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Ogunwole SM, Mwinnyaa G, Wang X, Hong X, Henderson J, Bennett WL. Preeclampsia Across Pregnancies and Associated Risk Factors: Findings From a High-Risk US Birth Cohort. J Am Heart Assoc 2021; 10:e019612. [PMID: 34398644 PMCID: PMC8649269 DOI: 10.1161/jaha.120.019612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Preeclampsia increases women's risks for maternal morbidity and future cardiovascular disease. The aim of this study was to identify opportunities for prevention by examining the association between cardiometabolic risk factors and preeclampsia across 2 pregnancies among women in a high‐risk US birth cohort. Methods and Results Our sample included 618 women in the Boston Birth Cohort with index and subsequent pregnancy data collected using standard protocols. We conducted log‐binomial univariate regression models to examine the association between preeclampsia in the subsequent pregnancy (defined as incident or recurrent preeclampsia) and cardiometabolic risk factors (ie, obesity, hypertension, diabetes mellitus, preterm birth, low birth weight, and gestational diabetes mellitus) diagnosed before and during the index pregnancy, and between index and subsequent pregnancies. At the subsequent pregnancy, 7% (36/540) had incident preeclampsia and 42% (33/78) had recurrent preeclampsia. Compared with women without obesity, women with obesity had greater risk of incident preeclampsia (unadjusted risk ratio [RR], 2.2 [95% CI, 1.1–4.5]) and recurrent preeclampsia (unadjusted RR, 3.1 [95% CI, 1.5–6.7]). Preindex pregnancy chronic hypertension and diabetes mellitus were associated with incident, but not recurrent, preeclampsia (hypertension unadjusted RR, 7.9 [95% CI, 4.1–15.3]; diabetes mellitus unadjusted RR, 5.2 [95% CI, 2.5–11.1]. Women with new interpregnancy hypertension versus those without had a higher risk of incident and recurrent preeclampsia (incident preeclampsia unadjusted RR, 6.1 [95% CI, 2.9–13]); recurrent preeclampsia unadjusted RR, 2.4 [95% CI, 1.5–3.9]). Conclusions In this diverse sample of high‐risk US women, we identified modifiable and treatable risk factors, including obesity and hypertension for the prevention of preeclampsia.
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Affiliation(s)
- S Michelle Ogunwole
- Department of Medicine Division of General Internal MedicineJohns Hopkins University School of Medicine Baltimore MD
| | - George Mwinnyaa
- Department of International HealthJohns Hopkins University Bloomberg School of Public Health Baltimore MD
| | - Xiaobin Wang
- Department of PediatricsJohns Hopkins University School of Medicine Baltimore MD.,Center on the Early Life Origins of Disease Department of Population, Family and Reproductive Health Johns Hopkins University Bloomberg School of Public Health Baltimore MD
| | - Xiumei Hong
- Center on the Early Life Origins of Disease Department of Population, Family and Reproductive Health Johns Hopkins University Bloomberg School of Public Health Baltimore MD
| | - Janice Henderson
- Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore MD
| | - Wendy L Bennett
- Department of Medicine Division of General Internal MedicineJohns Hopkins University School of Medicine Baltimore MD.,Center on the Early Life Origins of Disease Department of Population, Family and Reproductive Health Johns Hopkins University Bloomberg School of Public Health Baltimore MD
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Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol 2021; 138:e65-e90. [PMID: 34293771 DOI: 10.1097/aog.0000000000004479] [Citation(s) in RCA: 162] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 12/30/2022]
Abstract
Preterm birth is among the most complex and important challenges in obstetrics. Despite decades of research and clinical advancement, approximately 1 in 10 newborns in the United States is born prematurely. These newborns account for approximately three-quarters of perinatal mortality and more than one half of long-term neonatal morbidity, at significant social and economic cost (1-3). Because preterm birth is the common endpoint for multiple pathophysiologic processes, detailed classification schemes for preterm birth phenotype and etiology have been proposed (4, 5). In general, approximately one half of preterm births follow spontaneous preterm labor, about a quarter follow preterm prelabor rupture of membranes (PPROM), and the remaining quarter of preterm births are intentional, medically indicated by maternal or fetal complications. There are pronounced racial disparities in the preterm birth rate in the United States. The purpose of this document is to describe the risk factors, screening methods, and treatments for preventing spontaneous preterm birth, and to review the evidence supporting their roles in clinical practice. This Practice Bulletin has been updated to include information on increasing rates of preterm birth in the United States, disparities in preterm birth rates, and approaches to screening and prevention strategies for patients at risk for spontaneous preterm birth.
