Society for Maternal-Fetal Medicine Position Statement: Access to abortion care.

POSITION: The Society for Maternal-Fetal Medicine supports the right of all individuals to access the full spectrum of reproductive health services, including abortion care. Reproductive health decisions are best made by each individual with guidance and support from their healthcare providers. The Society opposes legislation and policies that limit access to abortion care or criminalize abortion care and self-managed abortion. In addition, the Society opposes policies that compromise the patient-healthcare provider relationship by limiting a healthcare provider's ability to counsel patients and provide evidence-based, medically appropriate treatment.

Permanent and long-acting reversible contraception volumes at a multihospital system in Ohio before and after Dobbs.

OBJECTIVES: Immediately following the Dobbs decision, Ohio prohibited abortion after the detection of fetal cardiac activity. We aimed to characterize changes in the uptake of long-acting reversible contraception (LARC) and permanent contraception following the abrupt enactment of restrictive abortion legislation. STUDY DESIGN: We conducted a retrospective cohort study using electronic medical record data of patients aged 15 to 55 who underwent permanent contraception (tubal ligation, vasectomy) or LARC placement (intrauterine device, contraceptive implant) at a multihospital system in northeast Ohio from January 1, 2022 to Decemeber 31, 2022, 6 months before and after Dobbs. We compared procedure volumes and patient characteristics. RESULTS: We identified 4247 tubal ligation and LARC procedures pre-Dobbs, including 725 (17.1%) permanent contraception and 3522 (82.9%) LARC. Post-Dobbs, the total number of tubal ligation and LARC procedures increased by 15.8% (4916), and there was a significant increase in the proportion of permanent contraception, (p < 0.001). Vasectomy volume increased by 33.3% post-Dobbs, from 1193 to 1590 procedures. Compared to pre-Dobbs, patients undergoing contraceptive procedures post-Dobbs were younger (tubal ligation and LARC, 30.9 median years [24.5, 36.8] vs 31.5 [25.2, 36.9], p = 0.011; vasectomy, median 36.6 years [32.9, 39.6] vs 37.2 [34.2, 40.4], p < 0.001) and more likely to report single relationship status (57.4% vs 55.9% for tubal ligation and LARC, p = 0.028% and 23.0% vs 18.1% for vasectomy, p = 0.002). CONCLUSIONS: This study demonstrates increased uptake of contraceptive procedures following the Dobbs decision. This rise in permanent contraception suggests a relationship between abortion policy and contraceptive decision-making, especially among younger patients. IMPLICATIONS: Increased permanent and long-acting reversible contraception procedures following Dobbs reveal shifting contraceptive choices, particularly among younger individuals, indicating a connection between abortion policy and reproductive decisions.

Associations between adverse childhood experiences and obstetrical outcomes in a predominantly Black-identifying and low-income pregnant population.

