bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes for Obstetrician or Midwifery Intrapartum Care of Low-Risk Hospital Births [ID: 1368407]
Authors: Agarwal Trisha , Anderson Jessica , Hurt Joseph , Lijewski Virginia , Smith Denise , Taylor Natalie
Published: May 2023

INTRODUCTION:

The objective of this study was to compare unplanned cesarean deliveries, labor interventions, and maternal and neonatal adverse outcomes in low-risk pregnant patients receiving intrapartum care managed by obstetricians or midwives.

METHODS:

We conducted a retrospective cohort study using perinatal data from a single academic tertiary center from 2013 to 2018. The sample included healthy nulliparous and multiparous patients with a term, singleton, vertex fetus managed by obstetricians or midwives. We included both induced and spontaneous labor as well as trial of labor after cesarean. We excluded patients with planned cesarean delivery or any high-risk diagnosis requiring prelabor transfer from midwife to obstetrician care.

RESULTS:

Our cohort included 7,694 patients; 3,543 (46%) received care from an obstetrician and 4,151 (54%) from a midwife. The overall cesarean rate was 11.8%. Patients receiving midwifery care had significantly lower cesarean rates (8.9% versus 15.2%, P<.01), including when analyzed by parity. Patients receiving obstetrician care more frequently experienced induction/augmentation, neuraxial anesthesia, and operative vaginal delivery. Patients of obstetricians had a higher maternal adverse composite outcome (23% versus 18%, P<.01). Midwifery patients had higher rates of shoulder dystocia (3% versus 2%, P<.01). In logistic regression, midwifery care had lower adjusted odds of unplanned cesarean birth (adjusted odds ratio, 0.49 [0.40–0.60] 95% CI).

CONCLUSION:

Wider integration of midwifery care for low-risk labor and delivery may reduce rates of unplanned cesarean delivery and optimize effective patient-centered care. Additional studies are needed to identify the mechanisms underlying these findings and the implications for systems-based change to improve vaginal delivery rates in the U.S.
Rate of Hypertensive Disorders of Pregnancy With Monoclonal Antibody Treatment for SARS-CoV-2 Infection [ID: 1376017]
Authors: Smith Caroline , Lemon Lara , McCreary Erin , Megli Christina
Published: May 2023

INTRODUCTION:

SARS-CoV-2 infection among pregnant patients been associated with elevated rates of hypertensive disorders of pregnancy (HDP). We have demonstrated that monoclonal antibodies did not result in significantly different rates of severe COVID-19 in pregnancy. We undertook this study to determine whether HDP was altered with monoclonal antibody (mAb) treatment for SARS-CoV-2.

METHODS:

Retrospective cohort study approved by the IRB of University of Pittsburgh of patients aged 12 or older with a pregnancy episode and positive SARS-CoV-2 test in the UPMC health system. Among 663 patients, 403 received mAb treatment and 260 did not receive mAb. Chart review was performed for diagnosis of gestational hypertension (gHTN), preeclampsia without severe features, severe preeclampsia/HELLP syndrome, and postpartum hypertensive disorder with no antepartum diagnosis (PPHTN). Student’s t test was used to compare groups, and P<.05 was considered significant.

RESULTS:

The majority of patients presented during the Omicron wave. In the mAb-treated group, 21.8% developed HDP, 13.2% gHTN, 2.5% nonsevere preeclampsia, 6.9% severe preeclampsia/HELLP, and 2.7% PPHTN. The group that received no mAb experienced rates that were not significantly different from the mAb treated: 17.3% HDP, 10.8% gHTN, 3.5% nonsevere preeclampsia, 2.3% severe preeclampsia/HELLP, and 1.9% PPHTN.

CONCLUSION:

The use of mAbs in pregnant patients infected with SARS-CoV-2 is not associated with a change in the rate of HDP with the Omicron variant. Patients treated with mAbs had a trend toward increased severe preeclampsia, although this was not statistically significant. An understanding of which populations benefit maximally from mAb treatment will assist in managing the most effective and efficient allocation of resources.
Effect of Tranexamic Acid in a Cohort of Placenta Accreta Spectrum Patients [ID: 1380346]
Authors: Hussein Nada , Harrison Rachel , Holmgren Calla , Phelps Alexandra , Steinberg Guy , Steinberg Guy
Published: May 2023

INTRODUCTION:

Use of tranexamic acid (TXA) is beneficial in the setting of obstetric hemorrhage. We sought to understand whether patients with placenta accreta spectrum disorder benefit from TXA administration during cesarean hysterectomy.

METHODS:

This is an IRB-approved retrospective cohort study of participants with suspected placenta accreta spectrum undergoing cesarean hysterectomy in a single hospital system. Those who received TXA were compared to those who did not. The primary outcome was the rate of blood transfusion. Secondary outcomes included maternal intensive care unit (ICU) admission, massive transfusion, length of postoperative stay, operative time, and a composite of adverse maternal outcomes. Chi-square, t tests, and Fisher’s exact test were used to compare baseline characteristics, and a logistic regression was performed with possible confounders.

RESULTS:

A total of 87 participants met criteria for the study; among those were 35 (40.2%) who received TXA. Baseline characteristics between groups were similar. Although not statistically significant in univariable analysis, there was a trend for those who received TXA to have lower blood loss overall (∼2,000 mL versus ∼2,300 mL, P=.483) and be less likely to require transfusion (48.6% versus 69.2%, P=.053). Further, they were statistically less likely to undergo ICU admission (22.9% versus 60.4%, P=.001). There was no difference in the other secondary outcomes including the combined adverse maternal outcome (40.0% versus 44.2%, P=.695). After controlling for confounders, TXA administration was independently associated with decreased rates of blood transfusion (adjusted odds ratio [aOR] 0.23, 95% CI 0.08–0.68) and ICU admission (aOR 0.16, 95% CI 0.05–0.48).