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Interpregnancy Interval and Severe Maternal Morbidity in Iowa, 2009 to 2014. Womens Health Issues 2021; 31:503-509. [PMID: 34088600 DOI: 10.1016/j.whi.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Maternal mortality and morbidity rates have risen significantly yet, little research has focused on how severe maternal morbidity (SMM) is associated with future reproductive health, such as birth spacing or the likelihood of subsequent SMM. This study focuses on the risk of SMM recurrence and the association of interpregnancy intervals with SMM. METHODS This population-based, retrospective cohort study used Iowa hospital discharge data longitudinally linked to birth certificate data between 2009 and 2014. To examine recurrence of SMM, crude and adjusted multivariable logistic regression models were generated. The associations between varying interpregnancy intervals and subsequent SMM were examined. Crude, stratified, and adjusted risk ratios and their associated 95% confidence intervals were estimated. RESULTS A total of 36,190 women were included in this study. Women with SMM in the index delivery had significantly higher odds of SMM in the subsequent delivery (adjusted odds ratio, 8.16; 95% confidence interval, 5.45-12.24) compared with women without SMM. Women with an interpregnancy interval of less than 6 months compared with 18 months or longer were more likely to experience SMM during their subsequent delivery, although the difference was not statistically significant (adjusted odds ratio, 1.41; 95% confidence interval-0.99, 2.03). CONCLUSIONS This study demonstrates that women who experience SMM are at markedly increased risk of subsequent SMM. Further investigation is necessary to inform optimal interpregnancy interval recommendations based on prior maternal health outcomes.
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54
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Davidson KW, Barry MJ, Mangione CM, Cabana M, Caughey AB, Davis EM, Donahue KE, Doubeni CA, Krist AH, Kubik M, Li L, Ogedegbe G, Pbert L, Silverstein M, Simon M, Stevermer J, Tseng CW, Wong JB. Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy: US Preventive Services Task Force Recommendation Statement. JAMA 2021; 325:2087-2093. [PMID: 34032823 DOI: 10.1001/jama.2021.6949] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons. In 2015, almost half of all persons began pregnancy with overweight (24%) or obesity (24%). Reported rates of overweight and obesity are higher among Black, Alaska Native/American Indian, and Hispanic women and lower among White and Asian women. Excess weight at the beginning of pregnancy and excess gestational weight gain have been associated with adverse maternal and infant health outcomes such as a large for gestational age infant, cesarean delivery, or preterm birth. OBJECTIVE The USPSTF commissioned a systematic review to evaluate the benefits and harms of behavioral counseling interventions to prevent adverse health outcomes associated with obesity during pregnancy and to evaluate intermediate outcomes, including excess gestational weight gain. This is a new recommendation. POPULATION Pregnant adolescents and adults in primary care settings. EVIDENCE ASSESSMENT The USPSTF concludes with moderate certainty that behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy have a moderate net benefit for pregnant persons. RECOMMENDATION The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. (B recommendation).
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Affiliation(s)
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | | | | | | | | | - Esa M Davis
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | - Li Li
- University of Virginia, Charlottesville
| | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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Nnaji HC, Asimadu EE, Aniebue UU. The effect of short interpregnancy interval on birthweight and other pregnancy outcomes in Enugu, Southeast Nigeria. J OBSTET GYNAECOL 2021; 42:244-247. [PMID: 34027820 DOI: 10.1080/01443615.2021.1904230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The time interval between one pregnancy and the next is a modifiable risk factor, and has an effect on pregnancy outcomes. This study compared the effects of short interpregnancy interval (IPI) on fetal birthweight and selected pregnancy outcomes amongst parturients in Enugu, Nigeria. Group A (Subjects) consisted of parturients with short IPI (IPI < 18 months), while group B (Controls) consisted of parturients with normal IPI (IPI ≥ 18 months). Relevant obstetric data were collected at delivery. Mean birthweight was 2664.13 ± 339.25g vs 3670.63 ± 452.69g in women with short IPI and normal IPI respectively (p < .0001). Women with short IPI were more likely to have low birthweight babies compared to those with normal IPI (OR = 7.331, p < .001). Maternal anaemia, preeclampsia and caesarean delivery were significantly more associated with short IPI. Women with short IPI are at greater risk of delivering newborn babies with significantly lower mean birthweight and other associated pregnancy complications than women with normal IPI.Impact StatementWhat is already known on this subject? Short interpregnancy interval has an adverse effect on pregnancy outcomes as shown in studies from Europe and the Americas.What do the results of this study add? This study adds to the body of evidence of the deleterious effects of inadequately spaced pregnancies and draws attention to this in West Africa, sub-Saharan Africa, and an area with low contribution to studies on the effect of short IPI on pregnancy outcomes.What are the implications of these findings for clinical practice and/or further research? With evidence from our own environment, it will further boost evidence for proper education of our mothers on the need for adequate birth spacing to avoid the adverse effects of a short IPI on the next pregnancy.
