Search

Patients remain at risk for persistent and de novo postpartum hypertension related to pregnancy. This review aims to summarize the current definitions, clinical practices, and novel systems innovations and therapies for postpartum hypertension.Recent changes to the definitions of hypertension outside of pregnancy have not yet impacted definitions or management of hypertensive disorders of pregnancy (HDP), though research examining the implications of these new definitions on risks of developing HDP and the resultant sequelae is ongoing. The administration of diuretics has been shown to reduce postpartum hypertension among women with HDP. Widespread implementation of telemedicine models and remote assessment of ambulatory blood pressures has increased data available on postpartum blood pressure trajectories, which may impact clinical management. Additionally, policy changes such as postpartum Medicaid extension and an increasing emphasis on building bridges to primary care in the postpartum period may improve long-term outcomes for women with postpartum hypertension. Prediction models utilizing machine learning are an area of ongoing research to assist with risk assessment in the postpartum period.The clinical management of postpartum hypertension remains focused on blood pressure control and primary care transition for cardiovascular disease risk reduction. In recent years, systemic innovations have improved access through implementation of new care delivery models. However, the implications of changing definitions of hypertension outside of pregnancy, increased data assessing blood pressure trajectories in the postpartum period, and the creation of new risk prediction models utilizing machine learning remain areas of ongoing research.

Background The purpose of this study was to estimate prevalence of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. Methods A cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1–3-month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. Results Data were collected from 9 health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient units. A total of 10 147 SARS-CoV-2 tests were administered, of which 124 were positive (1.2%). Positivity rates varied by site, ranging from 0–3.2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (P=.003, r=.782) and state (P=.007, r=.708). Conclusions Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2–related healthcare resource utilization in obstetric inpatient units may be best informed by surrounding community infection rates., There was a significant positive correlation between SARS-CoV-2 positivity rates in obstetric inpatient units and their surrounding county and state. Healthcare resource utilization related to SARS-CoV-2 testing in obstetric inpatient units may be best informed by surrounding community infection rates.

Persistent postpartum hypertension is a significant cause of maternal morbidity. Our objective was to study the effect of furosemide on postpartum blood pressure recovery in women with hypertensive disorders of pregnancy. We performed a randomized, double-blind, placebo-controlled trial of a 5-day course of 20 mg oral furosemide versus placebo in women with gestational hypertension and preeclampsia with/without severe features from June 2018 to October 2019. Primary outcomes were persistent hypertension at 7 days postpartum (using generalized linear models to calculate adjusted relative risk) and days to resolution of hypertension (Kaplan-Meier curves), stratified by severe/nonsevere hypertensive disease. Secondary outcomes included readmissions and need for additional hypertensive medication.We randomized 384 women (192 per group). Baseline characteristics were similar except cesarean delivery rate was higher in the furosemide group (29% versus 20%; P =0.04). In women randomized to furosemide, there was a 60% reduction in the prevalence of persistently elevated blood pressure at 7 days when controlling for cesarean (adjusted relative risk, 0.40 [95% CI, 0.20–0.81]). The magnitude of reduction was greater in women with nonsevere disease (adjusted relative risk, 0.26 [95% CI, 0.10–0.67]). Number of days to blood pressure resolution was significantly shorter among women with nonsevere disease randomized to furosemide (8.5 versus 10.5; P =0.001). There were no significant differences in readmissions or need for additional antihypertensive medication postpartum between groups. In this double-blinded randomized trial, a short course of postpartum furosemide significantly improved blood pressure control in women with hypertensive disorders of pregnancy, mostly among women without severe disease. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT035556761.