BACKGROUND: Recent literature indicates that adverse childhood experiences have been associated with poor obstetrical outcomes, including pregnancy loss, preterm birth, and low birthweight. Several studies have been conducted in primarily self-identified White individuals who report middle to high income levels. Less is known about the impact of adverse childhood experiences on obstetrical outcomes in minority-identifying and low-income populations, who are known to experience a greater number of adverse childhood experiences and are at higher risk of maternal morbidity. OBJECTIVE: This study aimed to examine associations between adverse childhood experiences and a broad range of obstetrical outcomes among predominantly Black-identifying pregnant persons who have low income and live in an urban area. STUDY DESIGN: This is a single-center retrospective cohort study of pregnant persons referred to a mental healthcare manager because of elevated psychosocial risks identified by screening tools or provider concerns during the study period from April 2018 to May 2021. Pregnant persons aged <18 years and those who did not speak English were excluded. Patients completed validated mental and behavioral health screening tools including the Adverse Childhood Experiences Questionnaire. Medical charts were reviewed for obstetrical outcomes, including preterm birth, low birthweight, hypertensive disorders of pregnancy, gestational diabetes mellitus, chorioamnionitis, sexually transmitted infection, maternal group B streptococcus carrier status, type of delivery, and attendance of a postpartum visit. Associations between high (≥4) and very high (≥6) of 10 adverse childhood experience score and obstetrical outcomes were analyzed using bivariate analysis and multivariate logistic regression, adjusting for confounding factors (significant at P<.05 in bivariate analysis). RESULTS: Our cohort included 192 pregnant persons, of whom 176 (91.7%) self-identified as Black or African American and 181 (94.8%) had public insurance (used as a proxy for low income). Adverse childhood experience score ≥4 was reported by 91 (47.4%) individuals and score ≥6 by 50 (26%). On univariate analysis, adverse childhood experience score ≥4 was associated with preterm birth (odds ratio, 2.17; 95% confidence interval, 1.02-4.61). Adverse childhood experience score ≥6 was associated with hypertensive disorders of pregnancy (odds ratio, 2.09; 95% confidence interval, 1.05-4.15) and preterm birth (odds ratio, 2.29; 95% confidence interval, 1.05-4.96). After accounting for chronic hypertension, associations between adverse childhood experience score and obstetrical outcomes were no longer significant. CONCLUSION: Approximately half of the pregnant persons referred to a mental healthcare manager had a high adverse childhood experience score, underscoring the high burden of childhood trauma on populations facing long-standing systemic racism and barriers to healthcare access. High and very high adverse childhood experience score may be associated with chronic health conditions that predate pregnancy and can alter obstetrical outcomes. Obstetrical care providers have a unique opportunity to mitigate risk of associated poor health outcomes during preconception and prenatal care by screening for adverse childhood experiences.

Society for Maternal-Fetal Medicine Consult Series #66: Prepregnancy evaluation and pregnancy management of patients with solid organ transplants.

