Patient Perception of Telemedicine in Maternal-Fetal Medicine.

Background: Maternal-fetal medicine (MFM) is a medical subspecialty that cares for patients with high-risk pregnancies. Methods: An IRB-approved survey was offered to patients in MFM offices of a tertiary health care system from March 2022 to May 2022. Demographics and responses to 15 statements about telemedicine were collected via a 5-point Likert scale. Exploratory factor analysis was performed to identify factors affecting patient perception of the telemedicine experience. We sought to examine perception of telemedicine in MFM, identify factors affecting perception, and identify whether specific demographics were associated with patients who view telemedicine appointments favorably. Results: Surveys were completed by 327 of 347 (94%) patients. A total of 233 (71%) patients felt that the telemedicine experience was equal in quality to in-person appointments, and 257 (79%) were open to telemedicine appointments in the future. Exploratory factor analysis yielded two factors: "physician attentiveness" and "technology comfort." Telemedicine was viewed favorably or neutrally for both factors. Education (lower) and marital status (single) were associated with a favorable perception of physician attentiveness. Ethnicity (Hispanic), employment status (employed), and prior telemedicine experience were associated with a favorable perception of technology comfort. Conclusion: Most patients felt the quality of telemedicine appointments was equal to those completed in person. Physician attentiveness and technology comfort affect telemedicine perception. Specific patient demographic characteristics were associated with differing perceptions of telemedicine in MFM. Our findings suggest that telemedicine is positively viewed for MFM and can be used for improving health care delivery efficiency in MFM.

Preeclampsia and Long-term Kidney Outcomes: An Observational Cohort Study.

RATIONALE & OBJECTIVE: Preeclampsia is a pregnancy-related complication characterized by acute hypertension and end-organ dysfunction. We evaluated the long-term association between preeclampsia and the risk of developing chronic hypertension and kidney disease. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: 27,800 adults with deliveries in the Geisinger Health System between 1996 and 2019. EXPOSURE: Preeclampsia. OUTCOME: Hypertension, reduced estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2), and albuminuria>300mg/g. ANALYTICAL APPROACH: Propensity-score matching and Cox proportional hazards models to evaluate the association between preeclampsia and incident hypertension, reduced eGFR, and albuminuria. RESULTS: Of 27,800 adults with pregnancies during the study period (mean age, 28 years; 3% Black race), 2,977 (10.7%) had at least 1 pregnancy complicated by preeclampsia. After matching for multiple characteristics, individuals with preeclampsia had a higher risk of developing chronic hypertension (HR, 1.77 [95% CI, 1.45-2.16]), eGFR<60mL/min/1.73m2 (HR, 3.23 [95% CI, 1.64-6.36]), albuminuria (HR, 3.60 [95% CI, 2.38-5.44]), and a subsequent episode of preeclampsia (HR, 24.76 [95% CI, 12.47-48.36]), compared with matched controls without preeclampsia. Overall, postpartum follow-up testing was low. In the first 6 months after delivery, 31% versus 14% of individuals with and without preeclampsia had serum creatinine tests, respectively, and testing for urine protein was the same in both groups, with only 26% having follow-up testing. LIMITATIONS: Primarily White study population, observational study, reliance on ICD codes for medical diagnosis. CONCLUSIONS: Individuals with a pregnancy complicated by preeclampsia had a higher risk of hypertension, reduced eGFR, and albuminuria compared with individuals without preeclampsia. PLAIN-LANGUAGE SUMMARY: Preeclampsia is a significant contributor to perinatal and maternal morbidity and is marked by new-onset hypertension and end-organ damage, including acute kidney injury or proteinuria. To gain insight into the long-term kidney effects of the disease, we compared adults with deliveries complicated by preeclampsia with those without preeclampsia in the Geisinger Health System, while also assessing postpartum testing rates. Our results demonstrate that pregnant individuals with preeclampsia are at a heightened risk for future hypertension, reduced eGFR, and albuminuria, with overall low rates of postpartum testing among both individuals with and without preeclampsia. These findings underscore the need to consider preeclampsia as an important risk factor for the development of chronic kidney disease. Further studies are required to determine optimal postpreeclampsia monitoring strategies.