CONCLUSION:

Tranexamic acid use in the setting of cesarean hysterectomy for PAS was associated with decreased risks of transfusion and ICU admission.
Profile and Outcomes of Women With Amniotic Fluid Embolism in the United States [ID: 1375935]
Authors: Akinyemi Oluwasegun , Guoyang Luo , Kuffour Gabriella , Welborn Lyvia Karoline , Weldeslase Terhas Asfiha
Published: May 2023

INTRODUCTION:

Amniotic fluid embolism (AFE) is one of the most catastrophic pregnancy complications and a significant cause of maternal mortality in the United States. The estimated incidence of AFE is 1:15,200 in North America. However, unanswered questions remain about its etiology, risk factors, perinatal morbidity, mortality, and treatment options. In the present study, we described the profile and outcomes of women who develop AFEs in the United States.

METHODS:

We collated data from the National Inpatient Sample Database from January 2010 to December 2017 to conduct a retrospective analysis of women who developed AFEs. We conducted a multivariate analysis to determine the risk of the development of AFE and the outcomes after its development. We included covariates such as women’s age, race and ethnicity, preexisting comorbidities, pregnancy-associated risk factors, and region of the country in the multivariate analysis. Samples were weighed to generate nationally representative estimates.

RESULTS:

There were 1,659 cases of AFE in the NIS during the study period. The median age of these women was 31 years (interquartile range of 26–36 years). 57.8% of the women underwent cesarean section, 48.2% developed disseminated intravascular coagulation, and 37.0% developed acute respiratory distress syndrome. The overall mortality rate was 12.9%. On univariate analysis, women between the ages of 31 and 40 years have a twofold incidence of developing AFE (odds ratio [OR] 2.51, 95% CI 1.45–4.35), while women between 41 and 50 years have a lower risk (OR 0.41, 95% CI 0.19–0.88) compared to the reference (women ≤20 years). Other risk factors include electrolyte abnormalities (OR 5.23, 95% CI 3.72–7.35) and cesarean section (OR 8.2, 95% CI 6.35–10.61). On multivariate analysis, only cesarean section and electrolyte abnormalities have a statistically significant association with the development of AFE.

CONCLUSION:

Amniotic fluid embolism remains a rare but catastrophic emergency with high morbidity and mortality in the United States.
Influence of Maternal Body Mass Index on Severe Maternal Morbidity in the United States [ID: 1383260]
Authors: Patel Priya , DeFranco Emily , Roulette Gregory
Published: May 2023

INTRODUCTION:

Rates of severe maternal morbidity (SMM) and maternal obesity are increasing in the United States. We aimed to quantify the influence of increasing maternal body mass index (BMI) on SMM at a population level among U.S. births.

METHODS:

This was a population-based retrospective cohort study of all singleton live births using U.S.-linked birth–death data from 2013 to 2017. The exposure variable, maternal BMI, was categorized as BMI less than 18, 18–24 (referent), 25–29.9, 30–34.9, 35–39.9, 40–49.9, 50–59.9, and 60–69.9. The primary outcome, SMM, was defined as a composite variable of any blood transfusion, uterine rupture, unplanned hysterectomy, eclampsia, or maternal intensive care unit admission during the delivery hospitalization of the parturient. Generalized linear modeling quantified the association between maternal prepregnancy BMI and SMM while adjusting for maternal race and low socioeconomic status (SES) (Medicaid). Rates of SMM per 10,000 live births and relative risks (95% CI) are reported stratified by BMI.

RESULTS:

The study population included 19,844,580 live births. The numbers of births stratified by maternal BMI are shown in the table. The lowest rate of SMM was among the normal BMI group (0.57%), with 57 cases per 10,000 live births. The rate and risk of SMM increased with each increasing class of maternal BMI, with the highest rate in the BMI 60–69 category (2.2%), 217 cases per 10,000 live births. Maternal BMI 60–69 experienced the highest risk of SMM, over a threefold increase, even after accounting for the confounding influence of maternal race and low SES.

CONCLUSION:

Very high maternal BMIs are associated with a high rate and risk of SMM. These findings highlight the importance of addressing this modifiable risk factor on a population basis. Public health initiatives aimed to educate women with obesity of childbearing age about weight loss before pursuing pregnancy could help to mitigate maternal mortality in the United States.
The Effect of Advanced Maternal Age on Adverse Outcomes Among Forceps-Assisted Vaginal Deliveries [ID: 1355950]
Authors: Cochrane Elizabeth , Bianco Angela , DeBolt Chelsea , Doctor Tahera , Roger Sarah , Wang Kelly
Published: May 2023

INTRODUCTION:

Delivery rates among patients of advanced maternal age (AMA) are increasing. Prior studies have shown that AMA is associated with increased pregnancy risks and adverse outcomes. This study’s objective was to evaluate whether AMA is associated with an increase in obstetric anal sphincter injury (OASIS) rates among patients who undergo forceps-assisted vaginal deliveries (FAVDs).

METHODS:

This was an IRB-approved, retrospective cohort study of singleton gestations with FAVD at a single institution between 2017 and 2021. Primary outcome was rate of OASIS among patients with and without AMA. Secondary outcomes included quantitative blood loss (QBL), neonatal composite of subgaleal and cephalohematoma (adverse neonatal composite), and neonatal intensive care unit (NICU) admission. Quantitative blood loss was assessed using Mann-Whitney U test. Remaining outcomes were assessed using multivariate logistic regression models while adjusting for provider clustering and confounding patient characteristics including episiotomy and birth weight.