Background Remdesivir is efficacious for severe coronavirus disease 2019 (COVID-19) in adults, but data in pregnant women are limited. We describe outcomes in the first 86 pregnant women with severe COVID-19 who were treated with remdesivir. Methods The reported data span 21 March to 16 June 2020 for hospitalized pregnant women with polymerase chain reaction–confirmed severe acute respiratory syndrome coronavirus 2 infection and room air oxygen saturation ≤94% whose clinicians requested remdesivir through the compassionate use program. The intended remdesivir treatment course was 10 days (200 mg on day 1, followed by 100 mg for days 2–10, given intravenously). Results Nineteen of 86 women delivered before their first dose and were reclassified as immediate “postpartum” (median postpartum day 1 [range, 0–3]). At baseline, 40% of pregnant women (median gestational age, 28 weeks) required invasive ventilation, in contrast to 95% of postpartum women (median gestational age at delivery 30 weeks). By day 28 of follow-up, the level of oxygen requirement decreased in 96% and 89% of pregnant and postpartum women, respectively. Among pregnant women, 93% of those on mechanical ventilation were extubated, 93% recovered, and 90% were discharged. Among postpartum women, 89% were extubated, 89% recovered, and 84% were discharged. Remdesivir was well tolerated, with a low incidence of serious adverse events (AEs) (16%). Most AEs were related to pregnancy and underlying disease; most laboratory abnormalities were grade 1 or 2. There was 1 maternal death attributed to underlying disease and no neonatal deaths. Conclusions Among 86 pregnant and postpartum women with severe COVID-19 who received compassionate-use remdesivir, recovery rates were high, with a low rate of serious AEs., Among 86 pregnant and postpartum women with severe coronavirus disease 2019 who received compassionate-use remdesivir, recovery rates from serious infection were high with a low rate of serious adverse events.

Objective This study was aimed to describe the hospitalization and early postpartum psychological experience for asymptomatic obstetric patients tested for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) as part of a universal testing program and report the impact of this program on labor and delivery health care workers' job satisfaction and workplace anxiety. Study Design This is a cohort study of asymptomatic pregnant women who underwent SARS-CoV-2 testing between April 13, 2020 and April 26, 2020. Semistructured interviews were conducted via telephone at 1 and 2 weeks posthospitalization to assess maternal mental health. Depression screening was conducted using the patient health questionnaire-2 (PHQ-2). An online survey of labor and delivery health care workers assessed job satisfaction and job-related anxiety before and during the novel coronavirus disease 2019 (COVID-19) pandemic, as well as employees' subjective experience with universal testing. Patient and employee responses were analyzed for recurring themes. Results A total of 318 asymptomatic women underwent SARS-CoV-2 testing during this 2-week period. Six of the eight women (75%) who tested positive reported negative in-hospital experiences secondary to perceived lack of provider and partner support and neonatal separation after birth. Among the 310 women who tested negative, 34.4% of multiparous women reported increased postpartum anxiety compared with their prior deliveries due to concerns about infectious exposure in the hospital and lack of social support. Only 27.6% of women, tested negative, found their test result to be reassuring. Job satisfaction and job-related anxiety among health care workers were negatively affected. Universal testing was viewed favorably by the majority of health care workers despite concerns about delays or alterations in patient care and maternal and neonatal separation. Conclusion Universal testing for SARS-CoV-2 in obstetric units has mixed effects on maternal mental health but is viewed favorably by labor and delivery employees. Ongoing evaluation of new testing protocols is paramount to balance staff and patient safety with quality and equality of care. Key Points Women with SARS-CoV-2 had a negative hospital experience. A negative SARS-CoV-2 test was not reassuring for patients. COVID-19 negatively impacts healthcare workers’ well-being.

The management of hypertensive disease of pregnancy presents an ongoing challenge after patients are discharged from delivery hospitalizations. Preeclampsia and other forms of postpartum hypertension increase the risk for severe maternal morbidity and mortality in the postpartum period, and both hypertension and its associated adverse events disproportionately affect black women. With its ability to transcend barriers to health care access, telemedicine can facilitate high-quality postpartum care delivery for preeclampsia management and thereby reduce racial disparities in obstetric care and outcomes. Here we discuss racial disparities in preeclampsia and the challenge of providing equitable postpartum preeclampsia care. We then describe the utility of novel telemedicine platforms and their application to combat these disparities in preeclampsia care.

Background: The purpose of this study was to estimate prevalence of asymptomatic SARS-CoV-2 infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. Methods: This was a cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1-3 month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. Findings: Data were collected from nine health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient unit. A total of 10,147 SARS-CoV-2 tests were administered, of which 124 were positive (1·2%). Positivity rates varied by site, ranging from 0-3·2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (p=·003, r=·782) and state (p=·007, r=·708). Interpretation: Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2 related healthcare resource utilization in obstetric inpatient units may be best-informed by surrounding community infection rates. Funding Information: Internal funding was used. Declaration of Interests: None to declare. Ethics Approval Statement: The study was IRB approved or determined exempt at each center.

