Racial and Ethnic Inequities in Cesarean Birth and Maternal Morbidity in a Low-Risk, Nulliparous Cohort.

OBJECTIVE: To evaluate race and ethnicity differences in cesarean birth and maternal morbidity in low-risk nulliparous people at term. METHODS: We conducted a secondary analysis of a randomized trial of expectant management compared with induction of labor in low-risk nulliparous people at term. The primary outcome was cesarean birth. Secondary outcome was maternal morbidity, defined as: transfusion of 4 or more units of red blood cells, any transfusion of other products, postpartum infection, intensive care unit admission, hysterectomy, venous thromboembolism, or maternal death. Multivariable modified Poisson regression was used to evaluate associations between race and ethnicity, cesarean birth, and maternal morbidity. Indication for cesarean birth was assessed using multivariable multinomial logistic regression. A mediation model was used to estimate the portion of maternal morbidity attributable to cesarean birth by race and ethnicity. RESULTS: Of 5,759 included participants, 1,158 (20.1%) underwent cesarean birth; 1,404 (24.3%) identified as non-Hispanic Black, 1,670 (29.0%) as Hispanic, and 2,685 (46.6%) as non-Hispanic White. Adjusted models showed increased relative risk of cesarean birth among non-Hispanic Black (adjusted relative risk [aRR] 1.21, 95% CI 1.03-1.42) and Hispanic (aRR 1.26, 95% CI 1.08-1.46) people compared with non-Hispanic White people. Maternal morbidity affected 132 (2.3%) individuals, and was increased among non-Hispanic Black (aRR 2.05, 95% CI 1.21-3.47) and Hispanic (aRR 1.92, 95% CI 1.17-3.14) people compared with non-Hispanic White people. Cesarean birth accounted for an estimated 15.8% (95% CI 2.1-48.7%) and 16.5% (95% CI 4.0-44.0%) of excess maternal morbidity among non-Hispanic Black and Hispanic people, respectively. CONCLUSION: Non-Hispanic Black and Hispanic nulliparous people who are low-risk at term undergo cesarean birth more frequently than low-risk non-Hispanic White nulliparous people. This difference accounts for a modest portion of excess maternal morbidity.

Neighborhood education status drives racial disparities in clinical outcomes in PPCM.

BACKGROUND: Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry. Additionally, clinical outcomes are worse in this subpopulation compared to White women with PPCM.  The extent to which socioeconomic parameters contribute to these racial disparities is not known. METHODS: We aimed to quantify the association between area-based proxies of socioeconomic status (SES) and clinical outcomes in PPCM, and to determine the potential contribution of these factors to racial disparities in outcomes. A retrospective cohort study was performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of Black individuals. The cohort included 220 women with PPCM, 55% of whom were Black or African American. Available data included clinical and demographic characteristics as well as residential address georeferenced to US Census-derived block group measures of SES. Rates of sustained cardiac dysfunction (defined as persistent LVEF <50%, LVAD placement, transplant, or death) were compared by race and block group-level measures of SES, and a composite neighborhood concentrated disadvantage index (NDI). The contributions of area-based socioeconomic parameters to the association between race and sustained cardiac dysfunction were quantified. RESULTS: Black race and higher NDI were both independently associated with sustained cardiac dysfunction (relative risk [RR] 1.63, confidence interval [CI] 1.13-2.36; and RR 1.29, CI 1.08-1.53, respectively). Following multivariable adjustment, effect size for NDI remained statistically significant, but effect size for Black race did not. The impact of low neighborhood education on racial disparities in outcomes was stronger than that of low neighborhood income (explaining 45% and 0% of the association with black race, respectively). After multivariate adjustment, only low area-based education persisted as significantly correlating with sustained cardiac dysfunction (RR 1.49; CI 1.02-2.17). CONCLUSIONS: Both Black race and NDI independently associate with adverse outcomes in women with PPCM in a single center study. Of the specific components of NDI, neighborhood low education was most strongly associated with clinical outcome and partially explained differences in race. These results suggest interventions targeting social determinants of health in disadvantaged communities may help to mitigate outcome disparities.

Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US.

