Population-level changes in perinatal death for pregnancies prior to and during the COVID-19 pandemic: A pregnancy cohort analysis.

BACKGROUND: Results of population-level studies examining the effect of the COVID-19 pandemic on the risks of perinatal death have varied considerably. OBJECTIVES: To explore trends in the risk of perinatal death among pregnancies beginning prior to and during the pandemic using a pregnancy cohort approach. METHODS: This secondary analysis included data from singleton pregnancies ≥20 weeks' gestation in Alberta, Canada, beginning between 5 March 2017 and 4 March 2021. Perinatal death (i.e. stillbirth or neonatal death) was the primary outcome considered. The risk of this outcome was calculated for pregnancies with varying gestational overlap with the pandemic (i.e. none, 0-20 weeks, entire pregnancy). Interrupted time series analysis was used to further determine temporal trends in the outcome by time period of interest. RESULTS: There were 190,853 pregnancies during the analysis period. Overall, the risk of perinatal death decreased with increasing levels of pandemic exposure; this outcome was experienced in 1.0% (95% confidence interval [CI] 0.9, 1.0), 0.9% (95% CI 0.8, 1.1) and 0.8% (95% CI 0.7, 0.9) of pregnancies with no overlap, partial overlap and complete pandemic overlap respectively. Pregnancies beginning during the pandemic that had high antepartum risk scores less frequently led to perinatal death compared to those beginning prior; 3.3% (95% CI 2.7, 3.9) versus 5.7% (95% CI 5.0, 6.5) respectively. Interrupted time-series analysis revealed a decreasing temporal trend in perinatal death for pregnancies beginning ≤40 weeks prior to the start of the COVID-19 pandemic (i.e. with pandemic exposure), with no trend for pregnancies beginning >40 weeks pre-pandemic (i.e. no pandemic exposure). CONCLUSION: We observed a decrease in perinatal death for pregnancies overlapping with the COVID-19 pandemic in Alberta, particularly among those at high risk of these outcomes. Specific pandemic control measures and government response programmes in our setting may have contributed to this finding.

Procedural abortion, provider-initiated preterm delivery and survival in pregnant people with cancer: A population-based cohort study.

OBJECTIVE: To assess whether procedural-induced abortion or provider-initiated preterm delivery are associated with improved survival in pregnant people with cancer. DESIGN: Retrospective population-based cohort study. SETTING: Provinces of Alberta and Ontario, Canada, 2003-2016. POPULATION: Females aged 18-50 years diagnosed with cancer at <20 weeks' (for the assessment of procedural-induced abortion) or <37 weeks' gestation (for the assessment of provider-initiated delivery). METHODS: Cox proportional hazard models assessed all-cause mortality in relation to procedural-induced abortion and provider-initiated preterm delivery, adjusting for cancer site, stage at diagnosis and age. Meta-analysis pooled the results across both provinces. MAIN OUTCOME MEASURES: All cause mortality. RESULTS: There were 512 pregnant people diagnosed with cancer at <20 weeks' gestation and 782 diagnosed with cancer at <37 weeks' gestation. Neither procedural-induced abortion (adjusted hazard ratio [aHR] = 1.39, 95% CI: 0.32-6.17) nor provider-initiated preterm delivery (aHR = 1.17, 95% CI: 0.76-1.81) were associated with improved survival following adjustment for age, stage at diagnosis and cancer site. CONCLUSIONS: Neither procedural-induced abortion nor provider-initiated preterm birth was associated with improved survival in pregnant people diagnosed with cancer; however, these obstetric interventions are highly personal decisions best decided by the pregnant person in consultation with their care providers.

Incidence of venous thromboembolism in patients with ovarian cancer receiving neoadjuvant chemotherapy: systematic review and meta-analysis.

