The association between maternal insurance status on maternal and neonatal outcomes in women with hypertensive disorders of pregnancy.

The objective of this study was to examine the association between maternal insurance status and maternal and neonatal adverse outcomes in women who had hypertensive disorders in pregnancy. A population-based retrospective cohort study was undertaken using the US Vital Statistics dataset on Period Linked Birth-Infant Data from 2016-2020. The study population was restricted to non-anomalous births from women whose pregnancies were complicated by hypertensive disorders. Insurance status was categorized as private, Medicaid, self-pay and other. The primary outcome was a composite of maternal adverse outcomes, which included admission to the intensive care unit, unplanned hysterectomy, maternal blood transfusion or uterine rupture. We examined the role of prenatal care in these relationships using a mediation analysis with Kotelchuck's Adequacy of Prenatal Care Utilization Index. Multivariable logistic regression models were used to estimate the association between maternal insurance status and adverse outcomes (using adjusted odds ratios [aOR] and 99% confidence interval [CI]). Of the 18,999,865 live births in the five-year study, 1,642,654 (8.6%) met the inclusion criteria. The frequency of the composite maternal adverse outcome was 1.3%. The maternal composite occurred more frequently in women with Medicaid (aOR = 1.11, 99% CI: 1.06, 1.16) or self-pay (aOR = 1.40, 99% CI: 1.25, 1.55) when compared to private insurance. Adjusting for prenatal care slightly attenuated this association, but remained significant. Among women with hypertensive disorders in pregnancy, women with Medicaid insurance or self-pay were more likely to experience maternal and neonatal adverse outcomes than women with private insurance.

Preterm cesarean delivery for nonreassuring fetal heart rate tracing: Risk factors and predictability of adverse outcomes.

OBJECTIVE: To compare adverse outcomes among preterm births that underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) versus those that did not. STUDY DESIGN: Consortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton at 23.0 to 36.6 weeks who labored for at least 2 h. Composite adverse neonatal outcomes included any of the following intraventricular hemorrhage grade III or IV, seizures, mechanical ventilation, sepsis, necrotizing enterocolitis 2 or 3, or neonatal death. Composite adverse maternal outcomes included any of the following postpartum hemorrhage, endometritis, blood transfusion, chorioamnionitis, admission to intensive care unit, thromboembolism, or death. RESULTS: Of 228,438 births, 29,592 (13.0%) delivered preterm, and 16,679 (56.4%) labored for at least 2 hrs. CD for NR FHRT was done in 1,220 (7.3%). The rate of composite adverse neonatal outcome was different among those that had CD for NR FHRT (26.7%) versus those that did not (16.6%; aRR 1.59, 95% CI 1.43-1.76). Composite adverse maternal outcomes did not differ between the groups. The area under the curve for risk factors to identify composite adverse neonatal outcome was 0.81, and for composite adverse maternal outcomes, 0.64. CONCLUSIONS: Subsequent to CD for NR FHRT, composite adverse neonatal outcome is 59% higher among preterm births when compared to delivery with reassuring tracing; composite adverse maternal outcomes did not differ between the groups.

Moderate-to-Severe Polyhydramnios: Cutoffs for Deepest Vertical Pocket Corresponding to Amniotic Fluid Index.

OBJECTIVE: Society for Maternal-fetal medicine Consult Series (#46) states "antenatal fetal surveillance is not required for mild idiopathic" polyhydramnios defined as amniotic fluid index (AFI) of 24 cm or a deepest vertical pocket (DVP) between 8 and 11 cm. The objective of this study was to determine the cutoff for DVP which correlates with AFI ≥ 30 cm. METHODS: This retrospective study of singleton third trimester ultrasounds included a study group randomly divided into test and validation. In the test group, DVP cutoffs correlating with AFI ≥ 30 cm which was used to define moderate-severe polyhydramnios were calculated in two ways, rounded to the nearest whole number: 1) a receiver operating curve and Youden's J statistic (DVP-Youden) and 2) calculation of the DVP percentile that corresponded with AFI of 30 cm (DVP-Percentile). Using the validation group, diagnostic characteristics were DVP-Youden and DVP-Percentile for diagnosis of AFI ≥ 30 cm and were compared against SMFM cutoffs (DVP-SMFM). RESULTS: Seventy one thousand eight hundred and ninety three ultrasound exams in the 3rd trimester had assessment of AFI and DVP. Moderate-severe polyhydramnios occurred in 286 (1.2%) in test group and 571 (1.2%) in validation group. AFI of 30 cm corresponded to the 98.9th percentile, which in turn correlated to a DVP of 10 cm (DVP-Percentile). The calculated cutoff for moderate-severe polyhydramnios was 8 cm for DVP-Youden. CONCLUSION: Using 8.0 cm rather than 12.0 cm increased the detection of moderate-severe polyhydramnios to 100% with a false positive rate under 5%. For those utilizing DVP for amniotic fluid evaluation, identification of a DVP ≥ 8.0 cm should prompt further evaluation with complete AFI.

