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BACKGROUND: Pharyngeal flow limitation during pregnancy may be a risk factor for adverse pregnancy outcomes but was previously challenging to quantify. Our objective was to determine whether a novel objective measure of flow limitation identifies an increased risk of pre-eclampsia (primary outcome) and other adverse outcomes in a prospective cohort: Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-be (nuMoM2b). METHODS: Flow limitation severity scores (0%=fully obstructed, 100%=open airway), quantified from breath-by-breath airflow shape, were obtained from home sleep tests during early (6-15â weeks) and mid (22-31â weeks) pregnancy. Multivariable logistic regression quantified associations between flow limitation (median overnight severity, both time-points averaged) and pre-eclampsia, adjusting for maternal age, body mass index (BMI), race, ethnicity, chronic hypertension and flow limitation during wakefulness. Secondary outcomes were hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM) and infant birthweight. RESULTS: Of 1939 participants with flow limitation data at both time-points (mean±sd age 27.0±5.4â years and BMI 27.7±6.1â kg·m-2), 5.8% developed pre-eclampsia, 12.7% developed HDP and 4.5% developed GDM. Greater flow limitation was associated with increased pre-eclampsia risk: adjusted OR 2.49 (95% CI 1.69-3.69) per 2sd increase in severity. Findings persisted in women without sleep apnoea (apnoea-hypopnoea index <5â events·h-1). Flow limitation was associated with HDP (OR 1.77 (95% CI 1.33-2.38)) and reduced infant birthweight (83.7 (95% CI 31.8-135.6)â g), but not GDM. CONCLUSIONS: Greater flow limitation is associated with increased risk of pre-eclampsia, HDP and lower infant birthweight. Flow limitation may provide an early target for mitigating the consequences of sleep disordered breathing during pregnancy.
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Pré-Eclâmpsia , Resultado da Gravidez , Humanos , Gravidez , Feminino , Adulto , Pré-Eclâmpsia/fisiopatologia , Estudos Prospectivos , Fatores de Risco , Adulto Jovem , Modelos Logísticos , Diabetes Gestacional/fisiopatologia , Sono/fisiologia , Peso ao Nascer , Análise Multivariada , Paridade , Polissonografia , Índice de Massa Corporal , Faringe/fisiopatologia , Hipertensão Induzida pela Gravidez/fisiopatologia , Recém-NascidoRESUMO
Guidelines for the management of first-trimester spontaneous and induced abortion vary in terms of rhesus factor D (RhD) testing and RhD immune globulin (RhIg) administration. These existing guidelines are based on limited data that do not convincingly demonstrate the safety of withholding RhIg for first-trimester abortions or pregnancy losses. Given the adverse fetal and neonatal outcomes associated with RhD alloimmunization, prevention of maternal sensitization is essential in RhD-negative patients who may experience subsequent pregnancies. In care settings in which RhD testing and RhIg administration are logistically and financially feasible and do not hinder access to abortion care, we recommend offering both RhD testing and RhIg administration for spontaneous and induced abortion at <12 weeks of gestation in unsensitized, RhD-negative individuals. Guidelines for RhD testing and RhIg administration in the first trimester must balance the prevention of alloimmunization with the individual- and population-level harms of restricted access to abortion.
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Aborto Induzido , Aborto Espontâneo , Troca Materno-Fetal , Feminino , Gravidez , Aborto Espontâneo/imunologia , Imunoglobulinas/imunologia , Sistema do Grupo Sanguíneo Rh-Hr/imunologia , Sociedades Médicas , Fatores de Tempo , HumanosRESUMO
Respiratory syncytial virus is a leading cause of lower respiratory tract illness globally in children aged <5 years. Each year, approximately 58,000 hospitalizations in the United States are attributed to respiratory syncytial virus. Infants aged ≤6 months experience the most severe morbidity and mortality. Until recently, prevention with the monoclonal antibody, palivizumab, was only offered to infants with high-risk conditions, and treatment primarily consisted of supportive care. Currently, 2 products are approved for the prevention of respiratory syncytial virus in infants. These include the Pfizer bivalent recombinant respiratory syncytial virus prefusion F protein subunit vaccine, administered seasonally to the pregnant person between 32 0/7 and 36 6/7 weeks of gestation, and the monoclonal antibody, nirsevimab, administered to infants aged up to 8 months entering their first respiratory syncytial virus season. With few exceptions, administering both the vaccine to the pregnant person and the monoclonal antibody to the infant is not recommended. All infants should be protected against respiratory syncytial virus using one of these strategies. Key considerations for pregnant individuals include examining available safety and efficacy data, weighing accessibility and availability, and patient preferences for maternal vaccination vs infant monoclonal antibody treatment. It will be critical for maternal-fetal medicine physicians to provide effective and balanced counseling to aid patients in deciding on a personalized approach to the prevention of respiratory syncytial virus in their infants.