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Affiliation(s)
- Henry C Nnaji
- Institute of Maternal and Child Health, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria.,Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Eric E Asimadu
- Institute of Maternal and Child Health, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria.,Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.,Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
| | - Uzochukwu U Aniebue
- Institute of Maternal and Child Health, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria.,Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.,Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
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Gifford K, McDuffie MJ, Rashid H, Knight EK, McColl R, Boudreaux M, Rendall MS. Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population. Contraception 2021; 104:284-288. [PMID: 34023380 DOI: 10.1016/j.contraception.2021.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type. STUDY DESIGN We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status. RESULTS Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI. CONCLUSIONS In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth. IMPLICATIONS Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.
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Affiliation(s)
- Katie Gifford
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States.
| | - Mary Joan McDuffie
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States
| | - Hira Rashid
- Office of Health Affairs, West Virginia University
| | - Erin K Knight
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States
| | - Rebecca McColl
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States
| | - Michel Boudreaux
- University of Maryland School of Public Health, University of Maryland, College Park, MD, United States
| | - Michael S Rendall
- Maryland Population Research Center, University of Maryland, College Park, MD, United States
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Changes in Rates of Inpatient Postpartum Long-Acting Reversible Contraception and Sterilization in the USA, 2012-2016. Matern Child Health J 2021; 25:1562-1573. [PMID: 33970416 DOI: 10.1007/s10995-021-03152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To examine recent rates of long-acting and permanent methods (LAPM) of contraception use during delivery hospitalization and correlates of their use. METHODS A retrospective cohort study utilizing the 2012-2016 National Inpatient Sample of hospitalizations in the United States of America. The International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes were used to identify deliveries, inpatient long-acting reversible contraception (IPP LARC), and postpartum tubal ligation (PPTL). We conducted univariable and multivariable logistic regression to examine associations between demographic, clinical, hospital and geographical characteristics with likelihood of LAPM including IPP LARC and PPTL. RESULTS Our sample included 3,642,328 unweighted deliveries. The rate of IPP LARC increased from 34.6 to 54.9 per 10,000 deliveries (58.7%), while the rate of PPTL utilization decreased from 719.5 to 671.8 per 10,000 deliveries (6.6%) over the study period. In multivariable analysis of LAPM utilization versus neither, cesarean delivery (aOR 7.25, 95% CI 7.08-7.43) was associated with greater utilization. Native American (aOR 4.01, 95% CI 2.91-5.53) race was associated with increased use of IPP LARC compared to a non-long-acting method of contraception. Age between 18 and 29 years (aOR 6.21, 95% CI 5.42-7.11) was associated with greater use of IPP LARC versus PPTL. Delivering in a rural hospital ((aOR 0.09, 95% CI 0.06-0.12) and cesarean delivery (aOR 0.09, 95% CI 0.06-0.12) were associated with greater use PPTL versus IPP LARC. CONCLUSIONS The IPP LARC rate remains at less than 10% the PPTL rates in our study timeframe. The demonstrated variation in uptake of highly effective methods of contraception inpatient after delivery offer possible opportunities for better understanding and improvement in access.
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Wu J, Ye J, OuYang Z, Wan Z, Zhang Q, Zhong B, Wei S. Outcomes of reproduction following cesarean scar pregnancy treatment: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 262:80-92. [PMID: 33993066 DOI: 10.1016/j.ejogrb.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To explore the reproductive outcomes of women with a history of cesarean scar pregnancy (CSP) and the influence of various treatments on subsequent pregnancy outcomes. STUDY DESIGN The PubMed, Embase, Medline, Cochrane Library and ClinicalTrial.gov databases were searched for studies with the outcomes of pregnancy after CSP treatment. Studies that reported reproductive outcomes after CSP with more than 5 followed cases were included. The main data collected includes the treatment methods of CSP and subsequent pregnancy outcomes. The main information includes intrauterine pregnancy, recurrent CSP (RCSP), and spontaneous miscarriage, while the secondary information includes complications during pregnancies and the outcomes of childbirths. According to different treatments (conservative treatment, surgical treatment without resection of cesarean scar, and surgical treatment with resection of cesarean scar), a stratified analysis was carried out to compare the influence of treatments on subsequent pregnancy outcomes. RESULTS A total of 32 studies including 3380 cases of CSP met the inclusion criteria, of which 583 cases conceived again after treatment (including 292 cases of unexpected pregnancy), and finally 178 cases delivered successfully. The follow-up time ranged from 3 to 72 months. Among women with fertility requirements, a total of 291 cases in 403 women were successfully conceived during the follow-up period in 15 studies. Thence the pregnancy rate of women with fertility requirements was 76.2 %. Among all of the 583 successfully conceived women, 83.4 % of them had intrauterine pregnancy, while 15.3 % of cases were RCSP. The total ectopic pregnancy rate reached 16.6 %, covering RCSP and other sites of ectopic pregnancy. 14.6 % of intrauterine pregnancy experienced spontaneous miscarriage. The intrauterine pregnancy rates of the conservative treatment group, the surgical treatment without resection of cesarean scar group, and the surgical treatment with resection of cesarean scar group were 93.1 %, 80.1 % and 86.0 % respectively; the corresponding RCSP rates were 6.9 %, 15.6 % and 14.0 % respectively; and the corresponding spontaneous miscarriage rates were 20.7 %, 13.9 % and 22.2 % respectively. CONCLUSION The outcomes of reproduction after CSP included intrauterine pregnancy, RCSP and other sites of ectopic pregnancy. Women with a history of CSP still have a high pregnancy rate, but the risk of RCSP and spontaneous miscarriage is also increased. It is impossible to clarify the effect of different treatments on subsequent pregnancy. Whether the resection and repair of cesarean scar can ameliorate reproductive outcomes needs to be further assessed. Further large-scale prospective studies, even RCTs with long-term follow-up are needed to expound the outcomes of reproduction after CSP and the effect of different treatments on subsequent reproductive outcomes.