The rate of solid organ transplant in reproductive-aged patients has increased in the past 3 decades. Concurrently, the range of medical immunosuppressive agents has increased, making it safer for reproductive-aged individuals who have received transplants to attempt and continue a pregnancy. In this Consult, we review the general considerations and contemporary approach to medical and obstetrical management of pregnant solid organ transplant recipients, discuss the perinatal outcomes and incidence of graft rejection specific to the most common types of organ transplants, and provide management recommendations based on the available evidence. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that all solid organ transplant recipients capable of pregnancy be offered prepregnancy counseling as part of the pretransplant evaluation and before any posttransplant pregnancy (Best Practice); (2) we recommend deferring pregnancy for at least 1 year (except for lung transplant recipients in which case a 2-year deferral is recommended) following solid organ transplant or any episode of acute cellular rejection (GRADE 1B); (3) we recommend that solid organ transplant recipients have stable allograft function and optimal control of chronic medical comorbidities before attempting pregnancy (GRADE 1B); (4) we recommend that solid organ transplant recipients of reproductive age use highly effective contraception when on mycophenolate or other immunosuppressive agents with known teratogenic risk (GRADE 1A); (5) we recommend that solid organ transplant recipients contemplating pregnancy transition to an appropriate immunosuppressive regimen before attempting pregnancy to establish stable medication dosing and allograft function (GRADE 1C); (6) we recommend close monitoring of serum drug levels during pregnancy and the postpartum period to guide immunosuppressive therapy dosing (GRADE 1C); (7) we recommend that solid organ transplant recipients who are pregnant or contemplating pregnancy receive all indicated vaccinations before and during pregnancy (GRADE 1C); (8) given the risk of fetal and neonatal sequelae secondary to cytomegalovirus infection in pregnancy, we suggest that solid organ transplant recipients ideally complete any indicated antiviral prophylaxis or treatment before pursuing pregnancy (GRADE 2B); (9) we recommend daily low-dose aspirin prophylaxis to reduce the risk for preeclampsia in pregnant solid organ transplant recipients and to reduce the risk for renal allograft failure in renal transplant recipients (GRADE 1C); (10) as for all pregnant people, we recommend that pregnant solid organ transplant recipients have access to mental health specialists and receive screening for depression during pregnancy and the postpartum period (Best Practice); (11) because of the increased incidence of fetal growth restriction and common coexisting medical morbidities, we recommend serial assessment of fetal growth every 4 to 6 weeks throughout gestation after the anatomic survey (GRADE 1C); (12) we suggest antenatal surveillance from 32 weeks of gestation unless other fetal or maternal factors are identified in which case initiation of surveillance at an earlier gestational age is indicated (GRADE 2C); (13) we recommend that renal function be assessed before pregnancy or in early pregnancy in all solid organ transplant recipients (kidney and non-kidney) (GRADE 1C); (14) we suggest individualized delivery timing for pregnant solid organ transplant recipients and to consider delivery at between 37+0/7 and 39+6/7 weeks of gestation; in the absence of other indications, we suggest delivery by 39+6/7 weeks gestation for pregnant solid organ transplant recipients (GRADE 2B); (15) given that a trial of labor is associated with a high success rate and lower neonatal morbidity without increasing maternal morbidity or compromising graft survival, we recommend that cesarean delivery be reserved for medical obstetrical indications in solid organ transplant recipients (GRADE 1C); (16) we recommend that blood pressure targets in pregnant renal transplant recipients with chronic hypertension follow guidelines for nonpregnant recipients with a target blood pressure of ≤130/80 mm Hg (GRADE 1C); (17) we recommend monthly urine cultures to screen for asymptomatic bacteriuria with treatment if positive to protect the graft in pregnant renal transplant recipients (GRADE 1C); (18) we recommend that pregnancies in pancreas-kidney transplant recipients be managed in a similar way as those of renal transplant recipients alone (GRADE 1C); (19) we recommend characterizing the underlying condition that led to liver transplantation and assessing baseline renal function in pregnant liver transplant recipients. (GRADE 1C); (20) because of the cardiovascular demand of pregnancy and the unique physiological implications of cardiac transplantation, we recommend that pregnant heart transplant recipients receive multidisciplinary care with cardiology, cardiac and/or obstetrical anesthesiology, and maternal-fetal medicine specialists (Best Practice); and (21) we recommend careful delivery planning to minimize hemodynamic stress (including considering operative vaginal delivery to minimize Valsalva) and suggest continuous intrapartum or intraoperative electrocardiographic monitoring for heart transplant recipients (GRADE 1C).

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic.

BACKGROUND: Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality, and studies have shown that more than 60% of cases are preventable. As part of a statewide quality Maternal Safety Quality Improvement Project, we adapted the Alliance for Innovation on Maternal Health Severe Hypertension in Pregnancy bundle in a consortium of maternity hospitals in Ohio to improve care processes and outcomes for patients with a severe hypertensive event during pregnancy or the postpartum period. OBJECTIVE: This study aimed to report the first year of data from this Maternal Safety Quality Improvement Project, including an assessment of the process measures by hospital level of maternal care designation, and provide perspective on the unique challenges of implementing a large-scale Maternal Safety Quality Improvement Project during a global pandemic. STUDY DESIGN: This Maternal Safety Quality Improvement Project engaged Ohio level 1 to 4 maternity hospitals and provided multimodal quality improvement support. Participating hospitals submitted monthly patient-level data, which included all cases of new-onset sustained severe hypertension. The primary process measure was the proportion of birthing people in Ohio with sustained severe hypertension who received treatment with appropriate acute antihypertensive therapy within 60 minutes. The secondary process measures included receipt of a follow-up appointment after hospital discharge within 72 hours (if discharged on medication) or 10 days (if discharged without medication), a blood pressure cuff on hospital discharge, and education about urgent maternal warning signs. Data for primary and secondary process measures were plotted on a biweekly basis, and statistical process control methods were used to identify special cause variation over time. Data were stratified by various demographic variables, including race or ethnicity, insurance status, and maternal level of care. To assess the effect of the COVID-19 pandemic on this Maternal Safety Quality Improvement Project, process measure data were compared with COVID-19 case volume in Ohio across the study epoch. RESULTS: A total of 29 hospitals participated in the project from July 2020 to September 2021. Data were collected on 4948 hypertensive events representing 4678 unique patients. In aggregate, the primary process measure (timely and appropriate treatment) demonstrated a 19.3% increase (from a baseline of 56.5% to 67.4%; P<.001). The secondary process measures demonstrated significant increases ranging from 26.1% to 166.8% (all P<.001). Both non-Hispanic Black and White pregnant or postpartum people demonstrated shifts and sustained improvements in the treatment of severe hypertension, which did not differ by race across the study period. Process measure improvements were achieved and sustained across peaks in the COVID-19 pandemic. CONCLUSION: This Ohio Maternal Safety Quality Improvement Project demonstrated meaningful changes in project process measures in the identification and treatment of severe hypertension in pregnancy and the postpartum period. Process measures improvements were achieved across all hospital levels of maternal care, and differences were not observed by race or ethnicity. Our findings suggest that a robust and comprehensive quality improvement initiative with appropriate support and resources can achieve meaningful gains in the setting of a global pandemic.

