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We evaluated the contributions of maternal age, year of death (period), and year of birth (cohort) on trends in hypertension-related maternal deaths in the United States. We undertook a sequential time series analysis of 155 710 441 live births and 3287 hypertension-related maternal deaths in the United States, 1979 to 2018. Trends in pregnancy-related mortality rate (maternal mortality rate [MMR]) due to chronic hypertension, gestational hypertension, and preeclampsia/eclampsia, were examined. MMR was defined as death during pregnancy or within 42 days postpartum due to hypertension. Trends in overall and race-specific hypertension-related MMR based on age, period, and birth cohort were evaluated based on weighted Poisson models. Trends were also adjusted for secular changes in obesity rates and corrected for potential death misclassification. During the 40-year period, the overall hypertension-related MMR was 2.1 per 100 000 live births, with MMR being almost 4-fold higher among Black compared with White women (5.4 [n=1396] versus 1.4 [n=1747] per 100 000 live births). Advancing age was associated with a sharp increase in MMR at ≥15 years among Black women and at ≥25 years among White women. Birth cohort was also associated with increasing MMR. Preeclampsia/eclampsia-related MMR declined annually by 2.6% (95% CI, 2.2–2.9), but chronic hypertension–related MMR increased annually by 9.2% (95% CI, 7.9–10.6). The decline in MMR was attenuated when adjusted for increasing obesity rates. The temporal burden of hypertension-related MMR in the United States has increased substantially for chronic hypertension–associated MMR and decreased for preeclampsia/eclampsia-associated MMR. Nevertheless, deaths from hypertension continue to contribute substantially to maternal deaths.

Placental abruption and cardiovascular disease (CVD) have common etiological underpinnings, and there is accumulating evidence that abruption may be associated with future CVD. We estimated associations between abruption and coronary heart disease (CHD) and stroke. The meta-analysis was based on the random-effects risk ratio (RR) and 95% confidence interval (CI) as the effect measure. We conducted a bias analysis to account for abruption misclassification, selection bias, and unmeasured confounding. We included 11 cohort studies comprising 6,325,152 pregnancies, 69,759 abruptions, and 49,265 CHD and stroke cases (1967–2016). Risks of combined CVD morbidity-mortality among abruption and nonabruption groups were 16.7 and 9.3 per 1,000 births, respectively (RR = 1.76, 95% CI: 1.24, 2.50; I2 = 94%; τ2 = 0.22). Women who suffered abruption were at 2.65-fold (95% CI: 1.55, 4.54; I2 = 85%; τ2 = 0.36) higher risk of death related to CHD/stroke than nonfatal CHD/stroke complications (RR = 1.32, 95% CI: 0.91, 1.92; I2 = 93%; τ2 = 0.15). Abruption was associated with higher mortality from CHD (RR = 2.64, 95% CI: 1.57, 4.44; I2 = 76%; τ2 = 0.31) than stroke (RR = 1.70, 95% CI: 1.19, 2.42; I2 = 40%; τ2 = 0.05). Corrections for the aforementioned biases increased these estimates. Women with pregnancies complicated by placental abruption may benefit from postpartum screening or therapeutic interventions to help mitigate CVD risks.

OBJECTIVE: Reports from the National Center for Health Statistics suggest that maternal mortality rates in the United States increased after the introduction of the pregnancy status checkbox on the 2003 revised US standard death certificate; however, this increase was because of an artifact of surveillance.(1–3) This study aimed to evaluate the trends in cardiovascular disease (CVD)-related pregnancy-associated mortality in the United States and assess the impact of ascertainment by death certificate type using national- and state-level data. STUDY DESIGN: We conducted a cross-sectional analysis of all live births and CVD-related pregnancy-associated deaths in the United States (1999–2018) based on the National Vital Statistics System data. The primary outcome was CVD-related pregnancy-associated deaths identified using the International Classification of Diseases, Tenth Revision, codes. To account for the effect of the implementation of the 2003 revised US standard death certificate on reported pregnancy-associated mortality ratios (PMRs), we used state-level indicators at the individual level to determine how many deaths were recorded each year according to the standard US death certificate (1989 revision) vs the 2003 revised version. We examined changes in 42-day PMRs (expressed per 100,000 live births) between 1999 and 2018 by death certificate type. The trends in PMRs were quantified based on rate ratios (RRs) with 95% confidence intervals (CIs), derived from log-linear regression models with a Poisson distribution (using a “log” link function with robust variance estimation).(4) RESULTS: Throughout the study period (1999–2018), there were 80,802,690 live births and 238 CVD-related deaths in the United States. The overall CVD-related PMR increased from 0.24 to 0.91 per 100,000 live births (adjusted RR, 3.32; 95% CI, 1.99–5.54). The overall CVD-related PMRs were 0.20 per 100,000 live births using the 1989 version and 0.38 per 100,000 live births using the 2003 version (Table). However, when we adjusted for death certificate type, there was a reduction in the overall risk between 1999 to 2000 and 2017 to 2018 (RR, 0.55; 95% CI, 0.12–2.48). Analyses stratified by CVD subtype, including pulmonary heart disease and hypertensive heart disease, are shown in the Table. CONCLUSION: In this large population-based cross-sectional analysis, we identified an increase in the CVD-related PMR in the United States from 1999 to 2018 using national data. However, in the analyses that adjusted for death certificate type, we found that the use of the 2003 revised US standard death certificate resulted in RRs that showed no difference in mortality rates throughout the study period. Despite the wide 95% CIs (highlighting imprecision in the estimates), this analysis suggests that the certificate version may be an effect modifier. We believe that the increased number of deaths captured by the 2003 revised US standard death certificate reflects a true increase in mortality rather than an artifact from misclassification. Although the study has some limitations, including its retrospective design based on data that lack specific clinical details regarding each death, this analysis suggests that the observed time trend of an increasing CVD-related PMR is not an artifact of the 2003 checkbox revision but a real trend that warrants attention.

