A prospective study of antepartum anxiety screening in patients with and without a history of spontaneous preterm birth.

BACKGROUND: Maternal stress has been identified as one of the most common clinical phenotypes associated with preterm birth. The American College of Obstetricians and Gynecologists recommends anxiety screening at least once in the perinatal period. The prevalence of perinatal anxiety is challenged by the absence of formalized screening protocols and underreporting in high-risk populations, such as those with a history of adverse pregnancy outcomes. OBJECTIVE: This study administered a validated anxiety screening tool in a cohort of patients with and without a previous spontaneous preterm birth and compared differences in score and rate of a positive screen between groups. Moreover, this study evaluated perinatal outcomes associated with a positive screen and described a referral protocol involving evaluation by a perinatal mental health counselor and clinical diagnoses. A hypothesis was made that patients with a previous history of spontaneous preterm birth would have higher self-reported anxiety symptoms than controls and that those with recurrent preterm delivery at <35 weeks of gestation would have the highest anxiety screening scores. STUDY DESIGN: This was a prospective observational cohort study administering the Generalized Anxiety Disorder 7-item screen to patients enrolled in 2 prenatal care clinics at our institution. The preterm birth cohort consisted of patients with a history of spontaneous preterm labor, premature rupture of membranes, or cervical insufficiency compared with the control cohort without this history. Screening was initiated at entry to prenatal care or referral to our high-risk obstetrical clinic. The inclusion criteria included English- or Spanish-speaking patients and singleton pregnancy, and the exclusion criteria included pregnancies complicated by a major congenital anomaly, enrollment after 34 weeks of gestation, delivery at <20 weeks of gestation, and incomplete delivery data. Referral to a mental health counselor was offered to those with a Generalized Anxiety Disorder 7-item screen score of ≥10. Perinatal outcomes as a comparison between the Generalized Anxiety Disorder 7-item screen-positive group and Generalized Anxiety Disorder 7-item screen-negative group were performed with statistical methods, including the Student t test, chi-square test, and Wilcoxon rank-sum test, with a P value of <.05 to determine significance. RESULTS: Between September 2020 and December 2021, 1349 participants were analyzed, with 143 patients (11%) in the previous preterm birth cohort and 1206 (89%) patients in the control cohort. Patients with a history of preterm birth and subsequent delivery at ≤35 weeks of gestation in the study pregnancy had significantly higher Generalized Anxiety Disorder 7-item screen scores than controls with delivery after 35 weeks of gestation (median score: 4 [interquartile range, 1-9] vs 2 [interquartile range, 0-6], respectively; P=.006). Overall, 187 participants (14%) screened positive with significantly higher rates in the previous preterm birth group than in the control group (20% vs 13%; P=.036). Of note, 117 patients (63%) accepted a referral, and 32 patients (17%) with a positive screen were diagnosed with a perinatal mood disorder. CONCLUSION: Patients with recurrent preterm birth have higher self-reported anxiety using the Generalized Anxiety Disorder 7-item screen than controls. Of those with a positive screen, 17% were diagnosed with a perinatal mood disorder.

A Randomized Trial of the Effects of Ambient Operating Room Temperature on Neonatal Morbidity.

