Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative.

BACKGROUND: We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. METHODS: We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. RESULTS: Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). DISCUSSION: Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.

Outcomes of Elective Induction of Labor at 39 Weeks from a Statewide Collaborative Quality Initiative.

OBJECTIVE: This article evaluates the impact of adopting a practice of elective induction of labor (eIOL) at 39 weeks among nulliparous, term, singleton, vertex (NTSV) pregnancies in a statewide collaborative. STUDY DESIGN: We used data from a statewide maternity hospital collaborative quality initiative to analyze pregnancies that reached 39 weeks without a medical indication for delivery. We compared patients who underwent an eIOL versus those who experienced expectant management. The eIOL cohort was subsequently compared with a propensity score-matched cohort who were expectantly managed. The primary outcome was cesarean birth rate. Secondary outcomes included time to delivery and maternal and neonatal morbidities. Chi-square test, t-test, logistic regression, and propensity score matching methods were used for analysis. RESULTS: In 2020, 27,313 NTSV pregnancies were entered into the collaborative's data registry. A total of 1,558 women underwent eIOL and 12,577 were expectantly managed. Women in the eIOL cohort were more likely to be ≥35 years old (12.1 vs. 5.3%, p < 0.001), identify as white non-Hispanic (73.9 vs. 66.8%, p < 0.001), and be privately insured (63.0 vs. 61.3%, p = 0.04). When compared with all expectantly managed women, eIOL was associated with a higher cesarean birth rate (30.1 vs. 23.6%, p < 0.001). When compared with a propensity score-matched cohort, eIOL was not associated with a difference in cesarean birth rate (30.1 vs. 30.7%, p = 0.697). Time from admission to delivery was longer for the eIOL cohort compared with the unmatched (24.7 ± 12.3 vs. 16.3 ± 11.3 hours, p < 0.001) and matched (24.7 ± 12.3 vs. 20.1 ± 12.0 hours, p < 0.001) cohorts. Expectantly managed women were less likely to have a postpartum hemorrhage (8.3 vs. 10.1%, p = 0.02) or operative delivery (9.3 vs. 11.4%, p = 0.029), whereas women who underwent an eIOL were less likely to have a hypertensive disorder of pregnancy (5.5 vs. 9.2%, p < 0.001). CONCLUSION: eIOL at 39 weeks may not be associated with a reduced NTSV cesarean delivery rate. KEY POINTS: · Elective IOL at 39 weeks may not be associated with a reduced NTSV cesarean delivery rate.. · The practice of elective induction of labor may not be equitably applied across birthing people.. · Further research is needed to identify best practices to support people undergoing labor induction..

Assessing Maternal and Fetal Risks Associated with Prolonged Induction of Labor.

OBJECTIVE: To assess whether prolonged induction of labor was associated with increased maternal or neonatal morbidity. STUDY DESIGN: We performed a retrospective cohort study of women undergoing induction of labor at a single institution. We included women with singletons ≥ 36 weeks with initial cervical dilation ≤4 cm. Prolonged induction of labor was defined as lasting > 36 hours from the time of initial method to delivery. A 2-to-1 propensity score-matched analysis was performed between women with and those without prolonged induction of labor. Maternal outcomes were cesarean delivery, chorioamnionitis, endometritis, postpartum hemorrhage, severe perineal laceration, and length of postpartum admission. Neonatal outcomes included Apgar scores, umbilical artery pH, and neonatal intensive care admission. RESULTS: Among 2,021 women, 407 (20.1%) had a prolonged induction. In unadjusted analyses, prolonged induction of labor was associated with increased cesarean delivery and chorioamnionitis. After 2-to-1 propensity score matching, there were 267 women with prolonged induction and 424 controls. Women with prolonged induction of labor had higher rates of cesarean delivery (35.6 vs. 16%, p < 0.001), chorioamnionitis (14.2 vs. 4.7%, p < 0.001), endometritis (6.4 vs. 1.9%, p = 0.002), and postpartum hemorrhage (18.8 vs. 11.9%, p = 0.008). There were no significant differences in neonatal outcomes. CONCLUSION: Overall length of induction impacts maternal outcome.

