The Birth and Beyond (BABY) study: protocol for a birth cohort study investigating the social and environmental determinants of pregnancy-related outcomes in Black American families.

INTRODUCTION: In the USA, Black birthing people and infants experience disproportionately worse pregnancy-related health outcomes. The causes for these disparities are unknown, but evidence suggests that they are likely socially and environmentally based. Efforts to identify the determinants of these racial disparities are urgently needed to elucidate the highest priority targets for intervention. The Birth and Beyond (BABY) study evaluates how micro-level (eg, interpersonal and family) and macro-level (eg, neighbourhood and environmental) risk and resiliency factors transact to shape birth person-infant health, and underlying psychobiological mechanisms. METHODS AND ANALYSIS: The BABY study will follow 350 Black families (birthing parents, non-birthing parents and infants) from pregnancy through the first postpartum year, with research visits during pregnancy and at infant ages 6 and 12 months. Research visits comprise a combination of interview about a range of recent and life course stress and resiliency exposures and supports, psychophysiological (sympathetic, parasympathetic and adrenocortical) assessment and behavioural observations of parent-infant coregulatory behaviours. Spatial analyses are completed by mapping parent current and past residential addresses onto archival public data (eg, about neighbourhood quality and racial segregation). Finally, EMRs are abstracted for information about birthing parent relevant medical history, pregnancy conditions and infant birth outcomes. Analyses will evaluate the risk and resiliency mechanisms that contribute to pregnancy and birth-related outcomes for Black birthing people and their infants, and the protective role of individual, familial, cultural, and community supports. ETHICS AND DISSEMINATION: The BABY study has been approved by the Institutional Review Board at Albany Medical Centre. The study team consulted with local organisations and groups comprised of stakeholders and community leaders and continues to do so throughout the study. Research results will be disseminated with the scientific and local community as appropriate.

Evaluating the Association between Prenatal Care Visits and Adverse Perinatal Outcome in Pregnancies Complicated by Opioid Use Disorder.

OBJECTIVE: This study aimed to evaluate the association between number of prenatal care visits and adverse perinatal outcome among pregnant individuals with opioid use disorder (OUD). STUDY DESIGN: This is a retrospective cohort of singleton, nonanomalous pregnancies complicated by OUD that delivered from January 2015 to July 2020 at our academic medical center. Primary outcome was the presence of composite adverse perinatal outcome, defined as one or more of the following: stillbirth, placental abruption, perinatal death, neonatal respiratory distress syndrome, need for morphine treatment, and hyperbilirubinemia. Logistic and linear regression estimated the association between the number of prenatal care visits and the presence of adverse perinatal outcome. A Mann-Whitney U test evaluated the association between number of prenatal care visits and length of hospital stay for the neonate. RESULTS: A total of 185 patients were identified, of which 35 neonates required morphine treatment for neonatal opioid withdrawal syndrome. During pregnancy, most individuals were treated with buprenorphine 107 (57.8%), whereas 64 (34.6%) received methadone, 13 (7.0%) received no treatment, and 1 (0.5%) received naltrexone. The median number of prenatal care visits was 8 (interquartile range: 4-10). With each additional visit per 10 weeks of gestational age, the risk of adverse perinatal outcome decreased by 38% (95% confidence interval [CI]: 0.451-0.854). The need for neonatal intensive care and hyperbilirubinemia also significantly decreased with additional prenatal visits. Neonatal hospital stay decreased by a median of 2 days (95% CI: 1-4) for individuals who received more than the median of eight prenatal care visits. CONCLUSION: Pregnant individuals with OUD who attend fewer prenatal care visits experience more adverse perinatal outcome. Future research should focus on barriers to prenatal care and interventions to improve access in this high-risk population. KEY POINTS: · Use of prenatal care affects newborn outcomes.. · More prenatal care shortens neonatal hospital stay.. · Prenatal care reduces certain adverse outcomes..

Implementing American College of Obstetricians and Gynecologists Outpatient Antepartum Testing Recommendations: Can Your Clinic Handle It?

