Increased Rates of Hypertensive Disorders of Pregnancy during the COVID-19 Pandemic.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) are common complications associated with severe maternal and neonatal morbidity. One goal of prenatal care, especially at term, is to screen for HDP. As treatment of HDP centers on delivery when appropriate, timely diagnosis is crucial. We postulated that reduced in-person visits during the coronavirus disease 2019 (COVID-19) pandemic may have resulted in delayed diagnosis of HDP with concomitant higher rates of maternal morbidity. We sought to investigate the prevalence of HDP during the COVID-19 pandemic, as well as median gestational age at time of delivery as compared with the prepandemic median. STUDY DESIGN: This was a retrospective cohort analysis comparing singleton deliveries at four large-volume hospitals during the COVID-19 pandemic (April-July 2020 during a statewide "stay-at-home" order) to those in a pre-COVID era (April-July 2019). Deliveries complicated by HDP were identified by International Classification of Disease, Tenth Revision codes. Rates of HDP and markers of severe disease were the primary outcomes compared between the groups; multivariate regression was used to calculate the odds ratio of severe disease among women with any diagnosis of HDP. RESULTS: The cohort included 9,974 deliveries: 5,011 in 2020 and 4,963 in 2019. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ significantly between the groups. There was an increase in HDP during the COVID era (9.0 vs. 6.9%; p < 0.01), which was significant even when controlling for patient parity (odds ratio = 1.41, 95% confidence interval: 1.20-1.66). Among women with HDP, gestational age at delivery did not differ between the cohorts, nor did the proportion of patients with severe disease. CONCLUSION: We found a statistically significant increase in the rate of HDP during the COVID-19 pandemic. However, there was no change in the proportion of severe disease, suggesting that this increase did not significantly impact clinical morbidity. KEY POINTS: · Rates of HDP increased during the COVID-19 pandemic.. · There was no change in the proportion of severe HDP.. · HDP-related maternal/neonatal morbidity was unchanged..

Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores.

OBJECTIVE: Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity. STUDY DESIGN: Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to "low-risk" term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots. RESULTS: A total of 14,497 maternal-neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated. CONCLUSION: A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries. KEY POINTS: · EOCS had moderate discrimination for Apgar <7.. · Predictive performance declined when limited to low-risk term singletons.. · Relationship between EOCS and Apgar <7 was likely driven by prematurity..

Change in Emergency Medical Services-Attended Out-of-Hospital Deliveries during COVID-19 in the United States.

BACKGROUND: The COVID-19 pandemic disrupted access to routine in-person prenatal care, potentially leading to higher risk of out-of-hospital deliveries. Unplanned out-of-hospital deliveries pose a substantial risk of morbidity and mortality for pregnant patients and newborns. Our objective was to determine the change in rate of emergency medical services (EMS)-attended out-of-hospital deliveries during the COVID-19 pandemic. We hypothesized that COVID-19-related stay-at-home orders were associated with a higher rate of out-of-hospital deliveries during the initial wave of COVID-19. METHODS: We conducted an interrupted time series analysis using the 2019 and 2020 National EMS Information System datasets. We included 9-1-1 scene activations for patients 12-50 years old with out-of-hospital deliveries who were treated and transported by EMS. We calculated the weekly rate of deliveries per 100,000 EMS emergency activations each year overall, and for each census division. The interruption modeled was the enactment of stay-at-home orders, with March 25-31 selected as when most orders had been enacted. We fit ordinary least squares regression models with Newey-West standard errors to adjust for autocorrelation, testing for a change in level and slope overall and by census division. RESULTS: A total of 10,778 out-of-hospital deliveries were included, 58% (n = 6,254) in 2020. The mean weekly rate of out-of-hospital deliveries in 2019 was 29.4 per 100,000 activations (95% CI: 28.4 to 30.4) versus 33.0 (95% CI: 31.8 to 34.1) in 2020. There was an immediate increase of 6.3 deliveries per 100,000 activations (95% CI: 3.3 to 9.3) after the week of March 25-31, with a subsequent decrease of 0.3 deliveries per 100,000 per week after (95% CI: -0.4 to -0.2). There were also statistically significant immediate increases in out-of-hospital deliveries after March 25-31 in the New England, East North Central, West South Central, and Mountain divisions. CONCLUSION: EMS-attended out-of-hospital deliveries remained rare during the COVID-19 pandemic, but there was an immediate increase during the initial wave of the pandemic with evidence of geographic variation. Large-scale disruptions in the health care system may result in increases in uncommon patient presentations to EMS.

Comparison of Maternal and Neonatal Subspecialty Care Provision by Hospital.