OBJECTIVE: Venous thromboembolism is associated with significant patient morbidity, mortality, and can lead to delays in treatment for patients with cancer. The objectives of this study were to identify the incidence of venous thromboembolism in patients with advanced ovarian cancer receiving neoadjuvant chemotherapy, and identify risk factors for venous thromboembolism. METHODS: A systematic literature search of biomedical databases, including Ovid Medline, Web of Science, Scopus, CINAHL, and Embase was performed on December 6, 2022 and updated on December 21, 2023 for peer reviewed articles. Studies were included if they were cohort studies or randomized controlled trials that evaluated the incidence of venous thromboembolism for patients with ovarian cancer receiving neoadjuvant chemotherapy. Risk of bias assessment was performed using the Newcastle Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Random effects meta-analysis was used to pool results across studies. RESULTS: A total of 2636 studies were screened, and 11 were included in the review. Ten were retrospective cohort studies, and one was a randomized controlled trial. The incidence of venous thromboembolism in the included studies ranged from 0% to 18.9%. The pooled incidence rate of venous thromboembolism was 10% (95% confidence interval (CI) 7% to 13%). This remained significant when restricted to only studies with a low risk of bias (pooled incidence of 11%, 95% CI 9% to 14%). Body mass index of ≥30 kg/m2 was a significant risk factor for venous thromboembolism with a pooled odds ratio of 1.76 (95% CI 1.13 to 2.76) CONCLUSIONS: The results from this study demonstrated a 10% incidence of venous thromboembolism for patients with advanced ovarian cancer receiving neoadjuvant chemotherapy. This suggests that there may be a role for universal thromboprophylaxis in this population. TRIAL REGISTRATION: PROSPERO CRD42022339602.

Exclusion of pregnant and lactating persons from breast cancer clinical trials: a review of active trials registered on ClinicalTrials.gov.

INTRODUCTION: Treatment of pregnancy-associated breast cancer is complex, as providers try to balance risks to the pregnant person and the developing fetus. Given increased case fatality and increasing incidence, there is a pressing need understand the efficacy and safety of different treatment regimens in this population; however, pregnant and lactating people have traditionally been excluded from participating in randomized controlled trials (RCTs). Given recent efforts to expand the inclusion criteria for oncology RCTs, this study aimed to review the inclusion/exclusion criteria of current breast cancer RCTs to assess what proportion of trials permitted enrollment of pregnant and lactating persons. MATERIAL AND METHODS: We conducted a comprehensive search of ClinicalTrials.gov in January 2022 to identify interventional studies of breast cancer in adults that were actively recruiting. The primary outcomes were the exclusion of pregnant and lactating people. RESULTS: The search identified 1706 studies, of which 1451 met eligibility criteria. Overall, 69.4% and 54.8% of studies excluded pregnant and lactating people, respectively. The exclusion of pregnant and lactating persons differed by study characteristics but extended across all trial designs, locations, phases and interventions. Exclusion of pregnant and lactating persons was most common in trials where the intervention was biological (86.3%), drug (83.5%) or radiation (81.5%). CONCLUSIONS: The exclusion of pregnant and lactating people from clinical trials contributes to evidence gaps in how to treat this population. A paradigm shift is needed that focuses on how research can be used to protect pregnant people from future harms, instead of protecting pregnant people from research-related risks.

Development and validation of the Cannabis Exposure in Pregnancy Tool (CEPT): a mixed methods study.

BACKGROUND: Evidence of associations between prenatal cannabis use (PCU) and maternal and infant health outcomes remains conflicting amid broad legalization of cannabis across Canada and 40 American states. A critical limitation of existing evidence lies in the non-standardized and crude measurement of prenatal cannabis use (PCU), resulting in high risk of misclassification bias. We developed a standardized tool to comprehensively measure prenatal cannabis use in pregnant populations for research purposes. METHODS: We conducted a mixed-methods, patient-oriented tool development and validation study, using a bias-minimizing process. Following an environmental scan and critical appraisal of existing prenatal substance use tools, we recruited pregnant participants via targeted social media advertising and obstetric clinics in Alberta, Canada. We conducted individual in-depth interviews and cognitive interviewing in separate sub-samples, to develop and refine our tool. We assessed convergent and discriminant validity internal consistency and 3-month test-retest reliability, and validated the tool externally against urine-THC bioassays. RESULTS: Two hundred fifty four pregnant women participated. The 9-item Cannabis Exposure in Pregnancy Tool (CEPT) had excellent discriminant (Cohen's kappa = -0.27-0.15) and convergent (Cohen's kappa = 0.72-1.0) validity; as well as high internal consistency (Chronbach's alpha = 0.92), and very good test-retest reliability (weighted Kappa = 0.92, 95% C.I. [0.86-0.97]). The CEPT is valid against urine THC bioassay (sensitivity = 100%, specificity = 82%). CONCLUSION: The CEPT is a novel, valid and reliable measure of frequency, timing, dose, and mode of PCU, in a contemporary sample of pregnant women. Using CEPT (compared to non-standardized tools) can improve measurement accuracy, and thus the quality of research examining PCU and maternal and child health outcomes.

