Antenatal Breast Milk Expression Survey of Individuals Whose Pregnancy Was Complicated by Diabetes: Exploring Knowledge, Perceptions, Experiences, and Milk Volume Expressed.

OBJECTIVE: Antenatal breast milk expression (ABE) offers a host of benefits, including reduced formula consumption, support for breastfeeding success, and increased maternal satisfaction. Despite these advantages, experience with ABE differs significantly, often leading to anxiety over perceived inadequate milk supply and eventual breastfeeding cessation. This study comprehensively evaluates the knowledge, attitudes, and real-world experiences of individuals with gestational or pregestational diabetes concerning ABE, with a focus on total milk volume expressed prior to birth. STUDY DESIGN: Utilizing a convenience sampling method, we surveyed individuals with gestational or pregestational diabetes from three health care facilities who were trained in ABE. Knowledge and perceptions were gauged through presurvey statements, while postsurvey statements were employed to measure experiences, both using a 5-point Likert scale. In parallel, a retrospective study assessed both maternal and infant outcomes among the same participant pool. Statistical comparisons between individuals with and without reservations were made using the Wilcoxon signed rank sum, Mann-Whitney, chi-square, and Fisher's exact tests. RESULTS: Of the 138 participants, 75% completed both survey segments, and 61% expressed reservations about ABE. Both groups were demographically similar and showed comparable newborn outcomes. However, individuals with reservations experienced heightened pain during ABE, reported lesser lactation support, and were less willing to repeat the process compared to those individuals without reservations. The median total ABE volume was significantly lower by 14 mL among those with reservations (7 vs. 21 mL, p = 0.009). Although both groups demonstrated improved attitudes toward the utility of ABE for individuals with gestational or pregestational diabetes, no significant shift occurred in the perception of ABE difficulty. CONCLUSION: Our results indicate that individuals with gestational or pregestational diabetes who have reservations about ABE face unique challenges and tend to express lower milk volumes. This underlines the need for specialized interventions and ongoing research to address antenatal lactation support and alleviate ABE-related concerns among individuals with gestational or pregestational diabetes. KEY POINTS: · Reservations of ABE were associated with reduced milk volumes.. · Regardless of reservations, ABE was felt to be beneficial.. · Our results underscore the need for more ABE education for those with reservations..

Associations between Hysterectomy and Metabolic Syndrome: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Metabolic syndrome is linked to an increased risk of incident cardiovascular disease (CVD) and all-cause mortality. Notable associations exist between hysterectomy with bilateral salpingo-oophorectomy and metabolic syndrome. However, there is emerging evidence that even with ovarian conservation, hysterectomy may be independently associated with long-term CVD risk. OBJECTIVE: To examine the associations between hysterectomy with ovarian preservation and metabolic syndrome risk in a multi-ethnic cohort. METHODS: We studied 3,367 female participants in the Multi-Ethnic Study of Atherosclerosis who had data on self-reported history of hysterectomy, oophorectomy, hystero-oophorectomy and metabolic syndrome at baseline (2000-2002). We used adjusted logistic regression to assess the cross-sectional associations between hysterectomy/oophorectomy subgroups and prevalent metabolic syndrome at baseline. Furthermore, we investigated 1,355 participants free of baseline metabolic syndrome and used adjusted Cox regression models to evaluate incident metabolic syndrome from exams 2 (2002-2004) to 6 (2016-2018). RESULTS: The mean±SD age was 59.0±9.5 years, with 42% White, 27% Black, 19% Hispanic, and 13% Chinese American participants. 29% and 22% had a history of hysterectomy and oophorectomy, respectively. Over a median follow-up period of 10.5 (3.01-17.62) years, there were 750 metabolic syndrome events. Hysterectomy [HR, 1.32 (95%CI, 1.01-1.73)] and hystero-oophorectomy [1.40 (1.13-1.74)] were both strongly associated with incident metabolic syndrome compared to having neither hysterectomy or oophorectomy. CONCLUSION: Hysterectomy, even with ovarian preservation, may be independently associated with a higher risk of metabolic syndrome. If other studies confirm these findings, screening and preventive strategies focused on females with ovary-sparing hysterectomy and the mechanisms underpinning these associations may be explored.

The association of obesity with post-cesarean inpatient opioid consumption.