Importance: Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge. Objective: To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US. Design, Setting, and Participants: In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020. Exposures: Timing of SMM diagnosis. Main Outcomes and Measures: Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention. Results: A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period. Conclusions and Relevance: In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

Maternal post-traumatic stress and depression symptoms and outcomes after NICU discharge in a low-income sample: a cross-sectional study.

BACKGROUND: Having a preterm newborn and the experience of staying in the neonatal intensive care unit (NICU) has the potential to impact a mother's mental health and overall quality of life. However, currently there are few studies that have examined the association of acute post-traumatic stress (PTS) and depression symptoms and infant and maternal outcomes in low-income populations. DESIGN/ METHODS: In a cross-sectional study, we examined adjusted associations between positive screens for PTS and depression using the Perinatal Post-traumatic stress Questionnaire (PPQ) and the Patient Health-Questionnaire 2 (PHQ-2) with outcomes using unconditional logistic and linear regression models. RESULTS: One hundred sixty-nine parents answered the questionnaire with 150 complete responses. The majority of our sample was Hispanic (68%), non-English speaking (67%) and reported an annual income of <$20,000 (58%). 33% of the participants had a positive PPQ screen and 34% a positive PHQ-2 screen. After adjusting for confounders, we identified that a positive PHQ-2 depression score was associated with a negative unit (95% CI) change on the infant's Vineland Adaptive Behavior Scales, second edition of - 9.08 (- 15.6, - 2.6) (p < 0.01). There were no significant associations between maternal stress and depression scores and infant Bayley Scales of Infant Development III scores or re-hospitalizations or emergency room visits. However, positive PPQ and screening score were associated with a negative unit (95% CI) unit change on the maternal Multicultural Quality of Life Index score of - 8.1 (- 12, - 3.9)(p < 0.01) and - 7.7 (- 12, - 3) (p = 0.01) respectively. CONCLUSIONS: More than one-third of the mothers in this sample screened positively for PTS and depression symptoms. Screening scores positive for stress and depression symptoms were associated with a negative change in some infant development scores and maternal quality of life scores. Thoughtful screening programs for maternal stress and depression symptoms should be instituted.

Disparities in Cardiovascular Disease Outcomes Among Pregnant and Post-Partum Women.

Background The incidence of cardiovascular disease among pregnant women is rising in the United States. Data on racial disparities for the major cardiovascular events during pregnancy are limited. Methods and Results Pregnant and post-partum women hospitalized from January 2007 to December 2017 were identified from the Nationwide Inpatient Sample. The outcomes of interest included: in-hospital mortality, myocardial infarction, stroke, pulmonary embolism, and peripartum cardiomyopathy. Multivariate regression analysis was used to assess the independent association between race and in-hospital outcomes. Among 46 700 637 pregnancy-related hospitalizations, 21 663 575 (46.4%) were White, 6 302 089 (13.5%) were Black, and 8 914 065 (19.1%) were Hispanic. The trends of mortality and stroke declined significantly in Black women, but however, were mostly unchanged among White women. The incidence of mortality and cardiovascular morbidity was highest among Black women followed by White women, then Hispanic women. The majority of Blacks (62.3%) were insured by Medicaid while the majority of White patients had private insurance (61.9%). Most of Black women were below-median income (71.2%) while over half of the White patients were above the median income (52.7%). Compared with White women, Black women had the highest mortality with adjusted odds ratio (aOR) of 1.45, 95% CI (1.21-1.73); myocardial infarction with aOR of 1.23, 95% CI (1.06-1.42); stroke with aOR of 1.57, 95% CI (1.41-1.74); pulmonary embolism with aOR of 1.42, 95% CI (1.30-1.56); and peripartum cardiomyopathy with aOR of 1.71, 95 % CI (1.66-1.76). Conclusions Significant racial disparities exist in major cardiovascular events among pregnant and post-partum women. Further efforts are needed to minimize these differences.

Racial Disparity in Postpartum Readmission due to Hypertension among Women with Pregnancy-Associated Hypertension.