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Affiliation(s)
- Jiawen Wu
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Jianbin Ye
- Department of Intensive Care Unit, Puning People's Hospital, Puning, China
| | - Zhenbo OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China.
| | - Zixian Wan
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Qiushi Zhang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Biting Zhong
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Shiyuan Wei
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
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Abstract
Teen pregnancy and parenting remain important public health issues in the United States and around the world. A significant proportion of teen parents reside with their families of origin, which may positively or negatively affect the family structure. Teen parents, defined as those 15 to 19 years of age, are at high risk for repeat births. Pediatricians can play an important role in the care of adolescent parents and their children. This clinical report updates a previous report on the care of adolescent parents and their children and addresses clinical management specific to this population, including updates on breastfeeding, prenatal management, and adjustments to parenthood. Challenges unique to teen parents and their children are reviewed, along with suggestions for the pediatrician on models for intervention and care.
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Affiliation(s)
- Makia E Powers
- Children's Healthcare of Atlanta and Morehouse School of Medicine, Atlanta, Georgia; and
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60
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Davis MB, Arendt K, Bello NA, Brown H, Briller J, Epps K, Hollier L, Langen E, Park K, Walsh MN, Williams D, Wood M, Silversides CK, Lindley KJ. Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5. J Am Coll Cardiol 2021; 77:1763-1777. [PMID: 33832604 DOI: 10.1016/j.jacc.2021.02.033] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Katherine Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Haywood Brown
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
| | - Joan Briller
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kelly Epps
- Division of Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
| | - Lisa Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Mary Norine Walsh
- Division of Cardiology, St. Vincent Heart Center, Indianapolis, Indiana, USA
| | - Dominique Williams
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Malissa Wood
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Candice K Silversides
- Division of Cardiology, Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Lappen JR, Pettker CM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B2-B15. [PMID: 33309560 DOI: 10.1016/j.ajog.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Kaimal A, Norton ME. Society for Maternal-Fetal Medicine Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B16-B23. [PMID: 33309561 DOI: 10.1016/j.ajog.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Women should be provided with evidence-based information when considering options for contraception and pregnancy management. When counseling about health conditions and available treatments, healthcare practitioners should employ strategies that encourage the incorporation of informed patient preferences into a shared decision-making process with the patient. To optimize the health of women at risk of experiencing adverse health outcomes during or after pregnancy, counseling should be a continuous process throughout the reproductive life course. The purpose of this Consult is to provide guidance for all healthcare practitioners about counseling reproductive-aged women who may be at high risk of experiencing maternal morbidity or mortality.
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Affiliation(s)
- Anjali Kaimal
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Mary E Norton
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Brock CO, Blackwell SC, Chauhan SP. Assessment of evidence underlying guidelines by the Society for Maternal-Fetal Medicine. Am J Obstet Gynecol 2021; 224:223.e1-223.e10. [PMID: 32835718 DOI: 10.1016/j.ajog.2020.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/03/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Society for Maternal-Fetal Medicine, sometimes together with the American College of Obstetricians and Gynecologists, publishes guidelines utilizing the Grading of Recommendations, Assessment, Development, and Evaluation system to rate the quality of evidence and assign the strength of its recommendations. The strength of recommendations is determined by the quality of evidence and 3 other strength determinants that are defined in this system. OBJECTIVE This study aimed to assess all recommendations by the Society for Maternal-Fetal Medicine assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system, determine the quality of evidence supporting them, evaluate the relationship between quality of evidence and strength of recommendations, and determine the extent to which the other 3 strength determinants were employed to assign recommendation strength. STUDY DESIGN All publications from the Society for Maternal-Fetal Medicine Publications and Guidelines website were reviewed, but only the ones with Grading of Recommendations, Assessment, Development, and Evaluation recommendations were analyzed. These were aggregated by their rating for quality of evidence and strength. Quality and strength were first compared across all recommendations. Subsequently, they were compared with stratification by recommendation topic and type (eg, interventions, counseling, screening, and diagnosis). References supporting each recommendation were also summarized by type (eg, randomized trial, retrospective study). The quality of evidence for each recommendation was then compared with the supporting reference types. Other characteristics that may contribute to strength were also evaluated. Finally, we compared recommendations authored jointly by the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists with those by the Society for Maternal-Fetal Medicine alone. RESULTS The Society for Maternal-Fetal Medicine published 24 documents containing 235 recommendations assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system. There were 35 (15%) recommendations supported by high-quality evidence; 34 (97%) were determined to be strong. Recommendations supported by moderate-quality (n=102) and low-quality (n=75) evidence were also rated as strong in 78% and 68% of cases, respectively. Recommendations were supported by randomized trials 8% of the time and references that summarize primary data (eg, meta-analyses, reviews, previous guidelines) 64% of the time. Recommendations with higher quality evidence ratings were more likely to be supported by references that summarize primary data (69% high-quality, 74% moderate-quality, 49% low-quality). Topics with recommendations authored jointly by the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists were supported by higher quality evidence than those by the Society for Maternal-Fetal Medicine alone (high quality, 26% vs 9%, respectively). CONCLUSION Recommendations by the Society for Maternal-Fetal Medicine assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system were supported by high-quality evidence in 15% of cases. This suggests that well-designed, high-quality clinical trials remain a priority in obstetrics. Strong recommendations were often made on the basis of Grading of Recommendations, Assessment, Development, and Evaluation strength determinants other than quality of evidence. Increased transparency of the Society for Maternal-Fetal Medicine's determination of strong recommendations based on strength determinants other than quality of the evidence may be useful to practicing clinicians.
