The Association between Sickle Cell Disease and Postpartum Severe Maternal Morbidity.

OBJECTIVE: To compare the risk of severe maternal morbidity (SMM) from the delivery admission to 42 days' postdischarge among persons with sickle cell disease (SCD) to those without SCD. STUDY DESIGN: This retrospective cohort study included deliveries ≥20 weeks' gestation at an urban safety net hospital in Atlanta, GA from 2011 to 2019. The exposure was SCD diagnosis. The outcome was a composite of SMM from the delivery admission to 42 days' postdischarge. SMM indicators as defined by the Centers for Disease Control and Prevention were identified using the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes; transfusion of blood products and sickle cell crisis were excluded. RESULTS: Of N = 17,354 delivery admissions, n = 92 (0.53%) had SCD. Persons with SCD versus without SCD had an increased risk of composite SMM (15.22 vs. 2.29%, p < 0.001), acute renal failure (6.52 vs. 0.71%, p < 0.001), acute respiratory distress syndrome (4.35 vs. 0.17%, p < 0.001), puerperal cerebrovascular disorders (3.26 vs. 0.10%, p < 0.001), sepsis (4.35 vs. 0.42%, p < 0.01), air and thrombotic embolism (5.43 vs. 0.10%, p < 0.001), and ventilation (2.17 vs. 0.09%, p < 0.01). Ultimately, those with SCD had an approximately 6-fold higher incidence risk ratio of SMM, which remained after adjustment for confounders (adjusted incidence risk ratio [aIRR]: 5.96, 95% confidence interval [CI]: 3.4-9.19, p < 0.001). Persons with SCD in active vaso-occlusive crisis at the delivery admission had an approximately 9-fold higher risk of SMM up to 42 days' postdischarge compared with those with SCD not in crisis at the delivery admission (incidence: 25.71 vs. 8.77%, p < 0.05; aIRR: 8.92, 95% CI: 4.5-10.04, p < 0.05). Among those with SCD, SMM at the delivery admission was primarily related to renal and cerebrovascular events, whereas most postpartum SMM was related to respiratory events or sepsis. CONCLUSION: SCD is significantly associated with an increased risk of SMM during the delivery admission and through 42 days' postdischarge. Active crisis at delivery further increases the risk of SMM. KEY POINTS: · Sickle cell disease was associated with an approximately 6-fold increased risk of SMM.. · Active vaso-occlusive crisis at delivery was associated with an approximately 9-fold increased risk of SMM.. · 48% of SMM events in persons with SCD occurred postpartum and were respiratory- or sepsis-related..

Implementation of a Postpartum Hemorrhage Safety Bundle at an Urban Safety-Net Hospital.

Background Postpartum hemorrhage (PPH) is a leading cause of preventable maternal morbidity and mortality. Standardized response to obstetric hemorrhage is associated with significant improvement in maternal outcomes, yet implementation can be challenging. Objective The primary objective is to describe the methodology for program implementation of the Alliance for Innovation on Maternal Health Safety Bundle on PPH at an urban safety-net hospital. Methods Over an 18-month period, interventions geared toward (1) risk assessment and stratification, (2) hemorrhage identification and management, (3) team communication and simulation, and (4) debriefs and case review were implemented. Hemorrhage risk assessment stratification rates were tracked overtime as an early measure of bundle compliance. Results Hemorrhage risk assessment stratification rates improved to >90% during bundle implementation. Conclusion Keys to implementation included multidisciplinary stakeholder commitment, stepwise and iterative approach, and parallel systems for monitoring and evaluation Implementation of a PPH safety bundle is feasible in a resource-constrained setting.

Executive Summary and Call to Action: Maternal Mortality Summit at National Medical Association Meeting, July 28, 2019 in Honolulu, Hawaii Obstetrics and Gynecology Section of the National Medical Association.