OBJECTIVE: Postpartum hypertension is a leading cause of readmission in the postpartum period. We aimed to examine the prevalence of racial/ethnic differences in postpartum readmission due to hypertension in women with antepartum pregnancy-associated hypertension. STUDY DESIGN: This was a multi-institutional retrospective cohort study of all women with antepartum pregnancy-associated hypertension diagnosed prior to initial discharge from January 2009 to December 2016. Antepartum pregnancy-associated hypertension, such as gestational hypertension, preeclampsia (with or without severe features), hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome, and eclampsia was diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions. Women with chronic hypertension and superimposed preeclampsia were excluded. Our primary outcome was postpartum readmission defined as a readmission due to severe hypertension within 6 weeks of postpartum. Risk factors including maternal age, gestational age at admission, insurance, race/ethnicity (self-reported), type of antepartum pregnancy-associated hypertension, marital status, body mass index (kg/m2), diabetes (gestational or pregestational), use of antihypertensive medications, mode of delivery, and postpartum day 1 systolic blood pressure levels were examined. Multivariable logistic regression models were performed to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). RESULTS: Of 4,317 women with pregnancy-associated hypertension before initial discharge, 66 (1.5%) had postpartum readmission due to hypertension. Risk factors associated with postpartum readmission due to hypertension included older maternal age (aOR = 1.44; 95% CI: 1.20-1.73 for every 5 year increase) and non-Hispanic black race (aOR = 2.12; 95% CI: 1.16-3.87). CONCLUSION: In women with pregnancy-associated hypertension before initial discharge, non-Hispanic black women were at increased odds of postpartum readmission due to hypertension compared with non-Hispanic white women.

Birth hospital and racial and ethnic differences in severe maternal morbidity in the state of California.

BACKGROUND: Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. OBJECTIVE: We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. STUDY DESIGN: This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. CONCLUSION: In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

Risk Factors for Maternal Readmission with Sepsis.

OBJECTIVE: Our primary objective was to identify risk factors for maternal readmission with sepsis. Our secondary objectives were to (1) assess diagnoses and infecting organisms at readmission and (2) compare early (<6 weeks) and late (6 weeks to 9 months postpartum) maternal readmission with sepsis. STUDY DESIGN: We identified our cohort using linked hospital discharge data and birth certificates for California deliveries from 2008 to 2011. Consistent with the 2016 sepsis classification, we defined sepsis as septicemia plus acute organ dysfunction. We compared women with early or late readmission with sepsis to women without readmission with sepsis. RESULTS: Among 1,880,264 women, 494 (0.03%) were readmitted with sepsis, 61% after 6 weeks. Risk factors for readmission with sepsis included preterm birth, hemorrhage, obesity, government-provided insurance, and primary cesarean. For both early and late sepsis readmissions, the most common diagnoses were urinary tract infection and pyelonephritis, and the most frequently identified infecting organism was gram-negative bacteria. Women with early compared with late readmission with sepsis shared similar obstetric characteristics. CONCLUSION: Maternal risk factors for both early and late readmission with sepsis included demographic characteristics, cesarean, hemorrhage, and preterm birth. Risks for sepsis after delivery persist beyond the traditional postpartum period of 6 weeks.

Maternal postpartum stress and toddler developmental delays: Results from a multisite study of racially diverse families.

Maternal psychosocial stress during pregnancy can adversely influence child development, but few studies have investigated psychosocial stress during the postpartum period and its association with risk of toddler developmental delays. Moreover, given the expanding diversity of the U.S. population, and well-documented health and stress disparities for racial and ethnic minorities, research examining the effect of postpartum stress on risk of developmental delays in diverse populations is of critical importance. In this study, data from the Community Child Health Network provided the opportunity to test maternal postpartum stress as a predictor of toddler risk of developmental delay in a sample of African American, Latina and non-Hispanic White women and their toddlers (N = 1537) recruited in urban, suburban, and rural communities. Postpartum maternal stress over 1 year was operationalized as perceived stress, life events, and negative impact of life events. Regression results revealed higher risk of developmental delays in toddlers whose mothers experienced more negative life events, greater negative impact of events, and higher perceived stress over the year. Prenatal stress, pregnancy/birth complications, and postpartum depression did not explain these associations. Maternal postpartum stress may contribute to increased risk for developmental delays and is an important target for psychosocial intervention.

