Regional Differences in the US in Outcomes with Preeclampsia.

This study explores preeclampsia outcomes across US regions and examines regional differences in specific preeclampsia-associated pregnancy complications and disease management. Patient-reported measures were obtained from The Preeclampsia Registry, an open-access database composed of women with at least one pregnancy diagnosed with a hypertensive disorder of pregnancy. Pregnancies and associated outcomes were stratified by US region (Northeast, Midwest, South and West). Among 2,667 pregnancies of which 92% were in White women, maximum systolic blood pressure at any time in pregnancy was highest among women in the South and Midwest (p=0.039). Furthermore, more women in the South received pre-pregnancy antihypertensives (p=0.026) and antenatal steroids (p=0.025) and delivered at an earlier gestational age (p=0.014) compared to women in other regions. Pregnancy complications such as elevated liver enzymes were higher in women in the South (p=0.019), and women in the South and West had additional end-organ damage such as renal complications (p<0.001) and hemolysis (p=0.008) as compared to women in other regions. Further investigation is needed to assess whether healthcare access or policy could be contributing to these regional discrepancies.

Variation and correlates of psychosocial wellbeing among nulliparous women with preeclampsia.

OBJECTIVES: To identify classes of psychosocial stressors among women who developed preeclampsia and to evaluate the associations between these classes and correlates of psychosocial wellbeing. STUDY DESIGN: We performed a secondary analysis of women who developed preeclampsia (n = 727) from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort (2010-2013). Latent class analysis was used to identify classes of social stressors based on seven psychological and sociocultural indicators. Associations between latent classes and correlates (demographics, health behavior, and health-systems level) were estimated using multinomial logistic regression. MAIN OUTCOME MEASURES: Classes of psychosocial wellbeing. RESULTS: Among women who developed preeclampsia, three classes reflective of psychosocial wellbeing were identified: Class 1: Intermediate Psychosocial Wellbeing (53 %), Class 2: Positive Psychosocial Wellbeing (31 %), Class 3: Negative Psychosocial Wellbeing (16 %). Women in the Negative Psychosocial Wellbeing Class were more likely to have poor sleep and a sedentary lifestyle compared with the Positive and Intermediate Psychosocial Wellbeing Classes. Both the Negative and Intermediate Psychosocial Wellbeing Classes reported concern about their quality of medical care compared with the Positive Psychosocial Wellbeing Class (adjusted odds ratio [aOR]: 6.19, 95 % confidence interval [CI]: 3.37, 11.36 and aOR: 2.19, 95 % CI: 1.31, 3.65, respectively). CONCLUSIONS: Women who develop preeclampsia are heterogenous and experience different intensities of internal and external stressors. Understanding the linkages between psychosocial wellbeing during pregnancy and modifiable behavioral and structural factors may inform future tailored management strategies for preeclampsia and the optimization of maternal postpartum health.

CT angiography for characterization of advanced placenta accreta spectrum: indications, risks, and benefits.

Placenta accreta spectrum disorder (PASD) encompasses various types of abnormal placentation in which chorionic villi directly adhere to or invade the myometrium. The incidence of PASD has dramatically risen in the US over the past 3 decades owing to the increased rates of patients undergoing cesarean sections. While PASD remains a significant cause of maternal morbidity and mortality, accurate prenatal identification and characterization of PASD is associated with improved outcomes. Although ultrasound is the first-line imaging modality in the evaluation of PASD, with MRI serving as an adjunct, computed tomography angiography (CTA) may also offer unique diagnostic advantages in cases of advanced PASD by providing superior visualization of placental and abdominopelvic vasculature and enabling the creation of comprehensive vascular maps to roadmap complex surgical interventions. This paper represents the first evaluation of CTA as a diagnostic tool and operative planning aid in this context. Appropriate indications and diagnostic advantages of CTA in this setting are reviewed, and key multimodal imaging features of normal and abnormal placentation are highlighted.

Heart Team Approach for Cardiogenic Shock Management in Pregnancy Complicated by Mechanical Mitral Valve Thrombosis.

