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The Antenatal Late Preterm Steroids (ALPS) trial demonstrated a 20% reduction in the risk of respiratory complications in neonates at risk for a late-preterm birth who were exposed to antenatal corticosteroids compared with those who were not.To assess whether new evidence of steroid administration for neonatal respiratory benefit in the late-preterm period is associated with changes in obstetric practice and the use of assisted ventilation for the neonate after delivery.This cross-sectional study of US births from February 1, 2015, to October 31, 2017, as ascertained from US natality data, included live-born, singleton neonates born between 34 and 36 completed weeks of gestation to people without pregestational diabetes. An interrupted time series analysis using Poisson regression models was conducted. Data were analyzed from July 11, 2022, to November 9, 2022.Public dissemination of the ALPS trial results, which occurred during a 9-month period from February 1, 2016 (first published online), to October 31, 2016 (time of the last major professional society's guideline update in the months after the trial's publication).Steroid use, any assisted ventilation use, and assisted ventilation use for more than 6 hours immediately after the dissemination period.A total of 707 862 births were included, divided among the 12-month predissemination period (n = 250 643), dissemination period (n = 195 736), and 12-month postdissemination period (n = 261 493). Most births were at 36 weeks of gestation (53.9% in the predissemination and postdissemination period; P = .10). Small but significant differences were found between the predissemination and postdissemination period cohorts: there were more individuals 35 years or older (19.5% vs 17.9%), fewer White individuals (67.8% vs 69.8%), and more publicly insured individuals (50.5% vs 50.1%) in the postdissemination period compared with the predissemination period, respectively (P .001 for all). Compared with what rates were expected based on the predissemination trends, the adjusted rate of steroid use increased from 5.0% to 11.7% (adjusted incidence rate ratio [IRR], 2.34; 95% CI, 2.13-2.57), and assisted ventilation use decreased from 8.9% to 8.2% (adjusted IRR, 0.91; 95% CI, 0.85-0.98) after the dissemination period. No change was observed in assisted ventilation use for more than 6 hours (adjusted IRR, 0.98; 95% CI, 0.87-1.10).These findings suggest that there was an immediate change in practice of administering antenatal steroids and a reduction in neonatal morbidity among late-preterm births associated with the dissemination of the ALPS trial, suggesting that this evidence may be translating into a reduction in immediate respiratory morbidity outside the context of a clinical trial.

Objective The aim of this study was to determine if a universally applied risk score threshold for severe maternal morbidity (SMM) resulted in different performance characteristics among subgroups of the population. Study Design This is a retrospective cohort study of deliveries that occurred between July 1, 2016, and June 30, 2020, in a single health system. We examined the performance of a validated comorbidity score to stratify SMM risk in our cohort. We considered the risk score that was associated with the highest decile of predicted risk as a “screen positive” for morbidity. We then used this same threshold to calculate the sensitivity and positive predictive value (PPV) of this “highest risk” designation among subgroups of the overall cohort based on the following characteristics: age, race/ethnicity, parity, gestational age, and planned mode of delivery. Results In the overall cohort of 53,982 women, the C-statistic was 0.755 (95% confidence interval [CI], 0.741–0.769) and calibration plot demonstrated that the risk score was well calibrated. The model performed less well in the following groups: non-White or Hispanic (C-statistic, 0.734; 95% CI, 0.712–0.755), nulliparas (C-statistic, 0.735; 95% CI, 0.716–0.754), term deliveries (C-statistic, 0.712; 95% CI, 0.694–0.729), and planned vaginal delivery (C-statistic, 0.728; 95% CI, 0.709–0.747). There were differences in the PPVs by gestational age (7.8% term and 29.7% preterm) and by planned mode of delivery (8.7% vaginal and 17.7% cesarean delivery). Sensitivities were lower in women who were Conclusion The performance of a risk score for SMM can vary by population subgroups when using standard thresholds derived from the overall cohort. If applied without such considerations, such thresholds may be less likely to identify certain subgroups of the population that may be at increased risk of SMM. Key Points

The aim of our study was to characterize urogenital symptoms in women with and without constipation, and by severity of constipation. This was a retrospective cohort study conducted at a pelvic floor disorder center in a tertiary healthcare facility from May 2007 through August 2019 and completed an intake questionnaire were included. We collected demographic, physical exam data and quality of life outcomes. The Urinary Distress Inventory (UDI-6) was used to assess urogenital symptoms. Women with constipation completed the Constipation Severity Instrument (CSI). We excluded women with a history of a bowel resection, inflammatory bowel disease, or pelvic organ prolapse symptoms. The cohort was then divided into two groups, constipated and non-constipated, and the prevalence and severity of urogenital-associated symptoms were compared. A secondary analysis was made among constipated subjects stratified by constipation severity based on CSI scores. During the study period, 875 women (59.5%) had chronic constipation. Women with chronic constipation were more likely to experience urogenital symptoms, such as dyspareunia, urinary hesitancy, and a sensation of incomplete bladder emptying (all p

OBJECTIVE To examine the association between county-level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns. DESIGN Cross-sectional study. SETTING Population-based study of US county-level birth data from 2015 to 2017. POPULATION Nulliparous women with term, singleton, vertex-presenting infants (NTSV) at low risk for morbidity. METHODS The primary exposure was county-level CD rates. MAIN OUTCOME MEASURES The outcome was morbidity among the low-risk NTSV cohort, categorised as severe (5-minute Apgar score of ≤3, assisted ventilation for ≥6 hours, severe neurologic injury or seizure, transfer or death) or moderate (5-minute Apgar score of 3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors. RESULTS The analysis included data from 2 753 522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4-23.6) and 52.5 (IQR 33.4-75.7) per 1000 births, respectively. In the unadjusted analysis using the risk-adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95% CI -0.9, -0.3) and 2.3 fewer (95% CI -3.4, -1.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses. CONCLUSIONS Lower county-level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA. TWEETABLE ABSTRACT Lower county-level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA.