RESULTS:

Nine hundred eighty-three records were included, 704 non-AMA and 279 AMA. Patients of AMA were more likely to be Caucasian and were less likely to be Hispanic, nulliparous, experience spontaneous labor, and undergo episiotomy. Patients of AMA did not demonstrate increased odds of OASIS compared to non-AMA patients (odds ratio [OR] 1.21 [0.78, 1.89]). When age was assessed continuously, there was no association between increasing age and rates of OASIS (OR 1.02 [0.98, 1.06]). There was no statistically significant difference in QBL among the two groups (357.0 versus 350.0 cc, P=.20), NICU admission or adverse neonatal composite.

CONCLUSION:

Advanced maternal age does not appear to be a risk factor for OASIS or other adverse outcomes in patients undergoing FAVD.
Surgical Site Infection Risk in Patients With Superobesity Undergoing Cesarean Delivery [ID: 1377550]
Authors: VanDillen Michael , Feltner Catherine , Gold Joann , Houser Molly , Lund Amanda
Published: May 2023

INTRODUCTION:

Studies have reported increasing surgical site infection rates with increases in body mass index (BMI). Given a recent increase in the prevalence of BMI of 50 or higher across the United States, we sought to determine the association between incremental increases in BMI and the risk of surgical site infections.

METHODS:

This represents an IRB-approved single-institution retrospective cohort of patients with superobesity who underwent cesarean delivery from 2019 to 2022. The patient population is composed of predominantly underserved Black women receiving care at a safety net hospital serving a tri-state area in the mid-South. SPSS was utilized for data analysis to assess associations between variables. Covariate analysis was performed with logistic regressions.

RESULTS:

A total of 246 patients were included in the analysis. Patients were predominantly Black (84%, n=204) with public insurance (88.5%, n=201), and a median age of 30. Patients had a median BMI of 54. The median surgical site infection rate was found to be 11.8% (n=29). Surgical site infection rate in Pfannenstiel versus vertical was 7.4% (n=14) versus 16% (n=23.2) (odds ratio 2.29, P=.01). Surgical infection risk was 6.1% in BMI 40–49, 12.7% in patients with superobesity with BMI higher than 50, and 18.3% in patients with BMI higher than 60.

CONCLUSION:

Our study found that increasing increments of obesity are associated with increased morbidity. Regardless of incision type, surgical site infection rates are high in BMI greater than 60. A diagnosis of preeclampsia and reported allergy to antibiotics were found to exacerbate the risk for infection. This relationship warrants further investigation on interventions to mitigate these risks.
Efficacy of Transcervical Balloon Catheter Versus Hygroscopic Dilator for Outpatient Prelabor Cervical Ripening [ID: 1382587]
Authors: McCue Brigid , Demertzis Kristen , Lin Brenda , Lu Anjanique Mariquit , Muscat Jolene , Shahani Disha Prakash
Published: May 2023

INTRODUCTION:

Outpatient preinduction cervical ripening with mechanical agents has been associated with reduced length of stay and cesarean delivery rates. This study aimed to demonstrate equivalence in efficacy and patient satisfaction between balloon catheter and hygroscopic dilators for outpatient cervical ripening.

METHODS:

This randomized control equivalence trial compared the 30-cc silicone Foley catheter (off-label) to Dilapan-S. Inclusion criteria were elective induction, low risk, group B streptococcus negative, and Bishop score of less than 6. The primary outcome was time from admission to delivery. Secondary outcomes included cesarean delivery rates, pain scores, and patient satisfaction. A power calculation determined 150 patients per arm were needed. Ochsner Health IRB approved CR00003326.

RESULTS:

Between March 1, 2019, and May 31, 2021, 8,150 deliveries occurred, with 1,605 patients meeting screening criteria and 175 completing the study. Time from admission to delivery for balloon was 17.7 hours versus 17.9 hours for dilators. The mean time difference was −0.1524 hours (90% CI –2.4617 to 2.1569), which was statistically significantly equivalent within the specified symmetrical 3-hour equivalence margin (P=.0215). Pain scores with insertion were 3.52 with balloon versus 3.87 with dilators. Satisfaction with outpatient cervical ripening was 91.7% with balloon versus 97.4% with dilators. Cesarean delivery rate of primiparous patients was 31% with balloon versus 25.3% with dilators.

CONCLUSION:

Although the enrollment goal was unmet, metrics suggested outpatient cervical ripening with balloon catheter and hygroscopic dilators were equivalent in time from admission to delivery and patient-reported pain scores. Further research is needed to assess a potential trend toward improved satisfaction and cesarean delivery rate with dilators.
Low-Dose Aspirin Prescription for Pregnant People at Risk for Preeclampsia [ID: 1356912]
Authors: Jaeke Elisha , Domeyer-Klenske Amy , Johnson Morgan , Palatnik Anna , Snowden Nina
Published: May 2023

INTRODUCTION:

Low-dose aspirin (LDA) prescription during pregnancy is recommended for preeclampsia prevention for patients with one or more high-risk factors and two or more moderate-risk factors. Despite recognition that LDA is beneficial for at-risk patients, there appear to be gaps in the practice of prescribing LDA. Our objective was to measure prescriber adherence in a Midwestern health network.

METHODS:

A retrospective cohort analysis was performed using data from the electronic health records (EHRs) of a Midwestern health network. Patients who began prenatal care prior to 28 weeks and gave birth between September 2021 and December 2021 were included. Risk factors for preeclampsia and LDA prescription were extracted from the EHRs, with public insurance serving as a proxy for low socioeconomic status. Patients were excluded if LDA was contraindicated or prescribed for a purpose other than preeclampsia prevention.