OBJECTIVE: The aim of the study is to determine the relationship between a hospital's provision of subspecialty neonatal and maternal care. Specifically, we sought to understand where women with high-risk maternal conditions received intrapartum care and estimate the potential transfer burden for those with maternal high-risk conditions delivering at hospitals without subspecialty maternal care. STUDY DESIGN: This is a descriptive study using data from 2015 State Inpatient Databases and the American Hospital Association Annual Survey. Characteristics were compared between hospitals based on the concordance of their maternal and neonatal care. The incidences of high-risk maternal conditions (pre-eclampsia with severe features, placenta previa with prior cesarean delivery, cardiac disease, pulmonary edema, and acute liver failure) were compared. To determine the potential referral burden, the percent of women with high-risk conditions delivering at a hospital without subspecialty maternal care but delivering in a county with a hospital with subspecialty maternal care was calculated. RESULTS: The analysis included 486,398 women who delivered at 544 hospitals, of which 104 (19%) and 182 (33%) had subspecialty maternal and neonatal care, respectively. Ninety-eight hospitals provided both subspecialty maternal and neonatal care; however, 84 hospitals provided only subspecialty neonatal care but no subspecialty maternal care. Among high-risk maternal conditions examined, approximately 65% of women delivered at a hospital with subspecialty maternal care. Of the remainder who delivered at a hospital without subspecialty maternal care, one-third were in a county where subspecialty care was present. For women with high-risk conditions who delivered in a county without subspecialty maternal care, the median distance to the closest county with subspecialty care was 52.8 miles (IQR: 34.3-87.7 miles). CONCLUSION: Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care. This discordance may present a challenge when both high-risk maternal and neonatal conditions are present. KEY POINTS: · High-risk women who deliver at hospitals without subspecialty care are in more rural areas.. · Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care.. · This discordance may present a challenge when both high-risk maternal and neonatal conditions are present..

The Application of a Standard Risk Threshold for the Stratification of Maternal Morbidity among Population Subgroups.

OBJECTIVE: The aim of this study was to determine if a universally applied risk score threshold for severe maternal morbidity (SMM) resulted in different performance characteristics among subgroups of the population. STUDY DESIGN: This is a retrospective cohort study of deliveries that occurred between July 1, 2016, and June 30, 2020, in a single health system. We examined the performance of a validated comorbidity score to stratify SMM risk in our cohort. We considered the risk score that was associated with the highest decile of predicted risk as a "screen positive" for morbidity. We then used this same threshold to calculate the sensitivity and positive predictive value (PPV) of this "highest risk" designation among subgroups of the overall cohort based on the following characteristics: age, race/ethnicity, parity, gestational age, and planned mode of delivery. RESULTS: In the overall cohort of 53,982 women, the C-statistic was 0.755 (95% confidence interval [CI], 0.741-0.769) and calibration plot demonstrated that the risk score was well calibrated. The model performed less well in the following groups: non-White or Hispanic (C-statistic, 0.734; 95% CI, 0.712-0.755), nulliparas (C-statistic, 0.735; 95% CI, 0.716-0.754), term deliveries (C-statistic, 0.712; 95% CI, 0.694-0.729), and planned vaginal delivery (C-statistic, 0.728; 95% CI, 0.709-0.747). There were differences in the PPVs by gestational age (7.8% term and 29.7% preterm) and by planned mode of delivery (8.7% vaginal and 17.7% cesarean delivery). Sensitivities were lower in women who were <35 years (36.6%), non-White or Hispanic (40.7%), nulliparous (38.9%), and those having a planned vaginal delivery (40.9%) than their counterparts. CONCLUSION: The performance of a risk score for SMM can vary by population subgroups when using standard thresholds derived from the overall cohort. If applied without such considerations, such thresholds may be less likely to identify certain subgroups of the population that may be at increased risk of SMM. KEY POINTS: · Predictive risk models are helpful at condensing complex information into an interpretable output.. · Model performance may vary among different population subgroups.. · Prediction models should be examined for their potential to exacerbate underlying disparities..

SARS-CoV-2 Placentitis Associated With B.1.617.2 (Delta) Variant and Fetal Distress or Demise.

There is limited information on the specific impact of maternal infection with the SARS-CoV-2 B.1.617.2 (delta) variant on pregnancy outcomes. We present 2 cases of intrauterine fetal demise and 1 case of severe fetal distress in the setting of maternal infection with delta-variant SARS-CoV-2. In all cases, fetal demise or distress occurred within 14 days of COVID-19 diagnosis. Evaluation revealed maternal viremia, high nasopharyngeal viral load, evidence of placental infection with delta-variant SARS-CoV-2, and hallmark features of SARS-CoV-2 placentitis. We suggest that delta-variant SARS-CoV-2 infection during pregnancy warrants vigilance for placental dysfunction and fetal compromise regardless of disease severity.