BACKGROUND: Obesity and prescription opioid misuse are important public health concerns in the United States. A common intersection occurs when women with obesity undergo cesarean birth and receive narcotic medications for postpartum pain. OBJECTIVE: To examine the association between obesity and inpatient opioid use after cesarean birth. METHODS: A retrospective cohort study of patients that underwent cesarean birth in 2015-2018. Primary outcome was post-cesarean delivery opioid consumption starting 24 h after delivery measured as morphine milliequivalents per hour (MME/h). Secondary outcome was MME/h consumption in the highest quartile of all subjects. Opioid consumption was compared between three BMI groups: non-obese BMI 18.5-29.9 kg/m2; obese BMI 30.0-39.9 kg/m2; and morbidly obese BMI ≥ 40.0 kg/m2 using univariable and multivariable analyses. RESULTS: Of 1620 patients meeting inclusion criteria, 496 (30.6%) were in the non-obese group, 753 (46.5%) were in the obese group, and 371 (22.9%) were in the morbidly obese group. In the univariate analysis, patients with obesity and morbid obesity required higher MME/h than patients in the non-obese group [1.3 MME/h (IQR 0.1, 2.4) vs. 1.6 MME/h (IQR 0.5, 2.8) vs. 1.8 MME/h (IQR 0.8, 2.9), for non-obese, obese, and morbidly obese groups respectively, p < 0.001]. In the multivariable analysis, this association did not persist. In contrast, subjects in the obese and morbidly obese groups were more likely to be in the highest quartile of MME/h opioid consumption compared with those in the non-obese group (23.5% vs. 48.1% vs. 28.4%, p < 0.001, respectively); with aOR 1.42 (95% CI 1.07-1.89, p = 0.016) and aOR 1.60 (95% CI 1.16-2.22, p = 0.005) for patients with obesity and morbid obesity, respectively. CONCLUSION: Maternal obesity was not associated with higher hourly MME consumption during inpatient stay after cesarean birth. However, patients with obesity and morbid obesity were significantly more likely to be in the top quartile of MME hourly consumption.

Association Between Recurrent Preeclampsia and Attendance at the Blood Pressure Monitoring Appointment After Birth.

OBJECTIVE: To examine the association between recurrent preeclampsia and attendance at the standard of care blood pressure monitoring appointment after birth. DESIGN: Retrospective cohort. SETTING: Single Magnet-accredited hospital affiliated with an academic medical center. PARTICIPANTS: Multiparous women who gave birth between 2010 and 2020 and were diagnosed with preeclampsia (N = 313). METHODS: We divided participants into two groups: those with prior preeclampsia (n = 119) and those without prior preeclampsia (n = 194). Using logistic regression, we calculated unadjusted and adjusted odds ratios to estimate the association between attendance at the postpartum blood pressure (PPBP) monitoring appointment and prior preeclampsia. We also explored the relationship between attendance at the PPBP monitoring appointment and use of magnesium sulfate during labor and birth and the relationship between attendance at the PPBP monitoring appointment and use of maintenance antihypertensive medications. RESULTS: In adjusted analysis, participants with prior preeclampsia were 66.4% less likely to attend the PPBP monitoring appointment compared with those without prior preeclampsia, adjusted OR = 0.34, 95% CI [0.18, 0.62]. Administration of magnesium sulfate during delivery admission and use of maintenance antihypertensive medications were not associated with a change in attendance at the PPBP appointment. CONCLUSION: Further research on patient-perceived risk of recurrent preeclampsia and improvement of systems to facilitate postpartum follow-up is needed.

Effects of physical activity on placental analytes in nulliparous persons.

INTRODUCTION: Physical activity during pregnancy has long been investigated for its role in preeclampsia prevention. The mechanism of this relationship is unknown, although some studies suggest physical activity may affect placental analytes throughout pregnancy. The objective of this study was to determine the effect of physical activity on preeclampsia-associated placental analytes using a prospective cohort of pregnant nulliparous patients. METHODS: This was a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be. Frequency and duration of up to three leisure activities was reported in the first and second trimesters and was analyzed, with participants either meeting or not meeting the recommended exercise of 150 min per week. Levels of the following placental analytes, placental growth factor, soluble endoglin, and soluble fms-like tyrosine kinase-1 (sFLT1), were analyzed stratified by the physical activity level. RESULTS: A total of 1,956 participants were included in the analysis. The level of sFLT1 in the first trimester was lower in the group that had ≥ 150 min per week of physical activity, compared to the group that had < 150 min (846.3 [821.6, 871,8] versus 893.0 [864.5,922.5], p = 0.017). There were no significant sFLT1 changes in the second trimester based on physical activity. After controlling for maternal demographic and clinical factors, sFLT1 levels in the second trimester were significantly lower (p = 0.049) in participants that had ≥ 150 min of physical activity per week. DISCUSSION: Our findings of decreased sFLT1 levels suggest this could be the mechanism explaining the association between PA in pregnancy and lower risk of preeclampsia.

Association between body mass index and chronic hypertension in patients with hypertension disorders of pregnancy one-year postpartum.