Background The coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 has challenged obstetrical care providers. Universal testing on labor and delivery units has been implemented by many hospitals to ensure patient and staff safety. Asymptomatic carrier rates are expected to vary based on geographic differences in disease prevalence, although differences within the same city have not been reported previously. In addition, clinical follow-up of women who had a negative result for severe acute respiratory syndrome coronavirus 2 during obstetrical hospitalization has not been included in any previous reports. Objective This study aimed to describe the prevalence of positive severe acute respiratory syndrome coronavirus 2 test results among asymptomatic pregnant women at 2 Philadelphia obstetrical hospitals, characterize the clinical course of those who had a positive result, and report symptom development among all women tested in the 2 weeks after hospitalization. Study Design This is an observational study of asymptomatic pregnant women who underwent severe acute respiratory syndrome coronavirus 2 testing at 2 academic health centers (Hospital of the University of Pennsylvania and Pennsylvania Hospital) in Philadelphia, Pennsylvania, between April 13, 2020, and April 26, 2020. All women tested were contacted via telephone for symptom follow-up at 1 and 2 weeks after discharge. Asymptomatic positive test rates are reported for the overall population and by hospital. The hospital and 2-week posthospital course are described for women who had a positive result for severe acute respiratory syndrome coronavirus 2. Posthospital symptom development among women who had a negative result for severe acute respiratory syndrome coronavirus 2 is also described. Results A total of 318 asymptomatic women underwent severe acute respiratory syndrome coronavirus 2 testing during this 2-week period; 8 women had a positive result. The overall asymptomatic test positive rate was 2.5%. The rate at Hospital of the University of Pennsylvania was 3.8% compared with 1.3% at Pennsylvania Hospital (P=.283). Of note, 3 women (37.5%) who were initially asymptomatic developed mild symptoms in the 2 weeks after a positive test result. Repeat severe acute respiratory syndrome coronavirus 2 testing was performed in 14 of the 310 women (4.5%) who initially had a negative result; 2 women (0.6%) had a positive result on repeat testing. Moreover, 242 (78.1%) and 213 (68.7%) of the 310 women who had a negative result for severe acute respiratory syndrome coronavirus 2 at the time of the initial hospitalization were followed up via telephone at 1 and 2 weeks after admission, respectively. Viral symptoms, including fevers, chills, shortness of breath, or cough, were self-reported in 4.5% and 4.2% of these women at 1 and 2 weeks after discharge, respectively. Conclusion The asymptomatic positive severe acute respiratory syndrome coronavirus 2 test rate among an obstetrical population in Philadelphia differed between 2 hospitals and was lower than that described in other geographic regions. This supports the importance of institution-specific testing protocols. The development of symptomatic severe acute respiratory syndrome coronavirus 2 infection after hospitalization among women with initial negative test results is uncommon.

As new information about coronavirus disease 2019 (COVID-19) is rapidly discovered, clinicians are better equipped to make informed decisions for their patients. While current research suggests COVID-19 viral antigen is not found in vaginal secretions, its detectability in the female lower genital tract may have clinical implications for obstetric and gynecologic care for women. We present a case of a woman at 31 weeks' gestation with simultaneous upper respiratory symptoms and vulvovaginitis. She was found to have a vulvar lesion positive for severe acute respiratory syndrome-COVID by viral swab. This case shows that COVID-19 is detectable in the vulva. This may have implications for health care workers' exposure and personal protective equipment needs. While vertical transmission has largely not been reported, the presence of detectable virus in the female lower genital tract makes this a continued possibility and area of study. KEY POINTS: · COVID-19 is detectable in the female lower genital tract.. · The detection of COVID-19 in the vulva may have implications for personal protective equipment use.. · The detection of COVID-19 in vulvovaginal lesions makes vertical transmission a continued possibility..

Background The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited. Objective This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2. Study Design This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen 50% within 24–48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission. Conclusion In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.