RESULTS:

A total of 360 patients qualified for LDA recommendation during the study period. Of the 120 patients with at least one high-risk factor, 86 (71.7%) were prescribed LDA. Of the 240 patients with at least two moderate-risk factors, 54 (22.5%) were prescribed LDA. Among the 34 patients with a high-risk factor who were not prescribed LDA, the most common missed indication was autoimmune disease. Among the 186 patients with two or more moderate-risk factors who were not prescribed LDA, the most common risk factors included sociodemographic risk, nulliparity, and obesity.

CONCLUSION:

Our data demonstrate the need for quality improvement interventions targeting patients with two or more moderate-risk factors or the high-risk factor of autoimmune disease.
The Conceptualization of Pregnancy-Associated Maternal Morbidity in Research Studies: A Scoping Review [ID: 1376717]
Authors: Feldman Sherry , D'Souza Rohan , Gupta Gauri
Published: May 2023

INTRODUCTION:

This study aimed to review the clinical literature to understand how maternal morbidity has been conceptualized.

METHODS:

We conducted a scoping review wherein we searched four databases until May 2022 for studies on maternal morbidity. We screened abstracts in duplicate and extracted data on the study scope, terms used to describe maternal morbidity, and conditions included. Results were presented descriptively.

RESULTS:

We identified 8,178 titles, of which 589 studies from 1986 to 2022 were included in the final analysis. Included studies used 73 terms to describe maternal morbidity. While 217 (37%) studies described maternal morbidity in the context of the general pregnant population, others described more specific contexts, for example, hypertensive disorders of pregnancy (43 studies, 7%), obesity (38 studies, 6%), and gestational and pregestational diabetes (31 studies, 5%). In terms of component outcomes, 156 (26%) studies utilized the World Health Organization criteria for maternal near miss and potentially life-threatening conditions or the Centers for Disease Control and Prevention criteria for severe maternal morbidity, while others included between one and 45 outcomes, the most frequent of which were intensive care unit admission, preeclampsia, eclampsia, hemorrhage, uterine rupture, hysterectomy, and blood transfusion. Notably, 36 (6%) studies included fetal or neonatal outcomes when describing maternal morbidity.

CONCLUSION:

Although maternal morbidity is reported in a large number of pregnancy studies, there is no consistency in what outcomes are included in its definition. There is need for a standardized definition of maternal morbidity that embodies the perspectives of persons with lived experience of pregnancy.
Promoting Best Practice in Obstetrics: Findings From a State-Based Perinatal Quality Collaborative Implementing the Obstetric Hemorrhage Maternal Safety Bundle [ID: 1377611]
Authors: Kheyfets Anna , Conklin Claire , Iverson Ronald , Meadows Audra , Vitek Kali
Published: May 2023

INTRODUCTION:

The Perinatal Neonatal Quality Improvement Network (PNQIN) of Massachusetts engaged hospital teams in a statewide improvement initiative to address maternal morbidity from obstetric hemorrhage (OB HEM) through support of implementation and adherence to best practices in screening for and diagnosis of OB HEM.

METHODS:

The Alliance for Innovation on Maternal Health (AIM) OB HEM bundle was adapted and implemented across hospitals in Massachusetts from June to December 2021. Each month, participating hospital teams joined educational webinars, learned quality improvement strategies, received access to resources for the intervention, and submitted data on six structure and five process measures. Severe maternal morbidity rates were provided using state hospital discharge data. Reliability of implementation was monitored by structure and process measure submission. Aggregate data were shared statewide.

RESULTS:

Fifty-three percent of birthing hospitals in the state (21 of 40) voluntarily participated. Baseline risk screening for OB HEM was 93% and quantitative blood loss measurement (QBL) was 60% in aggregate for all teams. Six participating hospitals reported all 11 measures monthly across the 6-month period. Half of these sites had all six structure measures in place at baseline and 83% reported completion of structure measures by the end of the study period. Among these six sites, the cumulative proportion QBL utilization increased 178% from 28% to 78% and documented OB HEM risk assessment during labor admission increased 8.4% from 83% to 90%.

CONCLUSION:

Implementation of the OB HEM bundle was effective in increasing adherence to evidence-based care among participating birth hospitals through a collaborative, quality improvement approach.
Placental Pathology After Low-Impact Maternal Trauma [ID: 1380074]
Authors: Sridhar Shobha , Chornock Rebecca , Kumnick Allison , Lotke Pamela
Published: May 2023

INTRODUCTION:

Placental abruption is the most common cause of fetal death in cases of blunt trauma, and the majority of abruptions occur within 24 hours of the injury. Because of this potential complication, the observation time after trauma remains controversial. Our study aims to demonstrate the incidence of placental abruption and abnormal placental pathology at the time of delivery in women who have experienced low-impact trauma.

METHODS:

This was a retrospective cohort study of pregnant patients between the years of 2014 and 2020 at MedStar Washington Hospital Center who presented to triage for low-impact trauma identified by “trauma,” “IPV,” “fall,” or “MVA.” MedStar Health Research Institute IRB approved this study. Data from their evaluation during triage visit, mode of delivery, and placental pathology were assessed. Patients were de-identified and analyses included χ2 tests, linear regression, and multinomial logistic regression analyses, as appropriate (α=0.05).

