Society for Maternal-Fetal Medicine Position Statement: Access to abortion care.

POSITION: The Society for Maternal-Fetal Medicine supports the right of all individuals to access the full spectrum of reproductive health services, including abortion care. Reproductive health decisions are best made by each individual with guidance and support from their healthcare providers. The Society opposes legislation and policies that limit access to abortion care or criminalize abortion care and self-managed abortion. In addition, the Society opposes policies that compromise the patient-healthcare provider relationship by limiting a healthcare provider's ability to counsel patients and provide evidence-based, medically appropriate treatment.

Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People with Gestational Diabetes.

OBJECTIVE: We aimed to evaluate uptake of the glucose tolerance test performed during delivery hospitalization as part of routine clinical care. STUDY DESIGN: This is a retrospective cohort study of people with GDM at a tertiary center. We collected 9 months of postimplementation data after the in-hospital ("early") glucose tolerance test was adopted as a routine screening option. Adherence was compared between those who elected early glucose tolerance testing versus those who deferred testing to the standard postpartum period. Bivariable statistics including demographics, care team, and postpartum testing/visit attendance were compared between those who received early testing and those who did not using chi-square, Fisher's exact, and t-tests. RESULTS: A total of 681 patients with GDM delivered during the study period. Of those who had an early glucose tolerance test ordered (n = 408), 340 (83.3%) completed the test. Among those who did not complete an early glucose tolerance test (ordered and not completed or never ordered), only 104/341 (30.5%) completed any postpartum glucose testing in the first 12 months of postpartum. There were significant differences in characteristics in terms of race/ethnicity, insurance, type of gestational diabetes (A1GDM vs. A2GDM), diabetes medications, obstetric care provider, and delivery mode. Among those who completed early testing, 43.7% of participants had impaired glucose metabolism and 6.5% had values concerning for overt diabetes mellitus. Among those who deferred testing to the standard 6- to 12-week period, 24.0% had impaired glucose metabolism and none had overt diabetes. Those who completed an early glucose tolerance test had a lower rate of postpartum visit attendance compared with those who deferred (75.6 vs. 91.5%, p < 0.01). CONCLUSION: In this cohort, when the early glucose tolerance test is offered in clinical practice, adherence rates are higher than when the test is deferred until the postpartum visit. KEY POINTS: · Adherence rates with the early glucose tolerance test (GTT) are higher than if the testing is deferred.. · Those who completed an early GTT had a lower rate of postpartum visit attendance compared with those who deferred.. · Offering an in-hospital postpartum GTT can help address low rates of glucose testing postpartum..

Early-Pregnancy Resilience Characteristics Before Versus During the COVID-19 Pandemic.

OBJECTIVE: Resilience is associated with mental and somatic health benefits. Given the social, physical, and mental health toll of the coronavirus disease 2019 (COVID-19) pandemic, we examined whether the COVID-19 pandemic was associated with population-level changes in resilience among pregnant people. STUDY DESIGN: Secondary analysis of a prospective cohort of nulliparous pregnant people <20 weeks' gestation from a single hospital. Participants completed baseline assessments of resilience characteristics, including dispositional optimism (DO), mindfulness, and proactive coping. For this analysis, participants recruited before the COVID-19 pandemic were compared with those recruited during the pandemic. The primary outcome was DO, assessed as a continuous score on the validated Revised Life Orientation Test. Secondary outcomes included continuous scores on mindfulness and proactive coping assessments. Bivariable analyses were completed using chi-squared and Mann-Whitney U tests. Multivariable linear regression compared resilience scores by recruitment time frame, controlling for confounders selected a priori: maternal age, education, and marital status. RESULTS: Of the 300 participants, 152 (50.7%) were recruited prior to the pandemic. Demographic and pregnancy characteristics differed between groups: the during-pandemic group was older, had higher levels of education, and were more likely to be married/partnered. There were no significant differences in any of the resilience characteristics before versus during the pandemic in bivariable or multivariable analyses. CONCLUSION: In this cohort, there were no differences in early pregnancy resilience characteristics before versus during the COVID-19 pandemic. This affirms that on a population level, resilience is a stable metric, even in the setting of a global pandemic. KEY POINTS: · Resilience is associated with mental and somatic health benefits.. · No difference in early-pregnancy resilience in those recruited before versus during the pandemic.. · Consistent with conceptualization of resilience as an innate characteristic..