Comparison of three antepartum risk assessment tools to predict significant postpartum hemorrhage in livebirths.

BACKGROUND: To adequately predict significant postpartum hemorrhage (PPH) at hospital admission, we evaluated and compared the accuracy of three risk assessment tools: 1. California Maternal Quality Care Collaborative (CMQCC), 2. American College of Obstetrics and Gynecology Safe Motherhood Initiative (ACOG SMI) and 3. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). STUDY DESIGN AND METHODS: This is a retrospective cohort study of people who delivered liveborn infants from January 2018 to June 2021 at our center. Patients with comorbidities necessitating higher hemoglobin values, those who refused blood transfusions, and missing pertinent data were excluded. Significant PPH was defined as a blood transfusion within 48 hours following delivery. Diagnostic statistics were calculated for each tool. RESULTS: Of the 11,679 included pregnancies, 232 (1.9%) people had significant PPH. Amongst those diagnosed as high-risk by the CMQCC tool, 67/1485 (4.5%) had significant PPH; 62/1672 (3.7%) by the ACOG SMI tool, and 85/1864 (4.6%) by the AWHONN tool had significant PPH. All tools have low sensitivity and high negative predictive values. The area under the receiver operating characteristics curve of the three tools is moderately poor (CMQCC: 0.58, ACOG SMI: 0.55, AWHONN:0.61). DISCUSSION: Upon admission to labor and delivery, all three studied tools are poor predictors of significant PPH. The development and validation of better PPH risk stratification tools are required with the inclusion of additional important variables.

Comparing Diagnosis of Fetal Growth Restriction and the Potential Impact on Management and Outcomes Using Different Growth Curves.

OBJECTIVES: The diagnosis of fetal growth restriction (FGR) is managed with close fetal surveillance and often requires iatrogenic delivery, as there is an associated increased risk of fetal demise. However, there is no standard reference for fetal growth. We sought to compare the intrauterine growth curve of Hadlock et al (Radiology 1991; 181:129-133) to other known growth curves to determine which one best identifies fetuses at risk without overburdening the patient and health care system with unnecessary intervention. METHODS: We retrospectively reviewed charts of singleton euploid pregnancies with a diagnosis of FGR (per Hadlock) at a tertiary care center from June 2014 to May 2015. We applied the estimated fetal weights from ultrasound at diagnosis of FGR to 4 population-based growth curves by Brenner et al (Am J Obstet Gynecol 1976; 126:555-564), Williams et al (Obstet Gynecol 1982; 59:624-632), Alexander et al (Obstet Gynecol 1996; 87:163-168), and Duryea et al (Obstet Gynecol 2014; 124:16-22) and reassessed the incidence of FGR using each curve. We reviewed pregnancy demographics, risk factors, pregnancy management, and outcomes of FGR cohorts on each curve to evaluate whether poor outcomes may be missed or interventions may be avoided using the population-based curves. A sensitivity analysis was also done to see how well each curve predicted small-for-gestational-age birth weights. RESULTS: Applying any of the population-based growth curves decreased the number of FGR diagnoses, iatrogenic deliveries, and primary cesarean deliveries. Brenner's growth curve identified the least number of FGR diagnoses at 22 of the 107 identified by Hadlock. Williams' growth curve performed best in the sensitivity analysis with sensitivity of 99% and specificity of 97%. A small number of patients with absent/reversed end-diastolic flow would have been missed by applying the population curves. CONCLUSIONS: Applying the population-based growth curves instead of Hadlock's for diagnosis of FGR decreases its incidence, therefore decreasing the number of visits for ultrasound and fetal surveillance and the number of iatrogenic deliveries. However, using these curves could miss a few fetuses with increased risk of fetal demise.

