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Background Patient navigation programs have shown promise for improving health but are not widely used in obstetric care. Our objective was to understand obstetric provider perspectives on how to implement patient navigation to optimize care during the postpartum period for low-income patients. Method Focus groups were conducted with obstetric physicians, nurses, and social workers who care for low-income pregnant and postpartum patients in an academic medical center. Semistructured interview guides were developed to elicit conversations about the potential value of patient navigators, recommendations for navigator training, and how navigators could be most effective in improving postpartum care. Analysis of themes was based on the constant comparative method. Results Twenty-six obstetric providers (six focus groups) discussed elements for a successful obstetric navigation program. Successful implementation themes included selecting navigators with appropriate interpersonal attributes, arranging navigator training, and identifying the most valuable services navigators could render. Desirable navigator attributes included persistence in patient advocacy, consistency, relatability, and a supportive manner. Training recommendations included learning the health care system, identifying where to obtain health system and community resources, and learning how be effective health educators. Suggested services were broad, ranging from traditional care coordination to specific educational and resource-driven tasks. Conclusions Obstetric providers perceive patient navigation to be a potentially beneficial resource to support low-income patients and offered recommendations for navigation implementation. These included suggestions for patient-centered navigators, with specific training and services focused on promoting care continuity and coordination.

OBJECTIVE: To examine the association between preconception diet quality, sedentary behavior, and physical activity with gestational weight gain (GWG) among Hispanic/Latina women METHODS: This was a prospective cohort study of participants from visits 1 (2008–2011) and 2 (2014–2017) of the Hispanic Community Health Study/Study of Latinos and singleton pregnancies between the 2 visits. Diet quality (alternative healthy eating index/AHEI-2010), sedentary behaviors, and physical activity (Global Physical Activity Questionnaire) were measured at visit 1 and accounted for preconception health behaviors. GWG was evaluated as a continuous and categorical variable according to the 2009 Institute of Medicine guidelines (inadequate, adequate, excessive). Linear and generalized logit survey regressions were used to study the association between health behaviors and GWG, using adequate GWG as the reference. RESULTS: Of the 457 women included, deliveries occurred at 3.2 years (mean) from visit 1; 48.7% of women had excessive GWG. Mean AHEI-2010 scores were

Background: Recent paradigm shifts in postpartum care have conceptualized the “fourth trimester” as a critical transitional period requiring tailored, ongoing health care. However, this concept presents challenges for providers, especially in low-resource settings. Our objective was to understand providers' perspectives on challenges in postpartum care to highlight strategies for optimizing care. Methods: Focus groups were conducted using a semistructured interview guide to elicit perspectives on barriers and facilitators to postpartum care. Participants included physicians, nurses, and social workers who care for low-income postpartum individuals. Interviews explored the provider experience of postpartum care, with a focus on barriers experienced by patients and providers, and tools for maintaining engagement. Analysis was performed using the constant comparative method and framed by the Social Ecological Model. Results: Participants (N = 26) all acknowledged the importance of the “fourth trimester” but identified multiple barriers to providing optimal postpartum care. Challenges providers perceived for patients and those they perceived for themselves often overlapped, including difficulty with appointment scheduling, insurance limitations, lack of provider continuity, and knowledge gaps. Providers identified ease of referrals to specialists, access to tangible services (e.g., contraception), and enhanced care coordination (e.g., patient navigation) as potential facilitators of improved postpartum care. Conclusions: Obstetric providers recognize the importance of postpartum care yet highlighted significant systems- and patient-based barriers to achieving optimal care. The development and implementation of postpartum care delivery system redesign, such as the use of patient navigators to improve health care utilization and resource attainment, may enhance care during this critical time. Clinical Trial No.: NCT03922334.

Purpose Childhood adversity is associated with increased risk of adult disease, including type II diabetes and hypertension. However, little is known about potential associations between childhood adversity and adverse pregnancy outcomes. The goal of this study was to examine the relationship between adverse childhood experiences (ACEs) and ever experiencing gestational diabetes mellitus (GDM) or a hypertensive disorder of pregnancy (HDP) in a cohort of Hispanic or Latina women. Methods We analyzed data from 2319 women from the Hispanic Community Health Study/Study of Latinos who had ever given birth to a liveborn infant. We fit separate logistic regression models accounting for sample weights to examine the association between ACEs and risk of GDM and HDP adjusting for Hispanic/Latino background, age at immigration to the United States, and education. Results Women who reported four or more ACEs did not show increased odds of GDM or HDP compared with those who reported three or fewer (GDM adjusted odds ratio: 0.8 [0.5, 1.3]; HDP adjusted OR: 1.0 [0.7, 1.5]). Conclusions Unlike previous research with majority non-Hispanic White cohorts, there was no association between ACEs and GDM or HDP. Future research should explore if this relationship varies by race/ethnicity in multiethnic cohorts.

The majority of patients having bariatric surgery are reproductive-age women who are advised to delay pregnancy for at least 12 months after surgery. Many women become pregnant sooner and the association between gestational weight gain (GWG) and maternal long-term weight is unknown.The primary objective of this study was to compare weight outcomes in pregnancies occurring12 months versus ≥ 12 months after bariatric surgery. The secondary objectives were to determine the association between time interval from bariatric surgery to pregnancy and maternal nutritional status and maternal and neonatal outcomes.This is a retrospective cohort study of women with singleton livebirths after bariatric surgery who received care at a single tertiary care center between 2009 and 2017. GWG was the difference in weight between the first prenatal visit and delivery. GWG adequacy was determined by the IOM 2009 guidelines according to prepregnancy BMI (inadequate, adequate, excessive). Postpartum weight retention was calculated as the difference between weight at first prenatal visit and measured postpartum weight. Weight outcomes along with maternal nutritional status and maternal and neonatal outcomes were compared between12 months versus ≥ 12 months after bariatric surgery with t-tests, Mann-Whitney U and chi-square tests, as appropriate.Of the 76 pregnancies that met inclusion criteria, 36.8% occurred12 months (median 7.2 months) and 63.2% occurred ≥ 12 months after surgery (median 26.9 months). Of those with pregnancies12 months from surgery, 34% had a restrictive procedure (adjustable gastric band or sleeve gastrectomy) while 66% had a combined restrictive-malabsorptive procedure (Roux-en-Y gastric bypass). In the ≥ 12 months group, 42.3% had a restrictive procedure while 57.7% had a combined restrictive-malabsorptive procedure. There were no significant differences in maternal age, ethnicity or nulliparity between groups, but there were more women with obesity in the12 months group (75Pregnancy12 months after bariatric surgery is associated with significantly lower mean GWG and a higher frequency of weight loss during pregnancy as well as less postpartum weight retention at 6 months. Although there were no differences birthweight, weight loss during pregnancy and its accompanying metabolic changes are concerning for a developing fetus. Further study is needed to determine the optimal timing of pregnancy after bariatric surgery with respect to both maternal and infant short and long-term outcomes.