A 27-year-old pregnant woman at 24 weeks of gestation was admitted with cardiogenic shock due to mechanical mitral valve thrombosis. Following discussion with the heart team, thrombolysis was achieved with tissue plasminogen activator therapy followed by heparin infusion. Ultimately, the patient required mitral valve replacement for persistently elevated gradients.

Psychosocial Stressors as a Determinant of Maternal Cardiovascular Health During Pregnancy.

Maternal psychosocial stress may be a risk factor for poor cardiovascular health (CVH) during pregnancy. We aimed to identify classes of psychosocial stressors in pregnant women and to evaluate their cross-sectional association with CVH. We performed a secondary analysis of women from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort (2010 to 2013). Latent class analysis was used to identify distinct classes of exposure to psychosocial stressors based on psychological (stress, anxiety, resilience, depression) and sociocultural indicators (social support, economic stress, discrimination). Optimal and suboptimal CVH was defined based on the presence of 0 to 1 and ≥2 risk factors (hypertension, diabetes mellitus, smoking, obesity, inadequate physical activity), respectively based on the American Heart Association Life's Essential 8. We used logistic regression to evaluate the association between psychosocial classes and CVH. We included 8,491 women and identified 5 classes reflective of gradations of psychosocial stress. In unadjusted models, women in the most disadvantaged psychosocial stressor class were approximately 3 times more likely to have suboptimal CVH than those in the most advantaged class (odds ratio 2.98, 95% confidence interval: 2.54 to 3.51). Adjusting for demographics minimally attenuated the risk (adjusted odds ratio 2.09, 95% confidence interval: 1.76 to 2.48). We observed variation across psychosocial stressor landscapes in women in the nuMoM2b cohort. Women in the most disadvantaged psychosocial class had a greater risk of suboptimal CVH which was only partially explained by differences in demographic characteristics. In conclusion, our findings highlight the association of maternal psychosocial stressors with CVH during pregnancy.

Racial disparities in care escalation for postpartum hemorrhage requiring transfusion.

BACKGROUND: Postpartum hemorrhage is a leading cause of maternal morbidity and mortality in the United States and disproportionately affects pregnant persons of color. OBJECTIVE: This study aimed to identify the demographic and obstetrical characteristics of those who received different levels of antihemorrhagic intervention in the setting of severe postpartum hemorrhage requiring blood transfusion. STUDY DESIGN: This was a retrospective cohort study of patients with documented postpartum hemorrhage (estimated blood loss of ≥1000 mL) and blood product transfusion. Moreover, 3 levels of antihemorrhagic intervention were defined as follows: level 1, administration of uterotonics only; level 2, performance of a procedure (ie, B-Lynch suture, O'Leary stitch, Bakri balloon, dilation and curettage, laceration repair, or embolization); and level 3, hysterectomy. Maternal demographics, obstetrical characteristics, and comorbidities were extracted from electronic health records. Ordinal logistic regression was used to estimate the odds of higher intervention levels adjusting for maternal demographic and obstetrical characteristics. RESULTS: Of note, 365 patients were included in this study, with a racial or ethnic composition of 30% White, 42% Black, 18% Hispanic, and 10% other. Moreover, 233 patients (64%) received level 1 intervention, 98 patients (27%) received level 2 intervention, and 34 patients (9%) received level 3 intervention. Patients receiving higher levels of intervention were more likely to have greater estimated blood loss (P<.001), have more transfusions (P<.001), and be of advanced maternal age (P=.004). Black and Hispanic patients were less likely to have received higher levels of intervention than White patients (P=.034). After adjusting for estimated blood loss, advanced maternal age, placenta accreta spectrum, and fibroids, Black patients remained significantly less likely to receive higher levels of intervention (adjusted odds ratio, 0.55; 95% confidence interval, 0.30-0.98). This difference persisted at an estimated blood loss of ≥3000 mL, with Black and Hispanic patients being significantly less likely to receive higher levels of intervention than White patients (odds ratio, 0.31 [95% confidence interval, 0.10-0.92] and 0.10 [95% confidence interval, 0.01-0.53], respectively). CONCLUSION: Among patients experiencing postpartum hemorrhage and receiving transfusion, Black patients are less likely to receive higher levels of antihemorrhagic intervention. This disparity is concerning in this high-risk population and requires further attention and investigation.