RESULTS:

Of 184 patients identified, delivery data were available for 144 (79%). The mean time from trauma to delivery was 9 weeks. After delivery, the placental pathology was grossly assessed or sent to pathology, and 76.6% were intact with 7.6% noting an infarct when sent to pathology. Observation time did not predict placental infarction or calcification. The type of trauma did not correlate with mode of delivery (P=.629), prelabor preterm rupture of membranes (P=.746), placental infarct (P=.358), intact placenta (P=.834), or placental calcification (P=.288).

CONCLUSION:

Although a small percentage of patients who experienced low-impact trauma had infarction identified on placental pathology, no patients experienced clinical or pathologic placental abruption in 24 hours after trauma.
Predicting Patients Requiring Treatment for Depression in the Postpartum Period From Common Electronic Medical Record Data Antepartum Using Machine Learning [ID: 1365796]
Authors: Wakefield Colin , Frasch Martin
Published: May 2023

INTRODUCTION:

Depression requiring treatment in the postpartum period significantly affects maternal and neonatal health. While preventive management of depression in pregnancy has been shown to decrease the negative effects, current methods for identifying at-risk patients are insufficient. Given the complexity of the diagnosis and interplay of clinical/demographic factors, we tested whether machine learning (ML) techniques can accurately identify patients at risk of depression requiring treatment in the postpartum period (PPD).

METHODS:

This is a retrospective cohort study of the NIH Nulliparous Pregnancy Outcomes Study (nuMoM2b), which enrolled 10,038 nulliparous people. The primary outcome was PPD. We constructed and optimized four ML models using distributed random forest modeling based on the nuMoM2b dataset. Model 1 utilized only readily obtainable sociodemographic data. Model 2 added maternal prepregnancy mental health data. Model 3 utilized recursive feature elimination to construct a parsimonious model. Model 4 further titrated the input data to exclude prepregnancy mental health variables.

RESULTS:

Of 8,454 births, 338 (4%) were complicated by PPD. Model 3 was the highest performing, demonstrating the area under the receiver operating characteristics curve (AUC) of 0.91 (±0.02). Models 1–3 identified the nine variables most predictive of depression hierarchically ranging from body mass index (highest), prior depression, age, income, medications, education, past medical history, race, and prior anxiety (lowest). In model 4, the AUC remained at 0.80 (±0.04).

CONCLUSION:

Counterintuitively, the presence of prepregnancy mental health conditions is not the most predictive factor of PPD. Furthermore, PPD can be predicted with high accuracy for individual patients using antepartum information commonly found in the electronic medical record.
Defined Protocol Including Quantitative Blood Loss Obviates the Need for Postpartum Day 1 Complete Blood Count in Uncomplicated Vaginal Deliveries [ID: 1371414]
Authors: Stansbury Nicholas , Creedon Douglas , Palacios Diana
Published: May 2023

INTRODUCTION:

A postpartum day 1 (PPD1) complete blood count (CBC) is a common postpartum practice. The purpose of PPD1 CBCs is to identify patients with anemia that may benefit from a blood transfusion (BT). However, after the introduction of quantitative blood loss (QBL), we questioned the benefit of PPD1 CBC collection. This study aimed to determine whether PPD1 CBCs provided clinical utility in objectively defined uncomplicated vaginal deliveries.

METHODS:

A retrospective chart review was performed on all vaginal deliveries from January 1, 2021 to January 31, 2022, at a single-site level IV maternity facility. Exclusion criteria were as follows: intraamniotic infections, QBL of 1,000 mL or more, starting hematocrit less than 35, or no documented QBL. Patients were divided into three groups based on QBL: less than 500 mL, 501–749 mL, and 750–999 mL.

RESULTS:

The total number of deliveries was 2,427. One thousand two hundred fifty-three met inclusion criteria: QBL less than 500 mL: 922; 501–749 mL: 240; and QBL 750–999 mL: 91. Among all included deliveries, one patient, in the QBL 750- to 999-mL group, received a BT due to symptomatic anemia but had hemoglobin and hematocrit greater than 7/21. The total cost of PPD1 CBCs for included deliveries was $87,710.

CONCLUSION:

None of the patients in this study who met the inclusion criteria received a BT based on the PPD1 CBC result. This indicates that a PPD1 CBC is of limited clinical utility when uncomplicated vaginal deliveries are defined using this purely objective protocol in the setting of QBL. Therefore, elimination of a PPD1 CBC is consistent with best practice and results in postpartum care cost reduction.
Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People With Gestational Diabetes [ID: 1375592]
Authors: Ayala Nina , Fain Audra , Hamel Maureen , Schlichting Lauren , Smith Megan , Werner Erika
Published: May 2023

INTRODUCTION:

The 2-hour glucose tolerance test (GTT) performed during delivery hospitalization is as predictive of postpartum dysglycemia as the 4- to 12-week test. Our objective was to assess test uptake as part of routine care rather than a research protocol.

METHODS:

This is a retrospective cohort study of patients with gestational diabetes mellitus (GDM) at a high volume center. The in-hospital (“early”) GTT began being offered in early 2021 as postpartum glucose screening option, and we collected 6 months of postimplementation data. Adherence to the GTT was compared between those who elected an early GTT versus those who deferred testing. Descriptive characteristics including demographics, care team characteristics, and postpartum testing/visit attendance were compared between those who received an early GTT and those who did not. Institutional review board approval was waived.

RESULTS:

Six hundred eighty-one patients with GDM delivered during the study period, and 340 (50%) received the early GTT. Of those who had an early GTT ordered (n=408), 83.3% completed the test. Among those who did not receive an early GTT, only 104 (30.5%) completed any postpartum glucose testing. There were significant differences in demographic characteristics among those who completed the early GTT compared to those who did not. When postpartum visit attendance was assessed, those who completed an early GTT had a lower rate of attendance compared to those who deferred (75.6% versus 91.5%, P<.01).