Background We aimed to evaluate the feasibility of using an activity-tracking device (ATD) during pregnancy and compare self-reported to ATD-calculated energy expenditure in a 2-phase study. Methods (Phase 1) Twenty-five pregnant women were asked about exercise, computer use, smartphone ownership, and ATD attitudes. Descriptive statistics were reported. (Phase 2) Women ≥18 years, smartphone owners, Results (Phase 1) Walking was the most common exercise; 8% did not perform any activity during pregnancy. All women had internet access and owned a smartphone. Women stated they would wear the ATD all the time during a pregnancy (88%), with the intent to improve their health (80%). (Phase 2) The characteristics of the 48 women were: pre-pregnancy BMI 28, 62% non-Hispanic black, 62% multiparas. Of the 18 women who completed the 36-week survey, only 56% wore the ATD daily, 33% had a lost or broken ATD, and 17% had technical problems; however, 94% enjoyed wearing it, 94% would recommend it to a pregnant friend, and 78% thought it helped them reach activity goals. According to ATD data, the median number of active days was 41 (IQR 20–73) and the median proportion of active days out of potential days was 22% (IQR 11–40). As gestational age increased, mean log steps decreased, active minutes decreased, and sedentary hours increased in unadjusted and adjusted models (P P = 0.66] and at 36 weeks [233 (86–907 range) vs. 218 (151–273 range), P = 0.68]). Conclusions Women reported high motivation to wear an ATD and high satisfaction with actually using an ATD during pregnancy; however adherence to the study protocol was lower than expected and ATD technical problems were frequent.

Introduction: During menopause, women experience an increase in cardiometabolic risk factors, thought to relate to aging and loss of endogenous estrogen. Menopause may also influence the gut microbiome, which plays a role in cardiometabolic risk. However, the menopause-microbiome relationship has not been examined in a large study and implications for disease are unknown. Hypothesis: Menopause alters gut microbiome composition, which may affect post-menopausal disease risk. Methods: Menopause was defined by self report of 12 months of amenorrhea, not due to surgery or other non-natural causes. Shotgun sequencing was used on stool from 2370 participants (301 pre-menopausal women; 1072 post-menopausal women; 997 men). Between pre- and post-menopausal women and age-matched men, we compared microbiome diversity, composition, and taxa. Results: Pre-menopausal women had higher gut microbiome diversity than post-menopausal women and men (all p Conclusions: Menopause is associated with a gut microbiome more similar to that of men, perhaps related to the common condition of a low estrogen state. In HCHS/SOL, menopause was associated with depletion of gut pathogens, which were related to increased diabetes risk. These findings require confirmation in other racial/ethnic groups.

Introduction: Polycystic Ovary Syndrome (PCOS) is associated with increased Metabolic Syndrome (MetS), however, these findings have not been characterized in Hispanic/Latina women who are disproportionately burdened by obesity and cardiovascular disease risk compared to non-Hispanic whites. It is also unclear if this association is moderated by elevated high-sensitivity C-Reactive Protein (hs-CRP) levels, a marker for inflammation and a predictor of cardiovascular disease. Hypothesis: In Hispanic/Latina women, we hypothesized that 1) PCOS (self-reported diagnosis and signs) is associated with a higher prevalence of MetS compared to those not reporting PCOS 2) elevated hs-CRP is associated with MetS, and 3) the PCOS-MetS association is moderated by elevated hs-CRP. Methods: We used information from reproductive and economic questionnaires and venous blood measurements collected in Hispanic Community Health Study/Study of Latinos (2008-2017), a U.S. community-based cohort study of Hispanic/Latino adults. PCOS was operationalized as either 1) signs of PCOS (e.g., menstrual cycles >35 days, irregular cycles (at age 20 to 40 years old when not using birth control pills or other hormone medications and not pregnant or breastfeeding) or 2) having answered “yes” to a self-reported question on PCOS. MetS was operationalized as ≥3 elevated subcomponents of MetS (i.e., waist circumference, hypertension, insulin resistance, lipid profile, and triglycerides). A hs-CRP value ≥3.0 mg/L was considered elevated. We adjusted for the complex survey study design, age, study center, Hispanic/Latina background, and age at immigration in all models. Results: The overall (unweighted N=9582) age ranged from 18 to 76 years (mean=41.74, SD=14.18). The prevalence of PCOS (self-reported diagnosis and signs) was 12% (1008/7366), prevalence of MetS was 40% (2380/3495), prevalence of elevated-hsCRP was 44% (3704/4667). PCOS was associated with a significantly higher odds of MetS before (OR 1.35, 95% CI: 1.06-1.71) and after adjusting for elevated-hsCRP (OR 1.29, 95%CI: 1.02-1.65). Elevated hs-CRP is significantly associated with MetS (OR 2.31, 95%CI: 1.95-2.76). There was no significant interaction effect of hs-CRP in the PCOS-MetS association. Conclusions: Prevalence of PCOS (self-reported and signs) was 12% in our sample of Hispanic/Latina women, which is consistent with the previous findings in non-Hispanic whites. Both PCOS (self-reported diagnosis and signs) and elevated hs-CRP were significantly associated with higher prevalence of MetS and could indicate women at metabolic disease risk.

Objective To determine the association between total gestational weight gain and perinatal outcomes. Study Design Data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be (NuMoM2b) study were used. Total gestational weight gain was categorized as inadequate, adequate, or excessive based on the 2009 Institute of Medicine guidelines. Outcomes examined included hypertensive disorders of pregnancy, mode of delivery, shoulder dystocia, large for gestational age or small for-gestational age birth weight, and neonatal intensive care unit admission. Results Among 8,628 women, 1,666 (19.3%) had inadequate, 2,945 (34.1%) had adequate, and 4,017 (46.6%) had excessive gestational weight gain. Excessive gestational weight gain was associated with higher odds of hypertensive disorders (adjusted odds ratio [aOR] = 2.05, 95% confidence interval [CI]: 1.78–2.36) Cesarean delivery (aOR = 1.24, 95% CI: 1.09–1.41), and large for gestational age birth weight (aOR = 1.49, 95% CI: 1.23–1.80), but lower odds of small for gestational age birth weight (aOR = 0.59, 95% CI: 0.50–0.71). Conversely, inadequate gestational weight gain was associated with lower odds of hypertensive disorders (aOR = 0.75, 95% CI: 0.62–0.92), Cesarean delivery (aOR = 0.77, 95% CI: 0.65–0.92), and a large for gestational age birth weight (aOR = 0.72, 95% CI: 0.55–0.94), but higher odds of having a small for gestational age birth weight (aOR = 1.64, 95% CI: 1.37–1.96). Conclusion Both excessive and inadequate gestational weight gain are associated with adverse maternal and neonatal outcomes.

OBJECTIVE To study the association of prepregnancy body mass index (BMI) and gestational weight gain with child neurodevelopmental outcomes. METHODS We performed a secondary analysis of data from two parallel, multicenter, randomized, double-blind, placebo-controlled thyroxine replacement trials in pregnant women with either hypothyroxinemia or subclinical hypothyroidism who delivered at term. Body mass index was categorized as normal (18.5-24.9), overweight (25.0-29.9), or obese (30 or greater). We also evaluated early (20 weeks of gestation or less), late (greater than 20 weeks of gestation), and total gestational weight gain and categorized gestational weight gain as inadequate, adequate, and excessive per 2009 Institute of Medicine guidelines. Neurodevelopmental outcomes included 5-year Wechsler Preschool and Primary Scale of Intelligence and 3-year Differential Ability Scales-II. Linear and logistic regression analyses were performed and adjusted for maternal age, race-ethnicity, education, insurance status, parity, smoking and alcohol use, thyroid status (subclinical hypothyroidism or hypothyroxinemia), treatment group, gestational age at delivery, and neonatal sex. RESULTS Of the 948 women included, 380 (40%), 305 (32%), and 263 (28%) had normal, overweight, and obese prepregnancy BMI, respectively. A total of 106 (11%), 212 (22%), and 630 (66%) of women had inadequate, adequate, and excessive total rates of gestational weight gain, respectively. Maternal differences among the BMI categories included race-ethnicity, education, insurance type, parity, and thyroid status (all P