Tight vs liberal control of mild postpartum hypertension: a randomized controlled trial.

BACKGROUND: High-quality evidence to inform the management of postpartum hypertension, including the optimal blood pressure threshold to initiate therapy, is lacking. Randomized trials have been conducted in pregnancy, but there are no published trials to guide management in the postpartum period. OBJECTIVE: This study aimed to test the hypothesis that initiating antihypertensive therapy in the postpartum period at a threshold of 140/90 mm Hg would result in less maternal morbidity than initiating therapy at a threshold of 150/95 mm Hg. STUDY DESIGN: We performed a pragmatic multicenter randomized controlled trial of patients aged 18 to 55 years with postpartum hypertension. Patients with chronic hypertension, gestational hypertension, and preeclampsia without severe features were randomized to 1 of 2 blood pressure thresholds to initiate treatment: persistent blood pressure of ≥150/95 mm Hg (institutional standard or "liberal control" group) or ≥140/90 mm Hg (intervention or "tight control" group). Our primary outcome was composite maternal morbidity defined as: severe hypertension (blood pressure ≥160/110 mm Hg) or preeclampsia with severe features, the need for a second antihypertensive agent, postpartum hospitalization >4 days, and maternal adverse outcome secondary to hypertension as evidenced by pulmonary edema, acute kidney injury (creatinine level ≥1.1 mg/dL), cardiac dysfunction (eg, elevated brain natriuretic peptide level) or cardiomyopathy, posterior reversible encephalopathy syndrome, cerebrovascular accident, or admission to an intensive care unit. Secondary outcomes included hospital readmission for hypertension, persistence of hypertension beyond 14 days, medication side effects, and time to blood pressure control. We calculated that 256 women would provide 90% power to detect a relative 50% reduction in the primary outcome from 36% in the standard blood pressure threshold group to 18%, with a 2-sided alpha set at 0.05 for significance. Data were analyzed using R statistical software. RESULTS: A total of 256 patients were randomized, including 128 to the "tight control" group (140/90 mm Hg) and 128 to the "liberal control" group (150/95 mm Hg). Patients in the "tight control" group had a higher body mass index at delivery (37.1±9.4 vs 34.9±8.1; P=.04); other demographic and obstetrical characteristics were similar between groups. The rate of the primary outcome was similar between groups (8.6% vs 11.7%; P=.41; relative risk, 0.73; 95% confidence interval, 0.35-1.53). The rates of all secondary outcomes and the individual components of the primary and secondary outcome measures were also similar between groups. CONCLUSION: In the postpartum period, initiation of antihypertensive therapy at a lower blood pressure threshold of 140/90 mm Hg did not decrease maternal morbidity or improve outcomes compared with a threshold of 150/95 mm Hg.

Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care.