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Perinatologia , Infecções por Vírus Respiratório Sincicial , Lactente , Criança , Gravidez , Feminino , Humanos , Infecções por Vírus Respiratório Sincicial/prevenção & controle , Infecções por Vírus Respiratório Sincicial/tratamento farmacológico , Palivizumab/uso terapêutico , Vírus Sinciciais Respiratórios , Anticorpos Monoclonais/uso terapêutico , Antivirais/uso terapêuticoRESUMO
Previable and periviable preterm prelabor rupture of membranes are challenging obstetric complications to manage, given the substantial risk of maternal morbidity and mortality with no guarantee of fetal benefit. The following are Society for Maternal-Fetal Medicine recommendations for the management of previable and periviable preterm prelabor rupture of membranes prior to the period when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient: (1) we recommend that pregnant patients with previable and periviable preterm prelabor rupture of membranes receive individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management to guide an informed decision. All patients with previable and periviable preterm prelabor rupture of membranes should be offered abortion care. Expectant management can also be offered in the absence of contraindications (GRADE 1C); (2) we recommend antibiotics for pregnant individuals who choose expectant management after preterm prelabor rupture of membranes at ≥ 24 0/7 weeks of gestation (GRADE 1B); (3) antibiotics can be considered after preterm prelabor rupture of membranes at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C); (4) administration of antenatal corticosteroids and magnesium are not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (GRADE 1B); (5) serial amnioinfusions and amniopatch are considered investigational and should be used only in a clinical trial setting; they are not recommended for routine care of previable and periviable preterm prelabor rupture of membranes (GRADE 1B); (6) cerclage management after preterm prelabor rupture of membranes is similar to cerclage management after preterm prelabor rupture of membranes at later gestational ages; it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making (GRADE 2C); (7) in subsequent pregnancies after a history of previable or periviable preterm prelabor rupture of membranes, we recommend following guidelines for management of pregnant persons with a prior spontaneous preterm birth (GRADE 1C).
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BACKGROUND: Angiogenic imbalances, characterized by an excess of antiangiogenic factors (soluble fms-like tyrosine kinase 1) and reduced angiogenic factors (vascular endothelial growth factor and placental growth factor), contribute to the mechanisms of disease in preeclampsia. The ratio of soluble fms-like tyrosine kinase 1 to placental growth factor has been used as a biomarker for preeclampsia, but the cutoff values may vary with gestational age and assay platform. OBJECTIVE: This study aimed to compare multiples of the median of the maternal plasma soluble fms-like tyrosine kinase 1 to placental growth factor ratio, soluble fms-like tyrosine kinase 1, placental growth factor, and conventional clinical and laboratory values in their ability to predict preeclampsia with severe features. STUDY DESIGN: We conducted a cohort study across 18 United States centers involving hospitalized individuals with hypertension between 23 and 35 weeks' gestation. Receiver operating characteristic curve analyses of maternal plasma biomarkers, highest systolic or diastolic blood pressures, and laboratory values at enrollment were performed for the prediction of preeclampsia with severe features. The areas under the curve were compared, and quasi-Poisson regression models were fitted to estimate relative risks. The primary outcome was preeclampsia with severe features within 2 weeks of enrollment. Secondary outcomes were a composite of severe adverse maternal outcomes (elevated liver enzymes, low platelets count, placental abruption, eclampsia, disseminated intravascular coagulation, and pulmonary edema) and a composite of severe adverse perinatal outcomes (birth weight below the third percentile, very preterm birth [<32 weeks' gestation], and fetal or neonatal death). RESULTS: Of the 543 individuals included in the study, preeclampsia with severe features within 2 weeks was observed in 33.1% (n=180) of them. A receiver operating characteristic curve-derived cutoff of 11.5 multiples of the median for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio provided good sensitivity (90.6%), specificity (76.9%), positive predictive value (66.0%), negative predictive value (94.3%), positive likelihood ratio (3.91), negative likelihood ratio (0.12), and accuracy (81.4%) for preeclampsia with severe features within 2 weeks. This cutoff was used to compare test positive cases (≥ cutoff) and test negative cases (< cutoff). Preeclampsia with severe features (66.0% vs 5.7%; P<.001) and composites of severe adverse maternal (8.11% vs 2.7%; P=.006) or perinatal (41.3% vs 10.14%; P=.001) outcomes within 2 weeks were more frequent in test positive cases than in test negative cases. A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the median was independently associated with preeclampsia with severe features (adjusted incidence rate ratio, 9.08; 95% confidence interval, 6.11-14.06; P<.001) and a composite of severe adverse perinatal outcomes (adjusted incidence rate ratio, 9.42; 95% confidence interval, 6.36-14.53; P<.001) but not with a composite of severe adverse maternal outcomes (adjusted incidence rate ratio, 2.20; 95% confidence interval, 0.95-5.54; P=.08). The area under the curve for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio in multiples of the median (0.91; 95% confidence interval, 0.89-0.94) for preeclampsia with severe features within 2 weeks was significantly higher (P<.001 for all comparisons) than either plasma biomarker alone or any other parameter with the exception of absolute soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio values. CONCLUSION: A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the mean among hospitalized patients with hypertension between 23 and 35 week's gestation predicts progression to preeclampsia with severe features and severe adverse perinatal outcomes within 2 weeks.
