Interpregnancy Body Mass Index Change and Offspring Mortality Risk following the Second Pregnancy.

OBJECTIVE: The aim of the study is to examine the impact of maternal interpregnancy body mass index (BMI) change on subsequent offspring mortality risk. STUDY DESIGN: This is a retrospective cohort study of women who had two consecutive live singleton deliveries of at least 20 weeks' gestation from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from the date of first delivery to the conception date of subsequent pregnancy. We categorized BMI change as: < - 1, -1 to 0, 0 to <1 (reference), 1 to 2, 2 to 4, ≥4 kg/m2. Our primary outcome was all-cause age-specific mortality during four time periods: neonatal (≤28 days), infant (29 days to <1 year old), childhood ((≥1 to <5 years old), and late childhood (5 to <18 years old). We also examined mortality specifically attributed to congenital anomalies. Analyses used Cox proportional hazard models stratified by full term (≥37 weeks) and preterm (<37 weeks) deliveries. All models were adjusted for relevant confounders. RESULTS: Of 266,752 women, among full-term deliveries, women with a BMI increase of 4 kg/m2 or more had an increased risk of neonatal mortality in their subsequent pregnancy (hazard ratio or HR = 1.72, 95% confidence interval or CI: 1.23-2.41) Women who lost 1 kg/m2 or more between deliveries also had increased neonatal mortality (HR = 1.46, 95% CI: 1.04-2.05). There were no differences in infant, early, or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy interval weight loss of 1 kg/m2 or more and weight gain of ≥4 kg/m2 also had increased risk of mortality associated with congenital anomalies or conditions arising during the neonatal period following their subsequent delivery. CONCLUSION: Women with significant interpregnancy weight gain and modest weight loss have a significant increased risk of neonatal mortality following their subsequent pregnancy. KEY POINTS: · Significant weight gain between deliveries increases the risk of neonatal death.. · Modest weight loss between deliveries increases the risk of neonatal death.. · This risk may be partially explained by increased risk of congenital malformations..

Gestational Weight Gain and Pregnancy Outcomes among Nulliparous Women.

OBJECTIVE: To determine the association between total gestational weight gain and perinatal outcomes. STUDY DESIGN: Data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be (NuMoM2b) study were used. Total gestational weight gain was categorized as inadequate, adequate, or excessive based on the 2009 Institute of Medicine guidelines. Outcomes examined included hypertensive disorders of pregnancy, mode of delivery, shoulder dystocia, large for gestational age or small for-gestational age birth weight, and neonatal intensive care unit admission. RESULTS: Among 8,628 women, 1,666 (19.3%) had inadequate, 2,945 (34.1%) had adequate, and 4,017 (46.6%) had excessive gestational weight gain. Excessive gestational weight gain was associated with higher odds of hypertensive disorders (adjusted odds ratio [aOR] = 2.05, 95% confidence interval [CI]: 1.78-2.36) Cesarean delivery (aOR = 1.24, 95% CI: 1.09-1.41), and large for gestational age birth weight (aOR = 1.49, 95% CI: 1.23-1.80), but lower odds of small for gestational age birth weight (aOR = 0.59, 95% CI: 0.50-0.71). Conversely, inadequate gestational weight gain was associated with lower odds of hypertensive disorders (aOR = 0.75, 95% CI: 0.62-0.92), Cesarean delivery (aOR = 0.77, 95% CI: 0.65-0.92), and a large for gestational age birth weight (aOR = 0.72, 95% CI: 0.55-0.94), but higher odds of having a small for gestational age birth weight (aOR = 1.64, 95% CI: 1.37-1.96). CONCLUSION: Both excessive and inadequate gestational weight gain are associated with adverse maternal and neonatal outcomes.

Interdelivery Interval and Medically Indicated Preterm Delivery.

OBJECTIVE: The objective of this study was to examine whether a medically indicated preterm delivery is relatively more likely following longer interdelivery intervals. STUDY DESIGN: This is a case-control study of women with two consecutive deliveries of a live singleton at the same institution between 2005 and 2015, with the subsequent delivery occurring preterm. Preterm deliveries were classified as spontaneous if women delivered following preterm labor, preterm premature rupture of membranes, or placental abruption. Preterm deliveries were classified as medically indicated if women underwent delivery for fetal or maternal medical indications. Interdelivery interval was categorized as < 18, 18 to 59, and 60 months or more. Characteristics of women who had a medically indicated versus spontaneous preterm delivery were compared. RESULTS: Of the 1,276 women, 25.6% had a medically indicated preterm delivery and 74.4% had a spontaneous preterm delivery. Compared with women with an interdelivery interval of 18 to 59 months (of whom 25.7% had a preterm delivery for medical indications), women with a shorter interdelivery interval were less likely (19.3%), while women with a longer interdelivery interval were more likely (37.4%; p = 0.003) to have a medically indicated preterm delivery. This relationship persisted even when accounting for other factors. CONCLUSION: Preterm deliveries are more likely to be medically indicated as the interdelivery interval lengthens.