Predicting primary cesarean delivery in pregnancies complicated by gestational diabetes mellitus.

BACKGROUND: Prediction models have shown promise in helping clinicians and patients engage in shared decision-making by providing quantitative estimates of individual risk of important clinical outcomes. Gestational diabetes mellitus is a common complication of pregnancy, which places patients at higher risk of primary CD. Suspected fetal macrosomia diagnosed on prenatal ultrasound is a well-known risk factor for primary CD in patients with gestational diabetes mellitus, but tools incorporating multiple risk factors to provide more accurate CD risk are lacking. Such tools could help facilitate shared decision-making and risk reduction by identifying patients with both high and low chances of intrapartum primary CD. OBJECTIVE: This study aimed to develop and internally validate a multivariable model to estimate the risk of intrapartum primary CD in pregnancies complicated by gestational diabetes mellitus undergoing a trial of labor. STUDY DESIGN: This study identified a cohort of patients with gestational diabetes mellitus derived from a large, National Institutes of Health-funded medical record abstraction study who delivered singleton live-born infants at ≥34 weeks of gestation at a large tertiary care center between January 2002 and March 2013. The exclusion criteria included previous CD, contraindications to vaginal delivery, scheduled primary CD, and known fetal anomalies. Candidate predictors were clinical variables routinely available to a practitioner in the third trimester of pregnancy found to be associated with an increased risk of CD in gestational diabetes mellitus. Stepwise backward elimination was used to build the logistic regression model. The Hosmer-Lemeshow test was used to demonstrate goodness of fit. Model discrimination was evaluated via the concordance index and displayed as the area under the receiver operating characteristic curve. Internal model validation was performed with bootstrapping of the original dataset. Random resampling with replacement was performed for 1000 replications to assess predictive ability. An additional analysis was performed in which the population was stratified by parity to evaluate the model's predictive ability among nulliparous and multiparous individuals. RESULTS: Of the 3570 pregnancies meeting the study criteria, 987 (28%) had a primary CD. Of note, 8 variables were included in the final model, all significantly associated with CD. They included large for gestational age, polyhydramnios, older maternal age, early pregnancy body mass index, first hemoglobin A1C recorded in pregnancy, nulliparity, insulin treatment, and preeclampsia. Model calibration and discrimination were satisfactory with the Hosmer-Lemeshow test (P=.862) and an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.74-0.77). Internal validation demonstrated similar discriminatory ability. Stratification by parity demonstrated that the model worked well among both nulliparous and multiparous patients. CONCLUSION: Using information routinely available in the third trimester of pregnancy, a clinically pragmatic model can predict intrapartum primary CD risk with reasonable reliability in pregnancies complicated by gestational diabetes mellitus and may provide quantitative data to guide patients in understanding their individual primary CD risk based on preexisting and acquired risk factors.

Experiences of stigma, psychological distress, and facilitative coping among pregnant people with gestational diabetes mellitus.

BACKGROUND: Gestational diabetes mellitus (GDM) has been rising in the United States, and it poses significant health risks to pregnant individuals and their infants. Prior research has shown that individuals with GDM also experience prevalent stress and mental health issues, which can further contribute to glucose regulation difficulties. Stigma associated with GDM may contribute to these mental health challenges, yet there is a lack of focused research on GDM-related stigma, its impact on psychological health, and effective coping mechanisms. Thus, this qualitative study aims to understand individuals' experiences related to GDM stigma, mental health, and facilitative coping. METHODS: In-depth, semi-structured interviews were conducted with 14 individuals with a current or recent (within the last year) diagnosis of GDM. Thematic analysis was employed to guide data analysis. RESULTS: Four themes emerged from data analysis: (1) experience of distal GDM stigma including stigmatizing provider interactions, stigma from non-medical spaces, and intersecting stigma with weight, (2) internalized GDM stigma, such as shame, guilt, and self-blame, (3) psychological distress, which included experiences of stress and overwhelm, excessive worry and fear, and loneliness and isolation, and (4) facilitative coping mechanisms, which included diagnosis acceptance, internet-based GDM community, active participation in GDM management, social and familial support, and time for oneself. CONCLUSIONS: Findings demonstrate the relevance of GDM stigma in mental health among people with GDM and the need for addressing GDM stigma and psychological health in this population. Interventions that can reduce GDM stigma, improve psychological wellness, and enhance positive coping may facilitate successful GDM management and healthy birth outcomes. Future quantitative, theory-driven research is needed to understand the prevalence of GDM stigma experiences and mechanisms identified in the current study, as well as among marginalized populations (e.g., individuals of color, sexual and gender minorities).

