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

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

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

This study evaluated the influence of early gestational weight gain (GWG) on neonatal outcomes among women with class III obesity.Retrospective cohort of women with class III obesity who gained more than the Institute of Medicine (IOM) guidelines (20lbs). Women gaining ≥75% of total gestational weight prior to 28 weeks (EWG) were compared to women gaining75% of their total weight prior to 28 weeks (SWG). The primary outcome was a neonatal composite morbidity and mortality. Secondary outcomes included individual components of composite and LGA.Of 144 women identified, 42 (29.2%) had EWG and 102 (70.8%) had SWG. Though 11% of the total population had composite neonatal morbidity, this did not differ between groups (Though adverse neonatal outcomes were common in this population, timing of gestational weight gain was not correlated. Increased rates of LGA and higher median birth weight in the SWG group suggests excessive GWG continuing in the third trimester of pregnancy may be of import for neonatal size.

Objective To assess the impact of gestational weight gain >20 pounds (more than Institute of Medicine [IOM] recommendations) on postpartum infectious morbidity in women with class III obesity. Methods This is a retrospective cohort of term, nonanomalous singleton pregnancies with body mass index ≥40 at a single institution from 2013 to 2017. Pregnancies with multiple gestation, late entry to care, and missing weight gain data are excluded. Primary outcome is a composite of postpartum infection (endometritis, urinary tract, respiratory, and wound infection). Secondary outcomes include components of composite, wound complication, readmission, and blood transfusion. Bivariate statistics compared demographics, pregnancy complications, and delivery characteristics of women exceeding IOM guidelines (GT20) with those who did not (LT20). Regression models were used to estimate adjusted odds of outcomes. Results Of 374 women, 144 (39%) gained GT20 and 230 (62%) gained LT20. Primiparous, nonsmokers more likely gained GT20 (p Conclusion Women with class III obesity who gain more than the IOM recommends are at increased risk for postpartum infectious morbidity.

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

Objective The aim of this study is to describe the impact of maternal weight gain on infant birth weight among women with Class III obesity. Study Design Retrospective cohort of women with body mass index (BMI) ≥40 kg/m2 at initial prenatal visit, delivered from July 2013 to December 2017. Women presenting 14/0 weeks of gestational age (GA), delivering preterm, or had multiples or major fetal anomalies excluded. Maternal demographics and complications, intrapartum events, and neonatal outcomes abstracted. Primary outcomes were delivery of large for gestational age or small for gestational age (SGA) infant. Bivariate statistics used to compare women gaining less than Institute of Medicine (IOM) recommendations (LTR) and women gaining within recommendations (11–20 pounds/5–9.1 kg) (at recommended [AR]). Regression models used to estimate odds of primary outcomes. Results Of included women (n = 230), 129 (56%) gained LTR and 101 (44%) gained AR. In sum, 71 (31%) infants were LGA and 2 (0.8%) were SGA. Women gaining LTR had higher median entry BMI (46 vs. 43, p 0.99). After controlling for confounders, the AOR of an LGA baby for LTR women was 0.79 (95% CI: 0.4–1.4). Conclusion In this cohort of morbidly obese women, gaining less than IOM recommendations did not impact risk of having an LGA infant, without increasing risk of an SGA infant.

Objective We investigated the association between gestational weight gain (GWG) and postpartum depression (PPD) in women with class III obesity. Study Design This is a retrospective cohort of women with body mass index (BMI) ≥ 40 kg/m2 at entry to care, first prenatal visit ≤14 weeks gestation, with singleton, nonanomalous pregnancies who delivered at term from July 2013 to December 2017. Women missing data regarding PPD were excluded. Primary outcome was PPD; classified as Edinburgh Postnatal Depression Scale (EPDS) score >13/30 or provider's report of depression. Participants were classified, according to Institute of Medicine GWG guidelines (11–20 pounds), as either less than 11 pounds (LT11) or at/more than 11 pounds (GT11). Bivariate statistics compared demographics and pregnancy characteristics. Logistic regression used to estimate odds of primary outcome. Results Of 275 women, 96 (34.9%) gained LT11 and 179 (65.1%) gained GT11 during pregnancy. The rate of PPD was 8.7% (n = 24), 9 (9.4%) in the LT11 group and 15 (8.4%) in the GT11 group (p = 0.82, odds ratio: 1.13, 95% confidence interval [CI]: 0.48, 2.69). When controlling for entry BMI and multiparity, adjusted odds of PPD was 1.07 (95% CI: 0.44, 2.63). No correlation was found between GWG and EPDS. Conclusion A relationship between GWG and PPD in class III obese women was not found in this cohort.

Objective To evaluate the first 5 years of the Human Resources for Health Rwanda program from the program onset in the July 2012-2016 academic years, and its effects on access to care through examination of: 1) the number of trained obstetrician-gynecologists (ob-gyns) who graduated from the University of Rwanda and the University of Rwanda-Human Resources for Health program and 2) a geospatial analysis of pregnant women's access to Rwandan public hospitals with trained ob-gyns. Methods We used GPS coordinates in this cross-sectional study to identify public (government) hospitals with ob-gyns in 2011 (before initiation of the program) compared with 2016 (year 5 of the program). We compared access to care for the years 2011 and 2016 through geocoding the proportion of pregnant women within 10 and 25 km from these hospitals and compared the travel time to these hospitals in the two time periods. We used a World Pop dataset of Rwandan pregnancies from 2015, ArcGIS for spatial operations, R for statistical analysis, zonal statistics for circular distances, and friction surface for travel time analysis. Results The number of ob-gyns in public hospitals increased from 14 to 49 nationally. Before the program, 18 residents graduated over a 7-year period (two residents per year); 33 graduated by year 5 (six residents per year). Rwandan faculty increased by 45%. In 2011, most providers were in the capital city. Between 2011 and 2016, the proportion of pregnant women living 10 km from an ob-gyn-staffed public hospital increased from 13.0% to 31.6%; within 25 km increased from 28.4% to 82.9%. Travel time analysis from 2011 to 2016 showed 49.1% of Rwandan women within 1 hour of a hospital and 85.6% within 2 hours. In 2016, this coverage increased to 87.5% and 98.3%, respectively. Conclusion In 5 years, the Human Resources for Health Rwanda program improved the number of residency graduates in obstetrics and gynecology and nationwide access to these providers. The program reduced rural-urban disparities in access to ob-gyns.

Purpose The American College of Obstetricians and Gynecologists (ACOG) and the American College of Medical Genetics and Genomics (ACMG) suggest carrier screening panel design criteria intended to ensure meaningful results. This study used a data-driven approach to interpret the criteria to identify guidelines-consistent panels. Methods Carrier frequencies in >460,000 individuals across 11 races/ethnicities were used to assess carrier frequency. Other criteria were interpreted on the basis of published data. A total of 176 conditions were then evaluated. Stringency thresholds were set as suggested by ACOG and/or ACMG or by evaluating conditions already recommended by ACOG and ACMG. Results Forty and 75 conditions had carrier frequencies of ≥1 in 100 and ≥1 in 200, respectively; 175 had a well-defined phenotype; and 165 met at least 1 severity criterion and had an onset early in life. Thirty-seven conditions met conservative thresholds, including a carrier frequency of ≥1 in 100, and 74 conditions met permissive thresholds, including a carrier frequency of ≥1 in 200; thus, both were identified as guidelines-consistent panels. Conclusion Clear panel design criteria are needed to ensure quality and consistency among carrier screening panels. Evidence-based analyses of criteria resulted in the identification of guidelines-consistent panels of 37 and 74 conditions.