OBJECTIVES: To determine the association between body mass index (BMI) and chronic hypertension (CHTN) one-year postpartum following pregnancies complicated by hypertensive disorders of pregnancy (HDP). STUDY DESIGN: A retrospective cohort study of patients with HDP (gestational hypertension or preeclampsia) in a single Midwestern academic center from 2014 to 2018. The primary outcome was CHTN at one-year postpartum, defined as systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg or taking antihypertensive medication at one-year postpartum. The primary exposure variable was BMI at one-year postpartum, categorized as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25-<30 kg/m2), and obese (≥30 kg/m2) and as continuous BMI variable. Descriptive statistics and adjusted logistic regression analysis were performed. RESULTS: Out of 596 patients with HDP included in this analysis, 275 (46.1 %) had CHTN one-year postpartum. Mean one-year postpartum BMI was 27.9 ± 5.2 kg/m2. Prevalence of CHTN at one-year postpartum was higher in obese (38.1 %) and overweight (30.0 %) groups compared to the normal weight group (29.9 %), p < 0.001. In multivariate logistic regression, obesity at one-year postpartum, compared to normal, was associated with 73 % higher likelihood of CHTN following HDP (adjusted OR 1.73, 95 % CI 1.06-2.84). With BMI as a continuous variable, each unit increase in BMI one-year postpartum was associated with 6 % higher likelihood of CHTN (adjusted OR 1.06, 95 % CI 1.02-1.15). CONCLUSIONS: Obesity at one-year postpartum following HDP was associated with a higher risk of CHTN compared with normal BMI. Weight is a modifiable risk factor that should be targeted in postpartum interventions to reduce cardiovascular disease following HDP.

Researching COVID to enhance recovery (RECOVER) pregnancy study: Rationale, objectives and design.

IMPORTANCE: Pregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER-Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads. METHODS: RECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators. DISCUSSION: RECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero. CLINICAL TRIALS.GOV IDENTIFIER: Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT05172011.

Perinatal Outcomes Associated With Management of Stage 1 Hypertension.

OBJECTIVE: To evaluate the association between maternal blood pressure (BP) below 130/80 mm Hg compared with 130-139/80-89 mm Hg and pregnancy outcomes. METHODS: We conducted a planned secondary analysis of CHAP (Chronic Hypertension and Pregnancy), an open label, multicenter, randomized controlled trial. Participants with mean BP below 140/90 mm Hg were grouped as below 130/80 mm Hg compared with 130-139/80-89 mm Hg by averaging postrandomization clinic BP throughout pregnancy. The primary composite outcome was preeclampsia with severe features, indicated preterm birth before 35 weeks of gestation, placental abruption, or fetal or neonatal death. The secondary outcome was small for gestational age (SGA). RESULTS: Of 2,408 patients in CHAP, 2,096 met study criteria; 1,328 had mean BP 130-139/80-89 mm Hg and 768 had mean BP below 130/80 mm Hg. Participants with mean BP below 130/80 mm Hg were more likely to be older, on antihypertensive medication, in the active treatment arm, and to have lower BP at enrollment. Mean clinic BP below 130/80 mm Hg was associated with lower frequency of the primary outcome (16.0% vs 35.8%, adjusted relative risk 0.45; 95% CI 0.38-0.54) as well as lower risk of severe preeclampsia and indicated birth before 35 weeks of gestation. There was no association with SGA. CONCLUSION: In pregnant patients with mild chronic hypertension, mean BP below 130/80 mm Hg was associated with improved pregnancy outcomes without increased risk of SGA. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT02299414.

Prospective Survey of Discrimination in Pregnant Persons and Correlation with Unplanned Healthcare Utilization.

OBJECTIVE: To determine the association between lifetime exposure to discrimination and unplanned healthcare utilization in pregnant persons. METHODS: This was a prospective cohort study of pregnant persons receiving care from 2021 to 2022. Primary data was collected from participants on sociodemographic factors and on Perceived Ethnic Discrimination Questionnaire (PED-Q), a validated 17-item scale measuring perceived lifetime interpersonal racial and ethnic discrimination in four domains: work/school, social exclusion, stigmatization, and threat. The primary outcome was unplanned healthcare utilization, defined as unplanned labor and delivery admissions, triage, Emergency Department, or urgent care visits. Bivariate and multivariate analyses were done to examine the association between lifetime exposure to discrimination and unplanned healthcare utilization. RESULTS: A total of 289 completed the PED-Q and were included in the analysis. Of these, 123 (42.6%) had unplanned healthcare utilization. Mean (SD) of lifetime racial and ethnic discrimination was significantly higher in people with unplanned healthcare utilization compared to those with planned healthcare utilization [1.67 (0.63) vs 1.48 (0.45), p = 0.003]. Univariate analysis showed that lifetime racial and ethnic discrimination was significantly associated with unplanned healthcare utilization (OR 1.96, 95% CI 0.23-3.11). Significant associations were found between unplanned healthcare utilization and maternal age (p = 0.04), insurance type (p = 0.01), married status (p < 0.001), education (p = 0.013), household income (p = 0.001), and chronic hypertension (p = 0.004). After controlling for potential confounding factors, self-reported lifetime racial and ethnic discrimination remained significantly associated with higher odds of unplanned healthcare utilization (aOR 1.78, CI 95% 1.01-3.11). CONCLUSION: We found that a higher level of self-reported lifetime racial and ethnic discrimination was associated with increased unplanned healthcare utilization during pregnancy.

Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women.

OBJECTIVE: Our objective was to examine associations between social determinants of health (cultural, neighborhood, and psychosocial factors) and adverse pregnancy outcomes (gestational age at birth [GAB], preterm birth [PTB], and preeclampsia) in Black women. STUDY DESIGN: Cross-sectional data (n = 204) comprised adult Black women aged ≥18 years who delivered between 2013 and 2022 in Milwaukee,Wisconsin. Sequential unadjusted linear and logistic regression models were run to evaluate associations between social determinants of health and pregnancy outcomes. Stepwise regressions with forward selection were run to test the contribution of the social determinants of health to adverse pregnancy outcomes, independent of the contribution of established risk factors. RESULTS: Mean GAB was 37.9 weeks, 19.6% had a PTB and 17.7% had preeclampsia. In all fully adjusted models, education (ß0.15, 95% confidence interval [CI]: 0.005, 0.29), nulliparity (ß -1.26, 95%CI: -2.08, -0.44), multifetal gestation (ß -2.67, 95% CI: -4.29, -1.05), and exposure to neighborhood violence (ß -0.13, 95%CI: -0.25, -0.005) were associated with shortened GAB. Education (adjusted odds ratio [aOR]: 0.83, 95%CI: 0.69, 0.99), provider trust (aOR: 0.94, 95%CI: 0.88, 0.99), chance health locus of control (aOR: 0.88, 95%CI: 0.78, 0.99), and anxiety (aOR: 0.81, 95%CI: 0.69, 0.95) were associated with reduced odds of PTB. Powerful others health locus of control (aOR: 1.16, 95%CI: 1.03, 1.32), depression (aOR: 1.17, 95%CI: 1.01, 1.34), nulliparity (aOR: 4.73, 95%CI: 1.79, 12.55), multifetal gestation (aOR: 17.78, 95%CI: 3.49, 90.50), diabetes (aOR: 4.71, 95%CI: 1.17, 19.00), and obstructive sleep apnea (aOR: 44.28, 95%CI: 2.50, 783.12) were associated with increased odds of PTB. Internal health locus of control (aOR: 1.13, 95%CI: 1.01, 1.25), depression (aOR: 1.09, 95%CI: 1.01, 1.17), preeclampsia in a previous pregnancy (aOR: 5.96, 95% CI: 2.22, 16.01), and kidney disease (aOR: 34.27, 95% CI: 1.54, 763.75) were associated with preeclampsia. CONCLUSION: Provider trust, health locus of control, neighborhood violence, depression, and anxiety were associated with adverse pregnancy outcomes in Black women, independent of demographic and clinical risk factors. KEY POINTS: · We identified associations between exposure to neighborhood violence and gestational age at birth.. · Trust, locus of control, depression, and anxiety were associated with preterm birth and preeclampsia.. · Future research should focus on interventions that address social and clinical factors..

Breastfeeding initiation and duration among people with mild chronic hypertension: a secondary analysis of the Chronic Hypertension and Pregnancy trial.