To evaluate the feasibility (adherence to the study protocol and satisfaction) of using an activity tracking device (ATD) in group prenatal care. Women participated if they (1) were in group prenatal care, (2) owned a smartphone, and (3) had no activity restrictions. Women were instructed to wear and sync the ATD daily. Protocol adherence and satisfaction were assessed via surveys. Mixed models assessed the relationship between gestational age and ATD data. Self-reported energy expenditure from the Pregnancy Physical Activity Questionnaire (PPAQ) was compared with ATD-calculated energy expenditure. The baseline characteristics of the 49 women were as follows: 24 years old, prepregnancy body mass index 28, 80% Hispanic, 86% nulliparas, and 21 weeks of gestation. Of the 30 women who completed the follow-up survey, 47% self-reported wearing the ATD daily, 27% reported a lost or broken ATD, and 22% reported technical problems; however, 97% enjoyed wearing it, 100% would recommend it to a pregnant friend, and 77% thought it helped them reach activity goals. According to ATD data, the median active days were 47 (interquartile range [IQR] 21–79) and the median proportion of active days of potential days was 43.7% (IQR 15.4–77.1). For women who wore the ATD for the first 7 days, mean steps/day were 7574 (range 3076–15,828), active minutes/day were 277 (range 145–475), and sedentary hours/day were 12 (range 7.8–16.2). As gestational age increased, mean log steps decreased, mean active minutes decreased, and mean sedentary hours increased in unadjusted and adjusted models (p

Background Cardiovascular risk in young adulthood is an important determinant of lifetime cardiovascular disease risk. Women with adverse pregnancy outcomes (APOs) have increased cardiovascular risk, but the relationship of other factors is unknown. Methods and Results Among 4471 primiparous women, we related first‐trimester atherogenic markers to risk of APO (hypertensive disorders of pregnancy, preterm birth, small for gestational age), gestational diabetes mellitus (GDM) and hypertension (130/80 mm Hg or antihypertensive use) 2 to 7 years after delivery. Women with an APO/GDM (n=1102) had more atherogenic characteristics (obesity [34.2 versus 19.5%], higher blood pressure [systolic blood pressure 112.2 versus 108.4, diastolic blood pressure 69.2 versus 66.6 mm Hg], glucose [5.0 versus 4.8 mmol/L], insulin [77.6 versus 60.1 pmol/L], triglycerides [1.4 versus 1.3 mmol/L], and high‐sensitivity C‐reactive protein [5.6 versus 4.0 nmol/L], and lower high‐density lipoprotein cholesterol [1.8 versus 1.9 mmol/L]; P P Conclusions Individual and combined first‐trimester atherogenic characteristics are associated with APO/GDM occurrence and hypertension 2 to 7 years later. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02231398.

BACKGROUND: Limited or uncertain availability of nutritionally adequate and safe food, known as food insecurity, has been associated with obesity and other adverse health outcomes, but has rarely been studied in pregnancy. Food insecurity may negatively affect behavioral and physiological changes during pregnancy and may be associated with poor perinatal outcomes including gestational weight gain. OBJECTIVE: Given the lack of information on the role of food insecurity in pregnancy and the possible relationship with perinatal outcomes such as gestational weight gain, the objective of this study was to examine the association between food insecurity and gestational weight gain in a diverse cohort of pregnant women. MATERIALS AND METHODS: This was an observational study of 299 English-speaking women who delivered live-born singleton gestations at ≥24 weeks at a single tertiary care center. During their postpartum hospitalizations, enrolled women completed a survey of food security status during pregnancy using the United States Department of Agriculture Household Food Security Survey Module. Scores were analyzed as inadequate (marginal, low, or very low) vs adequate (high) food security. Women without prepregnancy body mass index and gestational weight gain data were excluded. The primary outcome was gestational weight gain categorized as inadequate, adequate, or excessive based on 2009 National Academy of Medicine guidelines, which account for body mass index. Secondary outcomes included total gestational weight gain and other maternal and neonatal outcomes. Multivariable linear and multinomial logistic regressions were performed to assess the independent associations of food insecurity with gestational weight gain after controlling for potential confounding factors. RESULTS: Of the 299 women enrolled in the study, 11.0% (n = 33) reported inadequate food security during pregnancy. Women with inadequate food security were younger (P = .007), had a greater mean body mass index (P < .001), were more likely to be non-Hispanic black or Hispanic (P < .001) and publicly insured (P < .001), but were less likely to be employed (P < .001). Women with inadequate food security also had fewer prenatal visits (P < .001) and were less likely to have initiated prenatal care in the first trimester (P < .001). The occurrence of excessive gestational weight gain did not differ by food security status (33.3% inadequate food security vs. 43.6% adequate food security, an adjusted relative risk ratio of 0.42, 95% confidence interval 0.16 – 1.14). Median total gestational weight gain was lower for women with inadequate food security (9.2 kg, interquartile range 7.5 – 14.1) than for women with adequate food security (13.9 kg, interquartile range 10.6 – 16.7) (P < .001), and this difference persisted when controlling for potential confounders including prepregnancy body mass index (β = −2.5, 95% confidence interval −5.0 to −0.21). CONCLUSIONS: In this diverse, urban population, more than 1 in 10 women experienced food insecurity during pregnancy. Inadequate food security was associated with lower median total gestational weight gain, but not with excessive gestational weight gain as determined by the 2009 National Academy of Medicine categories.

Intrauterine vacuum-induced hemorrhage control may provide an effective treatment option for postpartum hemorrhage that has the potential to prevent severe maternal morbidity and mortality., OBJECTIVE: To evaluate the effectiveness and safety of an intrauterine vacuum-induced hemorrhage-control device for postpartum hemorrhage treatment. METHODS: A multicenter, prospective, single-arm treatment study of a novel intrauterine device that uses low-level vacuum to induce uterine myometrial contraction to achieve control of abnormal postpartum uterine bleeding and postpartum hemorrhage was undertaken at 12 centers in the United States. The primary effectiveness endpoint was the proportion of participants in whom use of the intrauterine vacuum-induced hemorrhage-control device controlled abnormal bleeding without requiring escalating interventions. The primary safety endpoint was the incidence, severity, and seriousness of device-related adverse events. Secondary outcomes included time to bleeding control, rate of transfusion, and device usability scored by each investigator using the device. RESULTS: Of 107 participants enrolled with primary postpartum hemorrhage or abnormal postpartum uterine bleeding, 106 received any study treatment with the device connected to vacuum, and successful treatment was observed in 94% (100/106, 95% CI 88–98%) of these participants. In those 100 participants, definitive control of abnormal bleeding was reported in a median of 3 minutes (interquartile range 2.0–5.0) after connection to vacuum. Eight adverse events deemed possibly related to the device or procedure were reported, all of which were outlined as risks in the study and all of which resolved with treatment without serious clinical sequelae. Transfusion of 1–3 units of red blood cells was required in 35 participants, and five participants required 4 or more units of red blood cells. The majority of investigators reported the intrauterine vacuum-induced hemorrhage-control device as easy to use (98%) and would recommend it (97%). CONCLUSION: Intrauterine vacuum-induced hemorrhage control may provide a new rapid and effective treatment option for abnormal postpartum uterine bleeding or postpartum hemorrhage, with the potential to prevent severe maternal morbidity and mortality. FUNDING SOURCE: Alydia Health, Inc. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02883673.