Legal, institutional, and payer policies regulating reproductive health care lack a shared language with medicine, resulting in great confusion and consternation. This paper critically examines the implications and ramifications of unclear language related to abortion care. Using a case-based approach, we highlight the ways in which language and terminology may affect the quality and accessibility of care. We also address repercussions for providers and patients within their team, institutional, state, and payer landscapes. In particular, we explore the stigmatization of abortion as both a word and a process, the role of caregivers as gatekeepers, the implications of viability as a limit for access, and the hierarchy of deservedness and value. Recognizing the role of language in these discussions is critical to building systems that honor the complexities of patient-centered reproductive decision-making, ensure access to comprehensive reproductive health care including abortion, and center patient autonomy. Healthcare providers are uniquely positioned to facilitate institutional, state, and national landscapes in which pregnant patients are supported in their autonomy and provided with just and equitable reproductive health care.

Body composition in term neonates of mothers with hypertensive disorders of pregnancy.

BACKGROUND: Neonates of gravidas with hypertensive disorders of pregnancy (HDP) are at increased lifelong risk of cardiometabolic complications. Neonatal adiposity measured by body composition (BC) is a better surrogate of nutritional status than birth weight. Data comparing BC in term neonates of hypertensive and normotensive pregnant patients is lacking. Our objective was to compare body composition in both groups of neonates. METHODS: This was a retrospective cohort study from March 2018 to June 2019 at our tertiary institution where term neonatal BC are routinely measured. Neonates of patients with HDP and matched controls were included. Skin fold thickness (SFT) and percent body fat (PBF) were calculated using a validated anthropometric formula and compared using Mann-Whitney U and chi-square tests. RESULTS: One hundred and forty-two neonates of patients with HDP were compared to 150 controls. Demographic characteristics were similar except for higher pre-pregnancy BMI (29.7 ± 8.4 vs 26.75 ± 7.1, p = <0.01) in the HDP group. SFT was not significantly different (4.6 vs 4.4 mm, p = 0.09) but PBF was higher in the hypertensive group (13.15 vs 11.72, p = 0.01). CONCLUSIONS: PBF is higher in neonates of mothers with HDP, which may contribute to an increased risk of cardiometabolic complications later in life. IMPACT: Birth weight percentiles do not explain the predisposition to cardiovascular complications in offspring of hypertensive mothers. Body composition estimation may provide an explanation for this increased risk. Percent body fat is higher in term neonates of mothers with hypertensive disorders of pregnancy than neonates of normotensive mothers. Body composition is different in term neonates of mothers with hypertensive disorders of pregnancy.

Comparing Two Testing Strategies: Universal versus Symptomatic SARS-CoV-2 Testing in Obstetric Patients.

OBJECTIVE: To compare universal severe acute respiratory syndrome coronvirus-2 (SARS-CoV-2) testing to symptomatic testing at two large academic centers. STUDY DESIGN: We performed a retrospective cohort study comparing the approach to testing at two academic centers in Northeast Ohio. The study period started with the inception of symptomatic testing for SARS-CoV-2 at both institutions in March 2020. Women younger than 18 years were excluded. The primary outcome was the SARS-CoV-2 positivity rate in symptomatic pregnant patients at both institutions. Our coprimary outcome was the additional positivity rate obtained from universal testing at the University Hospitals. The secondary outcome of interest was the percentage of SARS-CoV-2 screen positive mothers with screen positive neonates. Data were analyzed using Mann-Whitney U test for continuous variables with chi-square and Fisher's exact tests for proportions. RESULTS: During the study period, 144 pregnant women with symptoms of coronavirus disease 2019 (COVID-19) were tested at MetroHealth of which 27 resulted as positive for SARS-CoV-2 (18.7% positivity rate). University Hospitals tested 392 pregnant women with symptoms of COVID-19 of which 67 resulted as positive for SARS-CoV-2 (positivity rate 17.0%). In the universal testing program at University Hospitals, an additional 2,870 tests were performed on asymptomatic pregnant women of which 30 were positive for SARS-CoV-2 (1.0% positivity rate).There were no SARS-CoV-2 positive infants in our cohort, and all cases of maternal critical illness occurred in symptomatic patients. CONCLUSION: Universal and symptomatic testing approaches demonstrated similar clinical performance within a single geographic region in obstetric patients. KEY POINTS: · There is a lack of data to recommend an optimal approach to SARS-CoV-2 testing in obstetric patients.. · Universal testing detected few additional cases of SARS-CoV-2.. · Maternal and neonatal outcomes were unaffected by testing strategy..