ImportanceRisk-stratification tools are routinely used in obstetrics to assist care teams in assessing and communicating risk associated with delivery. Electronic health record data and machine learning methods may offer a novel opportunity to improve and automate risk assessment.ObjectiveTo compare the predictive performance of natural language processing (NLP) of clinician documentation with that of a previously validated tool to identify individuals at high risk for maternal morbidity.Design, Setting, and ParticipantsThis retrospective diagnostic study was conducted at Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, Massachusetts, and included individuals admitted for delivery at the former institution from July 1, 2016, to February 29, 2020. A subset of these encounters (admissions from February to December 2018) was part of a previous prospective validation study of the Obstetric Comorbidity Index (OB-CMI), a comorbidity-weighted score to stratify risk of severe maternal morbidity (SMM).ExposuresNatural language processing of clinician documentation and OB-CMI scores.Main Outcomes and MeasuresNatural language processing of clinician-authored admission notes was used to predict SMM in individuals delivering at the same institution but not included in the prospective OB-CMI study. The NLP model was then compared with the OB-CMI in the subset with a known OB-CMI score. Model discrimination between the 2 approaches was compared using the DeLong test. Sensitivity and positive predictive value for the identification of individuals at highest risk were prioritized as the characteristics of interest.ResultsThis study included 19 794 individuals; 4034 (20.4%) were included in the original prospective validation study of the OB-CMI (testing set), and the remaining 15 760 (79.6%) composed the training set. Mean (SD) age was 32.3 (5.2) years in the testing cohort and 32.2 (5.2) years in the training cohort. A total of 115 individuals in the testing cohort (2.9%) and 468 in the training cohort (3.0%) experienced SMM. The NLP model was built from a pruned vocabulary of 2783 unique words that occurred within the 15 760 admission notes from individuals in the training set. The area under the receiver operating characteristic curve of the NLP-based model for the prediction of SMM was 0.76 (95% CI, 0.72-0.81) and was comparable with that of the OB-CMI model (0.74; 95% CI, 0.70-0.79) in the testing set (P = .53). Sensitivity (NLP, 28.7%; OB-CMI, 24.4%) and positive predictive value (NLP, 19.4%; OB-CMI, 17.6%) were comparable between the NLP and OB-CMI high-risk designations for the prediction of SMM.Conclusions and RelevanceIn this study, the NLP method and a validated risk-stratification tool had a similar ability to identify patients at high risk of SMM. Future prospective research is needed to validate the NLP approach in clinical practice and determine whether it could augment or replace tools requiring manual user input.

PURPOSE: A deep learning artificial intelligence (AI) algorithm has been demonstrated to outperform embryologists in identifying euploid embryos destined to implant with an accuracy of 75.3% (1). Our aim was to evaluate the performance of highly trained embryologists in selecting top quality day 5 euploid blastocysts with and without the aid of a deep learning algorithm. MATERIALS AND METHODS: A non-overlapping series of 200 sets of day 5 euploid embryo images with known implantation outcomes was distributed to 17 highly trained embryologists. One embryo in each set was known to have implanted and one failed implantation. They were asked to select which embryo to transfer from each set. The same 200 sets of embryos, with indication of which embryo in each set had been identified by the algorithm as more likely to implant was then distributed. Chi-squared, t-test, and receiver operating curves were performed to compare the embryologist performeance with and without AI. RESULTS: Fourteen embryologists completed both assessments. Embryologists provided with AI results selected successfully implanted embryos in 73.6% of cases compared to 65.5% for those selected using visual assessments alone (p

Background Expression of angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2), host molecules required for viral entry, may underlie sex differences in vulnerability to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated whether placental ACE2 and TMPRSS2 expression vary by fetal sex in the presence of maternal SARS-CoV-2 infection. Methods Placental ACE2 and TMPRSS2 expression was quantified by quantitative reverse transcription polymerase chain reaction (RT-PCR) and by Western blot in 68 pregnant women (38 SARS-CoV-2 positive, 30 SARS-CoV-2 negative) delivering at Mass General Brigham from April to June 2020. The impact of fetal sex and maternal SARS-CoV-2 exposure on ACE2 and TMPRSS2 was analyzed by 2-way analysis of variance (ANOVA). Results Maternal SARS-CoV-2 infection impacted placental TMPRSS2 expression in a sexually dimorphic fashion (2-way ANOVA interaction, P = .002). We observed no impact of fetal sex or maternal SARS-CoV-2 status on ACE2. TMPRSS2 expression was significantly correlated with ACE2 expression in males (Spearman ρ = 0.54, P = .02) but not females (ρ = 0.23, P = .34) exposed to maternal SARS-CoV-2. Conclusions Sex differences in placental TMPRSS2 but not ACE2 were observed in the setting of maternal SARS-CoV-2 infection, which may have implications for offspring vulnerability to placental infection.