Objective The aim of this study was to describe sleep duration across gestation in women who wore an activity-tracking device (ATD) during pregnancy, and to study the association between sleep duration and adverse maternal and neonatal outcomes Study Design Women ≥ 18 years old who owned a smartphone were approached to participate in 2016 to 2017. Participants received instructions to wear and sync an ATD daily. Steps, sedentary hours, and sleep duration were wirelessly transmitted via cellular technology. We measured sleep duration for the main episode of sleep and excluded sleep times Results The majority of 94 participants self-reported minority racial–ethnic status (33% non-Hispanic black and 51% Hispanic), had government insurance (83%), were nulliparous (61%), and had pre-pregnancy overweight or obesity (56%). The mean (standard deviation) duration of sleep was 7.2 ± 2.4 hours per 24 hours. In mixed models analyses, gestational age was statistically significantly associated with mean hours of sleep (β = −0.02; 95% confidence interval: −0.04 to −0.01; p 0.05 for all comparisons. Conclusion The mean sleep duration was 7.2 ± 2.4 hours among the 94 women in this cohort and decreased with advancing gestational age. Further research is required to evaluate sleep measurements with ATD in pregnant women and how sleep duration and quality is related to maternal and neonatal outcomes.

Background Nearly half of all women exceed the 2009 Institute of Medicine guidelines for gestational weight gain. Excess gestational weight gain is associated with adverse pregnancy outcomes. Objective Our objective was to determine whether having a personal gestational weight gain goal consistent with the Institute of Medicine’s recommendations for appropriate gestational weight gain and whether having a discussion with one’s obstetrical provider regarding that goal were associated with appropriate gestational weight gain. Study Design This is a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be study, a prospective cohort study of nulliparous women. We asked women at their first study visit (between 6 and 13 weeks’ gestation) whether they had a gestational weight gain goal and what that goal was. Furthermore, we asked whether their provider discussed a gestational weight gain goal and what that goal was. We classified personal and provider-recommended gestational weight gain goals as consistent or inconsistent with the Institute of Medicine guidelines, taking into account a woman’s initial body mass index category (underweight, normal weight, overweight, and obese). We included women with live singleton term deliveries (between 37 and 43 weeks’ gestation) in this analysis. We classified the primary outcome, which was gestational weight gain (defined as the difference between first visit weight and final weight before delivery), as inadequate, appropriate, or excessive, based on the Institute of Medicine guidelines and initial body mass index category. We used Student t, Wilcoxon rank-sum, and chi-square tests for bivariable analyses, and multinomial logistic regression was performed to control for confounding variables. Results Of 6727 eligible women, 3799 (56.5% of all eligible women) stated they had a gestational weight gain goal. Of the 3799 women with a stated goal, 2589 (38.5% of all women) had a goal consistent with the Institute of Medicine’s recommendations. In addition, of the 6727 eligible women, 2188 (32.5%) reported that they discussed gestational weight gain with their provider, and 1548 of these (23.0% of all women) recalled that their provider gave a gestational weight gain goal in accordance with the Institute of Medicine guidelines. Although having any gestational weight gain goal was not associated with appropriate gestational weight gain, having a gestational weight gain goal that was consistent with the Institute of Medicine’s recommendations was associated with a reduced risk of excessive (adjusted relative risk ratio, 0.77; 95% confidence interval, 0.64–0.92) and inadequate weight gain (adjusted relative risk ratio, 0.66; 95% confidence interval, 0.53–0.82). Conversely, discussing gestational weight gain goals with a provider was not associated with either inadequate or excessive gestational weight gain even if the provider’s recommendations for gestational weight gain were consistent with the guidelines. Conclusion Nulliparas who delivered singleton pregnancies at term who had a personal gestational weight gain goal consistent with the Institute of Medicine’s recommendations were less likely to have excessive or inadequate gestational weight gain. Further study is required to evaluate the most effective way to communicate this information to patients.

Objective To examine the relationship of weight change during early, mid, and late pregnancy with the development of a hypertensive disorder of pregnancy (HDP). Study design These data are from a prospective cohort study of nulliparous women with live singleton pregnancies. “Early” weight change was defined as the difference between self-reported pre-pregnancy weight and weight at the first visit (between 6 and 13 weeks’ gestation); “mid” weight change was defined as the weight change between the first and second visits (between 16 and 21 weeks’ gestation); “late” weight change was defined as the weight change between the second and third visits (between 22 and 29 weeks’ gestation). Weight change in each time period was further characterized as inadequate, adequate, or excessive based on the Institute of Medicine’s (IOM’s) trimester-specific weekly weight gain goals based on pre-pregnancy body mass index. Multivariable Poisson regression was performed to adjust for potential confounders. Main outcome measure Development of any hypertensive disorder of pregnancy. Results Of 8296 women, 1564 (18.9%) developed a HDP. Weight gain in excess of the IOM recommendations during the latter two time periods was significantly associated with HDP. Specifically, trimester-specific excessive weight gain in the mid period (aIRR 1.16, 95% CI 1.01–1.35) as well as in the late period (aIRR = 1.19, 95% CI = 1.02–1.40) was associated with increased risk of developing HDP. The weight gain preceded the onset of clinically apparent disease. Conclusions Excessive weight gain as early as the early second trimester was associated with increased risks of development of HDP.

Objective: In the United States, there have been very few improvements in adverse birth outcomes, such as infant mortality, low birthweight, and preterm birth in recent years. Health promotion before pregnancy (e.g., preconception care) has been increasingly recognized as an important strategy by which to improve these reproductive outcomes. As of yet, no research has examined sexual orientation disparities in preconception health which has important implications for birth outcomes in the United States, since sexual minority women (SMW) are more likely to report stillbirths, low birthweight, and preterm infants than heterosexual women. Methods: This study addresses this gap by utilizing data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to examine sexual orientation disparities in women's preconception health 1 and 3 years before a live birth (n = 3,133). Results: Our findings suggest that, even after controlling for maternal characteristics, SMW are more likely to report adverse health conditions and behaviors before pregnancy relative to heterosexual women 1 year before the survey, including higher odds of binge drinking, other substance use, having a sexually transmitted infection diagnosis, and depression. Conclusions: Despite new public health policies aimed at improved preconception health, our findings suggest that SMW are even more vulnerable to poor preconception health than their heterosexual counterparts, which has important implications for maternal and child health. This study provides important evidence for the need to invest in the reproductive health of SMW, particularly in the context of pregnancy.