BackgroundMonitoring blood pressure at 72 hours and 7–10 days post partum in women with hypertensive disorders is recommended to decrease morbidity. However, there are no recommendations as to how to achieve this.ObjectiveTo compare the effectiveness of text-based blood pressure monitoring to in-person visits for women with hypertensive disorders of pregnancy in the immediate postpartum period.MethodsRandomised clinical trial among 206 postpartum women with pregnancy-related hypertension diagnosed during the delivery admission between August 2016 and January 2017. Women were randomised to 2 weeks of text-based surveillance using a home blood pressure cuff and previously tested automated platform or usual care blood pressure check at their prenatal clinic 4–6 days following discharge. The primary study outcome was a single recorded blood pressure in the first 10 days post partum. The ability to meet American Congress of Obstetricians and Gynecologists (ACOG) guidelines, defined as having a blood pressure recorded on postpartum days 3–4 and 7–10 was evaluated in the text message group. The study was powered to detect a 1.4-fold increase in a single recorded blood pressure using text messaging. All outcomes were analysed as intention to treat.Results206 women were randomised (103 in each arm). Baseline characteristics were similar. There was a statistically significant increase in a single blood pressure obtained in the texting group in the first 10 days post partum as compared with the office group (92.2% vs 43.7%; adjusted OR 58.2 (16.2–208.1), pConclusionsText-based monitoring is more effective in obtaining blood pressures and meeting current clinical guidelines in the immediate postdischarge period in women with pregnancy-related hypertension compared with traditional office-based follow-up.Trial registration numberNCT03185455, Remote Surveillance of Postpartum Hypertension (TextBP), https://clinicaltrials.gov.

BACKGROUND Up to 30% of patients with hypertensive disorders of pregnancy continue to have elevated blood pressures after delivery, often necessitating medication titration or hospital evaluation in the weeks following hospital discharge. A previous randomized controlled trial demonstrated that remote blood pressure monitoring programs led to an increase in the number of blood pressure measurements obtained and increased compliance with clinical guidelines regarding the monitoring of patients for persistent or worsening postpartum hypertension. OBJECTIVE The aims of this study were to measure the program participant response rates during the first 10 days after hospital discharge, to assess the replicability and scalability of the program, and to evaluate patient satisfaction at 3 distinct sites. STUDY DESIGN We conducted a prospective observational cohort study across 3 US academic medical centers during which postpartum participants with hypertensive disorders of pregnancy were enrolled in a previously validated, remote, text message-based blood pressure monitoring program known as Heart Safe Motherhood. English-speaking patients with access to a text message-enabled cell phone and with a diagnosis of hypertensive disorders of pregnancy were candidates for enrollment in the study. Each study site planned to enroll approximately 66 participants in this pilot implementation phase. All the enrolled participants received a validated blood pressure cuff, education on proper use of the device, and were sent text messages as a reminder to check their blood pressures twice daily for 10 days after discharge. They were asked to reply via text message with their blood pressure readings. All blood pressure readings were reviewed via a web-based platform by a physician. Physicians communicated with patients whose blood pressure levels exceeded 160 mm Hg systolic or 100 mm Hg diastolic to determine the next management steps. Enrollees were texted a survey at the end of the 10 days and the responses were recorded. The proportion of eligible parturients who were enrolled, the number of measured blood pressure values, and the postprogram survey results were measured. We assessed the number of patients who reported elevated blood pressures, required antihypertensive medication, and were readmitted for blood pressure control during the program duration. RESULTS A total of 199 participants were enrolled in the program: 66 at site A, 67 at site B, and 66 at site C. In the 10 days after hospital discharge, 192 (97%) participants submitted at least 1 blood pressure measurement via text message. More enrolled patients submitted a blood pressure measurement on postpartum days 7 to 10 (171, 86%) than on days 1 to 4 (134, 67%). A total of 126 (63%) participants submitted blood pressures during both time frames. Elevated blood pressures were recorded for 70 (35%) participants, 32 (16%) of whom were started on oral antihypertensives after discussing their blood pressure measurements with an on-call provider. A total of 10 participants (5%) required hypertension-related readmission after delivery. The end-of-program survey was completed by 98 (49%) of the participants. Of those who completed the survey, 93% agreed that the program helped them to monitor their blood pressure (89% at site A; 88% at site B, and 100% at site C), and 93% would recommend it to friends or family members (94% at site A, 96% at site, and 88% at site C). CONCLUSION Postpartum participants are willing and capable of using the Heart Safe Motherhood program for remote blood pressure monitoring and reported high satisfaction with the program across multiple sites. Our study demonstrated that this remote blood pressure monitoring program can be implemented successfully and demonstrated replicable efficacy at diverse sites.

