Development of standard definitions and grading for Maternal and Fetal Adverse Event Terminology.

OBJECTIVE: Adverse event (AE) monitoring is central to assessing therapeutic safety. The lack of a comprehensive framework to define and grade maternal and fetal AEs in pregnancy trials severely limits understanding risks in pregnant women. We created AE terminology to improve safety monitoring for developing pregnancy drugs, devices and interventions. METHOD: Existing severity grading for pregnant AEs and definitions/indicators of 'severe' and 'life-threatening' conditions relevant to maternal and fetal clinical trials were identified through a literature search. An international multidisciplinary group identified and filled gaps in definitions and severity grading using Medical Dictionary for Regulatory Activities (MedDRA) terms and severity grading criteria based on Common Terminology Criteria for Adverse Event (CTCAE) generic structure. The draft criteria underwent two rounds of a modified Delphi process with international fetal therapy, obstetric, neonatal, industry experts, patients and patient representatives. RESULTS: Fetal AEs were defined as being diagnosable in utero with potential to harm the fetus, and were integrated into MedDRA. AE severity was graded independently for the pregnant woman and her fetus. Maternal (n = 12) and fetal (n = 19) AE definitions and severity grading criteria were developed and ratified by consensus. CONCLUSIONS: This Maternal and Fetal AE Terminology version 1.0 allows systematic consistent AE assessment in pregnancy trials to improve safety.

Fetal growth restriction as the initial finding of preeclampsia is a clinical predictor of maternal and neonatal prognoses: a single-center retrospective study.

BACKGROUND: Preeclampsia (PE) is a hypertensive disorder specific to pregnancy that can cause severe maternal-neonatal complications. The International Society for the Study of Hypertension in Pregnancy revised the PE criteria in 2018; a PE diagnosis can be established in the absence of proteinuria when organ or uteroplacental dysfunction occurs. The initial findings of PE (IFsPE) at the first diagnosis can vary considerably across patients. However, the impacts of different IFsPE on patient prognoses have not been reported. Thus, we investigate the predictors of pregnancy complications and adverse pregnancy outcomes based on IFsPE according to the new criteria. METHODS: This retrospective study included 3729 women who delivered at our hospital between 2015 and 2019. All women were reclassified based on the new PE criteria and divided into three groups based on the IFsPE: Classification 1 (C-1), proteinuria (classical criteria); Classification 2 (C-2), damage to other maternal organs; and Classification 3 (C-3), uteroplacental dysfunction. Pregnancy complications and adverse pregnancy outcomes were assessed and compared among the three groups. RESULTS: In total, 104 women with PE were included. Of those, 42 (40.4%), 28 (26.9%), and 34 (32.7%) were assigned to C-1, C-2, and C-3 groups, respectively. No significant differences in maternal characteristics were detected among the three groups, except for gestational age at PE diagnosis (C-1, 35.5 ± 3.0 weeks; C-2, 35.2 ± 3.6 weeks; C-3, 31.6 ± 4.6 weeks, p <  0.01). The rates of premature birth at < 37 weeks of gestation, fetal growth restriction (FGR), and neonatal acidosis were significantly higher in the C-3 group compared to the C-1 and C-2 groups. Additionally, the composite adverse pregnancy outcomes of the C-3 group compared with C-1 and C-2 represented a significantly higher number of patients. CONCLUSIONS: PE patients with uteroplacental dysfunction as IFsPE had the most unfavorable prognoses for premature birth, FGR, acidosis, and composite adverse pregnancy outcomes.

Preconception, Antepartum, and Peripartum Care for the Woman With a Spinal Cord Injury: A Review of the Literature.