OBJECTIVE: Newborn hypothermia has been implicated in neonatal morbidity without randomized evidence that it compromises the infant. Our objective was to determine if a difference in operating room temperature at cesarean birth impacts neonatal morbidity. STUDY DESIGN: Women undergoing cesarean delivery of a liveborn infant without major malformations were included. The institutional preexisting operating room temperature of 20°C (67°F) was compared with an experimental group of 24°C (75°F) by cluster randomization assigned on a weekly basis. Newborn hypothermia was defined as axillary temperature on arrival to the nursery of less than 36.5°C (<97.7°F). The primary outcome was a composite of neonatal morbidity including respiratory support, sepsis, hypoglycemia, and neonatal death. RESULTS: Between November 2016 and May 2018, 5,221 women had cesarean deliveries at Parkland Hospital with 2,817 randomized to the standard care group and 2,404 to the experimental group. The rate of neonatal composite morbidity did not differ between the groups: standard care 398 (14%) versus experimental 378 (16%), p = 0.11. This was despite a significant decrease in the rate of neonatal hypothermia: standard care 1,195 (43%) versus experimental 414 (18%), p < 0.001. There was no difference in the composite outcome for preterm infants (<37 wk) between the groups: standard care 194 (49%) versus experimental 185 (54%), p = 0.25. CONCLUSION: An 8°F increase in operating room temperature was significantly associated with a reduced rate of neonatal hypothermia, although this decrease was not associated with a significant improvement in neonatal morbidity. However, the increase in operating room temperature was met with resistance from obstetricians and operating room personnel. This trial is registered (registration no.: NCT03008577).

Perinatal outcomes of young adolescent pregnancies in an urban inner city.

BACKGROUND: Although substantial efforts have been made to reduce the rates of adolescent pregnancy, the United States continues to have higher rates than other industrialized countries. Research and reporting usually focus on adolescents aged 15 to 19 years. Although less common, there are pregnant young adolescents that are ≤15 years of age, with developmental and social differences from older, high school-aged adolescents. OBJECTIVE: Because adolescent pregnancies are of particular concern because of long-term socioeconomic consequences to parent and child, we sought to determine whether young adolescents (≤15 years old) had worse perinatal outcomes than older adolescents (16-19 years old) and older parents (≥20 to 34 years old) among those living in an urban inner city. STUDY DESIGN: This was a study of pregnant individuals who delivered a singleton pregnancy without evidence of chronic hypertension or pregestational diabetes mellitus at a safety net hospital from January 2010 to May 2021. Parents were grouped by age at the time of delivery into young adolescents (≤15 years old) and older adolescents (16-19 years old). For a comparison group, nulliparous older parents aged 20 to 34 years with singleton pregnancies were analyzed for perinatal outcomes and compared with the adolescent cohorts. When analyzing baseline parental characteristics, a preponderance of obesity was noted in the young adolescent cohort. An analysis of parental characteristics and perinatal outcomes among young adolescents with obesity vs young adolescents without obesity ≤15 years old was performed. Statistical analysis included χ2 and Student t test with P values of <.05 considered significant. Logistic regression analysis was performed to control for potentially confounding demographic variables. RESULTS: Overall, 10,894 adolescent women delivered, with 868 young adolescents and 10,026 older adolescents. Pairwise comparisons showed young adolescents had a different race distribution than older adolescents (P=.006) and older parents (P<.001). Young adolescents were more likely to be Hispanic or non-Hispanic Black (P<.001) and accessed prenatal care at a later gestational age (19.7±8.9 weeks) compared with older adolescents (16.7±8.6 weeks) and the comparison older cohort of parents (15.7±8.7 weeks) (P<.001) and less frequently in pregnancy (P<.001) compared with older parents. Young adolescents were more likely to have preterm birth at <37 weeks of gestation (P<.001) and eclampsia (0.5% vs 0.1%) (P=.01) than older adolescents. Therefore, low birthweights of ≤2500 g (P=.02) and neonatal intensive care unit admission (P=.048) were also increased in adolescents. When adjusted for race, ethnicity, and body mass index, preeclampsia with severe features (P<.001) and preterm birth at <37 weeks of gestation (P=.048) remained significant. Young adolescents with obesity were more likely to have preeclampsia with severe features (odds ratio, 1.81; 95% confidence interval, 1.22-2.68) and be delivered via cesarean delivery (odds ratio, 2.71; 95% confidence interval, 1.85-3.99) than adolescents without obesity. CONCLUSION: In an urban inner city, young adolescent parents were more likely to be women of color, have later presentations to prenatal care, and have increased rates of preterm birth. Young adolescents had high rates of obesity, which was associated with increased rates of hypertensive disorders of pregnancy and cesarean delivery, than adolescents without obesity.