CONCLUSION:

When an early GTT is offered in clinical practice, adherence rates are still significantly higher than when the test is deferred until the postpartum visit.
Differences in Rural and Urban Treatment of Postpartum Depression and Anxiety in the United States [ID: 1377353]
Authors: Gimbel Lauren , Bruno Ann , Horns Joshua , Paudel Niraj , Silver Robert , Smid Marcela
Published: May 2023

INTRODUCTION:

The objective of this study was to evaluate pharmacologic and psychotherapy treatment among individuals with postpartum depression or anxiety living in urban versus rural areas of the United States.

METHODS:

We performed a retrospective cohort study of individuals diagnosed with postpartum depression or anxiety within 12 months of delivery from 2011 to 2020 in the MarketScan Commercial Research Database. Individuals with postpartum depression and anxiety were identified using International Classification of Diseases codes. Individuals previously receiving treatment were excluded. The exposure, urban residence, was determined by residence in a metropolitan statistical area. The primary outcome was a composite of pharmacologic and psychotherapy treatment. Secondary outcomes included components of the primary outcome and time from delivery to first prescription fill. Multivariable modeling adjusted for clinically relevant confounders including history of depression or anxiety. Sensitivity analysis included individuals with prior treatment.

RESULTS:

Of 1,602,058 individuals included, 1,415,793 (88%) had urban residence. Individuals with postpartum depression or anxiety residing in urban areas were less likely to receive treatment (adjusted hazard ratio [aHR] 0.86, 95% CI 0.85–0.88) than those residing in rural areas, including pharmacologic (aHR 0.75, 95% CI 0.73–0.77), and psychotherapy (aHR 0.94, 95% CI 0.92–0.96). Fifty percent of individuals filled a prescription by 107 days from delivery in urban compared to 100 days in rural areas. Results were similar in sensitivity analysis.

CONCLUSION:

Urban-residing individuals with postpartum depression or anxiety were less likely to receive pharmacologic or psychotherapy treatment than rural-residing individuals in this U.S. cohort. Future studies evaluating reasons for treatment differences are warranted.
Postpartum Insurance Discontinuity and Use of Prescription Contraceptive Methods [ID: 1377734]
Authors: Schaefer Kimberly , Hacker Michele , Hawkins Summer , Molina Rose
Published: May 2023

INTRODUCTION:

Medicaid eligibility income thresholds increase during pregnancy and historically ended 60 days postpartum. Thus, this postpartum period is especially vulnerable to insurance discontinuity, which may decrease access to contraception.

METHODS:

We used Pregnancy Risk Assessment Monitoring System survey data (2012–2020) in 42 states. Exposure, assessed 2 or more months after childbirth, was categorized as continuous insurance, insurance loss, discontinuous Medicaid-to-private, and discontinuous private-to-Medicaid. We used modified Poisson regression to estimate risk ratios (RRs) with 95% CIs for using contraception methods requiring prescriptions compared to nonprescription methods/none, adjusted for race and ethnicity, language, education, age, marital status, federal poverty level, and year. We then stratified by Medicaid expansion status at time of delivery.

RESULTS:

Of 246,088 respondents, 76.4% held continuous insurance from childbirth to 2 or more months postpartum, 11.9% lost insurance, 7.6% experienced discontinuity from Medicaid-to-private insurance, and 4.1% from private-to-Medicaid. Compared to continuous insurance, the adjusted RR for prescription postpartum contraception was 0.88 (CI 0.86–0.89) for loss of insurance, 0.99 (0.97–1.01) for discontinuous Medicaid-to-private, and 0.96 (0.93–0.98) for discontinuous private-to-Medicaid. Stratification by Medicaid expansion status yielded similar results. Of respondents in states or time periods without Medicaid expansion, 16.2% experienced insurance loss compared to 7.9% of those with Medicaid expansion.

CONCLUSION:

Insurance loss 2 or more months after childbirth was associated with decreased likelihood of prescription postpartum contraception, with a higher proportion of respondents without Medicaid expansion vulnerable to such insurance loss. Increased state adoption of the federal 12-month postpartum Medicaid extension option could improve access to prescription postpartum contraception.
Remote Patient Monitoring for Postpartum Hypertensive Disorders of Pregnancy [ID: 1378058]
Authors: Spiro Leah , Bairey Merz C. Noel , Bello Natalie , Kilpatrick Sarah , Minissian Margo , Wei Janet
Published: May 2023

INTRODUCTION:

Hypertensive disorders of pregnancy (HDP) account for 2.5–4.6% of readmissions within 6 weeks postpartum (PP); 60% occur in the first 7 days. A standardized approach to HDP management can improve outcomes through optimized PP blood pressure (BP) management. Remote patient monitoring (RPM) has established safety, outcomes, financial benefit, and increased compliance. The primary outcome of this study was to determine the feasibility of a standardized RPM program for PP patients with HDP.

METHODS:

Participants (n=30) received a phone application and BP monitor that automatically uploaded data to a nurse practitioner (NP)-monitored dashboard. Participants were asked to record a single BP twice daily (6 am–11 am and 6 pm–11 pm) until 10 days PP. Telehealth visits with an NP occurred at 48 hours postdischarge. Feasibility was measured using a one-sided t test of the proportion of participants with satisfaction (via validated Likert-style post-participation surveys) and adherence of 80% or higher (recorded BPs/expected BPs). Secondary outcomes included readmissions, elevated BPs (mild, 140–159/90–109 mm Hg; severe, ≥160/110 mm Hg), and antihypertensive medication up-titration.

