Association between gestational diabetes and cardiovascular disease within 24 months postpartum.

BACKGROUND: Cardiovascular disease is the leading cause of death among women in the United States. It is well established that gestational diabetes mellitus is associated with an overall lifetime increased risk of cardiometabolic disease, even among those without intercurrent type 2 diabetes. However, the association between gestational diabetes mellitus and short-term risk of cardiovascular disease is unclear. Establishing short-term risks of cardiovascular disease for patients with gestational diabetes mellitus has significant potential to inform early screening and targeted intervention strategies to reduce premature cardiovascular morbidity among women. OBJECTIVE: This study aimed to compare the risk of cardiovascular disease diagnosis in the first 24 months postpartum between patients with and without gestational diabetes mellitus. STUDY DESIGN: Our longitudinal population-based study included pregnant individuals with deliveries from 2007 to 2019 in the Maine Health Data Organization's All Payer Claims Database. We excluded records with gestational age <20 weeks, non-Maine residence, multifetal gestation, no insurance in the month of delivery or the 3 months before pregnancy, an implausibly short interval until next pregnancy (<60 days), pregestational diabetes mellitus, and any prepregnancy diagnosis of the cardiovascular conditions being examined postpartum. Gestational diabetes mellitus and cardiovascular disease (heart failure, ischemic heart disease, arrhythmia/cardiac arrest, cardiomyopathy, cerebrovascular disease/stroke, and new chronic hypertension) were identified by International Classification of Diseases 9/10 diagnosis codes. Cox proportional hazards models were used to estimate hazard ratios, adjusting for potential confounding factors. We assessed whether the association between gestational diabetes mellitus and chronic hypertension was mediated by intercurrent diabetes mellitus. RESULTS: Among the 84,746 pregnancies examined, the cumulative risk of cardiovascular disease within 24 months postpartum for those with vs without gestational diabetes mellitus was 0.13% vs 0.20% for heart failure, 0.16% vs 0.14% for ischemic heart disease, 0.60% vs 0.44% for cerebrovascular disease/stroke, 0.22% vs 0.16% for arrhythmia/cardiac arrest, 0.20% vs 0.20% for cardiomyopathy, and 4.19% vs 1.83% for new chronic hypertension. After adjusting for potential confounders, those with gestational diabetes had an increased risk of new chronic hypertension (adjusted hazard ratio, 1.56; 95% confidence interval, 1.32-1.86) within the first 24 months postpartum compared with those without gestational diabetes. There was no association between gestational diabetes and ischemic heart disease (adjusted hazard ratio, 0.75; 95% confidence interval, 0.34-1.65), cerebrovascular disease/stroke (adjusted hazard ratio, 1.13; 95% confidence interval, 0.78-1.66), arrhythmia/cardiac arrest (adjusted hazard ratio, 1.16; 95% confidence interval, 0.59-2.29), or cardiomyopathy (adjusted hazard ratio, 0.75; 95% confidence interval, 0.40-1.41) within the first 24 months postpartum. Those with gestational diabetes appeared to have a decreased risk of heart failure within 24 months postpartum (adjusted hazard ratio, 0.45; 95% confidence interval, 0.21-0.98). Our mediation analyses estimated that 28% of the effect of gestational diabetes on new chronic hypertension was mediated through intercurrent diabetes mellitus. CONCLUSION: Patients with gestational diabetes mellitus have a significantly increased risk of new chronic hypertension as early as 24 months postpartum. Most of this effect was not due to the development of diabetes mellitus. Our findings suggest that all women with gestational diabetes need careful monitoring and screening for new chronic hypertension in the first 2 years postpartum.

Acute health care utilization in the first 24 months postpartum by rurality and pregnancy complications: A prospective cohort study.

OBJECTIVE: To estimate the rate of acute health care use (hospitalizations and emergency department [ED] visits) among postpartum persons by rurality of residence and pregnancy complications. DATA SOURCES AND STUDY SETTING: 2006-2021 data from the Maine Health Data Organization's All Payer Claims Data. STUDY DESIGN: We estimated the rates of hospitalizations and ED visits during the first 24 months postpartum, separately, overall and by four-level rurality of residence (urban, large rural, small rural, and isolated rural) and by pregnancy complications (prenatal depression, hypertensive disorders of pregnancy [HDP], and gestational diabetes mellitus [GDM]). We used Poisson regression models, adjusting for potential confounders. Data were weighted to account for censoring before 24 months postpartum. DATA EXTRACTION METHODS: Deliveries during 2007-2019 (n = 122,412). PRINCIPAL FINDINGS: Approximately 4% of persons had at least one hospitalization within 24 months postpartum (mean monthly rate per 100 deliveries = 0.35). Adjusted rates were not different by rurality. Persons with prenatal depression (adjusted rate ratio [aRR] = 1.9; 95% confidence interval [CI] 1.5-2.5), HDP (aRR = 1.4; 1.0-2.0), and GDM (aRR = 1.4; 0.9-2.0) had higher hospitalization rates than those without these conditions. Approximately 44% of persons had at least one ED visit within 24 months postpartum (mean monthly rate per 100 deliveries = 5.4). Adjusted ED rates were higher for persons living in small rural areas as compared with urban areas (aRR = 1.3; 1.2-1.4). Persons with prenatal depression (aRR = 1.8; 1.7-1.9), HDP (aRR = 1.1; 1.0-1.2), and GDM (aRR = 1.3; 1.2-1.4) had higher ED rates than those without these conditions; ED rates were highest among those living in small rural areas. CONCLUSION: New policies and care practices may be needed to prevent acute health care encounters in the first 24 months after delivery for persons with common pregnancy conditions. Efforts to identify why postpartum people living in small rural areas have higher rates of ED visits are warranted.