Non-Hispanic black women are 3-4 fold more likely to experience a maternal death than white women in the US, a health disparity that has been persistent for the past 50 years. The complete explanation for this disparity is unknown, but awareness of factors contributing to this disparity is key in addressing it. To address the emerging public health issue of the high rate of maternal mortality in African American women, NMA leaders in obstetrics and gynecology and women's health care, family planning, and reproductive health gathered for the "Black Maternal Mortality Summit." The Summit was held in conjunction with the 117th Annual Convention and Scientific Assembly of the NMA. Reducing maternal mortality will take a multifaceted approach. It was the goal of this summit and writing group that this workshop and executive summary with recommendations will be a call to action to establish the will for developing and implementing developed guidelines and protocols to reduce maternal mortality among vulnerable patient populations.

Partnering of Public, Academic, and Private Entities to Reestablish Maternal Mortality Review in Georgia.

The pregnancy-related mortality ratio in the United States has increased over the past 25 years. Georgia's pregnancy-related mortality ratio is among the highest in the United States. Confronted with this harsh reality, Georgia reestablished maternal mortality review as one strategy to address its high maternal mortality. To achieve a comprehensive process for review of maternal deaths involved securing the knowledge, resources, and support of physician experts, public health agencies and professional organizations as well as representatives in the state legislature. The six key steps in successfully reinstating maternal mortality review were 1) establishing a maternal mortality advisory committee, 2) developing a defined methodology for comprehensive case identification, 3) convening an introductory maternal mortality review committee meeting, 4) securing legislative protection for the committee, 5) conducting a mock mortality review, and 6) completing a formal first-year case review and producing a summary report of initial findings. This first case review revealed the leading causes of pregnancy-related deaths in Georgia as hemorrhage, hypertension, cardiac disease, embolism, and seizures. Our objective in this commentary is to share our experiences and advocate for engaging public, private, and academic partners in working on complex and multifactorial public health issues such as high maternal mortality.

Pregnancy-Associated Deaths in Rural, Nonrural, and Metropolitan Areas of Georgia.

OBJECTIVE: To characterize pregnancy-associated deaths and examine the relationship between area of residence and pregnancy-associated deaths and pregnancy-related mortality ratios in Georgia from 2010 to 2012. METHODS: The cohort of pregnancy-associated deaths was reviewed and categorized as pregnancy-related or resulting from other medical conditions not related to pregnancy, suicide, drug toxicity, homicide, or motor vehicle accident. Georgia Online Analytical Statistical Information System data were used to calculate pregnancy-related mortality ratio by rural, nonrural, and metropolitan Atlanta area and by race. Causes of death and pregnancy-related mortality ratio were compared by area of residence and race using χ tests; a P value <.05 was considered significant. RESULTS: There were 262 pregnancy-associated deaths; 40.1% (n=105) were pregnancy-related. The 2010-2012 pregnancy-related mortality ratio was 26.5 per 100,000 live births and the pregnancy-related mortality ratio did not differ statistically among rural (27.1), nonrural (24.4), and metropolitan Atlanta (27.7) areas (P=.845). Most pregnancy-related deaths were the result of hemorrhage and cardiovascular factors. In aggregate, the pregnancy-related mortality ratio for black women was 49.5 compared with 14.3 for white women (P<.001). The gap in pregnancy-related mortality ratio between black and white women was highest for metropolitan Atlanta (51.6 compared with 12.4, P<.001), less in nonrural areas (50.3 compared with 12.0, P<.001), and comparable in rural areas (39.4 compared with 22.4, P=.281). CONCLUSION: Although the pregnancy-related mortality ratio was similar for rural, nonrural, and metropolitan Atlanta areas, it was significantly higher for black compared with white women living outside of rural areas.

The use of narcotics and street drugs during pregnancy.

All prenatal care providers should offer routine voluntary substance use screening to all patients. Parturients who screen positive for illicit substances require a multidisciplinary team approach to drug rehabilitation and prenatal care. This review will examine the pharmacological properties and the neonatal consequences of the use of opioids and amphetamines. Substance-abusing parturients typically abuse multiple substances simultaneously and have other comorbidities including psychosocial instability and mental illness. These comorbidities must be effectively addressed to achieve optimal health outcomes for both mother and infant.

Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study.

OBJECTIVE: To evaluate the acceptability and feasibility of rapid human immunodeficiency virus testing in obstetric outpatient settings. STUDY DESIGN: The Mother-Infant Rapid Intervention at Delivery (MIRIAD) study was a prospective, multicenter study. Women were offered rapid and conventional human immunodeficiency virus testing if they presented to outpatient settings late in pregnancy with undocumented human immunodeficiency virus status. We compared median times between conventional and rapid testing and between rapid point-of-care and rapid laboratory-based testing. RESULTS: Among eligible women who were offered participation, 90% accepted testing. The median time from blood draw to result available was faster for rapid testing (25 minutes) than conventional testing (23 hours; P < .0001). For rapid tests, point-of-care testing was faster than laboratory-based testing (24 minutes vs 35 minutes; P < .0001). Almost 96% of rapid test results were available within 1 hour. CONCLUSION: Rapid human immunodeficiency virus testing is acceptable, feasible, and provides results far sooner than conventional testing in obstetric outpatient settings.

Fetal cord blood mononuclear cells that are collected at term from HIV-1 infected women harbor transcriptionally active integrated proviral DNA.

OBJECTIVE: The purpose of this study was to determine levels of intrauterine infection and transcriptional activity in cord blood mononuclear cells that were collected at term from fetuses who were born to women who were infected with human immunodeficiency virus (HIV) and who received highly active antiretroviral therapy (HAART). STUDY DESIGN: RNA and DNA were isolated from maternal placental tissues and fetal cord blood specimens that were obtained at term from pregnant women who were infected with HIV and who received HAART. Levels of integrated HIV provirus and messenger RNA transcripts were determined by real-time polymerase chain reaction. RESULTS: Detectable levels of transcriptionally active integrated provirus were present in approximately 27% of cord blood samples (n = 22) that were collected from fetuses who born to HIV-positive mothers who received HAART. Levels of HIV-p24 antigen in cultures that were detected in randomly selected cord blood samples confirmed the presence of inducible infectious virus. CONCLUSION: These findings suggest that some fetuses from HIV-infected mothers who receive HAART and who may be HIV-negative infants after delivery can harbor circulating leukocytes that are infected productively by intrauterine transmission of HIV.

Human tissue mast cells are an inducible reservoir of persistent HIV infection.

We have proposed that, unlike other HIV-vulnerable cell lineages, progenitor mast cells (prMCs), cultured in vitro from undifferentiated bone marrow-derived CD34(+) pluripotent progenitors (PPPs), are susceptible to infection during a limited period of their ontogeny. As infected prMCs mature in culture, they lose expression of viral chemokine coreceptors necessary for viral entry and develop into long-lived, latently infected mature tissue mast cells (MCs), resistant to new infection. In vivo recruitment of prMCs to different tissue compartments occurs in response to tissue injury, growth, and remodeling or allergic inflammation, allowing populations of circulating and potentially HIV-susceptible prMCs to spread persistent infection to diverse tissue compartments. In this report, we provide in vivo evidence to confirm this model by demonstrating that HIV-infected women have both circulating prMCs and placental tissue MCs (PLMCs) that harbor inducible infectious HIV even after highly active antiretroviral therapy (HAART) during pregnancy. Furthermore, infectious virus, capable of infecting alloactivated fetal cord blood mononuclear cells (CBMCs), could be induced in isolated latently infected PLMCs after weeks in culture in vitro. These data provide the first in vivo evidence that tissue MCs, developed from infected circulating prMCs, comprise a long-lived inducible reservoir of persistent HIV in infected persons during HAART.

Maternal death at an inner-city hospital, 1949-2000.