BACKGROUND: Increased duration of breastfeeding improves maternal cardiovascular health and may be especially beneficial in high-risk populations, such as those with chronic hypertension. Others have shown that individuals with hypertension are less likely to breastfeed, and there has been limited research aimed at supporting breastfeeding goals in this population. The impact of perinatal blood pressure control on breastfeeding outcomes among people with chronic hypertension is unknown. OBJECTIVE: This study aimed to evaluate whether breastfeeding initiation and short-term duration assessed at the postpartum clinic visit differed according to perinatal blood pressure treatment strategy (targeting blood pressure <140/90 mm Hg vs reserving antihypertensive treatment for blood pressure ≥160/105 mm Hg). STUDY DESIGN: We performed a secondary analysis of the Chronic Hypertension and Pregnancy trial. This was an open-label, multicenter, randomized trial where pregnant participants with mild chronic hypertension were randomized to receive antihypertensive medications with goal blood pressure <140/90 mm Hg (active treatment) or deferred treatment until blood pressure ≥160/105 mm Hg (control). The primary outcome was initiation and duration of breastfeeding, assessed at the postpartum clinic visit. We performed bivariate analyses and log-binomial and cumulative logit regression models, adjusting models for variables that were unbalanced in bivariate analyses. We performed additional analyses to explore the relationship between breastfeeding duration and blood pressure measurements at the postpartum visit. RESULTS: Of the 2408 participants from the Chronic Hypertension and Pregnancy trial, 1444 (60%) attended the postpartum study visit and provided breastfeeding information. Participants in the active treatment group had different body mass index class distribution and earlier gestational age at enrollment, and (by design) were more often discharged on antihypertensives. Breastfeeding outcomes did not differ significantly by treatment group. In the active and control treatment groups, 563 (77.5%) and 561 (78.1%) initiated breastfeeding, and mean durations of breastfeeding were 6.5±2.3 and 6.3±2.1 weeks, respectively. The probability of ever breastfeeding (adjusted relative risk, 0.99; 95% confidence interval, 0.93-1.05), current breastfeeding at postpartum visit (adjusted relative risk, 1.01; 95% confidence interval, 0.94-1.10), and weeks of breastfeeding (adjusted odds ratio, 0.87; 95% confidence interval, 0.68-1.12) did not differ by treatment group. Increased duration (≥2 vs <2 weeks) of breastfeeding was associated with slightly lower blood pressure measurements at the postpartum visit, but these differences were not significant in adjusted models. CONCLUSION: In a secondary analysis of the cohort of Chronic Hypertension and Pregnancy trial participants who attended the postpartum study visit and provided breastfeeding information (60% of original trial participants), breastfeeding outcomes did not differ significantly by treatment group. This suggests that maintaining goal blood pressure <140/90 mm Hg throughout the perinatal period is associated with neither harm nor benefit for short-term breastfeeding goals. Further study is needed to understand long-term breastfeeding outcomes among individuals with chronic hypertension and how to support this population in achieving their breastfeeding goals.

Researching COVID to enhance recovery (RECOVER) pregnancy study: Rationale, objectives and design.

Importance: Pregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER- Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads. Methods: RECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators. Discussion: RECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero. Registration: NCT05172024.

Effect of a Best-Practice Alert on the Rate of Smoking Cessation among Pregnant Women.

OBJECTIVE: This study aimed to determine if a best-practice alert (BPA) implementation increases the rate of smoking cessation during pregnancy and affects pregnancy outcomes associated with smoking. STUDY DESIGN: This was a pretest-posttest study design where a BPA was added to electronic medical records (EMR) of pregnant persons who reported active smoking. The BPA provided the 5A's method to conduct counseling on smoking cessation. The rates of smoking cessation during pregnancy were compared 1.5 years before and after implementation of the BPA. Secondary outcomes examined whether counseling on smoking cessation was done, the number of the counseling sessions during pregnancy, and obstetric outcomes associated with maternal smoking. RESULTS: After implementation of the BPA, the rate of smoking cessation in pregnancy increased from 17.5% prior to BPA implementation to 54.9% after BPA implementation (p < 0.001). The rate of counseling on smoking cessation increased from 66.6% prior to BPA implementation to 95.6% after BPA implementation, with an increase noted also in the number of smoking cessation counseling sessions. In multivariate analyses, after controlling for maternal demographic and clinical factors, BPA implementation was significantly associated with higher rates of smoking cessation (adjusted odds ratio [aOR]: 3.44, 95% confidence interval [CI]: 2.17-5.51), higher rates of documented smoking cessation counseling in the EMR (aOR: 12.44, 95% CI: 6.06-25.64), and higher odds of conducting the counseling more than once (aOR: 6.90 95% CI: 4.45-10.88). CONCLUSION: The rate of smoking cessation and number of times pregnant persons were counseled increased after implementation of a BPA. The BPA could be a useful EMR tool to increase smoking cessation rates during pregnancy. KEY POINTS: · Smoking during pregnancy is a maternal and fetal concern.. · Prenatal care offers the chance to address smoking.. · BPA increases rates of smoking counseling and cessation..

GAP (gestational diabetes and pharmacotherapy) - study protocol for a randomized controlled, two-arm, single-site trial.