Expedited Partner Therapy: A Multicomponent Initiative to Boost Provider Counseling.

BACKGROUND: Expedited partner therapy prescription remains low and highly variable throughout the United States, leading to frequent reinfections with Chlamydia trachomatis and Neisseria gonorrhoeae . We examined provider counseling on expedited partner therapy before and after an electronic smart tool-based initiative. METHODS: In this quasi-experimental interrupted time-series study, we implemented an initiative of electronic smart tools and education for expedited partner therapy in March 2020. We reviewed the records of patients with chlamydia and/or gonorrhea at an urban, academic obstetrics and gynecology clinic in the preimplementation (March 2019-February 2020) and postimplementation (March 2020-February 2021) groups. Descriptive statistics and an interrupted time-series model were used to compare the percent of expedited partner therapy offered by clinicians to patients in each group. RESULTS: A total of 287 patient encounters were analyzed, 155 preintervention and 132 postintervention. An increase in expedited partner therapy counseling of 13% (95% confidence interval [CI], 2%-24%) was observed before the intervention (27.1% [42 of 155]) versus after the intervention (40.2% [53 of 132]). Significant increases in provider counseling were seen for patients who were single (15%; 95% CI, 3%-26%), 25 years or older (21%; 95% CI, 6%-37%), receiving public insurance (15%; 95% CI, 3%-27%), seen by a registered nurse (18%; 95% CI, 4%-32%), or seen for an obstetrics indication (21%; 95% CI, 4%-39%). No difference was seen in patients' acceptance of expedited partner therapy ( P = 1.00). CONCLUSIONS: A multicomponent initiative focused on electronic smart tools is effective at increasing provider counseling on expedited partner therapy. Further research to understand patient perceptions and acceptance of expedited partner therapy is critical.

Continuous non-invasive hemodynamic monitoring in early onset severe preeclampsia.

OBJECTIVES: Continuous hemodynamic monitoring offers the opportunity to individualize management in severe preeclampsia (PEC). We compared cardiac output (CO) and total peripheral resistance (TPR) measured by bioreactance (NICOM), Clearsite™ Fingercuff [CS), and 3D-echocardiography (3DE). STUDY DESIGN: This prospective observational study included 12 pregnant patients with early PEC. CO and TPR were measured simultaneously by NICOM, CS, and 3DE antepartum and 1-2 days postpartum. Using 3DE as the standard, CS and NICOM interchangeability, precision, accuracy, and correlation were assessed. RESULTS: Compared to 3DE-CO, CS-CO was highly correlated (R2 = 0.70, p = <0.0001) with low percentage error (PE 29%) which met criteria for interchangeablity. CS-TPR had strong correlation (R2 = 0.81, p = <0.0001) and low PE (29%). While CS tended to slightly overestimate CO (bias + 2.05 ±1.18 L/min, limit of agreement (LOA) -0.20 to 4.31) and underestimate TPR (bias -279 ±156 dyes/sec/cm5; LOA -580 to 18.4) these differences were unlikely to be clinically significant. Thus CS could be interchangeable with 3DE for CO and TPR. NICOM-CO had only moderate correlation with 3DE-CO (R2 = 0.29, p = 0.01) with high PE (52%) above threshold for interchangeability. NICOM-CO had low mean bias (-1.2 ±1.68 L/min) but wide 95% LOA (-4.41 to 2.14) suggesting adequate accuracy but low precision in relation to 3DE-CO. NICOM-TPR had poor correlation with 3DE-TPR (R2 = 0.32, p = 0.001) with high PE (67%), relatively low mean bias (238 ±256), and wide 95% LOA (-655 to 1131). NICOM did not meet the criteria for interchangeable with 3DE for CO and TPR. CONCLUSIONS: Clearsite Fingercuff, but not NICOM, has potential to be clinically useful for CO and TPR monitoring in severe preeclampsia.

Mental Health Within 24 Months After Delivery Among Women with Common Pregnancy Conditions.

