs. 14.9%, p < 0.02). CONCLUSION: There were no differences in symptoms of nausea and vomiting of pregnancy or medical conditions in pregnant women who use WPT with any frequency during pregnancy. However, sole WPT users had higher rates of asthma than dual/polysubstance WPT users. KEY POINTS: · Waterpipe tobacco use is one of the most common forms of tobacco use among reproductive age patients.. · Waterpipe tobacco use was not associated with any changes in nausea/vomiting of pregnancy symptoms.. · Future research on the use of waterpipe tobacco in pregnancy can aid in public health responses..

Maternal hypertensive disorders and survival without major morbidities among extremely low gestation newborns.

OBJECTIVE: Evaluate if odds of survival without major morbidity are higher among extremely low gestation neonates (ELGANs) born to mothers with chronic hypertension (cHTN) or hypertensive disorders of pregnancy (HDP) compared to ELGANs born to mothers without hypertension (HTN). STUDY DESIGN: Retrospective study of prospectively collected data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Included children had a birthweight of 401-1000 g and/or gestational age of 220/7 to 286/7 wks. The primary outcome was survival to discharge without major morbidity. Multivariable regression models were used to compare outcomes among ELGANs born to women with cHTN, HDP, and no HTN. RESULTS: Survival without morbidities for newborns of mothers with no HTN, cHTN and HDP (29.1%, 32.9%, 37.0% respectively) did not differ after adjustment. CONCLUSION: After adjusting for contributing variables maternal HTN is not associated with improved survival free of morbidity among ELGANs. TRIALS REGISTRATION: clinicaltrials.gov Identifier: NCT00063063 (generic database).

Third-Grade Educational Outcomes of the Children of Adolescent Women.

OBJECTIVES: To evaluate third-grade reading and math proficiency for children born to adolescent women compared with those born to non-adolescent women. METHODS: A statewide, retrospective cohort study was conducted in Rhode Island using third-grade year-end examination data from 2014 to 2017 as part of a statewide initiative to improve third grade reading levels. Children's third-grade reading and math proficiencies were compared between those born to nulliparous adolescent women (age 15-19 at the time of delivery), and nulliparous women 20 years or older at delivery. Bivariate analyses were conducted to compare maternal and child characteristics between adolescent and non-adolescent groups. Multivariable logistic regression was used to examine the association between having an adolescent mother and being proficient in reading and math after adjusting for lunch subsidy, core city residence, child race/ethnicity and sex. RESULTS: Of the 8,248 children meeting the inclusion criteria, 20% were born to adolescent women and the remaining 80% were born to non-adolescent women. After adjusting for potential confounders, children born to adolescent women were significantly less likely to be proficient in both reading (adjusted risk ratio (aRR) 0.77, 95% confidence interval (CI): 0.71-0.83) and math (aRR 0.78, 95% CI: 0.72-0.85). CONCLUSIONS FOR PRACTICE: Children born to adolescent women had significantly lower rates of reading and math proficiency when compared with children of non-adolescent women. These children may benefit from additional resources focused on early academic performance in order to address disparities in reading and math proficiency.

Prediction Model Assessing Risk of Delivery after Diagnosis of Abnormal Umbilical Artery Doppler.

OBJECTIVE: Umbilical artery Doppler (UAD) velocimetry abnormalities are associated with increased neonatal morbidity and mortality. Currently, there are no risk stratification methods to assist in antepartum management such as timing of antenatal corticosteroids (ACS). Therefore, we sought to develop a model to predict risk of delivery within 7 days following diagnosis of abnormal UAD velocimetry in patients with fetal growth restriction (FGR). STUDY DESIGN: Retrospective single referral center study of liveborn singleton pregnancies complicated by FGR and ≥1 abnormal UAD velocimetry value (≥95th percentile for gestational age [GA]). We considered 17 variables and used backward stepwise logistic regression to create a multivariable model for the prediction of delivery within 7 days. We assessed model fit with calibration, discrimination, likelihood ratios, and area under the curve. Internal validation of the model was assessed by using the bootstrap method. RESULTS: Between 2008 and 2015, a total of 176 patients were eligible and included for model development. Median (range) GA at initial eligibility was 32.1 weeks (28.1-36.1 weeks) and from initial eligibility until delivery was 21 days (0-104 days). Fifty-two patients (30%) were delivered in the 7 days following inclusion. GA at first abnormal UAD, severity of first abnormal UAD, oligohydramnios, preeclampsia, and pre-pregnancy BMI were included in the model. The model had an area under the ROC curve of 0.94 (95% confidence interval [CI]: 0.90-0.98), sensitivity of 85%, and specificity of 91%. If the model alone were used for ACS timing, 85% of the cohort who delivered in the following week would have received ACS, and ACS would not have been given to 91% who delivered later. Internal validation yielded similar results with a mean area under the curve (95% CI) of 0.94 (0.88-0.98). CONCLUSION: If validated externally, our model can be used to predict risk of delivery in patients with FGR and abnormal UAD velocimetry, potentially improving timing of ACS. KEY POINTS: · Risk of delivery in seven days can be predicted.. · Risk of delivery can inform corticosteroid timing.. · External validation can further develop a clinical aid..