Interdelivery Interval and Diabetes Mellitus in a Subsequent Pregnancy.

OBJECTIVE: We determined whether time between deliveries is associated with developing diabetes at the time of a subsequent delivery. STUDY DESIGN: This is a case-control study of women who had two consecutive singleton births at the same institution with no pregestational diabetes in the baseline pregnancy. Cases were defined as women who were diagnosed with any type of diabetes at the time of the subsequent delivery. Controls were defined as women who had no diagnosis of diabetes at the time of the subsequent delivery. Interdelivery interval (IDI) was categorized as < 18, 18 to 60, or > 60 months. RESULTS: Of 12,263 women, 4.1% (N = 501) were diagnosed with diabetes at the subsequent delivery. Women with diabetes were more likely to have an IDI of >60 months than women without diabetes (9.0 vs. 4.2%, p < 0.001). After controlling for confounding factors, an IDI > 60 months remained associated with development of pregestational or gestational diabetes by the conclusion of the subsequent pregnancy (adjusted odds ratio = 2.13 compared with an IDI of 18-60 months, 95% confidence interval 1.44-3.15). CONCLUSION: A longer IDI is an independent risk factor for the development of diabetes at the time of a subsequent delivery.

Identifying Fetal Growth Disorders Using Ultrasonography in Women With Diabetes.

OBJECTIVES: We evaluated the ability of third-trimester ultrasonography (US) to diagnose disorders of fetal growth among women with diabetes mellitus. METHODS: This work was a retrospective cohort study of women with diabetes who delivered term singleton neonates at a single academic medical center and who had a US examination within 5 weeks of delivery. We characterized the sensitivity, specificity, positive predictive value, and negative predictive value of US to detect large-for-gestational age (LGA) and small-for-gestational age (SGA) infants. Large and small for gestational age were defined as a US estimated fetal weight of greater than 90% and less than 10%, respectively, based on the Hadlock formula (Radiology 1991; 181:129-133); US estimates of LGA or SGA were compared with postnatal findings of LGA or SGA based on gestational age-based weight percentiles. Test characteristics were analyzed for the total cohort and by the type of diabetes. We compared the areas under the curve for receiver operating characteristic curves for different types of diabetes. RESULTS: Of 521 women, 3 (0.6%) screened positive for SGA, and 64 (12.3%) delivered an SGA neonate. In contrast, 129 (24.8%) screened positive for LGA, and 61 (11.7%) delivered an LGA neonate. The receiver operating characteristic curves did not differ significantly for different types of diabetes (P = .68). CONCLUSIONS: Ultrasonography in women with diabetes and term or late preterm pregnancies has high specificity but poor sensitivity for SGA and a low positive predictive value for LGA. The diagnostic capability of US to detect fetal growth abnormalities did not differ significantly by the type of diabetes.

Association between Sonographic Estimated Fetal Weight and the Risk of Cesarean Delivery among Nulliparous Women with Diabetes in Pregnancy.

OBJECTIVE: The objective of this study was to examine the association between an ultrasound-estimated fetal weight (US-EFW) and mode of delivery among nulliparous diabetic women. STUDY DESIGN: This is a retrospective cohort study of nulliparous women with medication-requiring gestational or pregestational diabetes who delivered term, singleton gestations following a trial of labor. We determined whether having had an US-EFW within 35 days of delivery was associated with cesarean delivery. RESULTS: Of 304 women who met the eligibility criteria, 231 (76.0%) had an US-EFW within 35 days of delivery. An US-EFW was associated with increased likelihood of intrapartum cesarean (51.5% for those with an ultrasound vs. 27.4% for those without, p < 0.001); this finding persisted even when controlling for birth weight and other confounding factors (adjusted odds ratio: 2.23, 95% confidence interval: 1.16-4.28). Among women with a recent US-EFW, a diagnosis of a large-for-gestational-age (LGA) fetus was associated with overall intrapartum cesarean frequency (65.2% for women with an LGA fetus vs. 46.1% for those without, p = 0.009), but this association did not remain significant in multivariable models. CONCLUSION: An US-EFW within 35 days of delivery among nulliparous women with medication-requiring diabetes was positively associated with intrapartum cesarean delivery.