Fetal heart rate tracings associated with eclamptic seizures.

BACKGROUND: Although there is a well-known association between fetal bradycardia and maternal eclampsia, the characteristics of fetal heart rate tracings after an eclamptic seizure have not previously been thoroughly described. Fetal heart rate changes are thought to be related to maternal lactic acidemia caused by vasospasm and uterine hyperactivity leading to placental hypoperfusion and fetal hypoxia. The decision to intervene in the case of an abnormal fetal heart rate tracing after an eclamptic seizure is often difficult; however, maternal resuscitation should be the primary focus. OBJECTIVE: This study aimed to quantify and characterize fetal heart rate changes associated with a maternal eclamptic seizure. Moreover, we sought to document subsequent obstetrical management following these seizures complicated by fetal heart rate decelerations. STUDY DESIGN: This was a retrospective study of fetal heart rate tracings associated with eclampsia during a 13-year period at a single institution. Eclampsia was diagnosed following the 2013 Executive Summary of the American College of Obstetricians and Gynecologists criteria. Tracings were independently reviewed and classified by 3 physicians using the National Institute of Child Health and Human Development Criteria. Hospital records were reviewed to ascertain obstetrical management after the eclamptic seizure. RESULTS: A total of 107 women were diagnosed with eclampsia from January 2009 to December 2021. Of these women, 31 experienced 34 intrapartum seizures during which time electronic fetal heart rate monitoring was ongoing. During the 34 seizures, fetal heart rate decelerations were documented in 79% of cases. The mean duration of bradycardia was 5.80±2.98 minutes with a range of 2 to 15 minutes. Fetal heart decelerations occurred, on average, 2.7±1.6 minutes after the onset of the eclamptic seizure. In half of the fetuses with fetal heart rate changes, fetal tachycardia followed, and in 48% of cases, there was minimal variability noted. As a result of the fetal heart rate tracings and clinical findings, 4 women underwent an emergent cesarean delivery, including 2 that were diagnosed with placental abruption. In this cohort, there were 4 cases of abruption. The mean duration from the seizure to delivery was 299±353 minutes. The mean neonatal cord pH was 7.20±0.11 with a mean base excess of -8.6±4.4 mmol/L. There was no perinatal death. CONCLUSION: After an eclamptic seizure, 79% of fetuses demonstrated prolonged decelerations, and half of the fetuses developed fetal tachycardia after recovery from the episode of bradycardia. Despite these periods of fetal heart rate decelerations associated with eclampsia, prioritization of maternal support and stabilization resulted in a favorable perinatal outcome without immediate operative intervention in more than two-thirds of cases.

The effect of normal saline on renal function and electrolytes in women with preeclampsia.

INTRODUCTION: Due to a nationwide shortage of Ringer's lactate, normal saline became the intravenous fluid of choice at our institution in May 2018. Recent studies have shown that the administration of normal saline in critically ill patients may have adverse renal effects. OBJECTIVE: Our objective was to evaluate the renal function effects; if any, of normal saline administered to women with preeclampsia receiving magnesium sulfate. MATERIALS AND METHODS: This is a prospective observational study of women identified with preeclampsia with severe features, requiring magnesium sulfate prophylaxis. The amount of normal saline administered was calculated and a basic metabolic panel was surveyed 12 h after initiation of magnesium sulfate prophylaxis. Laboratory analytes were examined according to the volume of intravenous normal saline received, including a comparison to those women who did not receive normal saline, to determine the impact of parameters after 12 h of magnesium sulfate prophylaxis. RESULTS: From May 2018 to November 2018, a total of 233 patients receiving magnesium sulfate were identified, 184 of which had received intravenous normal saline. No differences were identified at 12 h in serum chloride or creatinine between those patients who received intravenous normal saline and those who did not. This finding persisted when serum chloride and creatinine were analyzed across quartiles of normal saline received. Interestingly, serum calcium was found to decrease with increasing serum magnesium (p < .001). This association was also dependent upon the amount of intravenous fluids received (p < .001) when controlling for serum magnesium. CONCLUSION: Renal function indices were preserved despite the introduction of normal saline with oxytocin into routine practice. No dose-response relationship was identified when serum chloride and creatinine were analyzed across quartiles of normal saline received. Interestingly, serum calcium levels were noted to decline with both the amount of intravenous fluid received as well as with increasing serum magnesium levels.