RESULTS:

One hundred percent of participants completed the program. Overall adherence rate was 91%, and overall satisfaction rate was 92%. Of 450 recorded BP measurements, 88 (19.6%) were mild and 2 (0.4%) were severe, with 0 hospital readmissions. Medication up-titration occurred seven times in six participants (20%). We demonstrated feasibility with a proportion of 0.767 participants (P=.0027; CI: 0.577, 0.885).

CONCLUSION:

A standardized RPM program for PP HDP utilizing early telemedicine visits with an NP successfully demonstrated feasibility in a pilot sample of PP patients. Compliance with PP follow-up recommendations was high. Future work to improve systems innovation for BP optimization in PP patients is needed.
Multidisciplinary High-Risk Obstetrical Simulation Improves Periviability Counseling [ID: 1366577]
Authors: Burn Sabrina , Clark Lou , Cross Sarah , Rolfes Julie Johnson , Miller Joseph
Published: May 2023

INTRODUCTION:

The objective of this study was to determine the feasibility and effectiveness of multidisciplinary simulation in the development of skills required for high-risk periviability counseling.

METHODS:

Trainees were recruited from the University of Minnesota to participate in a faculty-observed standardized high-risk periviability patient simulation. The simulation was unique in that multiple specialties collaborated in the evaluation, counseling, and management of their patient. Trainees completed presimulation and postsimulation knowledge and comfort self-assessment surveys to evaluate skill improvement and merit of the study. Evaluations were also performed by faculty and simulated patients. An IRB waiver was obtained.

RESULTS:

Of the 18 participants, there were 6 neonatal intensive care unit fellows, 2 maternal–fetal medicine fellows, and 10 senior ob-gyn residents. Presimulation and postsimulation Likert surveys with scale 1–5, showed improvement in the ability of trainees to elicit patient values and tailor their conversations (pre-mean 2.84, SD 0.67; post-mean 3.39, SD 0.59), use patient-centered language (pre-mean 3.37, SD 0.74; post-mean 3.89, SD 0.57), ally with patients (pre-mean 3.37, SD 0.93; post-mean 3.94, SD 0.52), provide difficult medical information (pre-mean 3.32, SD 1.03; post-mean 3.67, SD 0.58), discuss medical uncertainty (pre-mean 3.11, SD 0.79; post-mean 3.50, SD 0.60), and understand their own implicit biases (pre-mean 3.26, SD 0.71; post-mean 3.50, SD 0.60). Trainees also reported an increased use of hopeful language that did not focus on statistical outcomes (pre-mean 3.00, SD 0.65; post-mean 3.33, SD 0.47) and discussion of multiple management options, including comfort cares (pre-mean 2.05, SD 1.05; post-mean 2.94, SD 0.85). The post surveys also reflected that trainees felt the simulation was useful, provided a safe environment to practice counseling (mean 4.83, SD 0.37), and better prepared them for future high-risk obstetrical scenarios (mean 4.83, SD 0.37).

CONCLUSION:

Multidisciplinary high-risk obstetrical simulation offers a unique opportunity for trainees to receive structured training and improve their ability to collaboratively counsel in rare high-risk obstetrical scenarios.
Utility of Ferritin at Registration as a Screen for Development of Anemia in Third Trimester [ID: 1362276]
Authors: Crary Isabelle , Koski Chloe , Rijhsinghani Asha
Published: May 2023

INTRODUCTION:

The objective of this study was to assess the utility of screening ferritin (<20 weeks of gestation) in pregnant patients on hemoglobin (Hgb) and hematocrit (Hct) later in gestation.

METHODS:

Pregnant patients who received nondiagnostic ferritin labs at less than 20 weeks of gestation from 2019 to 2021 were retrospectively identified. Patients were excluded if ferritin testing was conducted for diagnostic purposes or if the patient had a history of anemia. Labs at the time of registration, 28 weeks of gestation, and at delivery were analyzed. Anemia was defined as Hgb less than 11 g/dL. This study was approved by the University of Washington IRB, and patient consent was waived.

RESULTS:

Forty-four patients underwent routine ferritin screening at registration, with ferritin levels ranging from 10 to 136 ng/mL (average 52.5 ng/mL). Average Hgb/Hct at registration were 12.6 g/dL and 37.3%, respectively. At 28 weeks of gestation, Hgb/Hct were obtained on 42 patients, of whom 9 patients were diagnosed with anemia. Patients diagnosed with anemia had a screening ferritin level of 33.6 ng/mL, and nonanemic patients had a ferritin level of 57.4 ng/mL (P=.1). When a cutoff of 50 ng/mL was studied to compare patients with “low” versus “normal” ferritin, ferritin less than or equal to 50 ng/mL had significantly lower Hgb levels at 28 weeks compared to those with ferritin greater than 50 ng/mL (P=.013). On labor and delivery (L&D), Hgb/Hct was obtained on 44 patients, and 14 were diagnosed with anemia. Anemic patients on L&D had significantly lower screening ferritin compared to nonanemic, 31.9 and 62.2 ng/mL, respectively (P=.016).

CONCLUSION:

Ferritin screening in early pregnancy may help predict lower Hgb in later gestation. Using a higher ferritin cutoff of 50 ng/mL in early pregnancy for identifying patients at risk for anemia in the third trimester may be warranted. Larger prospective studies are needed to evaluate further the utility of ferritin screening.
Risk Factors for Discharge Against Medical Advice at Antepartum Hospitalizations [ID: 1373372]
Authors: Guo Pengfei , Campbell Katherine , Grechukhina Olga , Lee Emily , Xu Xiao
Published: May 2023

INTRODUCTION:

Antepartum obstetrical admissions are often unplanned. Despite counseling, some patients may choose to be discharged against medical advice (DAMA). This study examined patterns of DAMA at antepartum hospitalizations and associated patient characteristics.

