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Objective: To analyse trends, risk factors and adverse outcomes associated with antenatal pyelonephritis hospitalisations., Design: Retrospective cohort., Setting: A national sample of US delivery hospitalisations with associated antenatal hospitalisations., Population: US delivery hospitalisations in the Nationwide Readmissions Database from 2010 to 2020., Methods: Antenatal hospitalisations with a pyelonephritis diagnosis within the 9 months before delivery hospitalisation were analysed. Clinical, demographic and hospital risk factors associated with antenatal pyelonephritis hospitalisations were analysed with unadjusted and adjusted logistic regression models with unadjusted and adjusted odds ratios as measures of effect. Temporal trends in antenatal pyelonephritis hospitalisations were analysed with Joinpoint regression to determine the relative measure of average annual percent change (AAPC). Risk for severe maternal morbidity and sepsis during antenatal pyelonephritis hospitalisations was similarly analysed with Joinpoint regression., Results: Of an estimated 10.2 million delivery hospitalisations, 49 140 (0.48%) had an associated antenatal pyelonephritis hospitalisation. The proportion of deliveries with a preceding antenatal pyelonephritis hospitalisation decreased by 29% from 0.56% in 2010 to 0.40% in 2020 (AAPC -2.9%, 95% CI -4.0% to -1.9%). Antenatal pyelonephritis decreased, but risk for sepsis diagnoses increased during these hospitalisations from 3.7% in 2010 to 18.0% in 2020 (AAPC 17.2%, 95% CI 14.2%-21.1%). Similarly, risk for severe morbidity increased from 2.6% in 2010 to 4.4% in 2020 (AAPC 5.5%, 95% CI 0.8%-10.7%)., Conclusion: Antenatal pyelonephritis admissions appear to be decreasing in the USA. However, these hospitalisations are associated with a rising risk for sepsis and severe maternal morbidity., (© 2024 John Wiley & Sons Ltd.)

Background: Establishing local trimester-specific reference intervals for gestational TSH and free T4 (FT4) is often not feasible, necessitating alternative strategies. We aimed to systematically quantify the diagnostic performance of standardized modifications of center-specific nonpregnancy reference intervals as compared to trimester-specific reference intervals., Methods: We included prospective cohorts participating in the Consortium on Thyroid and Pregnancy. After relevant exclusions, reference intervals were calculated per cohort in thyroperoxidase antibody-negative women. Modifications to the nonpregnancy reference intervals included an absolute modification (per .1 mU/L TSH or 1 pmol/L free T4), relative modification (in steps of 5%) and fixed limits (upper TSH limit between 3.0 and 4.5 mU/L and lower FT4 limit 5-15 pmol/L). We compared (sub)clinical hypothyroidism prevalence, sensitivity, and positive predictive value (PPV) of these methodologies with population-based trimester-specific reference intervals., Results: The final study population comprised 52 496 participants in 18 cohorts. Optimal modifications of standard reference intervals to diagnose gestational overt hypothyroidism were -5% for the upper limit of TSH and +5% for the lower limit of FT4 (sensitivity, .70, CI, 0.47-0.86; PPV, 0.64, CI, 0.54-0.74). For subclinical hypothyroidism, these were -20% for the upper limit of TSH and -15% for the lower limit of FT4 (sensitivity, 0.91; CI, 0.67-0.98; PPV, 0.71, CI, 0.58-0.80). Absolute and fixed modifications yielded similar results. CIs were wide, limiting generalizability., Conclusion: We could not identify modifications of nonpregnancy TSH and FT4 reference intervals that would enable centers to adequately approximate trimester-specific reference intervals. Future efforts should be turned toward studying the meaningfulness of trimester-specific reference intervals and risk-based decision limits., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society.)