Society for Maternal-Fetal Medicine Special Statement: Maternal-fetal medicine subspecialist survey on abortion training and service provision.

Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess the attitudes of maternal-fetal medicine subspecialists about abortion services and the available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to associate and regular members of the Society for Maternal-Fetal Medicine to assess their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses were conducted on the survey responses. Of the 2751 members contacted, 546 Society for Maternal-Fetal Medicine members completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. More than 80% of the respondents reported availability of abortion services in their state, 70% reported availability at their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors contributing to the respondents' limited scope of abortion services or lack of any abortion services offered. In the univariable analysis, exposure to formal family planning training programs, fewer years since the completion of residency, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute's abortion policy landscape were factors associated with abortion provision (all P values <.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P=.20; adjusted odds ratio, 1.34; 95% confidence interval, 0.85-2.10), whereas a favorable state policy environment and fewer years since the completion of residency remained associated with abortion provision. The results of this survey suggest that factors at the individual, institutional, and state levels affect the provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare services.

Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality.

The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.

Delivery dose of methadone, but not buprenorphine, is associated with the risk and severity of neonatal opiate withdrawal syndrome.

BACKGROUND: Data on the relationship between the dose of opioid replacement therapy in pregnancy and the risk and severity of neonatal opioid withdrawal syndrome are conflicting and have methodological limitations. OBJECTIVE: To assess the association of methadone and buprenorphine dose at delivery with neonatal opioid withdrawal syndrome in a large cohort. STUDY DESIGN: We performed a retrospective cohort study using data from a comprehensive perinatal opioid dependency program from 2000 through 2016. Women with a history of opioid use disorder enrolled in a medication-assisted treatment program were included. Strict neonatal opioid withdrawal syndrome case definition and neonatal treatment guidelines were utilized throughout the study epoch. Comparisons were made between women on methadone and buprenorphine. The dose of opioid replacement at delivery and the risk and severity of neonatal opioid withdrawal syndrome were assessed with univariable analysis and multivariable logistic regression. In all analyses, methadone and buprenorphine dosing were evaluated as a continuous variable. RESULTS: Four hundred eighty two of 709 women (68.0%) met inclusion criteria including 344 on methadone (71.4%) and 138 on buprenorphine (28.6%). Nonopioid polysubstance abuse, body mass index, medication-assisted treatment compliance, birthweight, and other characteristics were similar between groups. Overall, the frequency of neonatal opioid withdrawal syndrome was not significantly different between the methadone and buprenorphine groups (56.8% vs 52.0%, P = .35). Dose at delivery ranged at 0-165 mg for methadone and 0-30 mg for buprenorphine. In a univariable analysis, methadone dose at delivery was associated with neonatal opioid withdrawal syndrome (83.0 ± 34.2 mg vs 71.9 ± 35.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P < .001), but buprenorphine dose at delivery was not (8.4 ± 4.4 vs 7.6 ± 4.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P = .30). Peak neonatal opioid withdrawal syndrome score, duration of neonatal opioid withdrawal syndrome treatment, and cumulative neonatal morphine exposure were significantly associated with delivery methadone dose but not buprenorphine dose. The association between delivery methadone dose and neonatal opioid withdrawal syndrome persisted in multivariable regression. CONCLUSION: The dose of methadone at the time of delivery is associated with the frequency and severity of neonatal opioid withdrawal syndrome, with higher doses associated with more severe neonatal opioid withdrawal syndrome when analyzed continuously. These data may inform future prospective studies on methadone dosing in pregnancy. While medication-assisted treatment agent and dose may have an impact on pertinent neonatal outcomes related to neonatal opioid withdrawal syndrome, the provision of medication-assisted treatment in pregnancy should reflect the goal of prevention of recidivism and maternal mortality and utilize an approach that balances fetal and maternal risk to optimize outcomes.