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Maternal sepsis is a signiï¬cant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).
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Pré-Eclâmpsia , Complicações Infecciosas na Gravidez , Sepse , Choque Séptico , Tromboembolia Venosa , Gravidez , Feminino , Humanos , Choque Séptico/diagnóstico , Choque Séptico/terapia , Perinatologia , Sepse/diagnóstico , Sepse/terapia , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/terapiaRESUMO
Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those found in younger pregnant populations, even in healthy individuals with no other comorbidities. There are several studies that suggest that advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetrical care with anticipated delivery at the age of 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.
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Complicações na Gravidez , Adulto , Idoso , Feminino , Humanos , Gravidez , Consenso , Atenção à Saúde , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/terapia , Complicações na Gravidez/etiologia , Resultado da Gravidez , Cuidado Pré-Natal , Estados UnidosRESUMO
The importance of a fully functioning placenta for a good pregnancy outcome is unquestioned. Loss of function can lead to pregnancy complications and is often detected by a thorough placental pathologic examination. Placental pathology has advanced the science and practice of obstetrics and neonatal-perinatal medicine by classifying diseases according to underlying biology and specific patterns of injury. Many past obstacles have limited the incorporation of placental findings into both clinical studies and day-to-day practice. Limitations have included variability in the nomenclature used to describe placental lesions, a shortage of perinatal pathologists fully competent to analyze placental specimens, and a troubling lack of understanding of placental diagnoses by clinicians. However, the potential use of placental pathology for phenotypic classification, improved understanding of the biology of adverse pregnancy outcomes, the development of treatment and prevention, and patient counseling has never been greater. This review, written partly in response to a recent critique published in a major obstetrics-gynecology journal, reexamines the role of placental pathology by reviewing current concepts of biology; explaining the most recent terminology; emphasizing the usefulness of specific diagnoses for obstetrician-gynecologists, neonatologists, and patients; previewing upcoming changes in recommendations for placental submission; and suggesting future improvements. These improvements should include further consideration of overall healthcare costs, cost-effectiveness, the clinical value added of placental assessment, improvements in placental pathology education and practice, and leveraging of placental pathology to identify new biomarkers of disease and evaluate novel therapies tailored to specific clinicopathologic phenotypes of both women and infants.