The impact of relationship factors on antenatal depression in the context of the COVID-19 pandemic.

BACKGROUND: Antenatal depression is the most prevalent pregnancy-associated mental health disorder. Previous studies have identified several risk factors for antenatal depression, including partner support. However, during the COVID-19 pandemic, many relationship dynamics changed. This study examined the extent to which relationship factors had an impact on antenatal depression in comparison with other well-researched factors in the context of the pandemic. METHODS: A secondary analysis was conducted using data from the P3 Cohort in Calgary, a longitudinal cohort study based in Alberta, Canada. Pregnant people (n = 872) completed self-report questionnaires and validated scales about sociodemographic, psychological, and relationship characteristics. Antenatal depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS). Logistic regression was used to assess the impact of reported characteristics on antenatal depression. Tests of model fit were used to examine whether the inclusion of variables related to relationship quality improved model fit after accounting for other known risk factors. RESULTS: Overall, 18.23% of participants experienced antenatal depression. Relationship factors including relationship unhappiness (OR = 1.98 [95% CI: 1.06-3.69]), having an upsetting partner (OR = 2.00 [95% CI: 1.17-3.40]), and having a lower quality of relationships with close friends and family (OR = 1.76 [95% CI: 1.14-2.73]) were associated with antenatal depression; however, inclusion of these relationship factors did not improve model fit after accounting for other known predictors. CONCLUSION: Overall, relationship factors were not associated with antenatal depression during the pandemic after accounting for other known risk factors. Stress and anxiety caused by the pandemic may have overshadowed the impact of relationship factors, or relationship factors may have contributed to higher levels of stress and anxiety more generally within our sample.

Improving Influenza Vaccine Uptake During Pregnancy Through Vaccination at Point of Care: A Before-and-After Study.

OBJECTIVES: Vaccine administration where pregnant individuals receive prenatal care may increase vaccine coverage. Availability of influenza vaccine at prenatal care visits is not standard in Canada. Since the 2016-2017 influenza season, pregnant individuals can receive the influenza vaccine at the point of care (POC) in an urban clinic in Calgary, Alberta. The objective of this study was to descriptively examine vaccination rates across multiple influenza seasons for a POC vaccination in pregnancy (VIP) intervention and describe associations between influenza vaccine coverage and comorbidities and area-level socioeconomic status. METHODS: A before-and-after study design was used to examine vaccine coverage across 6 consecutive influenza seasons: 2 before (2014-2015 and 2015-2016) and 4 after POC-VIP implementation (2016-2017 to 2019-2020). We identified the birth cohort and measured influenza vaccine uptake using clinical and administrative databases. Influenza vaccination rates were computed and compared using the Fisher exact test with statistical significance at a P value of 0.05. RESULTS: A total of 4443 pregnancies were identified during the study period. The influenza vaccination rate increased in the intervention years at 40.1 per 1000 patient-weeks (P < 0.001), compared to the pre-intervention influenza seasons at 11.7 per 1000 patient-weeks. Vaccine coverage did not statistically differ between pregnancies with or without comorbidities across most seasons. Vaccine coverage decreased as material deprivation increased in pre-intervention years. CONCLUSIONS: The vaccination rate was higher in the intervention years compared to the pre-intervention period. In this study, we applied a systematic methodology to examine vaccine coverage in pregnancy and presented a descriptive examination of a POC-VIP intervention.