Term Labor Outcomes after Cerclage Placement in a Multi-institutional Cohort.

OBJECTIVE: The placement of a cervical cerclage in early pregnancy could influence subsequent labor outcomes at term. Prior studies have yielded conflicting results regarding the potential association with adverse labor outcomes such as cesarean delivery (CD), cervical laceration, and prolonged labor. Our objective was to evaluate rate of CD and adverse maternal outcomes in women who labored at term with and without a cerclage within the Consortium on Safe Labor (CSL) cohort. We hypothesize that women with a cerclage in the incident pregnancy will have an increased frequency of CD and other adverse term labor outcomes. STUDY DESIGN: A retrospective cohort study was performed using data from the CSL. Women with live nonanomalous singleton gestations≥ 37 weeks with induced or spontaneous labor were identified. The risk of CD and other maternal and neonatal outcomes were compared between women with and without cerclage placement during pregnancy. Univariable and multivariable analyses were performed with adjustment for confounding factors. Planned subgroup analysis by history of CD was performed. RESULTS: A total of 374 of the 147,463 patients who met study inclusion criteria in the CSL (0.25%) had a cerclage. In univariable analysis, cerclage placement was associated with a significant increase in the frequency of CD (17.1 vs. 12.8%, p = 0.016, odds ratio: 1.4, 95% CI: 1.07-1.84), cervical lacerations, infectious morbidity, and blood loss. The association with CD persisted in multivariable regression. Cerclage placement was not associated with an increased risk of neonatal morbidity. CONCLUSION: Cerclage placement in pregnancy is associated with an increased risk of CD, cervical laceration, and infectious morbidity among women delivering at term. These findings suggest that cerclage placement may impact labor progression and outcomes. However, the magnitude of the association may not alter clinical decisions regarding cerclage placement in appropriate candidates.

Starting Health Disparities Education During Resident Orientation: Our Patients, Our Community.

Disparities in women's reproductive health outcomes are persistent and prevalent. Cultural competency education of trainees is central to reducing patient-, system-, and practitioner-level factors that promote disparate health outcomes. Such issues include health literacy, access to health care, and unconscious bias. We suggest that recognizing and reducing health disparities should be a longitudinal theme in resident education, first introduced during intern orientation and continued with dedicated didactics, experiential learning opportunities, grand rounds, and journal clubs built into the residency curricula. In this commentary, we present various methods of introducing health disparities education and commencing a larger conversation about inequity and race in medicine. We hope to encourage other training programs to incorporate this important topic earlier into their educational curriculum.

Contraction-Associated Maternal Heart Rate Decelerations: A Pragmatic Marker of Intrapartum Volume Status.

