Idiopathic Polyhydramnios: Severity and Perinatal Morbidity.

Objective To estimate the association between the severity of idiopathic polyhydramnios and adverse outcomes. Study Design Retrospective cohort study of deliveries at one hospital from 2000 to 2012 with an amniotic fluid index (AFI) measurement ≥24 + 0 weeks' gestation. Pregnancies complicated by diabetes, multiples, or fetal anomalies were excluded. Exposure was the degree of polyhydramnios: normal (AFI 5-24 cm), mild (≥ 24-30 cm), and moderate-severe (> 30 cm). Primary outcomes were perinatal mortality, neonatal intensive care unit (NICU) admission, and postpartum hemorrhage. Results There were 10,536 pregnancies: 10,188 with a normal AFI, 274 mild (78.74%), and 74 moderate-severe polyhydramnios (21.26%). Adverse outcomes were increased with idiopathic polyhydramnios: NICU admission (adjusted odds ratio [AOR] 3.71, 95% confidence interval [CI] 2.77-4.99), postpartum hemorrhage (AOR 15.81, 95% CI 7.82-31.96), macrosomia (AOR 3.41, 95% CI 2.61-4.47), low 5-minute Apgar score (AOR 2.60, 95% CI 1.57-4.30), and cesarean (AOR 2.16, 95% CI 1.74-2.69). There were increasing odds of macrosomia (mild: AOR 3.19, 95% CI 2.36-4.32; moderate-severe: AOR 4.44, 95% CI 2.53-7.79) and low 5-minute Apgar score (mild: AOR 2.24, 95% CI 1.23-4.08; moderate-severe: AOR 3.93, 95% CI 1.62-9.55) with increasing severity of polyhydramnios. Conclusion Idiopathic polyhydramnios is independently associated with increased risks of morbidity. There appears to be a dose-response relationship for neonatal macrosomia and low 5-minute Apgar score risks.

The perinatal quality collaborative of North Carolina's 39 weeks project: a quality improvement program to decrease elective deliveries before 39 weeks of gestation.

BACKGROUND: Despite long-standing guidelines from the American College of Obstetricians and Gynecologists that call for avoiding elective births prior to 39 weeks of gestation, elective deliveries make up almost one-third of US births occurring in weeks 36-38. Poor outcomes are more likely for infants born electively before 39 weeks than for those born at 39 weeks. The Perinatal Quality Collaborative of North Carolina (PQCNC) undertook the 39 Weeks Project in 2009-2010 with the aim of reducing the number of early-term elective deliveries in North Carolina hospitals. METHODS: Participating hospitals (N = 33) provided retrospective data on all early-term deliveries and created new policies, or amended or enforced existing policies, to accomplish the project's goals. Project activities included in-person learning sessions, regional meetings, webinars, electronic newsletters, a secure extranet Web site where participating hospitals could share relevant materials, and individual leadership consultations with hospital teams. Hospitals submitted monthly data to PQCNC, which provided ongoing training and data analysis. RESULTS: Elective deliveries before 39 weeks of gestation decreased 45% over the project period, from 2% to 1.1% of all deliveries. The proportion of elective deliveries among all scheduled early-term deliveries also decreased, from 23.63% to 16.19%. There was an increase in the proportion of patients with documented evidence of medical indications for early delivery, from 62.4% to 88.2%. LIMITATIONS: No data were collected to determine whether outcomes changed for patients whose deliveries were deferred. The project also depended on each hospital to code its own data. CONCLUSION: The PQCNC's 39 Weeks Project successfully decreased the rate of early-term elective deliveries in participating hospitals.

Scheduled deliveries: avoiding iatrogenic prematurity.

The balance of maternal, fetal, and neonatal risks of continued pregnancy versus iatrogenic delivery must be based on best evidence. Although avoiding elective deliveries prior to 39 weeks is well established to improve neonatal outcomes, several "soft" conditions are commonly considered to require delivery prior to 39 weeks. Review of existing literature suggests that with some of these conditions, delivery can be safely delayed until later in pregnancy or even allowed to proceed without intervention. Late preterm and early term deliveries contribute substantially to neonatal morbidity and health care costs and should be considered only if the risks of continuing the pregnancy exceed the neonatal risks related to early birth. In this article, we review some the common clinical scenarios that may result in scheduled early term or late preterm births, with a focus on practice strategies for improving maternal and neonatal outcomes.

Screening for infectious diseases in pregnant, foreign-born women from multiple global areas.