BACKGROUND: Gestational diabetes (GDM) complicates 10% of pregnancies in the US. First-line treatment is medical nutrition therapy (MNT) and exercise. Second line is pharmacotherapy. The definition of what constitutes an unsuccessful trial of MNT and exercise has not been established. Tight glycemic control has been demonstrated to reduce GDM-related neonatal and maternal clinical complications. However, it could also increase rates of small-for-gestational age and carry negative effects on patient-reported outcomes such as anxiety and stress. We will study the effect of earlier and stricter pharmacotherapy in GDM on clinical and patient-reported outcomes. METHODS: GDM and pharmacotherapy (GAP) study is a two-arm parallel, pragmatic randomized controlled trial, where 416 participants with GDM are randomized 1:1 to: 1) Intervention group - insulin initiation at 20% elevated glucose values on a weekly glucose log following MNT and exercise trial and insulin titration to keep elevated glucose values <20%; or 2) Active control group - insulin initiation at 40% elevated glucose values on a weekly log following MNT and exercise and insulin titration to keep elevated glucose values <40%. The primary outcome is a composite neonatal outcome of large-for-gestational-age, macrosomia, birth trauma, preterm birth, hypoglycemia, and hyperbilirubinemia. Secondary outcomes include preeclampsia, cesarean birth, small-for-gestational-age, maternal hypoglycemia, and patient-reported outcomes of anxiety, depression, perceived stress, and diabetes self-efficacy. CONCLUSIONS: The GAP study will investigate the optimal glycemic threshold for pharmacotherapy addition to MNT and exercise in GDM. The GAP study will promote standardization in GDM management and will have direct relevance for clinical practice.

Incidence of Adverse Pregnancy Outcomes Based on the Degree of Short Interpregnancy Interval in Urban Milwaukee Population.

INTRODUCTION: Short interpregnancy interval is defined as conception occurring within 18 months of a previous live birth. Studies show increased risks of preterm birth, low birth weight, and small for gestational age with short interpregnancy intervals; however, it is unclear if these risks are higher for all short interpregnancy intervals or only for those less than 6 months. The objective of this study was to evaluate prevalence of adverse pregnancy outcomes among people with short interpregnancy intervals, stratified by degree: less than 6 months, 6 to 11 months, and 12 to 17 months. METHODS: We conducted a retrospective cohort study of people with 2 singleton pregnancies between 2015 and 2018 at a single academic center. The following outcomes were compared between patients with interpregnancy intervals of less than 6 months, 6 to 11 months, 12 to 17 months, and 18 months or more; hypertensive disorders of pregnancy (gestational hypertension and preeclampsia), preterm birth at less than 37 weeks, low birth weight ( < 2500 g), congenital anomalies, and gestational diabetes. Bivariate and multivariate analyses were done to examine the independent role of the degree of short interpregnancy interval and each outcome. RESULTS: A total of 1,462 patients were included in the analysis, with 80 pregnancies occurring at interpregnancy intervals less than 6 months, 181 at 6 to 11 months, 223 at 12 to 17 months, and 978 at 18 months or more. In unadjusted analysis, patients with interpregnancy intervals less than 6 months had the highest rate of preterm birth at 15.0%. In addition, patients with interpregnancy intervals less than 6 months and 12 to 17 months had higher rates of congenital anomalies versus those with interpregnancy intervals of 18 months or more. In multivariate analysis, controlling for sociodemographic and clinical confounding factors, interpregnancy intervals less than 6 months were associated with 2.3 higher odds of preterm birth (95% CI, 1.13-4.68), and those 12 to 17 months were associated with 2.52 higher odds of congenital anomalies (95% CI, 1.22-5.20). The odds of gestational diabetes were lower with interpregnancy intervals of 6 to 11 months compared to those 18 months or more (aOR 0.26; 95% CI, 0.08-0.85). CONCLUSIONS: In this single-site cohort, people with interpregnancy intervals less than 6 months had higher odds of preterm birth, while those with interpregnancy intervals 12 to 17 months had higher odds of congenital anomalies, compared with the control group with interpregnancy intervals greater than or equal to 18 months. Future research should focus on identifying modifiable risk factors for short interpregnancy intervals and interventions to reduce them.

Strategies to reduce COVID-19 vaccine hesitancy among pregnant individuals: Data from a prospective survey of unvaccinated pregnant women.

OBJECTIVE: To explore strategies that could reduce coronavirus disease 2019 (COVID-19) vaccine hesitancy in pregnancy. METHODS: In 2021, the authors conducted a survey of pregnant women assessing attitudes and beliefs regarding COVID-19 vaccination. The present analysis reviewed trusted sources of information about COVID-19 vaccination that could reduce vaccine hesitancy among pregnant respondents. RESULTS: A total of 295 surveys were analyzed. Using 10-point Likert scales, intentions to accept COVID-19 vaccine were split between individuals with low (n = 126, 43%) and high (n = 141, 48%) intentions to receive the vaccine, with only a small percentage of women having midrange vaccination intentions (n = 28, 10%). When asked what would reduce their COVID-19 vaccine concerns, published data was the leading answer in both low (46.2%) and medium (35.7%) intention groups followed by personally knowing someone who got vaccinated during pregnancy (21.0% and 28.6% for low and medium groups, respectively). In contrast, an obstetrician's recommendation was the most common answer in the group with high intention to vaccinate (37.2%). Knowing someone who received the vaccine in pregnancy was the leading response for reducing concerns of COVID-19 vaccination among Black respondents. CONCLUSION: The survey identified several innovative and culturally specific approaches to address vaccine confidence and complacency and improve vaccine uptake in pregnant people.