Neonatal and maternal outcomes with trial of labor after two prior cesarean births: stratified by history of vaginal birth.

INTRODUCTION: To determine the impact of prior vaginal birth on neonatal and maternal outcomes among individuals undergoing a trial of labor after two cesarean births. MATERIALS AND METHODS: This was a cross-sectional study using the U.S. National Vital Statistics 2014-2018 period linked birth and infant death data. Inclusion criteria were term, cephalic, singleton pregnancies with two prior cesarean births. The primary exposure variable was a trial of labor after cesarean vs prelabor repeat cesarean birth. Cohorts were defined by the presence or absence of a prior vaginal birth. The primary outcome was a composite of adverse neonatal outcomes (Apgar score <5 at 5 min, assisted ventilation >6 h, neonatal seizures, or neonatal death within 27 days). Secondary outcomes included a maternal composite and the cesarean birth rate. Propensity score matching was used to account for baseline differences in treatment allocation within each cohort, and conditional logistic regression assessed the association between the exposure and outcomes. RESULTS: The composite neonatal adverse outcome was significantly higher in those undergoing a trial of labor after cesarean compared to prelabor repeat cesarean birth in both individuals without a prior vaginal birth (8.2 vs 11.6 per 1000 live births, OR 1.41; 95% CI 1.12-1.70) and with a prior vaginal birth (9.6 vs 12.4 per 1000 live births, OR 1.30; 95% CI 1.08-1.57). The composite maternal adverse outcome was significantly higher among individuals without a prior vaginal birth undergoing trial of labor after cesarean (6.0 vs 9.5 per 1000 live births, OR 1.59; 95% CI 1.26-2.09), but was similar in those with a prior vaginal birth (7.9 vs 9.3 per 1000 live births, OR 1.18; 95% CI 0.97-1.46). CONCLUSION: In individuals with two prior cesarean births, trial of labor after cesarean was associated with increased neonatal adverse outcomes when compared to prelabor repeat cesarean birth, irrespective of a history of vaginal birth. In individuals with a prior vaginal birth, the composite maternal adverse outcome was not elevated in the trial of labor cohort.

Semiquantitative Assessment of Amniotic Fluid Among Individuals With and Without Diabetes Mellitus.

OBJECTIVE: To compare the rate and severity of abnormal amniotic fluid volumes (oligohydramnios or polyhydramnios), as well as the distribution of amniotic fluid levels, in pregnancies with and without diabetes. METHODS: We performed a retrospective cohort study of singleton nonanomalous pregnancies receiving an ultrasound examination (USE) in the third trimester. Pregnancies were categorized into those with and without diabetes and subcategorized by diabetes type. The primary outcomes were oligohydramnios or polyhydramnios. Polyhydramnios was also examined by severity. The association between maternal diabetes status and oligohydramnios or polyhydramnios was assessed using logistic regression. In addition, we computed gestational age-specific amniotic fluid index (AFI) and deepest vertical pocket (DVP) centiles for pregnancies with and without diabetes. RESULTS: There were 60,226 USEs from 26,651 pregnancies that met inclusion criteria. There were 3992 (15.0%) pregnancies with diabetes and 22,659 (85.0%) without diabetes. Using AFI, the rate of polyhydramnios was 10.5 versus 3.8% (odds ratio [OR] 2.95; 95% confidence interval [CI] 2.62-3.32) for pregnancies with versus without diabetes, respectively; using DVP, the rate of polyhydramnios was 13.9 versus 5.4% (OR 2.84; 95% CI 2.56-3.15). Rates of oligohydramnios were also increased in pregnancies with diabetes (3.3 versus 2.6%; OR 1.26; 95% CI 1.04-1.52). The AFI and DVP were significantly higher in the cohort with diabetes between 28 and 36 weeks. CONCLUSION: Within our study population, pregnancies with diabetes had increased rates of oligohydramnios and polyhydramnios as well as increased gestational age-specific amniotic fluid volumes between 28 and 36 weeks. A higher prevalence of polyhydramnios was observed using DVP as compared to AFI; nevertheless, associations were similar using either method.