A retrospective study of gestational weight gain in relation to the Institute of Medicine's recommendations by maternal body mass index in rural Pennsylvania from 2006 to 2015.

BACKGROUND: In 2009, the Institute of Medicine (IOM) published guidance on gestational weight gain (GWG) modified by maternal pre-pregnancy body mass index (BMI). Estimates indicate that less than half of US pregnant women have GWG within recommendations. This study examined GWG from before (2006-2009) and after (2010-2015) the release of the IOM guidance in a rural, non-Hispanic white population to assess the proportion of women with GWG outside of IOM guidance, whether GWG became more likely to be within IOM guidance after 2010, and identify potential maternal factors associated with GWG outside of recommendations. METHODS: We examined GWG in 18,217 term singleton births between 2006 and 2015 in which maternal pre-pregnancy BMI could be calculated from electronic medical records at Geisinger, PA, and a subset of 12,912 births in which weekly GWG in the third trimester could be calculated. The primary outcome was whether GWG was below, within, or above recommendations based on maternal BMI. The relationships between GWG, maternal BMI, parity, age at conception, gestation length, and maternal blood pressure were examined. RESULTS: GWG declined with increasing maternal BMI, however, more than 50% of overweight and obese women gained above IOM recommendations. About one of five women gained below recommendations (21.3%) with underweight women the most likely to gain below recommendations (33.0%). The proportion of births with usable data increased after 2010, driven by a higher probability of recording maternal weight. However, the proportion of women who gained below, within or above recommendations did not change over the ten years. GWG above recommendations was associated with higher maternal BMI, lower parity, and longer gestation. GWG below recommendations was associated with lower maternal BMI, higher parity, shorter gestation, and younger age at conception. Maternal blood pressure was higher for GWG outside recommendations. CONCLUSIONS: Despite the publication of IOM recommendations in 2009 and an apparent increase in tracking maternal weight after 2010, GWG in this population did not change between 2006 and 2015. A majority of overweight and obese women gained above recommendations. GWG below recommendations continues to occur, and is prevalent among underweight women.

The effect of the MFM obesity protocol on cesarean delivery rates.

BACKGROUND: Obesity in pregnancy has an impact on both the mother and the fetus. To date, no universal protocol has been established to guide the management of pregnancy in obese woman. In April 2011, the Geisinger Maternal-Fetal Medicine Department implemented an obesity protocol in which women meeting the following criteria were delivered by their estimated due dates: (1) class III obese or (2) class II obese with additional diagnoses of a large-for-gestational-age fetus or pregnancy complicated by gestational diabetes or (3) class I obese with large-for-gestational-age and gestational diabetes. OBJECTIVE: We sought to assess the impact of this protocol on the rate of cesarean deliveries in obese women. STUDY DESIGN: We performed a retrospective cohort study of 5000 randomly selected women who delivered at Geisinger between January 2009 and September 2013, excluding those who delivered in 2011. The data were stratified into obese and nonobese and divided into before protocol and after protocol. Comparison across all groups was accomplished using Wilcoxon rank sum and Pearson's χ(2) tests. Potential confounders were controlled for using logistic regression. RESULTS: The cesarean delivery rate in the obese/after protocol group was 10.8% lower than in the obese/before protocol group (42.4% vs 31.6%, respectively; P < .0001). In addition, when controlling for age, race, smoking status, preeclampsia, gestational diabetes, and intrauterine growth restriction, obese women were 37% less likely to have a cesarean delivery after the protocol than they were before (odds ratio, 0.63; 95% confidence interval, 0.52, 0.76, P < .0001). CONCLUSION: Implementation of a maternal-fetal medicine obesity protocol did not increase the rate of cesarean deliveries in obese women. On the contrary, obese women were less likely to have a cesarean delivery after implementation of the protocol.

Antibiotic regimens for postpartum endometritis.

