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Leon-Martinez D, Bank TC, Lundsberg LS, Culhane J, Silasi M, Son M, Partridge C, Reddy UM, Hoffman MK, Merriam AA. Does Antenatal Progesterone Administration Modify the Risk of Neonatal Intraventricular Hemorrhage? Am J Perinatol 2024; 41:e46-e52. [PMID: 35436803 DOI: 10.1055/a-1827-6712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Progesterone administration has been associated with improved neurological outcomes following traumatic brain injury in adults. However, studies examining the effect of progesterone on the risk of neonatal intraventricular hemorrhage (IVH) are inconsistent. We sought to determine if maternal administration of intramuscular 17-α-hydroxyprogesterone caproate (17-OHPC) is associated with decreased rates of IVH in infants born before 32-weeks gestation. STUDY DESIGN This is a retrospective study of liveborn singleton deliveries between 20- and 32-weeks gestation at two large academic medical centers from January 1, 2012 to August 30, 2020. Data were extracted from hospital electronic medical record data warehouses using standardized definitions and billing and diagnosis codes. We evaluated receipt of 17-OHPC in the antepartum period and diagnosis of IVH (grade I-IV, per Volpe classification) during the neonatal delivery hospitalization encounter. Bivariate and multivariate analyses were performed to examine the association between 17-OHPC and neonatal IVH adjusting for potential confounders. Odds ratio (ORs) and 95% confidence intervals (CIs) were presented. RESULTS Among 749 neonates born between 20- and 32-week gestation, 140 (18.7%) of their mothers had received antenatal 17-OHPC and 148 (19.8%) were diagnosed with IVH after birth. No significant association was observed between maternal 17-OHPC and neonatal IVH in unadjusted (OR 1.14, 95% CI 0.72-1.78) or adjusted analyses (adjusted odds ratio 1.14, 95% CI 0.71-1.84). Independent of exposure to 17-OHPC, as expected, infants born <28-weeks gestation or those with very low birthweight (<1,500 g) were at an increased risk of IVH (OR 2.32, 95% CI 1.55-3.48 and OR 2.19, 95% CI 1.09-4.38, respectively). CONCLUSION Antenatal maternal 17-OHPC administration was not associated with the risk of neonatal IVH. Further research may be warranted to determine whether timing, route of delivery, and duration of progesterone therapy impact rates of neonatal IVH. KEY POINTS · This study aimed to compare the frequency of intraventricular hemorrhage in preterm neonates exposed to antenatal 17-α-hydroxyprogesterone caproate to those not exposed.. · In neonates born at <32-weeks gestation, maternal use of progesterone is not associated with the risk of intraventricular hemorrhage.. · In contrast to preclinical and adult data, this study suggests that progesterone exposure is not associated with the prevention of neonatal brain injury..
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Affiliation(s)
- Daisy Leon-Martinez
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Tracy C Bank
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer Culhane
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle Silasi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Moeun Son
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Caitlin Partridge
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Uma M Reddy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew K Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
| | - Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
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Merriam AA, Lundsberg L, Cutler AS, Maxam T, Paul M. Collaboration between maternal-fetal medicine and family planning: a survey of Northeast US academic medical centers. J Perinat Med 2024; 52:81-89. [PMID: 37853776 DOI: 10.1515/jpm-2023-0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To explore how complex family planning (CFP) and maternal-fetal medicine (MFM) in Northeast academic medical centers work together to provide abortion care. METHODS We distributed an exploratory cross-sectional online survey to CFP and MFM faculty and fellows at academic medical centers in the Northeast between July and September of 2020. The survey included demographic information, assessment of practice patterns, hospital/administration support and assessment of collaboration. Likert scale questions examined opinions about collaboration and an open-ended question solicited ideas for improvement. We performed bivariate analysis to examine the association between subspecialty and practice location regarding provision of abortion care and perceived barriers to care. RESULTS The response rate was 31 % and was similar by specialty. Of the 69 respondents, 83 % were MFMs, 75 % were faculty, and 54 % practiced in New York. More than 85 % reported personal participation in some portion of abortion care. The two most common perceived barriers to care were "lack or reluctance of physicians/staff" and state laws prohibiting termination. Nearly all (95 %) stated there was a good working relationship between CFP and MFM divisions; however, almost one-third agreed with or were neutral to the statements "MFM and CFP are siloed in terms of work/patient care." CONCLUSIONS Academic MFM and CFP providers in the Northeast collaborate well in providing abortion care, though our findings highlight areas that would benefit from improvement. Optimizing collaboration in the Northeast is important given its regional role for ensuring abortion access in the current national landscape. Improved education of all members of the patient care team on the importance of abortion access may also help provide optimal patient care where abortion services still legally exist.