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Affiliation(s)
- Clifton O Brock
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX.
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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Wilson EK, Koo HP, Minnis AM. Factors influencing women's decisions about pregnancy spacing: Findings from a focus group discussion study. Contraception 2020; 103:190-194. [PMID: 33285098 DOI: 10.1016/j.contraception.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Very short interpregnancy intervals are associated with negative health outcomes for mothers and children, and pregnancies with very short interpregnancy intervals are more likely to be unintended than pregnancies that are more widely spaced. The objective of this study was to improve understanding of women's motivations regarding pregnancy spacing. METHODS In 2017, we conducted 8 focus group discussions with 49 English- and Spanish-speaking postpartum women in central North Carolina. The groups explored participants' preferences for birth spacing and factors that influenced their decisions. We recorded, transcribed, and coded the discussions and analyzed these data for core themes. RESULTS Participants' ideas about when and whether to have more children were fluid-some had specific ideas during pregnancy or after delivery that changed over time; others had no definite plans. The primary reason for close birth spacing was to promote their children's having a closer relationship. Reasons for wider spacing included recovery from the previous pregnancy, challenges related to having 2 babies concurrently, and desire to wait for more favorable life circumstances. Participants did not mention health risks to children of short interpregnancy intervals and said that no health care providers discussed these risks with them. They had mixed perspectives about whether this information would influence their own child-spacing preferences but agreed that it should be shared with women to promote informed decision-making. CONCLUSION This study adds to limited research regarding the factors that women consider when determining pregnancy spacing. Better understanding of women's motivations can help inform counseling to help women achieve their desired pregnancy spacing.
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Affiliation(s)
| | - Helen P Koo
- RTI International, Research Triangle Park, NC, United States
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65
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Abstract
Preterm birth occurs in approximately 10% of all births in the United States and is a major contributor to perinatal morbidity and mortality (). Prelabor rupture of membranes (PROM) that occurs preterm complicates approximately 2-3% of all pregnancies in the United States, representing a significant proportion of preterm births, whereas term PROM occurs in approximately 8% of pregnancies (). The optimal approach to assessment and treatment of women with term and preterm PROM remains challenging. Management decisions depend on gestational age and evaluation of the relative risks of delivery versus the risks (eg, infection, abruptio placentae, and umbilical cord accident) of expectant management when pregnancy is allowed to progress to a later gestational age. The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented. This Practice Bulletin is updated to include information about diagnosis of PROM, expectant management of PROM at term, and timing of delivery for patients with preterm PROM between 34 0/7 weeks of gestation and 36 6/7 weeks of gestation.