OBJECTIVE: To define and characterize a maternal contraction-associated heart rate deceleration pattern and evaluate its association with maternal volume status. METHODS: We performed a prespecified secondary analysis of a prospectively collected cohort from a randomized controlled trial of maternal pulse pressure, epidural coload volume, and postepidural complications. Participants were healthy intrapartum women with nonanomalous singleton gestations at 35 weeks of gestation or greater and a category 1 fetal heart rate (FHR) pattern from admission to epidural placement. Those lacking continuous maternal pulse oximetry data before epidural placement were excluded. Maternal heart rate tracings were evaluated for the presence of a contraction-associated heart rate deceleration pattern before epidural placement. Women with and without a contraction-associated heart rate deceleration pattern were compared using univariable and multivariable analyses. The primary outcome was the frequency of a contraction-associated heart rate deceleration pattern in hypovolemic compared with euvolemic women as defined by admission pulse pressure (less than 45 and 50 mm Hg or greater, respectively). Secondary outcomes included the association of a contraction-associated heart rate deceleration pattern with postepidural complications related to maternal volume status including new-onset category 2 and 3 FHR abnormalities, maternal hypotension, and the need for resuscitative obstetric interventions. RESULTS: Of 414 trial participants, 388 (93.7%) met inclusion criteria, and 124 of these (32.0%) had a contraction-associated heart rate deceleration pattern before epidural placement. The presence of a contraction-associated heart rate deceleration pattern was more frequent among hypovolemic compared with euvolemic women as defined by admission pulse pressure (41.1% vs 13.6%, relative risk [RR] 3.0, 95% CI 1.9-4.8, P<.001). A contraction-associated heart rate deceleration pattern was associated with more frequent postepidural FHR abnormalities (43.5% vs 31.1%, RR 1.4, 95% CI 1.1-1.8, P=.02), diastolic hypotension (63.7% vs 50.0%, RR 1.3, 95% CI 1.1-1.5, P=.01), and the need for resuscitative interventions (33.9% vs 23.1%, RR 1.5, 95% CI 1.1-2.0, P=.03). In multivariable analysis with adjustment for baseline differences between groups, the associations between a contraction-associated heart rate deceleration pattern and abnormal FHR patterns, diastolic hypotension, and the need for resuscitative interventions persisted and were slightly strengthened. CONCLUSION: The maternal contraction-associated heart rate deceleration pattern is a pragmatic, bedside visual indicator of intrapartum maternal volume status. A contraction-associated heart rate deceleration pattern is threefold more frequent among hypovolemic compared with euvolemic women as defined by admission pulse pressure and is associated with postepidural complications including abnormal FHR patterns, diastolic hypotension, and the need for resuscitative interventions. The contraction-associated heart rate deceleration pattern highlights a novel role for intrapartum maternal heart rate assessment and may inform the individualization of intrapartum fluid management.

Cervical ripening balloon with and without oxytocin in multiparas: a randomized controlled trial.

BACKGROUND: The optimal method for induction of labor for multiparous women with an unfavorable cervix is unknown. OBJECTIVE: We sought to determine if induction of labor with simultaneous use of oxytocin and a cervical ripening balloon, compared with sequential use, increases the likelihood of delivery within 24 hours in multiparous women. STUDY DESIGN: We performed a randomized controlled trial from November 2014 through June 2017. Eligible participants were multiparous women with a vertex presenting, nonanomalous singleton gestation ≥34 weeks undergoing induction of labor. Women were excluded for admission cervical examination >2 cm, ruptured membranes, chorioamnionitis or evidence of systemic infection, placental abruption, low-lying placenta, >1 prior cesarean delivery, or contraindication to vaginal delivery. Patients were randomly allocated to the following cervical ripening groups: simultaneous (oxytocin with cervical ripening balloon) or sequential (oxytocin following cervical ripening balloon expulsion). The primary outcome was delivery within 24 hours of cervical ripening balloon placement. Secondary outcomes included induction-to-delivery interval, time to cervical ripening balloon expulsion, mode of delivery, and adverse maternal or neonatal outcomes. RESULTS: In all, 180 patients were randomized (90 simultaneous, 90 sequential). Baseline demographic and obstetric characteristics were similar between study groups. Women in the simultaneous group were significantly more likely to deliver within 24 hours of cervical ripening balloon placement compared to the sequential group (87.8% vs 73.3%, P = .02). The simultaneous group also had a significantly shorter induction-to-delivery interval and greater cervical dilation at cervical ripening balloon expulsion. There were no differences in mode of delivery, chorioamnionitis, or adverse maternal or neonatal outcomes. CONCLUSION: In multiparous women with an unfavorable cervix, the simultaneous use of cervical ripening balloon and oxytocin results in an increased frequency of delivery within 24 hours and a shorter induction-to-delivery interval.