Maternal morbidity and mortality remains a significant health care concern in the United States, as the rates continue to rise despite efforts to improve maternal health. In 2013, the United States ranked 60th in maternal mortality worldwide. We review the definitions, rates, trends, and top causes of severe maternal morbidity and mortality, as well as risk factors for adverse maternal outcomes. We describe current local and national initiatives in place to reduce maternal morbidity and mortality and offer suggestions for future research.

OBJECTIVE: Our objective was to evaluate postpartum blood pressure trends, and time to resolution of hypertension among women with hypertensive disorders of pregnancy, specifically focusing on impact of race and BMI on these trends. METHODS: We performed a secondary analysis of a randomized trial that utilized a text-message based home blood pressure monitoring system. BPs for this study included both inpatient postpartum BPs as well as home BPs obtained from the text-based program. Women were followed from 12 h of delivery to 16 days postpartum. Outcomes were: (1) postpartum BP trend summaries from a linear mixed-effects regression model and (2) time to resolution of hypertension (defined as ≥ 48 h of BPs < 140/90) depicted using Kaplan Meier survival curves with hazard ratio estimates of association using Cox models. RESULTS: Eighty-four women were included, of which 63% were black. Non-black women with a BMI < 35 kg/m(2) had steady decreases in systolic BP whereas other groups peaked around 6.5 days postpartum. BPs for women in the BMI < 35 group, regardless of race, remained in the normotensive range. Conversely, women with a BMI ≥ 35 had a systolic BP peak into the hypertensive range prior to declining. Diastolic BP peaked at an average of 8.5 days postpartum. Time to resolution of BPs differed by race and BMI groups (p = 0.012). Non-black women with a BMI < 35 had the shortest time to resolution and 81% of these women had resolution of hypertension. Only 49% of black women with a BMI < 35 had resolution of hypertension and approximately 40% of both black and non-black women with BMI ≥ 35 had resolution of hypertension. CONCLUSION: We identified race and BMI to be determinants of postpartum BP trends and hypertension resolution. Further study is needed to determine if race and BMI targeted postpartum hypertension interventions may lead to faster blood pressure recovery and lower maternal morbidity postpartum.

OBJECTIVE: To assess performance of risk stratification schemes in predicting adverse cardiac outcomes in pregnant women with congenital heart disease and to compare these schemes to clinical factors alone. DESIGN: Single-center retrospective study SETTING: Tertiary care academic hospital PATIENTS: Women ≥ 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating congenital heart disease who delivered between 1998 and 2014. CARPREG I and ZAHARA risk scores and modified World Health Organization (WHO) criteria were applied to each woman. OUTCOME MEASURES: The primary outcome was defined by ≥1 of the following: arrhythmia, heart failure/pulmonary edema, transient ischemic attack, stroke, dissection, myocardial infarction, cardiac arrest, death during gestation and up to 6 months post-partum. RESULTS: Of 178 women, the most common congenital heart disease lesions were congenital aortic stenosis (15.2%), ventricular septal defect (13.5%), atrial septal defect (12.9%), and tetralogy of Fallot (12.9%). Thirty-five women (19.7%) sustained 39 cardiac events. Observed vs. expected event rates were 9.9% vs 5% (p=0.02) for CARPREG I score 0 and 26.1% vs. 7.5% (p

Objective To examine the change in body mass index (BMI) categories between pregnancies and its effect on adverse pregnancy outcomes. Study Design We performed a retrospective cohort study of women with two consecutive deliveries from 2005 to 2010. Analysis was limited to women with BMI recorded at Results In total, 537 women were included, of whom 125 (23%) increased BMI category. There was no association between increase in BMI category and risk of preterm birth, IUGR, or pregnancy-related hypertension. Women who increased BMI category had an increased odds of GDM compared with women who remained in the same BMI category (6.4 vs. 2.2%; p = 0.018). The increased risk remained after controlling for age, history of GDM, and starting BMI (adjusted odds ratio: 8.2; 95% confidence interval: 2.1–32.7; p = 0.003). Conclusion Almost one-quarter of women increased BMI categories between pregnancies. This modifiable risk factor has a significant impact on the risk of GDM.