Use of a novel electronic maternal surveillance system to generate automated alerts on the labor and delivery unit.

BACKGROUND: Maternal early warning systems reduce maternal morbidity. We developed an electronic maternal surveillance system capable of visually summarizing the labor and delivery census and identifying changes in clinical status. Automatic page alerts to clinical providers, using an algorithm developed at our institution, were incorporated in an effort to improve early detection of maternal morbidity. We report the frequency of pages generated by the system. To our knowledge, this is the first time such a system has been used in peripartum care. METHODS: Alert criteria were developed after review of maternal early warning systems, including the Maternal Early Warning Criteria (MEWC). Careful consideration was given to the frequency of pages generated by the surveillance system. MEWC notification criteria were liberalized and a paging algorithm was created that triggered paging alerts to first responders (nurses) and then managing services due to the assumption that paging all clinicians for each vital sign triggering MEWC would generate an inordinate number of pages. For preliminary analysis, to determine the effect of our automated paging algorithm on alerting frequency, the paging frequency of this system was compared to the frequency of vital signs meeting the Maternal Early Warning Criteria (MEWC). This retrospective analysis was limited to a sample of 34 patient rooms uniquely capable of storing every vital sign reported by the bedside monitor. RESULTS: Over a 91-day period, from April 1 to July 1, 2017, surveillance was conducted from 64 monitored beds, and the obstetrics service received one automated page every 2.3 h. The most common triggers for alerts were for hypertension and tachycardia. For the subset of 34 patient rooms uniquely capable of real-time recording, one vital sign met the MEWC every 9.6 to 10.3 min. Anecdotally, the system was well-received. CONCLUSIONS: This novel electronic maternal surveillance system is designed to reduce cognitive bias and improve timely clinical recognition of maternal deterioration. The automated paging algorithm developed for this software dramatically reduces paging frequency compared to paging for isolated vital sign abnormalities alone. Long-term, prospective studies will be required to determine its impact on patient outcomes.

A Double-Blind, Randomized, Placebo-Controlled Trial of 17 Alpha-hydroxyprogesterone Caproate in the Management of Preterm Premature Rupture of Membranes.

OBJECTIVE: The objective of this study was to evaluate whether weekly administration of 17 α-hydroxyprogesterone caproate (17-OHPC) increases the number of women who achieve 34 weeks of gestation after preterm premature rupture of membranes (PPROM). STUDY DESIGN: We conducted a multicenter double-blind, randomized controlled trial of 17-OHPC versus placebo among women with PPROM. Women with singleton pregnancy, clinically confirmed PPROM, and without evidence of active infection or major fetal malformation between 240/7 and 320/7 weeks of pregnancy were offered enrollment. Women received weekly injections of 17-OHPC versus placebo until 340/7 weeks of gestation or delivery. The remainder of care was per hospital protocol. The primary outcome was achievement of 34 weeks of gestation. Secondary outcomes included length of latency and maternal and fetal outcomes. RESULTS: In this study, 21 women were enrolled. Eleven women received placebo and 10 received 17-OHPC. The study was closed prematurely secondary to poor enrollment. None of the women remained pregnant until 34 weeks of gestation. The median latency periods were 8 and 14.5 days for the placebo and 17-OHPC groups, respectively (p = 0.14). There were no differences in maternal or neonatal outcomes. CONCLUSION: We did not identify any benefit from administration of 17-OHPC in pregnancies complicated by PPROM.

Maternal leukocytosis after antenatal corticosteroid administration: a systematic review and meta-analysis.