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Placenta , Complicações na Gravidez , Humanos , Gravidez , Feminino , Placenta/patologia , Resultado da GravidezRESUMO
Rationale: Knowledge gaps exist regarding health implications of sleep-disordered breathing (SDB) identified in pregnancy and/or after delivery. Objectives: To determine whether SDB in pregnancy and/or after delivery is associated with hypertension (HTN) and metabolic syndrome (MS). Methods: nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be Heart Health Study) (N = 4,508) followed participants initially recruited during their first pregnancy. Participants returned for a visit 2-7 years after pregnancy. This study examined a subgroup who underwent SDB assessments during their first pregnancy (n = 1,964) and a repeat SDB assessment after delivery (n = 1,222). Two SDB definitions were considered: 1) apnea-hypopnea index (AHI) ⩾ 5 and 2) oxygen desaturation index (ODI) ⩾ 5. Associations between SDB and incident HTN and MS were evaluated with adjusted risk ratios (aRRs). Measurements and Main Results: The aRR for MS given an AHI ⩾ 5 during pregnancy was 1.44 (95% confidence interval [CI], 1.08-1.93), but no association with HTN was found. ODI ⩾ 5 in pregnancy was associated with both an increased risk for HTN (aRR, 2.02; 95% CI, 1.30-3.14) and MS (aRR, 1.53; 95% CI, 1.19-1.97). Participants with an AHI ⩾ 5 in pregnancy that persisted after delivery were at higher risk for both HTN (aRR, 3.77; 95% CI, 1.84-7.73) and MS (aRR, 2.46; 95% CI, 1.59-3.76). Similar associations were observed for persistent ODI ⩾ 5 after delivery. Conclusions: An AHI ⩾ 5 in pregnancy was associated with an increased risk of MS. An ODI ⩾ 5 in pregnancy was significantly associated with both HTN and MS. Participants with persistent elevations in AHI and ODI during pregnancy and at 2-7 years after delivery were at the highest risk for HTN and MS. Clinical trial registered with www.clinicaltrials.gov (NCT02231398).
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Doenças Cardiovasculares , Síndromes da Apneia do Sono , Doenças Cardiovasculares/complicações , Feminino , Humanos , Razão de Chances , Oxigênio , Polissonografia , Gravidez , Fatores de Risco , Síndromes da Apneia do Sono/complicaçõesRESUMO
OBJECTIVE: Silver dressings have been associated with a decrease in postoperative pain in selected populations, but it is unknown if the benefit can be observed after cesarean deliveries. We sought to evaluate the impact of silver nylon dressings in reducing postoperative pain after cesarean delivery. STUDY DESIGN: A secondary analysis of data from a blinded randomized clinical trial of women undergoing cesarean delivery scheduled and unscheduled at a single site was conducted. Women were recruited for participation from a single site and randomized to a silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient clinic at 1 and 6 weeks after delivery and patient responded to the modified patient scar assessment scale. The primary outcome of this analysis was inpatient opioid and nonopioid analgesic dispensed. The secondary outcome was patient-reported pain at the 1- and 6-week postpartum visits. Data were analyzed using chi-square test, Student's t-test, Fisher's exact test, Wilcoxon-Mann-Whitney's test, and logistic regression where appropriate. A p-value of < 0.05 was considered significant. RESULTS: Among the 649 participants, women allocated to the silver nylon dressing group, when compared with the gauze group, were similar in the amount of dispensed opioid and nonopioid analgesic medications (morphine equivalent milligrams of opioids dispensed [82.5 vs. 90 mg, p = 0.74], intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) [120 vs. 120 mg, p = 0.55], and oral NSAIDs [4,800 vs. 5,600 mg in the gauze group, p = 0.65]). After adjusting for confounding variables, postoperative wound infection (adjusted odds ratio [aOR]: 11.70; 95% confidence interval [CI]: 4.51-30.31) at 1-week postoperative and again at 6-week postoperative (aOR: 5.59; 95% CI: 1.03-30.31) but not gauze dressing was associated with patient-reported postoperative pain. CONCLUSION: Among women undergoing cesarean delivery, silver nylon dressing was not associated with a reduction in postoperative pain. KEY POINTS: · Silver dressings showed no decrease in pain medications.. · Wound infection is associated with pain postoperatively.. · Silver dressings did not reduce postoperative pain..