Understanding the lived experiences of severe postnatal psychiatric illnesses in English speaking South Asian women, living in the UK: a qualitative study protocol.

INTRODUCTION: The South Asian population is the UK's largest and fastest growing minority ethnic group. There is evidence to suggest the lay understanding of postnatal psychiatric illnesses of this group may fall outside the purview of Western biomedical perspectives. Alternative explanations include psychosocial, cultural and spiritual factors. Approaching psychiatric illnesses through a social perspective includes gaining insight to the patient's subjective experiences and understandings via qualitative inquiry. The objectives of this qualitative study are to explore South Asian women's narrative of living with a severe postnatal psychiatric illness and experiences of Perinatal Mental Health Services, care and support. METHODS AND ANALYSIS: Data collection is ongoing and will continue until 31 December 2018. Participants will be identified and recruited from Perinatal Mental Health Services in Birmingham and London. Eligible participants will be English speaking South Asian females aged 18 years or above with the capacity to give written informed consent. Participants are clinically diagnosed with a severe postnatal psychiatric illness. This qualitative study uses individual in-depth face-to-face interviews that aim to last 1 hour. Interviews will be audio recorded with participants' permission. Interview audio recordings will be transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). The primary goal of IPA is for the researcher to closely study and interpret how individuals make sense of their life experiences in a particular context by drawing on the fundamental principles of phenomenology, hermeneutics and idiography. ETHICS AND DISSEMINATION: The University of Birmingham, the South Birmingham Research Ethics Committee and the Health Research Authority have approved this study (approvals date: 18-12-2017 ref: 17/WM/0350). Local capability and capacity have been confirmed from Trust Research and Development departments. The researchers plan to publish the results from this study in journals and present findings at academic conferences.

Postpartum Mental Health Disorders in Indigenous Women: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review synthesized and evaluated the evidence on the prevalence of postpartum mental health disorders in Indigenous women. METHODS: Comprehensive searches of biomedical electronic databases including Medline, EMBASE, PsychINFO, CINAHL, and Web of Science were performed for peer-reviewed literature published from 1990 to September 2018. The search strategy included terms related to the postpartum period, mental health disorders, and Indigenous ancestry. Epidemiological observational studies that evaluated the prevalence of mental health disorders in the postpartum and included Indigenous women from Australia, Canada, New Zealand, and the United States were included. Two independent reviewers screened and evaluated the risk of bias of included studies. A narrative synthesis of study results was conducted. Prevalence estimates from homogeneous studies were pooled in a random-effects meta-analysis (Canadian Task Force Classification II-2). RESULTS: A total of 2297 references were initially identified, of which six studies were included in the review. All included studies evaluated the prevalence of postpartum depression (PPD) and were of moderate or low risk of bias. Other postpartum mental health disorders were not evaluated. Overall, Indigenous women had 87% increased odds of PPD compared with Caucasian groups of women (odds ratio 1.87; 95% confidence interval 1.14-3.09). Substantial heterogeneity across prevalence estimates was observed. CONCLUSION: Limited evidence suggests a greater burden of PPD affecting Indigenous women. There is insufficient evidence informing the prevalence of other postpartum mental health disorders in Indigenous women. More epidemiological research in this area is essential to provide accurate and reliable prevalence estimates of postpartum mental health disorders among Indigenous women.

Improving postpartum screening after diabetes in pregnancy: Results of a pilot study in remote Australia.

BACKGROUND: The postpartum period is a critical time to improve health outcomes for Aboriginal women, particularly for those who have chronic conditions. AIMS: To assess enhanced support methods (for women following diabetes in pregnancy (DIP)) to improve completion rates of recommended postpartum health checks. MATERIALS AND METHODS: Fifty-three Aboriginal women in the Northern Territory (NT) were contacted in the postpartum period to encourage medical check-ups. Messages were delivered through phone (call or text messages) or other methods (Facebook or email). The primary outcome was postpartum blood glucose testing (oral glucose tolerance testing (OGTT), random or fasting glucose and HbA1c). RESULTS: Establishing contact with women was difficult. Of 137 messages sent to 52 women, 22 responded (42%). Phone was the most common contact method with successful contact made from 16 of 119 (13%) attempts. Rates of postpartum OGTT completion were higher in the group successfully contacted (32% vs 7%). However, for any postpartum glucose testing (including OGTT and HbA1c) rates were 25 of 42 (60%) and neither success in making contact nor the contact method was associated with higher rates. CONCLUSIONS: The small sample size limits our conclusions; however, results highlight that engaging remote women postpartum is difficult. While rates of postpartum OGTT completion differed according to successful contacts, rates of any postpartum blood glucose testing did not. Further research is needed to explore feasible intervention methods to improve postpartum screening after a pregnancy complicated by diabetes.