Third-Grade Educational Outcomes of the Children of Adolescent Women.

OBJECTIVES: To evaluate third-grade reading and math proficiency for children born to adolescent women compared with those born to non-adolescent women. METHODS: A statewide, retrospective cohort study was conducted in Rhode Island using third-grade year-end examination data from 2014 to 2017 as part of a statewide initiative to improve third grade reading levels. Children's third-grade reading and math proficiencies were compared between those born to nulliparous adolescent women (age 15-19 at the time of delivery), and nulliparous women 20 years or older at delivery. Bivariate analyses were conducted to compare maternal and child characteristics between adolescent and non-adolescent groups. Multivariable logistic regression was used to examine the association between having an adolescent mother and being proficient in reading and math after adjusting for lunch subsidy, core city residence, child race/ethnicity and sex. RESULTS: Of the 8,248 children meeting the inclusion criteria, 20% were born to adolescent women and the remaining 80% were born to non-adolescent women. After adjusting for potential confounders, children born to adolescent women were significantly less likely to be proficient in both reading (adjusted risk ratio (aRR) 0.77, 95% confidence interval (CI): 0.71-0.83) and math (aRR 0.78, 95% CI: 0.72-0.85). CONCLUSIONS FOR PRACTICE: Children born to adolescent women had significantly lower rates of reading and math proficiency when compared with children of non-adolescent women. These children may benefit from additional resources focused on early academic performance in order to address disparities in reading and math proficiency.

Prediction Model Assessing Risk of Delivery after Diagnosis of Abnormal Umbilical Artery Doppler.

OBJECTIVE: Umbilical artery Doppler (UAD) velocimetry abnormalities are associated with increased neonatal morbidity and mortality. Currently, there are no risk stratification methods to assist in antepartum management such as timing of antenatal corticosteroids (ACS). Therefore, we sought to develop a model to predict risk of delivery within 7 days following diagnosis of abnormal UAD velocimetry in patients with fetal growth restriction (FGR). STUDY DESIGN: Retrospective single referral center study of liveborn singleton pregnancies complicated by FGR and ≥1 abnormal UAD velocimetry value (≥95th percentile for gestational age [GA]). We considered 17 variables and used backward stepwise logistic regression to create a multivariable model for the prediction of delivery within 7 days. We assessed model fit with calibration, discrimination, likelihood ratios, and area under the curve. Internal validation of the model was assessed by using the bootstrap method. RESULTS: Between 2008 and 2015, a total of 176 patients were eligible and included for model development. Median (range) GA at initial eligibility was 32.1 weeks (28.1-36.1 weeks) and from initial eligibility until delivery was 21 days (0-104 days). Fifty-two patients (30%) were delivered in the 7 days following inclusion. GA at first abnormal UAD, severity of first abnormal UAD, oligohydramnios, preeclampsia, and pre-pregnancy BMI were included in the model. The model had an area under the ROC curve of 0.94 (95% confidence interval [CI]: 0.90-0.98), sensitivity of 85%, and specificity of 91%. If the model alone were used for ACS timing, 85% of the cohort who delivered in the following week would have received ACS, and ACS would not have been given to 91% who delivered later. Internal validation yielded similar results with a mean area under the curve (95% CI) of 0.94 (0.88-0.98). CONCLUSION: If validated externally, our model can be used to predict risk of delivery in patients with FGR and abnormal UAD velocimetry, potentially improving timing of ACS. KEY POINTS: · Risk of delivery in seven days can be predicted.. · Risk of delivery can inform corticosteroid timing.. · External validation can further develop a clinical aid..

Waterpipe Tobacco (Hookah) Use in Pregnancy: Associations with Nausea and Vomiting of Pregnancy.