Maternal and neonatal adverse outcomes in individuals with a prior cesarean birth who undergo induction at 39 weeks.

OBJECTIVE: To compare the maternal and neonatal adverse outcomes among individuals with one or two prior cesarean deliveries who are induced at 39 weeks gestational age versus those that are expectantly managed. METHODS: This was a population-based cross-sectional study using U.S. National Vital Statistics 2014-2018 period linked birth and infant death data. Cohorts were individuals with one or two prior cesarean deliveries who were induced at 39.0 to 39.6 weeks gestation or underwent delivery from 40.0 to 41.6 weeks gestational age from either spontaneous labor or induction. The primary outcome was a composite of maternal adverse outcomes: admission to the intensive care unit, transfusion, uterine rupture, or unplanned hysterectomy. The secondary outcome was a composite of neonatal adverse outcomes, including: 5-minute Apgar score <5, assisted ventilation for >6 h, neonatal seizures, or neonatal mortality (death within 27 days of birth). RESULTS: Of 263,489 women who met the inclusion criteria 21,951 (8.3%) underwent induction at 39 weeks. The composite maternal adverse outcome was significantly higher in women who delivered at 40-41 weeks gestation when compared to the 39 week gestation induction of labor cohort (8.1 versus 9.4 per 1,000 births; aRR 1.18; 95% CI 1.01-1.39). The overall rate of composite neonatal adverse outcome was 10.4 per 1,000 live births. The composite neonatal adverse outcome was also significantly elevated among deliveries at 40-41 weeks gestation as well (8.6 vs. 10.8 per 1,000 live births; aRR 1.31; 95%CI 1.12-1.53). CONCLUSION: In women undergoing trial of labor after cesarean, induction of labor at 39 weeks gestation was associated with fewer maternal and neonatal adverse outcomes when compared to delivery at 40-41 weeks gestation.

Prostaglandins for induction in pregnancies with fetal growth restriction.

BACKGROUND: The data on safety of prostaglandin agents for induction of pregnancies with fetal growth restriction is limited. OBJECTIVE: To compare the rates of adverse outcomes among pregnancies with fetal growth restriction undergoing induction of labor with and without prostaglandins STUDY DESIGN: We performed a propensity-score-based secondary analysis of the Consortium on Safe Labor database. We included term, singleton, and nonanomalous pregnancies with fetal growth restriction (estimated fetal weight <10th percentile for gestational age). We excluded previous cesarean deliveries. The primary exposure was induction using prostaglandins (prostaglandin E1 or prostaglandin E2) compared with other methods. The primary outcome was a composite of adverse neonatal outcomes. The secondary outcomes included all cesarean deliveries and cesarean deliveries for nonreassuring fetal heart tracings. A subgroup analysis comparing the type of prostaglandin was planned a priori. The results are expressed as adjusted odds ratios with 95% confidence intervals. RESULTS: Of 756 (0.3%) inductions, 212 (28%) used prostaglandins (108 prostaglandin E1, 94 prostaglandin E2), and 553 (72%) used nonprostaglandin methods, including oxytocin (348, 63%), amniotomy (211, 38%), and/or mechanical dilation (9, 1%). There were no differences in the composite of adverse neonatal outcomes between the prostaglandin (10.4%) and the nonprostaglandin group (6.7%), adjusted odds ratio, 1.39 (0.64-3.03). The rate of cesarean delivery was higher in the inductions that received prostaglandins than those that did not (25.5% vs 14.8%, adjusted odds ratio, 1.80; 1.07-3.02). The rate of cesarean delivery for nonreassuring fetal heart tracings was higher for those that received prostaglandins than those that did not (16.0% vs 8.7%, adjusted odds ratio, 2.37; 1.28-4.41). When prostaglandin E1 and prostaglandin E2 were examined independently, there were similar increases in the composite of adverse neonatal outcomes and cesarean delivery rates for both prostaglandin E1 and prostaglandin E2 compared with nonprostaglandin controls. CONCLUSION: There were no differences in the composite of adverse neonatal outcomes when prostaglandins were used for induction in pregnancies with fetal growth restriction compared with other methods. However, there was a higher rate of cesarean delivery and cesarean delivery indicated for nonreassuring fetal heart tracings when prostaglandins (both prostaglandin E1 and prostaglandin E2) were used, compared with nonprostaglandin methods.