Disparities in death rates in women with peripartum cardiomyopathy between advanced and developing countries: A systematic review and meta-analysis.

There is limited information about differences in maternal deaths from peripartum cardiomyopathy (PPCM) between advanced and developing countries. To review the literature to define the global prevalence of death from PPCM, and to determine the differences in PPCM mortality rates and risk factors between advanced and developing countries. Studies in the English language reporting mortality data on patients with PPCM were included from searches of MEDLINE, Embase, CINAHL, the Cochrane Library, the Web of Science Core Collection and Scopus from 01 January 2000 to 11 May 2016. Of the 4294 articles identified, 1.07% were included. The primary outcome was death; rates of heart transplant, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular events, embolism and cardiac arrest were recorded. Studies were categorized as having been conducted in advanced or developing countries. Data from 46 studies, 4925 patients and 13 countries were included. There were 22 studies from advanced countries (n=3417) and 24 from developing countries (n=1508); mean follow-up was 2.6 (range 0-8.6) years. Overall mortality prevalence was 9% (95% confidence interval [CI] 6-11%). The mortality rate in developing countries (14%, 95% CI 10-18%) was significantly higher than that in advanced countries (4%, 95% CI 2-7%). There was no difference in the prevalence of risk factors (chronic hypertension, African descent, multiple gestation and multiparity) between advanced and developing countries. Studies with a higher prevalence of women of African descent had higher death rates (correlation coefficient 0.29, 95% CI 0.13-0.52). The risk of death in women with PPCM was higher in developing countries than in advanced countries. Women of African descent had an increased risk of death.

Maternal and fetal prognosis of subsequent pregnancy in black African women with peripartum cardiomyopathy.

BACKGROUND: The aim of this study was to describe maternal and fetal outcomes after pregnancy complicated by peripartum cardiomyopathy (PPCM). METHODS: We included women that had subsequent pregnancy (SSP) after PPCM and assessed maternal prognosis and pregnancy outcomes, in-hospital up to one week after discharge. Clinical and echocardiographic data were collected comparing alive and deceased women. Factors associated with pregnancy outcomes were assessed. RESULTS: Twenty-nine patients were included, with a mean age of 26.7 ± 4.6 years and a mean gravidity number of 2.3 ± 0.5 of. At the last medical control before subsequent pregnancy, there was no congestive heart failure, the mean left ventricular diastolic diameter (LVDD) was 53 ± 4 mm and the left ventricular ejection fraction (LVEF) was ≥50% in 13 cases (44.8%). Maternal outcomes were marked by 14 deaths (48.3%). Among the factors tested in univariate analysis, LVEF at admission had an excellent receiver-operating characteristic (ROC) curve to predict maternal mortality (AUC = 0.95; 95% CI 0.87-1, p < 0.001), with a cut off value of < 40% (sensitivity = 93% and specificity = 87%). Concerning fetal outcomes, baseline LVEF had the best area under the curve (AUC) to predict abortion or prematurity among all variables (AUC = 0.75; 95% CI 0.58-092, p = 0.003), with a cut-off value of < 50% (sensitivity = 79%, specificity = 67%). CONCLUSIONS: SSP outcomes are still severe in our practice. Maternal mortality remains high and is linked to ventricular systolic function at admission (due to pregnancy), while fetal outcomes are linked to baseline LVEF before pregnancy.

Dynamic 3T pelvic floor magnetic resonance imaging in women progressing from the nulligravid to the primiparous state.