Objective: The aim of this study is to estimate the risk of a new mental health diagnosis within the first 24 months postpartum among women with common pregnancy conditions, overall and by rurality. Materials and Methods: This longitudinal population-based study used the Maine Health Data Organization's All-Payer Claims Data to estimate the cumulative risk of a new mental health disorder diagnosis in the first 24 months postpartum among women with deliveries during 2007-2019 and who did not have a mental health diagnosis before pregnancy. Cox models were used to estimate hazard ratios for common pregnancy conditions (prenatal depression, gestational diabetes [GDM], and hypertensive disorders of pregnancy [HDP]) on the new diagnosis of five mental health conditions, separately. Models were adjusted for maternal demographics and pregnancy characteristics. Results: Of the 123,125 deliveries, the cumulative risk of being diagnosed in the first 24 months postpartum with depression was 28%, anxiety 25%, bipolar disorder 3%, post-traumatic stress disorder 6%, and schizophrenia/psychotic disorder 1%. Women with prenatal depression were at higher risk of having a postpartum mental health diagnosis compared with women without prenatal depression (adjusted hazard ratios [aHRs] ranged from 2.5 [for anxiety] to 4.1 [for postpartum depression]). Risk of having postpartum depression was modestly higher among women with HDP, as was the risk of postpartum bipolar disorder among those with GDM. Findings were generally similar between women living in rural versus urban areas. Conclusions: Effective interventions to prevent, screen, and treat mental health conditions among women with pregnancy complications for an extended time postpartum are warranted.

Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine.

OBJECTIVE: Preliminary findings from selected health systems revealed interruptions in reproductive health care services due to the COVID-19 pandemic. We estimated changes in postpartum contraceptive provision associated with the start of the COVID-19 pandemic in Maine. METHODS: We used the Maine Health Data Organization's All Payer Claims Database for deliveries from October 2015 through March 2021 (n = 45 916). Using an interrupted time-series analysis design, we estimated changes in provision rates of long-acting reversible contraception (LARC), permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic. We performed 6- and 12-month analyses (April 2020-September 2020, April 2020-March 2021) as compared with the reference period (October 2015-March 2020). We used Poisson regression models to calculate level-change rate ratios (RRs) and 95% CIs. RESULTS: The 6-month analysis found that provision of LARC (RR = 1.89; 95% CI, 1.76-2.02) and moderately effective contraception (RR = 1.51; 95% CI, 1.33-1.72) within 3 days of delivery increased at the start of the COVID-19 pandemic, while provision of LARC (RR = 0.95; 95% CI, 0.93-0.97) and moderately effective contraception (RR = 1.08; 95% CI, 1.05-1.11) within 60 days of delivery was stable. Rates of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased. RRs from the 12-month analysis were generally attenuated. CONCLUSION: Disruptions in postpartum provision of permanent contraception occurred at the beginning of the COVID-19 pandemic in Maine. Public health policies should include guidance for contraceptive provision during public health emergencies and consider designating permanent contraception as a nonelective procedure.

Association of Prenatal Depression With New Cardiovascular Disease Within 24 Months Postpartum.

Background Although depression is well established as an independent risk factor for cardiovascular disease (CVD) in the nonpregnant population, this association has largely not been investigated in pregnant populations. We aimed to estimate the cumulative risk of new CVD in the first 24 months postpartum among pregnant individuals diagnosed with prenatal depression compared with patients without depression diagnosed during pregnancy. Methods and Results Our longitudinal population-based study included pregnant individuals with deliveries during 2007 to 2019 in the Maine Health Data Organization's All Payer Claims Data. We excluded those with prepregnancy CVD, multifetal gestations, or no continuous health insurance during pregnancy. Prenatal depression and CVD (heart failure, ischemic heart disease, arrhythmia/cardiac arrest, cardiomyopathy, cerebrovascular disease, and chronic hypertension) were identified by International Classification of Diseases, Ninth Revision (ICD-9)/International Classification of Diseases, Tenth Revision (ICD-10) codes. Cox models were used to estimate hazard ratios (HRs), adjusting for potential confounding factors. Analyses were stratified by hypertensive disorder of pregnancy. A total of 119 422 pregnancies were examined. Pregnant individuals with prenatal depression had an increased risk of ischemic heart disease, arrhythmia/cardiac arrest, cardiomyopathy, and new hypertension (adjusted HR [aHR], 1.83 [95% CI, 1.20-2.80], aHR, 1.60 [95% CI, 1.10-2.31], aHR, 1.61 [95% CI, 1.15-2.24], and aHR, 1.32 [95% CI, 1.17-1.50], respectively). When the analyses were stratified by co-occurring hypertensive disorders of pregnancy, several of these associations persisted. Conclusions The cumulative risk of a new CVD diagnosis postpartum was elevated among individuals with prenatal depression and persists even in the absence of co-occurring hypertensive disorders of pregnancy. Further research to determine the causal pathway can inform postpartum CVD preventive measures.

Association between hypertensive disorders of pregnancy and cardiovascular diseases within 24 months after delivery.