Objectives The diagnosis of fetal growth restriction (FGR) is managed with close fetal surveillance and often requires iatrogenic delivery, as there is an associated increased risk of fetal demise. However, there is no standard reference for fetal growth. We sought to compare the intrauterine growth curve of Hadlock et al (Radiology 1991; 181:129-133) to other known growth curves to determine which one best identifies fetuses at risk without overburdening the patient and health care system with unnecessary intervention. Methods We retrospectively reviewed charts of singleton euploid pregnancies with a diagnosis of FGR (per Hadlock) at a tertiary care center from June 2014 to May 2015. We applied the estimated fetal weights from ultrasound at diagnosis of FGR to 4 population-based growth curves by Brenner et al (Am J Obstet Gynecol 1976; 126:555-564), Williams et al (Obstet Gynecol 1982; 59:624-632), Alexander et al (Obstet Gynecol 1996; 87:163-168), and Duryea et al (Obstet Gynecol 2014; 124:16-22) and reassessed the incidence of FGR using each curve. We reviewed pregnancy demographics, risk factors, pregnancy management, and outcomes of FGR cohorts on each curve to evaluate whether poor outcomes may be missed or interventions may be avoided using the population-based curves. A sensitivity analysis was also done to see how well each curve predicted small-for-gestational-age birth weights. Results Applying any of the population-based growth curves decreased the number of FGR diagnoses, iatrogenic deliveries, and primary cesarean deliveries. Brenner's growth curve identified the least number of FGR diagnoses at 22 of the 107 identified by Hadlock. Williams' growth curve performed best in the sensitivity analysis with sensitivity of 99% and specificity of 97%. A small number of patients with absent/reversed end-diastolic flow would have been missed by applying the population curves. Conclusions Applying the population-based growth curves instead of Hadlock's for diagnosis of FGR decreases its incidence, therefore decreasing the number of visits for ultrasound and fetal surveillance and the number of iatrogenic deliveries. However, using these curves could miss a few fetuses with increased risk of fetal demise.

17-alpha hydroxyprogesterone caproate (17 P) is a progestin commonly used during pregnancy to reduce risk of recurrent preterm birth. History of thromboembolism is a contraindication to 17 P and the package insert for 17 P recommends discontinuation in the setting of an acute VTE event. The objective of this study was to determine whether 17 P is associated with increased risk of VTE.The MarketScan claims database was used to perform a retrospective cohort of women who underwent delivery from 4/2008 to 1/2015. We identified women who received 17 P during pregnancy based on pharmacy benefits. Risk for VTE including deep vein thrombosis, pulmonary embolism, or both was stratified based on the presence or absence of 17 P pharmacy receipt. Both antenatal and delivery hospitalization VTE events were asceratined and these periods were analyzed individually. Relative risk (RR) was determined based on 17 P receipt.Among 4,775,667 delivery hospitalizations, 18,745 women received 17 P. Among women who did not receive 17 P, 0.52% of women (No significant increased risk for VTE was noted with 17 P receipt. While new research has led to reconsideration of clinical use of 17 P for preterm birth prevention based on efficacy, findings from this analysis do not support major risk for thrombosis.