Although it is known that corticosteroid administration causes leukocytosis, the magnitude and length of time this leukocytosis persists is unknown during pregnancy. This study aimed to establish the expected range of maternal leukocytosis in healthy pregnant women at risk for preterm delivery after antenatal corticosteroid administration. PubMed, Embase and ClinicalTrials.gov were searched to identify the studies in healthy women at risk for preterm delivery without signs of clinical infection that reported white blood cell values preceding and after antenatal corticosteroid administration. The inverse variance weighting technique was used to calculate the weighted means and the standard deviation from the mean for each time period. Six studies met inclusion criteria and included 524 patients and 1406 observations. Mean ± standard deviation maternal white blood cell count values prior to antenatal corticosteroid administration and up to 24, 48, 72 and 96 hours after corticosteroid administration were 10.4 ± 2.4, 13.6 ± 3.6, 12.1 ± 3.0, 11.5 ± 2.9 and 11.1 ± 2.5 × 109/L, respectively. Leukocytosis in healthy, non-infected women is expected to peak 24 hours after antenatal corticosteroid administration and the magnitude of increase is small. Impact statement What is already known on this subject: While it is well known that administration of antenatal corticosteroids causes leukocytosis, it is currently unknown the magnitude and length of time the leukocytosis persists. What the results of this study add: This study establishes the expected range and the temporal progression and regression with antenatal corticosteroid administration in healthy pregnant women at risk for preterm delivery without clinical signs of infection. What the implications are of these findings for clinical practice and/or further research: Clinicians may wish to consider further investigation into the clinical cause, whether infectious or non-infectious, for absolute values and changes outside this range.

Maternal glucose response to betamethasone administration.

OBJECTIVE: This study aims to describe the pattern of maternal glucose response to betamethasone administration using a continuous glucose monitoring system. STUDY DESIGN: A prospective observational trial was conducted among women receiving clinically indicated betamethasone between 24 and 34 weeks gestation. At the time of initial betamethasone administration, a continuous glucose monitoring device was inserted which measured interstitial fluid glucose levels every 5 minutes. Glucose levels were monitored for 7 days, until delivery, or until hospital discharge, whichever came first. We recorded the percentage of time women spent above three glucose thresholds: 110, 144, and 180 mg/dL, respectively. RESULTS: A total of 17 women were enrolled at the time of betamethasone administration and data were available for 15 patients. There were 11 nondiabetic and 4 diabetic women. Both diabetic and nondiabetic women had the highest recorded blood glucose readings between 24 and 48 hours after the first injection of betamethasone. In that period, nondiabetic women spent 73, 40, and 17% of the time with blood glucose levels above the 110, 144, and 180 mg/dL thresholds, respectively. CONCLUSION: Nondiabetic women receiving betamethasone manifest significant hyperglycemia after betamethasone administration. If delivery is imminent, maternal glucose response to betamethasone may need to be monitored to prevent possible neonatal hypoglycemia.

High rate of preterm birth in pregnancies complicated by rheumatoid arthritis.

OBJECTIVE: To describe the outcomes of pregnancies complicated by rheumatoid arthritis (RA) and to estimate potential associations between disease characteristics and pregnancy outcomes. STUDY DESIGN: We reviewed all pregnancies complicated by RA delivered at our institution from June 2001 through June 2009. Fisher exact tests were used to calculate odds ratios. Univariable regression was performed using STATA 10.1 (StataCorp, College Station, TX). A p value of ≤ 0.05 was considered statistically significant. RESULTS: Forty-six pregnancies in 40 women were reviewed. Sixty percent of pregnancies had evidence of disease flare and 28% delivered prior to 37 weeks. We did not identify associations between preterm birth and active disease at conception or during pregnancy. In univariate analysis, discontinuation of medication because of pregnancy was associated with a significantly earlier gestational age at delivery (362/7 versus 383/7 weeks, p = 0.022). CONCLUSION: Women with RA may be at higher risk for preterm delivery.

Placental transcriptome analysis of hypertensive pregnancies identifies distinct gene expression profiles of preeclampsia superimposed on chronic hypertension.