Background Acute myocardial infarction (AMI) in pregnancy is a rare event and of the causes, coronary artery vasospasm (CAV) is considered even more uncommon. Purpose We present a new case report of a woman at 32 weeks of pregnancy with an AMI from CAV with a normal coronary angiogram. We performed a systematic review of similar cases of spontaneous AMI related to CAV to better understand its characteristics and management. AMI was defined as elevated cardiac enzymes (troponin or CKMB) with chest pain and/or electrocardiogram (EKG) changes consistent with ischemia. Methods We use the terms “acute myocardial infarction”, “myocardial infarction”, “coronary artery vasospasm” and “pregnancy” for our PubMed review. We also evaluated all references in identified manuscripts. Six cases of AMI in pregnancy due to CAV have been reported as of November 2016, including ours. Results and conclusion Six cases of AMI due to CAV during pregnancy or postpartum are reported in the literature, including ours. Patients experiencing this condition tend to be of advanced maternal age, multigravida and in their third trimester or postpartum. Successful management with a combination of long acting nitrates and/or calcium channel blockers achieved symptomatic control in all published cases. Obstetric outcomes were mostly normal, with the majority experiencing uncomplicated deliveries at term.

First-trimester ultrasound provides valuable information to help optimize the management of multifetal pregnancies. First trimester ultrasound the use of ultrasound and screening for aneuploidy has been well studied in singleton pregnancies. While evidence supporting the use of ultrasound in multiple gestations is well established, aneuploidy screening continues to evolve and its role in the prenatal setting has been less well studied. We review the importance of early first trimester ultrasound in assessing gestational age and chorionicity and early identification of anomalies, and review the various methods and limitations of aneuploidy screening and invasive diagnostic procedures in multiples.

Although the number of cesarean deliveries increased from 23% to 34.7% between 1996 and 2006, forceps and vacuum use declined, from 6.3% to 1.7% and 6.8% to 5.5%, respectively. When spontaneous vaginal delivery in the second stage of labor is not a possibility, operative vaginal delivery may be a safe, acceptable alternative to cesarean delivery. We explore indications for operative deliveries and the benefits and risks as compared with cesarean. In addition, we review the barriers to forceps and vacuum use and the importance of continued training to increase the number of providers who are able to safely perform these skills.

To evaluate the risk of cesarean delivery among both nulliparous and multiparous women undergoing a term induction of labor compared to women that present in spontaneous labor at term.We performed a retrospective cohort study of term (≥37 weeks) singleton pregnancies between 2005 and 2010 comparing women that had an induction to those that presented in spontaneous labor. Multiparity was defined as a prior delivery after 20 weeks' gestation. Chi-square was used to compare categorical variables. Multivariable logistic regression was used to control for confounders. Analyses were stratified by parity.863 women were included in the analysis. There were 605 inductions (cesarean rate 23%) and 257 spontaneous labor (cesarean rate 7%), OR 3.4, 95% CI [2.1-5.4]. Stratified by parity, nulliparas undergoing induction had an increased cesarean rate compared to spontaneous labor (27% versus 11%, OR 3.13, 95% CI [1.76-5.57]) as did multiparas (13% versus 3%, OR 4.04, 95% CI [1.36-11.94]). This increased risk for cesarean after induction remained in both nulliparous and multiparous women even after controlling for confounders (aOR 2.90, 95% CI [1.60-5.25] and aOR 3.47, 95% CI [1.12-10.67], respectively). Neither starting cervical exam nor indication for induction altered this increased risk.The increased risk of cesarean in women undergoing an induction is present regardless of parity and indication for induction. This should be taken into account when counseling women regarding risks of induction, regardless of parity. Future studies should focus on other clinical characteristics of induction that may mitigate this risk.