Interdelivery weight gain and risk of cesarean delivery following a prior vaginal delivery.

BACKGROUND: Approximately one third of all deliveries in the United States are via cesarean. Previous research indicates weight gain during pregnancy is associated with an increased risk of cesarean delivery. It remains unclear, however, whether and to what degree weight gain between deliveries (ie, interdelivery weight gain) is associated with cesarean delivery in a subsequent pregnancy following a vaginal delivery. OBJECTIVES: The objective of the study was to determine whether interdelivery weight gain is associated with an increased risk of intrapartum cesarean delivery following a vaginal delivery. STUDY DESIGN: This was a case-control study of women who had 2 consecutive singleton births of at least 36 weeks' gestation between 2005 and 2016, with a vaginal delivery in the index pregnancy. Women were excluded if they had a contraindication to a trial of labor (eg, fetal malpresentation or placenta previa) in the subsequent pregnancy. Maternal characteristics and delivery outcomes for both pregnancies were abstracted from the medical record. Maternal weight gain between deliveries was measured as the change in body mass index at delivery. Women who underwent a subsequent cesarean delivery were compared with those who had a repeat vaginal delivery using χ2 statistics for categorical variables and Student t tests or analysis of variance for continuous variables. Multivariable logistic regression was used to determine whether interdelivery weight gain remained independently associated with intrapartum cesarean delivery after adjusting for potential confounders. RESULTS: Of 10,396 women who met eligibility criteria and had complete data, 218 (2.1%) had a cesarean delivery in the subsequent pregnancy. Interdelivery weight gain was significantly associated with cesarean delivery and remained significant in multivariable analysis for women with a body mass index increase of at least 2 kg/m2 (adjusted odds ratio, 1.53, 95% confidence interval, 1.03-2.27 for a body mass index increase of 2 kg/m2 to <4 kg/m2; adjusted odds ratio, 1.99, 95% confidence interval, 1.19-3.34 for body mass index increase of 4 kg/m2 or more). Furthermore, women who gained 2 kg/m2 or more were significantly more likely to undergo cesarean delivery specifically for the indications of arrest of dilation or arrest of descent (adjusted odds ratio, 2.01, 95% confidence interval, 1.21-3.33 for body mass index increase of 2 to <4 kg/m2; adjusted odds ratio, 2.34, 95% confidence interval, 1.15-4.76 for body mass index increase of ≥4 kg/m2). Contrarily, women who lost ≥2 kg/m2 were less likely to undergo any cesarean delivery (adjusted odds ratio, 0.41, 95% confidence interval, 0.21-0.78) as well as less likely to undergo cesarean delivery for an arrest disorder (adjusted odds ratio, 0.29, 95% confidence interval, 0.10-0.82). Weight gain or loss was not significantly associated with a cesarean delivery for fetal indications. CONCLUSION: Among women with a prior vaginal delivery, interdelivery weight gain was independently associated with an increased risk of intrapartum cesarean delivery in a subsequent pregnancy.

Human Immunodeficiency Virus in Pregnancy.

Approximately 5000 people living with human immunodeficiency virus (HIV) give birth each year. Perinatal transmission of HIV will occur in about 15% to 45% of pregnancies without treatment. With appropriate antiretroviral therapy for pregnant people as well as appropriate intrapartum and postpartum interventions, the rate of perinatal transmission can be reduced to less than 1%. Antiretroviral therapy will also reduce health risks for pregnant patients living with HIV. All pregnant people should be offered the opportunity to learn their HIV status and access treatment as needed.

Adherence to Sexually Transmitted Infection Screening in Pregnancy.