OBJECTIVE: Waterpipe tobacco (WPT) use is common among reproductive age patients and is often perceived as safer than cigarette use. Prior studies have shown a decrease in nausea and vomiting symptoms among pregnant women who use cigarettes, but no studies to date have examined these symptoms in pregnant women who use WPT. This study was aimed to investigate the extent of symptoms of nausea/vomiting of pregnancy among participants who self-reported WPT use during pregnancy. STUDY DESIGN: Secondary analysis of a prospective cohort study examining WPT use during pregnancy. Participants completed the Pregnancy-Unique Quantification of Emesis (PUQE) during first and third trimesters. Medical conditions were determined by medical record review. Participants were evaluated by sole WPT use versus dual/polysubstance WPT use and frequency of WPT use. RESULTS: Ninety-nine (100%) participants completed the PUQE questionnaire during first trimester and 82 (82.8%) completed the PUQE during third trimester. Almost all (91.9%) participants reported moderate nausea/vomiting symptoms at both assessments. There was no difference in frequency of WPT use in pregnancy or rates of dual/polysubstance WPT use in participants with all levels of the PUQE questionnaire. There was also no difference in rates of WPT use or PUQE scores between sole WPT users and dual/polysubstance users. When comparing low and high WPT use, those who were in the higher frequency use group had higher waterpipe dependence scale scores (7.2 vs. 5.3, p < 0.02). With regard to maternal medical comorbidities, the only difference between groups was that sole WPT users were more likely to have a diagnosis of asthma than dual/polysubstance users (36.8 vs. 14.9%, p < 0.02). CONCLUSION: There were no differences in symptoms of nausea and vomiting of pregnancy or medical conditions in pregnant women who use WPT with any frequency during pregnancy. However, sole WPT users had higher rates of asthma than dual/polysubstance WPT users. KEY POINTS: · Waterpipe tobacco use is one of the most common forms of tobacco use among reproductive age patients.. · Waterpipe tobacco use was not associated with any changes in nausea/vomiting of pregnancy symptoms.. · Future research on the use of waterpipe tobacco in pregnancy can aid in public health responses..

Universal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Testing for Obstetric Inpatient Units Across the United States.

BACKGROUND: The purpose of this study was to estimate prevalence of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. METHODS: A cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1-3-month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. RESULTS: Data were collected from 9 health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient units. A total of 10 147 SARS-CoV-2 tests were administered, of which 124 were positive (1.2%). Positivity rates varied by site, ranging from 0-3.2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (P=.003, r=.782) and state (P=.007, r=.708). CONCLUSIONS: Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2-related healthcare resource utilization in obstetric inpatient units may be best informed by surrounding community infection rates.

Maternal urinary OPE metabolite concentrations and blood pressure during pregnancy: The HOME study.

BACKGROUND: Few studies have examined the association between maternal exposure to organophosphate esters (OPEs) and systolic/diastolic blood pressure (SBP/DBP) during pregnancy. METHODS: We analyzed data from 346 women with a singleton live birth in the HOME Study, a prospective birth cohort in Cincinnati, Ohio, USA. We quantified four OPE metabolites in maternal spot urine samples collected at 16 and 26 weeks pregnancy, standardized by specific gravity. We calculated intraclass correlation coefficients (ICCs). We extracted the first two recorded BP measurements (<20 weeks), the two highest recorded BP measurements (≥20 weeks), and diagnoses of hypertensive disorders of pregnancy (HDP) via chart review. Women with two BP measurements ≥140/90 mmHg or HDP noted in the chart at ≥20 weeks pregnancy were defined as HDP cases. We used linear mixed models and modified Poisson regression with covariate adjustment to estimate associations between OPE concentrations as continuous variables or in tertiles with maternal BP and HDP. RESULTS: ICCs of OPEs were 0.17-0.45. Diphenyl phosphate (DPHP) had the highest geometric mean concentration among OPE metabolites. Increasing the average bis(2-chloroethyl) phosphate (BCEP) concentrations were positively associated with two highest recorded DBP ≥20 weeks pregnancy. Compared with women in the 1st DPHP tertile, women in the 3rd tertile at 16 weeks pregnancy had 1.72 mmHg (95% CI: -0.01, 3.46) higher DBP <20 weeks pregnancy, and women in the 3rd tertile of the average DPHP concentrations had 2.25 mmHg (95% CI: 0.25, 4.25) higher DBP ≥20 weeks pregnancy. 33 women (9.5%) were identified with HDP. Di-n-butyl phosphate (DNBP) concentrations at 16 weeks were positively associated with HDP, with borderline significance (RR = 2.98, 95% CI 0.97-9.15). Other OPE metabolites were not significantly associated with HDP. CONCLUSION: Maternal urinary BCEP and DPHP concentrations were associated with increased BP during pregnancy. Maternal urinary DNBP concentrations were associated with HDP, with borderline significance.