Association of Antenatal Steroid Exposure at 21 to 22 Weeks of Gestation With Neonatal Survival and Survival Without Morbidities.

Importance: The provision of antenatal corticosteroids to pregnant patients at gestational age (GA) 22 6/7 weeks or less remains controversial and lacks support from randomized clinical trials. Objective: To compare rates of survival and survival without major morbidities among infants born at GA 22 0/7 to 23 6/7 weeks after exposure to antenatal steroids at 22 6/7 weeks' gestation or less vs no exposure to antenatal steroids. Design, Setting, and Participants: This cohort study enrolled infants born at GA 22 0/7 to 23 6/7 weeks between January 1, 2016, and December 31, 2019, at centers in the National Institute of Child Health and Human Development Neonatal Research Network. Infants who did not receive intensive care and infants with antenatal steroid exposure after GA 22 6/7 weeks were excluded. Exposure: Infants were classified as having no, partial, or complete exposure to antenatal steroids. Main Outcomes and Measures: The primary outcome was survival to discharge. The main secondary outcome was survival without major neonatal morbidity. The associations of differential exposures to antenatal steroids with outcomes were evaluated using logistic regression, adjusting for GA, sex, race, maternal education, small for GA status, mode of delivery, multiple birth, prolonged rupture of membranes, year of birth, and Neonatal Research Network center. Results: A total of 431 infants (mean [SD] GA, 22.6 [0.5] weeks; 232 [53.8%] boys) were included, with 110 infants (25.5%) receiving no antenatal steroids, 80 infants (18.6%) receiving partial antenatal steroids, and 241 infants (55.9%) receiving complete antenatal steroids. Seventeen infants were exposed to antenatal steroids at GA 21 weeks. Among infants exposed to complete antenatal steroids, 130 (53.9%) survived to discharge, compared with 30 infants (37.5%) with partial antenatal steroid exposure and 239 infants (35.5%) with no antenatal steroids. Infants born after complete antenatal steroid exposure, compared with those without antenatal steroid exposure, were more likely to survive to discharge (adjusted odds ratio [aOR], 1.95 [95% CI, 1.07-3.56]) and to survive without major morbidity (aOR, 2.74 [95% CI, 1.19-6.30]). Conclusions and Relevance: In this retrospective cohort study, among infants born between GA 22 0/7 and 23 6/7 weeks who received intensive care, exposure to a complete course of antenatal steroids at GA 22 6/7 weeks or less was independently associated with greater odds of survival and survival without major morbidity. These data suggest that the use of antenatal steroids in patients at GA 22 6/7 weeks or less could be beneficial when active treatment is considered.

Early childhood educational outcomes of children associated with vaginal birth after cesarean delivery.

BACKGROUND: Rates of vaginal birth after cesarean delivery have decreased and cesarean delivery rates have increased in the last 2 decades. Evidence on short-term neonatal outcomes is available, but data on long-term childhood outcomes following vaginal birth after cesarean delivery are insufficient. Long-term childhood outcome data are essential in decision-making regarding mode of delivery. OBJECTIVE: This study aimed to evaluate the association between delivery mode and long-term educational outcomes of the children of pregnant individuals with a previous cesarean delivery. STUDY DESIGN: This was a retrospective cohort study linking Rhode Island third-grade education data from 2014 to 2017 to birth certificate data. Data were obtained from a statewide database using Department of Education data, and were linked to Department of Health birth certificate data. Participants were children of multiparous women who were term, singleton births without congenital anomalies. Children delivered by primary cesarean delivery were excluded. The exposure was mode of delivery classified as vaginal birth after cesarean delivery, repeated cesarean delivery, or repeated vaginal birth. The primary outcome was children's third-grade reading and math proficiency. Bivariate analyses were conducted to assess differences in demographic variables. Bivariable and multivariable log-binomial regression was used to examine the association between subject proficiency and predictors including mode of delivery, maternal education, sex, child race or ethnicity, and lunch subsidy. RESULTS: Of the 10,923 children who met the inclusion criteria, 2.0% were delivered by vaginal birth after cesarean delivery, 22.0% by repeated cesarean delivery, and 76.0% by repeated vaginal delivery. After adjustment for confounders, there was no difference in reading proficiency (adjusted risk ratio, 0.98; 95% confidence interval, 0.84-1.15) or math proficiency (adjusted risk ratio, 0.99; 95% confidence interval, 0.84-1.15) between those born by vaginal birth after cesarean delivery and those born by repeated cesarean delivery. There was no difference found in either proficiency between children born by repeated vaginal birth and those born by repeated cesarean delivery (reading: adjusted risk ratio, 0.97; 95% confidence interval, 0.93-1.01; math: adjusted risk ratio, 0.97; 95% confidence interval, 0.92-1.02). CONCLUSION: In comparison with repeated cesarean delivery, both vaginal birth after cesarean delivery and repeated vaginal birth were not associated with differences in educational outcomes. This may aid in counseling about long-term safety outcomes regarding vaginal birth after cesarean delivery and may assist in shared decision-making when selecting between trial of labor after cesarean delivery and repeated cesarean delivery.