Objective: Professional guidelines and state law require screening for sexually transmitted infections (STI) during pregnancy. Our objective was to evaluate adherence to these recommendations. Methods: This is a retrospective cohort study of patients initiating prenatal care before 20 weeks' gestation. Demographic characteristics and STI screening were abstracted from prenatal records. Tests of interest included initial syphilis, human immunodeficiency virus (HIV), hepatitis B, chlamydia, and gonorrhea tests, as well as repeat (third trimester) syphilis and HIV tests. All patients were eligible for initial screening. Patients were eligible for analysis of whether they received adherent repeat third trimester screening for syphilis (mandated by state law) and HIV (institutional protocol) if they delivered at or after 32 weeks' gestation. Adherent screening was defined as performance of all recommended screening. Results: Of 2370 patients, 1816 (76.6%) received adherent initial STI screening and 181 (7.8% of 2308 patients who delivered at or after 32 weeks' gestation) received adherent repeat third trimester STI screening. After adjusting for covariates, private insurance (adjusted odds ratio [aOR] 1.45, confidence interval [95% CI] 1.12-1.95) was associated with adherent initial screening, whereas being non-Hispanic Black or Hispanic were associated with lower odds of adherent initial screening. Factors associated with adherent repeat third trimester STI screening were younger age (aOR 0.93, 95% CI 0.90-0.97) and non-Hispanic Black race (aOR 3.24, 95% CI 1.94-5.42). Those with private insurance (aOR 0.10, 95% CI 0.06-0.15) were less likely to receive adherent repeat third trimester screening. Conclusion: STI screening rates remain suboptimal. Multiple disparities exist in performance both of initial and repeat third trimester screening.

Obstetrician-gynecologists, religious institutions, and conflicts regarding patient-care policies.

OBJECTIVE: The purpose of this study was to assess how common it is for obstetrician-gynecologists who work in religiously affiliated hospitals or practices to experience conflict with those institutions over religiously based policies for patient care and to identify the proportion of obstetrician-gynecologists who report that their hospitals restrict their options for the treatment of ectopic pregnancy. STUDY DESIGN: We mailed a survey to a nationally representative sample of 1800 practicing obstetrician-gynecologists. RESULTS: The response rate was 66%. Among obstetrician-gynecologists who practice in religiously affiliated institutions, 37% have had a conflict with their institution over religiously based policies. These conflicts are most common in Catholic institutions (52%; adjusted odds ratio, 8.7; 95% confidence interval, 1.7-46.2). Few reported that their options for treating ectopic pregnancy are limited by their hospitals (2.5% at non-Catholic institutions vs 5.5% at Catholic institutions; P = .07). CONCLUSION: Many obstetrician-gynecologists who practice in religiously affiliated institutions have had conflicts over religiously based policies. The effects of these conflicts on patient care and outcomes are an important area for future research.

Using digital communication technology fails to improve longitudinal evaluation of an HIV prevention program aimed at Indian truck drivers and cleaners.

HIV prevention programs for truck drivers and cleaners (TDC) in India are limited. Longitudinal follow-up presents an obstacle to program effectiveness evaluation. We asked 3,028 TDC in a truck-driver HIV prevention program in Hyderabad to leave a cellular telephone number; we contacted participants 6 months after the intervention to assess sexual risk behavior change. Married, older, and better educated participants were more likely to leave phone numbers. Only 6.5% of TDC were reachable after 6 months. Longitudinal follow-up of this mobile sub-population remains a challenge, and more effective methods for evaluating HIV prevention programs are needed.

Preconception care and severe maternal morbidity in the United States.