Association between peripartum hysterectomy and venous thromboembolism.

BACKGROUND: The risk of venous thromboembolism after delivery is modified by mode of delivery, with the risk of venous thromboembolism being higher after cesarean delivery than vaginal delivery. The risk of venous thromboembolism after peripartum hysterectomy is largely unknown. OBJECTIVE: This study aimed to compare the incidence and risk of venous thromboembolism among women who had and did not have a peripartum hysterectomy. Furthermore, we sought to compare the risk of venous thromboembolism after hysterectomy with other patient, pregnancy, and delivery risk factors known to be associated with venous thromboembolism. STUDY DESIGN: This was a cross-sectional study of women with delivery encounters identified in the Nationwide Readmissions Database from October 2015 to December 2017. Delivery encounters and all variables of interest were identified using the International Classification of Diseases, Tenth Revision diagnosis and procedure codes. The incidence of venous thromboembolism during delivery and rehospitalizations within 6 weeks after discharge was compared among women who had and did not have a peripartum hysterectomy. Multivariable logistic regressions were used to estimate associations between venous thromboembolism and hysterectomy, adjusted for the following characteristics: maternal age, payer at time of delivery, obesity, hypertension, diabetes mellitus, tobacco use, multifetal gestation, peripartum infection, and peripartum hemorrhage. Similarly, venous thromboembolism risk was compared by mode of delivery, including hysterectomy. Diagnoses that may have been indications for peripartum hysterectomy were identified among patients who underwent a hysterectomy and compared between those who did and did not have venous thromboembolism. Analyses used survey weights to obtain population estimates. RESULTS: Of the 4,419,037 women with deliveries, 5098 (11.5 per 10,000 deliveries) underwent a hysterectomy. Moreover, 110 patients (215.8 per 10,000 deliveries) were diagnosed with venous thromboembolism after hysterectomy. The risk of venous thromboembolism was significantly higher in women who underwent a hysterectomy than in women who did not have a hysterectomy (unadjusted odds ratio, 25.1 [95% confidence interval, 20.0-31.5]; adjusted odds ratio, 11.2 [95% confidence interval, 8.7-14.5]; P<.001). Comparing the risk of venous thromboembolism by mode of delivery, the unadjusted and adjusted incidences of venous thromboembolism were 6.9 (95% confidence interval, 6.5-7.3) and 7.4 (95% confidence interval, 6.9-7.8) per 10,000 deliveries among women after vaginal delivery without peripartum hysterectomy, 12.5 (95% confidence interval, 11.8-13.1) and 11.3 (95% confidence interval, 10.7-12.0) per 10,000 deliveries after cesarean delivery without hysterectomy; and 217.2 (95% confidence interval, 169.1-265.2) and 96.9 (95% confidence interval 76.9-126.5) per 10,000 deliveries after hysterectomy, regardless of mode of delivery. Of the 110 diagnoses of venous thromboembolism with peripartum hysterectomy, 89 (81%) occurred during delivery admission. Of the remaining 21 cases, 50% occurred within the first 10 days after discharge from delivery, and 75% occurred within 25 days after discharge. CONCLUSION: These findings have demonstrated that peripartum hysterectomy is associated with a markedly increased risk of venous thromboembolism in the postpartum period, even when controlling for other known risk factors for postpartum thromboembolic events. Here, the incidence of venous thromboembolism after peripartum hysterectomy (2.2%) met some guideline-based risk thresholds for routine thromboprophylaxis, potentially for at least 2 weeks after delivery. Further investigation into the role of routine venous thromboembolism prophylaxis during and after delivery is needed.

Natural language processing of admission notes to predict severe maternal morbidity during the delivery encounter.