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Analgésicos não Narcóticos , Prata , Gravidez , Humanos , Feminino , Prata/uso terapêutico , Nylons , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Bandagens , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Anti-Inflamatórios não EsteroidesRESUMO
OBJECTIVE: Our objective was to determine whether objectively measured sleep-disordered breathing (SDB) during pregnancy is associated with an increased risk of adverse neonatal outcomes in a cohort of nulliparous individuals. STUDY DESIGN: Secondary analysis of the nuMom2b sleep disordered breathing substudy was performed. Individuals underwent in-home sleep studies for SDB assessment in early (6-15 weeks' gestation) and mid-pregnancy (22-31 weeks' gestation). SDB was defined as an apnea-hypopnea index ≥5 events/h at either time point. The primary outcome was a composite outcome of respiratory distress syndrome, transient tachypnea of the newborn, or receipt of respiratory support, treated hyperbilirubinemia or hypoglycemia, large-for-gestational age, seizures treated with medications or confirmed by electroencephalography, confirmed sepsis, or neonatal death. Individuals were categorized into (1) early pregnancy SDB (6-15 weeks' gestation), (2) new onset mid-pregnancy SDB (22-31 weeks' gestation), and (3) no SDB. Log-binomial regression was used to calculate adjusted risk ratios (RR) and 95% confidence intervals (CIs) representing the association. RESULTS: Among 2,106 participants, 3% (n = 75) had early pregnancy SDB and 5.7% (n = 119) developed new-onset mid-pregnancy SDB. The incidence of the primary outcome was higher in the offspring of individuals with early (29.3%) and new onset mid-pregnancy SDB (30.3%) compared with individuals with no SDB (17.8%). After adjustment for maternal age, chronic hypertension, pregestational diabetes, and body mass index, new onset mid-pregnancy SDB conferred increased risk (RR = 1.43, 95% CI: 1.05, 1.94), where there was no longer statistically significant association between early pregnancy SDB and the primary outcome. CONCLUSION: New onset, mid-pregnancy SDB is independently associated with neonatal morbidity. KEY POINTS: · Sleep disordered breathing (SDB) is a common condition impacting pregnancy with known maternal risks.. · Objectively defined SDB in pregnancy was associated with a composite of adverse neonatal outcomes.. · New onset SDB in mid pregnancy conferred statistically significant increased risk..
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The burden of preeclampsia, a substantial contributor to perinatal morbidity and mortality, is not born equally across the population. Although the prevalence of preeclampsia has been reported to be 3% to 5%, racial and ethnic minority groups such as non-Hispanic Black women and American Indian or Alaskan Native women are widely reported to be disproportionately affected by preeclampsia. However, studies that add clarity to the causes of the racial and ethnic differences in preeclampsia are limited. Race is a social construct, is often self-assigned, is variable across settings, and fails to account for subgroups. Studies of the genetic structure of human populations continue to find more variations within racial groups than among them. Efforts to examine the role of race and ethnicity in biomedical research should consider these limitations and not use it as a biological construct. Furthermore, the use of race in decision making in clinical settings may worsen the disparity in health outcomes. Most of the existing data on disparities examine the differences between White and non-Hispanic Black women. Fewer studies have enough sample size to evaluate the outcomes in the Asian, American Indian or Alaskan Native, or mixed-race women. Racial differences are noted in the occurrence, presentation, and short-term and long-term outcomes of preeclampsia. Well-established clinical risk factors for preeclampsia such as obesity, diabetes, and chronic hypertension disproportionately affect non-Hispanic Black, American Indian or Alaskan Native, and Hispanic populations. However, with comparable clinical risk factors for preeclampsia among women of different race or ethnic groups, addressing modifiable risk factors has not been found to have the same protective effect for all women. Abnormalities of placental formation and development, immunologic factors, vascular changes, and inflammation have all been identified as contributing to the pathophysiology of preeclampsia. Few studies have examined race and the pathophysiology of preeclampsia. Despite attempts, a genetic basis for the disease has not been identified. A number of genetic variants, including apolipoprotein L1, have been identified as possible risk modifiers. Few studies have examined race and prevention of preeclampsia. Although low-dose aspirin for the prevention of preeclampsia is recommended by the US Preventive Service Task Force, a population-based study found racial and ethnic differences in preeclampsia recurrence after the implementation of low-dose aspirin supplementation. After implementation, recurrent preeclampsia reduced among Hispanic women (76.4% vs 49.6%; P<.001), but there was no difference in the recurrent preeclampsia in non-Hispanic Black women (13.7 vs 18.1; P=.252). Future research incorporating the National Institute on Minority Health and Health Disparities multilevel framework, specifically examining the role of racism on the burden of the disease, may help in the quest for effective strategies to reduce the disproportionate burden of preeclampsia on a minority population. In this model, a multilevel framework provides a more comprehensive approach and takes into account the influence of behavioral factors, environmental factors, and healthcare systems, not just on the individual.