The impact of baseline proteinuria in pregnant women with pregestational diabetes mellitus.

BACKGROUND: The incidence of diabetes in pregnancy has increased dramatically with the rising rates of obesity. Because there are a number of recognized adverse maternal and fetal outcomes associated with diabetes, there have been several attempts to classify this disorder for perinatal risk stratification. One of the first classification systems for pregnancy was developed by White nearly 70 years ago. More recently, efforts to stratify diabetic disease severity according to vasculopathy have been adopted. Regardless of classification system, vasculopathy-associated effects have been associated with worsening pregnancy outcomes. Defining vasculopathy within an organ system, however, has not been consistent. For example, definitions of diabetic kidney disease differ from the previously used threshold of ≥500 mg/d by White for pregnancy to varying thresholds of albuminuria by the American Diabetes Association. OBJECTIVE: To evaluate a proteinuria threshold that was a relevant determinant of perinatal risk in a cohort of women with type 2 diabetes. MATERIALS AND METHODS: This was a retrospective cohort study of women with pregestational diabetes delivered of nonanomalous, singleton, liveborn infants. All women were assessed for baseline maternal disease burden with a 24-hour proteinuria quantification performed before 20 weeks' gestation. Women with <500 mg/d on 24-hour urine collections were included. Perinatal outcomes were analyzed according to the following protein excretion values: 50-100, 101-200, 201-300, and 301-499 mg/d. Based on trends noted in these results and using the prior definition of the American Diabetes Association of 300 mg/d of albumin for diabetic kidney disease, women were then analyzed according to 24-hour urine collections of ≤300 or >300 mg/d. RESULTS: Between 2009 and 2016, a total of 594 women with pregestational diabetes were found to meet study criteria. When analyzed according to protein excretion values 50-100, 101-200, 201-300, and 301-499 mg/d, there were no differences in maternal demographics. The rate of preeclampsia with severe features (P for trend = .02), preterm birth at <37 weeks (P for trend <.001), and birthweight <10th percentile (P for trend = .02) were significantly associated with increasing proteinuria excretion, with the highest rates in the >300 mg/d group. Perinatal outcomes were then examined in the context of 24-hour urine protein excretion values of ≤300 or >300 mg/d, with no differences in maternal demographics. Protein excretion values >300 mg/d were significantly associated with preterm birth <37 weeks (P = .003), preeclampsia with severe features (P = .002), and birthweight <10th percentile (P = .048). CONCLUSION: White's classification in 1949 was developed to stratify perinatal risks based on maternal disease burden, and it was found that urinary protein excretion of >500 mg/d was associated with adverse pregnancy outcomes. In a contemporary cohort of pregnant women, proteinuria >300 mg/d was associated with preterm birth, preeclampsia with severe features, and birthweight <10th percentile.

Perinatal outcomes associated with abnormal cardiac remodeling in women with treated chronic hypertension.