Persistent hypertension at 3 months postpartum among women with hypertensive disorders of pregnancy at a tertiary hospital in Southwestern Uganda.

BACKGROUND: Hypertension is a key contributor to the global epidemic of cardiovascular disease and is responsible for more deaths worldwide than any other cardiovascular risk factor. Hypertensive disorders of pregnancy, of which preeclampsia and eclampsia are the most common forms, have been shown to be a female-specific risk factor for chronic hypertension. OBJECTIVE: This study aimed to determine the proportion and risk factors for persistent hypertension at 3 months after delivery among women with hypertensive disorders of pregnancy in Southwestern Uganda. STUDY DESIGN: This was a prospective cohort study of pregnant women with hypertensive disorders of pregnancy admitted for delivery at Mbarara Regional Referral Hospital in Southwestern Uganda from January 2019 to December 2019; however, women with chronic hypertension were excluded from the study. The participants were followed up for 3 months after delivery. Participants with a systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg or receiving antihypertension therapy at 3 months after delivery were considered to have persistent hypertension. Multivariable logistic regression was used to determine independent risk factors associated with persistent hypertension. RESULTS: A total of 111 participants with hypertensive disorders of pregnancy diagnosed at hospital admission were enrolled with a follow-up rate of 49% (54/111) at 3 months after delivery. Of these women, 21 of 54 (39%) had persistent hypertension 3 months after delivery. In the adjusted analyses, an elevated serum creatinine level (>106.08 µmol/L [≤1.2 mg/dL]) at admission for delivery was the only independent risk factor for persistent hypertension at 3 months after delivery (adjusted relative risk, 1.93; 95% confidence interval, 1.08-3.46; P=.03), controlling for age, gravidity, and eclampsia. CONCLUSION: Approximately 4 of 10 women presenting with hypertensive disorders of pregnancy at our institution remained hypertensive 3 months after delivery. Innovative strategies are needed to identify these women and provide long-term care to optimize blood pressure control and reduce future cardiovascular disease after hypertensive disorders of pregnancy.

Hypertensive Disorders of Pregnancy and the Cardiovascular System: Causes, Consequences, Therapy, and Prevention.

Hypertensive disorders of pregnancy continue to be significant contributors to adverse perinatal outcome and maternal mortality, as well as inducing life-long cardiovascular health impacts that are proportional to the severity and frequency of pregnancy complications. The placenta is the interface between the mother and fetus and its failure to undergo vascular maturation in tandem with maternal cardiovascular adaptation by the end of the first trimester predisposes to hypertensive disorders and fetal growth restriction. While primary failure of trophoblastic invasion with incomplete maternal spiral artery remodeling has been considered central to the pathogenesis of preeclampsia, cardiovascular risk factors associated with abnormal first trimester maternal blood pressure and cardiovascular adaptation produce identical placental pathology leading to hypertensive pregnancy disorders. Outside pregnancy blood pressure treatment thresholds are identified with the goal to prevent immediate risks from severe hypertension >160/100 mm Hg and long-term health impacts that arise from elevated blood pressures as low as 120/80 mm Hg. Until recently, the trend for less aggressive blood pressure management during pregnancy was driven by fear of inducing placental malperfusion without a clear clinical benefit. However, placental perfusion is not dependent on maternal perfusion pressure during the first trimester and risk-appropriate blood pressure normalization may provide the opportunity to protect from the placental maldevelopment that predisposes to hypertensive disorders of pregnancy. Recent randomized trials set the stage for more aggressive risk-appropriate blood pressure management that may offer a greater potential for prevention for hypertensive disorders of pregnancy. KEY POINTS: · Optimal management of maternal blood pressure to prevent preeclampsia and its risks is undefined.. · Early gestational rheological damage to the intervillous space predisposes to preeclampsia and FGR.. · First trimester blood pressure management may need to aim for normotension to prevent preeclampsia..