BACKGROUND: The pathogenesis of preeclampsia superimposed on chronic hypertension (SI) is poorly understood relative to preeclampsia (PreE) occurring in pregnant people without chronic hypertension. Placental transcriptomes in pregnancies complicated by PreE and SI have not been previously compared. METHODS: We identified pregnant people in the University of Michigan Biorepository for Understanding Maternal and Pediatric Health with hypertensive disorders affecting singleton, euploid gestations (N = 36) along with non-hypertensive control subjects (N = 12). Subjects were grouped as: (1) normotensive (N = 12), (2) chronic hypertensive (N = 13), (3) preterm PreE with severe features (N = 5), (4) term PreE with severe features (N = 11), (5) preterm SI (N = 3), or (6) term SI (N = 4). Bulk RNA sequencing of paraffin-embedded placental tissue was performed. The primary analysis assessed differential gene expression relative to normotensive and chronic hypertensive placentas, where Wald adjusted P values < 0.05 were considered significant. Unsupervised clustering analyses and correlation analyses were performed between conditions of interest, and a gene ontology was constructed. RESULTS: Comparing samples from pregnant people with hypertensive diseases to non-hypertensive controls, there were 2290 differentially expressed genes. The log2-fold changes in genes differentially expressed in chronic hypertension correlated better with term (R = 0.59) and preterm (R = 0.63) PreE with severe features than with term (R = 0.21) and preterm (R = 0.22) SI. A relatively poor correlation was observed between preterm SI and preterm PreE with severe features (0.20) as well as term SI and term PreE with severe features (0.31). The majority of significant genes were downregulated in term and preterm SI versus normotensive controls (92.1%, N = 128). Conversely, most term and preterm PreE with severe features genes were upregulated compared to the normotensive group (91.8%, N = 97). Many of the upregulated genes in PreE with the lowest adjusted P values are known markers of abnormal placentation (e.g., PAAPA, KISS1, CLIC3), while the downregulated genes with the greatest adjusted P values in SI have fewer known pregnancy-specific functions. CONCLUSIONS: We identified unique placental transcriptional profiles in clinically relevant subgroups of individuals with hypertension in pregnancy. Preeclampsia superimposed on chronic hypertension was molecularly distinct from preeclampsia in individuals without chronic hypertension, and chronic hypertension without preeclampsia, suggesting that preeclampsia superimposed on hypertension may represent a distinct entity.

Mediation effects of DNA methylation and hydroxymethylation on birth outcomes after prenatal per- and polyfluoroalkyl substances (PFAS) exposure in the Michigan mother-infant Pairs cohort.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are chemicals that are resistant to degradation and ubiquitous in our environments. PFAS may impact the developing epigenome, but current human evidence is limited to assessments of total DNA methylation. We assessed associations between first trimester PFAS exposures with newborn DNA methylation, including 5-methylcytosine (5-mC) and 5-hydroxymethylcytosine (5-hmC). DNA methylation mediation of associations between PFAS and birth outcomes were explored in the Michigan Mother Infant Pairs cohort. Nine PFAS were measured in maternal first trimester blood. Seven were highly detected and included for analysis: PFHxS, PFOA, PFOS, PFNA, PFDA, PFUnDA, and MeFOSAA. Bisulfite-converted cord blood DNA (n = 141) and oxidative-bisulfite-converted cord blood (n = 70) were assayed on Illumina MethylationEPIC BeadChips to measure total DNA methylation (5-mC + 5-hmC) and 5-mC/5-hmC. Correcting for multiple comparisons, beta regressions were used to assess associations between levels of PFAS and total methylation, 5-mC, or 5-hmC. Nonlinear mediation analyses were used to assess the epigenetic meditation effect between PFAS and birth outcomes. RESULTS: PFAS was significantly associated with total methylation (q < 0.05: PFHxS-12 sites; PFOS-19 sites; PFOA-2 sites; PFNA-3 sites; PFDA-4 sites). In 72 female infants and 69 male infants, there were sex-specific associations between five PFAS and DNA methylation. 5-mC and 5-hmC were each significantly associated with thousands of sites for PFHxS, PFOS, PFNA, PFDA, PFUnDA, and MeFOSAA (q < 0.05). Clusters of 5-mC and 5-hmC sites were significant mediators between PFNA and PFUnDA and decreased gestational age (q < 0.05). CONCLUSIONS: This study demonstrates the mediation role of specific types of DNA methylation on the relationship between PFAS exposure and birth outcomes. These results suggest that 5-mC and 5-hmC may be more sensitive to the developmental impacts of PFAS than total DNA methylation.

Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis.

INTRODUCTION: Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals. METHODS: This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient. RESULTS: Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%). CONCLUSIONS: Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.

Delivering equity: preterm birth by socioeconomic class before and after coverage of 17-hydroxyprogesterone caproate.

OBJECTIVE: We compare the preterm birth rate across socioeconomic strata in Michigan before and after the decision by Michigan Medicaid to provide coverage for 17-hydroxyprogesterone caproate (17-OHP), a costly medication for recurrent preterm birth prevention. STUDY DESIGN: We retrospectively analyzed births recorded in the Michigan Department of Health & Human Services database from 2008-2016, comparing the rate of preterm birth stratified by standardized US Census Bureau socioeconomic levels (affluent, higher-middle class, lower-middle class, and poverty) across three time periods: pre-Federal Drug Administration approval of 17-OHP (2008-2011), pre-Medicaid coverage (2012-2014), and post-Medicaid coverage (2015-2016). RESULTS: Of 1,034,901 total live births, 10% (N = 103,869) were premature. An ANOVA with post-hoc testing showed the preterm birth rate was highest for those living in poverty, lower for the lower-middle class, and lowest for the collective higher-middle and affluent classes. The preterm birth rate dropped for all classes after Michigan Medicaid began paying for 17-OHP, but inter-class gaps remained. CONCLUSION: Extended financial coverage for 17-OHP may have contributed to modest decreases in preterm birth rates, but this policy did not equalize outcomes between those with disparate resources.

Open-labelled randomised controlled trial of 12 hours versus 24 hours modified Pritchard regimen in the management of eclampsia and pre-eclampsia in Ghana (MOPEP Study): study protocol.

INTRODUCTION: Hypertensive disorders of pregnancy continue to be a major contributor to maternal and perinatal morbidity and mortality. Magnesium sulfate therapy is the standard of care for seizure prophylaxis and treatment for pre-eclampsia and eclampsia respectively, despite wide disparities in dosing regimens and routes of administration. This study compares the clinical efficacy of magnesium sulfate in the reduction of seizure occurrence or recurrence with the 12 hours versus 24 hours modified Pritchard regimens in the management of severe pre-eclampsia and eclampsia. METHODS AND ANALYSIS: This study is an open labelled randomised controlled trial. The study participants are patients admitted to the Korle Bu Teaching Hospital (KBTH) in Accra, Ghana with a diagnosis of antepartum, intrapartum or postpartum eclampsia or pre-eclampsia with severe features. All study participants will be administered a loading dose of magnesium sulfate, followed by maintenance dosing. Participants in the control group will receive magnesium sulfate for 24 hours after diagnosis, while those in the treatment group will receive magnesium sulfate for 12 hours after diagnosis. The primary outcome of this study is the occurrence of a seizure any time after the completion of treatment in the assigned group. Secondary outcome measures include maternal health outcomes, magnesium sulfate toxicities and fetal health outcomes. Data collection was started in October 2018 with a target enrolment of 1245 participants with severe pre-eclampsia and 844 participants with eclampsia with a projected study period of 2-3 years. ETHICS AND DISSEMINATION: Ethical approval was obtained from the KBTH Institutional Review Board (IRB) in Ghana. University of Michigan involvement is limited to protocol development and statistical analysis of de-identified data, and has been granted a Not Regulated Determination by the University of Michigan IRB. Results of the study will be shared at clinical forums at the KBTH and will be submitted for publication in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: Pan African Clinical Trial Registry through the South African Medical Research Council (PACTR201811515303983).

A randomized-controlled trial to assess the effect of ibuprofen on postpartum blood pressure in women with hypertensive disorders of pregnancy.