We sought to develop a prediction model using prenatal diagnosis codes that could help clinicians objectively stratify a women’s risk for delivery-related morbidity. We performed a prospective cohort study of women delivering at a single academic medical center between 2016 and 2019. Diagnosis codes from outpatient encounters were extracted from the electronic health record. Standard and common machine-learning methods for variable selection were compared. The performance characteristics from the selected model in the training data set—a LASSO model with a lambda that minimized the Bayes information criteria—were compared in a testing and external validation set. The model identified a group of women, those in the highest decile of predicted risk, who were at a two to threefold increased risk of maternal morbidity. As EHR data becomes more ubiquitous, other data types generated from the prenatal period may improve the model’s performance.

PURPOSE: To assess whether anti-Müllerian hormone (AMH) can predict response to ovulation induction (OI) with clomiphene citrate (CC), letrozole (LET), or follicle-stimulating hormone (FSH) in women with polycystic ovary syndrome (PCOS) undergoing OI/intrauterine inseminations (IUI). METHODS: A total of 738 OI/IUI cycles from 242 patients at an academic center were stratified in three groups by medication: CC (n = 295), LET (n = 180), and FSH (n = 263), in a retrospective fashion. Ovarian response to treatment (RT, development of at least one dominant follicle) was assessed using mixed effects logistic regression models. RESULTS: Overall, RT cycles had lower AMH levels compared to no-RT cycles (p < 0.001). This finding persisted when analysis was limited to oral agents but attenuated in FSH cycles. For CC and LET cycles, the predicted probability (PProb) for RT decreased as AMH levels increased (PProb (95%CI): 97% (93–100), 79% (70–88), and 75% (61–89); 85% (78–93), 75% (67–83), and 73% (63–86) for AMH pct.: ≤ 25th, ≥ 50th, and ≥ 75th, for CC and LET, respectively)). However, RT was noted in 98.5% of FSH/IUI cycles regardless of AMH. For CC cycles, those with AMH ≥ 75th pct. had lower odds for RT over cycles with AMH < 75th pct. (OR 0.2, 95%CI 0.04–0.8, p = 0.02). Similarly, lower odds for RT were observed in LET cycles with AMH ≥ 75th pct. (0.6, 0.3–1.4, p = 0.25). CONCLUSION: In PCOS, increasing serum AMH levels are associated with lower probability of RT to oral agents. Our findings constitute a valuable tool for the clinician when counseling PCOS patients and designing a personalized ovulation induction treatment strategy.

OBJECTIVE To estimate the incidence of failed induction of labor and the associated patient risk factors. METHODS We performed a case-control study from a cohort of nulliparous women who delivered between 39 and 41 weeks of gestation after an induction of labor in one of seven hospitals. Cases of failed induction were defined using the Obstetric Care Consensus criteria (ie, cesarean delivery performed in early labor [less than 6 cm dilatation] after at least 12 hours of oxytocin administration from membrane rupture). For each case of failed induction, the next four women who did not meet the criteria for failed induction of labor were selected for the control group, matched by hospital. We identified characteristics associated with failed induction of labor using a multivariable conditional logistic regression that was constructed with backward stepwise method for variable selection. RESULTS Across the hospitals, 4,123 of 10,175 nulliparous women were induced (40.5%), of whom 82 had a failed induction of labor (2.0%). A total of 328 women were selected for the matched control group. Baseline characteristics were similar between the groups. Compared with women in the control group, women with a failed induction were more likely to have a delivery body mass index (BMI) of 40 or higher (28.0 vs 8.2%, P

OBJECTIVE We aimed to evaluate the association between hemoglobin A1c (HbA1c) levels and midurethral sling (MUS) complications. METHODS This was a multihospital, retrospective cohort study from 2010 to 2020. We included all women with diabetes mellitus who underwent a synthetic mesh MUS procedure and had a preoperative HbA1c within 3 months of surgery. The primary outcome was a composite of complications, including MUS mesh exposure, surgical site granulation tissue or infection, urinary tract infection, surgical site pain beyond 6 weeks postoperatively, and MUS failure. A sensitivity analysis analyzing MUS failure alone was performed. RESULTS During the study period, 109 women met the inclusion criteria. Most were White (52.2%) and had a median body mass index of 31.2 kg/m2, and 84.9% were postmenopausal. Median HbA1c was 7.2% (interquartile range, 6.3%-7.7%). Urinary tract infection was the most common complication in 12 (11.0%) women. Mesh exposure was diagnosed in 7 (6.4%) women. Seventeen (15.6%) had MUS failure. On univariate regression analysis, a higher HbA1c was associated with increased odds of composite complications (odds ratio, 1.67; 95% confidence interval, 1.20-2.32; P = 0.002) and MUS failure (odds ratio, 1.81, 95% confidence interval, 1.26-2.60; P = 0.001). On multivariate analysis, higher HbA1c levels were associated with a composite of complications and failure (P < 0.05). Based on the receiver operating characteristic curve, HbA1c greater than 8% demonstrated a specificity of 85.7% and a sensitivity of 50% for MUS failure. CONCLUSIONS In diabetic patients, a higher HbA1c was associated with a higher risk of MUS complications and failure. Obtaining an HbA1c within 3 months of surgery may help with risk stratification.