Mode of delivery among women with maternal cardiac disease.

OBJECTIVE: To determine if maternal cardiac disease affects delivery mode and to investigate maternal morbidity. STUDY DESIGN: Retrospective cohort study performed using electronic medical record data. Primary outcome was mode of delivery; secondary outcomes included indication for cesarean delivery, and rates of severe maternal morbidity. RESULTS: Among 14,160 deliveries meeting inclusion criteria, 218 (1.5%) had maternal cardiac disease. Cesarean delivery was more common in women with maternal cardiac disease (adjusted odds ratio 1.63 [95% confidence interval 1.18-2.25]). Patients delivered by cesarean delivery in the setting of maternal cardiac disease had significantly higher rates of severe maternal morbidity, with a 24.38-fold higher adjusted odds of severe maternal morbidity (95% confidence interval: 10.56-54.3). CONCLUSION: While maternal cardiac disease was associated with increased risk of cesarean delivery, most were for obstetric indications. Additionally, cesarean delivery in the setting of maternal cardiac disease is associated with high rates of severe maternal morbidity.

Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association.

The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

Pregnancy-Associated Extracorporeal Membrane Oxygenation in the United States.

OBJECTIVE: The use of extracorporeal membrane oxygenation (ECMO) therapy has increased in the adult population. Studies from the H1N1 influenza pandemic suggest that ECMO deployment in pregnancy is associated with favorable outcomes. With increasing numbers of pregnant women affected by COVID-19 (coronavirus disease 2019) and potentially requiring this life-saving therapy, we sought to compare comorbidities, costs, and outcomes between pregnancy- and nonpregnancy-associated ECMO therapy among reproductive-aged female patients. STUDY DESIGN: We used the 2013 to 2019 National Readmissions Database. Diagnosis and procedural coding were used to identify ECMO deployment, potential indications, comorbid conditions, and pregnancy outcomes. The primary outcome was in-hospital mortality during the patient's initial ECMO stay. Secondary outcomes included length of stay and hospital charges/costs, occurrence of thromboembolic or bleeding complications during ECMO hospitalization, and mortality and readmissions up to 330 days following ECMO stay. Univariate and multivariate regression models were used to model the associations between pregnancy status and outcomes. RESULTS: The sample included 324 pregnancy-associated hospitalizations and 3,805 nonpregnancy-associated hospitalizations, corresponding to national estimates of 665 and 7,653 over the study period, respectively. Pregnancy-associated ECMO had lower incidence of in-hospital death (adjusted odds ratio [aOR]: 0.56, 95% confidence interval [CI]: 0.41-0.75) and bleeding complications (aOR: 0.67, 95% CI: 0.49-0.93). Length of stay was significantly shorter (adjusted rate ratio (aRR): 0.86, 95% CI: 0.77-0.96) and total hospital costs were less (aRR: 0.83, 95% CI: 0.75-0.93). Differences in the incidence of thromboembolic events (aOR: 1.04, 95% CI: 0.78-1.38) were not statistically significant. CONCLUSION: Pregnancy-associated ECMO therapy had lower incidence of in-hospital death, bleeding complications, total inpatient cost, and length of stay when compared with nonpregnancy-associated ECMO therapy without increased thromboembolic complications. Pregnancy-associated ECMO therapy should be offered to eligible patients. KEY POINTS: · Pregnancy-related ECMO use was compared with nonpregnant use.. · Outcomes were equal or favored pregnancy-related deployment.. · These data may be useful when considering ECMO use in pregnancy..

Temporal trends of arrhythmias at delivery hospitalizations in the United States: Analysis from the National Inpatient Sample, 2009-2019.