Objective: To determine risks for non-transfusion severe maternal morbidity and transfusion during a second delivery hospitalisation based on clinical risk factors and obstetric complications from an index, first delivery hospitalisation., Design: Retrospective cohort., Population: Delivery hospitalisations in the 2010-2017 New York State Inpatient Database., Methods: Patients with a first index delivery hospitalisation followed by a second delivery hospitalisation during the study period were included. Clinical risk factors and obstetric complications were obtained from the first index delivery hospitalisation. Adjusted logistic regression models for non-transfusion severe maternal morbidity during the second delivery were performed with adjusted (aORs) odds ratios as measures of effect. These analyses were then repeated for the outcome of transfusion., Results: Of 624 500 paired delivery hospitalisations to 312 250 women, severe maternal morbidity occurred among 0.85% of second deliveries (n = 2672). When adjusted analysis was performed, several clinical factors were associated with severe maternal morbidity in a subsequent pregnancy, including severe maternal morbidity during the index pregnancy (aOR 8.4, 95% CI 7.0, 9.9), transfusion (aOR 2.0, 95% CI 1.6, 2.4) and pregestational diabetes (aOR 2.2, 95% 1.6, 2.9). When analyses were repeated for transfusion, several factors were associated with increased risk, including severe maternal morbidity (aOR 1.5, 95% CI 1.2, 1.8), index transfusion (aOR 6.3, 95% CI 5.6, 7.0), chronic heart disease (aOR 1.6, 95% 1.4, 1.9) and pregestational diabetes (aOR 1.7, 95% 1.3, 2.2)., Conclusion: Many obstetric complications and chronic conditions identified during an index delivery hospitalisation are associated with severe morbidity during a second, subsequent delivery. Index severe maternal morbidity is associated with the highest odds. These findings may be of use in patient counselling and risk stratification., (© 2024 John Wiley & Sons Ltd.)

Objective:  This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States., Study Design:  The 2000-2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association., Results:  An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection., Conclusion:  Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity., Key Points: · Sepsis increased over the study period for deliveries with and without chronic condition diagnoses.. · Endometritis and wound infection decreased over the study period.. · Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes.., Competing Interests: M.E.D'A. had a senior leadership role in ACOG II's Safe Motherhood Initiative which received unrestricted funding from Merck for Mothers. A.M.F. is supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1R01HD104943), however, this funding was not used to support this research. A.M.F. has also served on an advisory board for Biogen and Sage. T.W. serves as a consultant on the medical advisory board for Delfina, Inc. D.G. serves on the scientific advisory board for the Jada device through Organon and the Cooper Surgical Obstetrical Safety Council. The other authors did not report any potential conflict of interest., (Thieme. All rights reserved.)

Objective: Routine health care visits offer the opportunity to screen older adults for symptoms of Alzheimer's disease (AD). Many women see their gynecologist as their primary health care provider. Given this unique relationship, the Women's Preventive Services Initiative and the American College of Obstetrics and Gynecology advocate for integrated care of women at all ages. It is well-established that women are at increased risk for AD, and memory screening of older women should be paramount in this effort. Research is needed to determine the feasibility and value of memory screening among older women at the well-woman visit. Materials and Methods: Women aged 60 and above completed a 5-item subjective memory screener at their well-woman visit at the Columbia University Integrated Women's Health Program. Women who endorsed any item were considered to have a positive screen and were given the option to pursue clinical evaluation. Rates of positive screens, item endorsement, and referral preferences were examined. Results: Of the 530 women approached, 521 agreed to complete the screener. Of those, 17.5% ( n = 91) were classified as positive. The most frequently endorsed item was difficulty with memory or thinking compared with others the same age. Among women with positive screens, 57.5% were interested in pursuing clinical referrals to a memory specialist. Conclusion: Results support the feasibility and potential value of including subjective memory screening as part of a comprehensive well-woman program. Early identification of memory loss will enable investigation into the cause of memory symptoms and longitudinal monitoring of cognitive change.