OBJECTIVE To investigate whether biomarkers from different pathways of spontaneous preterm birth (cervical membrane degradation [fetal fibronectin], cervical remodeling [soluble E-cadherin], and inflammation (elafin, surfactant protein-D, interleukin-6 [IL-6]) were superior to one biomarker alone in predicting preterm birth. Our secondary objective was to examine the association of these biomarkers with cervical length in predicting preterm birth. METHODS We performed a single-center, prospective cohort study from August 2011 to November 2012 of asymptomatic women at risk for spontaneous preterm birth as a result of obstetric and gynecologic history. Cervicovaginal fluid and cervical length measurements were collected at two time points (20-23 6/7 weeks and 24-27 6/7 weeks of gestation). RESULTS Among the 104 women with complete data, the preterm birth rate was 24.5%. Prior preterm birth (P=.006) and cervical length at visit 1 (P=.003) were significantly associated with preterm birth, whereas fetal fibronectin and median biomarker levels (elafin, soluble E-cadherin, IL-6) were not. Median surfactant protein-D levels at visit 1 by preterm birth status were statistically but not clinically different (0.44 ng/mL compared with 0.40 ng/mL, P

To evaluate the association between mode of delivery and length of labor on readmission for postpartum hypertension in women with pregnancy-related hypertension.Nested case control study within a cohort of 99 women with pregnancy-related hypertension who delivered at our institution between 2005 and 2009. Data were abstracted for clinical and labor information. Mode of delivery and length of labor were compared between women with previously diagnosed pregnancy-related hypertension readmitted within 4 weeks post partum (25 cases) and those not readmitted (74 controls). Categorical and continuous variables were compared using χ(2) and T-tests, respectively. Multivariable logistic regression controlled for confounders.Hypertension readmission was not associated with mode of delivery (cases: 10(40%) spontaneous vaginal delivery, 15(60%) cesarean delivery; controls: 38(51%) spontaneous vaginal delivery, 36(49%) cesarean delivery, P=0.33). Length of labor appeared longer in cases, with a trend toward significance (median: 15.5 [7,28] h vs 10.75 [5.8,15.9] h, P=0.12) and was significantly associated with readmission after controlling for delivery mode, induction and parity (adjusted odds ratio=1.06 [1 to 1.12], P=0.048). Readmitted patients were less likely to have initially been started on antihypertensive medications after controlling for age, race and chronic hypertension (adjusted odds ratio=0.23 [0.06 to 0.88], P=0.03).Postpartum readmission for hypertension in women with known pregnancy-related hypertension is not associated with mode of delivery, appears increased in those with longer length of labor and decreased in those initially started on antihypertensive medications. This provides targets for future research to continue to improve transitions of care and reduce preventable readmissions.

Data surrounding the use of a random urine protein:creatinine ratio (PCR) in the diagnosis of preeclampsia is conflicting. We sought to determine whether PCR in early pregnancy can replace the 24-hour urine collection as the primary screening test in patients at risk for baseline proteinuria.Women requiring a baseline evaluation for proteinuria supplied a urine sample the morning after their 24-hour collection. The PCR was analyzed as a predictor of significant proteinuria (≥150 mg). A regression equation to estimate the 24-hour protein value from the PCR was then developed.Sixty of 135 subjects enrolled completed the study. The median 24-hour urine protein and PCR were 90 mg (IQR: 50-145) and 0.063 (IQR: 0.039-0.083), respectively. Fifteen patients (25%) had significant proteinuria. PCR was strongly correlated with the 24-hour protein value (r = 0.99, p 0.001) and highly predictive of significant proteinuria (AUC = 0.86). A PCR cut-point of 0.079 yielded a sensitivity of 93.3% and a specificity of 57.8%. The resulting regression equation [total protein = 46.5 + 904.2*PCR] accurately estimates the actual 24-hour protein (95% CI: ±88 mg).A random urine PCR accurately estimates the 24-hour protein excretion in the first half of pregnancy and can be used as the primary screening test for baseline proteinuria in at-risk patients.