BACKGROUND: Severe maternal morbidity and mortality remain public health priorities in the United States, given their high rates relative to other high-income countries and the notable racial and ethnic disparities that exist. In general, accurate risk stratification methods are needed to help patients, providers, hospitals, and health systems plan for and potentially avert adverse outcomes. OBJECTIVE: Our objective was to understand if machine learning methods with natural language processing of history and physical notes could identify a group of patients at high risk of maternal morbidity on admission for delivery without relying on any additional patient information (eg, demographics and diagnosis codes). STUDY DESIGN: This was a retrospective study of people admitted for delivery at 2 hospitals (hospitals A and B) in a single healthcare system between July 1, 2016, and June 30, 2020. The primary outcome was severe maternal morbidity, as defined by the Centers for Disease Control and Prevention; furthermore, we examined nontransfusion severe maternal morbidity. Clinician documents designated as history and physical notes were extracted from the electronic health record for processing and analysis. A bag-of-words approach was used for this natural language processing analysis (ie, each history or physical note was converted into a matrix of counts of individual words (or phrases) that occurred within the document). The least absolute shrinkage and selection operator models were used to generate prediction probabilities for severe maternal morbidity and nontransfusion severe maternal morbidity for each note. Model discrimination was assessed via the area under the receiver operating curve. Discrimination was compared between models using the DeLong test. Calibration plots were generated to assess model calibration. Moreover, the natural language processing models with history and physical note texts were compared with validated obstetrical comorbidity risk scores based on diagnosis codes. RESULTS: There were 13,572 delivery encounters with history and physical notes from hospital A, split between training (Atrain, n=10,250) and testing (Atest, n=3,322) datasets for model derivation and internal validation. There were 23,397 delivery encounters with history and physical notes from hospital B (Bvalid) used for external validation. For the outcome of severe maternal morbidity, the natural language processing model had an area under the receiver operating curve of 0.67 (95% confidence interval, 0.63-0.72) and 0.72 (95% confidence interval, 0.70-0.74) in the Atest and Bvalid datasets, respectively. For the outcome of nontransfusion severe maternal morbidity, the area under the receiver operating curve was 0.72 (95% confidence interval, 0.65-0.80) and 0.76 (95% confidence interval, 0.73-0.79) in the Atest and Bvalid datasets, respectively. The calibration plots demonstrated the bag-of-words model's ability to distinguish a group of individuals at a substantially higher risk of severe maternal morbidity and nontransfusion severe maternal morbidity, notably those in the top deciles of predicted risk. Areas under the receiver operating curve in the natural language processing-based models were similar to those generated using a validated, retrospectively derived, diagnosis code-based comorbidity score. CONCLUSION: In this practical application of machine learning, we demonstrated the capabilities of natural language processing for the prediction of severe maternal morbidity based on provider documentation inherently generated at the time of admission. This work should serve as a catalyst for providers, hospitals, and electronic health record systems to explore ways that artificial intelligence can be incorporated into clinical practice and evaluated rigorously for their ability to improve health.

Impact of a Hybrid Model of Prenatal Care on the Diagnosis of Fetal Growth Restriction.

OBJECTIVE: Fetal growth restriction (FGR) is associated with poor neonatal outcomes and stillbirth, and screening via fundal height or ultrasound is routinely performed. During the novel coronavirus disease 2019 (COVID-19) pandemic, we developed a hybrid model of prenatal care which decreased the frequency of in-person visits and incorporated telemedicine visits. We sought to determine if prenatal FGR diagnoses decreased with this hybrid model compared with routine prenatal care. STUDY DESIGN: This was a retrospective cohort study of singleton nonanomalous neonates with birth weights <10th percentile at term. The "routine care" group was consisted of those who born between April and July 2019 with in-person prenatal care, and the "hybrid care" group was consisted of those who born between April and July 2020 with both in-person and telemedicine prenatal cares at a collaborative academic practice. The primary outcome was the rate of diagnosis of small for gestational age (SGA) as defined as infant birth weight <10th percentile without a prenatal diagnosis of FGR. The secondary outcome was timing of diagnosis of FGR. RESULTS: Overall, 1,345 and 1,296 women gave birth in the routine and hybrid groups, respectively. The number of in-person prenatal care visits decreased from 15,024 in the routine period to 7,727 in the hybrid period; 3,265 telemedicine visits occurred during the hybrid period. The total number of prenatal patients remained relatively stable at 3,993 and 3,753 between periods. Third trimester ultrasounds decreased from 2,929 to 2,014 between periods. Birth weights <10 percentile occurred in 115 (8.6%) births during the routine period and 79 (6.1%) births during the hybrid period. Of 115, 44 (38.3%) cases were prenatally diagnosed with FGR in the routine versus 28 of 79 (35.4%) in the hybrid group (p = 0.76). Median gestational age at diagnosis did not vary between groups (36 vs. 37 weeks, p = 0.44). CONCLUSION: A hybrid prenatal care model did not alter the detection of FGR. Future efforts should further explore the benefits of incorporating telemedicine into prenatal care. KEY POINTS: · Telemedicine visits can provide comprehensive prenatal care.. · FGR was diagnosed equally with hybrid versus routine prenatal care.. · FGR diagnosis was not delayed with hybrid care..

Maternal Morbidity in the Second Stage of Labor: Analysis to Simulate the Clinical Choice.