OBJECTIVE: This study was conducted to determine the difference in the number of pregnancies that would qualify for outpatient fetal testing between our current academic practice and that of the 2021 American College of Obstetricians and Gynecologists (ACOG) antepartum recommendations. STUDY DESIGN: We performed a retrospective study of all pregnancies that delivered and received prenatal care at our institution between January 1, 2019, and May 31, 2021. The timing and amount of outpatient antepartum testing was determined for each patient. Our current antepartum testing guidelines (clinic protocol) were compared with the 2021 ACOG recommendations (ACOG protocol). Statistical analysis was performed with descriptive statistics and z scoring to compare the total amount of antepartum testing utilized with each protocol. RESULTS: A total of 1,335 pregnancies were included in the study. With the ACOG protocol, an additional 310 (23.2%) of pregnancies would qualify for antepartum testing (57.8% with ACOG protocol vs. 34.6% with clinic protocol). Most of the increased testing was due to maternal age with additional risk factors, hypertensive disorders, diabetes, prepregnancy body mass index ≥ 35, and complex fetal anomalies or aneuploidies. Overall, the ACOG protocol would require an additional 570 antepartum tests (z-score = 4.04, p = 0.000005) over the study period, which is equivalent to 19 additional tests per month and 5 per week. Only nine stillbirths occurred during this time, of which two would have had antepartum testing with both protocols, one would have only had testing per ACOG, and two would have had testing individualized per ACOG. CONCLUSION: More pregnancies would require outpatient antenatal testing with adoption of the ACOG protocol. A 23% increase in testing would equate to five additional antepartum tests per week. Although this study cannot assess the clinical impact of additional testing, minimal scheduling resources are needed to accommodate this increase. KEY POINTS: · Most pregnancies have risk factors for stillbirth.. · Most pregnancies qualify for fetal testing per ACOG.. · More resources are needed for this increased testing..

Stillbirth in women with diabetes: a retrospective analysis of fetal autopsy reports.

INTRODUCTION: Diabetes in pregnancy is associated with an increased rate of stillbirth. There are a wide variety of factors that have been implicated including placental insufficiency, hypoxia, hyperinsulinemia and impaired cardiac function. Furthermore, there is evidence that diabetic pregnancies have an increased rate of fetal cardiomyopathy as compared to non-diabetic pregnancies. Prior studies have indicated that this association can also be an etiology for diabetic stillbirth. The purpose of this study was to determine if diabetic pregnancies have an increased risk of fetal cardiomyopathy identified on fetal autopsy as compared to non-diabetic women with a stillbirth in a cohort of pregnancies that had evaluation with a fetal autopsy. MATERIALS AND METHODS: Retrospective cohort study of women with a stillbirth who consented to fetal autopsy at an academic medical center from 2011 to 2017. Stillbirth was defined as an intrauterine fetal demise at ≥20 weeks' gestation. Women with diabetes defined as pre-gestational diabetes type 1, pre-gestational diabetes type 2, and gestational diabetes were compared to women without diabetes. Primary outcome was fetal cardiomyopathy. Other etiologies for stillbirth were also evaluated and classified according to the Stillbirth Collaborative Research Network (SCRN) initial causes of fetal death. Fisher exact test, χ2 test, and Mann Whitney U tests were performed as appropriate, with p < .05 considered significant. Generalized linear models were performed for fetal organ weights controlling for gestational age of delivery, maternal chronic hypertension, delivery body mass index, and birthweight. RESULTS: A total of 78 women elected to have fetal autopsy examinations during the study period. Of these, 75 had complete information available for review. A total of 60 women did not have diabetes and 15 women had diabetes. Of pregnancies complicated by diabetes, 11 had insulin dependent diabetes and 4 had non-insulin dependent diabetes. Fetal cardiomyopathy was diagnosed on autopsy for 7 (46.7%) of pregnancies with diabetes and 2 (3.3% of pregnancies without diabetes (RR 14.00 [95% CI 3.23-60.65], p < .001). These associations were still significant even when analyzing only those pregnancies without fetal congenital heart disease (7 [46.7%] diabetic pregnancies with cardiomyopathy versus 1 [2.0%] nondiabetic pregnancy with cardiomyopathy, RR 23.80 [95% CI 3.17-178.46], p < .001). There was no difference between diabetic and non-diabetic pregnancies in regards to other causes for stillbirth. Stillbirths in pregnancies with diabetes also had larger fetal heart, liver, and adrenal weights on fetal autopsy. CONCLUSION: Women with diabetes have 14 times the risk of fetal cardiomyopathy identified at fetal autopsy as compared to women without diabetes. As the prediction and prevention of diabetic stillbirth is limited, information on potential causes of stillbirth may help future research identify those pregnancies at the greatest risk for adverse outcome.