Background Retained placenta affects 2% to 3.3% of all vaginal deliveries and is one of the leading causes of postpartum hemorrhage worldwide. Despite the prevalence of this condition, there is limited guidance on its management. Objective A systematic review and meta-analysis were performed to evaluate the efficacy of pharmacologic interventions for the management of retained placenta. Study Design PubMed, ClinicalTrials.gov , Cochrane Library, Web of Science, and Scopus were searched for full-text publications in English. Search terms included “retained placenta” AND “treatment” OR “therapy” OR “disease management” OR “Pitocin” OR “misoprostol” OR “Cytotec” OR “dinoprostone” OR “nitroglycerin” OR “carbetocin” OR “ergotamine,” with no restriction on publication dates. Only randomized controlled trials were included. The primary outcome was the need for manual extraction of the placenta or dilation and curettage. Reviewers evaluated the quality of included articles using the Cochrane Collaboration’s tool for assessing the risk of bias. Pooled risk ratios were estimated based on random- and fixed-effects analyses. Interstudy heterogeneity was considered when I2≥50%. Results The literature search identified 29 randomized controlled trials that met the inclusion criteria (2682 subjects). The most commonly used agent across the studies was oxytocin administered via umbilical vein injection; there was high heterogeneity among these studies (I2=62%). Oxytocin was inferior to carbetocin (risk ratio, 1.61; 95% confidence interval, 1.03–2.52) and prostaglandins (risk ratio, 2.63; 95% confidence interval, 1.18–5.86) for the primary outcome. For oxytocin, prostaglandin agents, and nitroglycerin, there was a trend toward favoring the study drug for the primary outcome compared with control or placebo. Compared with placebo or control, estimated blood loss was lower if pharmacologic interventions were administered, with a mean difference of 121.5 mL (95% confidence interval, −185.7 to −52.3). There was no difference in postpartum hemorrhage or the need for blood transfusion between pharmacologic interventions and placebo or control. Conclusion Pooled estimates for oxytocin via umbilical vein injection, prostaglandin agents, and nitroglycerin performed favorably compared with placebo or control for the management of retained placenta. Carbetocin and prostaglandin agents were superior to oxytocin in reducing the need for manual extraction or dilation and curettage.

Current trends in patient safety include protocolization of care with assumed compliance to the protocol by health care providers. In 2016, Schuster et al. found that implementation of a protocol for management of obese pregnant patients that included delivery by estimated due date (EDD) actually resulted in a decrease in cesarean deliveries. Although compliance to the aspect of the protocol that affected the primary outcome of that study was evaluated, compliance to every aspect of the protocol was not analyzed. Recent studies have suggested improvements in protocol outcomes when compliance is measured. Therefore, we sought to evaluate compliance to the other aspects of the Geisinger Maternal Fetal Medicine obesity protocol (MOP).The objective of this study was to identify compliance with all elements of the Geisinger MOP and identify areas for potential improvement with regards to compliance.We performed a secondary analysis of the original study to evaluate compliance with protocol aspects during the study period. Ninety-seven patients were randomly selected for chart review. We assessed compliance with each element of the protocol, including early diabetes screening, fetal monitoring, growth ultrasounds, and delivery by EDD using simple statistics.By obesity class, compliance was as follows: for class I obese patients, compliance with early diabetes screening was 30% (12/36 patients). For class II obese patients, compliance with early diabetes screening was 57.1% (12/21 patients), and compliance with serial growth ultrasounds was 85.7% (18/21 patients). For class III obese patients, compliance with early diabetes screening was 74.4% (29/39 patients), compliance with serial growth ultrasounds was 84.6% (33/39 patients), compliance with nonstress tests was 82.0% (32/39 patients). Compliance with the recommendation for delivery by estimated due date was 95% (37/39 class III obese patients).Although compliance was excellent with delivery by EDD, compliance with remaining recommendations was low. This suggests additional interventions are important to maintain compliance.