OBJECTIVE: To describe and compare infectious diseases commonly screened for during pregnancy among pregnant immigrant women from multiple global regions. STUDY DESIGN: We retrospectively reviewed the charts of all women born outside the United States who delivered at Vanderbilt University Medical Center during 2003-2006. These women were identified through the birth certificate applications for their children. The primary outcomes were prevalence of positive tests for tuberculosis, HIV, hepatitis B, gonorrhea and Chlamydia, rubella immunity and syphilis. RESULTS: During the years 2003-2006, 1,767 immigrant women gave birth at Vanderbilt University Medical Center. The women were from Africa (17%), Asia (25%), Europe (11%), Latin America (26%), Middle East (18%), North America (2%) and Oceana (1%). There were no statistically significant differences in prevalence among immigrant groups for positive purified protein derivatives (PPDs), rubella titers, rapid plasma reagin (syphilis) and gonorrhea. Significantly more women from Asia and Africa had positive hepatitis B surface antigen. Asian women were less likely than other immigrant groups to be positive for HIV. Significant differences were also noted among groups for Chlamydia. Screening rates differed by immigrant groups and were related to mode of testing. CONCLUSION: Our data reinforce the importance of screening for diseases for which vaccinations are available, especially for hepatitis B and rubella. The data also show the importance of following up positive PPDs, particularly among pregnant immigrant women. Screening differences among groups may exist, and further research is needed to examine causal factors.

Ethiopian and American Collaboration: Process, Accomplishments, and Lessons Learned.

From 2015 to 2018, the Ethiopian Society of Obstetricians & Gynecologists (ESOG), the American College of Obstetricians and Gynecologists, the Ethiopian Federal Ministry of Health, and the Center for International Reproductive Health Training at the University of Michigan collaborated to define and execute the goals of ESOG to enhance education, research, publishing, and clinical care in Ethiopia. We outline the processes used to define and execute these goals, accomplishments toward achieving them, and key lessons learned.

Machine Learning and Statistical Models to Predict Postpartum Hemorrhage.

OBJECTIVE: To predict a woman's risk of postpartum hemorrhage at labor admission using machine learning and statistical models. METHODS: Predictive models were constructed and compared using data from 10 of 12 sites in the U.S. Consortium for Safe Labor Study (2002-2008) that consistently reported estimated blood loss at delivery. The outcome was postpartum hemorrhage, defined as an estimated blood loss at least 1,000 mL. Fifty-five candidate risk factors routinely available on labor admission were considered. We used logistic regression with and without lasso regularization (lasso regression) as the two statistical models, and random forest and extreme gradient boosting as the two machine learning models to predict postpartum hemorrhage. Model performance was measured by C statistics (ie, concordance index), calibration, and decision curves. Models were constructed from the first phase (2002-2006) and externally validated (ie, temporally) in the second phase (2007-2008). Further validation was performed combining both temporal and site-specific validation. RESULTS: Of the 152,279 assessed births, 7,279 (4.8%, 95% CI 4.7-4.9) had postpartum hemorrhage. All models had good-to-excellent discrimination. The extreme gradient boosting model had the best discriminative ability to predict postpartum hemorrhage (C statistic: 0.93; 95% CI 0.92-0.93), followed by random forest (C statistic: 0.92; 95% CI 0.91-0.92). The lasso regression model (C statistic: 0.87; 95% CI 0.86-0.88) and logistic regression (C statistic: 0.87; 95% CI 0.86-0.87) had lower-but-good discriminative ability. The above results held with validation across both time and sites. Decision curve analysis demonstrated that, although all models provided superior net benefit when clinical decision thresholds were between 0% and 80% predicted risk, the extreme gradient boosting model provided the greatest net benefit. CONCLUSION: Postpartum hemorrhage on labor admission can be predicted with excellent discriminative ability using machine learning and statistical models. Further clinical application is needed, which may assist health care providers to be prepared and triage at-risk women.

Gottesfeld-Hohler Memorial Foundation Risk Assessment for Early-Onset Preeclampsia in the United States: Think Tank Summary.

Preeclampsia is responsible for significant maternal and neonatal morbidity and is associated with a substantial economic burden. Aspirin has been shown to be effective in decreasing the risk of preterm preeclampsia; however, there is no consensus on the target population for aspirin prophylaxis. In May 2018, the Gottesfeld-Hohler Memorial Foundation organized a working group meeting with the goal of identifying the optimal preeclampsia risk-assessment strategy and consequent intervention in the United States. The meeting brought together experts from the leading professional societies. We discussed available literature and trends in preeclampsia risk assessment, current professional guidelines for identifying women at risk for preeclampsia, prophylactic use of aspirin in the United States and Europe, cost-effectiveness data, and feasibility of implementation of different assessment tools and preventive strategies in the United States. We identified specific knowledge gaps and future research directions in preeclampsia risk assessment and prevention that need to be addressed before practice change.

Maternal-fetal surgery: where are we and how did we get here?

Using the criteria proposed in 1982 to justify consideration of in utero surgical treatment of fetal disorders, the development of maternal-fetal treatment is described, and an assessment of current status is provided. Significant issues remain, and many questions are unanswered. By using three different disorders, congenital diaphragmatic hernia, open spina bifida, and twin-to-twin transfusion, the complexity and sophistication of the field are explored, as well as the existing gaps in understanding.