BACKGROUND: Despite the well-known association between hypertensive disorders of pregnancy and cardiovascular diseases, there are limited data on which specific cardiovascular diagnoses have the greatest risk profiles during the first 24 months after delivery. Most existing data on hypertensive disorders of pregnancy and short-term cardiovascular disease risks are limited to the immediate postpartum period; however, it is crucial to determine cardiovascular disease risk up to 24 months after delivery to inform cardiovascular disease screening protocols during the extended postpartum period. OBJECTIVE: This study aimed to delineate the risk of cardiovascular diagnoses in the first 24 months after delivery among patients with hypertensive disorders of pregnancy compared with patients without hypertensive disorders of pregnancy. STUDY DESIGN: This longitudinal population-based study included pregnant individuals with deliveries during 2007 to 2019 in the Maine Health Data Organization's All Payer Claims Data. This study excluded patients with preexisting cardiovascular disease, with multifetal pregnancies, or without continuous insurance during pregnancy. Hypertensive disorders of pregnancy and cardiovascular diseases (categorized by specific conditions: heart failure, ischemic heart disease, arrhythmia or cardiac arrest, cardiomyopathy, cerebrovascular disease or stroke, and new chronic hypertension) were identified using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, diagnosis codes. Cox proportional hazards models were used to estimate hazard ratios, adjusting for potential confounding factors. RESULTS: Of the 119,422 pregnancies examined, the cumulative risk of cardiovascular disease within 24 months after delivery for those with hypertensive disorders of pregnancy vs those without hypertensive disorders of pregnancy was 0.6% vs 0.2% for heart failure, 0.3% vs 0.1% for ischemic heart disease, 0.2% vs 0.2% for arrhythmia or cardiac arrest, 0.6% vs 0.2% for cardiomyopathy, 0.8% vs 0.4% for cerebrovascular disease or stroke, 1.6% vs 0.7% for severe cardiac disease (composite outcome of heart failure, cerebrovascular disease or stroke, or cardiomyopathy), and 9.7% vs 1.5% for new chronic hypertension. After adjustment for potential confounders, those with hypertensive disorders of pregnancy had an increased risk of heart failure, cerebrovascular disease, cardiomyopathy, and severe cardiac disease within the first 24 months after delivery (adjusted hazard ratio, 2.81 [95% confidence interval, 1.90-4.15], 1.43 [95% confidence interval, 1.07-1.91], 2.90 [95% confidence interval, 1.96-4.27], and 1.90 [95% confidence interval, 1.54-2.30], respectively) compared with those without hypertensive disorders of pregnancy. In addition, those with hypertensive disorders of pregnancy had an increased risk for new chronic hypertension diagnosed after 42 days after delivery (adjusted hazard ratio, 7.29; 95% confidence interval, 6.57-8.09). There was no association between hypertensive disorders of pregnancy and ischemic heart disease (adjusted hazard ratio, 0.92; 95% confidence interval, 0.55-1.54) or cardiac arrest or arrhythmia (adjusted hazard ratio, 0.90; 95% confidence interval, 0.52-1.57). In addition, among women with hypertensive disorders of pregnancy, the highest proportion of first cardiovascular disease diagnoses occurred during the first month after delivery for cardiomyopathy (44%), heart failure (39%), cerebrovascular disease or stroke (39%), and severe cardiac disease (41%). CONCLUSION: Patients with hypertensive disorders of pregnancy had an increased risk of developing new chronic hypertension, heart failure, cerebrovascular disease, and cardiomyopathy within 24 months after delivery. There was no association between hypertensive disorders of pregnancy and ischemic heart disease or cardiac arrest or arrhythmia. Patients with hypertensive disorders of pregnancy need targeted early postpartum interventions and increased monitoring in the first 24 months after delivery. This may preserve long-term health and improve maternal and neonatal outcomes in a subsequent pregnancy.

Rural-urban residence and sequelae of hypertensive disorders of pregnancy in the first year postpartum, 2007 - 2019.

OBJECTIVES: To estimate the association between rural residence and sequelae of hypertensive disorders of pregnancy (HDP) in the first year postpartum. STUDY DESIGN: We used the Maine Health Data Organization's All Payer Claims Data to identify women with HDP who delivered during 2007-2019 and did not have chronic hypertension or pre-pregnancy cardiac conditions (n = 8882). We used Cox proportional hazards modeling to estimate rural-urban hazard ratios (HR) and 95% confidence intervals (CI), adjusting for HDP subtype, age, insurance, nulliparity, and co-morbidities. Results were stratified by HDP subtype and timing of acute care visits. MAIN OUTCOME MEASURES: Risk of at least one emergency room or inpatient visit related to hypertension or cardiovascular conditions in the first year postpartum and receipt of outpatient antihypertensive medications from 4 days to 1 year postpartum, separately. RESULTS: Overall, risk of at least one acute care visit in the first year postpartum was not different between rural vs urban women (4.2% vs 4.2%; adjusted HR 0.98; 95% CI 0.79,1.21), and outpatient receipt of antihypertensive medication was not different (12.9% vs 12.8%; adjusted HR 0.99; 95% CI 0.87, 1.12). However, stratified analyses suggested some differences (e.g. preeclampsia with severe features: acute care visit adjusted HR 1.54; 95% CI 0.95, 2.49). CONCLUSIONS: Rural and urban women do not differ in the risks of these common HDP sequelae, though rural women may have increased risk by HDP subtype or timing of acute care visit. Future research should investigate postpartum interventions for reducing HDP sequelae in rural and urban women.