IMPORTANCE: Spinal cord injury (SCI) may result in temporary or permanent loss of sensory, motor, and autonomic function, presenting unique medical and psychosocial challenges in women during their childbearing years. OBJECTIVE: The aim of this study was to review the literature and describe the spectrum of pregnancy considerations, complications, and evidence-based obstetric practices in women with SCI. EVIDENCE ACQUISITION: A literature search was undertaken using the search engines of PubMed and Web of Science using the terms "spinal cord injury" or "spinal cord complications" and "pregnancy outcomes" or "pregnancy complications." The search was limited to the English language, and there was no restriction on the years searched. RESULTS: The search identified 174 abstracts, 50 of which are the basis for this review. Pregnancy in women who have experienced an SCI requires a multidisciplinary approach. Common complications during pregnancy include recurrent urinary tract infection, upper respiratory tract infection, hypertension, venous thromboembolism, and autonomic dysreflexia (AD), which is a potentially life-threatening complication. Obstetricians should avoid potential triggers and be familiar with acute management of AD. Postpartum complications include difficulty initiating and maintaining breastfeeding and increased risk of postpartum depression and other mental health issues. CONCLUSIONS AND RELEVANCE: Obstetricians caring for women with an SCI must be familiar with the unique challenges and complications that may occur during pregnancy and puerperium. RELEVANCE STATEMENT: An evidence-based literature review of the care of pregnant women with spinal cord injury.

Implications of the vaginal microbiome and potential restorative strategies on maternal health: a narrative review.

The vaginal microbiome undergoes dramatic shifts before and throughout pregnancy. Although the genetic and environmental factors that regulate the vaginal microbiome have yet to be fully elucidated, high-throughput sequencing has provided an unprecedented opportunity to interrogate the vaginal microbiome as a potential source of next-generation therapeutics. Accumulating data demonstrates that vaginal health during pregnancy includes commensal bacteria such as Lactobacillus that serve to reduce pH and prevent pathogenic invasion. Vaginal microbes have been studied as contributors to several conditions occurring before and during pregnancy, and an emerging topic in women's health is finding ways to alter and restore the vaginal microbiome. Among these restorations, perhaps the most significant effect could be preterm labor (PTL) prevention. Since bacterial vaginosis (BV) is known to increase risk of PTL, and vaginal and oral probiotics are effective as supplemental treatments for BV prevention, a potential therapeutic benefit exists for pregnant women at risk of PTL. A new method of restoration, vaginal microbiome transplants (VMTs) involves transfer of one women's cervicovaginal secretions to another. New studies investigating recurrent BV will determine if VMTs can safely establish a healthy Lactobacillus-dominant vaginal microbiome. In most cases, caution must be taken in attributing a disease state and vaginal dysbiosis with a causal relationship, since the underlying reason for dysbiosis is usually unknown. This review focuses on the impact of vaginal microflora on maternal outcomes before and during pregnancy, including PTL, gestational diabetes, preeclampsia, and infertility. It then reviews the clinical evidence focused on vaginal restoration strategies, including VMTs.

Adenomyosis and infertility: the role of the junctional zone.

OBJECTIVE: Adenomyosis is a benign uterine disorder characterized by the invasion of the endometrium within the myometrium, starting from the junctional zone (JZ), the inner hormone dependent layer of the myometrium that plays an important role in sperm transport, implantation and placentation. The resulting histological abnormalities and functional defects may represent the pathogenic substrate for infertility and pregnancy complications. The objective of this paper is to review the literature to evaluate the correlation between inner myometrium alterations and infertility and to assess the role of JZ in the origin of adverse obstetric outcomes of both spontaneous and in vitro fertilization (IVF) pregnancies. METHODS: we searched Pubmed for all original and review articles in the English language from January1962 until December 2019, using the MeSH terms of 'adenomyosis', 'junctional zone', combined with 'infertility', 'obstetrical outcomes', 'spontaneous conception', 'in vitro fertilization' and 'classification'. The review was divided into three sections to assess this pathogenic correlation, evaluating also the importance of classification of the disease. RESULTS AND CONCLUSIONS: Absent or incomplete remodeling of the JZ can affect uterine peristalsis, alter vascular plasticity of the spiral arteries and activate inflammatory pathways, all related to adverse obstetric outcomes. Despite these observations, there is still limited evidence whether adenomyosis is a cause of infertility. However, it is reasonable to screen patients for adenomyosis, to consider pregnant women with diffuse adenomyosis at high risk of adverse obstetric outcomes, and to evaluate the importance of a noninvasive validated classification in the management of women with adenomyosis.

Systematic classification of maternal and fetal intervention-related complications following open fetal myelomeningocele repair - results from a large prospective cohort.

