Sonographic Evaluation of the Placenta in Fontan Patients: A Case Series.

Due to the advancements in pediatric cardiothoracic surgery and medical management, more individuals with congenital heart disease are reaching reproductive age. It is well established that individuals with Fontan circulation are at an increased risk for maternal and fetal adverse outcomes including maternal cardiovascular complications, hypertensive disorders of pregnancy, preterm birth, and fetal growth restriction. Early onset of poor placental health likely related to chronically elevated central venous pressure/low cardiac output inherited to Fontan circulation may play a role in the development of these outcomes. In this case series, we present second-trimester placental imaging findings and pregnancy outcomes of three individuals with Fontan circulation who delivered at a tertiary center in the Southeastern United States.

Maternal and Fetal Outcomes Associated With Infective Endocarditis in Pregnancy.

BACKGROUND: Infective endocarditis (IE) is a rare but serious infection that complicates pregnancy. Little is known about IE management and outcomes in this population. METHODS: The National Readmissions Database was used to obtain data between October 2015 and October 2018. Billing codes identified admissions for IE in female patients of reproductive age. Demographic characteristics, comorbidities, and outcomes were compared between patients with maternity-associated and nonmaternity-associated IE and obstetric patients who delivered with and without IE. Weighted regressions were used to examine outcomes in adjusted models. RESULTS: We identified 12 602 reproductive-aged female patients with a diagnosis of IE, of which 382 (weighted national estimate, 748) were maternity-associated. Of these cases, 117 (weighted national estimate, 217) occurred during a delivery admission. Compared with patients with nonmaternity-associated IE, maternity-associated infection was associated with younger age (mean, 29.0 vs 36.6 years; P < .001), Medicaid coverage (72.5% vs 47.2%; P < .001), and drug use (76.2% vs 59.8%; P < .001). Mortality was comparable (8.1% vs 10.6%; adjusted rate ratio [aRR], 1.03; 95% confidence interval [CI]: .71-1.48). Compared with patients who delivered without IE, IE complicating delivery was associated with worse maternal and fetal outcomes, including maternal mortality (17.2% vs <0.01%; aRR, 323.32; 95% CI: 127.74-818.37) and preterm birth (55.7% vs 10.1%; aRR, 3.61; 95% CI, 2.58-5.08). CONCLUSIONS: Maternity-associated IE does not appear to confer additional risk for adverse outcome over nonmaternity-associated infection. Patients who deliver with IE have worse maternal and fetal outcomes than those whose deliveries are not complicated by IE.

Postpartum Pyelonephritis and Risk of Severe Maternal Morbidity.

OBJECTIVE: Pyelonephritis is the most common nonobstetric cause for hospitalization during pregnancy. The maternal and obstetric complications associated with antepartum pyelonephritis are well described. However, it is not clear whether these risks extend into the postpartum period. The primary objective of this study was to describe the morbidity associated with postpartum pyelonephritis, by comparing the morbidity associated with pyelonephritis in the postpartum period to morbidity seen during pregnancy or delivery. METHODS: A retrospective cohort study was performed using the Nationwide Readmissions Database (NRD), an all-payor sample of discharges from approximately 60% of U.S. hospitalizations. Discharges between October 2015 and December 2018 were included. Maternity-associated hospitalizations, diagnosis of pyelonephritis, comorbid conditions, and incidence of severe maternal morbidity were identified using International Classification of Disease-10th Revision (ICD-10) diagnosis and procedure codes. Bivariate statistics, weighted to account for the complex survey methods in the NRD, were used to evaluate the association between antepartum, delivery, and postpartum hospital stays associated with pyelonephritis and maternal morbidity. Weighted regression models were used to evaluate the association between admission timing and maternal outcomes. RESULTS: A total of 32,850 pyelonephritis admissions were identified, corresponding to a national estimate of 61,837 admissions. Of these, 1,465 (2.4%) were postpartum, 55,056 (89.0%) were antepartum, and 5,317 (8.6%) involved a delivery stay. Rates of severe maternal morbidity were higher in the postpartum group than the antepartum or delivery hospitalization groups (59.5 vs. 12.9 and 15.8%, respectively, p < 0.001); when compared with antepartum hospitalizations, the adjusted relative risk for composite severe maternal morbidity for postpartum hospitalizations was 4.68 (95% confidence interval [CI]: 4.33, 5.05). Most of this difference was driven by rates of sepsis (53.2 vs. 11.0 vs. 10.9%). CONCLUSION: Though relatively uncommon, postpartum hospitalizations for pyelonephritis are associated with higher rates of severe maternal morbidity, driven by differential rates of sepsis, than are antepartum or delivery-associated hospitalizations.

Venous thromboembolism incidence among patients recommended for pharmacologic thromboembolism prophylaxis after cesarean delivery in selected guidelines.

BACKGROUND: Multiple guidelines regarding risk stratification for venous thromboembolism (VTE) incidence following cesarean delivery have been promulgated. OBJECTIVE: To estimate the percentage of cesarean delivery patients for which pharmacologic VTE would be recommended and subsequent incidence of VTE, based on several guidelines. PATIENTS/METHODS: This retrospective cohort study used data from the Nationwide Readmissions Database from October 2015 through December 2017. Diagnosis and procedure codes were used to identify patients undergoing cesarean delivery, incidence of VTE, and risk factors used to stratify risk in the existing guidelines. Time-to-event analysis was used to analyze data, stratified by risk categorization in 2011 American College of Obstetricians and Gynecologists (ACOG), 2012 American College of Chest Physicians (ACCP), 2015 Royal College of Obstetricians and Gynaecologists (RCOG), and 2018 American Society of Hematology (ASH) guidelines. RESULTS/CONCLUSIONS: In a cohort of 1 235 149 cesarean deliveries, VTE incidence was 2.1 per 1000 deliveries at 330 days following delivery (95% confidence interval: 2.0-2.2). Proportions of patients that would be recommended for pharmacologic prophylaxis ranged from 0.2% in 2018 ASH guidelines to 73.4% in 2015 RCOG criteria. Among groups considered at elevated risk for VTE for which pharmacologic prophylaxis would be recommended, VTE incidence varied from 35.2 per 1000 deliveries based on 2018 ASH criteria to 2.5 per 1000 in 2015 RCOG criteria. In a large cohort of cesarean deliveries in the United States, application of different risk stratification guidelines identified widely different proportions at risk of VTE following delivery, with implications for being categorized as having elevated risk.