Use of family history of cardiovascular disease or chronic hypertension to better identify who needs postpartum cardiovascular risk screening.

BACKGROUND: Individuals with pregnancies complicated by hypertensive disorders of pregnancy are at increased risk of cardiovascular disease. However, not all who have hypertensive disorders of pregnancy are at risk, and not all who have uncomplicated pregnancies are without risk. OBJECTIVE: This study aimed to determine if use of first-degree family history of cardiovascular disease or chronic hypertension better identifies individuals who need postpartum cardiovascular risk screening. STUDY DESIGN: Participants were included if they had pregnancies complicated by hypertensive disorders of pregnancy or uncomplicated, term pregnancies. Individuals with a first-degree relative with chronic hypertension, myocardial infarction, or stroke were deemed to have a positive family history and were thus included. RESULTS: Four groups were considered: 302 individuals with hypertensive disorders of pregnancy who had a positive family history, 218 individuals with hypertensive disorders of pregnancy with no family history, 39 control individuals with a positive family history, and 63 control individuals with no family history. Among individuals with hypertensive disorders of pregnancy, those with a positive family history were more likely to be diagnosed with chronic hypertension, and to have elevated 30-year lipid, 30-year body mass index, and lifetime cardiovascular disease risk score (all P<.05). Among individuals with uncomplicated pregnancies, those with a positive family history were more likely to be diagnosed with chronic hypertension (P<.05) and meet criteria for metabolic syndrome (P<.05). CONCLUSION: First-degree family history of cardiovascular disease and/or chronic hypertension can be used to reliably identify individuals without pregnancy complications who should have postpartum cardiovascular risk screening, and may better determine which individuals who have a pregnancy complicated by hypertensive disorders of pregnancy would most benefit from postpartum cardiovascular risk screening.

High-sensitivity C-reactive protein use in cardiovascular risk screening at 6 to 12 months postpartum following hypertensive disorders of pregnancy.

BACKGROUND: Patients with a hypertensive disorder of pregnancy are more likely to have underlying cardiovascular risk factors and are at increased risk of future cardiovascular disease. These patients are more likely to be diagnosed with new-onset chronic hypertension and meet the criteria for metabolic syndrome postpartum. High-sensitivity C-reactive protein is a marker of general inflammation and may be used to identify increased risk for cardiovascular disease. OBJECTIVE: This collaborative data-sharing study between Yale University, United States (Yale Hearts Moms study) and Queen's University, Canada (Maternal Health Clinic) aimed to study the utility of high-sensitivity C-reactive protein in postpartum cardiovascular risk screening, as determined by 30-year risk (Framingham) and metabolic syndrome 6 to 12 months postpartum. STUDY DESIGN: Patients with a hypertensive disorder of pregnancy (n=478) or an uncomplicated, term pregnancy (n=90) had cardiovascular risk screening and risk scoring performed at 6 to 12 months postpartum. Patients were excluded if they had a multiple gestation or chronic hypertension, diabetes mellitus, or cardiovascular disease diagnosed before pregnancy. Patients were categorized according to high-sensitivity C-reactive protein (mg/L) into Normal (<3.0), High (3.1 to <10.0), and Acute (≥10.0) groups. The primary outcome of the study was risk for future cardiovascular events, calculated through surrogate measures such as hypertension and cholesterol. Kruskal-Wallis and chi-square tests were used to compare groups, with post hoc tests corrected using the Bonferroni method. Multivariable logistic regression was used to assess the association between high-sensitivity C-reactive protein and cardiovascular risk, adjusting for relevant medical and sociodemographic variables. Analysis was completed with IBM SPSS Statistics, version 27. RESULTS: Patients in the High and Acute high-sensitivity C-reactive protein groups were more likely to have a body mass index ≥30, to have experienced a hypertensive disorder of pregnancy, to have a lower household income, and to have not breastfed or to have breastfed for <6 months, when compared with the Normal high-sensitivity C-reactive protein group (all P<.05). Patients in the High and Acute high-sensitivity C-reactive protein groups had higher 30-year cardiovascular risk scores and were more likely to have metabolic syndrome when compared with the Normal high-sensitivity C-reactive protein group (all P<.05). Patients with High high-sensitivity C-reactive protein had 2-fold odds of metabolic syndrome 6 to 12 months after delivery, compared with those in the Normal high-sensitivity C-reactive protein group (adjusted odds ratio, 2.85 [95% confidence interval, 1.66-4.91]), adjusting for hypertensive disorder of pregnancy, body mass index, clinic site, breastfeeding, income, and family history of cardiovascular disease. Those with Acute high-sensitivity C-reactive protein also seemed to have elevated odds of metabolic syndrome compared with the Normal high-sensitivity C-reactive protein group (adjusted odds ratio, 2.52 [95% confidence interval, 1.24-5.12]). The odds of chronic hypertension were significantly higher (P<.05) in the High high-sensitivity C-reactive protein group (adjusted odds ratio, 1.72 [95% confidence interval, 1.12-2.65]) compared with the Normal group. CONCLUSION: Individuals with elevated postpartum high-sensitivity C-reactive protein are at increased risk of cardiovascular disease 6 to 12 months postpartum after a pregnancy complicated by a hypertensive disorder of pregnancy. Future research is critical to determine the most comprehensive and accurate method and timing of postpartum cardiovascular risk screening to decrease the incidence of preventable cardiovascular mortality among women.