Background: Cardiac arrhythmias are associated with increased maternal morbidity. There are limited data on trends of arrhythmias among women hospitalized for delivery. Materials and methods: We used the National Inpatient Sample (NIS) database to identify delivery hospitalizations for individuals aged 18-49 years between 2009 to 2019 and utilized coding data from the 9th and 10th editions of the International Classification of Diseases to identify supraventricular tachycardias (SVT), atrial fibrillation (AF), atrial flutter, ventricular tachycardia (VT), and ventricular fibrillation (VF). Arrhythmia trends were analyzed by age, race-ethnicity, hospital setting, and hospital geographic regions. Multivariable logistic regression was used to evaluate the association of demographic, clinical, and socioeconomic characteristics with arrhythmias. Results: Among 41,576,442 delivery hospitalizations, the most common arrhythmia was SVT (53%), followed by AF (31%) and VT (13%). The prevalence of arrhythmia among delivery hospitalizations increased between 2009 and 2019. Age > 35 years and Black race were associated with a higher arrhythmia burden. Factors associated with an increased risk of arrhythmias included valvular disease (OR: 12.77; 95% C1:1.98-13.61), heart failure (OR:7.13; 95% CI: 6.49-7.83), prior myocardial infarction (OR: 5.41, 95% CI: 4.01-7.30), peripheral vascular disease (OR: 3.19, 95% CI: 2.51-4.06), hypertension (OR: 2.18; 95% CI: 2.07-2.28), and obesity (OR 1.69; 95% CI: 1.63-1.76). Delivery hospitalizations complicated by arrhythmias compared with those with no arrhythmias had a higher proportion of all-cause in-hospital mortality (0.95% vs. 0.01%), cardiogenic shock (0.48% vs. 0.00%), preeclampsia (6.96% vs. 3.58%), and preterm labor (2.95% vs. 2.41%) (all p < 0.0001). Conclusion: Pregnant individuals with age > 35 years, obesity, hypertension, valvular heart disease, or severe pulmonary disease are more likely to have an arrhythmia history or an arrhythmia during a delivery hospitalization. Delivery hospitalizations with a history of arrhythmia are more likely to be complicated by all-cause in-hospital mortality, cardiovascular, and adverse pregnancy outcomes (APOs). These data highlight the increased risk associated with pregnancies among individuals with arrhythmias.

Severe ovarian hyperstimulation syndrome requiring recurrent large-volume paracenteses until 21 weeks' gestation: a case report.

Objective: To report a case of severe ovarian hyperstimulation syndrome (OHSS) persisting into the late second trimester of a singleton pregnancy. Design: Case report. Setting: Academic tertiary care center. Patients: A 29-year-old woman with severe OHSS after fresh embryo transfer after controlled ovarian hyperstimulation requiring intervention until 21 weeks' gestation in a singleton pregnancy. Interventions: Thorough evaluation of an unusual case of severe OHSS and medical/procedural management of its sequelae in the setting of ongoing pregnancy. Main Outcome Measuress: The clinical development of severe OHSS during pregnancy and its effect on pregnancy outcomes. Results: Severe OHSS persisted until 21 weeks' gestation with reaccumulating ascitic fluid, which impacted pregnancy outcomes. Conclusions: Clinicians should be aware of the risk of severe OHSS and its possible effect on pregnancy outcomes beyond the first trimester.

Differences in Surgery Classification and Indications for Peripartum Hysterectomy at a Major Academic Institution.