Prospective study of coding practices for cesarean deliveries.

OBJECTIVE: To assess consistency of hospital coding for patients with cesarean delivery-related admissions. METHODS: Hospital coders from 11 participating institutions received a brief questionnaire and a standardized, inpatient record that was developed for nine hypothetical patients who delivered by cesarean delivery. They were asked to assign a diagnosis-related group (DRG) for each case and to submit the DRG, assigned International Classification of Diseases, 9th Revision (ICD-9) codes, and any relevant Physicians' Current Procedural Terminology Coding System codes used in their coding for each case. These responses were analyzed by mean analysis and analysis of variance tests to evaluate variation in coding practices submitted. RESULTS: Each participating academic hospital has a level III nursery, takes maternal transports, and has a residency and maternal-fetal medicine staff. Consensus in DRG coding was found in only two thirds of cases. Variation in use of ICD-9 codes existed, with 13.7% of ICD-9 codes assigned by all of the coding departments and 24.2% of ICD-9 codes uniquely used by a single institution. Variation in use of Physicians' Current Procedural Terminology Coding System codes also occurred, with 16.3% of the procedure codes used in the same case by all institutions and 28.6% used by a single institution. CONCLUSION: Documenting providers, coders, and institutions should exercise caution in the use of DRG codes, procedure codes, and ICD-9 codes for cesarean deliveries. The variability noted reflects the difficulty of the coding process and judgments that need to be made by the coders in assigning the codes. LEVEL OF EVIDENCE: III.

Serum Uric Acid Measurement in Women With Hypertensive Disorders of Pregnancy.

A 27-year-old asymptomatic primigravid woman at 36 weeks of gestation is evaluated in the labor and delivery unit with new-onset hypertension of 145/92 mm Hg (with similar measurements 4 hours apart). A spot urine protein/creatinine ratio is 0.35, serum transaminases and creatinine level are normal, and uric acid is 6.0 mg/dL (upper limit of normal for adult woman is 6.0 mg/dL but typically 4-5 mg/dL in the third trimester). Antenatal fetal testing and growth on ultrasound scan are reassuring. She is discharged for home management and ultimately delivered at 37 weeks of gestation for preeclampsia without severe features.

Survival of infants with spina bifida and the role of maternal prepregnancy body mass index.

OBJECTIVE: To investigate first-year survival of infants born with spina bifida, and examine the association of maternal prepregnancy body mass index (BMI) with infant mortality. METHODS: This is a retrospective cohort study of 1,533 liveborn infants with nonsyndromic spina bifida with estimated dates of delivery from 1998 to 2011 whose mothers were eligible for the National Birth Defects Prevention Study (NBDPS). NBDPS data were linked to death records to conduct survival analyses. Kaplan-Meier survival functions estimated mortality risk over the first year of life. Cox proportional hazards models estimated hazard ratios (HRs) for maternal prepregnancy BMI categorized as underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), and obese (≥30). RESULTS: Infant mortality risk among infants with spina bifida was (4.4% [3.52, 5.60%]). Infants with multiple co-occurring defects, very preterm delivery, multiple gestation, high-level spina bifida lesions, or non-Hispanic Black mothers had an elevated risk of infant mortality. Maternal prepregnancy underweight and obesity were associated with higher infant mortality (15.7% [7.20, 32.30%] and 5.82% [3.60, 9.35%], respectively). Adjusted HR estimates showed underweight and obese mothers had greater hazard of infant mortality compared to normal weight mothers (HR: 4.5 [1.08, 16.72] and 2.6 [1.36, 8.02], respectively). CONCLUSION: The overall risk of infant mortality for infants born with spina bifida was lower than most previously reported estimates. Infants born with spina bifida to mothers who were underweight or obese prepregnancy were at higher risk of infant mortality. This study provides additional evidence of the importance of healthy maternal weight prior to pregnancy.

Bias in Obstetrician-Gynecologists' Workplaces.

Obstetrician-gynecologists (ob-gyns) face similar types of biases in the workplace as any people in society. In this first of three articles exploring this issue, we present the stories from ob-gyns who describe their experiences dealing with these biases. These stories serve to personalize the issue and to encourage us to personally face bias in the workplace to build our own resilience and strength, to support those who are personally attacked or diminished, and to develop workplace cultures that are inclusive, diverse, and strong.

Institutional Responses to Harassment and Discrimination in Obstetrics and Gynecology.

Institutional harassment and discrimination are prevalent in the field of medicine and are detrimental to the well-being of individuals, teams, and the work environment. The familiar framework of an obstetric safety bundle is used here to propose 11 practical steps a health care team or institution may take to prepare for and respond to workplace harassment and discrimination in a systematic fashion.