Racial and ethnic differences in severe maternal morbidity among singleton stillbirth deliveries.

BACKGROUND: Despite growing evidence suggesting racial or ethnic disparities in the risk of severe maternal morbidity among live births, there is little research investigating potential differences in severe maternal morbidity risk among stillbirths across race and ethnicity. OBJECTIVE: This study aimed to compare the risk of severe maternal morbidity by race and ethnicity among patients with singleton stillbirth pregnancies. STUDY DESIGN: We used the California Linked Birth File database to perform a retrospective analysis of singleton stillbirth pregnancies delivered at 20 to 42 weeks' gestation between 2007 and 2011. The database contained information from fetal death certificates linked to maternal hospital discharge records. We defined severe maternal morbidity using the Centers for Disease Control and Prevention composite severe maternal morbidity indicator and compared rates of severe maternal morbidity across racial and ethnic groups. Multivariable regression analysis was used to examine how race and ethnicity were associated with severe maternal morbidity risk after accounting for the influence of patients' clinical risk factors, socioeconomic characteristics, and attributes of the delivery hospital. RESULTS: Of the 9198 patients with singleton stillbirths, 533 (5.8%) experienced severe maternal morbidity. Non-Hispanic Black patients had a significantly higher risk of severe maternal morbidity (10.6% vs 5.2% in non-Hispanic White patients, 5.2% in Hispanic patients, and 5.1% in patients with other race or ethnicity; P<.001). The higher risk of severe maternal morbidity among non-Hispanic Black patients persisted even after adjusting for patients' clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.74; 95% confidence interval, 1.21-2.50). Further analysis separating blood-transfusion and nontransfusion severe maternal morbidity showed a higher risk of blood transfusion in non-Hispanic Black patients, which remained significant after adjusting for patients' clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.64; 95% confidence interval, 1.11-2.43). However, the higher risk of nontransfusion severe maternal morbidity in non-Hispanic Black patients was no longer significant after adjusting for patients' clinical risk factors (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.38; 95% confidence interval, 0.83-2.30). CONCLUSION: Severe maternal morbidity occurred in 5.8% of patients with a singleton stillbirth. Risk of severe maternal morbidity in stillbirth was higher in patients with non-Hispanic Black race, which was likely owing to a higher risk of hemorrhage, as evidenced by increased rate of blood transfusion.

Seizing the Window of Opportunity Within 1 Year Postpartum: Early Cardiovascular Screening.

Background Our objective was to assess new chronic hypertension 6 to 12 months postpartum for those with hypertensive disorder of pregnancy (HDP) compared with normotensive participants. Methods and Results We performed a prospective cohort study of participants with singleton gestations and no known preexisting medical conditions who were diagnosed with HDP compared with normotensive women with no pregnancy complications (non-HDP). Participants underwent cardiovascular risk assessment 6 to 12 months after delivery. Primary outcome was onset of new chronic hypertension at 6 to 12 months postpartum. We also examined lipid values, metabolic syndrome, prediabetes, diabetes, and 30-year cardiovascular disease (CVD) risk. Multivariable logistic regression was performed to assess the association between HDP and odds of a postpartum diagnosis of chronic hypertension while adjusting for parity, body mass index, insurance, and family history of CVD. There were 58 participants in the HDP group and 51 participants in the non-HDP group. Baseline characteristics between groups were not statistically different. Participants in the HDP group had 4-fold adjusted odds of developing a new diagnosis of chronic hypertension 6 to 12 months after delivery, compared with those in the non-HDP group (adjusted odds ratio, 4.60 [95% CI, 1.65-12.81]), when adjusting for body mass index, parity, family history of CVD, and insurance. Of the HDP group, 58.6% (n=34) developed new chronic hypertension. Participants in the HDP group had increased estimated 30-year CVD risk and were more likely to have metabolic syndrome, a higher fasting blood glucose, and higher low-density lipoprotein cholesterol. Conclusions Participants without known underlying medical conditions who develop HDP have 4-fold increased odds of new diagnosis of chronic hypertension by 6 to 12 months postpartum as well as increased 30-year CVD risk scores. Implementation of multidisciplinary care models focused on CVD screening, patient education, and lifestyle interventions during the first year postpartum may serve as an effective primary prevention strategy for the development of CVD.