To evaluate the association between gestational weight gain and maternal and neonatal outcomes in a large, geographically diverse cohort.Trained chart abstractors at 25 hospitals obtained maternal and neonatal data for all deliveries on randomly selected days over 3 years (2008-2011). Gestational weight gain was derived using weight at delivery minus prepregnancy or first-trimester weight and categorized as below, within, or above the Institute of Medicine (IOM) guidelines in this retrospective cohort study. Maternal (primary or repeat cesarean delivery, third- or fourth-degree lacerations, severe postpartum hemorrhage, hypertensive disease of pregnancy) and neonatal (preterm birth, shoulder dystocia, macrosomia, hypoglycemia) outcomes were compared among women in the gestational weight gain categories in unadjusted and adjusted analyses with odds ratios (ORs) and 95% CI reported. Covariates included age, race-ethnicity, tobacco use, insurance type, parity, prior cesarean delivery, pregestational diabetes, hypertension, and hospital type.Of the 29,861 women included, 51% and 21% had gestational weight gain above and below the guidelines, respectively. There was an association between gestational weight gain above the IOM guidelines and cesarean delivery in both nulliparous women (adjusted OR 1.44, 95% CI 1.31-1.59) and multiparous women (adjusted OR 1.26, 95% CI 1.13-1.41) and hypertensive diseases of pregnancy in nulliparous and multiparous women combined (adjusted OR 1.84, 95% CI 1.66-2.04). For the neonatal outcomes, gestational weight gain above the IOM guidelines was associated with shoulder dystocia (adjusted OR 1.74, 95% CI 1.41-2.14), macrosomia (adjusted OR 2.66, 95% CI 2.03-3.48), and neonatal hypoglycemia (adjusted OR 1.60, 95% CI 1.16-2.22). Gestational weight gain below the guidelines was associated with spontaneous (adjusted OR 1.50, 95% CI 1.31-1.73) and indicated (adjusted OR 1.34, 95% CI 1.12-1.60) preterm birth.In a large, diverse cohort with prospectively collected data, gestational weight gain below or above guidelines is associated with a variety of adverse pregnancy outcomes.

INTRODUCTION The objective of this study was to compare gestational weight gain (GWG) among women in group and traditional prenatal care. METHODS This is a retrospective cohort study of women who received prenatal care between 2011 and 2015 in a setting in which low-risk women had the option of group prenatal care. Women with height and initial and final weight were eligible. Women who chose group prenatal care were compared with women who chose traditional prenatal care and gave birth during the same study period. A propensity score analysis was used to create a matched control group from women who received traditional prenatal care. Bivariable comparisons of demographics, maternal characteristics, and GWG as a categorical variable (inadequate, adequate, or excessive per the 2009 Institute of Medicine guidelines) were performed with chi-square or Wilcoxon rank-sum tests. A logistic regression analysis was performed to estimate the association of group prenatal care with excessive GWG. RESULTS The final sample included 818 women who received either group or traditional prenatal care and were matched according to age, body mass index (BMI), nulliparity, and marital status. In the unadjusted analysis, women in group prenatal care had lower odds of excessive GWG (odds ratio [OR], 0.75; 95% CI, 0.57-0.99), but the statistical significance of this finding did not persist in the adjusted analysis (OR, 0.77; 95% CI, 0.45-1.30). When the analyses were limited to women who had at least 5 group or traditional prenatal care visits, there were no differences in excessive GWG in unadjusted (OR, 0.83; 95% CI, 0.59-1.16) or adjusted (OR, 0.97; 95% CI, 0.24-3.96) analyses. DISCUSSION In this propensity score matched cohort study of predominantly Hispanic women, there were no differences in excessive GWG between women in group compared with traditional prenatal care. Further study is indicated to determine the relationship between prenatal care model and GWG outcomes.

Objectives While being overweight (body mass index [BMI] >25) prior to pregnancy is linked to antenatal depression, whether weight is confounded by socioeconomic and/or medical risks is unclear. Study Design We assessed 66 healthy privately insured pregnant women at M = 35.0 ± 3.3 weeks for symptoms of depression (Inventory for Depressive Symptoms—Self-Report (IDS-SR 30), lifetime history of depression and other psychiatric conditions (Mini International Neuropsychiatric Interview), and pre-pregnancy BMI derived from pre-pregnancy weight (by recall) and directly measured height. Pre-pregnancy overweight (BMI > 25) and antenatal depression (score of mild or greater [14] on the IDS-SR 30) were assessed using logistic regression, controlling for past major depressive disorder (MDD) and demographic factors showing significant between group differences. Results Pre-pregnancy overweight (n = 17; 25.8%) was associated with an increased risk of third trimester depression, independent of past MDD and marital status (odds ratio = 7.47; 95% confidence interval [2.09–26.68]; B (standard error) = 2.010 [0.650]). Conclusion Replication in a larger sample is suggested to confirm an independent effect of pregravid overweight on third trimester depression.

To evaluate the association between prenatal stress and gestational weight gain (GWG). This was an analysis of women recruited between 2013–2015 from four sites in the US. We tested associations between responses at 32–35 weeks to the Life Experiences Survey (LES), a 37-item measure of events and perceived stress, and GWG categories. Bivariable comparisons and logistic regression were used to estimate the association between the total LES score and the odds of achieving adequate GWG. Among the 725 women, those with adequate GWG had lower median LES scores (5) compared to women with inadequate (7) and excessive (7) GWG, p = 0.02. After adjusting for age, initial BMI, income, education, marital status and gestational diabetes, lower LES scores (multiples of the median) were associated with adequate GWG (aOR 0.81, 95% CI 0.67–0.98). Lower reported stress, as measured by the LES, was associated with a greater chance of women achieving adequate GWG. This relationship highlights the potential for interventions directed toward psychosocial support to have salutary effects upon GWG.

To study patterns of induced labor at term in hypertensive women.We performed a retrospective cohort study using the Consortium on Safe Labor database; a multicenter study of labor and delivery practices from electronic medical records in 19 hospitals. 55,572 women were studied: 28,254 nulliparas and 27,318 multiparas, undergoing induction of labor at term without a prior cesarean with a singleton vertex live born fetus. Four hypertensive groups were defined: chronic hypertension (n=1164), gestational hypertension (n=1861), preeclampsia (n=1513) and superimposed preeclampsia (n=655), compared to controls (no hypertension, n=50,379). Labor characteristics and patterns were compared among the groups, stratified by parity.Interval-censored regression analysis estimated median and 95th% duration of labor, stratified by centimeter-by-centimeter dilation. Repeated-measures analysis established mean labor curves.Time to progress from 4 to 10 cm was 7.5, 6.4, 4.9 and 4.6h in nulliparous women with superimposed preeclampsia, chronic hypertension, preeclampsia and gestational hypertension respectively, which differed from controls (4.9h; p0.05 for chronic hypertension and superimposed preeclampsia). Multiparous women required 3.8, 3.9, 3.2 and 3.3h, respectively, compared to controls (3.2h, p0.05 except preeclampsia p=0.1) to progress from 4 to 10cm. Second stage of labor without epidural was longer for all nulliparous groups compared to controls except for women with chronic hypertension, but second stage did not differ in multiparas.Regardless of parity, women with chronic disease, chronic hypertension and superimposed preeclampsia, labor longer whereas those with relatively acute disease, gestational hypertension and preeclampsia, progress more rapidly.