The main objective of the study was to determine the frequency of detection of selected infectious respiratory viruses and bacteria in healthy horses presented over a 12-month period for routine dental care at 2 veterinary hospitals. Nasal secretions were collected from 579 horses and tested for equine herpesviruses (EHV-1, EHV-2, EHV-4, EHV-5), equine influenza virus (EIV), equine rhinitis A and B viruses (ERAV, ERBV), Streptococcus equi subspecies equi ( S equi), S equi subspecies zooepidemicus ( S zooepidemicus), and methicillin-resistant Staphylococcus aureus (MRSA) using routine diagnostic quantitative polymerase chain reaction assays. True respiratory pathogens (EHV-1, EHV-4, EIV, ERBV, and MRSA) were detected in 129 (22%) of the horses. Commensal respiratory pathogens (EHV-2, EHV-5, and S zooepidemicus) were detected in 515 (89%) of the study horses. ERAV and S equi were not detected in any of the study horses. The horses showed statistical differences between the 2 veterinary hospitals in regard to breed, age, presence of nasal discharge, rectal temperature, and detection of true and commensal respiratory pathogens. The data generated from the present study supports the risk for the transmission of true and commensal respiratory pathogens from subclinical shedders to susceptible horses. Equine veterinarians performing routine dental care should engage in routine biosecurity practices, with the goal to reduce disease spread.

Objective To characterize the obstetric outcomes and placental pathology in live births arising from vanishing twin pregnancies compared with nonreduced in vitro fertilization (IVF) pregnancies. Methods This is a retrospective cohort study of live births resulting from fresh embryo transfers after IVF cycles with autologous oocytes from 2004 through 2017 at a large academic fertility center. Clinical information and pathology reports were reviewed. Placental diagnoses were coded using established nosology by expert placental pathologists. Analysis of variance, Kruskal-Wallis, Pearson's χ, and Fisher exact tests were used, as appropriate, to compare pathology categories between pregnancy outcomes. Mixed effects logistic regression models were generated to reveal the association between pregnancy outcome and placenta pathology, controlling for pregnancies arising in the same woman and various suspected confounders. Results Of 905 fresh autologous IVF cycles with placental pathology available for review, we identified 73 vanishing twin pregnancies (8.1%), 556 singleton pregnancies (61.4%), and 276 twin pregnancies (30.5%). Vanishing twin syndrome was not associated with preterm delivery, route of delivery, growth restriction or other obstetric outcomes as compared with IVF singleton pregnancies. However, vanishing twin syndrome pregnancies showed distinctive placental pathologies including an increased rate of small placentas (less than the 10th percentile by weight), with more anatomical abnormalities than IVF singleton pregnancies (odds ratio 1.73, 95% CI 0.94-3.19; adjusted odds ratio 2.15, 95% CI 1.08-4.28). The frequency of placental vascular and inflammatory pathologies associated with IVF vanishing twin syndrome pregnancies were similar to that of IVF singleton pregnancies. Loss of a twin after 8 weeks of gestation was not associated with greater risks of placental pathologies. Conclusion In vitro fertilization pregnancies affected by vanishing twin syndrome did not have significant differences in obstetric or perinatal outcomes as compared with twin or singleton gestations. However, early twin loss was potentially associated with differences in placental development associated with a higher rate of small placentas and other anatomic pathologies.

ObjectiveTo characterize the relationship between hemoglobin A1c (HbA1c) levels and glucose tolerance across pregnancy and postpartum.Design and ParticipantsIn a longitudinal study of pregnant women with gestational diabetes risk factors (N = 102), we performed oral glucose tolerance testing (OGTT) and HbA1c measurements at 10–15 weeks of gestation, 24–30 weeks of gestation (N = 73), and 6–24 weeks postpartum (N = 42). Complete blood counts were obtained from clinical records. We calculated HbA1c-estimated average glucose levels and compared them with mean OGTT glucose levels (average of fasting, 1- and 2-hour glucose levels). Linear mixed effects models were used to test for longitudinal changes in measurements.ResultsMean OGTT glucose increased between 10–15 and 24–30 weeks of gestation (β = 8.1 mg/dL, P = .001), while HbA1c decreased during the same time period (β = –0.13%, P < .001). At 10–15 weeks of gestation and postpartum the discrepancy between mean OGTT glucose and HbA1c-estimated average glucose was minimal (mean [standard deviation]: 1.2 [20.5] mg/dL and 0.16 [18.1] mg/dL). At 24–30 weeks of gestation, the discrepancy widened (13.2 [17.9] mg/dL, β = 12.7 mg/dL, P < .001, compared to 10–15 weeks of gestation, with mean OGTT glucose being higher than HbA1c-estimated average glucose). Lower hemoglobin at 24–30 weeks of gestation was associated with a greater discrepancy (β = 6.4 mg/dL per 1 g/dL lower hemoglobin, P = .03 in an age- and gestational age-adjusted linear regression model).ConclusionsHbA1c accurately reflects glycemia in the 1st trimester, but underestimates glucose intolerance in the late 2nd trimester. Lower hemoglobin level is associated with greater underestimation. Accounting for gestational age and maternal hemoglobin may improve the clinical interpretation of HbA1c levels during pregnancy.