Background: A major goal of contemporary obstetrical practice is to optimize fetal growth and development throughout pregnancy. To date, fetal growth during prenatal care is assessed by performing ultrasonographic measurement of 2-dimensional fetal biometry to calculate an estimated fetal weight. Our group previously established 2-dimensional fetal growth standards using sonographic data from a large cohort with multiple sonograms. A separate objective of that investigation involved the collection of fetal volumes from the same cohort., Objective: The Fetal 3D Study was designed to establish standards for fetal soft tissue and organ volume measurements by 3-dimensional ultrasonography and compare growth trajectories with conventional 2-dimensional measures where applicable., Study Design: The National Institute of Child Health and Human Development Fetal 3D Study included research-quality images of singletons collected in a prospective, racially and ethnically diverse, low-risk cohort of pregnant individuals at 12 U.S. sites, with up to 5 scans per fetus (N=1730 fetuses). Abdominal subcutaneous tissue thickness was measured from 2-dimensional images and fetal limb soft tissue parameters extracted from 3-dimensional multiplanar views. Cerebellar, lung, liver, and kidney volumes were measured using virtual organ computer aided analysis. Fractional arm and thigh total volumes, and fractional lean limb volumes were measured, with fractional limb fat volume calculated by subtracting lean from total. For each measure, weighted curves (fifth, 50th, 95th percentiles) were derived from 15 to 41 weeks' using linear mixed models for repeated measures with cubic splines., Results: Subcutaneous thickness of the abdomen, arm, and thigh increased linearly, with slight acceleration around 27 to 29 weeks. Fractional volumes of the arm, thigh, and lean limb volumes increased along a quadratic curvature, with acceleration around 29 to 30 weeks. In contrast, growth patterns for 2-dimensional humerus and femur lengths demonstrated a logarithmic shape, with fastest growth in the second trimester. The mid-arm area curve was similar in shape to fractional arm volume, with an acceleration around 30 weeks, whereas the curve for the lean arm area was more gradual. The abdominal area curve was similar to the mid-arm area curve with an acceleration around 29 weeks. The mid-thigh and lean area curves differed from the arm areas by exhibiting a deceleration at 39 weeks. The growth curves for the mid-arm and thigh circumferences were more linear. Cerebellar 2-dimensional diameter increased linearly, whereas cerebellar 3-dimensional volume growth gradually accelerated until 32 weeks followed by a more linear growth. Lung, kidney, and liver volumes all demonstrated gradual early growth followed by a linear acceleration beginning at 25 weeks for lungs, 26 to 27 weeks for kidneys, and 29 weeks for liver., Conclusion: Growth patterns and timing of maximal growth for 3-dimensional lean and fat measures, limb and organ volumes differed from patterns revealed by traditional 2-dimensional growth measures, suggesting these parameters reflect unique facets of fetal growth. Growth in these three-dimensional measures may be altered by genetic, nutritional, metabolic, or environmental influences and pregnancy complications, in ways not identifiable using corresponding 2-dimensional measures. Further investigation into the relationships of these 3-dimensional standards to abnormal fetal growth, adverse perinatal outcomes, and health status in postnatal life is warranted., (Published by Elsevier Inc.)