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Pré-Eclâmpsia/etnologia , Etnicidade , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Humanos , Pré-Eclâmpsia/fisiopatologia , Pré-Eclâmpsia/prevenção & controle , Gravidez , Prevalência , Fatores Raciais , Racismo , Fatores de RiscoRESUMO
OBJECTIVE: The study aimed to evaluate the impact of obesity on the management and outcomes of postpartum hemorrhage. STUDY DESIGN: We conducted a retrospective cohort study of women who delivered at a tertiary care center between February 1, 2013 and January 31, 2014 and experienced a postpartum hemorrhage. Charts were reviewed for clinical and sociodemographic data, and women were excluded if the medical record was incomplete. Hemorrhage-related severe morbidity indicators included blood transfusion, shock, renal failure, transfusion-related lung injury, cardiac arrest, and use of interventional radiology procedures. Obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese women were compared. Data were analyzed using Chi-square, Student's t-test, Mann-Whitney U test, and linear regression where appropriate. The p-value <0.05 was significant. RESULTS: Of 9,890 deliveries, 2.6% (n = 262) were complicated by hemorrhage. Obese women were more likely to deliver by cesarean section (55.5 vs. 39.8%, p = 0.016), undergo a cesarean after labor (31.1 vs. 12.2%, p = 0.001), and have a higher quantitative blood loss (1,313 vs. 1,056 mL, p = 0.003). Both groups were equally likely to receive carboprost, methylergonovine, and misoprostol, but obese women were more likely to receive any uterotonic agent (95.7 vs. 88.9%, p = 0.007) and be moved to the operating room (32.3 vs. 20.4, p = 0.04). There was no difference in the use of intrauterine pressure balloon tamponade, interventional radiology, or decision to proceed with hysterectomy. The two groups were similar in time to stabilization. There was no difference in the need for blood transfusion. Obese women required more units of blood transfused (2.2 ± 2 vs. 2 ± 5 units, p = 0.023), were more likely to have any hemorrhage-related severe morbidity (34.1 vs. 25%, p = 0.016), and more than one hemorrhage related morbidity (17.1 vs. 7.9, p = 0.02). After controlling for confounding variables, quantitative blood loss, and not BMI was predictive of the need for transfusion. CONCLUSION: Despite similar management, obese women were more likely to have severe morbidity and need more units of blood transfused. KEY POINTS: · Obese women were more likely to have a higher quantitative blood loss and require more units of blood transfused.. · Obese women were more likely to experience any hemorrhage-related severe morbidity.. · Although obese women were more likely to be moved to the operating room for intervention, the rates of intrauterine pressure balloon tamponade, interventional radiology or hysterectomy were the same for obese and non-obese women..
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Hemorragia Pós-Parto , Cesárea/efeitos adversos , Feminino , Humanos , Histerectomia/efeitos adversos , Obesidade/complicações , Obesidade/epidemiologia , Obesidade/terapia , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/terapia , Gravidez , Estudos RetrospectivosRESUMO
OBJECTIVE: The objective of this study is to examine the relationship between body mass index (BMI) and complications for patients undergoing postpartum permanent contraception. STUDY DESIGN: Retrospective cohort study of patients aged 18 or older who had a vaginal delivery at an academic hospital between 2011 and 2016 and underwent a postpartum tubal ligation during the delivery admission. There were three comparative groups: nonobese (BMI ≤ 29 kg/m2), obese (BMI 30-39 kg/m2), and morbidly obese BMI (≥40 kg/m2). The outcome of interest was composite operative complications which included any occurrence of an intraoperative, postoperative, or anesthesia complication. RESULTS: A total of 921 patients were included for analysis. Average operative time was statistically longer for patients in the morbidly obese group (33 minutes) vs. the nonobese (25 minutes) and obese (29 minutes) groups (p < 0.0001). Composite complications were greater for the obese groups, but not statistically significant (5.1 vs. 6 vs. 16%, p = 0.06). Wound complications were significantly greater for the obese groups (0.8 vs. 1.5 vs. 5.5%, p = 0.01). A logistic regression model demonstrated that only operative time was predictive of operative complications. CONCLUSION: Overall complications of postpartum tubal complications are low; however, our study did demonstrate significantly longer operative time and wound complications for patients with obesity. The findings of our study indicate that postpartum permanent contraception can remain as an option for these patients. Further studies may help identify the best practices to decrease operative time and subsequent wound complications. This study contributes to the limited data regarding obesity and postpartum permanent contraception. We found increased operative time and wound complications for obese patients. Additional studies may identity best practices to decrease these complications. Given our findings of overall low operative complications, postpartum permanent contraception can remain an option for obese patients.