INTRODUCTION AND HYPOTHESIS: The objective was to prospectively characterize dynamic pelvic 3-Tesla magnetic resonance imaging (dp3T MRI) findings in nulligravida women and characterize changes 6 months after delivery in the same woman. METHODS: In this prospective study, nulligravida women seeking assisted reproductive technology for pregnancy were recruited. After physical examination by Pelvic Organ Prolapse Quantification (POP-Q), Brink assessment and measures including the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7, pre-pregnancy dp3T MRI at rest, with strain, and evacuation were performed. Assessments were repeated ≥6 months postpartum. Analysis included Welch and paired t tests for continuous variables, Fisher's exact test for differences in categorical outcomes, and paired t tests for postpartum symptoms. RESULTS: Nineteen subjects (mean ± SD age, 31 ± 5 years) completed baseline clinical and dp3T MRI studies, 15 delivered and 10 (30.5 ± 3 years) completed pre-pregnancy and post-delivery clinical and dp3T MRI assessments. There were no significant changes in scores of validated questionnaires (all p > 0.05) or on POP-Q measures post-delivery. Two (20%) subjects without pre-pregnancy levator tears had tears on MRI post-delivery. MRI measures of pelvic organ descent were increased post-delivery. Seventeen pelvic soft-tissue parameters increased by greater than 10% post-delivery, including 5 out of 70 (7.1%), 17 out of 110 (15.5%), and 50 out of 110 (45.5%) values exceeding thresholds at rest, strain, and evacuation respectively. CONCLUSIONS: Dynamic pelvic 3T MRI detected levator tears and increased pelvic organ descent, which can be directly attributed to pregnancy and delivery.

Evaluation of the NZ guidelines for screening for persistent postpartum hyperglycaemia following gestational diabetes.

BACKGROUND: Recent New Zealand guidelines recommend annual glycated haemoglobin (HbA1c) measurements from three months postpartum, replacing the glucose tolerance test (GTT) at six weeks, to screen for persistent hyperglycaemia following gestational diabetes. Data suggest that this screening approach may miss cases of type 2 diabetes, but are they detected at subsequent screening and will screening rates improve? AIMS: Our aim was to evaluate the effectiveness of HbA1c monitoring in improving screening rates following gestational diabetes and in detecting postpartum hyperglycaemia. MATERIALS AND METHODS: During 2015 in Christchurch, all women with gestational diabetes were offered HbA1c and GTT measurements at three months postpartum and subsequent annual HbA1c measurements were recommended. Data from electronic hospital records were collected for a minimum 18 months postpartum. RESULTS: Of the cohort of 333 women, 218 (65%) completed both HbA1c and GTT at three months postpartum, 74 (22%) HbA1c only, 16 (5%) GTT only, 25 (8%) no screening; 184 (55%) had subsequent HbA1c tests. Diabetes was detected by GTT in five (2%) women and by HbA1c in only one out of five (20%); the disagreement between tests resolved in three out of four (75%) women with subsequent testing. Prediabetes was detected by GTT in 30 (14%) women; however, HbA1c only detected five out of 30 (17%) and subsequent HbA1c testing identified a further two out of 30 with prediabetes. CONCLUSIONS: HbA1c measurement at three months postpartum had a good uptake. However, most cases of diabetes were identified by subsequent HbA1c testing, the uptake of which was suboptimal. The importance of annual HbA1c monitoring following gestational diabetes needs greater emphasis.

Labor therapeutics and BMI as risk factors for postpartum preeclampsia: A case-control study.

OBJECTIVES: This study aims at identifying associations between therapeutics used during labor and the occurrence of postpartum preeclampsia (PPPE), a poorly understood entity. STUDY DESIGN AND MAIN OUTCOME MEASURES: This is a case-control study of women who received an ICD-9 code for PPPE (cases) during the years 2009-2011, compared to women with a normotensive term pregnancy, delivery and postpartum period until discharge (controls), matched on age (±1year) and delivery date (±3months). Cases were defined as women having a normotensive term pregnancy, delivery and initial postpartum period (48h post-delivery) but developing hypertension between 48h and 6weeks postpartum. Single variable and multiple variable models were used to determine significant risk factors. RESULTS: Forty-three women with PPPE were compared to 86 controls. Use of vasopressors and oxytocin did not differ between cases and controls, but rate of fluids administered during labor (OR=1.68 per 100cc/h; 95% CI: 1.09-2.59, p=0.02) and an elevated pre-pregnancy/first trimester BMI (OR=1.18 per kg/m2, 95% CI: 1.07-1.3, p=0.001) were identified as significant risk factors in multivariate analysis. CONCLUSIONS: We identified two potentially modifiable risk factors for PPPE; further studies are needed to better define the role of these two variables in the development of PPPE.