Association between time of delivery and composite adverse outcomes in pregnancies complicated by hypertensive disorders.

INTRODUCTION: A potential manner to lower the morbidity with the hypertensive disoreders of pregancy is to explore the time of day of delivery. OBJECTIVE: To compare composite neonatal adverse outcomes among term women with hypertensive disorders. METHODS: This population-based cohort study used the U.S. vital statistics dataset from 2013 to 2017. Time of delivery was categorized into three shifts. The primary outcome was composite neonatal adverse outcome.. RESULTS: Compared to neonates delivered at the first shift, the risk of composite neonatal adverse outcome was higher at the third shift (aRR = 1.19, 95% CI = 1.13-1.25). CONCLUSION: the risk of composite neonatal adverse outcome is higher if the delivery occurs at the third (23:00-7:00) shift.

Labor induction with prostaglandin E1 versus E2: a comparison of outcomes.

OBJECTIVE: To compare the peripartum outcomes when labor is induced with prostaglandins E1 versus E2. METHODOLOGY: The Consortium of Safe Labor database was utilized. Women with non-anomalous singletons >24 weeks gestation undergoing induction were analyzed. The primary endpoint was a composite adverse maternal outcome with a composite adverse neonatal outcome as our secondary outcome. RESULTS: Of the 228,438 births within the database, 8229 (10.8%) met inclusion criteria with 4703 (55.7%) receiving PGE1, and 3741 (44.3%), PGE2. The rate of vaginal delivery was similar between both. Composite adverse maternal outcome, was more likely among the prostaglandin E1: 7.2% vs. 1.5% (aOR 4.20; 95% CI 3.02-5.85); similar trend observed with composite adverse neonatal outcome rates: 4.6% vs. 1.4% (aOR 1.69; 95% CI 1.14-2.50). CONCLUSION: Utilization of prostaglandin E1, compared to E2, was associated with an increased likelihood of adverse maternal and neonatal outcomes.

Adverse maternal and neonatal outcomes among low-risk women with obesity at 37-41 weeks gestation.

OBJECTIVE: To evaluate adverse neonatal and maternal outcomes among women with obesity and no additional comorbidities at 37-41 weeks. METHODS: This was a population based retrospective cohort study performed using US vital statistics data from 2014-2017. We included women with body mass index ≥ 30.0 kg/m2 and a singleton, cephalic, non-anomalous pregnancy who attempted labor and delivered between 37 0/7-41 6/7 weeks. Women with chronic hypertension, gestational diabetes, or pregestational diabetes were excluded. The co-primary outcomes were composite neonatal morbidity (Apgar score < 5 at 5 min, assisted ventilation > 6 h, neonatal seizures, or neonatal death within 27 days) and composite maternal morbidity (admission to the intensive care unit, blood transfusion, uterine rupture, or unplanned hysterectomy) with completed weeks of gestation as the primary exposure variable. All outcomes were examined using multivariate Poisson regression and were reported as adjusted risk ratios (aRR) with 95 % confidence intervals (95 % CI). RESULTS: There were 15.8 million live births between 2014-2017, of whom 5.1 million (32.1 %) met the inclusion criteria. Composite neonatal morbidity was significantly increased in women delivering at 37 weeks (aRR 1.84; 95 % CI 1.78-1.90), 38 weeks (aRR 1.14; 95 % CI 1.10-1.17), 40 weeks (aRR 1.19; 95 % CI 1.16-1.22), and 41 weeks (aRR 1.49; 95 % CI 1.44-1.53) compared to 39 weeks. Composite maternal morbidity was similarly increased at 37 weeks (aRR 1.26; 95 % CI 1.19-1.34), 38 weeks (aRR 1.07; 95 % CI 1.02-1.13), 40 weeks (aRR 1.16; 95 % CI 1.11-1.20), and 41 weeks (aRR 1.42; 95 % CI 1.34-1.49). CONCLUSION: Composite neonatal and maternal morbidity among women with obesity and no additional comorbidities is increased with delivery at 37, 38, 40, or 41 weeks compared with 39 weeks.

