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The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.

Heart disease is the leading cause of mortality in adult women. Beyond the traditional risk factors of obesity, diabetes, and hypercholesterolemia, women with the pregnancy complications of preeclampsia, gestational diabetes, prematurity, and low birth weight for gestational age (fetal growth restriction) are at higher risk for later development of cardiovascular disease. Education of women and providers about the association of pregnancy complications and cardiovascular disease should begin in the postpartum period. Postpartum cardiovascular risk screening and lifestyle modifications should be considered standard of care and are essential to improving cardiac health as a preventive strategy.

OBJECTIVE: This study explores OB/GYN providers’ knowledge about published health and healthcare disparities in women’s reproductive health. METHOD: We collected demographic and health disparities knowledge information from OB/GYN providers who were members of ACOG District IV using an online survey (n=483). We examined differences across groups using statistical tests and regression analyses in a structural equation modeling approach. RESULTS: Receiving disparities education was positively associated with higher self-reported disparities knowledge and disparities quiz performance (p

Introduction: Protests and the call to action in the aftermath of the deaths of Black citizens at the hands of police officers have reawakened the consciousness of American society on policing and the need for reforms. Racism in policing has a long history dating back to slave patrols following the Civil War. Criminal anti Black police behavior violates the police oath to “protect and defend” all individuals. Materials and methods: This forum was convened to gain a better appreciation for the challenges of community policing and patterns of violence against Black citizens. Members of the forum including police leaders and legal authorities were presented with a series of questions related to various aspects of policing including training of police officers, how their units would have responded to the recent episodes of police violence against Black people, and what are the legal arguments for victims and police officers accused of excessive use of force? The panel deliberated and discussed remedies for reimagining and reforming policing to prevent excessive use of force that leads to repetitive patterns of loss of life in communities of color. Conclusion: The forum panel concluded that reimagining policing especially at the community level will require multiple strategies that must include recruitment of a diverse group of police officers who can better represent their communities and society. As important, is better screening, testing and vetting of applicants to the police academy to route out those individuals who may demonstrate the potential for adverse behaviors antithetical to the police oath to protect and defend all people regardless of race and/or ethnicity.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first “Putting the ‘M’ back in Maternal-Fetal Medicine” session was held at the Society for Maternal-Fetal Medicine’s (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the “M in MFM” meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a “report card” looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Objective To evaluate patient eligibility and accessibility of magnetic resonance–guided focused ultrasound (MRgFUS) for women with symptomatic uterine leiomyomas who desire conservative therapy. Design Retrospective analysis of 169 patients referred for minimally invasive treatment of leiomyomas between November 2007 and February 2009. Clinical eligibility for MRgFUS was determined by Food and Drug Administration–based treatment guidelines. All patients underwent pretreatment pelvic imaging to determine candidacy for the procedure. Patient(s) Premenopausal women with symptomatic uterine leiomyomas. Setting Academic medical center. Main Outcome Measure(s) Eligibility for MRgFUS based on clinical and anatomic patient criteria. Result(s) Forty-seven percent of patients (80/169) were determined clinically eligible for the procedure. Of these, 16% of patients (27/169) were found to be eligible for MRgFUS based on imaging results. Overall, the main reasons for ineligibility were very large leiomyomas (8%; 14/169), cost (12%; 21/169), and desired fertility (14%; 23/169). An additional 48% of patients declined MRgFUS for unstated reasons, often after obtaining financial and insurance coverage information. Conclusion(s) Currently, many women with leiomyomas are unable to obtain MRgFUS treatment for multiple reasons, including uterine size, desire for fertility, and, most commonly, financial limitations. With increasing clinical experience, further research, and broadened insurance coverage, it may be possible to increase accessibility and expand eligibility criteria for this minimally invasive therapy.

Objective To examine racial diversity in clinical studies on uterine leiomyomas included in a review of evidence-based practice because of the disproportionate burden of fibroids in Black women. Design Review of 106 studies cited in the Agency for Healthcare Research and Quality (AHRQ) report on uterine leiomyomas. Setting Academic medical centers. Patient(s) None. Intervention(s) Estimation of the racial diversity of enrollment in studies on leiomyomas that did not report racial composition by two hypothetical models. Main Outcome Measure(s) Representation of Black women in studies from the AHRQ report. Result(s) Of the 106 analyzed studies, 81 studies did not report patients' race or ethnicity. Twenty-two of the 25 studies with reported race or ethnicity included Black participants. Analysis of studies reporting race and ethnicity, including studies specifically of African-American women, suggests that Black women comprise approximately half of all study participants. However, when estimating the proportion of Black women based on population demographics in each country, the representation of Black women in clinical leiomyoma studies appears to be closer to 15%. Conclusion(s) Most studies on uterine leiomyomas cited in the AHRQ evidence-based report did not report participation by race or ethnicity.

Objective This study was undertaken to determine why residents choose obstetrics and gynecology. Study design Applicants to obstetrics and gynecology residency programs were surveyed; a 5-point scale (5 = most important) was used to rate various aspects of the specialty. Univariate statistics were performed. Bivariate analysis comparing results that were based on gender and timing of decisions was completed with Student t test, χ 2 , and Kruskal-Wallis tests. Results A total of 153 applicants (42% response rate) from 10 programs participated; 85.3% of respondents were female. Surgical opportunities, variety of clinical experience, and fast-paced/high-acuity experiences attract applicants to obstetrics and gynecology. When considering programs, resident camaraderie, gynecologic experience, and commitment to education were most important. Over 70% of residents decided to pursue obstetrics and gynecology during or after their third-year clerkship. Conclusion Surgical opportunities and clinical variety appeal to applicants. The majority choose obstetrics and gynecology during or after their core clerkship. In addition, program dynamics are important when choosing a residency.