OBJECTIVE: To systematically categorise all maternal and fetal intervention-related complications after open fetal myelomeningocele (fMMC) repair of the first 124 cases operated at the Zurich Centre for Fetal Diagnosis and Therapy. DESIGN: A prospective cohort study. SETTING: Single centre. POPULATION: Mothers and fetuses after fMMC repair. METHODS: Between 2010 and 2019, we collected and entered all maternal complications following fMMC repair into the Clavien-Dindo classification. For fetal complications, a classification system based on the Medical Dictionary for Regulatory Activities terminology of Adverse Events was used including the preterm definitions of the World Health Organization. MAIN OUTCOME MEASURES: Systematic classification of maternal and fetal complications following fMMC repair. RESULTS: Gestational ages at surgery and birth were 25.0 ± 0.8 and 35.4 ± 2.0 weeks, respectively. In 17% of all cases, no maternal complications occurred. Maternal intervention-related complications were observed as follows: 69% grade 1, 36% grade 2, 25% grade 3, 6% grade 4 and 0% grade 5. In 34%, no fetal complications were noted; however, 43% of the fetuses developed a grade 1, 14% a grade 2, 8% a grade 3, 2% a grade 4 and 2% a grade 5 complication. CONCLUSION: This study raises awareness of complications following open fMMC repair; 6% of mothers and 2% of fetuses experienced a severe complication (grade 4) and perinatal death rate of 2% was observed (grade 5). These data are useful for prenatal counselling, they help to improve the system of fetal surgical care, and they allow benchmarking with other centres as well as comparison with fetoscopic approaches. TWEETABLE ABSTRACT: Systematic classification of all maternal and fetal intervention-related complications following open fMMC repair.

Use of the Robson Classification System to Assess Cesarean Delivery Rate in a Tertiary Hospital in the Basque Country.

OBJECTIVES: To assess the rate of cesarean delivery at Basurto University Hospital (Bilbao, Spain) between 2015 and 2017 and to determine the cause of an increase in this rate during 2017. METHODS: We retrospectively reviewed 6975 deliveries between 2015 and 2017, classifying women using the Robson classification. We analyzed extended perinatal mortality and perinatal outcomes during the study period and performed a comparative analysis of cesarean deliveries by year and Robson group. Comparisons were made with analysis of variance and χ2 or Fisher's exact tests. RESULTS: During the study period, 928 cesarean deliveries (13.3%) were performed. Extended perinatal mortality in this period was 7.0%. We detected an increase in the rate of cesarean delivery in 2017 in Group 1 women (P = 0.0224), with significant differences in the homogeneity of the distribution of cesarean deliveries performed for fetal distress between years in this group (P = 0.0093). Auditing the cases of cesareans performed for fetal distress in Group 1 in 2017, we found that the indication was appropriate in all cases, but in 39.4%, the management of uterine contractions during labour was considered suboptimal. CONCLUSION: Classifying cesarean deliveries using the Robson classification allows us to compare cesarean rates in different years and analyze any increases in these rates. Increases are sometimes attributed to changes in the obstetric population, but when investigated may be found to be related to potentially correctable problems. It is not necessary to have a high rate of cesarean delivery to warrant internal audit.

Classification of Thyroid Dysfunction in Pregnant Women Differs by Analytical Method and Type of Thyroid Function Test.

CONTEXT: Physiological alterations challenge the assessment of maternal thyroid function in pregnancy. It remains uncertain how the reference ranges vary by week of pregnancy, and how the classification of disease varies by analytical method and type of thyroid function test. DESIGN: Serum samples from Danish pregnant women (n = 6282) were used for the measurement of thyrotropin (TSH), total and free thyroxine (T4), total and free 3,5,3'-triiodothyronine (T3), and T-uptake using "Method A" (Cobas 8000, Roche Diagnostics). TSH and free T4 were also measured using "Method B" (ADVIA Centaur XP, Siemens Healthineers). MAIN OUTCOME MEASURES: Pregnancy week- and method-specific reference ranges were established among thyroid antibody-negative women (n = 4612). The reference ranges were used to classify maternal thyroid function, and results were compared by analytical method and type of thyroid function test. RESULTS: The reference ranges for TSH showed a gradual decrease during pregnancy weeks 4 to 14, a gradual increase was observed for total T4, total T3, and T-uptake, whereas free T4 and free T3 showed less variation. When TSH and free T4 were used, Method A classified 935 (14.9%) with abnormal thyroid function, Method B a total of 903 (14.4%), and the methods agreed on 554 individuals. When TSH and total T4 were used, 947 (15.1%) were classified with abnormal thyroid function, and classifications by either total T4 or free T4 agreed on 584 individuals. CONCLUSIONS: Even when pregnancy week- and method-specific reference ranges were established, the classification of maternal thyroid dysfunction varied considerably by analytical method and type of thyroid function test.

Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): development of a novel classification system.

OBJECTIVE: Twin pregnancies have a significantly higher perinatal mortality than singleton pregnancies. Current classification systems for perinatal death lack twin-specific categories, potentially leading to loss of important information regarding cause of death. We introduce and test a classification system designed to assign a cause of death in twin pregnancies (CoDiT). DESIGN: Retrospective cross-sectional study. SETTING: Tertiary maternity unit in England with a perinatal pathology service. POPULATION: Twin pregnancies in the West Midlands affected by fetal or neonatal demise of one or both twins between 1 January 2005 and 31 December 2016 in which postmortem examination was undertaken. METHODS: A multidisciplinary panel designed CoDiT by adapting the most appropriate elements of singleton classification systems. The system was tested by assigning cause of death in 265 fetal and neonatal deaths from 144 twin pregnancies. Cause of death was validated by another obstetrician blinded to the original classification. MAIN OUTCOME MEASURES: Inter-rater, intra-rater, inter-disciplinary agreement and cause of death. RESULTS: Cohen's Kappa demonstrated 'strong' (>0.8) inter-rater, intra-rater and inter-disciplinary agreement (95% CI 0.70-0.91). The commonest cause of death irrespective of chorionicity was the placenta; twin-to-twin transfusion syndrome (TTTS) was the commonest placental cause in monochorionic twins and acute chorioamnionitis in dichorionic twins. CONCLUSIONS: This novel classification system records causes of death in twin pregnancies from postmortem reports with high inter-user agreement. We highlight differences in aetiology of death between monochorionic and dichorionic twins. TWEETABLE ABSTRACT: New classification system for #twin cause of death 'CoDiT' shows high rater agreement.

Anesthesia for Nonobstetric Surgery in Pregnancy.

Nonobstetric surgery during pregnancy occurs in 1% to 2% of pregnant women. Physiologic changes during pregnancy may have an impact when anesthesia is needed. Anesthetic agents commonly used during pregnancy are not associated with teratogenic effects in clinical doses. Surgery-related risks of miscarriage and prematurity need to be elucidated with well-designed studies. Recommended practices include individualized use of intraoperative fetal monitoring and multidisciplinary planning to address the timing and type of surgery, anesthetic technique, pain management, and thromboprophylaxis. Emergency procedures should be performed immediately and elective surgery should be deferred during pregnancy.

Intraoperative Fetal Monitoring for Nonobstetric Surgery.

Necessary nonobstetric surgical procedures should not be withheld from pregnant women for fear of risks to the women and their pregnancies; however, careful preoperative planning should be undertaken to mitigate risks that may be present. Fetal monitoring recommendations will be dependent on the woman's preferences, gestational age of the pregnancy, and situational-specific risks (including anticipated risk of cardiovascular instability). Some fetal heart rate changes (lower baseline, less variability) can be anticipated, depending on anesthetic agents utilized during the procedure, and should not routinely prompt delivery.

Cohort study of high maternal body mass index and the risk of adverse pregnancy and delivery outcomes in Scotland.