Maternal Obesity and the Risk of Early-Onset and Late-Onset Hypertensive Disorders of Pregnancy.

OBJECTIVE: To evaluate the relationship between maternal body mass index (BMI) at delivery and rates of early-onset and late-onset hypertensive disorders of pregnancy. METHODS: We performed a population-based, retrospective cohort study using U.S. Vital Statistics period-linked birth and infant death certificates from 2014 to 2017. Women who delivered a nonanomalous singleton live neonate from 24 to 41 completed weeks of gestation were included. We excluded women with chronic hypertension and those with BMIs less than 18.5. The primary exposure was maternal BMI, defined as nonobese (BMI 18.5-29.9; referent group), class 1 obesity (BMI 30.0-34.9), class 2 obesity (BMI 35.0-39.9), and class 3 obesity (BMI 40.0 or greater). The primary outcome was delivery with hypertensive disorders of pregnancy (gestational hypertension, preeclampsia, or eclampsia) at less than 34 weeks of gestation or at 34 weeks or more. Multivariable Poisson regression was used to estimate relate risk and adjust for confounding variables. Results are presented as adjusted relative risk (aRR) and 95% CIs. RESULTS: Of the 15.8 million women with live births during the study period, 14.0 million (88.6%) met inclusion criteria, and 825,722 (5.9%) had hypertensive disorders of pregnancy. The risk of early-onset hypertensive disorders of pregnancy was significantly higher in women with class 1 obesity (aRR 1.13; 95% CI 1.10-1.16), class 2 obesity (aRR 1.57; 95% CI 1.53-1.62), and class 3 obesity (aRR 2.18; 95% CI 2.12-2.24), compared with nonobese women. The risk of late-onset hypertensive disorders of pregnancy was also significantly increased in women with class 1 obesity (aRR 1.71; 95% CI 1.70-1.73), class 2 obesity (aRR 2.60; 95% CI 2.58-2.62), and class 3 obesity (aRR 3.93; 95% CI 3.91-3.96) compared with nonobese women. CONCLUSION: Compared with nonobese women, the risk of early-onset and late-onset hypertensive disorders of pregnancy is significantly and progressively increased among women with increased class of obesity.

Identification of newborns with birthweight ≥ 4,500g: Ultrasound within one- vs. two weeks of delivery.

OBJECTIVE: Our objective was to compare the diagnostic characteristics of sonographic estimated fetal weight (SEFW) done within 7 versus 8-14 days before delivery for detection of fetal macrosomia (birthweight ≥ 4500 g). STUDY DESIGN: We performed a multicenter, retrospective cohort study of all non-anomalous singletons with SEFW ≥ 4000 g by Registered Diagnostic Medical Sonographers conducted within 14 days of delivery. Cohorts were grouped by time interval between ultrasound and delivery: 0-7 days versus 8-14 days. The detection rate (DR) and false positive rate (FPR) for detection of birthweight (BW) ≥ 4500 g were compared between groups with subgroup analysis for diabetic women. Area under the receiver operator curve (AUC) was calculated to analyze all possible SEFW cutoffs within our cohort. RESULTS: A total of 330 patients met inclusion criteria with 250 (75.8 %) having SEFW within 7 days and 80 (24.2 %) with SEFW 8-14 days prior to delivery. The rate of macrosomia was 15.1 % (N = 51). The DR for macrosomia was significantly higher when SEFW was performed within 7 days of delivery compared to 8-14 days among non-diabetic (73.0 % vs 7.1 %; p < 0.001) and diabetic women (76.5 % vs 16.7 %; p = 0.02). There was no significant change in FPR in either group. The AUC for detection of macrosomia was significantly higher when SEFW was performed within 7 days versus 8-14 days (0.89 vs 0.63; p < 0.01). CONCLUSION: With SEFW ≥ 4000 g, the detection of BW ≥ 4500 g is significantly higher when the sonographic examination is within 7 days of birth irrespective of maternal diabetes.