Objective: Given that updated estimates of Ehlers-Danlos syndrome and risks for obstetric complications including postpartum readmission may be of public health significance, we sought to analyze associated obstetric trends and outcomes in a nationally representative population., Study Design: The 2016 to 2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations to women aged 15 to 54 with and without Ehlers-Danlos syndrome were identified. Temporal trends in Ehlers-Danlos syndrome diagnoses during delivery hospitalizations were analyzed using joinpoint regression to estimate the average annual percent change with 95% confidence intervals (CIs). To determine whether adverse obstetric outcomes during the delivery were associated with Ehlers-Danlos syndrome, unadjusted and adjusted logistic regression models were fit with unadjusted (odds ratio [OR]) and adjusted ORs with 95% CIs as measures of association. In addition to analyzing adverse delivery outcomes, risk for 60-day postpartum readmission was analyzed., Results: An estimated 18,214,542 delivery hospitalizations were included of which 7,378 (4.1 per 10,000) had an associated diagnosis of Ehlers-Danlos syndrome. Ehlers-Danlos syndrome diagnosis increased from 2.7 to 5.2 per 10,000 delivery hospitalization from 2016 to 2020 (average annual percent change increase of 16.1%, 95% CI: 9.4%, 23.1%). Ehlers-Danlos syndrome was associated with increased odds of nontransfusion severe maternal morbidity (OR: 1.84, 95% CI: 1.38, 2.45), cervical insufficiency (OR: 2.14, 95% CI: 1.46, 3.13), postpartum hemorrhage (OR: 1.41, 95% CI: 1.17, 1.68), cesarean delivery (OR: 1.26, 95% CI: 1.17, 1.36), and preterm delivery (OR: 1.35, 95% CI: 1.16, 1.56). Estimates for transfusion, placental abruption, and placenta previa did not differ significantly. Risk for 60-day postpartum readmission was 3.0% among deliveries with Ehlers-Danlos (OR: 1.76, 95% CI: 1.37, 2.25)., Conclusion: Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period and was associated with a range of adverse obstetric outcomes and complications during delivery hospitalizations as well as risk for postpartum readmission., Key Points: · Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period.. · Ehlers-Danlos was associated with a range of adverse obstetric outcomes.. · Ehlers-Danlos was associated with increased readmission risk.., Competing Interests: Dr. D'Alton had a senior leadership role in American College of Obstetricians and Gynecologists II's Safe Motherhood Initiative, which received unrestricted funding from Merck for Mothers. Dr. Friedman is supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1R01HD104943); however, this funding was not used to support this research. Dr. Friedman has served on an advisory board for Sage and Biogen. Dr. Wen serves as a consultant on the medical advisory board for Delfina, Inc. The other authors did not report any potential conflicts of interest., (Thieme. All rights reserved.)

Background: International guidelines recommend targeted screening to identify gestational thyroid dysfunction. However, currently used risk factors have questionable discriminative ability. We quantified the risk for thyroid function test abnormalities for a subset of risk factors currently used in international guidelines. Methods: We included prospective cohort studies with data on gestational maternal thyroid function and potential risk factors (maternal age, body mass index [BMI], parity, smoking status, pregnancy through in vitro fertilization, twin pregnancy, gestational age, maternal education, and thyroid peroxidase antibody [TPOAb] or thyroglobulin antibody [TgAb] positivity). Exclusion criteria were pre-existing thyroid disease and use of thyroid interfering medication. We analyzed individual participant data using mixed-effects regression models. Primary outcomes were overt and subclinical hypothyroidism and a treatment indication (defined as overt hypothyroidism, subclinical hypothyroidism with thyrotropin >10 mU/L, or subclinical hypothyroidism with TPOAb positivity). Results: The study population comprised 65,559 participants in 25 cohorts. The screening rate in cohorts using risk factors currently recommended (age >30 years, parity ≥2, BMI ≥40) was 58%, with a detection rate for overt and subclinical hypothyroidism of 59%. The absolute risk for overt or subclinical hypothyroidism varied <2% over the full range of age and BMI and for any parity. Receiver operating characteristic curves, fitted using maternal age, BMI, smoking status, parity, and gestational age at blood sampling as explanatory variables, yielded areas under the curve ranging from 0.58 to 0.63 for the primary outcomes. TPOAbs/TgAbs positivity was associated with overt hypothyroidism (approximate risk for antibody negativity 0.1%, isolated TgAb positivity 2.4%, isolated TPOAb positivity 3.8%, combined antibody positivity 7.0%; p  < 0.001), subclinical hypothyroidism (risk for antibody negativity 2.2%, isolated TgAb positivity 8.1%, isolated TPOAb positivity 14.2%, combined antibody positivity 20.0%; p  < 0.001) and a treatment indication (risk for antibody negativity 0.2%, isolated TgAb positivity 2.2%, isolated TPOAb positivity 3.0%, and combined antibody positivity 5.1%; p  < 0.001). Twin pregnancy was associated with a higher risk of overt hyperthyroidism (5.6% vs. 0.7%; p  < 0.001). Conclusions: The risk factors assessed in this study had poor predictive ability for detecting thyroid function test abnormalities, questioning their clinical usability for targeted screening. As expected, TPOAb positivity (used as a benchmark) was a relevant risk factor for (subclinical) hypothyroidism. These results provide insights into different risk factors for gestational thyroid dysfunction.