OBJECTIVES: To test the hypothesis that ibuprofen is equivalent to acetaminophen in its effect on postpartum blood pressure in women with gestational hypertension or preeclampsia without severe features. STUDY DESIGN: Single-center randomized, crossover, equivalence trial among women with hypertensive disorders of pregnancy without severe features after vaginal delivery. Participants were assigned in a double-blind fashion to ibuprofen 600 mg or acetaminophen 650 mg every 6 h for 24 h followed by crossover to the other drug. We assessed clinical blood pressures and ambulatory blood pressure monitor measurements. Intention-to-treat analyses were performed using a linear mixed model adjusted for time period. MAIN OUTCOME MEASURES: The mean difference in systolic blood pressure through 24 h of drug exposure with an equivalence margin of 10 mmHg. RESULTS: Of 185 screened women, 74 enrolled prior to delivery. Forty-three women remained eligible and were randomized to ibuprofen first (n = 20, 46.5%) or acetaminophen first (n = 23, 53.5%). A total of 37 women (86.0%) received study drug (ibuprofen first n = 19, acetaminophen first n = 18). Most participants were white (91.9%) and had gestational hypertension (86.5%); mean (SD) age was 31.0 (6.5) years. The mean adjusted difference in systolic blood pressure was 1.0 mmHg (95% CI, -3.7 to 5.7 mmHg), which was within the equivalence margin. A linear mixed model did not demonstrate a main effect of group assignment, nor did it show an interaction effect with time period. CONCLUSIONS: Among women with gestational hypertension and preeclampsia without severe features, ibuprofen is an equally safe option as acetaminophen with respect to postpartum blood pressure concerns.

Cardiac remodeling in morbidly obese women and its association with adverse perinatal outcomes.

OBJECTIVES: To determine the association of cardiac remodeling in early pregnancy and adverse perinatal outcomes among women with BMI ≥ 40 kg/m2. STUDY DESIGN: We performed a retrospective cohort study including women with BMI ≥ 40 kg/m2 without known cardiac disease. Women who underwent screening transthoracic echocardiography prior to gestational age 24 weeks were included. Women were analyzed by group with normal or abnormal geometry, including concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Multivariable logistic regression was used to assess the association of abnormal geometry with perinatal outcomes. We had 80% power with alpha 0.05 to detect a 3.0-fold increase in the primary outcome among women with abnormal geometry. MAIN OUTCOME MEASURES: Our primary outcome was a composite of adverse perinatal outcomes including any 1 of the following: preterm birth (<37 weeks), low birth weight (<2500 g), or hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. RESULTS: Of 140 women, 53 (37.9%) had abnormal geometry. The average BMI was similar between those with normal and abnormal geometry (44.7 vs. 44.2 kg/m2, p = 0.53). The primary outcome occurred in 20.7% with normal geometry and 30.2% with abnormal geometry (p = 0.20). After adjustment for parity, chronic hypertension, and tobacco use, abnormal cardiac geometry was not associated with the composite primary outcome (adjusted OR 2.01 [95% CI 0.84-4.78]) but was associated with hypertensive disorders of pregnancy (adjusted OR 2.82 [95% CI 1.03-7.78]). CONCLUSIONS: Cardiac remodeling early in pregnancy is associated with hypertensive disorders of pregnancy.

Hospital contribution to variation in rates of vaginal birth after cesarean.

OBJECTIVE: To determine the influence of delivery hospital on the rate of vaginal birth after cesarean (VBAC). STUDY DESIGN: This retrospective cohort study used claims data from Blue Cross and Blue Shield of Michigan. Women with a prior cesarean and a singleton livebirth between 2012 and 2016 were included. We calculated the hospital-specific risk-standardized VBAC rates and median odds ratio as a measure of variation. RESULT: Hospital-level adjusted rates varied nearly tenfold (3.7%-35.5%). Compared to the lowest volume hospitals (1st quartile), the likelihood of VBAC increased for those in the 2nd (adjusted OR 2.75 [95% CI 1.23-6.17]), 3rd (adjusted OR 3.73 [95% CI 1.59-8.75]), and 4th quartiles (adjusted OR 2.9 [95% CI 1.11-7.72]). The median OR suggested significant variation by hospital after adjustment. CONCLUSION: The delivery hospital itself explains a large amount of the variation in rates of VBAC after adjustment for patient and hospital characteristics.