OBJECTIVE: Peripartum hysterectomy is associated with increased morbidity and mortality relative to elective gynecologic hysterectomy and its incidence has grown with the rising cesarean delivery rate. We sought to understand indications and perioperative outcomes for peripartum hysterectomy at our academic institution and to evaluate differences among racial/ethnic groups. STUDY DESIGN: We performed a retrospective chart review of women at a tertiary care center who underwent delivery of a newborn and had a peripartum hysterectomy during the same admission between 2008 and 2018. Demographic, clinical, and socioeconomic characteristics of patients were compared with respect to patient's race/ethnic group. RESULTS: A total of 112 hysterectomies were included in our study. White women undergoing peripartum hysterectomy were more likely to have had an elective/anticipated peripartum hysterectomy (vs. a nonelective/emergent peripartum hysterectomy) than Black women. There were racial differences detected in the indication for peripartum hysterectomy; White women were more likely to have abnormal placentation (75 vs. 54% in Black women, p = 0.036), whereas Black women were more likely to present with postpartum hemorrhage (27 vs. 2%, p = 0.002). Black women were also more likely to undergo reoperation after peripartum hysterectomy (15 vs. 2% in White women, p = 0.048). There were no differences in any other perioperative outcomes including blood transfusion, accidental laceration, and 30-day readmission. CONCLUSION: Differences exist among elective versus nonelective peripartum hysterectomy by race/ethnicity and in indications for peripartum hysterectomy by race/ethnicity. Further investigation should be performed to determine whether the differences identified are due to disparate management of atony/postpartum hemorrhage or inequitable referral patterns for suspected abnormal placentation by race/ethnicity. KEY POINTS: · White patients were more likely to have an elective hysterectomy when compared with Black women.. · Abnormal placentation was the indication more often for White patients; hemorrhage for Black ones.. · Black patients were likely to be nulliparous or at greater gestational age at the time of hysterectomy..

Pregnancy Considerations in the Multidisciplinary Care of Patients with Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension (PAH) is a vasoconstrictive disease of the distal pulmonary vasculature resulting in adverse right heart remodeling. Pregnancy in PAH patients is associated with high maternal morbidity and mortality as well as neonatal and fetal complications. Pregnancy-associated changes in the cardiovascular, pulmonary, hormonal, and thrombotic systems challenge the complex PAH physiology. Due to the high risks, patients with PAH are currently counseled against pregnancy based on international consensus guidelines, but there are promising signs of improving outcomes, particularly for patients with mild disease. For patients who become pregnant, multidisciplinary care at a PAH specialist center is needed for peripartum monitoring, medication management, delivery, postpartum care, and complication management. Patients with PAH also require disease-specific counseling on contraception and breastfeeding. In this review, we detail the considerations for reproductive planning, pregnancy, and delivery for the multidisciplinary care of a patient with PAH.

Racial Differences in Delivery Outcomes Among Women With Peripartum Cardiomyopathy.

Background: Peripartum cardiomyopathy (PPCM) is a rare idiopathic cardiomyopathy associated with pregnancy that occurs more frequently among Black women. However, less is known about the association of race/ethnicity with outcomes at the time of delivery in women with PPCM. Methods: We used data from the 2016-2018 National Inpatient Sample (NIS) database to identify women with a diagnosis of PPCM based on International Classification of Diseases, 10th revision (ICD-10) codes. Using adjusted logistic regression, the association of race with PPCM and adverse cardiovascular (CV) outcomes with PPCM was evaluated across racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander). Results: Among 11,304,996 delivery hospitalizations, PPCM was present in 8735 (0.08%). After adjusting for CV risk factors (chronic hypertension, diabetes, and obesity) and socioeconomic factors (insurance status, hospital income, and residential income), Black and Native American women had greater adjusted odds of developing PPCM (adjusted odds ratio [aOR] 1.89; 95% confidence interval [CI] 1.66-2.15; aOR 1.60; 95% CI 1.02-2.50, respectively), compared with White women. In stratified analysis of CV events, however, Asian/Pacific Islander women with PPCM were the most likely to have CV complications (aOR 98; 95% CI 29-333 for pulmonary edema). Conclusions: In the US, at the time of delivery hospitalization, Black and Native American women are the most likely to develop PPCM, despite adjustment for CV and socioeconomic risk factors, but Asian women have higher odds of having CV complications.