Preterm prelabor rupture of membranes: evaluating latency and neonatal morbidity for pregnancies with expectant management ≥34 weeks.

OBJECTIVE: To evaluate the association between latency and neonatal morbidity for pregnancies with expectant management of PPROM ≥34 w. MATERIALS AND METHODS: A retrospective cohort of singletons with PPROM from 2011 to 2016. Exposure was defined as latency (period from diagnosis of PPROM to delivery) and was analyzed as a count variable (i.e. number of days) and binary variable (≥7 days and <7 days; ≥21 days and <21 days). Primary outcome was composite neonatal morbidity defined as need for respiratory support, culture positive neonatal sepsis, and/or neonatal antibiotics >72 h. Fisher's exact test, chi-square test, Mann-Whitney U and binary logistic regression tests were performed with p<.05 considered significant. RESULTS: Of 813 pregnancies, 104 met inclusion criteria: 73 (70.2%) pregnancies with PPROM diagnosed at <34 weeks and 31 (29.8%) pregnancies with PPROM diagnosed ≥34 weeks. A total of 58 (55.8%) pregnancies had a latency of ≥7 days and 46 (44.2%) had a latency <7 days. There was no difference in composite neonatal morbidity for latency ≥7 d versus <7 d (aOR 0.92; 95% CI 0.30-2.82) or latency as a count variable (aOR 0.70; 95% CI 0.23-2.13). However, a latency ≥21 d was associated with increased composite neonatal morbidity (aOR 10.24, 95% CI 1.42-73.99). CONCLUSION: In pregnancies with PPROM expectantly managed ≥34 w, a latency of ≥7 d is not associated with significant differences in neonatal morbidity. However, different latency thresholds may be more clinically relevant for late preterm pregnancies. The increase in composite neonatal morbidity associated with a latency >21 days should be an area of future investigation and may suggest there is a population of pregnancies with PPROM which may not benefit from expectant management past 34 weeks.

Impact of obesity on blood pressures measured at alternative locations during pregnancy.

BACKGROUND: In patients with obesity, the distribution of subcutaneous tissue can make blood pressure measurement on the standard location of the upper arm difficult. In these cases, alternative locations, such as the lower arm or wrist, are commonly used. It is unknown whether there is a discrepancy in these measurements for pregnant patients at extremes of body mass index. OBJECTIVE: We hypothesized that noninvasive blood pressure measurements on the lower arm and wrist will differ from blood pressure measurements on the upper arm and that this difference will be greater with increasing body mass index. STUDY DESIGN: We conducted a prospective observational study of pregnant patients from July 2020 to August 2020. We collected study subjects' biometric measurements and took 3 blood pressure measurements (systolic and diastolic blood pressures) from the upper arm, lower arm, and wrist. Measurements on the lower arm and wrist were considered alternative locations and compared with measurements on the upper arm. We stratified patients by body mass index. Agreement between locations was assessed using the Bland-Altman analysis. We used linear regression to assess the blood pressure discrepancy dependence on body mass index. RESULTS: We included 100 patients with 20 patients from each body mass index class. Blood pressure measurements at each site correlated but were discrepant. For the lower arm, there was an upward bias of 11.5 mm Hg (limit of agreement, +30.7 to -7.8) for systolic blood pressure and 11.2 mm Hg (limit of agreement, +25.9 to -2.9) for diastolic blood pressure compared with the upper arm. For the wrist, there was an upward bias of 7.1 mm Hg (limit of agreement, +35.1 to -20.9) for systolic blood pressure and 7.3 mm Hg (limit of agreement, +26.2 to -11.7) for diastolic blood pressure compared with the upper arm. Overall, there was a greater discrepancy in blood pressure measurements between the lower and upper arms with increasing body mass index. When comparing blood pressure measurements between the lower and upper arms, the discrepancy increased by 0.43 mm Hg (P<.001) for systolic blood pressure and 0.18 mm Hg (P=.02) for diastolic blood pressure with each increasing body mass index unit. There was no statistically significant change in the discrepancy of systolic (P=.45) or diastolic (P=.86) blood pressure in the upper arm vs the wrist based on body mass index. CONCLUSION: This study highlighted that blood pressure measurements are higher when taken at alternative locations, such as the lower arm and wrist, and that lower arm blood pressure measurements are increasingly discrepant from upper arm blood pressure measurements with increasing body mass index.