Predicting Progression from Gestational Diabetes to Impaired Glucose Tolerance Using Peridelivery Data: An Observational Study.

OBJECTIVE: This article aimed to develop a predictive model to identify persons with recent gestational diabetes mellitus (GDM) most likely to progress to impaired glucose tolerance postpartum. STUDY DESIGN: We conducted an observational study among persons with GDM in their most recent pregnancy, defined by Carpenter-Coustan criteria. Participants were followed up from delivery through 1-year postpartum. We used lasso regression with k-fold cross validation to develop a multivariable model to predict progression to impaired glucose tolerance, defined as HbA1c≥5.7%, at 1-year postpartum. Predictive ability was assessed by the area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV). RESULTS: Of 203 participants, 71 (35%) had impaired glucose tolerance at 1-year postpartum. The final model had an AUC of 0.79 (95% confidence interval [CI]: 0.72, 0.85) and included eight indicators of weight, body mass index, family history of type 2 diabetes, GDM in a prior pregnancy, GDM diagnosis<24 weeks' gestation, and fasting and 2-hour plasma glucose at 2 days postpartum. A cutoff point of ≥ 0.25 predicted probability had sensitivity of 80% (95% CI: 69, 89), specificity of 58% (95% CI: 49, 67), PPV of 51% (95% CI: 41, 61), and NPV of 85% (95% CI: 76, 91) to identify women with impaired glucose tolerance at 1-year postpartum. CONCLUSION: Our predictive model had reasonable ability to predict impaired glucose tolerance around delivery for persons with recent GDM. KEY POINTS: · We developed a predictive model to identify persons with GDM most likely to develop IGT postpartum.. · The final model had an AUC of 0.79 (95% CI: 0.72, 0.85) and included eight clinical indicators.. · If validated, our model could help prioritize diabetes prevention efforts among persons with GDM..

Term Labor Induction and Cesarean Delivery Risk among Obese Women with and without Comorbidities.

OBJECTIVE: Findings of the recent ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, showing reduced cesarean risk with elective labor induction among low-risk nulliparous women at 39 weeks' gestation, have the potential to change interventional delivery practices but require examination in wider populations. The aim of this study was to identify whether term induction of labor was associated with reduced cesarean delivery risk among women with obesity, evaluating several maternal characteristics associated with obesity, induction, and cesarean risk. STUDY DESIGN: We studied administrative records for 66,280 singleton, term births to women with a body mass index ≥30, without a prior cesarean delivery, in New York City from 2008 to 2013. We examined elective inductions in 39 and 40 weeks' gestation and calculated adjusted risk ratios for cesarean delivery risk, stratified by parity and maternal age. We additionally evaluated medically indicated inductions at 37 to 40 weeks among women with obesity and diabetic or hypertensive disorders, comorbidities that are strongly associated with obesity. RESULTS: Elective induction of labor was associated with a 25% (95% confidence interval: 19-30%) lower adjusted risk of cesarean delivery as compared with expectant management at 39 weeks of gestation and no change in risk at 40 weeks. Patterns were similar when stratified by parity and maternal age. Risk reductions in week 39 were largest among women with a prior vaginal delivery. Women with comorbidities had reduced cesarean risk with early term induction and in 39 weeks. CONCLUSION: Labor induction at 39 weeks was consistently associated with reduced risk of cesarean delivery among women with obesity regardless of parity, age, or comorbidity status. Cesarean delivery findings from induction trials at 39 weeks among low-risk nulliparous women may generalize more broadly across the U.S. obstetric population, with potentially larger benefit among women with a prior vaginal delivery. KEY POINTS: · We found reduced cesarean risk with induction at 39 weeks.. · Results were consistent for age and comorbidity subgroups.. · Risk reductions were largest among multiparous women..

Postpartum Use of Weight Loss and Metformin for the Prevention of Type 2 Diabetes Mellitus: a Review of the Evidence.