Objective: This study aimed to evaluate cesarean rates and risk for obstetric complications among deliveries with a history of prior uterine surgery., Study Design: This serial cross-sectional study analyzed deliveries with and without prior uterine surgery in the 2016-2019 Nationwide Inpatient Sample. Unadjusted and adjusted logistic regression models were performed to assess risk of nontransfusion severe maternal morbidity (SMM) and other obstetric complications based on the presence or absence of prior uterine surgery with unadjusted and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) as measures of association. Adjusted models accounted for demographic, hospital, and delivery factors. Demographics and clinical factors among deliveries with and without a prior history of uterine surgery diagnosis were compared with the chi-square test with p  < 0.05 considered statistically significant., Results: Of 14.7 million delivery hospitalization identified, 6,910 (4.7 per 10,000) had a history of uterine surgery and 111,710 (0.76%) experienced SMM. Women with prior uterine surgery were more likely to be older, to be of unknown race or ethnicity, and to have private insurance ( p  < 0.01 for all). Eighty-five percent of deliveries with prior uterine surgery were performed by cesarean compared with 32% of deliveries without prior uterine surgery ( p  < 0.01). In adjusted analysis, compared with patients without prior uterine surgery, patients with prior uterine surgery were not at increased risk for SMM (aOR 1.23, 95% CI 0.73-2.07). Evaluating obstetric complications, patients with prior uterine surgery had a decreased risk of postpartum hemorrhage (aOR 0.64, 95% CI 0.43-0.96) and an increased risk of peripartum hysterectomy (aOR 4.12, 95% CI 1.75-9.67), and no difference in other obstetric complications assessed., Conclusion: These findings suggest that current clinical practice results in similar delivery risks among patients with compared with without prior uterine surgery., Key Points: · Risk for most adverse outcomes is similar among patients with prior uterine surgery.. · Risk for peripartum hysterectomy was higher with prior uterine surgery.. · Risk for SMM was not higher with prior uterine surgery.., Competing Interests: A.M.F. has also served on an advisory board for Biogen and Sage. T.W. serves as a consultant on the medical advisory board for Delfina, Inc. C.A. serves as a consultant for Cooper Surgical and Intuitive., (Thieme. All rights reserved.)

Objective: Gastroschisis is a full-thickness congenital defect of the abdominal wall through which intestines and other organs may herniate. In a prior analysis, attempted vaginal delivery with fetal gastroschisis appeared to increase through 2013, although cesarean delivery remained common. The objective of this analysis was to update current trends in attempted vaginal birth among pregnancies complicated by gastroschisis., Study Design: We performed an updated cross-sectional analysis of live births from 2014 and 2020 using data from the U.S. National Vital Statistics System and evaluated trends in attempted vaginal deliveries among births with gastroschisis. Trends were evaluated using joinpoint regression. We constructed logistic regression models to evaluate the association between demographic and clinical variables and attempted vaginal delivery in the setting of gastroschisis., Results: Among 5,355 deliveries with gastroschisis meeting inclusion criteria, attempted vaginal delivery increased significantly from 68.9% to 75.1%, an average annual percent change of 1.7% (95% confidence interval [CI], 0.8-2.5). Among gastroschisis-complicated pregnancies, patients 35 to 39 years old (adjusted odds ratio [aOR], 0.53; 95% CI, 0.37-0.79) and Hispanic race/ethnicity (aOR, 0.69; 95% CI, 0.58-0.62) were at lower likelihood of attempted vaginal delivery in adjusted analyses., Conclusion: These findings suggest that vaginal delivery continues to increase in the setting of gastroschisis. Further reduction of surgical delivery for this fetal defect may be possible., Key Points: · Vaginal deliveries increased among gastroschisis pregnancies.. · Hispanic patients were less likely to attempt vaginal delivery.. · Some gastroschisis pregnancies still deliver surgically.., Competing Interests: M. E. D. had a senior leadership role in ACOG II's Safe Motherhood Initiative, which received unrestricted funding from Merck for Mothers. T. W. serves as a consultant on the medical advisory board for Delfina Care Inc. The other authors did not report any potential conflicts of interest., (Thieme. All rights reserved.)