OBJECTIVE: The aim of the study is to analyze maternal morbidity in the second stage of labor in a manner that approximates clinical choice. STUDY DESIGN: The study design comprises secondary analysis of the Consortium for Safe Labor, which included 228,688 deliveries at 19 hospitals between 2002 and 2008. We included the 107,675 women who were undergoing a trial of labor without a prior uterine scar or history of substance abuse, who reached the second stage, with a liveborn, nonanomalous, vertex, singleton, at term of at least 2,500 g. Maternal complications included postpartum fever, hemorrhage, blood transfusion, thrombosis, intensive care unit (ICU) admission, hysterectomy, and death. For maternal complications, we simulated the clinical choice by comparing operative vaginal or cesarean deliveries to continued expectant management at every hour in the second stage. For neonatal complications, we modeled the risk of severe neonatal complication by second stage duration for spontaneous vaginal deliveries only, adjusting for maternal demographics, comorbidities, and delivery hospital. Severe neonatal complications included death, asphyxia, hypoxic-ischemic encephalopathy (HIE), seizure, sepsis with prolonged stay, need for mechanical ventilation, and 5-minute Apgar score <4. RESULTS: Maternal morbidity was higher with operative vaginal/cesarean delivery versus continued expectant management for every hour in the second stage, a difference that was statistically significant at hour 2 (18.4 vs. 14.7%; p <0.01). Overall, 951 (0.88%) deliveries were complicated by a severe neonatal complication. A second stage over 4 hours was associated with an adjusted odds of severe neonatal complication of 2.10 (95% confidence interval [CI]: 1.32-3.34) as compared with women who delivered in the first hour. CONCLUSION: There is a trade-off between maternal and neonatal morbidity in the second stage of labor. Serious neonatal complications rise throughout, however, there is no time at which maternal morbidity is improved with a cesarean or operative vaginal delivery. Strategies are needed to identify neonates at highest risk of complication for targeted intervention. KEY POINTS: · Severe neonatal complications increase with every hour in the second stage.. · Shortening the second stage is associated with higher maternal complications at every hour.. · There is a trade-off between maternal and neonatal morbidity in the second stage..

Outpatient Expectant Management of Term Prelabor Rupture of Membranes: A Retrospective Cohort Study.

OBJECTIVE: To examine outcomes among women with prelabor rupture of membranes (PROM) who declined induction and chose outpatient expectant management compared with those admitted for induction. STUDY DESIGN: This is a retrospective cohort study of term women with singleton, vertex-presenting fetuses who presented with PROM between July 2016 and June 2017 and were eligible for outpatient expectant management (n = 166). The primary outcomes were time from PROM to delivery and time from admission to delivery. Maternal and neonatal outcomes were also compared between groups. Multivariable linear regressions were used to assess time differences between groups, adjusting for known maternal and pregnancy characteristics. RESULTS: Compared with admitted patients, women managed expectantly at home had significantly longer PROM to delivery intervals (median 29.2 vs. 17 hours, p < 0.001), but were more likely to deliver within 24 hours of admission (95.1 vs. 82.9%, p = 0.004). In the adjusted analysis, PROM to delivery was 7 hours longer (95% confidence interval [CI]: 3.9-10.0) and admission to delivery was 5.3 hours shorter (95% CI: 2.8-7.7) in the outpatient expectant management cohort. There were no differences in secondary outcomes. CONCLUSION: Outpatient management of term PROM is associated with longer PROM to delivery intervals, but shorter admission to delivery intervals.

Oxytocin Compared to Buccal Misoprostol for Induction of Labor after Term Prelabor Rupture of Membranes.

OBJECTIVE: This study was aimed to determine if admission-to-delivery times vary between term nulliparous women with prelabor rupture of membranes (PROM) who initially receive oxytocin compared with buccal misoprostol for labor induction. STUDY DESIGN: This is a retrospective cohort of 130 term, nulliparous women with PROM and cervical dilation of ≤2 cm who underwent induction of labor with intravenous oxytocin or buccal misoprostol. The primary outcome was time from admission to delivery. Linear regressions with log transformation were used to estimate the effect of induction agent on time to delivery. RESULTS: Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (16.9 vs. 19.9 hours, p = 0.013). There were no significant differences in secondary outcomes between the groups. In the adjusted model, women who received misoprostol had a 22% longer time from admission to delivery (95% CI 5.0-42.0%) compared with women receiving oxytocin. CONCLUSION: In term nulliparous patients with PROM, intravenous oxytocin is associated with faster admission-to-delivery times than buccal misoprostol.

Investigating Decreased Rates of Nulliparous Cesarean Deliveries during the COVID-19 Pandemic.