Objective To identify the association of the Affordable Care Act's Medicaid expansion with payment for delivery, early access to prenatal care, preterm birth, and birth weights considered small for gestational age (SGA). Methods A difference-in-difference design was used to assess changes in outcomes before and after Medicaid expansion in expansion states, using nonexpansion states as a control group. We used national birth certificate data from 2009 to 2017. Difference-in-difference linear probability models were used to assess the effects of the policy implementation, adjusting for demographics, month of birth, state, year, and county-level unemployment rates. Standard errors were clustered at the state level. Two prespecified subgroup analyses were performed of nulliparous women and women with no more than a high school diploma. Results The study sample included 8,701,889 women from 15 expansion states and 9,509,994 from 11 nonexpansion states. In the adjusted analysis, the percentage of Medicaid-covered deliveries increased by 2.3 absolute percentage points (95% CI 0.2-4.4, P=.04) in expansion states compared with nonexpansion states. There were no significant changes in the proportion of women who were uninsured, as there was a relative decrease in the percentage of deliveries covered by private insurance (-2.8 percentage points [95% CI -4.9 to -0.8, P=.01]). There were also no significant differences in the rate of women initiating prenatal care in the first trimester, preterm birth rates, or rates of low birth weight after the Medicaid expansion. Findings were similar in both subgroups. Conclusion Medicaid expansion was associated with increased Medicaid coverage for childbirth in expansion states; similar gains in private coverage were seen in nonexpansion states. There were no associations with changes in early access to prenatal care, preterm birth, or SGA birth weights.

ObjectiveTo assess knowledge and confidence in COVID-19 vaccine counseling among practitioners who provide care to pregnant persons and to describe factors associated with confidence in counseling.Study DesignA web-based anonymous survey was distributed via email to a cross-sectional convenience sample of OB/GYN, Primary Care, and Internal Medicine faculty at three hospitals in a single healthcare network in Massachusetts. Individual demographics and institution-specific variables were included in the survey along with questions assessing both attitudes toward COVID-19 illness in pregnancy as well as confidence in counseling regarding the use of the vaccine for pregnant patients.ResultsAlmost all providers (151, 98.1%) reported already receiving or being scheduled to receive a COVID-19 vaccine, and a majority of providers (111, 72.1%) reported that they believe the benefits of the mRNA COVID-19 vaccine in pregnancy outweigh the risks. Forty-one (26.6%) reported feeling very confident in counseling patients who primarily speak English about the evidence for mRNA vaccination in pregnancy, and 36 (23%) reported feeling very confident in counseling patients who are not primarily English-speaking. Forty-three providers (28.1%) expressed strong confidence in their comfort talking to individuals with vaccine hesitancy based on historic and continued racism and systemic injustices. The sources that survey respondents most commonly used to find information regarding COVID-19 vaccination in pregnancy were the CDC (112, 74.2%), hospital-specific resources (94, 62.3%) and ACOG (82, 54.3%).ConclusionWhile providers reported high personal uptake of COVID-19 vaccination and felt that the benefits of vaccination outweigh the risks in pregnancy, less than one-third felt very confident in counseling pregnant patients about available evidence for mRNA vaccine safety in pregnancy. Ensuring that providers feel comfortable bridging the gap between their belief that the vaccine is beneficial for pregnant patients and their comfort with holding conversations with patients regarding vaccination is paramount in order to ensure equitable access to vaccines for pregnant patients.

INTRODUCTION To evaluate the effect on engagement, relational connection, and burnout of an intervention involving clinical faculty meeting in interprofessional self-facilitated groups and to determine whether a written discussion guide is necessary to achieve benefit. METHODS This is a randomized controlled trial, conducted at a large US academic medical center from May to August 2018. Subjects included 25 clinical physicians, nurse practitioners, and certified nurse midwives. The intervention involved three monthly self-facilitated groups for faculty. Groups were randomized to have no discussion guide, or to receive a one-page guide. Outcomes of burnout, engagement, and empowerment in work, and stress from uncertainty were assessed using validated metrics. RESULTS Rates of emotional exhaustion and depersonalization decreased significantly over the course of the 3-month study (56%-36%; P < .001; and 20%-15%; P = .006) and overall burnout decreased from 56% to 41% of faculty (P = .002). The percentage of faculty who felt engaged in their work increased from 80% to 96% (P = .03). No statistically significant differences in empowerment at work or in reaction to uncertainty were seen. The groups without a discussion guide had equivalent outcomes and benefits. Cost per participant was under $100. DISCUSSION A three-month, low-cost, self-facilitated series of dinner meetings for interprofessional clinical faculty decreased burnout and improved engagement, sense of connection to colleagues, and sense of departmental commitment to well-being. Structured discussion guides were not necessary to achieve benefit. This study broadens the possibilities for cost-effective opportunities to transform institutional culture and effectively enhance faculty well-being.