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OBJECTIVE: Since 2010, the American College of Obstetrics and Gynecology have released three committee opinions to recommend and reaffirm the utility of magnesium sulfate for neuroprotection and later for tocolysis to achieve antenatal steroid course completion in preterm labor. We sought to determine changes in antenatal magnesium sulfate exposure and other tocolytic agents for pregnancies resulting in neonatal intensive care unit (NICU)-admitted preterm infants. STUDY DESIGN: Using the Pediatrix Clinical Data Warehouse, we evaluated all inborn infants delivered between 22 and 33 weeks' gestation and admitted to the intensive care units from 2009 to 2018. We classified patients based on antenatal exposure to tocolytic medications: calcium channel blockers (nifedipine and amlodipine), betamimetics (terbutaline, theophylline, and ritodrine), prostaglandin inhibitors (indomethacin), and magnesium sulfate. RESULTS: A total of 229,781 patients met inclusion criteria. During the study period, magnesium sulfate exposure increased from 27.6 to 57.7% of births while betamimetic exposure decreased from 10.2 to 5.2%. Increasing magnesium sulfate exposure over time was seen at all gestational ages examined and magnesium exposure was most common between 23 and 31 weeks' gestation. By 2017 to 2018, 70.5% of 24 to 29 weeks' gestation NICU infants received exposure to at least one tocolytic agent while this remained at 53.7% of 32 to 33 weeks' NICU admitted infants. Antenatal steroid exposure increased from 74.8 to 87.4% during the study period. CONCLUSION: For NICU-admitted preterm infants, prenatal exposure patterns to tocolytic agents has shifted since 2009 with prenatal magnesium sulfate exposure increasing significantly. Antenatal steroid exposure has risen concurrently. Exposure to tocolytic agents is the highest among preterm infants born between 24 and 29 weeks' gestation. KEY POINTS: · Exposure to magnesium sulfate significantly increased from 2009 to 2018 for NICU admitted infants.. · Concurrently, the use of other tocolytics decreased significantly.. · The use of antenatal steroids has been rising over time..
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Tocolíticos , Humanos , Recém-Nascido , Lactente , Feminino , Gravidez , Tocolíticos/uso terapêutico , Unidades de Terapia Intensiva Neonatal , Sulfato de Magnésio/uso terapêutico , Recém-Nascido Prematuro , Tocólise/métodosRESUMO
The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.
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Mortalidade Materna , Complicações na Gravidez/prevenção & controle , Medição de Risco/métodos , Algoritmos , Anormalidades Congênitas , Feminino , Humanos , Saúde Materna , Período Pós-Parto , Gravidez , Gravidez de Alto Risco , Fatores de RiscoRESUMO
Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess the attitudes of maternal-fetal medicine subspecialists about abortion services and the available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to associate and regular members of the Society for Maternal-Fetal Medicine to assess their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses were conducted on the survey responses. Of the 2751 members contacted, 546 Society for Maternal-Fetal Medicine members completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. More than 80% of the respondents reported availability of abortion services in their state, 70% reported availability at their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors contributing to the respondents' limited scope of abortion services or lack of any abortion services offered. In the univariable analysis, exposure to formal family planning training programs, fewer years since the completion of residency, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute's abortion policy landscape were factors associated with abortion provision (all P values <.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P=.20; adjusted odds ratio, 1.34; 95% confidence interval, 0.85-2.10), whereas a favorable state policy environment and fewer years since the completion of residency remained associated with abortion provision. The results of this survey suggest that factors at the individual, institutional, and state levels affect the provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare services.
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Aborto Induzido/educação , Aborto Induzido/estatística & dados numéricos , Atitude do Pessoal de Saúde , Perinatologia/educação , Aborto Induzido/métodos , Serviços de Planejamento Familiar , Feminino , Humanos , Internato e Residência/estatística & dados numéricos , Masculino , Padrões de Prática Médica , Gravidez , Encaminhamento e Consulta , Serviços de Saúde Reprodutiva , Sociedades Médicas , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: Little is known about the extent to which severe maternal morbidity (SMM) at delivery impacts early and late postpartum readmission. OBJECTIVES: We examined readmission rates for women with and without SMM (and their 18 subtypes) at delivery and characterised the most common medical reasons for readmissions. METHODS: We conducted a retrospective cohort study utilising the 2016-2017 Nationwide Readmissions Database among women giving births in the United States. Deliveries were classified according to the presence or absence of 18 SMM indicators defined by the Centers for Disease Control and Prevention using the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnosis and procedure codes. The primary outcome of this study was all-cause early (≤7 day) and late (8 to 42 day) postpartum readmission. Survey-weighted Poisson regression with robust error variance was used to generate adjusted risk ratios (RR) and 95% confidence intervals (CI) to investigate the association between SMM and early and late postpartum readmission. Additionally, we compared principal diagnoses codes during readmission hospitalisations among women with and without SMM at delivery. RESULTS: Of the 6 193 852 women examined, 4.9% (n = 4928) with any SMM and 1.4% (n = 83 995) with no SMM were readmitted within 42 days after delivery. After adjusting for obstetric co-morbidities and sociodemographic factors, women with any SMM were 57% (RR 1.57, 95% CI 1.47, 1.67) more likely to have an early readmission and 69% (RR 1.69, 95% CI 1.57, 1.82) more likely to have a late readmission compared to women with no SMM at delivery. However, the risk was attenuated when excluding women with blood transfusion only. Women with and without SMM were readmitted predominantly for obstetric complications and infections. CONCLUSIONS: Women with SMM at delivery were more likely to experience both early and late postpartum readmission, independent of their obstetrical co-morbidity burden and sociodemographic factors.