OBJECTIVE: To examine the association between high maternal weight status and complications during pregnancy and delivery. SETTING: Scotland. PARTICIPANTS: Data from 132 899 first-time singleton deliveries in Scotland between 2008 and 2015 were used. Women with overweight and obesity were compared with women with normal weight. Associations between maternal body mass index and complications during pregnancy and delivery were evaluated. OUTCOME MEASURES: Gestational diabetes, gestational hypertension, pre-eclampsia, placenta praevia, placental abruption, induction of labour, elective and emergency caesarean sections, pre-term delivery, post-term delivery, low Apgar score, small for gestational age and large for gestational age. RESULTS: In the multivariable models controlling for potential confounders, we found that, compared with women with normal weight, the odds of the following outcomes were significantly increased for women with overweight and obesity (overweight adjusted ORs; 95% CI, followed by the same for women with obesity): gestational hypertension (1.61; 1.49 to 1.74), (2.48; 2.30 to 2.68); gestational diabetes (2.14; 1.86 to 2.46), (8.25; 7.33 to 9.30); pre-eclampsia (1.46; 1.32 to 1.63) (2.07; 1.87 to 2.29); labour induction (1.28; 1.23 to 1.33), (1.69; 1.62 to 1.76) and emergency caesarean section (1.82; 1.74 to 1.91), (3.14; 3.00 to 3.29). CONCLUSIONS: Women with overweight and obesity in Scotland are at greater odds of adverse pregnancy and delivery outcomes. The odds of these conditions increases with increasing body mass index. Health professionals should be empowered and trained to deliver promising dietary and lifestyle interventions to women at risk of overweight and obesity prior to conception, and control excessive weight gain in pregnancy.

Estimating the obstetric co-morbidity burden using administrative data: The impact of the pregnancy-related assessment window.

BACKGROUND: Despite increased research using large administrative databases to identify determinants of maternal morbidity and mortality, the extent to which these databases capture obstetric co-morbidities is unknown. OBJECTIVE: To evaluate the impact that the time window used to assess obstetric co-morbidities has on the completeness of ascertainment of those co-morbidities. METHODS: We conducted a five-year analysis of inpatient hospitalisations of pregnant women from 2010-2014 using the Nationwide Readmissions Database. For each woman, using discharge diagnoses, we identified 24 conditions used to create the Obstetric Comorbidity Index. Using various assessment windows for capturing obstetric co-morbidities, including the delivery hospitalisation only and all weekly windows from 7 to 280 days, we calculated the frequency and rate of each co-morbidity and the degree of underascertainment of the co-morbidity. Under each scenario, and for each co-morbidity, we also calculated the all-cause, 30-day readmission rate. RESULTS: There were over 3 million delivery hospitalisations from 2010 to 2014 included in this analysis. Compared with a full 280-day window, assessment of obstetric co-morbidities using only diagnoses made during the delivery hospitalisation would result in failing to identify over 35% of cases of chronic renal disease, 28.5% cases in which alcohol abuse was documented during pregnancy, and 23.1% of women with pulmonary hypertension. For seven other co-morbidities, at least 1 in 20 women with that condition would have been missed with exclusive reliance on the delivery hospitalisation for co-morbidity diagnoses. Not only would reliance on delivery hospitalisations have resulted in missed cases of co-morbidities, but for many conditions, estimates of readmission rates for women with obstetric co-morbidities would have been underestimated. CONCLUSIONS: An increasing proportion of maternal and child health research is based on large administrative databases. This study provides data that facilitate the assessment of the degree to which important obstetric co-morbidities may be underascertained when using these databases.

Trajectories of antenatal maternal psychological stress and their association with gestational age and neonatal anthropometry: A prospective cohort study of multi-ethnic Asian women in an urban setting.

PURPOSE: To determine common temporal change patterns (i.e., trajectories) of perceived antenatal psychological stress throughout the pregnancy, and to examine associations between these identified trajectories and neonatal birth outcomes. METHODS: 926 participants from a prospective cohort study of multi-ethnic Asian women from an urban setting with uncomplicated singleton pregnancies completed the Perceived Stress Scale in their first, second, and third trimesters, and just prior to parturition. Gestational age, neonatal weight, length, and head circumference were recorded at birth. Longitudinal trajectories of antenatal psychological stress were characterized with group-based trajectory modelling; associations between trajectories and neonatal outcomes were assessed with analyses of covariance and covariate-adjusted linear regressions. RESULTS: Three distinct non-fluctuating trajectories of antenatal psychological stress were identified, with 43 % of women experiencing significant levels of stress throughout the pregnancy. Women in this persistently-higher stress trajectory delivered neonates who were 57.5 g lighter and with head circumferences of 20 mm less than their counterparts in the other trajectories. Each one-point increase on the Perceived Stress Scale was associated with a decrease of 5.64 g in birthweight and a decrease of 0.4 mm in head circumference. CONCLUSIONS: This study delineated three meaningful trajectories of antenatal psychological stress. The persistently-higher antenatal psychological stress trajectory, experienced by two in five women, was associated with lower birthweight and possibly smaller head circumference. While further research is needed to better appreciate the clinical relevance of these findings, it highlights the importance of psychosocial support even for healthy pregnant women with uncomplicated pregnancies in Asian settings.

Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death.

BACKGROUND: There is no international consensus on the definition and components of severe maternal morbidity (SMM). OBJECTIVES: To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada. METHODS: Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality. RESULTS: There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4). CONCLUSIONS: The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

Monitoring severe acute maternal morbidity across Europe: A feasibility study.

BACKGROUND: Monitoring severe acute maternal morbidity (SAMM) appears essential for optimising care and informing health care policies, especially given changes in obstetric practices and mother profiles. International comparisons can identify areas where improvement is needed, but the comparability of indicators must be evaluated. OBJECTIVE: To assess the feasibility of monitoring SAMM using common definitions from hospital discharge databases across Europe. METHODS: We used hospital discharge data in eight countries (2 826 868 deliveries) to identify women with SAMM among all hospitalisations of women of reproductive age admitted for antenatal or delivery care. Five SAMM indicators were investigated: eclampsia, septicaemia, hysterectomy, hysterectomy associated with a diagnosis of obstetric haemorrhage, and red blood cell (RBC) transfusion associated with a diagnosis of obstetric haemorrhage. Between-country variation was described, by the ratio of the highest to lowest rates, while external validation was assessed by comparing with population-based studies on maternal morbidity. RESULTS: Ratios for hysterectomy and red blood cell (RBC) transfusion in the context of obstetric haemorrhage were 1:2.1 and 1:3.5, respectively. High values of hysterectomy and low values of transfusion were both consistent with high maternal mortality from haemorrhage (France, Italy, Portugal). Ratios across countries were relatively low for eclampsia (1:3.4) but very high for septicaemia (1:22.5). Compared to population-based morbidity estimates, eclampsia was over-reported in hospital databases whereas the two indicators of severe haemorrhage had good external validity. CONCLUSIONS: In association with diagnosis codes indicating obstetric haemorrhage, hysterectomy and RBC transfusion appear to be good candidates for surveillance of maternal morbidity in Europe.

A single gestational weight gain recommendation is possible for all classes of pregnant women with obesity.

OBJECTIVES: Obesity is a known risk factor for adverse pregnancy outcomes; however, appropriate gestational weight gain (GWG) may mitigate these risks. We investigated whether the singular 2009 Institute of Medicine (IOM) GWG guidelines were appropriate for all women with obesity, or whether separate recommendations were needed by class. METHODS: This cross-sectional study of pregnant women with obesity used 2014 U.S. birth certificate data (N=646,642) and included only term pregnancies. Adjusted log-binomial regression models examined the relative risk of adverse maternal, obstetric, and neonatal outcomes for pregnant women with class I-III obesity who: lost weight during pregnancy, gained below IOM guidelines, or gained above IOM guidelines, compared to women who gained within IOM guidelines. RESULTS: Most women (55.1; 95% CI: 55.0-55.3) gained above IOM guidelines. As BMI severity increased, significantly fewer women had excessive GWG (Class I: 61.6%, 95% CI: 61.4-61.7; II: 50.7%, 95% CI: 50.4-50.9; III: 41.1%, 95% CI: 40.8-41.4). All classes of women with obesity who lost weight during pregnancy or gained below had a significantly decreased risk for caesarean delivery (RR (95% CI) class I: 0.92 (0.90-0.94); II: 0.91 (0.89-0.93); III: 0.92 (0.90-0.93)) and large-for-gestational age (LGA) births (class I: 0.80 (0.77-0.83); II: 0.76 (0.73-0.78); III: 0.73 (0.70-0.75)), but significantly increased risk of small-for-gestational age (SGA) births (class I: 1.34 (1.26-1.43); II: 1.38 (1.28-1.49); III: 1.35 (1.24-1.46)). CONCLUSION: The observed pattern of association was the same for all obese classes, hence evidence supports a possible singular GWG recommendation for all women with obesity, regardless of class.

Association Between Stillbirth at 23 Weeks of Gestation or Greater and Severe Maternal Morbidity.