Clinical outcomes of peripartum cardiomyopathy: a 15-year nationwide population-based study in Asia.

Peripartum cardiomyopathy (PPCM) is the development of heart failure during late pregnancy to months postpartum with potential fatal outcome. However, the disease is not well-studied in Asia.We aimed to investigate the epidemiology and clinical outcomes of PPCM in Taiwan.Electronic medical records were retrieved from Taiwan National Health Insurance Research Database from 1997 to 2011. Patients with PPCM were separated into 3 groups based on the timing of diagnosis. Early: PPCM diagnosed first to ninth month of pregnancy. Traditional: PPCM diagnosed last month of pregnancy till fifth month post-delivery. Late: PPCM diagnosed sixth to twelfth month post-delivery. Primary outcomes defined as cardiac death, all-cause mortality, and major adverse cardiovascular events (MACE) within 1 year.A total of 3,506,081 deliveries during 1997 to 2011 were retrieved and 925 patients with PPCM were identified. Overall incidence of PPCM was 1:3,790 during the 15 years. Early, Traditional, and Late group each had 88, 742, and 95 patients. Cardiac death occurred in 31 patients, all-cause mortality in 72 patients, and MACE in 65 patients. Late group had 2- to 3-fold event rates in cardiac death, all-cause mortality, and MACE compared with Early and Traditional groups. Cumulative incidence showed significant differences for cardiac death (P = .0011), all-cause mortality (P = .0031), and MACE (P = .0014) among 3 groups. Multivariate Cox model showed Late group had significantly worse outcomes after adjusted for clinical variables compared with 2 other groups.Our study is the largest national cohort among Asian countries that showed timing of diagnosis of PPCM had different outcomes. Late diagnosis portended significantly increased morbidity and mortality, even after adjusted for clinical variables.

Comparison of Clinical Characteristics and Outcomes of Peripartum Cardiomyopathy Between African American and Non-African American Women.

Importance: Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry, but well-powered studies to explore differences in severity of disease and clinical outcomes are lacking. Objective: To compare the clinical characteristics, presentation, and outcomes of PPCM between African American and non-African American women. Design, Setting, and Participants: This retrospective cohort study using data from January 1, 1986, through December 31, 2016, performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of African American individuals, included 220 women with PPCM. Main Outcomes and Measures: Demographic and clinical characteristics and echocardiographic findings at presentation, as well as clinical outcomes including cardiac recovery, time to recovery, cardiac transplant, persistent dysfunction, and death, were compared between African American and non-African American women with PPCM. Results: A total of 220 women were studied (mean [SD] age at diagnosis, 29.5 [6.6] years). African American women were diagnosed with PPCM at a younger age (27.6 vs 31.7 years, P < .001), were diagnosed with PPCM later in the postpartum period, and were more likely to present with a left ventricular ejection fraction less than 30% compared with non-African American women (48 [56.5%] vs 30 [39.5%], P = .03). African American women were also more likely to worsen after initial diagnosis (30 [35.3%] vs 14 [18.4%], P = .02), were twice as likely to fail to recover (52 [43.0%] vs 24 [24.2%], P = .004), and, when they did recover, recovery took at least twice as long (median, 265 vs 125.5 days; P = .02) despite apparent adequate treatment. Conclusions and Relevance: In a large cohort of women with well-phenotyped PPCM, this study demonstrates a different profile of disease in African American vs non-African American women. Further work is needed to understand to what extent these differences stem from genetic or socioeconomic differences and how treatment of African American patients might be tailored to improve health outcomes.