Implementation of Multiple Marker Screening for Preterm Preeclampsia in a Single Tertiary Obstetric Centre.

OBJECTIVES: Early assessment of pregnant individuals for risk of preterm preeclampsia (PE) is possible at the 11-14 week ultrasound visit using a validated multiple marker algorithm, allowing timely use of preventative low-dose acetylsalicylic acid (LDA) in high-risk patients. With no established early screening program for preterm PE in Canada, our objectives were to assess the acceptability and operational impact of routine screening for preterm PE during the 11-14 week ultrasound visit, evaluate uptake and adherence to LDA when recommended, and assess screening performance. METHODS: A prospective implementation study of preterm PE screening among pregnant patients at the ultrasound unit of a tertiary obstetric centre in Toronto, Canada. RESULTS: A total of 1057 patients were screened, with an acceptance rate of 87.1%. First-trimester ultrasound appointment time increased by a median time of 7 minutes (Interquartile range 6-9). By 16 weeks gestation, 88.7% of high-risk patients had started LDA, with adherence of 88.7%‒94.6% from 16‒36 weeks. Satisfaction with counselling was ≥7/10 in more than 95% of patients. There were 7 cases of preterm PE (0.73%), 3 in the low-risk group (0.35%), and 4 in the high-risk group (4.1%). When accounting for LDA use, the treatment-adjusted detection rate was 78.6%. CONCLUSIONS: We demonstrate successful implementation of a validated, effective screening and prevention program for preterm PE as a first step in the implementation of a broader program adaptable for cultural, access/equity considerations, and marker availability.

Bilateral salpingo-oophorectomy at the time of benign hysterectomy among females with disabilities: a population-based cross-sectional study.

BACKGROUND: Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking. OBJECTIVE: This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years. STUDY DESIGN: This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group. RESULTS: Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group. CONCLUSION: Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial.

The REDUCED trial: a cluster randomized trial for REDucing the utilization of CEsarean delivery for dystocia.

BACKGROUND: To reduce cesarean delivery rates in nulliparous women, guidelines for diagnosing nonprogressive labor have been developed by the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. These are mainly based on data from the Consortium for Safe Labor study. The guidelines have not been tested in a clinical trial, so the efficacy and safety of this new approach is uncertain. OBJECTIVE: This study aimed to assess whether adoption of new guidelines for diagnosing nonprogressing labor would reduce cesarean delivery rates. STUDY DESIGN: We conducted a cluster randomized controlled trial of a knowledge translation program of the guidelines in 26 Canadian hospitals (13 control sites and 13 intervention sites). The sites included all intrapartum care sites in Alberta that perform cesarean delivery and deliver at least 70 nulliparous women annually. The baseline period started on January 1, 2015. The intervention was initiated at the first intervention site in January 2017. The follow-up period began at the first intervention site in February 2017 and lasted till February 2020. The primary outcome was the rate of cesarean delivery in nulliparous women with vertex presentation in labor at term. The secondary outcomes included spontaneous vaginal birth and maternal and neonatal safety. The main data source for the primary and secondary outcomes was the Alberta Perinatal Health Program database. The cesarean delivery rates were assessed using repeated measures mixed effects logistic regression applied to individual births. RESULTS: The analysis was based on 45,193 deliveries at intervention sites and 43,725 deliveries at control sites. There was no evidence of a decrease in the rate of cesarean delivery in association with the intervention (baseline-adjusted odds ratio, 0.94; 95% confidence interval [0.85-1.05]; P=.259). The rate of spontaneous vaginal delivery increased slightly (baseline-adjusted odds ratio, 1.10; 95% confidence interval, [1.01-1.18]; P=.024). We did not observe any differences in adverse maternal or neonatal outcomes. CONCLUSION: Cesarean delivery rates in nulliparous women were not reduced by the application of recent guidelines for the diagnosis of nonprogressive labor. Spontaneous vaginal delivery-a secondary outcome-was increased in the intervention group. The intervention appears to be safe.

The association of gestational age at birth with trajectories of early childhood developmental delay among late preterm and early term born children: A longitudinal analysis of All Our Families pregnancy cohort.