Introduction: La cardiomyopathie du péripartum (CMPP) est une rare cardiomyopathie idiopathique associée à la grossesse qui apparaît plus fréquemment chez les femmes noires. Toutefois, on en connaît peu sur l'association entre la race/l'origine ethnique et les issues au moment de l'accouchement chez les femmes atteintes d'une CMPP. Méthodes: Nous avons utilisé les données de la base de données de l'échantillon national des données de patients hospitalisés (NIS, de l'anglais National Inpatient Sample) de 2016-2018 pour trouver les femmes qui avaient un diagnostic de CMPP selon les codes de la Classification internationale des maladies, 10e révision (CIM-10). À l'aide de la régression logistique ajustée, nous avons évalué l'association de la race à la CMPP et les événements cardiovasculaires (CV) indésirables entre les groupes raciaux/ethniques (Blanches, Noires, Hispaniques, Asiatiques/îliennes du Pacifique). Résultats: Parmi les 11 304 996 hospitalisations liées à l'accouchement, on a noté la présence de la CMPP 8 735 (0,08 %) fois. Après l'ajustement des facteurs de risque CV (hypertension chronique, diabète et obésité) et des facteurs socioéconomiques (statut en matière d'assurances, indemnités journalières en cas d'hospitalisation et revenu familial), le risque relatif ajusté (RRa) des femmes noires et autochtones de manifester une CMPP était plus élevé (RRa 1,89; intervalle de confiance [IC] à 95 % 1,66-2,15; RRa 1,60; IC à 95 % 1,02-2,50, respectivement) que les femmes blanches. Toutefois, dans l'analyse stratifiée des événements CV, les femmes asiatiques et des îles du Pacifique qui avaient une CMPP étaient plus susceptibles d'avoir des complications CV (RRa 98; IC à 95 % 29-333 pour l'œdème pulmonaire). Conclusions: Aux É.-U., lors des hospitalisations liées à l'accouchement, les femmes noires et autochtones sont les plus susceptibles de manifester une CMPP, en dépit de l'ajustement des facteurs de risque CV et des facteurs socioéconomiques, mais les femmes asiatiques ont un risque plus élevé d'avoir des complications CV.

The Association of Preterm Birth With Maternal Nativity and Length of Residence Among Non-Hispanic Black Women.

Background: Preterm birth (PTB) is associated with future cardiovascular disease (CVD) risk and disproportionally affects non-Hispanic Black (NHB) women. Limited data exist on the influence of length of US residence on nativity-related disparities in PTB. We examined PTB by maternal nativity (US born vs foreign born) and length of US residence among NHB women. Methods: We analyzed data from 2699 NHB women (1607 US born; 1092 foreign born) in the Boston Birth Cohort, originally designed as a case-control study. Using multivariable logistic regression, we investigated the association of PTB with maternal nativity and length of US residence. Results: In the total sample, 29.1% of women delivered preterm (31.4% and 25.6% among US born and foreign born, respectively). Compared with foreign born, US-born women were younger (25.8 vs 29.5 years), had higher prevalence of obesity (27.6% vs 19.6%), smoking (20.5% vs 4.9%), alcohol use (13.2% vs 7.4%), and moderate to severe stress (73.5% vs 59.4%) (all P < 0.001). Compared with US-born women, foreign-born women had lower odds of PTB after adjusting for sociodemographic characteristics, alcohol use, stress, parity, smoking, body mass index, chronic hypertension, and diabetes (adjusted odds ratio [aOR], 0.79; 95% confidence interval [CI], 0.65-0.97). Foreign-born NHB women with < 10 years of US residence had 43% lower odds of PTB compared with US-born (aOR, 0.57; 95% CI, 0.43-0.75), whereas those with ≥ 10 years of US residence did not differ significantly from US-born women in their odds of PTB (aOR, 0.76; 95% CI, 0.54-1.07). Conclusions: The prevalence of CVD risk factors and proportion of women delivering preterm were lower in foreign-born than US-born NHB women. The "foreign-born advantage" was not observed with ≥ 10 years of US residence. Our study highlights the need to intensify public health efforts in exploring and addressing nativity-related disparities in PTB.