Maternal weight is thought to impact labor. With rising rates of obesity and inductions, we sought to evaluate labor times among induced women by body mass index (BMI) category.Retrospective cohort study of term inductions from 2005 to 2010. BMI categories were: normal weight (NW), overweight (OW), and obese (Ob) (18.5-24.9, 25-29.9, ≥30 kg/m(2)). Kruskal-Wallis tests compared median latent labor (LL) length and active labor (AL) length. Chi-square determined associations. Multivariable logistic regression controlled for confounders. Analyses were stratified by parity.A total of 448 inductions were analyzed. For nulliparas, there was no difference in LL by BMI category (p = 0.22). However, OW nulliparas had a longer AL compared to NW and Ob nulliparas (3.2, 1.7, 2.0 h, p = 0.005). For multiparas, NW had the shortest LL (5.5 h, p = 0.025) with no difference in AL among BMI categories (p = 0.42). The overall cesarean rate was 23% with no difference by BMI category (p = 0.95). However, Ob women had a greater percentage of first stage cesareans (41%) and NW had a greater percentage of second stage cesareans (55%), p = 0.06.The association between BMI and labor length among inductions differs by phase of labor and parity. BMI also influences the stage of labor in which a cesarean occurs.

Background Reversed diastolic flow in the middle cerebral artery has been described as a terminal sign in the growth-restricted fetus. The implication of this in a normally grown fetus is unknown. Case Middle cerebral artery Doppler velocimetry was performed at 28 weeks of gestation in the setting of decreased fetal movement and a category 2 fetal heart tracing. The middle cerebral artery pulsatility index was elevated, and follow-up studies revealed reversed flow. The fetus had appropriate growth, with mild polyhydramnios and no signs of cardiomegaly, effusion, or hydrops. Fetal death was diagnosed 4 days later in the setting of extensive intracranial hemorrhage. Conclusion Regardless of fetal growth, persistent reversed middle cerebral artery Doppler with an elevated pulsatility index may be a feature of impending death.

Although the rate of inductions continues to rise, there is a paucity of data investigating subsequent pregnancy outcomes after induction. Our objective was to compare term inductions with term spontaneous labor and evaluate the rate of subsequent spontaneous preterm birth (sPTB).A retrospective cohort study of women with 2 consecutive deliveries from 2005 through 2010 was performed. Term inductions or term spontaneous labor in the index pregnancy was included, and those with a prior sPTB were excluded. Data were obtained through chart abstraction. The primary outcome was sPTB (37 weeks) in a subsequent pregnancy. Categorical variables were compared with χ(2) analyses, and logistic regression was used to calculate odds.Eight hundred eighty-seven women were included (622 inductions, 265 spontaneous labor). The overall subsequent sPTB rate was 7.2%. Term inductions were less likely to have a subsequent sPTB compared with term spontaneous labor (6% vs 11%; odds ratio [OR], 0.49; 95% confidence interval, 0.29-0.81; P = .005). This remained after adjusting for confounders (adjusted OR, 0.55; P = .04). The sPTB risk depended on gestational age of index delivery. At 37-38.9 weeks, the sPTB rate after spontaneous labor was 24% vs 9% after induction (OR, 3.0; 95% confidence interval, 1.44-6.16; P = .003). This was not significant for 39-39.9 weeks (P = .2) or 40 weeks or longer (P = .8).Induction is not a risk factor for subsequent sPTB. Spontaneous labor, however, in the early term period is associated with subsequent sPTB. Further investigation among early term deliveries is warranted to evaluate the risk of sPTB and target interventions in this cohort.

proxy for comparing triplet test scores. RESULTS: Triplets with an adjusted age of six months to 2 years were tested using the BSID-II on at least one occasion and some of these triplets were tested a second time. On both occasions, triplets scored significantly lower than singletons (Table I). Triplets over 2 years did not significantly differ from singletons using the KBIT-2. Triplets scored a significantly higher average score than singletons using the BOT-2 Standard Score. CONCLUSION: Early analysis of triplets, with an adjusted age of 6 months to 2 years of age, display a significantly lower cognitive development when compared to singleton pregnancies, but this observation disappears when they reach age two. In fact, the motor development of triplets in our study show advanced skills when compared to singletons. This observation is possibly related to the phenomenon known as catch-up growth/development. These data may be biased due to the high percentage of assisted reproductive technology used, implying a higher likelihood of affluent households.