OBJECTIVE To compare gestational weight gain among women in group prenatal care with that of women in individual prenatal care. METHODS In this retrospective cohort study, women who participated in group prenatal care from 2009 to 2015 and whose body mass indexes (BMIs) and gestational weight gain were recorded were matched with the next two women who had the same payer type, were within 2-kg/m prepregnancy BMI and 2-week gestational age at delivery, and had received individual prenatal care. Bivariate comparisons of demographics and antenatal complications were performed for women in group and individual prenatal care, and weight gain was categorized as "below," "met," or "exceeded" goals according to the 2009 Institute of Medicine guidelines. Logistic regression analysis estimated the association between excessive weight gain and model of care, with adjustment for confounders, stratified by BMI. RESULTS Women in group prenatal care (n=2,117) were younger and more commonly non-Hispanic black, nulliparous, and without gestational diabetes (P≤.005 for all). Women in group prenatal care more commonly exceeded the weight gain goals (55% compared with 48%, P

ObjectiveTo examine iron metabolism during the second and third trimesters in African American women with high-risk pregnancies.DesignLongitudinal pilot study.SettingLarge, university-based, urban Midwestern U.S. medical center.ParticipantsConvenience sample of 32 African American women with high-risk pregnancies seeking care at an urban maternal-fetal medicine clinic.MethodsNonfasting venous blood was collected in the second and third trimesters to assess iron status, hepcidin, and systemic inflammation. Anthropometric and survey data were obtained via self-report. Descriptive statistics were calculated from these data, and changes in the clinical parameters between the second and third trimesters were evaluated via paired t tests. Associations among demographic, reproductive, anthropometric, inflammatory, and iron-related parameters were also assessed in each trimester.ResultsThe mean age of participants was 28.3 (± 6.8) years, and mean prepregnancy body mass index was 31.9(±10.7) kg/m2. In the longitudinal analysis, significant (p< .05) declines in serum iron, ferritin, transferrin saturation, and C-reactive protein were observed between the second and third trimesters. There was no statistically significant change in hepcidin between trimesters. When using a ferritin level cut-point of less than 15ng/ml and soluble transferrin receptor level of greater than 28.1nmol/L, 48%of the participants (14 of 29) were classified with iron deficiency in the third trimester.ConclusionIn this pilot study, iron deficiency was prevalent among a small cohort of African American women with high-risk pregnancies. Hepcidin concentrations were greater than previously reported in healthy, pregnant, primarily White women, which suggests decreased iron bioavailability in this high-risk group.

The nutritional status of a woman during pregnancy and lactation is not only critical for her health but for future generations. Although a nutritionist or registered dietitian can help facilitate dietary counseling and interventions, physicians also need to be cognizant of nutritional needs during pregnancy because they differ significantly compared with nonpregnant populations. Furthermore, an individualized approach to nutritional counseling that considers a woman's nutritional status and body mass index is recommended.

OBJECTIVE: Much of the literature on clinical decision-making regarding the optimal route of delivery for periviable birth, 23 0/7 – 25 6/7 weeks’ gestation, has focused on neonatal risks. In fact, routine cesarean delivery at these early gestational ages has not been shown to improve neonatal mortality or neurological outcomes. Neonatal risks associated with route of delivery are well known. Conversely, there is a paucity of data on maternal morbidity associated with route of delivery. We examined maternal morbidity according to attempted route of delivery in women undergoing periviable birth. STUDY DESIGN: In a secondary analysis of the Consortium on Safe Labor, a retrospective cohort study, maternal outcomes were compared between attempted vaginal delivery and planned cesarean delivery in women undergoing periviable birth. Analyses were repeated to compare maternal outcomes among actual mode of delivery (vaginal delivery vs. cesarean delivery). Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) with 95% confidence intervals (95% CI), controlling for predefined covariates. RESULTS: Of 678 women who underwent periviable birth, 558 (82.3%) and 120 (17.7%) attempted vaginal delivery and planned cesarean delivery, respectively. Of 558 women who attempted a vaginal delivery, 411 (73.7%) achieved a vaginal delivery. Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery were less likely to have endometritis (3.1% vs. 15.0%; aRR 0.18, 95% CI 0.09-0.35). Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery had 7 days shorter total length of hospital stay (P

Objective Maternal obesity is associated with many adverse obstetric outcomes including cesarean delivery. It is unclear whether induction of labor can reduce these risks. Previous studies report conflicting results on the outcomes of elective induction of labor among obese women. This study aimed to compare maternal and neonatal outcomes between obese women undergoing elective induction of labor and those undergoing expectant management at ≥39 weeks. Study Design This was a retrospective cohort study from the Consortium on Safe Labor of obese women (defined by prepregnancy body mass index≥ 30kg/m2) with singleton gestations at ≥39 weeks without medical comorbidities from 2002 through 2008. Women scheduled for medically indicated induction of labor were excluded. The primary outcome of cesarean delivery was compared between obese women undergoing elective induction of labor and expectant management during 39th, 40th, and 41st weeks using univariable and multivariable analyses, stratifying by parity. Results In all, 7,298 nulliparous and 9,789 parous women were eligible for analysis. After controlling for potential confounders, elective induction of labor during 39th week in nulliparous and parous women was associated with lower odds of cesarean delivery (39.1 vs. 41.6%, adjusted odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.30–0.74 for nulliparous and 5.5 vs. 10.1%, adjusted OR: 0.34, 95% CI: 0.20–0.61 for parous women) compared with expectant management. Elective induction of labor during 40th and 41st weeks was not associated with lower odds of cesarean delivery. In addition, macrosomia was reduced in nulliparous women undergoing elective induction of labor during the 40th week (12.1 vs. 18.5%, adjusted OR: 0.56, 95% CI: 0.35–0.87) and in parous women undergoing elective induction of labor during 39th (11.6 vs. 17.6%, adjusted OR: 0.50, 95% CI: 0.38–0.66) and 40th weeks (16.4 vs. 22.2%, adjusted OR: 0.53, 95% CI: 0.36–0.78). Conclusion Elective induction of labor at 39 weeks, when compared with expectant management, was associated with lower cesarean deliveries in obese nulliparous and parous women.

Objectives Little is known about maternal and infant health among sexual minority women (SMW), despite the large body of research documenting their multiple preconception risk factors. This study used data from the 2006–2015 National Survey of Family Growth (NSFG) to investigate sexual orientation inequities in pregnancy and birth outcomes, including miscarriage, stillbirth, preterm birth, and birth weight. Methods Women reported 19,955 study eligible pregnancies and 15,996 singleton live births. Sexual orientation was measured using self-reported identity and histories of same-sex sexual experiences (heterosexual-WSM [women who only report sex with men]; heterosexual-WSW [women who report sex with women]; bisexual, and lesbian). Logistic regression models were used that adjusted for several maternal characteristics. Results Compared to heterosexual-WSM, heterosexual-WSW (OR 1.25, 95% CI 1.00–1.58) and bisexual and lesbian women (OR 1.77, 95% CI 1.34–2.35) were more likely to report miscarriage, and bisexual and lesbian women were more likely to report a pregnancy ending in stillbirth (OR 2.85, 95% CI 1.40–5.83). Lesbian women were more likely to report low birth weight infants (OR 2.64, 95% CI 1.38–5.07) and bisexual and lesbian women were more likely to report very preterm births (OR 1.84, 95% CI 1.11–3.04) compared to heterosexual-WSM. Conclusions for Practice This study documents significant sexual orientation inequities in pregnancy and birth outcomes. More research is needed to understand the mechanisms that underlie disparate outcomes and to develop interventions to improve sexual minority women’s maternal and infant health.