BACKGROUND: Like infants born very preterm (<32 weeks), late preterm (≥34 and <37 weeks) and early term (≥37 and <39 weeks) births have been associated with increased risk of developmental delay (DD); yet, the evidence remains heterogeneous across the continuum of gestational ages, hindering early identification and intervention. OBJECTIVE: To estimate the association of gestational age at birth with early childhood trajectories of DD in early childhood for infants born ≥34 and <41 weeks, and determine how various maternal, pregnancy and infant characteristics relate to these trajectory groups. METHODS: Analysis of mother-child dyad data with infants born ≥34 and <41 weeks gestational age within an observational pregnancy cohort in Alberta, Canada, from 2008 to 2011 (n = 2644). The association between gestational age and trajectories of the total number of Ages and Stages Questionnaire domains indicating risk of DD from 1 through 5 years of age were estimated using group-based trajectory modelling along with other perinatal risk factors. RESULTS: Three distinct trajectory groups were identified: low-risk, moderate-risk (transiently at risk of DD in one domain over time) and high-risk (consistently at risk of delay in ≥2 domains over time). Per week of decreasing gestational age, the risk ratio of membership in the high-risk group increases by 1.77 (95% confidence interval [CI] 1.43, 2.20) or 1.84 (95% CI 1.49, 2.27) relative to the moderate-risk and low-risk respectively. Increasing maternal age, identifying as Black, indigenous or a person of colour, elevated maternal depressive symptoms in pregnancy, and male infant sex were associated with high- and moderate-risk trajectories compared to the low-risk trajectory. CONCLUSIONS: In combination with decreasing gestational age, poor maternal mental health and social determinants of health increase the probability of membership in trajectories with increased risk of DD, suggesting that additional monitoring of children born late preterm and early term is warranted.

Emergency Department Visits During Pregnancy.

STUDY OBJECTIVE: Pregnant women often seek care in an emergency department (ED). We sought to describe the frequency, characteristics, and factors associated with increased ED visits during pregnancy. METHODS: We conducted a retrospective cohort study using administrative health data of all pregnancies resulting in a live birth at 20 or more weeks of gestation in Alberta, Canada, from 2011 to 2017. The primary outcome was the occurrence of any ED visit during pregnancy. The secondary outcomes were ED visit characteristics and discharge disposition. We calculated rate ratios (RRs) and 95% confidence intervals (CIs) for associations between sociodemographic and clinical factors and increased ED visits during pregnancy using random-effect negative binomial regression adjusting for multiple pregnancies per person during the study period. RESULTS: We included 255,929 pregnancies from 193,965 women. Of all the pregnancy episodes followed, 37.3% (95% CI 37.1 to 37.5) had at least 1 ED visit, resulting in a total of 226,811 ED visits and an overall ED visit rate of 94.0 visits per 100 pregnancies (95% CI 93.6 to 94.3). Most visits were nonobstetric (46.4%) and resulted in ED discharge (85.3%). Increased ED visits were associated with living in remote (RR 6.9; 95 %CI 6.7 to 7.1) or rural (RR 3.4; 95% CI 3.4 to 3.5) areas, younger age (RR 1.9; 95% CI 1.8 to 2.0), intensive prenatal care (RR 1.5; 95% CI 1.5 to 1.5), major/moderate health conditions (RR 1.6; 95% CI 1.6 to 1.6), mental health conditions (RR 1.6; 95% CI 1.5 to 1.6), and high antepartum risk score (RR 1.1; 95% CI 1.1 to 1.1). CONCLUSION: Approximately 1 in 3 women in our sample visited the ED during pregnancy. A higher number of visits occurred in those with rural/remote residence, younger maternal age, and concomitant health conditions.

Association of postpartum medication practices with early breastfeeding cessation among mothers with chronic conditions: A prospective cohort study.