To assess whether testing blood glucose four times daily compared with four times every other day would lead to similar birth weights among patients with gestational diabetes mellitus (GDM).This noninferiority randomized controlled trial was conducted at five centers. After receiving a diagnosis of GDM, women tested their blood glucose every day for 7 days. After that period, compliant women without hyperglycemia requiring treatment were randomized to either blood glucose testing four times a day or every other day. Noninferiority would be declared if the mean birth weight in the every-other-day group was no higher than 165 g (5% difference assuming an average birth weight of 3,296 g) compared with the four times a day group. A total sample size of 286 women allowed noninferiority to be tested (one-sided .05 level of significance).From May 2013 to May 2016, of the 293 women with GDM who were randomized, 149 (51%) were tested four times a day and 144 (49%) were tested every other day. Between the two groups, there were no significant differences with regard to need for medical treatment, induction, gestational age at delivery, mode of delivery, rate of preeclampsia, or shoulder dystocia. Birth weight was similar between both groups and the upper bound of the 90% confidence interval (CI) was less than 165 g, establishing noninferiority with a mean difference of -41 g (90% CI -137 to 54 g). Rate of compliance with blood glucose testing was higher in the every-other-day group (89% compared with 92%, P.01). The differences in rates of macrosomia and birth weight greater than the 95th percentile were not clinically significant. Neonatal outcomes including neonatal hypoglycemia were similar.Among patients with well-controlled GDM, testing blood glucose values every other day did not increase birth weight, although it did increase compliance with testing when compared with women who tested every day.ClinicalTrials.gov, NCT01818557.

Objective The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively. Methods The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBP Results Patients with severe blunt injury (ISS ≥ 9) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, p = 0.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and Conclusion ISS ≥ 9 and SBP

Purpose To determine the impact of a single episode of minor trauma during pregnancy on maternal and fetal outcomes. Methods This is a retrospective cohort study of pregnant women who experienced minor trauma at ≥24 weeks gestation between 2004 and 2014. The subjects who experienced minor trauma (minor trauma group) were matched by gestational age at the time of minor trauma, body mass index, and age to a cohort of women who did not experience trauma in pregnancy (control group). The primary obstetrical outcome was preterm delivery and the primary neonatal outcomes were APGAR scores and neonatal intensive care unit admission. Results There were no significant differences between the two groups with respect to demographics or other risk factors for preterm delivery. Average gestational age at the time of delivery was 39 weeks regardless of whether a woman experienced minor trauma. Preterm delivery occurred more often in the control group (11.8% versus 7.9%, p = 0.0428) as did the rate of neonatal intensive care unit admissions (8.6% versus 5%, p = 0.0273). A subgroup analysis was performed excluding patients with a medically indicated delivery and there was no difference in the rate of preterm delivery (6.4% in the control group, 4% in the minor trauma group, p-value 0.9052). Among women with a spontaneous preterm delivery, the rates of preterm labor (3.0% control versus 2.0% minor trauma, p-value 0.75) and preterm premature rupture of membranes were found to be similar between the two groups (3.8% control versus 2.0% minor trauma PPROM, p-value 0.75). Conclusions One episode of minor trauma in pregnancy does not increase the risk for preterm delivery, premature rupture of membranes, or poor neonatal outcomes.

Cervical ectopic pregnancy (CEP) is rare, and occurs when the blastocyst implants into the endocervical canal. They are particularly dangerous because they are difficult to diagnose, and typically present with massive hemorrhage necessitating hysterectomy. Therefore, there exists a need to definitively diagnose this condition earlier.

Coronavirus disease 2019 may be associated with adverse maternal and neonatal outcomes in pregnancy, but there are few controlled data to quantify the magnitude of these risks or to characterize the epidemiology and risk factors.This study aimed to quantify the associations of coronavirus disease 2019 with adverse maternal and neonatal outcomes in pregnancy and to characterize the epidemiology and risk factors.We performed a matched case-control study of pregnant patients with confirmed coronavirus disease 2019 cases who delivered between 16 and 41 weeks' gestation from March 11 to June 11, 2020. Uninfected pregnant women (controls) were matched to coronavirus disease 2019 cases on a 2:1 ratio based on delivery date. Maternal demographic characteristics, coronavirus disease 2019 symptoms, laboratory evaluations, obstetrical and neonatal outcomes, and clinical management were chart abstracted. The primary outcomes included (1) a composite of adverse maternal outcome, defined as preeclampsia, venous thromboembolism, antepartum admission, maternal intensive care unit admission, need for mechanical ventilation, supplemental oxygen, or maternal death, and (2) a composite of adverse neonatal outcome, defined as respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, 5-minute Apgar score of5, persistent category 2 fetal heart rate tracing despite intrauterine resuscitation, or neonatal death. To quantify the associations between exposure to mild and severe or critical coronavirus disease 2019 and adverse maternal and neonatal outcomes, unadjusted and adjusted analyses were performed using conditional logistic regression (to account for matching), with matched-pair odds ratio and 95% confidence interval based on 1000 bias-corrected bootstrap resampling as the effect measure. Associations were adjusted for potential confounders.A total of 61 confirmed coronavirus disease 2019 cases were enrolled during the study period (mild disease, n=54 [88.5%]; severe disease, n=6 [9.8%]; critical disease, n=1 [1.6%]). The odds of adverse composite maternal outcome were 3.4 times higher among cases than controls (18.0% vs 8.2%; adjusted odds ratio, 3.4; 95% confidence interval, 1.2-13.4). The odds of adverse composite neonatal outcome were 1.7 times higher in the case group than to the control group (18.0% vs 13.9%; adjusted odds ratio, 1.7; 95% confidence interval, 0.8-4.8). Stratified analyses by disease severity indicated that the morbidity associated with coronavirus disease 2019 in pregnancy was largely driven by the severe or critical disease phenotype. Major risk factors for associated morbidity were black and Hispanic race, advanced maternal age, medical comorbidities, and antepartum admissions related to coronavirus disease 2019.Coronavirus disease 2019 during pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes, an association that is primarily driven by morbidity associated with severe or critical coronavirus disease 2019. Black and Hispanic race, obesity, advanced maternal age, medical comorbidities, and antepartum admissions related to coronavirus disease 2019 are risk factors for associated morbidity.