BACKGROUND: Postpartum endometritis occurs when vaginal organisms invade the endometrial cavity during the labor process and cause infection. This is more common following cesarean birth. The condition warrants antibiotic treatment. OBJECTIVES: Systematically, to review treatment failure and other complications of different antibiotic regimens for postpartum endometritis. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2014) and reference lists of retrieved studies. SELECTION CRITERIA: We included randomized trials of different antibiotic regimens after cesarean birth or vaginal birth; no quasi-randomized trials were included. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: The review includes a total of 42 trials, and 40 of these trials contributed data on 4240 participants.Regarding the primary outcomes, seven studies compared clindamycin plus an aminoglycoside versus penicillins and showed fewer treatment failures (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.46 to 0.90). There were more treatment failures in those treated with an aminoglycoside plus penicillin when compared to those treated with gentamycin/clindamycin (RR 2.57, 95% CI 1.48 to 4.46). There were more treatment failures (RR 1.66, 95% CI 1.01 to 2.74) and wound infections (RR 1.88, 95% CI 1.08 to 3.28) in those treated with second or third generation cephalosporins (excluding cephamycins) versus those treated with clindamycin plus gentamycin. In four studies comparing once-daily with thrice-daily dosing of gentamicin, there were fewer failures with once-daily dosing. There were more treatment failures (RR 1.94, 95% CI 1.38 to 2.72) and wound infections (RR 1.88, 95% CI 1.17 to 3.02) in those treated with a regimen with poor activity against penicillin-resistant anaerobic bacteria as compared to those treated with a regimen with good activity against penicillin-resistant anaerobic bacteria. There were no differences between groups with respect to severe complications and no trials reported any maternal deaths.Regarding the secondary outcomes, three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, found no differences in recurrent endometritis or other outcomes. Four trials that compared clindamycin plus aminoglycoside versus cephalosporins identified fewer wound infections in those treated with clindamycin plus an aminoglycoside (RR 0.53, 95% CI 0.30 to 0.93). There were no differences between groups for the outcomes of allergic reactions. The overall risk of bias was unclear in the most of the studies. The quality of the evidence using GRADE comparing clindamycin and an aminoglycoside with another regimen (compared with cephalosporins or penicillins) was low to very low for therapeutic failure, severe complications, wound infection and allergic reaction. AUTHORS' CONCLUSIONS: The combination of clindamycin and gentamicin is appropriate for the treatment of endometritis. Regimens with good activity against penicillin-resistant anaerobic bacteria are better than those with poor activity against penicillin-resistant anaerobic bacteria. There is no evidence that any one regimen is associated with fewer side-effects. Following clinical improvement of uncomplicated endometritis which has been treated with intravenous therapy, the use of additional oral therapy has not been proven to be beneficial.

Antenatal testing in uncomplicated pregnancies: should testing be initiated after 40 or 41 weeks?

OBJECTIVE: This study aims to compare outcomes of antenatal testing in women who received testing between 40 weeks and 40+6 weeks versus those who received testing at ≥41 weeks. MATERIALS AND METHODS: This retrospective study included women without maternal comorbidities, who were referred for outpatient antenatal testing for gestational age ≥40 weeks. We compared women who received antenatal testing between 40 and 40+6 weeks (Group 1), to those who were only tested at ≥41 weeks (Group 2). RESULTS: A total of 827 Group 1 and 244 Group 2 pregnancies were evaluated. One-hundred and eighty-nine (18%) were sent to labor and delivery (L&D) for further evaluation. There were no significant differences between groups in terms of being sent or admitted to labor and delivery, the reason for which women were sent, induction of labor, mode of delivery, neonatal length of stay, or admission to intensive care. CONCLUSION: Pregnancies tested at 40 weeks were identified as abnormal and sent to L&D at the same rate as those tested at 41 weeks. Therefore, it may be reasonable to initiate fetal surveillance at the estimated date of delivery.

Tocolytics for preterm premature rupture of membranes.