Severe maternal morbidity and mortality remain public health priorities in the United States, given their high rates relative to other high-income countries and the notable racial and ethnic disparities that exist. In general, accurate risk stratification methods are needed to help patients, providers, hospitals, and health systems plan for and potentially avert adverse outcomes.Our objective was to understand if machine learning methods with natural language processing of history and physical notes could identify a group of patients at high risk of maternal morbidity on admission for delivery without relying on any additional patient information (eg, demographics and diagnosis codes).This was a retrospective study of people admitted for delivery at 2 hospitals (hospitals A and B) in a single healthcare system between July 1, 2016, and June 30, 2020. The primary outcome was severe maternal morbidity, as defined by the Centers for Disease Control and Prevention; furthermore, we examined nontransfusion severe maternal morbidity. Clinician documents designated as history and physical notes were extracted from the electronic health record for processing and analysis. A bag-of-words approach was used for this natural language processing analysis (ie, each history or physical note was converted into a matrix of counts of individual words (or phrases) that occurred within the document). The least absolute shrinkage and selection operator models were used to generate prediction probabilities for severe maternal morbidity and nontransfusion severe maternal morbidity for each note. Model discrimination was assessed via the area under the receiver operating curve. Discrimination was compared between models using the DeLong test. Calibration plots were generated to assess model calibration. Moreover, the natural language processing models with history and physical note texts were compared with validated obstetrical comorbidity risk scores based on diagnosis codes.There were 13,572 delivery encounters with history and physical notes from hospital A, split between training (AIn this practical application of machine learning, we demonstrated the capabilities of natural language processing for the prediction of severe maternal morbidity based on provider documentation inherently generated at the time of admission. This work should serve as a catalyst for providers, hospitals, and electronic health record systems to explore ways that artificial intelligence can be incorporated into clinical practice and evaluated rigorously for their ability to improve health.

There is a persistent bias toward higher prevalence and increased severity of coronavirus disease 2019 (COVID-19) in males. Underlying mechanisms accounting for this sex difference remain incompletely understood. Interferon responses have been implicated as a modulator of COVID-19 disease in adults and play a key role in the placental antiviral response. Moreover, the interferon response has been shown to alter Fc receptor expression and therefore may affect placental antibody transfer. Here, we examined the intersection of maternal-fetal antibody transfer, viral-induced placental interferon responses, and fetal sex in pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Placental Fc receptor abundance, interferon-stimulated gene (ISG) expression, and SARS-CoV-2 antibody transfer were interrogated in 68 human pregnancies. Sexually dimorphic expression of placental Fc receptors, ISGs and proteins, and interleukin-10 was observed after maternal SARS-CoV-2 infection, with up-regulation of these features in placental tissue of pregnant individuals with male fetuses. Reduced maternal SARS-CoV-2–specific antibody titers and impaired placental antibody transfer were also observed in pregnancies with a male fetus. These results demonstrate fetal sex-specific maternal and placental adaptive and innate immune responses to SARS-CoV-2.

Three newly identified equine parvoviruses (equine parvovirus hepatitis (EqPV-H), equine parvovirus CSF (EqPV-CSF) and equine copivirus (Eqcopivirus)) have recently been discovered in horses with respiratory signs. However, the clinical impact of these three equine parvoviruses has yet to be determined. Nasal fluid samples and blood from 667 equids with acute onset of fever and respiratory signs submitted to a diagnostic laboratory were analyzed for the presence of common equine respiratory pathogens (equine influenza virus, equine herpesvirus-1/-4, equine rhinitis A and B virus, S. equi subspecies equi) as well as EqPV-H, EqPV-CSF and Eqcopivirus by qPCR. An additional 87 clinically healthy horses served as controls. One hundred and seventeen sick horses tested qPCR-positive for at least one of the three parvoviruses. Co-infections with common respiratory pathogens and parvoviruses were seen in 39 sick equids. All 87 clinically healthy horses tested qPCR-negative for all tested common respiratory pathogens and 10 healthy horses tested qPCR-positive for one of the equine parvoviruses. When the frequency of detection for EqPV-H, EqPV-CSF and Eqcopivirus of equids with respiratory signs was compared to that of clinically healthy horses, the difference was not statistically significant (p &gt, 0.05), suggesting that the three recently identified equine parvoviruses do not contribute to the clinical picture of equids with respiratory disease.

This cross-sectional study evaluates the association between dissemination of the Antenatal Late Preterm Steroid trial and changes in steroid exposure among term newborns.

Intrahepatic cholestasis of pregnancy is associated with a significant risk of stillbirth, which contributes to variation in clinical management. Recent Society for Maternal-Fetal Medicine guidance recommends delivery at 36 weeks of gestation for patients with serum bile acid levels of100 μmol/L, consideration for delivery between 36 and 39 weeks of gestation stratified by bile acid level, and against preterm delivery for those with clinical features of cholestasis without bile acid elevation.This study aimed to investigate institutional practices before the publication of the new delivery timing recommendations to establish the maternal and neonatal effects of late preterm, early-term, and term deliveries in the setting of cholestasis.This study examined maternal and neonatal outcomes of 441 patients affected by cholestasis delivering 484 neonates in a 4-hospital system over a 30-month period. Logistic and linear regression analyses were performed to assess neonatal outcomes concerning peak serum bile acid levels at various gestational ages controlling for maternal comorbidities, multiple pregnancies, and neonatal birthweight.With the clinical flexibility afforded by the new guidelines, pregnancy prolongation to term may have been achieved in 91 patients (21%), and 286 patients (74%) with bile acid elevation could have delivered at a later gestational age. Preterm deliveries of patients with bile acid levels of10 μmol/L were associated with higher rates of neonatal intensive care unit admission and adverse neonatal outcomes than early-term deliveries.Study data suggested an opportunity for education and practice change to reflect current Society for Maternal-Fetal Medicine guidelines in efforts to reduce potential neonatal morbidities associated with late preterm deliveries among pregnancies affected by cholestasis.