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Regan AK, Arnaout A, Marinovich L, Marston C, Patino I, Kaur R, Gebremedhin A, Pereira G. Interpregnancy interval and risk of perinatal death: a systematic review and meta-analysis. BJOG 2020; 127:1470-1479. [PMID: 32378279 DOI: 10.1111/1471-0528.16303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Interpregnancy interval (IPI) <6 months is a potentially modifiable risk factor for adverse perinatal health outcomes. OBJECTIVE This systematic review evaluated the international literature on the risk of perinatal death associated with IPI. SEARCH STRATEGY Two independent reviewers screened titles and abstracts identified in MEDLINE, EMBASE and Scopus from inception to 4 April 2019 (Prospero Registration #CRD42018092792). SELECTION CRITERIA Studies were included if they provided a description of IPI measurement and perinatal death, including stillbirth and neonatal death. DATA COLLECTION AND ANALYSIS A narrative review was performed for all included studies. Random effects meta-analysis was used to compare unadjusted odds of perinatal death associated with IPI <6 months and IPI ≥6 months. Analyses were performed by outcome of the preceding pregnancy and study location. MAIN RESULTS Of the 624 unique articles identified, 26 met the inclusion criteria. The pooled unadjusted odds ratio of perinatal death for IPI <6 months was 1.34 (95% CI 1.17-1.53) following a previous live birth, 0.85 (95% CI 0.73-0.99) following a previous miscarriage and 1.07 (95% CI 0.84-1.36) following a previous stillbirth compared with IPI ≥6 months. However, few high-income country studies reported an association after adjustment. Fewer studies evaluated the impact of long IPI on perinatal death and what evidence was available showed mixed results. CONCLUSIONS Results suggest a possible association between short IPI and risk of perinatal death following a live birth, particularly in low- to middle-income countries. TWEETABLE ABSTRACT Short IPI <6 months after a live birth was associated with greater risk of perinatal death than IPI ≥6 months.
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Affiliation(s)
- A K Regan
- School of Public Health, Texas A&M University, College Station, TX, USA.,School of Public Health, Curtin University, Perth, WA, Australia
| | - A Arnaout
- School of Public Health, Curtin University, Perth, WA, Australia
| | - L Marinovich
- School of Public Health, Curtin University, Perth, WA, Australia
| | - C Marston
- London School of Tropical Medicine and Hygiene, London, UK
| | - I Patino
- School of Public Health, Texas A&M University, College Station, TX, USA
| | - R Kaur
- School of Public Health, Texas A&M University, College Station, TX, USA
| | - A Gebremedhin
- School of Public Health, Curtin University, Perth, WA, Australia
| | - G Pereira
- School of Public Health, Curtin University, Perth, WA, Australia.,Centre for Fertility and Health, Norwegian Public Health Institute, Oslo, Norway
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Krist AH, Davidson KW, Mangione CM, Barry MJ, Cabana M, Caughey AB, Curry SJ, Donahue K, Doubeni CA, Epling JW, Kubik M, Ogedegbe G, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Unhealthy Drug Use: US Preventive Services Task Force Recommendation Statement. JAMA 2020; 323:2301-2309. [PMID: 32515821 DOI: 10.1001/jama.2020.8020] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE An estimated 12% of adults 18 years or older and 8% of adolescents aged 12 to 17 years report unhealthy use of prescription or illegal drugs in the US. OBJECTIVE To update its 2008 recommendation, the USPSTF commissioned reviews of the evidence on screening by asking questions about drug use and interventions for unhealthy drug use in adults and adolescents. POPULATION This recommendation statement applies to adults 18 years or older, including pregnant and postpartum persons, and adolescents aged 12 to 17 years in primary care settings. This statement does not apply to adolescents or adults who have a currently diagnosed drug use disorder or are currently undergoing or have been referred for drug use treatment. This statement applies to settings and populations for which services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. EVIDENCE ASSESSMENT In adults, the USPSTF concludes with moderate certainty that screening by asking questions about unhealthy drug use has moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred. In adolescents, because of the lack of evidence, the USPSTF concludes that the benefits and harms of screening for unhealthy drug use are uncertain and that the balance of benefits and harms cannot be determined. RECOMMENDATION The USPSTF recommends screening by asking questions about unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents. (I statement).
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Affiliation(s)
| | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | | | | | | | | | | | | | | | | | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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Abstract
Pregnancy and the postpartum period are ideal times for health care providers to identify and address the contraceptive needs and desires of patients. In addition to the opportunity to promote healthy pregnancy spacing, individuals can also be cared for at a time when it is convenient, they have access to health care, and they are motivated to prevent repeat pregnancy. Patient-centered care using a shared medical decision-making framework can not only promote positive patient-provider interactions but also increase positive outcomes. Comprehensive provision of information on all methods and identification of contraceptive preferences can help patients select the best option.
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Affiliation(s)
- Serina Floyd
- Planned Parenthood of Metropolitan Washington, DC, Washington, DC, USA.