OBJECTIVE: To estimate whether stillbirth at 23 weeks of gestation or more is associated with increased risk of severe maternal morbidity compared with live birth, when stratified by maternal comorbidities. METHODS: This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes within the Healthcare Cost and Utilization Project's Florida State Inpatient Database. The first delivery of female Florida residents aged 13-54 years old from 2005 to 2014 was included. The exposure was an ICD-9-CM code of stillbirth at 23 weeks of gestation or more; the control was an ICD-9-CM code of singleton live birth. Deliveries were stratified by the presence of 1 or more conditions within a well-validated maternal morbidity composite using ICD-9-CM codes during delivery hospitalization. The primary outcome was an ICD-9-CM diagnosis or procedure code during delivery hospitalization of any indices within the Centers for Disease Control and Prevention's severe maternal morbidity composite. Multivariable analyses adjusted for maternal sociodemographic factors and delivery mode to compare outcomes after stillbirth with live-birth delivery. RESULTS: Nine thousand five hundred twenty-three women who delivered stillborn fetuses and 1,353,044 with liveborn neonates were included. Among 6,590 stillbirths and 935,913 live births without maternal comorbidities, severe maternal morbidity was significantly more common during stillbirth delivery (n=345 [5.2%]), corresponding to a seven-fold increased risk compared with live birth (n=8,318 [0.9]; adjusted odds ratio [aOR] 7.05 [95% CI 6.27-7.93]). Among 2,933 stillbirths and 417,131 live births with maternal comorbidities, severe maternal morbidity was significantly more common during stillbirth delivery (n=390 [13.3%]): the risk was more than six-fold higher comparatively (n=11,122 [2.7%]; aOR 6.21 [95% CI 5.54-6.96]). Most maternal comorbidities were individually associated with higher risk of severe maternal morbidity during stillbirth compared with live-birth delivery. CONCLUSION: Though severe maternal morbidity is overall uncommon, delivering a stillborn fetus 23 weeks of gestation or greater is associated with increased likelihood of severe maternal morbidity, particularly among women with comorbidities, suggesting health care providers must be vigilant about severe maternal morbidity during stillbirth delivery.

Peripartum Outcomes Before and After Hurricane Harvey.

OBJECTIVE: To evaluate the association between Hurricane Harvey landfall with maternal and neonatal morbidity. METHODS: Using an institutional perinatal database from two hospitals in Houston, Texas, women with nonanomalous singletons delivering after 24 weeks of gestation between August 2011 and June 2018 were included. To evaluate the possible association of hurricane landfall with pregnancy outcomes, gravid women delivering within 280 days (40 weeks of gestation) on or after August 25, 2017 (the day of hurricane landfall) were categorized as exposed, and women who delivered before August 25, 2017, were the reference group. Composite maternal morbidity included any of the following: hypertensive disorders of pregnancy, chorioamnionitis, endometritis, blood transfusion, peripartum hysterectomy, maternal critical care admission, pulmonary edema, or maternal death. Composite neonatal morbidity included any of the following: 5-minute Apgar score 3 or less, respiratory distress syndrome, use of ventilator or continuous positive airway pressure, suspected newborn sepsis, seizure, stillbirth, or neonatal death. Adjusted odds ratios (aORs) were calculated after correcting for possible confounders identified on univariate analysis. Disruption in outcome trends were measured in time series analyses. RESULTS: Of 40,502 deliveries in our database, 29,179 (72%) met the inclusion criteria, with 3,842 (13.2%) delivering within 280 days of Hurricane Harvey landfall. Women delivering after Hurricane Harvey were on average less likely to be obese and more likely to be older, Caucasian, married, have a household income higher than $75,000, a high school education, and private insurance. However, compared with the cohort of gravid patients who delivered before Hurricane Harvey, composite maternal morbidity increased by 27% (11.5% vs 14.7%, aOR 1.27, 95% CI 1.14-1.42) after the storm. Composite neonatal morbidity increased by 50% (7.8% vs 11.9%, aOR 1.52, 95% CI 1.34-1.71). In time series analyses, we observed a significant shift in composite maternal morbidity specific to women of low socioeconomic status (estimate 2.87, P=.028). CONCLUSION: Despite having fewer at-risk baseline characteristics, gravid patients delivering after landfall by Hurricane Harvey had a significantly higher likelihood of adverse outcomes as did their neonates.