Routine postpartum care is essential for managing pregnancy complications, like hypertension and diabetes, or screening for new conditions, such as depression. Insurance coverage can impact women's ability to access these postpartum services, with women who change or lose insurance postpartum having a lower likelihood of receiving the recommended postpartum care. Pregnancy-related Medicaid eligibility is only federally guaranteed for a minimum of 60 days after birth, creating the potential for publicly insured women to lose their insurance and their access to postpartum care.The objective of this study was to examine the rates of postpartum readmission and predictors of uninsurance at readmission before and after 60 days postpartum for Medicaid vs privately paid births.This was a retrospective cohort study in which data from the 2017 Nationwide Readmissions Database were used. Women who delivered with Medicaid or private insurance between January 2017 and June 2017 were included. Potential readmissions that were identified between 0 and 180 days after their childbirth hospitalization were included. The primary outcomes of interest were postpartum readmission and delivery payer at postpartum readmission, evaluated at 30-day intervals up to 180 days postpartum. Multivariable logistic regressions were used to determine the association of the risk for readmission and the risk for being uninsured at the time of readmission with insurance provider at the time of delivery. The analysis was also conducted for a subset of acute-cause readmissions or those not likely to be related to chronic or preexisting medical conditions.A total of 24,719 (2.7%) patients were readmitted within 180 days after delivery: 14,179 (54.1%) had Medicaid delivery insurance and 10,540 (40.2%) had private insurance at delivery. Readmission rates decreased over the time intervals after delivery for both delivery payer types, but were consistently higher for those with Medicaid. The rate of uninsurance at readmission increased more with each postpartum month for those with Medicaid than for those with private insurance at delivery: from 0.9% (95% confidence interval, 0.7-1.1) at 0 to 30 days to 9.7% (95% confidence interval, 8.1-11.6) at 150 to 180 days postpartum for those with Medicaid and from 0.2% (95% confidence interval, 0.1-0.4) at 0 to 30 days to 2.6% (95% confidence interval, 1.6-4.1) at 150 to 180 days postpartum for those with private insurance. Medicaid coverage at the time of delivery was a significant predictor of being readmitted (adjusted odds ratio, 1.86; 95% confidence interval, 1.75-1.97) and uninsured at the time of readmission (adjusted odds ratio, 3.99; 95% confidence interval, 2.88-5.52) when compared with being privately insured. Findings were similar for the acute-cause readmissions.Women with Medicaid at delivery have a higher risk for readmission and uninsurance at readmission than privately insured women beyond 60 days postpartum. This analysis provides further evidence of the insurance instability women face in the postpartum period, especially by those insured by Medicaid at the time of delivery, and should promote discussions among policymakers, payers, and providers on strategies to ensure coverage and access to care for women and their families after childbirth. For states considering to expand their eligibility criteria to 1 year postpartum, this study provides evidence on the vulnerabilities and unique risks that women with Medicaid face after 60 days postpartum.

BACKGROUND Although there are many indications for a cesarean delivery, the “optimal” cesarean delivery rate is unknown. Neonatal and maternal morbidity have largely not been considered in the generation of hospital-level cesarean delivery rate targets. OBJECTIVE We sought to examine if the widely adopted and reported markers of maternal and neonatal morbidity were associated with hospital cesarean delivery rates to provide context for potential comparison and consideration for defining cesarean delivery rate targets. We hypothesized that hospitals with higher cesarean delivery rates would have increased rates of severe maternal morbidity, though we were less certain of the associations of the cesarean delivery rates with unexpected newborn complications. STUDY DESIGN This is a cross-sectional, ecological study using data from the 2016 Nationwide Readmission Database of hospitals with at least 100 deliveries per year. The exposure of interest was hospital cesarean delivery rate. The outcomes were (1) severe maternal morbidity with and without transfusion—in accordance with the Centers for Disease Control and Prevention's definition, and (2) neonatal morbidity—defined using The Joint Commission's Perinatal Quality metric of moderate and severe unexpected newborn complications among term, singleton, and nonanomalous neonates. Before assuming a single linear relationship to model the associations between morbidity and cesarean delivery rates, the Joinpoint Regression Analysis program was used to examine for potential splines in the relationships with both severe maternal morbidity (with and without transfusion) and severe and moderate unexpected newborn complications. Poisson regression model was then used to determine the association between morbidity and cesarean delivery rates. RESULTS The analysis included 831,111 deliveries from 621 hospitals. The mean cesarean delivery rate was 30.5%. The median severe maternal morbidity rate was 1.40 per 100 deliveries (interquartile range, 0.71–2.21 per 1000 deliveries). Excluding transfusion, the median severe maternal morbidity rate was 0.47 per 100 deliveries (interquartile range, 0.22–0.73 per 100 deliveries). The median rate of severe and moderate unexpected newborn complications was 1.01 per 100 low-risk newborns (interquartile range, 0.64–1.69 per 100 low-risk newborns) and 1.79 per 1000 low-risk newborns (interquartile range, 0.94–2.93 per 100 low-risk newborns), respectively. In the unadjusted analysis, every percentage point increase in a hospital's cesarean delivery rate was associated with a 3.4% (95% confidence interval, 2.3%–4.4%) and a 2.3% (95% confidence interval, 1.0%–3.5%) increase in severe maternal morbidity including and excluding transfusion, respectively. After adjustment for the case mix and hospital factors, only the relationship with severe maternal morbidity including transfusion remained significant: 3.3% (95% confidence interval, 1.7%–4.9%) increase in severe maternal morbidity per 1 percentage point increase in the cesarean delivery rate. There was no observed association between cesarean delivery rates and unexpected newborn complications CONCLUSION Severe maternal morbidity and unexpected newborn complications occur in fewer than 5 in 100 births. Findings from this analysis of hospitals with cesarean delivery rates ranging from 6.8%–56.3% suggest that those with lower cesarean delivery rates have lower severe maternal morbidity (which includes transfusion) and similar unexpected newborn complications compared with hospitals with higher cesarean delivery rates. This work may provide a helpful context to providers, hospitals, and policymakers who are measuring and reporting outcomes. Regarding neonatal morbidity in particular, the Joint Commission manual notes that the unexpected newborn complication metric was specifically designed to be compared against maternal-focused metrics such as cesarean delivery rates. More work is needed to define and identify appropriate measures of maternal and neonatal morbidity for these types of comparisons.