OBJECTIVE: Preventing the first cesarean delivery (CD) is important as CD rates continue to rise. During the novel coronavirus disease 2019 (COVID-19) pandemic, quality improvement metrics at our hospital identified lower rates of CD. We sought to investigate this change and identify factors that may have contributed to the decrease. STUDY DESIGN: We compared nulliparous singleton deliveries at a large academic hospital during the COVID-19 pandemic (April through July 2020 during a statewide "stay-at-home" order) to those in the same months 1 year prior to the pandemic (April through July 2019). The primary outcome, mode of delivery, was obtained from the electronic medical record system, along with indication for CD. RESULTS: The cohort included 1,913 deliveries: 892 in 2019 and 1,021 in 2020. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ between the groups. Median gestational age at delivery was the same in both groups. The CD rate decreased significantly during the COVID-19 pandemic compared with prior (28.9 vs. 33.6%; p = 0.03). There was a significant increase in the rate of labor induction (45.7 vs. 40.6%; p = 0.02), but no difference in the proportion of inductions that were elective (19.5 vs. 20.7%; p = 0.66). The rate of CD in labor was unchanged (15.9 vs. 16.3%; p = 0.82); however, more women attempted a trial of labor (87.0 vs. 82.6%; p = 0.01). Thus, the proportion of CD without a trial of labor decreased (25.1 vs. 33.0%; p = 0.04). CONCLUSION: There was a statistically significant decrease in CD during the COVID-19 pandemic at our hospital, driven by a decrease in CD without a trial of labor. The increased rate of attempted trial of labor suggests the presence of patient-level factors that warrant further investigation as potential targets for decreasing CD rates. Additionally, in a diverse and medically complex population, increased rates of labor induction were not associated with increased rates of CD. KEY POINTS: · Primary CD rate fell during COVID-19 pandemic.. · Decrease was driven by more women attempting labor.. · Higher rate of induction without rise in CD rate was found..

Fragmentation of postpartum readmissions in the United States.

BACKGROUND: Fragmentation of care, wherein a patient is readmitted to a hospital different from the initial point of care, has been shown to be associated with worse patient outcomes in other medical specialties. However, postpartum fragmentation of care has not been well characterized in obstetrics. OBJECTIVE: To characterize risk for and outcomes associated with fragmentation of postpartum readmissions wherein the readmitting hospital is different than the delivery hospital. METHODS: The 2010 to 2014 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions within 60 days of delivery hospitalization discharge for women aged 15-54 years were identified. The primary outcome, fragmentation, was defined as readmission to a different hospital than the delivery hospital. Hospital, demographic, medical, and obstetric factors associated with fragmented readmission were analyzed. Adjusted log-linear models were performed to analyze risk for readmission with adjusted risk ratios and 95% confidence intervals as the measures of effect. The associations between fragmentation and secondary outcomes including (1) length of stay >90th percentile, (2) hospitalization costs >90th percentile, and (3) severe maternal morbidity were determined. Whether specific indications for readmission such as hypertensive diseases of pregnancy, wound complications, and other conditions were associated with higher or lower risk for fragmentation was analyzed. RESULTS: From 2010 to 2014, 141,276 60-day postpartum readmissions were identified, of which 15% of readmissions (n = 21,789) occurred at a hospital different from where the delivery occurred. Evaluating individual readmission indications, fragmentation was less likely for hypertension (11.1%), wound complications (10.7%), and uterine infections (11.0%), and more likely for heart failure (28.6%), thromboembolism (28.4%), and upper respiratory infections (33.9%) (P < .01 for all). In the adjusted analysis, factors associated with fragmentation included public insurance compared to private insurance (Medicare: adjusted risk ratio, 1.68; 95% confidence interval, 1.52, 1.86; Medicaid: adjusted risk ratio, 1.28; 95% confidence interval, 1.24, 1.32). Fragmentation was associated with increased risk for severe maternal morbidity during readmissions in both unadjusted (relative risk, 1.84; 95% confidence interval, 1.79, 1.89) and adjusted (adjusted risk ratio, 1.81; 95% confidence interval, 1.76, 1.86) analyses. In adjusted analyses, fragmentation was also associated with increased risk for length of stay >90th percentile (relative risk, 1.48; 95% confidence interval, 1.42-1.54) and hospitalization costs >90th percentile (adjusted risk ratio, 1.74; 95% confidence interval, 1.67, 1.81). CONCLUSION: This study of nationwide estimates of postpartum fragmentation found discontinuity of postpartum care was associated with increased risk for severe morbidity, high costs, and long length of stay. Reduction of fragmentation may represent an important goal in overall efforts to improve postpartum care.

High Fetal Fraction on First Trimester Cell-Free DNA Aneuploidy Screening and Adverse Pregnancy Outcomes.