Risk factors for needing postpartum antihypertensive medications with hypertensive disorders: Timing of diagnosis, presence of proteinuria, and severity of disease.

OBJECTIVES: Evaluate the association between the need for post-partum antihypertensive medications in patients with hypertensive disorders of pregnancy (HDP) and the following: timing of disease onset (antepartum vs. intrapartum), presence of proteinuria, and severity of disease. STUDY DESIGN: This was a retrospective cohort study. We reviewed the charts of 204 patients diagnosed with HDP: 106 were diagnosed antepartum and 98 diagnosed intrapartum. Patients withchronichypertensionwereexcluded. MAIN OUTCOME MEASURES: The need for outpatient antihypertensive medications at time of hospital discharge was the primary outcome. We performed logistic regression of covariates and a stratified analysis for each specific HDP (gestational hypertension (GHTN), preeclampsia and preeclampsia with severe features). RESULTS: While the diagnosis of HDP in the antepartum period was a statistically significant risk factor for needing postpartum anti-hypertensive medications at discharge in bivariate analysis RR 2.07 (1.27-3.37), p = 0.001, it did not remain significant after correction for the covariates RR 1.41 (0.45-4.49), P = 0.55. However, the presence of proteinuria was an independent risk factor after logistic regression. Compared to GHTN, there was a significant difference in the need for postpartum anti-hypertensive medications in patients with preeclampsia OR 10.70 (1.54-74.42), p = 0.017 and in preeclampsia with severe features OR 112.14 (20.05-627.22), p < 0.001. CONCLUSION: Timing of onset of HDP (antepartum vs. intrapartum) was not an independent risk factor for needing antihypertensive medications postpartum. However, proteinuria and the presence of severe features were. Patients with proteinuria and those with severe disease may warrant closer surveillance in the post-partum period than those without proteinuria.

Second trimester uterocervical angle and spontaneous preterm birth in twins.

Objective: To determine if there is an association between uterocervical angle (UCA) and spontaneous preterm birth (sPTB) < 37 weeks for women with twins.Materials and methods: Retrospective cohort study from 2014 to 2017 of twin pregnancies with cervical length (CL) screening between 15 0/7 and 24 6/7 weeks. Monochorionic-monoamniotic twins were excluded. Post-hoc UCA measurements were analyzed as a continuous variable and a wide UCA was also defined as an angle >95° and >110°. The primary outcome was sPTB < 37 weeks. Secondary outcomes were sPTB <34 weeks, <32 weeks, CL, and performance metrics for UCA. Binary logistic regression controlled for age, tobacco use, prior sPTB, CL, and gestational age at CL measurement.Results: A total of 114 women were studied. The rate of sPTB <37 weeks was 35.0%, <34 weeks was 21.4%, and <32 weeks was 17.1%. As a continuous variable, mean UCA was 117.9° (SD 27.1°) for delivery ≥37 weeks and 133.1° (SD 23.1°) <37 weeks (p = .002). A wider mean UCA was also associated with sPTB <34 weeks (sPTB ≥34 weeks: 120.9° [SD 26.5°] vs. <34 weeks: 133.0° [SD 22.8°], p = .025) and sPTB <32 weeks (sPTB ≥32 weeks: 121.2° [SD 25.9°] vs. <32 weeks: 135.0° [SD 24.0°], p = .018). However, after controlling for age, prior sPTB, tobacco use, CL measurement, and gestational age at CL measurement, UCA was not associated with sPTB <37 weeks, <34 weeks, or <32 weeks. UCA >110° was associated with sPTB <37 weeks after controlling for confounders (aOR 3.6 [95% CI 1.2-10.5], p = 0.02). There was no association between UCA >110° and sPTB <34 or <32 weeks. Furthermore, a UCA >95° was not associated with sPTB <37, <34, or <32 weeks. As a screening tool for sPTB <37 weeks, a UCA of >110° had a sensitivity of 85.7%, specificity of 43.1%, positive predictive value of 53.2%, negative predictive value of 80.0%, positive likelihood ratio of 1.5, and negative likelihood ratio of 0.3.Conclusions: In a cohort of dichorionic-diamniotic and monochroionic-diamniotic twins, UCA >110° was associated with sPTB <37 weeks. However, second trimester UCA had a low positive likelihood ratio and was not a robust marker for the prediction of sPTB in twins.