Does Prepregnancy Weight or Maternal BMI at Betamethasone Administration Impact Late Preterm Respiratory Morbidity?

OBJECTIVE: We sought to determine if maternal prepregnancy body mass index (BMI) is a risk factor for neonatal respiratory morbidity and to determine if increasing BMI decreased the efficacy of betamethasone (BMZ). STUDY DESIGN: This was a secondary analysis of the Antenatal Late Preterm Steroids trial, double-blind, randomized controlled trial involving 2,831 women between 340/7 and 365/7 weeks who received BMZ or a matching placebo. We compared the rate of neonatal respiratory morbidity among prepregnancy BMI classes in both the placebo and treatment groups. We also stratified the treatment effect by maternal BMI at the time of delivery. RESULTS: A total of 2,822 women were identified with maternal weight recorded at delivery; 2,740 women also had self-reported prepregnancy weight available. When stratified by prepregnancy BMI class, there was no difference in neonatal respiratory morbidity in the BMZ or in placebo groups. When analyzed by BMI at delivery, there was no difference in the rate of neonatal respiratory morbidity, and BMI was not a predictor of treatment response (odds ratio = 1.00, 95% confidence interval = 0.99-1.02). CONCLUSION: Maternal prepregnancy BMI is not associated with late preterm neonatal respiratory morbidity. Maternal obesity does not decrease the efficacy of BMZ for preventing late preterm neonatal respiratory morbidity.

Intrahepatic cholestasis of pregnancy: Review of six national and regional guidelines.

Intrahepatic cholestasis of pregnancy (ICP) is a poorly understood disease of the late second or third trimester of pregnancy, typically associated with rapid resolution following delivery. It is characterized by pruritis, elevated serum bile acids, and abnormal liver function tests and has been linked to stillbirth, meconium passage, respiratory distress syndrome and fetal asphyxial events. The incidence is highly variable, dependent both on the ethnic makeup of the population as well as the diagnostic criteria being used. Management is challenging for clinicians, as laboratory abnormalities often lag behind clinical symptoms making diagnosis difficult. The American Congress of Gastroenterology, Government of Western Australia Department of Health, the Royal College of Obstetricians and Gynaecologists, Society for Maternal Fetal Medicine, European Association for the Study of the Liver, and South Australia Maternal and Neonatal Community of Practice have all released guidelines to address the risks, diagnosis and management of ICP. We performed a descriptive review of these guidelines along with a literature search to address conflicting recommendations and highlight new evidence. The variations in the guidelines reflect the heterogeneity of the literature and the challenges of diagnosing and managing ICP.

Subtotal Resection of an Anaplastic Ganglioglioma in Pregnancy.

BACKGROUND: Anaplastic ganglioglioma is a rare malignant brain tumor associated with high morbidity and mortality. The diagnosis of a central nervous system malignancy in the early 3rd trimester presents management challenges to both neurosurgeons and obstetricians. CASE: A 33-year-old woman, gravida 2 para 1, presented at 28 6/7 weeks with four months of worsening headaches, nausea, vomiting, and mental status changes due to a 7.5 cm anaplastic ganglioglioma. Maternal deterioration necessitated subtotal tumor debulking allowing prolongation of the gestation to 34 6/7 weeks. After delivery, the patient underwent further resection, followed by chemotherapy and radiation. Both mother and infant are well. DISCUSSION: This case underscores the importance of timely diagnostic imaging in pregnant women and demonstrates subtotal tumor debulking as a viable means of prolonging gestation.