INTRODUCTION: Use of medications is a common concern for breastfeeding women, particularly when they are strongly needed or unavoidable to manage maternal chronic conditions. Yet the influence of medication usage patterns on breastfeeding duration in mothers with chronic conditions is unclear. The objective of this study was to examine whether postpartum medication practices were associated with shorter breastfeeding duration or earlier than planned breastfeeding cessation among mothers with chronic conditions. MATERIAL AND METHODS: We analyzed 346 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study (Alberta, Canada) who initiated breastfeeding after birth. Data were collected through self-report questionnaires spanning late pregnancy to 6 months postpartum. Based on reported use of preexisting medications while breastfeeding, women were classified as continuing medications (reference group), discontinuing one or more medications, or those who did not use preexisting medications. Cox proportional hazards regression was used to analyze the association of medication practices and overall breastfeeding duration in weeks. Logistic regression was used to analyze the association of medication practices and earlier than planned breastfeeding cessation. Multivariable models adjusted for demographic and health-related factors. RESULTS: Overall, 30.6% of women with chronic conditions stopped breastfeeding in the first 6 months, almost all of whom did so earlier than planned. In multivariable models, medication discontinuation was significantly associated with shorter breastfeeding duration (adjusted hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03-2.70) and earlier than planned breastfeeding cessation (adjusted odds ratio [OR] 1.85, 95% CI 1.01-3.42), whereas medication non-use was not associated with differences in breastfeeding outcomes. CONCLUSIONS: Women with chronic conditions who discontinued preexisting medications while breastfeeding had significantly shorter breastfeeding duration and were less likely to meet their breastfeeding goals in the first 6 months postpartum compared to women who continued preexisting medications.

Breastfeeding difficulties in the first 6 weeks postpartum among mothers with chronic conditions: a latent class analysis.

BACKGROUND: Breastfeeding difficulties frequently exacerbate one another and are common reasons for curtailed breastfeeding. Women with chronic conditions are at high risk of early breastfeeding cessation, yet limited evidence exists on the breastfeeding difficulties that co-occur in these mothers. The objective of this study was to explore clusters of breastfeeding difficulties experienced up to 6 weeks postpartum among mothers with chronic conditions and to examine associations between chronic condition types and breastfeeding difficulty clusters. METHODS: We analyzed 348 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study from Alberta, Canada. Data were collected through self-report questionnaires. We used latent class analysis to identify clusters of early breastfeeding difficulties and multinomial logistic regression to examine whether types of chronic conditions were associated with these clusters, adjusting for maternal and obstetric factors. RESULTS: We identified three clusters of breastfeeding difficulties. The "physiologically expected" cluster (51.1% of women) was characterized by leaking breasts and engorgement (reference outcome group); the "low milk production" cluster (15.4%) was discerned by low milk supply and infant weight concerns; and the "ineffective latch" cluster (33.5%) involved latch problems, sore nipples, and difficulty with positioning. Endocrine (adjusted relative risk ratio [RRR] 2.34, 95% CI 1.10-5.00), cardiovascular (adjusted RRR 2.75, 95% CI 1.01-7.81), and gastrointestinal (adjusted RRR 2.51, 95% CI 1.11-5.69) conditions were associated with the low milk production cluster, and gastrointestinal (adjusted RRR 2.44, 95% CI 1.25-4.77) conditions were additionally associated with the ineffective latch cluster. CONCLUSION: Half of women with chronic conditions experienced clusters of breastfeeding difficulties corresponding either to low milk production or to ineffective latch in the first 6 weeks postpartum. Associations with chronic condition types suggest that connections between lactation physiology and disease pathophysiology should be considered when providing breastfeeding support.

Interview With CSCI Joe Doupe Young Investigator Awardee, Dr. Amy Metcalfe.

Dr. Amy Metcalfe is an Associate Professor in the Departments of Obstetrics and Gynecology, Medicine, and Community Health Sciences at the University of Calgary. She is also the Maternal and Child Health Program Director with the Alberta Children's Hospital Research Institute. Dr. Metcalfe's training is a perinatal epidemiologist whose research broadly focuses on the management of chronic illness during pregnancy, and how events in pregnancy impact women's health and wellbeing throughout the life course. Current major projects include co-leading the P3 Cohort study (https://p3cohort.ca), a longitudinal pregnancy cohort study, and the GROWW (Guiding interdisciplinary Research On Women's and girls' health and Wellbeing) Training Program (https://www.growwprogram.com).