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Readmissão do Paciente , Período Pós-Parto , Transfusão de Sangue , Feminino , Hospitalização , Humanos , Morbidade , Gravidez , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
Obesity and diabetes increase hypertensive disorders of pregnancy (HDP) risk, thus preventive interventions are heavily studied. How pregestational prediabetes and related interventions impact HDP risk is less characterized. Therefore, we searched and reviewed the literature to assess the impact on HDP risk of prediabetes and varied interventions. We identified 297 citations related to pregnancy, prediabetes, and early pregnancy interventions. We also reviewed the references and citations of included articles. We included five studies assessing HDP outcomes in women with first trimester hemoglobin A1c in the prediabetes range (5.7-6.4%). One prospective observational study demonstrated first trimester hemoglobin A1c (5.9-6.4%) is associated with increased HDP risk, while another prospective observational study and one retrospective observational study had similar trends without statistical significance. A small and underpowered randomized controlled trial demonstrated initiating gestational diabetes mellitus treatment (i.e., diet, monitoring, ± insulin) in response to first trimester hemoglobin A1c (5.7-6.4%) did not statistically reduce HDP compared with standard care. One retrospective observational study suggested metformin, when started early, may reduce HDP risk in patients with prediabetes. Pregestational prediabetes appears to increase HDP risk. Interventions (i.e., metformin, diet/glucose monitoring, and/or exercise) to reduce HDP risk require additional study with long-term follow-up.
Assuntos
Hipertensão Induzida pela Gravidez/epidemiologia , Obesidade/epidemiologia , Estado Pré-Diabético/terapia , Automonitorização da Glicemia , Dietoterapia , Exercício Físico , Feminino , Hemoglobinas Glicadas/análise , Humanos , Hipertensão Induzida pela Gravidez/prevenção & controle , Metformina/uso terapêutico , Estado Pré-Diabético/epidemiologia , Gravidez , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Despite increased research using large administrative databases to identify determinants of maternal morbidity and mortality, the extent to which these databases capture obstetric co-morbidities is unknown. OBJECTIVE: To evaluate the impact that the time window used to assess obstetric co-morbidities has on the completeness of ascertainment of those co-morbidities. METHODS: We conducted a five-year analysis of inpatient hospitalisations of pregnant women from 2010-2014 using the Nationwide Readmissions Database. For each woman, using discharge diagnoses, we identified 24 conditions used to create the Obstetric Comorbidity Index. Using various assessment windows for capturing obstetric co-morbidities, including the delivery hospitalisation only and all weekly windows from 7 to 280 days, we calculated the frequency and rate of each co-morbidity and the degree of underascertainment of the co-morbidity. Under each scenario, and for each co-morbidity, we also calculated the all-cause, 30-day readmission rate. RESULTS: There were over 3 million delivery hospitalisations from 2010 to 2014 included in this analysis. Compared with a full 280-day window, assessment of obstetric co-morbidities using only diagnoses made during the delivery hospitalisation would result in failing to identify over 35% of cases of chronic renal disease, 28.5% cases in which alcohol abuse was documented during pregnancy, and 23.1% of women with pulmonary hypertension. For seven other co-morbidities, at least 1 in 20 women with that condition would have been missed with exclusive reliance on the delivery hospitalisation for co-morbidity diagnoses. Not only would reliance on delivery hospitalisations have resulted in missed cases of co-morbidities, but for many conditions, estimates of readmission rates for women with obstetric co-morbidities would have been underestimated. CONCLUSIONS: An increasing proportion of maternal and child health research is based on large administrative databases. This study provides data that facilitate the assessment of the degree to which important obstetric co-morbidities may be underascertained when using these databases.