Impact of Maternal Obesity on Perinatal Outcomes in Preterm Prelabor Rupture of Membranes ≥34 Weeks.

OBJECTIVE: This study aimed to compare pregnancy outcomes in obese and nonobese women with preterm prelabor rupture of membranes (PPROM) ≥34 weeks. STUDY DESIGN: The present study is a secondary analysis of a multicenter retrospective cohort of singletons with PPROM from 2011 to 2017. Women with a delivery body mass index (BMI) ≥30 kg/m2 (obese) were compared with women with a BMI < 30 kg/m2 (nonobese). Pregnancies were stratified based on delivery policies of expectant management until 35 weeks versus immediate delivery ≥34 weeks. The primary outcome was a composite neonatal outcome (neonatal sepsis, antibiotic administration for duration >72 hours after delivery or respiratory support). Univariate analysis and general estimating equations models including maternal age, delivery timing, mode of delivery, hospital, and gestational age were used with p < 0.05 level of significance. RESULTS: Among 259 pregnancies, 47% were obese. Pregnant women with obesity had increased composite neonatal outcome versus nonobese pregnancies (adjusted odds ratio [aOR] = 1.48 [95% confidence interval (CI): 1.01-2.17]). Obesity was also associated with increased neonatal antibiotic administration for a duration >72 hours after delivery, respiratory support, ventilation, oxygen supplementation, and surfactant administration. When stratified by delivery policies there was no significant difference in perinatal outcomes based on obesity. CONCLUSION: Obese women with PPROM ≥34 weeks have an increased odds of adverse neonatal respiratory and infectious outcomes compared with nonobese women.

Temporal Themes in Periviable Birth: A Qualitative Analysis of Patient Experiences.

Objective Periviable birth accounts for a very small percentage of preterm deliveries but a large proportion of perinatal and neonatal morbidity. Understanding parental experiences during and after periviable deliveries may help healthcare providers determine how to best support women during these medically complex, emotionally charged clinical encounters. Methods This is a qualitative study with a voluntary sample of women who delivered between 22 and 25 weeks gestation at an academic medical center from 2014 to 2016. Women's narratives of each periviable birth experience were transcribed and analyzed using consensus coding and a grounded theory approach to identify key themes that describe parental experiences. Results A total of 10 women were interviewed. Four emergent temporal themes: (1) the time preceding admission: feeling dismissed; (2) transfer or admission to a tertiary care center: anxiety and doubt; (3) the birth itself: fear of the outcome; and (4) the postpartum period: reflection and communication. Conclusions for practice Women that experience a periviable birth may benefit from continuous support and clear communication. Overall, care for these patients should be expanded to address the specific psychosocial needs identified during the distinctive, periviable temporal themes that emerged during interviews. Continuous longitudinal support in the form of a designated person or team should be provided to women experiencing a potential periviable birth in order to help mitigate the fear and anxiety associated with these complex birth experiences.

Prenatal Prediction of Difficult Intubation in Periviable Neonates Using Standard Fetal Biometric Parameters.