Receipt of COVID-19 Vaccine During Pregnancy and Preterm or Small-for-Gestational-Age at Birth - Eight Integrated Health Care Organizations, United States, December 15, 2020-July 22, 2021.

COVID-19 vaccines are recommended during pregnancy to prevent severe maternal morbidity and adverse birth outcomes; however, vaccination coverage among pregnant women has been low (1). Concerns among pregnant women regarding vaccine safety are a persistent barrier to vaccine acceptance during pregnancy. Previous studies of maternal COVID-19 vaccination and birth outcomes have been limited by small sample size (2) or lack of an unvaccinated comparison group (3). In this retrospective cohort study of live births from eight Vaccine Safety Datalink (VSD) health care organizations, risks for preterm birth (<37 weeks' gestation) and small-for-gestational-age (SGA) at birth (birthweight <10th percentile for gestational age) after COVID-19 vaccination (receipt of ≥1 COVID-19 vaccine doses) during pregnancy were evaluated. Risks for preterm and SGA at birth among vaccinated and unvaccinated pregnant women were compared, accounting for time-dependent vaccine exposures and propensity to be vaccinated. Single-gestation pregnancies with estimated start or last menstrual period during May 17-October 24, 2020, were eligible for inclusion. Among 46,079 pregnant women with live births and gestational age available, 10,064 (21.8%) received ≥1 COVID-19 vaccine doses during pregnancy and during December 15, 2020-July 22, 2021; nearly all (9,892; 98.3%) were vaccinated during the second or third trimester. COVID-19 vaccination during pregnancy was not associated with preterm birth (adjusted hazard ratio [aHR] = 0.91; 95% CI = 0.82-1.01). Among 40,627 live births with birthweight available, COVID-19 vaccination in pregnancy was not associated with SGA at birth (aHR = 0.95; 95% CI = 0.87-1.03). Results consistently showed no increased risk when stratified by mRNA COVID-19 vaccine dose, or by second or third trimester vaccination, compared with risk among unvaccinated pregnant women. Because of the small number of first-trimester exposures, aHRs for first-trimester vaccination could not be calculated. These data add to the evidence supporting the safety of COVID-19 vaccination during pregnancy. To reduce the risk for severe COVID-19-associated illness, CDC recommends COVID-19 vaccination for women who are pregnant, recently pregnant (including those who are lactating), who are trying to become pregnant now, or who might become pregnant in the future (4).

Unrepaired Maternal Vein of Galen Malformation in Pregnancy: A Case Report.

We present a case of a pregnant patient with an unrepaired vein of Galen malformation (VGAM) and left ventricular (LV) dilation. Patients with VGAM lesions typically present during childhood with cardiac failure or developmental delay prompting embolization. Therefore, it is highly unusual for an adult to present with an unrepaired lesion.1 It poses challenges for obstetric and anesthetic management during pregnancy and delivery to reduce the risk of heart failure, arrhythmia, and intracranial hemorrhage. Our patient safely delivered a term neonate by cesarean delivery with neuraxial analgesia at a Level IV Maternal Care Center.

Cost of vaccine delivery strategies in low- and middle-income countries during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has disrupted immunization services critical to the prevention of vaccine-preventable diseases in many low- and middle- income countries around the world. These services will need to be modified in order to minimize COVID-19 transmission and ensure the safety of health workers and the community. Additional budget will be required to implement these modifications that ensure safe delivery. METHODS: Using a simple modeling analysis, we estimated the additional resource requirements associated with modifications to supplementary immunization activities (campaigns) and routine immunization services via fixed sites and outreach in 2020 US dollars. We considered the following four categories of costs: (1) personal protective equipment (PPE) & infection prevention and control (IPC) measures for immunization sessions; (2) physical distancing and screening during immunization sessions; (3) delivery strategy changes, such as changes in session sizes and frequency; and (4) other operational cost increases, including additional social mobilization, training, and hazard pay to compensate health workers. RESULTS: We found that implementing a range of measures to protect health workers and communities from COVID-19 transmission could result in a per-facility start-up cost of $466-799 for routine fixed-site delivery and $12-220 for routine outreach delivery, and $12-108 per immunization campaign site. A recurrent monthly cost of $137-1,024 for fixed-site delivery and $152-848 for outreach delivery per facility could be incurred, and a $0.32-0.85 increase in the cost per dose during campaigns. CONCLUSIONS: By illustrating potential cost implications of providing immunization services through a range of strategies in a safe manner, these estimates can provide a benchmark for program managers and policy makers on the additional budget required. These findings can help country practitioners and global development partners planning the continuation of immunization services in the context of COVID-19.