The patient with severe preeclampsia and its associated conditions of eclampsia and HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome usually present to Labor and Delivery and are often cared for completely by the obstetrical team, however in more complicated cases these patients should be treated with a multidisciplinary approach including critical care and other subspecialties as needed. Preeclampsia is a systemic disease characterized by hypertension and proteinuria that occurs in pregnancy and the puerperium. Severe complications include seizure (eclampsia), cerebral hemorrhage, liver capsule hematoma and rupture, renal failure and oliguria as well as pulmonary edema, heart failure and cardiomyopathy. This chapter reviews a typical presentation of severe preeclampsia, eclampsia and HELLP syndrome and management of this condition.

Context: Although studies support the efficacy of the Foley catheter (FC) as a cervical ripening agent in pregnant women at term with intact membranes, its efficacy has not been well studied in women with premature rupture of membranes (PROM). Objective: To compare the interval to delivery in women with PROM who underwent induction of labor and cervical ripening with mechanical (FC) vs nonmechanical (prostaglandin [PG]) cervical ripening agents. Design: Retrospective medical record review at 2 hospitals of pregnant women who delivered between January 2009 and April 2011. Setting: Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, and Christiana Care Health System in Newark, Delaware. Patients: Pregnant women with singleton gestations 36 weeks or greater who presented with PROM. Interventions: Cervical ripening with FC or PG. Main Outcome Measures: The primary outcome was time from induction until delivery. Secondary outcomes included epidural use, maximum temperature during labor, number of vaginal examinations, occurrence of tachysystole, oxytocin dose, delivery mode, chorioamnionitis, and neonatal Apgar score. Results: Of 155 medical records of patients who met the inclusion criteria, 33 women underwent cervical ripening with PG (ie, misoprostol) and 122 with FC. The interval to delivery was almost halved in women who underwent cervical ripening with FC compared with misoprostol (736 vs 1354 minutes; PP Conclusion: Foley catheters may help shorten the interval to delivery in women who are candidates for cervical ripening after PROM at or near term. There does not appear to be an increased risk for cesarean delivery or chorioamnionitis in those treated with FC.

Obesity in pregnancy has an impact on both the mother and the fetus. To date, no universal protocol has been established to guide the management of pregnancy in obese woman. In April 2011, the Geisinger Maternal-Fetal Medicine Department implemented an obesity protocol in which women meeting the following criteria were delivered by their estimated due dates: (1) class III obese or (2) class II obese with additional diagnoses of a large-for-gestational-age fetus or pregnancy complicated by gestational diabetes or (3) class I obese with large-for-gestational-age and gestational diabetes.We sought to assess the impact of this protocol on the rate of cesarean deliveries in obese women.We performed a retrospective cohort study of 5000 randomly selected women who delivered at Geisinger between January 2009 and September 2013, excluding those who delivered in 2011. The data were stratified into obese and nonobese and divided into before protocol and after protocol. Comparison across all groups was accomplished using Wilcoxon rank sum and Pearson's χ(2) tests. Potential confounders were controlled for using logistic regression.The cesarean delivery rate in the obese/after protocol group was 10.8% lower than in the obese/before protocol group (42.4% vs 31.6%, respectively; P.0001). In addition, when controlling for age, race, smoking status, preeclampsia, gestational diabetes, and intrauterine growth restriction, obese women were 37% less likely to have a cesarean delivery after the protocol than they were before (odds ratio, 0.63; 95% confidence interval, 0.52, 0.76, P.0001).Implementation of a maternal-fetal medicine obesity protocol did not increase the rate of cesarean deliveries in obese women. On the contrary, obese women were less likely to have a cesarean delivery after implementation of the protocol.