BACKGROUND: In the United States, approximately 52,000 women per year (accounting for 1.46% of births) experience severe maternal morbidity, which is defined as a complication that causes significant maternal harm or risk of death. It disproportionately affects women from racial or ethnic minorities, people with chronic diseases, and those with Medicaid or no insurance. Preconception care has been hailed as a strategy to improve pregnancy outcomes and reduce disparities, but its broad benefits for maternal outcomes have not been demonstrated. OBJECTIVE: Our objective was to measure the association between preconception care and the odds of severe maternal morbidity among women with Medicaid. STUDY DESIGN: This is a secondary analysis of Medicaid claims using the Medicaid Analytic Extract files (2010-2012). We used the International Classification of Diseases, Ninth Revision codes, published by the US Office of Population Affairs' Quality Family Planning program to define 7 domains of preconception care. The primary outcome was maternal death within 12 weeks of delivery or severe maternal morbidity during birth hospitalization, defined by the presence of any diagnosis or procedure on the severe maternal morbidity International Classification of Diseases, Ninth Revision code list from the Centers for Disease Control and Prevention. Because this list may overestimate severe maternal morbidity by counting any blood transfusion, our secondary outcome used the same code list but without transfusion. We reviewed care in the year before conception and used logistic regression to estimate the association between each domain and severe maternal morbidity for all births to women enrolled in Medicaid and aged 15 to 45 years with births during 2012. We performed a subgroup analysis for women with chronic disease (kidney disease, hypertension, or diabetes). RESULTS: Severe maternal morbidity or death occurred in 26,285 births (1.74%) when including blood transfusions and 9,481 births (0.63%) when excluding transfusions. Receiving contraceptive services in the year before conception was associated with decreased odds of severe maternal morbidity (adjusted odds ratio, 0.92; 95% confidence interval, 0.88-0.95) and pregnancy test services were associated with increased odds (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.14). In the primary analysis, no significant associations were observed for other preconception care domains. Among those women with at least 1 chronic disease, contraceptive care (adjusted odds ratio, 0.84; 95% confidence interval, 0.75-0.95) and routine physical or gynecologic exams (adjusted odds ratio, 0.79; 95% confidence interval, 0.71-0.88) were associated with decreased odds of severe maternal morbidity. Similar associations were found for severe maternal morbidity when excluding blood transfusion. CONCLUSIONS: Contraceptive services in the year before conception and routine exams for women with chronic disease are associated with decreased odds of severe maternal morbidity or death for Medicaid enrollees.

Spousal intimate partner violence is associated with HIV and Other STIs among married Rwandan women.

HIV is a health problem in Rwanda, where the adult HIV prevalence is 3.1% (WHO 2008 in Online database of HIV/AIDS epidemiological data, found at: http://www.who.int/globalatlas ); the majority of those infected are women (UNAIDS 2008 in http://data.unaids.org/pub/Report/2008/rwanda_2008_country_progress_report_en.pdf ). Prior studies indicate that intimate partner violence is frequently associated with increased HIV risk in women, often because men who abuse their wives also exhibit riskier sexual behaviors (Silverman et al. in JAMA 300:703-710 2008. Population-based data from the 2005 Rwanda Demographic and Health Survey indicate that women with few, if any, other sexual risk factors who have experienced sexual, physical, or emotional abuse within their marriages are 1.61-3.46 times as likely to test positive for HIV, and 2.14-4.11 times more likely to report another STI. These findings confirm prior clinical studies that indicate that intimate partner violence is a correlate of HIV/STIs in Rwanda. Further research is needed to determine whether Rwandan men that abuse their wives have higher baseline rates of HIV/STI infection.

Identifying fetal growth disorders using ultrasound in obese nulliparous women.

OBJECTIVE: We evaluated the ability of third trimester ultrasound to diagnose fetal growth disorders among obese women. METHODS: This is a retrospective cohort study of obese nulliparous women who delivered term singleton neonates who had an ultrasound within 5 weeks of delivery. We characterized the sensitivity, specificity, positive predictive value and negative predictive value of ultrasound to detect large-for-gestational age (LGA) and small-for-gestational age (SGA) infants. Antenatally, LGA and SGA were defined as an ultrasound estimated fetal weight >90% or <10% based on the Hadlock formula. Postnatally, LGA or SGA designation was based on gestational age-based birthweight percentiles. Test characteristics were analyzed for the total cohort and by class of obesity (class II, body mass index [BMI] = 35.0-39.9 kg/m2 versus class III, BMI ≥ 40 kg/m2). We compared the area under the curve for receiver-operating characteristic (ROC) curves for different classes of obesity. RESULTS: Of 690 women, 13 (1.9%) screened positive for SGA and 19 (2.8%) delivered an SGA neonate. In contrast, 158 (22.9%) screened positive for LGA and 97 (14.1%) delivered an LGA neonate. The sensitivity of ultrasound for SGA was 26.3% and the specificity was 98.8%. The sensitivity for LGA was 75.3% and the specificity was 85.7%. The ROC curves did not differ significantly for different classes of obesity (p = .69 for SGA, p = .75 for LGA). CONCLUSION: Ultrasound in obese women who delivered term pregnancies has a high specificity but poor sensitivity for SGA and a low positive predictive value for LGA.

Periconception glycemic control and congenital anomalies in women with pregestational diabetes.