OBJECTIVE: To test the hypothesis that high fetal fraction (FF) on first trimester cell-free deoxyribonucleic acid (cfDNA) aneuploidy screening is associated with adverse perinatal outcomes. STUDY DESIGN: This is a single-institution retrospective cohort study of women who underwent cfDNA screening at <14 weeks' gestation and delivered a singleton infant between July 2016 and June 2018. Women with abnormal results were excluded. Women with high FF (≥95th percentile) were compared with women with normal FF (5th-95th percentiles). Outcomes investigated were preterm birth, small for gestational age, and hypertensive disorders of pregnancy. RESULTS: A total of 2,033 women met inclusion criteria. The mean FF was 10.0%, and FF >16.5% was considered high (n = 102). Women with high FF had a greater chance of delivering a small for gestational age infant

Low Fetal Fraction and Birth Weight in Women with Negative First-Trimester Cell-Free DNA Screening.

OBJECTIVE: To determine the association between low fetal fraction and birth weight among women with a negative cell-free DNA (cfDNA) result for common aneuploidies in the first trimester. STUDY DESIGN: This is a retrospective cohort of women who delivered a singleton between July 2016 and June 2018 at a single institution and had normal cfDNA testing in the first trimester. The primary variable of interest was "low fetal fraction," which was defined as fetal fractions less than 5th percentile among all fetal fractions in the cohort (fetal fraction < 5.34%). The primary outcomes were birth weight ≤ 5th and ≤ 10th percentiles. Multivariable logistic regressions assessed for the association between low fetal fraction and birth weight. RESULTS: A total of 7,478 women delivered a singleton at ≥24 weeks' gestation, of which 2,387 (32%) underwent genetic screening through cfDNA; the majority were in the first trimester (n = 2,052 [86%]). 2,035 met the inclusion criteria. Birth weight ≤ 5th percentile was significantly higher in the low fetal fraction group (6.9 vs. 3.2%; p = 0.04). A low fetal fraction was associated with higher odds of an infant with a low birth weight: adjusted odds ratio (aOR) of 2.32 (95% CI 1.15-4.67) for birth weight ≤ 10th percentile (p = 0.02) and aOR of 3.73 (95% CI 1.40-9.03) for birth weight ≤ 5th percentile (p = 0.004). CONCLUSION: Low fetal fractions of ≤ 5th percentile were associated with an increased risk of birth weights ≤ 5th and ≤ 10th percentiles in women with negative cfDNA screening in the first trimester. Future work is needed to further investigate this relationship and to determine the potential clinical implications, such as third-trimester screening for growth restriction in women with low fetal fractions and negative cfDNA screening results.

Unexpected term NICU admissions: a marker of obstetrical care quality?

BACKGROUND: Unexpected admissions of term neonates to the neonatal intensive care unit and unexpected postnatal complications have been proposed as neonatal-focused quality metrics for intrapartum care. Previous studies have noted significant variation in overall hospital neonatal intensive care unit admission rates; however, little is known about the influence of obstetric practices on these rates or whether variation among unanticipated admissions in low-risk, term neonates can be attributed to systemic hospital practices. OBJECTIVE: The objective of the study was to examine the relative effects of patient characteristics and intrapartum events on unexpected neonatal intensive care unit admissions and to quantify the between-hospital variation in neonatal intensive care unit admission rates among this group of neonates. STUDY DESIGN: We performed a retrospective cross-sectional study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), singleton, nonanomalous, liveborn infants without an a priori risk for neonatal intensive care unit admission were included. The primary outcome was neonatal intensive care unit admission among this population. Multilevel mixed-effect models were used to calculate adjusted odds ratios for demographics (age, race, insurer), pregnancy characteristics (parity, gestational age, tobacco use, birthweight), maternal comorbidities (chronic and pregnancy-induced hypertension), hospital characteristics (delivery volume, hospital and neonatal intensive care unit level, academic affiliation), and intrapartum events (prolonged second stage, induction of labor, trial of labor after cesarean delivery, chorioamnionitis, meconium-stained amniotic fluid, and abruption). Intraclass correlation coefficients were used to estimate the between-hospital variance in a series of hierarchical models. RESULTS: Of the 143,951 infants meeting all patient and hospital inclusion criteria, 7995 (5.6%) were admitted to the neonatal intensive care unit after birth. In the fully adjusted model, the factors associated with the highest odds for neonatal intensive care unit admission included: nulliparity (adjusted odds ratio, 1.62 [95% confidence interval, 1.53-1.71]), large for gestational age (adjusted odds ratio, 1.59 [95% confidence interval, 1.47-1.71]), and small for gestational age (adjusted odds ratio, 1.60 [95% confidence interval, 1.47-1.73]). Induction of labor (adjusted odds ratio, 0.95 [95% confidence interval, 0.89-1.01]) was not associated with increased odds of neonatal intensive care unit admission compared with women who labored spontaneously. The events associated with higher odds of neonatal intensive care unit admission included: prolonged second stage (adjusted odds ratio, 1.66 [95% confidence interval, 1.51-1.83]); chorioamnionitis (adjusted odds ratio, 3.89 [95% confidence interval, 3.42-4.44]), meconium-stained amniotic fluid (adjusted odds ratio, 1.96 [95% confidence interval, 1.82-2.10]), and abruption (adjusted odds ratio, 2.64 [95% confidence interval, 2.16-.21]). Compared with women who did not labor, the odds of neonatal intensive care unit admission were lower for women who labored: adjusted odds ratio, 0.48 (95% confidence interval, 0.45-0.52) for women with no uterine scar and adjusted odds ratio, 0.83 (95% confidence interval, 0.73-0.94) for women with a uterine scar. There was significant variation in neonatal intensive care unit admission rates by hospital, ranging from 2.9% to 11.2%. After accounting for case mix and hospital characteristics, the between-hospital variance was 1.9%, suggesting that little of the variation was explained by the effect of the hospital. CONCLUSION: This study contributes to the currently limited understanding of term, neonatal intensive care unit admission rates as a marker of obstetrical care quality. We demonstrated that significant variation exists in hospital unexpected neonatal intensive care unit admission rates and that certain intrapartum events are associated with an increased risk for neonatal intensive care unit admission after delivery. However, the between-hospital variation was low. Unmeasured confounders and extrinsic factors, such as neonatal intensive care unit bed availability, may limit the ability of unexpected term neonatal intensive care unit admissions to meaningfully reflect obstetrical care quality.