Background Group visits for chronic medical conditions in non-pregnant populations have demonstrated successful outcomes including greater weight loss compared to individual visits for weight management. It is plausible that group prenatal care can similarly assist women in meeting gestational weight gain goals. The purpose of this study was to evaluate the effect of group vs. traditional prenatal care on gestational weight gain. Methods A keyword search of Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, and Google Scholar was performed up to April 2017. Studies were included if they compared gestational weight gain in a group prenatal care setting to traditional prenatal care in either randomized controlled trials, cohort, or case-control studies. The primary and secondary outcomes were excessive and adequate gestational weight gain according to the Institute of Medicine guidelines. Heterogeneity was assessed with the Q test and I2 statistic. Pooled relative risks (RRs) and confidence intervals (CI) were reported with random-effects models from the randomized controlled trials (RCT) and cohort studies. Results One RCT, one secondary analysis of an RCT, one study with “random assignment”, and twelve cohort studies met the inclusion criteria for a total of 13,779 subjects. Thirteen studies used the CenteringPregnancy model, defined by 10 sessions that emphasize goal setting and self-monitoring. Studies targeted specific populations such as adolescents, African-Americans, Hispanics, active-duty military or their spouses, and women with obesity or gestational diabetes. There were no significant differences in excessive [7 studies: pooled rates 47% (1806/3582) vs. 43% (3839/8521), RR 1.09, 95% CI 0.97–1.23] or adequate gestational weight gain [6 studies: pooled rates 31% (798/2875) vs. 30% (1410/5187), RR 0.92, 95% CI 0.79–1.08] in group and traditional prenatal care among the nine studies that reported categorical gestational weight gain outcomes in the meta-analysis. Conclusions Group prenatal care was not associated with excessive or adequate gestational weight gain in the meta-analysis. Since outcomes were overall inconsistent, we propose that prenatal care models (e.g., group vs. traditional) should be evaluated in a more rigorous fashion with respect to gestational weight gain. Electronic supplementary material The online version of this article (10.1186/s12884-018-2148-8) contains supplementary material, which is available to authorized users.

Objective The objective of this study was to determine if mid-trimester cervical length is associated with the inverse relationship between maternal body mass index (BMI) at delivery and spontaneous preterm birth (SPTB). Materials and Methods This was a retrospective cohort of women with a singleton pregnancy without prior SPTB who underwent routine transvaginal cervical length assessment between 18 and 24 weeks. Women were categorized into four BMI groups: (1) 18.5 to 24.9, (2) 25 to 29.9, (3) 30 to 34.9, and (4) ≥ 35 kg/m2. Univariable and multivariable analyses were conducted to determine whether BMI group was associated with SPTB at

Objective To compare perinatal outcomes in women with oligohydramnios and an unfavorable cervix undergoing labor induction with misoprostol to prostaglandin E2. Study Design We conducted a secondary analysis of women with oligohydramnios undergoing labor induction in the Consortium on Safe Labor study (2002–2008). Oligohydramnios was recorded in the medical chart. We evaluated perinatal outcomes. We limited the analysis to women with an unfavorable cervix defined by simplified Bishop score ≤ 4. Misoprostol was compared with prostaglandin E2. Women could have received oxytocin, underwent mechanical dilation, or had artificial rupture of membranes, but women who underwent induction with both misoprostol and prostaglandin E2 were excluded. We calculated adjusted odds ratios with 95% confidence intervals, controlling for maternal age, maternal body mass index (kg/m 2 ), parity, and mechanical dilation. Results Among women with oligohydramnios and an unfavorable cervix who underwent induction of labor, 141 (39.4%) received misoprostol and 217 (60.6%) received prostaglandin E2. There were no significant differences in cesarean delivery, chorioamnionitis, postpartum hemorrhage, transfusion, neonatal intensive care unit (NICU) admission, NICU stay > 72 hours, mechanical ventilation, and neonatal sepsis. Conclusion In women with oligohydramnios and an unfavorable cervix, induction of labor with misoprostol was comparable to prostaglandin E2.

To compare wound complications between staples versus subcuticular suture for skin closure in obese women (body mass index (BMI)⩾30 kg m(-2)) after cesarean delivery (CD).We conducted a retrospective cohort study to compare wound complications between staples and subcuticular suture closure in women, with a prepregnancy BMI⩾30 kg m(-2) after CD between 2006 and 2011 at an inner-city teaching hospital. Wound complication was defined as a composite of wound disruption (hematoma or seroma) or infection diagnosed up to 6 weeks postpartum. Variables collected include age, parity, prior CDs, prior abdominal surgeries, incision type, chorioamnionitis, maternal comorbidities (hypertension, diabetes) and gestational age.Of the 1147 women included in the study, women with staple closure were older and had higher BMIs (40.6±9.3 versus 36.1±5.4) and were more likely to be multiparous, have a prior CD, diabetes and hypertension compared with women with subcuticular suture. The overall occurrence of wound complications was 15.5% (178/1147). Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions.In obese women, skin closure with staples at the time of CD is associated with a higher rate of wound complications compared with subcuticular suture. Skin closure with subcuticular suture over staples should be considered in obese women undergoing a CD regardless of skin incision type.

Objective The objective of this study was to compare severe morbidity due to obstetrical hemorrhage and its potential preventability before and after a mandated provider training initiative on obstetric hemorrhage. Study Design Cases of severe morbidity due to obstetric hemorrhage during 2006 ( n = 64 before training initiative) and 2010 ( n = 71 after training initiative) were identified by a two-factor scoring system of intensive care unit admission and/or transfusion of ≥ 3 units of blood products and reviewed by an expert panel. Preventable factors were categorized as provider, system, and/or patient related. Results Potential preventability did not differ between 2006 and 2010, p = 0.19. Provider factors remained the most common preventable factor (88.2% in 2006 vs. 97.4% in 2010, p = 0.18), but the distribution in types of preventable factors improved over time for delay or failure in assessment (20.6 vs. 0%, p p p = 0.015) with a notable decline in factors related to policies and procedures (26.5 vs. 2.6%, p Conclusion We found significant improvement in provider assessment and treatment of obstetric hemorrhage and a significant reduction in preventable factors related to policies and procedures after the training initiative.

Objective This study aims to compare how national guidelines approach the management of obesity in reproductive age women. Study Design We conducted a search for national guidelines in the English language on the topic of obesity surrounding the time of a pregnancy. We identified six primary source documents and several secondary source documents from five countries. Each document was then reviewed to identify: (1) statements acknowledging increased health risks related to obesity and reproductive outcomes, (2) recommendations for the management of obesity before, during, or after pregnancy. Results All guidelines cited an increased risk for miscarriage, birth defects, gestational diabetes, hypertension, fetal growth abnormalities, cesarean sections, difficulty with anesthesia, postpartum hemorrhage, and obesity in offspring. Counseling on the risks of obesity and weight loss before pregnancy were universal recommendations. There were substantial differences in the recommendations pertaining to gestational weight gain goals, nutrient and vitamin supplements, screening for gestational diabetes, and thromboprophylaxis among the guidelines. Conclusion Stronger evidence from randomized trials is needed to devise consistent recommendations for obese reproductive age women. This research may also assist clinicians in overcoming one of the many obstacles they encounter when providing care to obese women.

Objective To compare maternal and neonatal morbidities among obese women and their offspring by attempted delivery approach. Methods We performed a retrospective cohort study of 47,372 obese women at delivery (body mass index 30 or greater) eligible for vaginal delivery who were carrying singleton vertex fetuses at 37 weeks of gestation or greater. Prior cesarean delivery, congenital anomalies, and antepartum stillbirth were exclusion criteria. We analyzed outcomes by attempted delivery route and stratified by parity. The composite maternal outcome included intensive care admission, death, hemorrhage, transfusion, or thromboembolism. The neonatal composite included intensive care unit admission, death, seizure, ventilator use, birth injury, or asphyxia. Adjusted relative risks (RRs) and 95% confidence intervals (CIs) were calculated using Poisson regression. Results Among nulliparous women attempting vaginal delivery (n=15,268), the success rate was 72.6% and among parous women (n=23,426), it was 93.7%. The maternal composite outcome rate was not statistically higher among nulliparous women (7.7% compared with 4.2% [adjusted RR 1.58, 95% CI 0.96-2.59]) but it was among parous women (7.6% compared with 2.5% [adjusted RR 2.45, 95% CI 1.23-4.90]) attempting vaginal delivery related to hemorrhage, blood transfusion, or both. In contrast, the neonatal composite outcome rate was lower in parous women (6.0% compared with 11.6% [adjusted RR 0.65, 95% CI 0.51-0.83]) but not in nulliparous women (10.2% compared with 12.4% [adjusted RR 0.91, 95% CI 0.74-1.12]) parous. Conclusion In obese nulliparous women, attempted vaginal delivery was not associated with increased composite maternal or neonatal morbidity. In obese parous women, attempted vaginal delivery was associated with increased composite maternal morbidity and lower composite neonatal morbidity. Level of evidence II.