INTRODUCTION: To assess the relationship between periconception glycemic control and congenital anomalies in a contemporary, diverse population of women with pregestational diabetes. RESEARCH DESIGN AND METHODS: This is a retrospective cohort study of all pregnant women with pregestational diabetes at a single institution (2003-2017) in the USA. The primary outcome was frequency of major or minor congenital anomalies. Glycemic control was assessed by periconception glycosylated hemoglobin (HbA1c). The association of periconception HbA1c with pregnancy outcomes was assessed using bivariable and multivariable analyses. RESULTS: Our sample included 351 women, of which 63.8% had type 2 diabetes. Our study cohort is racially and ethnically diverse, with approximately equal numbers of women identifying as white non-Hispanic, black non-Hispanic and Hispanic, with 3.4% identifying as Asian. Of these 351 women, 52 (14.8%) had a fetus with a congenital anomaly, of whom the majority (n=43) had a major anomaly. Over half (51.1%) of all major anomalies were cardiovascular. Compared with the group with the best glycemic control (HbA1c ≤7.4%), which had an anomaly frequency of 10.2%, the frequency of congenital anomalies increased significantly with each category of worsening glycemic control (HbA1c 7.5%-9.4%: 20.6%, adjusted OR (aOR) 2.35, 95% confidence interval (CI) 1.08 to 5.13; HbA1c 9.5% to 11.4%: 25.8%, aOR 2.86, 95% CI 1.08 to 7.59; HbA1c ≥11.5%: 37.5%, aOR 7.66, 95% CI 2.27 to 25.9). CONCLUSION: In a diverse cohort of women with pregestational diabetes, higher periconception HbA1c, especially HbA1c >9.5, was significantly associated with major congenital fetal anomalies. Our study sample is reflective of the current population of pregnant women with diabetes, including women with type 2 diabetes and from racial and ethnic minorities.

Neonatal hypoglycemia after antenatal late preterm steroids in individuals with diabetes.

OBJECTIVE: To establish whether administration of antenatal late preterm steroids to pregnant people with diabetes resulted in higher risk of neonatal hypoglycemia. STUDY DESIGN: This is a retrospective cohort study of individuals with pre-gestational or gestational diabetes admitted between 34 0/7-36 6/7 weeks' gestation before and after introduction of an antenatal late preterm steroids protocol. The primary outcome was any neonatal blood glucose ≤ 60 mg/dL in the first 24 h of life. RESULTS: Of 123 mother-neonate pairs, 52.8% (N = 65) delivered during the post-protocol period; 75.4% of those (N = 49) received late preterm steroids. 59.7% (N = 34) of the pre-protocol neonates and 81.5% (N = 53) of the post-protocol neonates had hypoglycemia (p = 0.008). After controlling for gestational age at delivery and mode of delivery, neonates in the post-protocol group had increased odds of hypoglycemia (adjusted odds ratio 2.96, 95% confidence interval 1.29-6.82). CONCLUSION: Neonates born to mothers with diabetes who received late preterm corticosteroids experienced greater odds of hypoglycemia.

Unintended pregnancy and viral suppression in pregnant women living with HIV.

BACKGROUND: Approximately half of pregnancies in the United States are unintended; the likelihood of unintended pregnancy may be even higher for women living with HIV. Women with unintended pregnancies often have worse obstetrical outcomes than women who planned their pregnancies, although the relationship of unintended pregnancy to outcomes among women living with HIV in the United States is unknown. OBJECTIVE: This study aimed to determine whether pregnancy intendedness among women living with HIV attending a specialty obstetrical clinic was associated with achievement of maternal viral suppression by delivery, a key component of preventing perinatal transmission of HIV. STUDY DESIGN: This is a retrospective cohort study of pregnant women living with HIV who received prenatal care and had a live-born infant at a single tertiary center (2007-2014). Women were asked as part of routine clinical care whether they intended their current pregnancy. Women who expressed at their initial obstetrician visit that their pregnancy was mistimed or undesired were determined to have an unintended pregnancy. Women were considered virally suppressed when the HIV RNA viral load was <20 copies/mL. We examined whether pregnancy intendedness was associated with whether the viral load was undetectable at the time of delivery. We also determined whether women with unintended pregnancies were less likely to be on antiretroviral therapy at the time of entry to prenatal care. Wilcoxon rank-sum tests and chi-square tests were used for bivariable analyses, and logistic and linear regression were used for multivariable analyses. RESULTS: Of the 215 women who met inclusion criteria, 201 (93.5%) had complete data on pregnancy intendedness. Of these 201 women, 137 (68.2%) had an unintended pregnancy. Unintended pregnancy was associated with lower odds of viral suppression at delivery (95.3% of women with planned pregnancies were virally suppressed at delivery compared with 76.6% of women with unplanned pregnancies; adjusted odds ratio, 0.22; 95% CI, 0.05-0.89, after adjusting for potential confounders). In this study, 48.9% of women with unintended pregnancies presented later in pregnancy for prenatal care (after the first trimester) compared with 21.9% of women with intended pregnancies (P<.001). Women with unintended pregnancies were also less likely to be on antiretroviral therapy before entry to prenatal care (20.4% of women with unintended pregnancies vs 50.0% of women with intended pregnancies; adjusted odds ratio, 0.35; 95% CI, 0.15-0.81; P<.001). CONCLUSION: Among pregnant women living with HIV, women with an unintended pregnancy were less likely to be on antiretroviral therapy before initiating prenatal care and were less likely to be virally suppressed at the time of delivery.