Unplanned Extubations Requiring Reintubation in Pediatric Critical Care: An Epidemiological Study.

OBJECTIVES: Unplanned extubations are an infrequent but life-threatening adverse event in pediatric critical care. Due to the rarity of these events, previous studies have been small, limiting the generalizability of findings and the ability to detect associations. Our objectives were to describe unplanned extubations and explore predictors of unplanned extubation requiring reintubation in PICUs. DESIGN: Retrospective observational study and multilevel regression model. SETTING: PICUs participating in Virtual Pediatric Systems (LLC). PATIENTS: Patients (≤ 18 yr) who had an unplanned extubation in PICU (2012-2020). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed and trained a multilevel least absolute shrinkage and selection operator (LASSO) logistic regression model in the 2012-2016 sample that accounted for between-PICU variations as a random effect to predict reintubation after unplanned extubation. The remaining sample (2017-2020) was used to externally validate the model. Predictors included age, weight, sex, primary diagnosis, admission type, and readmission status. Model calibration and discriminatory performance were evaluated using Hosmer-Lemeshow goodness-of-fit (HL-GOF) and area under the receiver operating characteristic curve (AUROC), respectively. Of the 5,703 patients included, 1,661 (29.1%) required reintubation. Variables associated with increased risk of reintubation were age (< 2 yr; odds ratio [OR], 1.5; 95% CI, 1.1-1.9) and diagnosis (respiratory; OR, 1.3; 95% CI, 1.1-1.6). Scheduled admission was associated with decreased risk of reintubation (OR, 0.7; 95% CI, 0.6-0.9). With LASSO (lambda = 0.011), remaining variables were age, weight, diagnosis, and scheduled admission. The predictors resulted in AUROC of 0.59 (95% CI, 0.57-0.61); HL-GOF showed the model was well calibrated (p = 0.88). The model performed similarly in external validation (AUROC, 0.58; 95% CI, 0.56-0.61). CONCLUSIONS: Predictors associated with increased risk of reintubation included age and respiratory primary diagnosis. Including clinical factors (e.g., oxygen and ventilatory requirements at the time of unplanned extubation) in the model may increase predictive ability.

Predicting prolonged length of stay in hospitalized children with respiratory syncytial virus.

BACKGROUND: Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infections in children. This study aimed to predict the prolonged length of stay in children admitted to hospital with RSV. METHODS: Children aged <2 years with RSV in the National Inpatient Sample (NIS) were included in the analyses. The primary outcome was prolonged length of stay (≥90th percentile). Logistic regression models were developed using data from 2016; internal validation was completed using a bootstrapped sample. Data from 2017 were used to validate out-of-sample discrimination and calibration of the models. RESULTS: The sample included 9589 children; 1054 had prolonged length of stay (≥7 days). Children who were younger, transferred from another hospital, and required intubation during admission had a higher risk of prolonged length of stay. The prediction model included age, transport, intubation, comorbidities, hospital location, and teaching status. The area under the receiver operating characteristic curve was 0.73, demonstrating good predictive ability. The model performed similarly in external validation. CONCLUSIONS: Variables that predict the prolonged length of stay for RSV include younger age, transport, intubation, comorbidities, hospital location, and teaching status. This can be used to predict children who will have a prolonged length of stay when hospitalized for RSV. IMPACT: There are no recommended treatments for RSV; medical care involves supportive treatment such as oxygen delivery, hydration, and antipyretics. The clinical course is difficult to predict, partially attributable to the supportive nature of care and the sparsity of evidence-based therapies for this population. A prediction model was developed, demonstrating variables that predict prolonged length of stay in RSV hospitalizations, including age, interhospital transport, intubation, comorbidities, hospital location, and teaching status. The model was developed with a sample size of 9589 that is representative of all hospitalizations in the United States.

Comparing adverse neonatal and maternal outcomes of chlamydia, gonorrhoea, and syphilis infections and co-infections in pregnancy.