Introduction: L'accouchement avant terme (AAT) est associé à un risque futur de maladie cardiovasculaire (MCV) et touche disproportionnellement les femmes noires non hispaniques (NNH). Les données sur l'influence de la durée de résidence aux É.-U. sur les disparités de l'AAT liées au lieu de naissance sont limitées. Nous avons examiné l'AAT en fonction du lieu de naissance de la mère (née aux É.-U. vs née à l'étranger) et la durée de résidence aux É.-U. chez les femmes NNH. Méthodes: Nous avons analysé les données de 2 699 femmes NNH (1 607 nées aux É.-U.; 1 092 nées à l'étranger) de la Boston Birth Cohort, conçue à l'origine comme une étude cas-témoins. À l'aide de la régression logistique multivariée, nous avons examiné l'association de l'AAT au lieu de naissance de la mère et à la durée de résidence aux É.-U. Résultats: Dans l'échantillon total, 29,1 % des femmes qui avaient accouché avant terme (soit 31,4 % des femmes nées aux É.-U. et 25,6 % des femmes nées à l'étranger). Comparativement aux femmes nées à l'étranger, les femmes nées aux É.-U. étaient plus jeunes (25,8 vs 29,5 ans), montraient une prévalence plus élevée d'obésité (27,6 % vs 19,6 %), du tabagisme (20,5 % vs 4,9 %), de la consommation d'alcool (13,2 % vs 7,4 %) et de stress modéré à important (73,5 % vs 59,4 %) (toutes les valeurs P < 0,001). Comparativement aux femmes nées aux É.-U., les femmes nées à l'étranger avaient un risque inférieur d'AAT après l'ajustement des caractéristiques sociodémographiques, de la consommation d'alcool, du stress, de la parité, du tabagisme, de l'indice de masse corporelle, de l'hypertension chronique et du diabète (ratio d'incidence approché ajusté [RIAa], 0,79; intervalle de confiance [IC] à 95 %, 0,65-0,97). Les femmes NNH nées à l'étranger de < 10 ans de résidence aux É.-U. avaient une probabilité 43 % plus faible d'AAT que les femmes nées aux É.-U. (RIAa, 0,57; IC à 95 %, 0,43-0,75), tandis que les femmes de ≥ 10 ans de résidence aux É.-U. ne montraient pas de différence significative dans leur probabilité d'AAT par rapport aux femmes nées aux É.-U. (RIAa, 0,76; IC à 95 %, 0,54-1,07). Conclusions: La prévalence des facteurs de risque de MCV et la proportion de femmes qui accouchent avant terme étaient plus faibles chez les femmes NNH nées à l'étranger que chez les femmes NNH nées aux É.-U. L'« avantage d'être nées à l'étranger ¼ n'était pas observé lors de ≥ 10 ans de résidence aux É.-U. Notre étude illustre la nécessité d'intensifier les efforts de santé publique pour explorer et remédier aux disparités liées au lieu de naissance dans l'AAT.

Inpatient Management and OBICU Care for Pregnant Patients With Severe COVID-19 Disease.

This manuscript will review intensive care management considerations for pregnant patients with severe COVID-19 disease.

A review of the alternative pathway of complement and its relation to HELLP syndrome: is it time to consider HELLP syndrome a disease of the alternative pathway.

Complement is a part of the innate immune system with a critical role in host defense. Although essential for survival, when dysregulated or excessively triggered complement activation can cause tissue damage and drive inflammatory and immune disorders. The alternative pathway of complement (APC) is especially important for survival against infection and can be triggered by a variety of settings: infection, trauma, surgery, or pregnancy. This excessive drive of complement manifest distinctive hemolytic diseases like atypical hemolytic uremic syndrome (aHUS) and paroxysmal nocturnal hemoglobinuria (PNH). These diseases share phenotypic similarities to HELLP syndrome: a hypertensive disorder of pregnancy with hemolysis, elevated liver enzymes, and low platelets. In this manuscript, there will be a brief review of complement activation and a description of important regulator proteins. The review will further discuss pregnancy as a major trigger of the alternative pathway, and how diseases of the APC are treated during pregnancy. Finally, the similarities between HELLP syndrome and diseases of the APC will be examined.

Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy Outcomes: A Review.

IMPORTANCE: A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs. OBSERVATIONS: A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians. CONCLUSIONS AND RELEVANCE: These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.