Outcomes of shared institutional review board compared with multiple individual site institutional review board models in a multisite clinical trial.

BACKGROUND: Institutional review boards play a crucial role in initiating clinical trials. Although many multicenter clinical trials use an individual institutional review board model, where each institution uses their local institutional review board, it is unknown if a shared (single institutional review board) model would reduce the time required to approve a standard institutional review board protocol. OBJECTIVE: This study aimed to compare processing times and other processing characteristics between sites using a single institutional review board model and those using their individual site institutional review board model in a multicenter clinical trial. STUDY DESIGN: This was a retrospective study of sites in an open-label, multicenter randomized control trial from 2014 to 2021. Participating sites in the multicenter Chronic Hypertension and Pregnancy trial were asked to complete a survey collecting data describing their institutional review board approval process. RESULTS: A total of 45 sites participated in the survey (7 used a shared institutional review board model and 38 used their individual institutional review board model). Most sites (86%) using the shared institutional review board model did not require a full-board institutional review board meeting before protocol approval, compared with 1 site (3%) using the individual institutional review board model (P<.001). Median total approval times (41 vs 56 days; P=.42), numbers of submission rounds (1 vs 2; P=.09), and numbers of institutional review board stipulations (1 vs 4; P=.12) were lower for the group using the shared institutional review board model than those using the individual site institutional review board model; however, these differences were not statistically significant. CONCLUSION: The findings supported the hypothesis that the shared institutional review board model for multicenter studies may be more efficient in terms of cumulative time and effort required to obtain approval of an institutional review board protocol than the individual institutional review board model. Given that these data have important implications for multicenter clinical trials, future research should evaluate these findings using larger or multiple multicenter trials.

Blood pressure changes in gestational hypertension, preeclampsia, and chronic hypertension from preconception to 42-day postpartum.

OBJECTIVE: To investigate blood pressure changes from preconception to 42-day postpartum in patients with gestational hypertension, preeclampsia, and chronic hypertension. STUDY DESIGN: Secondary analysis of patients diagnosed with a hypertensive disorder of pregnancy (HDP) antenatally or postpartum, who were enrolled prospectively in a postpartum remote blood pressure (BP) monitoring program between March 2017 and May 2020. BP were collected at 47 time points: preconception, each trimester, delivery day, and every postpartum day through 42-days postpartum. The primary outcome of the study was to examine changes in BP over time and between the types of HDP for 42 days postpartum. Secondary outcomes included the difference in timing of BP stabilization (BPs < 140/90 mmHg for ≥ 48 h), BP resolution (stabilized without antihypertensive medication use), and antihypertensive medication usage at 42-day postpartum between the HDP groups. RESULTS: A total of 1,194 patients were included in the cohort; 224 (18.8 %) had chronic hypertension (CHTN), 525 (43.9 %) had gestational hypertension (GHTN), 153 (12.8 %) had preeclampsia, and 292 (24.5 %) had preeclampsia with severe features. Postpartum BP peaked on days 5-7 postpartum with rapid decrease from postpartum day 7 until postpartum day 14, followed by very small resolution/stabilization in BP values between day 15 and 42 postpartum. By 6 weeks postpartum, 60.5 % of patients with CHTN still required antihypertensive medications to maintain BP < 140/90 mmHg. In the group of patients with preeclampsia with severe features, 32.6 % still required antihypertensive medications to maintain BP < 140/90 mmHg. Finally, 16.1 % patients with GHTN and 23.8 % of patients with preeclampsia without severe features required antihypertensive use at 6 weeks postpartum. The groups of CHTN and GHTN had significant reduction in SBPs at 42-days postpartum compared to their pre-conception BP (p < 0.001 for both groups). While diastolic BP at 42-days postpartum were not different in CHTN, GHTN and preeclampsia groups, compared to preconception, women with preeclampsia with severe features had higher diastolic BP at the end of 6-weeks postpartum period compared to preconception readings (p = 0.007). CONCLUSION: Our study adds new information by examining BP trajectories through 42 days postpartum and demonstrates that all types of HDP are at risk of BP spikes and intervention through 42 days postpartum. We found that patients with CHTN had slower stabilization and resolution of their BP compared to patients with GHTN and preeclampsia with and without severe features. In addition, even at 42 days postpartum, a substantial proportion of patients with HDP, including GHTN, required antihypertensive treatment to maintain BP within stage I hypertension.

O-GlcNAc transferase contributes to sex-specific placental deregulation in gestational diabetes.