BACKGROUND: In women with preterm labor, tocolysis has not been shown to improve perinatal mortality; however, it is often given for 48 hours to allow for the corticosteroid effect for fetal maturation. In women with preterm premature rupture of membranes (PPROM), the use of tocolysis is still controversial. In theory, tocolysis may prolong pregnancy in women with PPROM, thereby allowing for the corticosteroid benefit and reducing the morbidity and mortality associated with prematurity. OBJECTIVES: To assess the potential benefits and harms of tocolysis in women with preterm premature rupture of membranes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 January 2014). SELECTION CRITERIA: We included pregnant women with singleton pregnancies and PPROM (23 weeks to 36 weeks and six days). We included any tocolytic therapy compared to no tocolytic, placebo, or another tocolytic. DATA COLLECTION AND ANALYSIS: All review authors assessed the studies for inclusion. We extracted and quality assessed data. MAIN RESULTS: We included eight studies with a total of 408 women. Seven of the studies compared tocolysis to no tocolysis. One study compared nifedipine to terbutaline. Compared to no tocolysis, tocolysis was not associated with a significant effect on perinatal mortality in women with PPROM (risk ratio (RR) 1.67; 95% confidence interval (CI) 0.85 to 3.29). Tocolysis was associated with longer latency (mean difference (MD) 73.12 hours; 95% CI 20.21 to 126.03; three trials of 198 women) and fewer births within 48 hours (average RR 0.55; 95% CI 0.32 to 0.95; six trials of 354 women; random-effects, Tau² = 0.18, I² = 43%) compared to no tocolysis. However, tocolysis was associated with increased five-minute Apgar of less than seven (RR 6.05; 95% CI 1.65 to 22.23; two trials of 160 women) and increased need for ventilation of the neonate (RR 2.46; 95% CI 1.14 to 5.34; one trial of 81 women). In the subgroup analysis comparing betamimetic to no betamimetics, tocolysis was associated with increased latency and borderline significance for chorioamnionitis. Prophylactic tocolysis with PPROM was associated with increased overall latency, without additional benefits for maternal/neonatal outcomes. For women with PPROM before 34 weeks, there was a significantly increased risk of chorioamnionitis in women who received tocolysis. However, neonatal outcomes were not significantly different. There were no significant differences in maternal/neonatal outcomes in subgroup analyses comparing cox inhibitor versus no tocolysis, calcium channel blocker versus betamimetic, antibiotic, corticosteroid or combined antibiotic/corticosteroid. AUTHORS' CONCLUSIONS: Our review suggests there is insufficient evidence to support tocolytic therapy for women with PPROM, as there was an increase in maternal chorioamnionitis without significant benefits to the infant. However, studies did not consistently administer latency antibiotics and corticosteroids, both of which are now considered standard of care.

Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery.

BACKGROUND: Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate. OBJECTIVES: To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS: We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection. AUTHORS' CONCLUSIONS: Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates.

Morphine sleep in pregnancy.

OBJECTIVES: To determine the incidence of admission in labor after morphine sleep (therapeutic rest), patient characteristics associated with labor, and adverse outcomes associated with treatment. METHODS: We reviewed medical records of women treated with morphine sleep from December 2005 to December 2009. Variables evaluated included medications used for treatment, cervical examination, maternal demographic characteristics and obstetric history, fetal heart rate patterns, and maternal/neonatal outcomes. These characteristics were compared between those admitted in labor after morphine sleep versus those discharged. RESULTS: Fifty-eight women received morphine sleep: 36 (62%) were admitted in labor, 17 (29%) were discharged, and 5 (9%) were admitted secondary to category II fetal heart rate tracings. All fetuses had category I fetal heart rate tracings prior to treatment. Median dose of morphine sulfate was 20 mg. Those with effacement > 50% (p < 0.01) and carrying term gestations (p < 0.01) were more likely to be admitted in labor after treatment. There were no adverse maternal outcomes. There were no significant differences in neonatal outcomes. CONCLUSION: Sixty-two percent of women were admitted in labor after morphine sleep. Admission effacement > 50% and term gestational age were associated with admission in labor. There were no significant differences in maternal or neonatal morbidity in those admitted versus discharged home after treatment with morphine sleep.