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69
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Lewkowitz AK, López JD, Carter EB, Duckham H, Strickland T, Macones GA, Cahill AG. Impact of a novel smartphone application on low-income, first-time mothers' breastfeeding rates: a randomized controlled trial. Am J Obstet Gynecol MFM 2020; 2:100143. [PMID: 33345878 DOI: 10.1016/j.ajogmf.2020.100143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/09/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Low-income women are less likely to exclusively breastfeed at postpartum day 2 compared with high-income women, but focus groups of low-income women have suggested that on-demand videos on breastfeeding and infant behavior would support exclusive breastfeeding beyond postpartum day 2. Smartphone applications provide on-demand video. OBJECTIVE This study aimed to determine whether a novel smartphone application-Breastfeeding Friend-increases breastfeeding rates for low-income, first-time mothers. STUDY DESIGN This double-blinded randomized trial recruited low-income, first-time mothers at 36 weeks' gestation. Consenting women received a complimentary Android smartphone and internet service before 1:1 randomization to Breastfeeding Friend or a control smartphone application. Breastfeeding Friend was created by a multidisciplinary team of perinatologists, neonatologists, lactation consultants, and a middle school teacher and was refined by end-user focus groups. Breastfeeding Friend contained on-demand education and videos on breastfeeding and newborn behavior, tailored to a fifth-grade reading level. The control smartphone application contained digital breastfeeding handouts. The primary outcome was exclusive breastfeeding at postpartum day 2; secondary outcomes were breastfeeding rates until 6 months postpartum and patient-reported best breastfeeding resource. Primary statistical analyses compared outcomes between study groups through intention-to-treat analysis; prespecified secondary analyses did so per protocol. A total of 170 women (85 per arm) were needed to determine whether Breastfeeding Friend increased exclusive breastfeeding at postpartum day 2 from 34% (known baseline) to 56%. RESULTS A total of 253 women were approached; 170 women enrolled. Most participants were black, with more than half reporting annual household incomes of less than $25,000. Exclusive breastfeeding rates at postpartum day 2 were low and similar among Breastfeeding Friend and control smartphone application users (n=30 [36.6%] vs n=30 [35.7%]; relative risk, 1.02; 95% confidence interval, 0.068-1.53). Breastfeeding rates until 6 months postpartum were also similar between study groups: the rate of exclusive breastfeeding was 8.3% (n=5) and 10.4% (n=7) in the Breastfeeding Friend and control smartphone application groups, respectively (relative risk, 0.8; 95% confidence interval, 0.27-2.38). At 6 weeks postpartum, most Breastfeeding Friend smartphone application users (n=34 [52.3%]) rated their smartphone application as providing the best breastfeeding support. Excluding women who did not use their study smartphone application (Breastfeeding Friend, n=18 [21.4%]; control smartphone application, n=9 [10.6%]) did not affect outcomes. CONCLUSION Neither of the smartphone applications improved breastfeeding rates among low-income, first-time mothers above the known baseline rates, despite user perception that Breastfeeding Friend was the best breastfeeding resource at 6 weeks postpartum. By demonstrating the feasibility of smartphone application-based interventions within a particularly high-needs population, our research supports efforts in obstetrics to examine whether mobile health improves peripartum health outcomes.
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Affiliation(s)
- Adam K Lewkowitz
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO; Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, Providence, RI.
| | - Julia D López
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - Ebony B Carter
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - Hillary Duckham
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - Tianta Strickland
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - George A Macones
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO; Department of Women's Health, University of Texas at Austin, Dell Medical School, Austin, TX
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
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Abstract
Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).
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Blackwell S, Louis JM, Norton ME, Lappen JR, Pettker CM, Kaimal A, Landy U, Edelman A, Teal S, Landis R. Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning. Am J Obstet Gynecol 2020; 222:B2-B18. [PMID: 32252942 DOI: 10.1016/j.ajog.2019.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Salahuddin M, Mandell DJ, Lakey DL, Ramsey PS, Eppes CS, Davidson CM, Ortique CF, Patel DA. Maternal comorbidity index and severe maternal morbidity during delivery hospitalizations in Texas, 2011-2014. Birth 2020; 47:89-97. [PMID: 31659788 DOI: 10.1111/birt.12465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Severe maternal morbidity (SMM) prevalence was 194.0 per 10 000 deliveries in Texas in 2015. Chronic, behavioral, and pregnancy-induced conditions, as captured by a maternal comorbidity index, increase the risk for delivery-related morbidity and mortality. The objective of the study was to examine the association between maternal comorbidity index and SMM among delivery hospitalizations in Texas. METHODS Delivery-related hospitalizations among Texan women aged 15-49 years were identified using the 2011-2014 Texas all-payer inpatient hospitalization public use data files (n = 1 434 441). The primary outcome of interest was SMM, based on the Alliance for Innovation on Maternal Health's coding scheme. The exposure of interest was a maternal comorbidity index. Multivariable logistic regression model was used to examine the association between maternal comorbidity index and SMM. RESULTS SMM prevalence remained consistent between 2011 and 2014 (196.0-197.0 per 10 000 deliveries, P > .05; n = 1 434 441). Nearly 40% of delivery-related hospitalizations had a maternal comorbidity index of at least 1, and the proportion of deliveries in the highest risk category of comorbidity index (≥5) increased by 12.0% from 2011 to 2014. SMM prevalence was highest among the youngest and oldest age groups. With each unit increase in maternal comorbidity index, the odds of SMM increase was 1.43 (95% CI 1.42-1.43). CONCLUSIONS Maternal comorbidity index is associated with SMM; however, the low predictive power of the model suggests that other, unmeasured factors may influence SMM in Texas. These findings highlight a need to understand broader contextual factors (practitioner, facility, systems of care, and community) that may be associated with SMM to reduce maternal morbidity and mortality in Texas.