Practice Variation in Antenatal Steroid Administration for Anticipated Late Preterm Birth: A Physician Survey.

OBJECTIVE: The objective of this study was to measure knowledge and practice variation in late preterm steroid use. STUDY DESIGN: Electronic survey of American College of Obstetricians and Gynecologists (ACOG) members about data supporting the ACOG/Society for Maternal-Fetal Medicine (SMFM) recommendations and practice when caring for women with anticipated late preterm birth (PTB), 340/7 to 366/7 weeks. RESULTS: Of 352 administered surveys, we obtained 193 completed responses (55%); 82.5% were generalist obstetrician-gynecologists (OB/GYNs), and 42% cared for women with anticipated late PTB at least weekly. Most believed that late preterm steroids provided benefit by reducing respiratory distress syndrome (93%), transient tachypnea of the newborn (83%), and neonatal intensive care unit admission (82%). More than half administered late preterm steroids to women with multiple gestations (73%), and pregestational diabetes (55-80%) depending on glycemic control. OB/GYNs administered steroids to insulin-dependent and poorly controlled diabetics more often than MFMs (75 vs. 46% and 59 vs. 37% respectively, p < 0.05 for both). While providers believed there was increased maternal hyperglycemia (88%) and neonatal hypoglycemia (59%), 88% believed neonatal respiratory benefits outweighed these risks. Respondents agreed research is needed to determine who are appropriate candidates (77%) and how to minimize adverse outcomes (82%). CONCLUSION: Most providers are administering late preterm steroids to all women, even those populations who have been excluded from previous trials. Despite widespread use, providers believe more research is needed to optimize management.

Using Cervical Dilation to Predict Labor Onset: A Tool for Elective Labor Induction Counseling.

OBJECTIVE: To evaluate whether cervical dilation predicts the timing and likelihood of spontaneous labor at term. STUDY DESIGN: This was a retrospective cohort of nulliparous women with singleton pregnancies who delivered at term from 2013 to 2015. Outpatient cervical examinations performed after 37 weeks and prior to labor onset were collected. Survival analysis was used to analyze time to spontaneous labor with cervical dilation as the primary predictor, modeled as continuous and categorical variables (<1 cm, 1 cm, >1 cm). RESULTS: Our cohort included 726 women; 407 (56%) spontaneously labored, 263 (36%) were induced, and 56 (8%) had an unlabored cesarean delivery. Women with >1-cm dilation were three times more likely to spontaneously labor (adjusted hazard ratio [aHR]: 3.1; 95% confidence interval [CI]: 2.4-4) than those with <1-cm dilation. At 39 weeks, 60% of women with >1-cm dilation went into spontaneous labor as compared with only 28% of those with <1-cm dilation (aHR: 2.9; 95% CI: 2-4.4). CONCLUSION: In our cohort of nulliparous women at term, those with cervical dilation > 1 cm were significantly more likely to go into labor in the following week. This information can aid in counseling about elective induction of labor.