Evidence-based cesarean delivery: preoperative management (part 7).

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

The impact of prepregnancy body mass index on pregnancy and neonatal outcomes.

CONTEXT: The obesity epidemic in the United States is continuing to worsen. Obesity is a known risk factor for pregnancy morbidity. However, many studies use the patient's body mass index (BMI) at the time of delivery, do not stratify by class of obesity, or utilize billing codes as the basis of their study, which are noted to be inaccurate. OBJECTIVES: This study aims to investigate the prepregnancy BMI class specific risks for pregnancy and neonatal complications based on a prepregnancy BMI class. METHODS: We conducted a retrospective cohort study of 40,256 pregnant women with 55,202 singleton births between October 16, 2007 and December 3, 2023. We assessed the risk of pregnancy and neonatal morbidity based on the maternal prepregnancy BMI category. The primary outcome was composite maternal morbidity, including hypertensive disorders of pregnancy (i.e., gestational hypertension [GHTN] and preeclampsia), and gestational diabetes mellitus (GDM), adjusted for pregestational diabetes mellitus and chronic hypertension (cHTN). Secondary maternal outcomes included preterm premature rupture of membranes (PPROM), preterm delivery (PTD<37 and <32 weeks), induction of labor (IOL), cesarean delivery (CD), and postpartum hemorrhage (PPH). Neonatal outcomes included a composite adverse outcome (including stillbirth, intraventricular hemorrhage (IVH), hypoglycemia, respiratory distress syndrome [RDS], APGAR [Appearance, Pulse, Grimace, Activity, and Respiration] <7 at 5 min, and neonatal intensive care unit [NICU] admission), birthweight, fetal growth restriction (FGR), and macrosomia. RESULTS: Composite maternal morbidity (odds ratio [OR] 4.40, confidence interval [CI] 3.70-5.22 for class III obesity [BMI≥40.0 kg/m2] compared with normal BMI), hypertensive disorders of pregnancy (HDP), GDM, PTD, IOL, CD, PPH, neonatal composite morbidity, hypoglycemia, RDS, APGAR<7 at 5 min, NICU admission, and macrosomia showed a significant increasing test of trend among BMI classes. Increased BMI was protective for FGR. CONCLUSIONS: Our data provides BMI-class specific odds ratios (ORs) for adverse pregnancy outcomes. Increased BMI class significantly increases the risk of HDP, GDM, IOL, CD, composite adverse neonatal outcomes, and macrosomia, and decreases the risk of FGR. Attaining a healthier BMI category prior to conception may lower pregnancy morbidity.

Effectiveness of 17-α-hydroxyprogesterone caproate on preterm birth prevention in women with history-indicated cerclage.

OBJECTIVE: To determine whether 17-α-hydroxyprogesterone caproate (17P) reduces the incidence of preterm birth in women with a history-indicated cerclage. STUDY DESIGN: Retrospective cohort study of women who received a cerclage for a prior preterm birth, analyzed based on exposure to 17P. The primary outcome variable was delivery < 35 weeks. Secondary outcomes were preterm birth < 37, 32, 28, and 24 weeks; interval between cerclage placement and delivery; gestational age at delivery; and infant birth weight. RESULTS: Fourteen women received 17P and 80 did not. Baseline characteristics did not differ between these two groups. Preterm delivery at < 35 weeks did not differ between those who received 17P and those who did not (29% versus 15%, p = 0.46). There were no significant differences between the groups for any other outcome. CONCLUSION: 17P does not appear to have an effect on preterm birth < 35 weeks in women with a history-indicated cerclage.

Pregnancy Outcomes in Patients Enrolled in the Healthy Beginnings Plus Program.