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Affiliation(s)
- Meliha Salahuddin
- Texas Collaborative for Healthy Mothers and Babies, University of Texas Health Science Center at Tyler, Population Health, Office of Health Affairs, University of Texas System, Austin, Texas, USA
| | - Dorothy J Mandell
- Texas Collaborative for Healthy Mothers and Babies, University of Texas Health Science Center at Tyler, Population Health, Office of Health Affairs, University of Texas System, Austin, Texas, USA
| | - David L Lakey
- Texas Collaborative for Healthy Mothers and Babies, Office of Health Affairs, University of Texas System, Austin, Texas, USA
| | - Patrick S Ramsey
- Texas Collaborative for Healthy Mothers and Babies, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Catherine S Eppes
- Texas Collaborative for Healthy Mothers and Babies (TCHMB), Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Christina M Davidson
- Texas Collaborative for Healthy Mothers and Babies (TCHMB), Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Carla F Ortique
- Texas Collaborative for Healthy Mothers and Babies (TCHMB), Baylor College of Medicine, Houston, Texas, USA
| | - Divya A Patel
- Texas Collaborative for Healthy Mothers and Babies, University of Texas Health Science Center at Tyler, Population Health, Office of Health Affairs, University of Texas System, Austin, Texas, USA
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Lewkowitz AK, Rosenbloom JI, Keller M, López JD, Macones GA, Olsen MA, Cahill AG. Association between stillbirth ≥23 weeks gestation and acute psychiatric illness within 1 year of delivery. Am J Obstet Gynecol 2019; 221:491.e1-491.e22. [PMID: 31226297 PMCID: PMC6829063 DOI: 10.1016/j.ajog.2019.06.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Stillbirth has been associated with emotional and psychologic symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known. OBJECTIVE The purpose of this study was to determine whether women have a higher risk of experiencing clinician-diagnosed psychiatric morbidity in the year after stillbirth vs livebirth. STUDY DESIGN This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department databases. The first delivery of female Florida residents aged 13-54 years old from 2005-2014 was included; women with International Classification of Diseases, 9th Revision, Clinical Modification coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during delivery hospitalization of a stillbirth at ≥23 weeks gestation. The primary outcome was a primary or secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during an Emergency Department encounter or inpatient admission within 1 year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite of drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth vs livebirth using multivariable logistic regression, adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model. RESULTS A total of 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within 1 year of hospital discharge after stillbirth, 4.0% of the women (n=331) had an Emergency Department encounter or inpatient admission that was coded for psychiatric morbidity; the risk was nearly 2.5 times higher compared with livebirth (1.6%; n=19,746); adjusted odds ratio, 2.47; 95% confidence interval, 2.20- 2.77). Women also had higher risk of having an Emergency Department encounter or inpatient admission coded for drug or alcohol use or dependence in the year after delivery of stillbirth vs livebirth (124 [1.5%] vs 7033 [0.6%]; adjusted odds ratio, 2.41; 95% confidence interval, 1.99-2.90). Cox proportional hazard modeling suggested that the highest risk interval for postpartum psychiatric illness was within 4 months of stillbirth delivery (adjusted hazard ratio, 3.26; 95% confidence interval, 2.63-4.04), although the risk remained high during the 4-12 months after delivery (adjusted hazard ratio, 2.42; 95% confidence interval, 2.13-2.76). CONCLUSION Coding for psychiatric illness or substance misuse in Emergency Department visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly 2 per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until 4 months after delivery.
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Affiliation(s)
- Adam K Lewkowitz
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO.
| | - Joshua I Rosenbloom
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - Matt Keller
- Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Julia D López
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - George A Macones
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - Margaret A Olsen
- Department of Medicine, Washington University in St. Louis, St. Louis, MO; Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
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Lewkowitz AK, Rosenbloom JI, Keller M, López JD, Macones GA, Olsen MA, Cahill AG. Association Between Severe Maternal Morbidity and Psychiatric Illness Within 1 Year of Hospital Discharge After Delivery. Obstet Gynecol 2019; 134:695-707. [PMID: 31503165 PMCID: PMC7035949 DOI: 10.1097/aog.0000000000003434] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge. METHODS This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome. RESULTS A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58-1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05-3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64-2.23]). CONCLUSION Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.
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Affiliation(s)
- Adam K Lewkowitz
- Department of Obstetrics and Gynecology, the Center for Administrative Data Research, Department of Medicine, and the Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
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75
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Seifer DB, Kallen AN. A counterintuitive lesson in family planning? Patience first: taking a "gap year" after live birth from assisted reproductive technology before frozen embryo transfer is performed. Fertil Steril 2019; 111:1109-1110. [PMID: 31056317 DOI: 10.1016/j.fertnstert.2019.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 11/27/2022]
Affiliation(s)
- David B Seifer
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Amanda N Kallen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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