Exploring the Cost of eLearning in Health Professions Education: Scoping Review.

BACKGROUND: Existing research on the costs associated with the design and deployment of eLearning in health professions education is limited. The relative costs of these learning platforms to those of face-to-face learning are also not well understood. The lack of predefined costing models used for eLearning cost data capture has made it difficult to complete cost evaluation. OBJECTIVE: The key aim of this scoping review was to explore the state of evidence concerning cost capture within eLearning in health professions education. The review explores the available data to define cost calculations related to eLearning. METHODS: The scoping review was performed using a search strategy with Medical Subject Heading terms and related keywords centered on eLearning and cost calculation with a population scope of health professionals in all countries. The search was limited to articles published in English. No restriction was placed on literature publication date. RESULTS: In total, 7344 articles were returned from the original search of the literature. Of these, 232 were relevant to associated keywords or abstract references following screening. Full-text review resulted in 168 studies being excluded. Of these, 61 studies were excluded because they were unrelated to eLearning and focused on general education. In addition, 103 studies were excluded because of lack of detailed information regarding costs; these studies referred to cost in ways either indicating cost favorability or unfavorability, but without data to support findings. Finally, 4 studies were excluded because of limited cost data that were insufficient for analysis. In total, 42 studies provided data and analysis of the impact of cost and value in health professions education. The most common data source was total cost of training (n=29). Other sources included cost per learner, referring to the cost for individual students (n=13). The population most frequently cited was medical students (n=15), although 12 articles focused on multiple populations. A further 22 studies provide details of costing approaches for the production and delivery of eLearning. These studies offer insight into the ways eLearning has been budgeted and project-managed through implementation. CONCLUSIONS: Although cost is a recognized factor in studies detailing eLearning design and implementation, the way cost is captured is inconsistent. Despite a perception that eLearning is more cost-effective than face-to-face instruction, there is not yet sufficient evidence to assert this conclusively. A rigorous, repeatable data capture method is needed, in addition to a means to leverage existing economic evaluation methods that can then test eLearning cost-effectiveness and how to implement eLearning with cost benefits and advantages over traditional instruction.

Driving simulators in the clinical assessment of fitness to drive in sleepy individuals: A systematic review.

Road traffic injuries are projected to be the leading cause of death for those aged between 15 and 29 years by the year 2030, and sleepiness is estimated to be the underlying cause in up to 15-20% of all motor vehicle accidents. Sleepiness at the wheel is most often caused by socially induced sleep deprivation or poor sleep hygiene in otherwise healthy individuals, medical disorders, or the intake of drugs. Validated methods for objectifying sleepiness are urgently sought, particularly in the context of driving. Based on the assumption that the identification and treatment of sleepiness, and its causes, may prevent motor vehicle accidents, driving simulators are a seemingly promising diagnostic tool. Despite the rising use of these in research, the reliability of their conclusions in healthy sleepy individuals and patients is still unclear. This systematic review aims to evaluate the practical value of driving simulators in a clinical environment when judging fitness to drive in sleepy individuals. From the 1674 records screened, 12 studies in sleepy individuals containing both simulated and real driving data were included. In general, simulated driving did not reliably predict real-life motor vehicle accidents, and especially not on an individual level, despite the moderate relationship between simulated and real-road test driving performance. The severity of sleepiness is most likely not the critical factor leading to motor vehicle accidents, but rather the perception of sleepiness. The self-perception of sleepiness related impairment, and risky behaviour while at the wheel should also be considered as key influencing factors.

An ASK1-p38 signalling pathway mediates hydrogen peroxide-induced toxicity in NG108-15 neuronal cells.

Reactive oxygen species (ROS) are believed to be involved in many forms of neurodegeneration, including ischaemic infarct damage and Alzheimer's disease. Despite the known involvement of p38 and JNK MAP kinases in mediating apoptosis and cell death in a variety of cell types, the details of the signalling pathways activated in neuronal cells by ROS are poorly characterised. Recently TAK1 (MAP3K7), a kinase upstream of JNK and p38, has attracted attention as a possible mediator of ischaemic cell death. This study tested the hypothesis that hydrogen peroxide (H2O2), which produces ROS, induces apoptosis in the NG108-15 neuronal cell line via activation of either TAK1 or the related kinase ASK1 (MAP3K5). H2O2 caused a concentration-dependent reduction in cell viability associated with caspase 3 activation. Loss of cell viability was inhibited by a selective caspase 3 inhibitor, and by the p38 inhibitor SB203580, but was not affected by the JNK inhibitor SP600125. The selective TAK1 inhibitor 5Z-7-oxozeaenol (5Z-7) exacerbated the loss of cell viability, whereas the ASK1 inhibitor NQDI-1 completely prevented caspase activation and cell death. These results show that pharmacological inhibition of ASK1 is neuroprotective, implicating an ASK1-p38 signalling pathway in ROS-induced apoptosis in neurones. The results also imply that the role of TAK1 may be neuroprotective rather than pro-degenerative.