OBJECTIVE: To evaluate the effectiveness of enrollment in the Healthy Beginnings Plus Program (HB) on pregnancy outcomes. DESIGN: Retrospective cohort study of 12,299 singleton pregnancies birthed between January 2007 and December 2018. SETTING/LOCAL PROBLEM: Individuals of low socioeconomic status are at increased risk for adverse pregnancy outcomes, such as preterm birth (PTB) and low-birth-weight (LBW) neonates. Pennsylvania offers HB to pregnant individuals with Medical Assistance insurance to provide additional psychosocial and obstetric resources to routine prenatal care to minimize risk. PARTICIPANTS: Individuals with Medical Assistance insurance enrolled in HB (n = 4,645), individuals with Medical Assistance insurance not enrolled in HB (n = 2,874), and individuals with private insurance (n = 4,780). MEASUREMENTS: Primary outcomes were rates of PTB and LBW neonates. Secondary outcomes included rates of gestational diabetes, gestational hypertension, small-for-gestational-age neonates, and admission to the NICU. RESULTS: There were no differences in PTB (adjusted OR [aOR] = 0.93, 95% confidence interval [CI] [0.76, 1.13]) or LBW neonates (aOR = 1.06, 95% CI [0.86, 1.31]) between individuals with Medical Assistance enrolled in HB versus those with Medical Assistance insurance not enrolled in HB. Individuals with Medical Assistance enrolled in HB were less likely to develop gestational hypertension compared to individuals with Medical Assistance insurance not enrolled in HB (aOR = 1.41, 95% CI [1.25, 1.59]) and individuals with private insurance (aOR = 0.85, 95% CI [0.76, 0.96]). They also attended more prenatal visits than individuals with Medical Assistance insurance not enrolled in HB (12.0 vs. 14.0, p < .01). CONCLUSION: Although there was no significant difference between groups for the primary outcomes studied, individuals with Medical Assistance insurance enrolled in HB attended more prenatal visits than those who did not enroll in HB. Similar programs should evaluate outcomes and consider whether changes are needed.

Retrospective application of algorithms to improve identification of pregnancy outcomes from the electronic health record.

OBJECTIVE: To improve upon the accuracy of ICD codes for identifying maternal and neonatal outcomes by developing algorithms that incorporate readily available EHR data. STUDY DESIGN: Algorithms were developed for gestational hypertension (GHTN), pre-eclampsia (PreE), gestational diabetes mellitus (GDM) and were compared to ICD codes and chart review. Accuracy and sensitivity analyses were calculated with their respective 95% confidence limits for each of the comparisons between algorithms, ICD codes alone, and chart review. RESULTS: Sensitivity of GHTN ICD codes was 8.1% vs. 83.8% for the algorithm when compared to chart review. In comparison to chart review, sensitivity of ICD codes for PreE was 7.5% vs. 71.4% for the algorithm. GDM had similar sensitivity rates for both ICD codes and the algorithm. CONCLUSION: Application of algorithms, validated by chart review, enhanced capture of several outcomes. Algorithms should be obligatory adjunct tools to the ICD codes for identification of outcomes of interest.

Women's beliefs of pain after childbirth: Critical insight for promoting behavioral strategies to regulate pain and reduce risks for maternal mortality.

OBJECTIVE: Promoting behavioral strategies to better regulate pain and decrease the use of prescription pain medications immediately after childbirth is an attractive approach to reduce risks for adverse outcomes associated with the maternal mortality crisis. This study aimed to understand women's beliefs and experiences about pain management to identify important insights for promoting behavioral strategies to control postpartum pain. METHODS: N = 32 postpartum women participated in a semi-structured interview about beliefs/experiences with managing postpartum pain. Higher- and lower-order themes were coded; descriptive statistics were used to summarize results. RESULTS: Major trends emerging from the data were: (1) most women used a combination of medications (e.g., oxycodone and acetaminophen) and behavioral strategies (e.g., physical activity) in the hospital (94 %) and at discharge (83 %); (2) some women reported disadvantages like negative side effects of medications and fatigue from physical activity; and (3) some women reported they would have preferred to receive more evidence-based education on behavioral strategies during prenatal visits. CONCLUSION: Our findings showed that most women were prescribed medications while in the hospital and at discharge, and used non-prescription, behavioral strategies. PRACTICAL IMPLICATIONS: Future research is needed to test behavioral strategies in randomized clinical trials and clinical care settings to identify impact on reducing adverse maternal health outcomes.