Association of Cervical Effacement With the Rate of Cervical Change in Labor Among Nulliparous Women.

OBJECTIVE: To assess the association of cervical effacement with the rate of intrapartum cervical change among nulliparous women. METHODS: We conducted a secondary analysis of a prospective trial of intrapartum fetal pulse oximetry. For women who had vaginal deliveries, interval-censored regression was used to estimate the time to dilate at 1-cm intervals. For each given centimeter of progressive cervical dilation, women were divided into those who had achieved 100% cervical effacement and those who had not. The analysis was performed separately for women in spontaneous labor and those who were given oxytocin. RESULTS: A total of 3,902 women were included in this analysis, 1,466 (38%) who underwent labor induction, 1,948 (50%) who underwent labor augmentation (combined for the analysis), and 488 (13%) who labored spontaneously. For women in spontaneous labor, the time to dilate 1 cm was shorter for those who were 100% effaced starting at 4 cm of cervical dilation (P=.01 to <.001). For women who received oxytocin, the time to dilate 1 cm was shorter for those who were 100% effaced throughout labor (P<.001). CONCLUSION: The rate of cervical dilation among nulliparous women is associated with not only the degree of cervical dilation, but also with cervical effacement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00098709.

The effects of respiratory failure on delivery in pregnant patients with H1N1 2009 influenza.

BACKGROUND: The majority of hospitalizations for H1N1 complications have been in people with high-risk comorbidities, including pregnancy. Here we describe the obstetric and critical care treatment of three patients with confirmed H1N1 influenza virus infection complicated by acute respiratory failure. CASES: We describe the clinical and therapeutic courses of three patients with confirmed H1N1 2009 influenza virus infection complicating singleton, twin, and triplet gestations, each of which were complicated by respiratory failure. CONCLUSION: These three cases illustrate that a high index of suspicion, prompt treatment, timing and mode of delivery considerations, and interdisciplinary treatment are integral to the care of pregnant patients with H1N1 influenza infections complicated by acute respiratory failure.

The effect of preterm premature rupture of membranes on neonatal mortality rates.

OBJECTIVE: To estimate the effect of preterm premature rupture of membranes (PROM) on neonatal mortality. METHODS: A cross-sectional study using a state perinatal database (California Perinatal Quality Care Collaborative) was performed. Prenatal data, including ruptured membranes, corticosteroid administration, maternal age, maternal race, maternal hypertension, mode of delivery, and prenatal care, were recorded. Mortality rates were compared for neonates born between 24 and 34 weeks of gestation without preterm PROM to those with recent (less than 18 hours before delivery) and prolonged (more than 18 hours before delivery) preterm PROM. Neonatal sepsis rates were also examined. RESULTS: Neonates born between 24 0/7 and 34 0/7 weeks of gestation from 127 California neonatal intensive care units between 2005 and 2007 were included (N=17,501). When analyzed by 2-week gestational age groups, there were no differences in mortality rates between those born with and without membrane rupture before delivery. The presence of prolonged preterm PROM was associated with decreased mortality at 24 to 26 weeks of gestation (18% compared with 31% for recent preterm PROM; odds ratio [OR] 1.79; confidence interval [CI] 1.25-2.56) but increased mortality at 28 to 30 weeks of gestation (4% compared with 3% for recent preterm PROM; OR 0.44; CI 0.22, 0.88) when adjusted for possible confounding factors. Sepsis rates did not differ between those with recent or prolonged preterm PROM at any gestational age. CONCLUSION: The presence of membrane rupture before delivery was not associated with increased neonatal mortality in any gestational age group. The effects of a prolonged latency period were not consistent across gestational ages.