METHODS:

Using 2019 National Inpatient Sample (NIS) data, we identified pregnant patients aged 12–50 years with antepartum admissions. The primary outcome was DAMA determined based on patients' discharge disposition status. Patients' sociodemographic and clinical characteristics were measured based on hospital discharge records and diagnosis/procedure codes. Characteristics of DAMA and non-DAMA patients were compared using chi-square tests and multivariable logistic regression, while accounting for NIS complex sample design to generate nationally representative estimates.

RESULTS:

Among 214,935 patients in the sample, 8,495 (4.0%) were DAMA. The risk of DAMA was significantly higher among Black than White patients (5.4% versus 3.8%, P<.001, adjusted odds ratio [OR] 1.25, 95% CI 1.09–1.43), Medicaid than privately insured patients (5.4% versus 1.7%, P<.001, adjusted OR 2.49, 95% CI 2.12–2.93), and patients with (versus without) obstetrical/comorbid conditions, such as substance use disorders (11.3% versus 2.7%, P<.001, adjusted OR 3.30, 95% CI 2.76–3.96), prior preterm birth (8.1% versus 3.9%, P<.001, adjusted OR 2.04, CI 1.44–2.89), hypertensive disorders of pregnancy (5.4% versus 3.8%, P<.001, adjusted OR 1.70, 95% CI 1.43–2.03), and chronic hypertension (6.2% versus 3.8%, P<.001, adjusted OR 1.51, 95% CI 1.28–1.79).

CONCLUSION:

Patients who are DAMA in the antepartum period have certain sociodemographic and clinical characteristics that may place them at higher risk of adverse obstetrical outcomes. Risk-stratified, targeted patient support during admission may be beneficial.
Stay Home, Stay Connected: Providing Supplemental Education and Psychosocial Support for Pregnant People [ID: 1375777]
Authors: Gates Brittany , Aaron Bryan , Kilbane Emma , Maben-Feaster Rosalyn , Peahl Alex , Stukenberg Zoe
Published: May 2023

INTRODUCTION:

The traditional medical model of prenatal care may miss opportunities for anticipatory guidance and psychosocial support for pregnant people. We describe Stay Home, Stay Connected (SHSC), a virtual, service-learning, pregnancy support group that supplements routine prenatal care.

METHODS:

Stay Home, Stay Connected was implemented during the acute COVID-19 pandemic and updated in January 2022 in keeping with relaxation of COVID-19 restrictions. The program consists of monthly small-group sessions with 8–10 pregnant people at similar gestational age, led by an obstetric provider (eg, physician, midwife) and medical, midwifery, and social work students. Recorded group classes on mental health and wellness are available on-demand. In our IRB-exempt assessment of SHSC patients from January 2022 to October 2022, we obtained consent and collected surveys at enrollment and after sessions to assess participants' reasons for joining and overall satisfaction.

RESULTS:

Since program updates, 80 patients have participated in 5 small groups, led by 4 providers and 8 students. Of the 80 patients registered for SHSC, 65 (81%) completed the enrollment survey. The top reasons for joining SHSC were desire for extra support, more information about pregnancy, and connection with other patients. The majority of participants who completed satisfaction surveys, reported sessions were helpful to their learning (32/34, 94%) and feeling supported (25/26, 96%). All participants surveyed reported they would recommend SHSC to other pregnant patients.

CONCLUSION:

A virtual service-learning pregnancy support group remains feasible and acceptable for participants after the acute COVID-19 pandemic. We are continuing to expand and develop SHSC to fulfill unmet needs in pregnancy.
Effect of Maternal Depressive Symptoms on Prenatal Care Utilization and Milestones [ID: 1376259]
Authors: Jang Minyoung , Esguerra Cybill , Olson Sarah , Voegtline Kristin
Published: May 2023

INTRODUCTION:

Depression is a common complication of pregnancy, but research is limited regarding its effect antepartum. This study assessed the relationship between maternal depressive symptoms and prenatal care utilization.

METHODS:

This retrospective cohort includes pregnant women who completed first- or second-trimester depression screening using the Edinburgh Postnatal Depression Scale (EPDS) between 2020 and 2021. Patient and pregnancy-related characteristics were compared between women who screened positive versus negative for depression. Multivariate logistic regression models were used to estimate odds of completing prenatal care milestones. The IRB approved a consent waiver.

RESULTS:

Of 718 women who completed the EPDS in early pregnancy, 85 (12%) screened positive for depression. A greater proportion of these women were younger (P=.034), unpartnered (P=.005), publicly insured (P=.013), had a history of substance use (P<.0001) or prior psychiatric diagnosis (P<.0001), and started prenatal care later (P=.002) than those who screened negative. Although there were no significant differences in total routine prenatal care visits (P=.123), the adjusted odds of completing third-trimester milestones including glucose tolerance testing (odds ratio [OR] [95% CI] 0.596 [0.364–0.975]) and group B streptococcus testing (OR [95% CI] 0.559 [0.330–0.947]) were lower among women who screened positive for depression. In addition, higher EPDS scores were positively correlated with number of labor and delivery triage visits (r=0.103, P=.006).

CONCLUSION:

Women who screen positive for depression during pregnancy are a socially vulnerable group at risk of starting prenatal care late, missing major milestones, and overusing nonroutine medical services. Early mental health screening and intervention in pregnancy may help improve prenatal outcomes.