INTRODUCTION: Gestational diabetes (GDM) is traditionally thought to emerge from placental endocrine dysregulations, but recent evidence suggests that fetal sex can also impact GDM development. Understanding the molecular mechanisms through which sex modulates placenta physiology can help identify novel molecular targets for future clinical care. Thus, we investigated the nutrient-sensing O-GlcNAc pathway as a potential mediator of sex-specific placenta dysfunction in GDM. METHODS: Expression levels of O-GlcNAc enzymes were measured in male and female (n = 9+/gender) human placentas based on the maternal diagnosis of GDM. We then simulated the observed differences in both BeWo cells and human syncytiotrophoblasts primary cells (SCT) from male and female origins (n = 6/gender). RNA sequencing and targeted qPCR were performed to characterize the subsequent changes in the placenta transcriptome related to gestational diabetes. RESULTS: O-GlcNAc transferase (OGT) expression was significantly reduced only in male placenta collected from mothers with GDM compared to healthy controls. Similar downregulation of OGT in trophoblast-like BeWo male cells demonstrated significant gene expression deregulations that overlapped with known GDM-related genes. Notably, placental growth hormone (GH) production was significantly elevated, while compensatory factors against GH-related insulin resistance were diminished. Inflammatory and immunologic factors with toxic effects on pancreatic ß cell mass were also increased, altogether leaning toward a decompensatory diabetic profile. Similar changes in hormone expression were confirmed in male human primary SCTs transfected with siOGT. However, down-regulating OGT in female primary SCTs did not impact hormone production. CONCLUSION: Our study demonstrated the significant deregulation of placental OGT levels in mothers with GDM carrying a male fetus. When simulated in vitro, such deregulation impacted hormonal production in BeWo trophoblast cells and primary SCTs purified from male placentas. Interestingly, female placentas were only modestly impacted by OGT downregulation, suggesting that the sex-specific presentation observed in gestational diabetes could be related to O-GlcNAc-mediated regulation of placental hormone production.

The Association of Race and Ethnicity with Severe Maternal Morbidity among Individuals Diagnosed with Hypertensive Disorders of Pregnancy.

OBJECTIVE: This study aimed to examine whether there are racial disparities in severe maternal morbidity (SMM) in patients with hypertensive disorders of pregnancy (HDP). STUDY DESIGN: Secondary analysis of an observational study of 115,502 patients who had a live birth at ≥20 weeks in 25 hospitals in the United States from 2008 to 2011. Only patients with HDP were included in this analysis. Race and ethnicity were categorized as non-Hispanic White, non-Hispanic Black (NHB), and Hispanic and were abstracted from the medical charts. Patients of other races and ethnicities were excluded. Associations were estimated between race and ethnicity, and the primary outcome of SMM, defined as any of the following, was estimated by unadjusted logistic and multivariable backward logistic regressions: blood transfusion ≥4 units, unexpected surgical procedure, need for a ventilator ≥12 hours, intensive care unit (ICU) admission, or failure of ≥1 organ system. Multivariable models were run classifying HDP into three levels as follows: (1) gestational hypertension; (2) preeclampsia (mild, severe, or superimposed); and (3) eclampsia or HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. RESULTS: A total of 9,612 individuals with HDP met inclusion criteria. No maternal deaths occurred in this cohort. In univariable analysis, non-Hispanic White patients were more likely to present with gestational hypertension whereas NHB and Hispanic patients were more likely to present with preeclampsia. The frequency of the primary outcome, composite SMM, was higher in NHB patients compared with that in non-Hispanic White or Hispanic patients (11.8 vs. 4.5% in non-Hispanic White and 4.8% in Hispanic, p < 0.001). This difference was driven by a higher frequency of blood transfusions and ICU admissions among NHB individuals. Prior to adjusting the analysis for confounding factors, the odds ratio (OR) of primary composite outcomes in NHB individuals was 2.85 (95% confidence interval [CI]: 2.38, 3.42) compared with non-Hispanic White. After adjusting for sociodemographic and clinical factors, hospital site, and the severity of HDP, the OR of composite SMM did not differ between the groups (adjusted OR [aOR] = 1.26, 95% CI: 0.95, 1.67 for NHB, and aOR = 1.29, 95% CI: 0.94, 1.77 for Hispanic, compared with non-Hispanic White patients). Sensitivity analysis was done to exclude one single site that was an outliner with the highest ICU admissions and demonstrated no difference in ICU admission by maternal race and ethnicity. CONCLUSION: NHB patients with HDP had higher rates of the composite SMM compared with non-Hispanic White patients, driven mainly by a higher frequency of blood transfusions and ICU admissions. However, once severity and other confounding factors were taken into account, the differences did not persist. KEY POINTS: · Black patients with HDP had higher frequency of SMM compared with non-Hispanic White patients.. · The SMM disparities were driven by blood transfusions and ICU admissions.. · After adjustment for confounders, including HDP severity, the significant difference in SMM did not persist..