Pregnant African American women are more likely to live in neighborhoods with more disorder (e.g., vacant housing, littler, crime) and to have vitamin D deficiency due to their darker skin pigmentation and poor production of vitamin D [25(OH)D] from ultraviolet rays. However, no study has examined the potential link between neighborhood disorder and 25(OH)D status in African American pregnant women. Forty-one pregnant African American women completed validated questionnaires about perceived neighborhood disorder (6 items; 3-point scale; range 6–18) and with concurrent serum levels of 25-hydroxyvitamin D [25(OH)D] assessed during pregnancy at 18–24 weeks gestation. Higher levels of perceived neighborhood disorder were associated with lower levels of serum 25(OH)D. Pregnant African American women who report higher disorder in their neighborhood may spend less time outside. Health care providers should include assessment of perceived neighborhood disorder. Future research needs to evaluate the relationships among neighborhood disorder and 25(OH)D levels among pregnant African American women.

Pregnancy in women with obesity is an important public health problem with short- and long-term implications for maternal and child health. Obesity complicates almost all aspects of pregnancy. Given the growing prevalence of obesity in women, obstetric providers need to understand the risks associated with obesity in pregnancy and the unique aspects of management for women with obesity. Empathic and patient-centered care, along with knowledge, can optimize outcomes for women and children.

Background Providers need to be comfortable addressing obesity and gestational weight gain so they may give appropriate care; however, health care providers lack guidelines for the most effective educational strategies to assist in providing optimal care. Objective To identify studies that involved the obstetric provider in interventions for either the perinatal management of obesity and/or gestational weight gain in a systematic review. Search strategy A keyword search of databases was performed up to April 2017. Selection criteria Obstetric providers who participated in an intervention with the aim to change a provider’s clinical practice, knowledge, and/or satisfaction with the intervention in relation to the perinatal management of obesity or gestational weight gain were included. Provider intervention could include training or education, changes in systems or organization of care, or resources to support practice. PROSPERO database #42016038921. Data collection and analysis Bias was assessed according to the validated Mixed Methods Appraisal Tool. The following variables were synthesized: study location and setting, provider and patient characteristics, intervention features, outcomes and efficacy, and strengths and weakness. Main results Of the 6,821 abstracts screened, seven studies (4 quantitative, 3 mixed-methods) with a total of 335 providers met the inclusion criteria; two of which focused on the management of obesity, three focused on gestational weight gain, and two focused on both topics. Interventions that incorporated motivational interviewing skills (n = 2), required additional training for the research study and addressed specific knowledge deficits such as nutrition and exercise (n = 3), and interfaced with the electronic medical record (n = 1) demonstrated the greatest impact on provider outcomes. Provider reported satisfaction scores were generally favorable, but none addressed provider-level efficacy in practice change. Conclusions Given the limited number of studies, varying range of provider participation, and lack of provider-level efficacy, further evaluation of provider training and involvement in interventions for perinatal obesity or gestational weight gain is indicated to determine best practices for provider and patient outcomes.

To compare adipokinins between women experiencing preterm labor (PTL) and prior preterm deliveries (PTD).In this prospective observational cohort, 110 women with a singleton35 weeks at increased risk of PTD were studied. Serum leptin, adiponectin, and resistin were obtained at three times (23-34 weeks, 35-36 weeks, at delivery) and analyzed via enzyme-linked immunosorbent assay. The adipokinins were compared across time and between PTL (n = 59) and prior PTD (n = 51) groups using generalized estimated equation models.There were no differences in leptin, adiponectin, or resistin levels over the three times between the PTL and PTD groups. There was a trend toward higher leptin levels (p = 0.06 unadjusted analysis, p = 0.09 adjusted analysis) at 23-34 weeks. When stratified by body mass index (BMI), there were differences in leptin (p 0.001 for BMI 30; p = 0.77 for BMI ≥ 30) and adiponectin (p = 0.04 for BMI 30; p = 0.09 for BMI ≥ 30), but not in resistin over the three times between the PTL and prior PTD groups.There were no significant differences in adipokinins in women with PTL and a prior PTD. The trends toward higher leptin levels at 23-34 weeks in women with PTL may represent a compensatory response and require further evaluation in the study of treatments for PTL.

To compare outcomes in small for gestational age neonates induced with misoprostol to other cervical ripening agents. We hypothesized that misoprostol use will demonstrate no significant difference in outcomes compared with alternative agents.Small for gestational age neonates (10th percentile for gestational age) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) sponsored Consortium on Safe Labor database were analyzed. Neonates induced with misoprostol ± oxytocin (n = 451) were compared with neonates induced with prostaglandin E2 ± oxytocin and/or mechanical dilation ± oxytocin (n = 663). Primary outcomes included intrapartum fetal distress, cesarean section for fetal distress, cesarean section for any reason, neonatal intensive care unit admission, low 5-minute Apgar, and composite neonatal morbidity. Multiple logistic regression was used to calculate adjusted odds ratios (aORs). Data were analyzed using SAS.Small for gestational age neonates induced with misoprostol ± oxytocin compared with alternative agents had decreased low 5-minute Apgar scores (aOR 0.27 [0.10-0.71]). No significant differences were demonstrated among very small for gestational age neonates (5th percentile for gestational age).Our results suggest that misoprostol does not increase risk of adverse outcomes in small for gestational age neonates; however, prospective studies are warranted to further assess optimal cervical ripening agents in this population.

Prenatal care providers are advised to evaluate maternal weight at each regularly scheduled prenatal visit, monitor progress toward meeting weight gain goals, and provide individualized counseling if significant deviations from a woman’s goals occur. Today, nearly 50% of women exceed their weight gain goals with overweight and obese women having the highest prevalence of excessive weight gain. Risks of inadequate weight gain include low birth weight and failure to initiate breastfeeding whereas the risks of excessive weight gain include cesarean deliveries and post-partum weight retention for the mother and large for gestational age infants, macrosomia, and childhood overweight or obesity for the offspring. Prenatal care providers have many resources and tools they can use to incorporate weight and other health behavior counseling into their routine prenatal practices. Because many women are motivated to improve their health behaviors, pregnancy is often considered the optimal time to intervene for issues related to eating habits and physical activity so as to prevent excessive weight gain. Gestational weight gain is a potentially modifiable risk factor for a number of adverse maternal and neonatal outcomes and meta-analyses of randomized controlled trials report that diet or exercise interventions during pregnancy can help reduce excessive weight gain. However, health behavior interventions for gestational weight gain have not significantly improved other maternal and neonatal outcomes and have limited effectiveness in overweight and obese women.