Objective: Our purpose was to determine whether the continuation of antibiotics postoperatively after cesarean section in patients whose labors were complicated by chorioamnionitis would reduce the incidence of endometritis. Study Design: Patients with a clinical diagnosis of chorioamnionitis treated with ampicillin during labor and who required cesarean delivery for obstetric indications received preoperative intravenous clindamycin and gentamicin and were randomized into 2 groups. Group 1 received no scheduled postoperative antibiotics and group 2 continued to receive clindamycin 900 mg every 8 hours and gentamicin 1.5 mg/kg every 8 hours until afebrile for a minimum of 24 hours (temperature ≤100°F). Results: Sixty-one patients were randomized to group 1 and 55 patients were randomized to group 2. The duration of labor, the duration of membrane rupture, and the number of intrapartum vaginal examinations were statistically insignificant between the 2 groups. The mean duration of maternal postoperative hospital stay was 4 days for both groups. There were no statistically significant differences in the rate of endometritis for group 1, 9 of 61 (14.8%), versus group 2, 12 of 55 (21.8%), P = .32. Conclusions: In patients whose labors were complicated by chorioamnionitis and who underwent cesarean section, the continuation of preoperative clindamycin and gentamicin in the postoperative period did not reduce the risk of endometritis compared with a single preoperative dose. (Am J Obstet Gynecol 1998;179:1261-6.)

Patients with the variant form of xeroderma pigmentosum (XP) have clinical XP including a high frequency of skin cancer but, in contrast to the other forms of XP, have normal post-ultraviolet (UV) DNA excision repair and nearly normal post-UV survival. However, like excision repair-deficient XP cells, the XP variant cells are UV hypermutable. We used a UV-treated plasmid shuttle vector, pZ189, to examine the DNA repair defect in lymphoblastoid cells from an XP variant patient, XPPHBE, and a normal control. Plasmid repair, mutagenesis, and replication occur within transfected cells in a process dependent on the cells' repair capacity. With the XP variant cells post-UV, plasmid survival was normal with but there was an abnormally increased post-UV plasmid mutation frequency. Sequence analysis of the mutated plasmids revealed an increased frequency of plasmids with single base substitution mutations with the XP variant cells. As in earlier studies with UV mutagenesis, there was a predominance of G:C-->A:T base substitution mutations with plasmids recovered from both cell lines. The frequency of G:C-->C:G transversions was significantly higher with plasmids recovered from the XP variant cells than from normal cells. The location of mutations in the marker gene was non-random with different mutagenic hotspots found in plasmids recovered from the XP variant cells and from the normal cells. This study suggests that plasmid UV hypermutability in the presence of normal UV survival may be related to the increased UV skin cancer susceptibility of XP variant patients.

In order to examine possible cell-type specificity in mutagenic events, a shuttle-vector plasmid, pZ18, carrying a bacterial suppressor tRNA marker gene, was treated with ultraviolet radiation and propagated in Epstein-Barr virus transformed lymphoblastoid cell lines from a patient, XP12BE, with xeroderma pigmentosum (XP), group A, and a normal control. XP is a skin-cancer-prone disorder with UV hypersensitivity and defective DNA repair. Plasmid survival and mutations inactivating the marker gene were scored by transforming an indicator strain of E. coli . An earlier report on this data [Seetharam et al., (1990) J. Mol. Biol., 212, 433] indicated lower survival and higher mutation frequency with the UV-treated plasmid passed through the XP12Be(EBV) line. In the present report, sequence analysis of 198 mutant plasmids revealed a predominance of G:C → A:T transitions with both lymphoblastoid cell lines. This finding is consistent with the bias of polymerases toward insertion of an adenine opposite non-coding photoproducts (dinucleotides or other lesions). Transversion mutagenesis, non-adjacent double mutations, and triple-base mutations may involve other mechanisms. These results were compared to similar data from a fibroblast line from the same patient [Bredberg et al., (1986) Proc. Natl. Acad. Sci. (U.S.A.), 83, 8273]. The frequency of G:C → A:T transitions was higher, and there were fewer plasmids with multiple-base substitutions and with transversion mutations with both XP lymphoblasts and fibroblasts than with the normal lymphoblasts and fibroblasts. There were no significant differences in classes or types of mutations in the UV-treated plasmid replicated in the XP lymphoblasts and the XP fibroblasts. This suggests that the major features of UV mutagenesis in different cell types from the same individual are similar.

The purpose of this study was to examine predictors associated with cesarean delivery (CD) among extremely obese women undergoing a trial of labor (TOL).Using a delivery database, we identified all pregnant women delivering at our institution from Jan. 1, 2008, through July 31, 2010, weighing275 lb at the time of delivery who attempted a TOL with a singleton gestation34 weeks' gestation. Demographic and obstetrical factors were compared for those having a successful vaginal delivery to those having a CD.During the study period, there were 357 pregnant women who weighed275 lb (all with body mass index [BMI]40 kg/m(2)), and among these, 248 (69.5%) attempted a TOL. Women having a CD had a greater BMI (51.6 vs 49.9 kg/m(2), P = .038), were less likely to be parous (32.2% vs 65.8%, P.0001), and were more likely to be induced (80.5% vs 57.8%) compared to those having a vaginal delivery. Using a multivariable logistic regression model, among nulliparous women, maternal age, parity, and cervical dilation at time of admission were independent predictors for CD. Furthermore, an increase in BMI of 10 kg/m(2) was associated with a 3.5 increased odds (P = .002) for CD.Among nulliparous extremely obese women attempting a TOL, BMI was an independent predictor of CD, with the rate of CD increasing further with increasing BMI. The underlying mechanisms for failed TOL in the setting of maternal obesity remain largely unknown.