BACKGROUND: While maternal sexually transmitted infections (STIs) during pregnancy have been extensively studied, fewer studies have directly compared the associations of different infections and co-infections or investigated the association between STIs in pregnancy and maternal outcomes. OBJECTIVES: We examine associations between STIs and co-infections in pregnancy on risks of adverse neonatal and maternal outcomes. METHODS: Data from the 2019 US natality files (n = 3,747,882) were used to assess the associations between STIs in pregnancy on adverse pregnancy outcomes. Five mutually exclusive STI groups were examined: a single chlamydia, syphilis, or gonorrhoeal infection, chlamydia and gonorrhoea co-infection, and syphilis co-infection (with chlamydia, gonorrhoea, or both). Demographic and obstetric characteristics among each STI group were compared to those of an uninfected comparison group. Prevalence ratios (PR) of adverse neonatal outcomes (preterm birth, small for gestational age [SGA] births, and 5-min APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score < 7) and maternal outcomes (gestational hypertension) by STI status were examined using log-binomial regression. RESULTS: Increased prevalence of preterm birth was apparent, especially among those with a syphilis infection (PR 1.19, 95% confidence intreval [CI] 1.10, 1.30 for single infections and PR 1.31, 95% CI 1.10, 1.57 for co-infections). All STI groups, except gonorrhoea and chlamydia co-infections, were associated with an increased prevalence of gestational hypertension, with the strongest association among those with syphilis co-infections (PR 1.41, 95% CI 1.13, 1.76). CONCLUSIONS: An increased prevalence was of preterm birth and low APGAR scores were associated with syphilis infection. Increased prevalence of GH among those with STIs warrants further investigation into the relationships and corresponding mechanisms of STIs in pregnancy on adverse maternal outcomes.

Emergency Department Visits During the Postpartum Period: A Canadian Cohort Study.

STUDY OBJECTIVE: Challenges in transitioning from obstetric to primary care in the postpartum period may increase emergency department (ED) visits. This study described the frequency, characteristics, and predictors of maternal ED visits in the postpartum period. METHODS: Retrospective cohort study of all live-birth pregnancies occurring in Alberta (Canada) between 2011 and 2017. Individual-level health and ED utilization data was linked across 5 population health databases. We calculated age-standardized ED visit rates in the postpartum period and used negative binomial regression models to assess the outcome of any ED visit in the postpartum period associated with relevant sociodemographic and clinical factors. Results were reported using rate ratios (RRs) and 95% confidence intervals (95% CIs). RESULTS: Data on 255,929 pregnancies from 193,965 individuals were analyzed. During the study period, 44.7% of pregnancies had 1 or more ED visits; 29.7% of visits occurred within 6 weeks after delivery. Increased postpartum ED visits were associated with living in remote (RR, 2.8; 95% CI, 2.6 to 2.9) or rural areas (RR, 2.3; 95% CI, 2.3 to 2.4), age less than 20 years (RR, 2.5; 95% CI, 2.4 to 2.6), mental (RR, 1.6; 95% CI, 1.6 to 1.7) and major/moderate health conditions (RR, 1.5; 95% CI, 1.5 to 1.6), multiparity 4 or more (RR, 2.0; 95% CI, 1.9 to 2.1), cesarean delivery (RR, 1.4; 95% CI, 1.4 to 1.4), and intensive prenatal care (RR, 1.4; 95% CI, 1.4 to 1.5). CONCLUSION: Almost one third of ED visits in the postpartum occurred within 6 weeks immediately after delivery. Potential gaps in equitable access and quality of prenatal care should be bridged by appropriate transitions to primary care in the postpartum period.

Impact of a Clinical Intervention to Decrease Opioid Prescribing in a Post-Cesarean Delivery.

A quality assurance study was completed following the implementation of a standardized opioid prescribing and education protocol post cesarean delivery. The primary goal was to determine the need for a policy on postpartum opioid prescribing practices and whether the protocol worked. There was a decrease in the number of tablets provided post intervention and no statistically significant maternal or neonatal readmissions for suspected opioid toxicity or pain control. Combination prescribing of Tylenol 3 and/or tramadol and another opioid occurred in both groups. Our results show a need for concise guidelines regarding opioid prescribing following cesarean delivery.