PURPOSE OF REVIEW: As many as 70% of patients diagnosed with gestational diabetes mellitus (GDM) will go on to develop type 2 diabetes (T2DM) within their lifetimes. Implementing strategies to mitigate this progression in the postpartum period when patients are already connected to care is essential in optimizing lifelong health for our patients. Both lifestyle modification and metformin have been investigated as options to reduce type 2 diabetes risk in patients with a history of GDM. RECENT FINDINGS: The current model for postpartum testing and care of patients with GDM has been shown to have poor uptake rates. Similarly, intervening with lifestyle modification postpartum has not resulted in significant diabetes risk reduction in prospective studies. Metformin is known to decrease insulin resistance and is also associated with weight loss. Data from large prospective studies has indicated that metformin may be a useful addition to lifestyle modifications to prevent progression to diabetes, but additional studies are needed specifically in postpartum individuals. Metformin is a safe in the postpartum period and may reduce diabetes risk if started soon after delivery in individuals with GDM, but additional studies are needed to determine which individuals with GDM are most likely to benefit from this medication.

Society for Maternal-Fetal Medicine Special Statement: Maternal-fetal medicine subspecialist survey on abortion training and service provision.

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.

Risk Factors for Progression From Gestational Diabetes to Postpartum Type 2 Diabetes: A Review.

Gestational diabetes mellitus (GDM) complicates 6% to 8% of pregnancies and up to 50% of women with GDM progress to type 2 diabetes mellitus (DM) within 5 years postpartum. Clinicians have little guidance on which women are most at risk for DM progression or when evidence-based prevention strategies should be implemented in a woman's lifecycle. To help address this gap, the authors review identifiable determinants of progression from GDM to DM across the perinatal period, considering prepregnancy, pregnancy, and postpartum periods. The authors categorize evidence by pathways of risk including genetic, metabolic, and behavioral factors that influence progression to DM among women with GDM.

Comparing Glucose Challenge Test Screening Thresholds in Obese and Overweight Gravidas.

OBJECTIVE: Given the paucity of contemporary data examining glucose challenge test (GCT), thresholds for gestational diabetes (GDM) screening in obese and overweight women, we sought to compare the sensitivity and testing characteristics of different screen positive GCT cut-offs in women with a prepregnancy body mass index (BMI) ≥ 25 kg/m2. STUDY DESIGN: This is a retrospective cohort study of obese and overweight women with singleton pregnancies who underwent GCT between 24 and 296/7 weeks and had a value between 130 and 199 mg/dL necessitating a 3-hour glucose tolerance test (GTT). Exclusion criteria were pregestational diabetes mellitus, multigestation, use of diabetes medications, and bariatric surgery. RESULTS: Between August 2015 and January 2016, 19% (n = 496) of women with a BMI ≥ 25 kg/m2 required a GTT to test for GDM, 27.8% (n = 138) of whom were diagnosed with GDM. Mean age was 30 years, mean BMI = 31.6 kg/m2, and 30.4% were Hispanic. The 130 mg/dL threshold compared with 140 mg/dL was more sensitive (absolute increase: 11.3%, 95% confidence interval [CI]: 6.7-17%), but less specific (absolute decrease: 6.4%, 95% CI: 5.5-7.5%). CONCLUSION: Shared decision making should be used to determine GCT cut-offs as some patients may prefer to undergo a GTT rather than miss a diagnosis of GDM.

Association between Respiratory Morbidity and Labor in Pregnancies with Gestational Diabetes Mellitus.

OBJECTIVE: This study aimed to the assess risk of respiratory morbidity in neonates born to women with gestational diabetes mellitus (GDM) delivered after labor compared with those delivered without exposure to labor. STUDY DESIGN: This is a secondary analysis of a prospective single-center cohort study of singleton pregnancies complicated by GDM. Neonates who were liveborn and delivered at ≥34 weeks' gestation were included. The primary outcome was respiratory morbidity defined as respiratory distress syndrome (RDS) or transient tachypnea of the newborn (TTN) resulting in neonatal intensive care unit (NICU) admission. Neonates born after labor (either spontaneous or induced) were compared with those delivered by cesarean delivery without labor. Associations between labor and neonatal morbidities were estimated using logistic regression. Covariates were adjusted for if they differed significantly between neonates exposed to and not exposed to labor (p < 0.05) and there was biologic plausibility that they would affect neonatal respiratory morbidity. RESULTS: Of the 581 neonates meeting study inclusion criteria, 23.2% delivered without exposure to labor. Those who did and did not experience labor delivered at similar gestational ages (38.6 vs. 38.4 weeks). Thirty-six neonates (6.2%) developed RDS or TTN and were admitted to the NICU. Exposure to labor was associated with a lower frequency of respiratory morbidity requiring admission to NICU, 4.9% (22/446) versus 10.4% (14/135) (p = 0.04). After adjusting for parity, body mass index, birth weight, gestational weight gain more than Institute of Medicine guidelines, race, and exposure to labor were associated with an adjusted odds ratio of 0.41 (95% confidence interval: 0.18-0.89). CONCLUSION: Exposure to labor was associated with decreased odds of respiratory morbidity in neonates born to mothers with GDM. Limiting elective cesarean in this population can reduce health care costs and optimize neonatal health. KEY POINTS: · Labor is associated with less respiratory morbidity.. · We should limit elective cesarean delivery with GDM.. · This approach could reduce health care costs..