PURPOSE: We sought to determine whether pregnancies conceived in those with male factor infertility have unique placental pathology profiles compared to those undergoing infertility treatments for other indications. METHODS: This was a retrospective cohort study of placental pathology from 464 live births conceived from autologous fresh IVF cycles at an academic fertility center from 2004 to 2017. Placental pathology was compared between live births arising from patients with male factor infertility alone and those with another infertility diagnosis. Placental outcomes were compared with parametric or non-parametric tests; logistic regression was performed to account for potential confounders. RESULTS: Compared to cycles performed for a non-male factor diagnosis, male factor infertility cycles had a higher mean paternal age (38.2 years vs. 36.5 years, p

Background: In pregnant and postpartum (PP) women, an oral glucose tolerance test (OGTT) is the diagnostic test of choice for glucose intolerance. Consistent with classic studies outside of pregnancy, we recently found that lower carbohydrate intake on the day before an OGTT in pregnancy was associated with higher post-load OGTT glucose. Here, we test for a relationship between carbohydrate intake and OGTT glucose in PP women. Methods: PP women (N=84, median [IQR] = 9 [8-14] weeks PP) completed a 75 g OGTT and a validated self-administered 24-hr dietary recall. We tested for an association between carbohydrate intake in the day before the OGTT and 1-hr OGTT glucose using linear regression, with adjustment for age, race, BMI, time postpartum, and caloric intake. We also tested for associations with 30 minute and 2-hr OGTT glucose and glucose area under the curve (AUC). A subset of women (N=72) had completed the same protocol during pregnancy (median=26 weeks gestation). Results: PP women with lower carbohydrate intake ( Conclusion: While carbohydrate intake in the day prior to an OGTT may alter gestational diabetes diagnosis, we found no relationship between carbohydrate intake and OGTT glucose among PP women. Metabolic factors that differentiate the pregnant and postpartum state may account for our findings. Disclosure E. A. Rosenberg: None. E. W. Seely: None. K. James: None. M. J. Callahan: None. S. Nelson: None. C. E. Powe: None. Funding National Institutes of Health (K23DK113218); Robert Wood Johnson Foundation (T32DK007028); Massachusetts General Hospital

Objective: Assessments for diabetes are vital to pregnancy and postpartum (PP) care, but screening, conducted with oral glucose tolerance tests (OGTTs), is cumbersome. Outside of pregnancy, percent glycated albumin (%GAlb) reflects average glycemia over a period of weeks. %GAlb may not be subject to the same limitations as hemoglobin A1c in pregnancy, as it does not rely on stable red blood cell kinetics. We studied %GAlb as a potential glycemic marker during gestation and PP. Study Design: Pregnant women (N=50) in the Study of Pregnancy Regulation of Insulin and Glucose cohort underwent 75g OGTTs at a mean of 13 weeks (SD 1.6, V1) and 26 weeks (SD 1.4, V2) of gestation and 11 weeks (SD 4.9) PP. Non-pregnant controls had a single OGTT. We measured GAlb on frozen plasma samples. Results: Serum total GAlb and total albumin decreased from V1 to V2 and increased PP to levels higher than at V1. %GAlb declined between V1 and V2 (β= -0.64 95% CI [-0.8, -0.4] p Conclusions: %GAlb decreases during gestation and remains decreased PP, despite a return of total albumin and total GAlb to baseline. Given the lack of correlation with OGTT glucose levels or hemoglobin A1c, %GAlb is unlikely to be useful in assessing glycemia in pregnant or PP women. Disclosure M. D. Soffer: None. K. James: None. M. J. Callahan: None. W. H. Barth: None. C. E. Powe: None.

As intrapartum fevers are not always infectious in origin, determining whether antibiotics are indicated is challenging. We previously sought to create a point-of-care calculator using clinical data available at the time of an intrapartum fever to identify the subset of women who require antibiotic treatment to avoid maternal and neonatal morbidity. Despite the use of a comprehensive dataset from our institutions, we were unable to propose a valid and highly predictive model. In this commentary, we discuss why our model failed, as well as future research directions to identify and treat true intraamniotic infection. Developing a risk-stratification model is paramount to minimizing maternal and neonatal exposure to unnecessary antibiotics while allowing for early identification of women and babies at risk for infectious morbidity. KEY POINTS: · Determining whether antibiotics are indicated in intrapartum fever is challenging.. · Developing a risk-stratification model for febrile laboring women is critical to decreasing harm.. · A point-of-care calculator based on clinical and biomarker data is the necessary approach..