OBJECTIVE: To assess whether standard fetal biometric parameters can be used to predict difficult intubations in periviable neonates undergoing resuscitation. STUDY DESIGN: This is a retrospective case-control study of periviable neonates delivered at 23 to 256/7 weeks at an academic hospital during a 5-year period in whom intubation was attempted. Standard fetal biometric measurements were included if they were taken within 7 days of delivery. Primary outcome was intubation in one attempt and was compared with more than one attempt. Data were also collected for fetal gestational age at delivery, neonatal birth weight, estimated fetal weight, head circumference, biparietal diameter, and abdominal circumference. Parametric and nonparametric statistical tests used p < 0.05 as significant. RESULTS: In total, 93 neonates met the inclusion criteria. The mean estimated fetal weight was 675 g (standard deviation [SD] ± 140), and the mean neonatal birth weight was 706 g (SD ± 151). The median interval between fetal ultrasound and delivery was 3 days (range: 0-7 days). A total of 45 neonates (48.3%) required more than one intubation attempt. The median number of intubation attempts was 1 (range: 1-10). There was no association between intubation difficulty and fetal abdominal circumference, biparietal diameter, head circumference, gestational age, estimated fetal weight, and neonatal birth weight (all p > 0.05). CONCLUSION: Standard biometry in periviable neonates does not predict intubation difficulty.

Preterm Prelabor Rupture of Membranes: Outcomes with Expectant Management until 34 versus 35 Weeks.

OBJECTIVE: To evaluate outcomes with expectant management of preterm prelabor rupture of membranes (PROM) until 35 weeks versus immediate delivery at ≥34 weeks. STUDY DESIGN: This was a multicenter retrospective cohort study of singletons with preterm PROM at >20 weeks from 2011 through 2017. Groups were defined as expectant management until 35 weeks versus immediate delivery at ≥34 weeks. Primary outcome was composite neonatal morbidity: need for respiratory support, culture positive neonatal sepsis, or antibiotic administration for >72 hours. Univariate and general estimating equation models were used with p < 0.05 considered significant. RESULTS: A total of 280 mother-infant dyads were included. There was no difference in composite neonatal outcome in pregnancies managed with expectant management compared with immediate delivery (43.4 vs. 37.5%; p = 0.32). Those with expectant management had shorter length of neonatal intensive care unit (NICU) admission but higher rates of neonatal antibiotics for > 72 hours, endometritis, and histological chorioamnionitis. There were no cases of fetal demise, neonatal death, or maternal sepsis, and only three cases of neonatal sepsis. CONCLUSION: There is no difference in composite neonatal morbidity in pregnancies with preterm PROM managed with expectant management until 35 weeks as compared with immediate delivery at 34 weeks. Expectant management is associated with a decreased length of NICU admission but increased short-term infectious morbidity.

Alcoholic Pancreatitis Masquerading as Preeclampsia.

BACKGROUND: Coexisting medical complications in pregnancy can present in a fashion similar to preeclampsia and can be challenging to differentiate. CASE: We present a patient who, at 27 3/7 weeks of gestation, fulfilled diagnostic criteria for severe preeclampsia, including hypertension, proteinuria, headache, abnormal serum creatinine levels, thrombocytopenia, and liver function abnormalities, but who nevertheless did not have preeclampsia. Instead, she was diagnosed with alcoholic pancreatitis based on a history of heavy alcohol use and elevated amylase and lipase. Abnormal laboratory values resolved with supportive therapy, and she continued to term without subsequent recurrence of proteinuria or hypertension. CONCLUSION: Alcoholic pancreatitis can be mistaken for preeclampsia.

HOXA11 promotes fibroblast proliferation and regulates p53 in uterosacral ligaments.

The uterosacral ligaments (USLs) are key support structures of the uterus and upper vagina. Previously, we have shown that HOXA11 is necessary for the development of the USLs, is deficient in women with pelvic organ prolapse (POP) and regulates expression of extracellular matrix (ECM) proteins. Here we sought to determine if HOXA11 regulates cell proliferation in the USLs in women. Like others, we have found that, there is decreased cellularity in prolapsed USLs compared to USLs in women with normal pelvic support. We have also demonstrated that HOXA11 promotes cell proliferation in murine fibroblasts and primary human USL cells in vitro. These findings support a relationship between HOXA11 expression, rates of proliferation and phenotypic abnormalities in the USL. Based on these findings, we sought to determine if HOXA11 regulates p53, a tumor suppressor gene which controls progression through the cell cycle and regulates ECM genes. We have demonstrated that expression of HOXA11 represses expression of p53, suggesting a mechanism by which HOXA11 regulates of the morphology and integrity of the USLs. A better understanding of the influence of these genes on the homeostasis of the ECM and interactions with each other may prove beneficial in defining the underlying etiologies of the development of POP and aid in the development of new treatment options for women with this disorder.