Two-day postpartum compared with 4- to 12-week postpartum glucose tolerance testing for women with gestational diabetes.

BACKGROUND: A majority of women in the United States with gestational diabetes mellitus do not undergo the recommended 4- to 12-week postpartum glucose tolerance test. OBJECTIVE: This study aimed to compare the diagnostic value of the 2-day postpartum glucose tolerance test with the 4- to 12-week postpartum glucose tolerance test to identify impaired glucose metabolism at 1 year after delivery among women with gestational diabetes. STUDY DESIGN: Postpartum women who delivered at 1 hospital between January 2017 and July 2018 were offered enrollment in a prospective cohort if they had gestational diabetes mellitus diagnosed by Carpenter-Coustan criteria or a 1-hour glucose challenge test result of ≥200 mg/dL, spoke English or Spanish, and planned to remain in the hospital for at least 2 days after delivery. Participating women underwent a 75-gram 2-hour glucose tolerance test on postpartum day 2 and were incentivized to have a 4- to 12-week glucose tolerance test and measurement of glycosylated hemoglobin at 1 year after delivery. Participants and providers were blinded to the 2-day postpartum results. The diagnostic value of an abnormal 2-day postpartum glucose tolerance test (fasting result of ≥100 mg/dL or 2-hour glucose tolerance test result of ≥140 mg/dL) was compared with that of an abnormal 4- to 12-week glucose tolerance test to identify impaired glucose metabolism (≥5.7% glycosylated hemoglobin) and diabetes (≥6.5% glycosylated hemoglobin) at 1 year after delivery. Receiver operating characteristic (ROC) curves were also compared at 2 days and 4-12 weeks after delivery. RESULTS: Of the 300 recruited women, 296 (99%) completed the 2-day postpartum glucose tolerance test, and 202 (68%) returned for the 4- to 12-week glucose tolerance test. Approximately 1 year after delivery, 203 (68%) women had their glycosylated hemoglobin measured, of whom 35% had impaired glucose metabolism and 4% had diabetes. The study population was diverse (46% nonwhite). Furthermore, 56% were obese (mean body mass index, 32 kg/m2), and 55% had received medication to control their glucose during pregnancy. There were no significant differences between the 2-day and 4- to 12-week postpartum glucose tolerance tests in predicting impaired glucose metabolism based on ≥5.7% glycosylated hemoglobin in 1 year after delivery: sensitivity (46% vs 36%); specificity (79% vs 84%); positive predictive value (52% vs 53%); and negative predictive value (75% vs 72%). There was also no difference between the 2-day and the 4- to 12-week glucose tolerance tests in identifying diabetes at 1 year after delivery. Both the 2-day and 4- to 12-week glucose tolerance tests had similar ROC curves in identifying impaired glucose metabolism and diabetes at 1 year after delivery. CONCLUSION: Two-day postpartum glucose tolerance tests have similar diagnostic value as 4- to 12-week postpartum glucose tolerance tests in predicting impaired glucose metabolism and diabetes at 1 year after delivery and are associated with nearly 100% adherence to the test. Thus, changing the timing of the glucose tolerance test should be considered.

Should women with gestational diabetes be screened at delivery hospitalization for type 2 diabetes?