OBJECTIVE: The purpose of this study was to determine the rates and causes of maternal deaths at an inner-city hospital from 1949 through 2000. STUDY DEATH: Death summaries, autopsy reports, and previously collected data were reviewed for maternal deaths from January 1949 through December 2000. The chi(2) and Fisher exact tests were used to test the relationship between time and classification of death. RESULTS: There were 290 maternal deaths and 314,436 live births, for a hospital-specific maternal mortality rate of 92.2 per 100,000. The percentage of deaths that were related directly to pregnancy decreased, and the percentage of deaths that were unrelated to pregnancy increased (P <.001). This is attributable to a decrease in deaths from obstetric infections and hemorrhage and an increase in deaths from nonobstetric infections and homicide. CONCLUSION: The major causes of maternal death in our hospital have changed. A better understanding of these causes may lead to more effective prevention efforts.

Human immunodeficiency virus infection is a risk factor for adverse perinatal outcome.

OBJECTIVE: The purpose of this study was to examine the relationship between maternal human immunodeficiency virus infection and adverse perinatal outcomes. STUDY DESIGN: A retrospective cohort study was conducted in a population of pregnant women who were delivered in a large inner-city hospital between January 1, 1988, and December 31, 1995. The study population consisted of 563 women who were human immunodeficiency virus seropositive and 2252 control subjects who were human immunodeficiency virus seronegative. Results were analyzed with descriptive statistics, chi2 tests, and logistic regression to adjust for potential confounders. RESULTS: Women who were seropositive were more likely than control subjects to deliver low birth weight infants (29.3% vs 16.3%; odds ratio, 2.11; 95% CI, 1.68-2.64), preterm infants (28.9% vs 18.2%; odds ratio, 1.83; 95% CI, 1.45-2.38), and intrauterine growth-restricted infants (16.5% vs 10.6%; odds ratio, 1.66; 95% CI, 1.26-2.19). They were also more likely to have perinatal deaths (11.5% vs 8.3% odds ratio, 1.41; 95% CI, 1.03-1.95). The risk of fetal malformations, fetal distress, and route of delivery were similar between the groups. After race, parity, alcohol use, prenatal care, diabetes mellitus, hypertension, percent ideal body weight, and sexually transmitted diseases were controlled with logistic regression, the increased risk of low birth weight (adjusted odds ratio, 1.45; 95% CI, 1.14-1.86) and preterm delivery (adjusted odds ratio, 1.32; 95% CI, 1.04-1.70) persisted. CONCLUSION: Parturients in our inner-city hospital who were infected with human immunodeficiency virus are at increased risk for delivery of low-birth-weight and premature infants.

Risk of adverse pregnancy outcomes in young adolescent parturients in an inner-city hospital.

OBJECTIVE: Our purpose was to determine the relationship between adolescence and pregnancy-related outcomes. STUDY DESIGN: A retrospective cohort study was conducted in a population of adolescents delivered in a large inner-city hospital. The study population consisted of 14,718 adolescents and 11,830 nonadolescent controls. Pregnancy outcomes were compared in young adolescents (n = 2930) and mature adolescents (n = 11,788) versus controls. RESULTS: Adolescents were significantly more likely than controls to be African American, single, diagnosed with a sexually transmitted disease during pregnancy, and reside with others (P <.001). Adolescents were significantly more likely than controls to have eclampsia (relative risk [RR] 2.23, 95% CI 1.37-3.66) and preterm delivery (RR 1.12, 95% CI 1.04-1.21). Young adolescents were significantly more likely than controls to have preeclampsia (RR 1.33, 95% CI 1.15-1.54), eclampsia (RR 3.24, 95% CI 1.70-6.14), preterm delivery (RR 1.47, 95% CI 1.31-1.64), low-birth-weight delivery (RR 1.47, 95% CI 1.31-1.64), and very-low-birth-weight delivery (RR 1.25, 95% CI 1.01-1.56). Finally, mature adolescents were significantly more likely than controls to have eclampsia (RR 1.99, 95% CI 1.19-3.34). CONCLUSION: Young adolescents are at increased risk for adverse pregnancy outcomes.