BACKGROUND: Adverse maternal outcomes associated with chronic hypertension include accelerated hypertension and resultant target organ damage. One example is long-standing hypertension leading to maternal cardiac dysfunction. Our group has previously identified that features of such injury manifest as cardiac remodeling with left ventricular hypertrophy. Moreover, these features of cardiac remodeling identified in women with chronic hypertension during pregnancy were associated with adverse perinatal outcomes. Recent definitions of maternal cardiac remodeling using echocardiography have been expanded to include measurements of wall thickness. We hypothesized that these new features characterizing cardiac remodeling in women with chronic hypertension may also be associated with adverse perinatal outcomes. OBJECTIVE: There were 3 aims in this study of women with treated chronic hypertension during pregnancy: to (1) apply the updated definitions of maternal cardiac remodeling; (2) elucidate whether these features of cardiac remodeling were associated with adverse perinatal outcomes; and (3) determine which, if any, of the newly defined cardiac remodeling strata were most damaging when compared to women with normal cardiac geometry. STUDY DESIGN: This was a retrospective study of women with treated chronic hypertension during pregnancy delivered from January 2009 through January 2016. Cardiac remodeling was categorized by left ventricular mass index and relative wall thickness into 4 groups determined using the 2015 American Society of Echocardiography guidelines: normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Perinatal outcomes were analyzed according to each category of cardiac remodeling compared with outcomes in women with normal geometry. RESULTS: A total of 314 women with treated chronic hypertension underwent echocardiography at a mean gestational age of 17.9 weeks. There were no differences between maternal age (P = .896), habitus (P = .36), or duration of chronic hypertension (P = .212) among the 4 groups. Abnormal cardiac remodeling was found in 51% and was significantly associated with increased rates of superimposed preeclampsia (P = .015), preterm birth (P < .001), and neonatal intensive care admission (P = .003). These outcomes reached the greatest significance when comparisons were made between eccentric hypertrophy and normal geometry. CONCLUSION: Using current American Society of Echocardiography guidelines, 51% of women with treated chronic hypertension during pregnancy have some degree of abnormal cardiac remodeling. Any suggestion of maternal cardiac remodeling, regardless of subtype, was associated with increased risks for superimposed preeclampsia and preterm birth with its resultant perinatal sequelae. Eccentric ventricular hypertrophy, previously thought to mimic exercise physiology, appears to be the most associated with adverse perinatal outcomes. Despite evidence of cardiac remodeling, ejection fraction was preserved.

Frequency and consequences of ventricular hypertrophy in pregnant women with treated chronic hypertension.

BACKGROUND: Ventricular hypertrophy is a known sequela of long-standing chronic hypertension with associated morbidity and mortality. OBJECTIVE: We sought to assess the frequency and importance of left ventricular hypertrophy in gravidas treated for chronic hypertension during pregnancy. STUDY DESIGN: This was a retrospective study of pregnant women with chronic hypertension who were delivered at our hospital from January 2009 through February 2015. All women who were given antihypertensive therapy underwent maternal echocardiography and were managed in a dedicated, high-risk prenatal clinic. Left ventricular hypertrophy was defined using the criteria of the American Society of Echocardiography as left ventricular mass indexed to maternal body surface area with a value of >95 g/m2. Maternal and infant outcomes were then analyzed according to the presence or absence of left ventricular hypertrophy. RESULTS: Of 253 women who underwent echocardiography, 48 (19%) met criteria for left ventricular hypertrophy. Women in this latter cohort were significantly more likely to be African American (P = .031), but there were no other demographic differences. More than 85% of the entire cohort had a body mass index >30 kg/m2 and a third of all women had class III obesity with a body mass index of >40 kg/m2. Importantly, duration of chronic hypertension (P = .248) and gestational age at time of echocardiography (P = .316) did not differ significantly between the groups. Left ventricular function was preserved in both groups as measured by left ventricular ejection fraction (P = .303). Those with ventricular hypertrophy were at greater risk to be delivered preterm (P = .001), to develop superimposed preeclampsia (P = .028), and to have an infant requiring intensive care (P = .023) when compared with women without ventricular hypertrophy. These findings persisted after adjustment for age, race, and parity. The gestational age at delivery according to measured left ventricular size was also examined and with increasing ventricular mass there was a significant association with the severity of preterm birth (P < .001). CONCLUSION: Left ventricular hypertrophy was identified in 1 in 5 women given antepartum treatment for chronic hypertension. Further analysis showed that these women were at significantly greater risk for superimposed preeclampsia and its attendant perinatal sequelae of preterm birth.