BACKGROUND: Less than one-half of women with gestational diabetes mellitus are screened for type 2 diabetes postpartum. Other approaches to postpartum screening need to be evaluated, including the role of screening during the delivery hospitalization. OBJECTIVE: To assess the performance of an oral glucose tolerance test administered during the delivery hospitalization compared with the oral glucose tolerance test administered at a 4- to 12-week postpartum visit. STUDY DESIGN: We conducted a combined analysis of patient-level data from 4 centers (6 clinical sites) assessing the utility of an immediate postpartum 75-g oral glucose tolerance test during the delivery hospitalization (PP1) for the diagnosis of type 2 diabetes compared with a routine 4- to 12-week postpartum oral glucose tolerance test (PP2). Eligible women underwent a 75-g oral glucose tolerance test at both PP1 and PP2. Sensitivity, specificity, and negative and positive predictive values of the PP1 test were estimated for diagnosis of type 2 diabetes, impaired fasting glucose, or impaired glucose tolerance. RESULTS: In total, 319 women completed a PP1 screening, with 152 (47.6%) lost to follow-up for the PP2 oral glucose tolerance test. None of the women with a normal PP1 oral glucose tolerance test (n=73) later tested as having type 2 diabetes at PP2. Overall, 12.6% of subjects (n=21) had a change from normal to impaired fasting glucose/impaired glucose tolerance or a change from impaired fasting glucose/impaired glucose tolerance to type 2 diabetes. The PP1 oral glucose tolerance test had 50% sensitivity (11.8-88.2), 95.7% specificity (91.3-98.2%) with a 98.1% (94.5-99.6%) negative predictive value and a 30% (95% confidence interval, 6.7-65.3) positive predictive value for type 2 diabetes vs normal/impaired fasting glucose/impaired glucose tolerance result. The negative predictive value of having type 2 diabetes at PP2 compared with a normal oral glucose tolerance test (excluding impaired fasting glucose/impaired glucose tolerance) at PP1 was 100% (95% confidence interval, 93.5-100) with a specificity of 96.5% (95% confidence interval, 87.9-99.6). CONCLUSION: A normal oral glucose tolerance test during the delivery hospitalization appears to exclude postpartum type 2 diabetes mellitus. However, the results of the immediate postpartum oral glucose tolerance test were mixed when including impaired fasting glucose or impaired glucose tolerance. As a majority of women do not return for postpartum diabetic screening, an oral glucose tolerance test during the delivery hospitalization may be of use in certain circumstances in which postpartum follow-up is challenging and resources could be focused on women with an abnormal screening immediately after the delivery hospitalization.

Prospective, randomized, double-blind, placebo-controlled evaluation of the Pharmacokinetics, Safety and Efficacy of Recombinant Antithrombin Versus Placebo in Preterm Preeclampsia.

BACKGROUND: Despite expectant management, preeclampsia remote from term usually results in preterm delivery. Antithrombin, which displays antiinflammatory and anticoagulant properties, may have a therapeutic role in treating preterm preeclampsia, a disorder characterized by endothelial dysfunction, inflammation, and activation of the coagulation system. OBJECTIVE: This randomized, placebo-controlled clinical trial aimed to evaluate whether intravenous recombinant human antithrombin could prolong gestation and therefore improve maternal and fetal outcomes. STUDY DESIGN: We performed a double-blind, placebo-controlled trial at 23 hospitals. Women were eligible if they had a singleton pregnancy, early-onset or superimposed preeclampsia at 23 0/7 to 30 0/7 weeks' gestation, and planned expectant management. In addition to standard therapy, patients were randomized to receive either recombinant human antithrombin 250 mg loading dose followed by a continuous infusion of 2000 mg per 24 hours or an identical saline infusion until delivery. The primary outcome was days gained from randomization until delivery. The secondary outcome was composite neonatal morbidity score. A total of 120 women were randomized. RESULTS: There was no difference in median gestational age at enrollment (27.3 weeks' gestation for the recombinant human antithrombin group [range, 23.1-30.0] and 27.6 weeks' gestation for the placebo group [range, 23.0-30.0]; P=.67). There were no differences in median increase in days gained (5.0 in the recombinant human antithrombin group [range, 0-75] and 6.0 for the placebo group [range, 0-85]; P=.95). There were no differences between groups in composite neonatal morbidity scores or in maternal complications. No safety issues related to recombinant human antithrombin were noted in this study, despite the achievement of supraphysiological antithrombin concentrations. CONCLUSION: The administration of recombinant human antithrombin in preterm preeclampsia neither prolonged pregnancy nor improved neonatal or maternal outcomes.