Evaluation of an Intrapartum Insulin Regimen for Women With Diabetes.

OBJECTIVE: To examine whether an insulin protocol for intrapartum glucose control among parturients with diabetes was associated with improved outcomes. METHODS: This is a retrospective cohort study of women with pregestational or gestational diabetes delivering a liveborn neonate at Northwestern Memorial Hospital. Before 2011, women with diabetes were given intravenous (IV) insulin or glucose during labor at the discretion of the on-call endocrinologist. In 2011, a standardized protocol was designed to titrate insulin and glucose infusions. Outcomes were compared between two time periods: January 2005-December 2010 (before implementation) and January 2012-December 2017 (after implementation) with 2011 excluded to account for a phase-in period. Maternal outcomes included intrapartum hyperglycemia (blood glucose greater than 125 mg/dL) and hypoglycemia (blood glucose less than 60 mg/dL). Neonatal outcomes included hypoglycemia (blood glucose less than 50 mg/dL), intensive care admission, and IV dextrose therapy. t tests, Wilcoxon rank sum tests, and χ tests were used for bivariable analyses. Linear and logistic multivariable regression were used to account for confounding factors. RESULTS: Of 3,689 women, 928 (25.2%) delivered before 2011. After protocol implementation, frequencies of both maternal intrapartum hyperglycemia (51.3% vs 37.9%) and hypoglycemia decreased (6.1% vs 2.5%), both P<.001; respective adjusted odds ratio [aOR] 0.64, 95% CI 0.54-0.77 and 0.50, 95% CI 0.33-0.78. The frequency of neonatal hypoglycemia, however, increased (36.6% vs 49.2%, P<.001; aOR 1.73, 95% CI 1.45-2.07). Admission to the neonatal intensive care unit and need for IV dextrose therapy were similar across time periods. CONCLUSION: A formal protocol to manage insulin and glucose infusions for parturients with diabetes was associated with improved intrapartum maternal glucose control, but an increased frequency of neonatal hypoglycemia.

Weight gain in early, mid, and late pregnancy and hypertensive disorders of pregnancy.

OBJECTIVE: To examine the relationship of weight change during early, mid, and late pregnancy with the development of a hypertensive disorder of pregnancy (HDP). STUDY DESIGN: These data are from a prospective cohort study of nulliparous women with live singleton pregnancies. "Early" weight change was defined as the difference between self-reported pre-pregnancy weight and weight at the first visit (between 6 and 13 weeks' gestation); "mid" weight change was defined as the weight change between the first and second visits (between 16 and 21 weeks' gestation); "late" weight change was defined as the weight change between the second and third visits (between 22 and 29 weeks' gestation). Weight change in each time period was further characterized as inadequate, adequate, or excessive based on the Institute of Medicine's (IOM's) trimester-specific weekly weight gain goals based on pre-pregnancy body mass index. Multivariable Poisson regression was performed to adjust for potential confounders. MAIN OUTCOME MEASURE: Development of any hypertensive disorder of pregnancy. RESULTS: Of 8296 women, 1564 (18.9%) developed a HDP. Weight gain in excess of the IOM recommendations during the latter two time periods was significantly associated with HDP. Specifically, trimester-specific excessive weight gain in the mid period (aIRR 1.16, 95% CI 1.01-1.35) as well as in the late period (aIRR = 1.19, 95% CI = 1.02-1.40) was associated with increased risk of developing HDP. The weight gain preceded the onset of clinically apparent disease. CONCLUSIONS: Excessive weight gain as early as the early second trimester was associated with increased risks of development of HDP.