Techniques and materials for skin closure in caesarean section.

BACKGROUND: Caesarean section is a common operation with no agreed upon standard regarding certain operative techniques or materials to use. With regard to skin closure, the skin incision can be re-approximated by a subcuticular suture immediately below the skin layer, by an interrupted suture, or by staples. A great variety of materials and techniques are used for skin closure after caesarean section and there is a need to identify which provide the best outcomes for women. OBJECTIVES: To compare the effects of skin closure techniques and materials on maternal and operative outcomes after caesarean section. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012). SELECTION CRITERIA: All randomized trials comparing different skin closure materials in caesareans were selected. Two review authors independently extracted the data. DATA COLLECTION AND ANALYSIS: We identified 18 trials and included 10, but only eight trials contributed data. Three trials were not randomized controlled trials; three were ongoing; and one did not compare skin closure materials, but rather suture to suture and drain placement. MAIN RESULTS: The two methods of skin closure for caesarean that have been most often compared are non-absorbable staples and absorbable subcutaneous sutures. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with similar incidences of wound infection. Other important secondary outcomes, such as wound complications, were also similar between the groups in women with Pfannenstiel incisions. However, it is important to note, that for both of these outcomes (wound infection and wound complication), staples may have a differential effect depending on the type of skin incision, i.e., Pfannenstiel or vertical. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with an increased risk of skin separation, and therefore, reclosure. However, skin separation was variably defined across trials, and most staples were removed before four days postpartum. AUTHORS' CONCLUSIONS: There is currently no conclusive evidence about how the skin should be closed after caesarean section. Staples are associated with similar outcomes in terms of wound infection, pain and cosmesis compared with sutures, and these two are the most commonly studied methods for skin closure after caesarean section. If staples are removed on day three, there is an increased incidence of skin separation and the need for reclosure compared with absorbable sutures.

Techniques and materials for skin closure in caesarean section.

BACKGROUND: Caesarean section is a common operation with no agreed upon standard regarding certain operative techniques or materials to use. With regard to skin closure, the skin incision can be re-approximated by a subcuticular suture immediately below the skin layer, by an interrupted suture, or by staples. A great variety of materials and techniques are used for skin closure after caesarean section and there is a need to identify which provide the best outcomes for women. OBJECTIVES: To compare the effects of skin closure techniques and materials on maternal and operative outcomes after caesarean section. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012). SELECTION CRITERIA: All randomized trials comparing different skin closure materials in caesareans were selected. Two review authors independently abstracted the data. DATA COLLECTION AND ANALYSIS: We identified 19 trials and included 11, but only eight trials contributed data. Three trials were not randomized controlled trials; two were ongoing; one study was terminated and the results were not available for review; one is awaiting classification; and one did not compare skin closure materials, but rather suture to suture and drain placement. MAIN RESULTS: The two methods of skin closure for caesarean that have been most often compared are non-absorbable staples and absorbable subcutaneous sutures. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with similar incidences of wound infection. Other important secondary outcomes, such as wound complications, were also similar between the groups in women with Pfannenstiel incisions. However, it is important to note, that for both of these outcomes (wound infection and wound complication), staples may have a differential effect depending on the type of skin incision, i.e., Pfannenstiel or vertical. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with an increased risk of skin separation, and therefore, reclosure. However, skin separation was variably defined across trials, and most staples were removed before four days postpartum. AUTHORS' CONCLUSIONS: There is currently no conclusive evidence about how the skin should be closed after caesarean section. Staples are associated with similar outcomes in terms of wound infection, pain and cosmesis compared with sutures, and these two are the most commonly studied methods for skin closure after caesarean section. If staples are removed on day three, there is an increased incidence of skin separation and the need for reclosure compared with absorbable sutures.