Objective: To assess trends and outcomes associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) during US delivery hospitalizations., Study Design: The National Inpatient Sample from 2000 to 2019 was used for this repeated cross-sectional analysis. We identified delivery hospitalizations with and without SLE. Temporal trends in SLE during delivery hospitalizations were determined using joinpoint regression. Adjusted logistic regression models accounting for demographic, clinical, and hospital factors were used to determine adjusted odds ratios (aORs) for adverse outcomes based on the presence or absence of SLE., Results: Of an estimated 76 698 775 delivery hospitalizations identified in the NIS, 79386 (0.10%) had an associated diagnosis of SLE. Over the study period, SLE increased from 6.7 to 14.6 cases per 10 000 delivery hospitalizations (average annual percent change 4.5%, 95% CI 4.0-5.1). Deliveries with SLE had greater odds of non-transfusion severe morbidity (aOR 2.21, 95% CI 2.00, 2.44) and underwent a larger absolute increase in morbidity risk over the study period. SLE was associated with a range of other adverse outcomes including preterm delivery, eclampsia, cesarean delivery, and blood transfusion., Conclusion: The proportion of deliveries to women with SLE has increased over time in the US, and SLE and APS are associated with a broad range of adverse outcomes., (© 2023 International Federation of Gynecology and Obstetrics.)

Objective: To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis., Methods: We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure., Results: Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum., Conclusion: Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions., Competing Interests: Financial Disclosure Mary E. D'Alton had a senior leadership role in ACOG II's Safe Motherhood Initiative, which received unrestricted funding from Merck for Mothers. Alexander Friedman is supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (1R01HD104943); however, this funding was not used to support this research. He reports serving on a panel for Sage Therapeutics and Biogen. Timothy Wen serves as a consultant on the medical advisory board for Delfina, Inc. Dena Goffman serves on the scientific advisory board for the Jada device through Organon and the Cooper Surgical Obstetrical Safety Council. She reports that her institution received funding from the NICHD EnCore Moms maternal sepsis and the NICHD Obstetric Hemorrhage Technical Skill Simulation. Lisa Nathan reports receiving payment from Organon. Jean Ju Sheen reports receiving payment from UpToDate. Money was paid to their institution from Materna Medical (clinical trial for Prep vaginal dilator device in labor). The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Context: Guidelines recommend use of population- and trimester-specific thyroid-stimulating hormone (TSH) and free thyroxine (FT4) reference intervals (RIs) in pregnancy. Since these are often unavailable, clinicians frequently rely on alternative diagnostic strategies. We sought to quantify the diagnostic consequences of current recommendations., Methods: We included cohorts participating in the Consortium on Thyroid and Pregnancy. Different approaches were used to define RIs: a TSH fixed upper limit of 4.0 mU/L (fixed limit approach), a fixed subtraction from the upper limit for TSH of 0.5 mU/L (subtraction approach) and using nonpregnancy RIs. Outcome measures were sensitivity and false discovery rate (FDR) of women for whom levothyroxine treatment was indicated and those for whom treatment would be considered according to international guidelines., Results: The study population comprised 52 496 participants from 18 cohorts. Compared with the use of trimester-specific RIs, alternative approaches had a low sensitivity (0.63-0.82) and high FDR (0.11-0.35) to detect women with a treatment indication or consideration. Sensitivity and FDR to detect a treatment indication in the first trimester were similar between the fixed limit, subtraction, and nonpregnancy approach (0.77-0.11 vs 0.74-0.16 vs 0.60-0.11). The diagnostic performance to detect overt hypothyroidism, isolated hypothyroxinemia, and (sub)clinical hyperthyroidism mainly varied between FT4 RI approaches, while the diagnostic performance to detect subclinical hypothyroidism varied between the applied TSH RI approaches., Conclusion: Alternative approaches to define RIs for TSH and FT4 in pregnancy result in considerable overdiagnosis and underdiagnosis compared with population- and trimester-specific RIs. Additional strategies need to be explored to optimize identification of thyroid dysfunction during pregnancy., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society.)