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Affiliation(s)
| | | | - Abigail S Cutler
- University of Wisconsin School of Medicine and Public Health, Madison, USA
| | | | - Maureen Paul
- Beth Israel Deaconess Medical Center, Boston, USA
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Merriam AA, Metz TD, Allshouse AA, Silver RM, Haas DM, Grobman WA, Simhan HN, Wapner RJ, Wing D, Mercer BM, Parry S, Reddy UM. Reply: The Risk Factor for Maternal Morbidity is Racism, Not Race. Am J Perinatol 2023. [PMID: 37863072 DOI: 10.1055/a-2195-6914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Affiliation(s)
- Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, Connecticut
| | - Torri D Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Hyagriv N Simhan
- Department of Obstetrics and Gynecology, The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Deborah Wing
- Department of Obstetrics and Gynecology, University of California-Irvine, Irvine, California
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
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Merriam AA. Navigating Infertility When Practicing Obstetrics. Obstet Gynecol 2023; 142:1255-1257. [PMID: 37708517 DOI: 10.1097/aog.0000000000005350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/13/2023] [Indexed: 09/16/2023]
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White KJ, Son M, Lundsberg LS, Culhane JF, Partridge C, Reddy UM, Merriam AA. Low-Dose Aspirin during Pregnancy and Postpartum Bleeding. Am J Perinatol 2023; 40:1390-1397. [PMID: 37211010 DOI: 10.1055/a-2096-5199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE This study aimed to investigate whether aspirin 81 mg daily for preeclampsia prevention is associated with increased risk of postpartum blood loss at the time of delivery. STUDY DESIGN This is a retrospective cohort study performed at a tertiary hospital from January 2018 to April 2021. Data were extracted from the electronic medical record. Patients prescribed low-dose aspirin (LDA) were compared with patients who were not. The primary outcome was a composite of postpartum blood loss, defined as: estimated blood loss (EBL) >1,000 mL, documentation of International Classification of Diseases-9/-10 codes for postpartum hemorrhage (PPH), or red blood cell (RBC) transfusion. Bivariate analysis, and unadjusted and adjusted logistic regression modeling were performed. RESULTS Among 16,980 deliveries, 1,922 (11.3%) were prescribed LDA. Patients prescribed LDA were more likely to be >35 years old, nulliparous, obese, taking other anticoagulants, or have diagnoses of diabetes, systemic lupus erythematosus, fibroids, or hypertensive disease of pregnancy. After adjusting for potential confounders, the significant association between LDA use and the composite did not persist (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 1.0-1.3) nor did the association between EBL > 1,000 mL (aOR: 1.0, 95% CI: 0.9-1.3) and RBC transfusion (aOR: 1.3, 95% CI: 0.9-1.7). The association between LDA and PPH remained significant (aOR: 1.3, 95% CI: 1.1-1.6). Patients who discontinued LDA <7 days prior to delivery had an increased risk of the postpartum blood loss composite compared discontinuation ≥7 days (15.0 vs. 9.3%; p = 0.03). CONCLUSION There may be an association between LDA use and increased risk of postpartum bleeding. This suggests that use of LDA outside the recommended guidelines should be cautioned and further investigation is needed to determine its ideal dosing and timing of discontinuation. KEY POINTS · There may be an association with LDA and an increased risk of postpartum bleeding.. · Patients who discontinued LDA less than 7 days prior to delivery had an increased rate of postpartum bleeding.. · Additional research is need to determine optimal LDA dose and timing of discontinuation..
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Affiliation(s)
- Kelsey J White
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Moeun Son
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer F Culhane
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Caitlin Partridge
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
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Grechukhina O, Lipkind HS, Lundsberg LS, Merriam AA, Raab C, Leon-Martinez D, Campbell KH. Severe Maternal Morbidity Review and Preventability Assessment in a Large Academic Center. Obstet Gynecol 2023; 141:857-860. [PMID: 36897178 DOI: 10.1097/aog.0000000000005116] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/22/2023] [Indexed: 03/11/2023]
Abstract
With the goal of identifying factors contributing to severe maternal morbidity (SMM) at our institution, we established a formal SMM review process. We performed a retrospective cohort study including all SMM cases as defined by American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine consensus criteria that were managed at Yale-New Haven Hospital over a 4-year period. Overall, 156 cases were reviewed. The SMM rate was 0.49% (95% CI 0.40-0.58). The leading causes of SMM were hemorrhage (44.9%) and nonintrauterine infection (14.1%). Two thirds of the cases were deemed to be preventable. Preventability was mostly associated with health care professional-level (79.4%) and system-level (58.8%) factors that could coexist. Detailed case review allowed for identification of preventable causes of SMM, revealed gaps in care, and allowed for implementation of practice changes targeting health care professional-level and system-level factors.
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Affiliation(s)
- Olga Grechukhina
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, Connecticut
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Doughty KN, Abeyaratne D, Merriam AA, Taylor SN. Self-Efficacy and Outcomes in Women with Diabetes: A Prospective Comparative Study. Breastfeed Med 2023; 18:307-314. [PMID: 36999939 PMCID: PMC10124167 DOI: 10.1089/bfm.2022.0298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Background: Breastfeeding is especially beneficial to women with diabetes and their infants, yet diabetic mothers frequently experience less favorable breastfeeding outcomes. Objectives: To identify facilitators and barriers to breastfeeding for women with diabetes by comparing cognitive and social factors, health and hospital-related factors, and breastfeeding outcomes between women with and without diabetes. Design/Methods: Women with any type of diabetes (n = 28) and without diabetes (n = 29) were recruited during pregnancy. Data were collected from the electronic medical record and maternal surveys at 24-37 weeks' gestation, birth hospitalization, and 4 weeks' postbirth. We compared differences in mother's regard for breastfeeding, breastfeeding intention, and birth hospital experience by diabetes status, and estimated odds ratios for exclusive breastfeeding (EBF) and unmet intention to breastfeed. Results: Women with and without diabetes had similar breastfeeding intentions, attitudes, and self-efficacy. Women with diabetes were less likely to EBF, and more likely to have unmet intentions to EBF at hospital discharge, compared to women without diabetes. At 4 weeks' postpartum, there was no difference in breastfeeding by diabetes status, although EBF at hospital discharge was strongly associated with EBF at 4 weeks. Infant neonatal intensive care unit (NICU) admission and hypoglycemia were significantly associated with diabetes status, reduced EBF rates, and unmet breastfeeding intentions. Conclusions: Despite having a strong intent to breastfeed, women with diabetes experienced less favorable early breastfeeding outcomes and were less likely to meet their own breastfeeding goals. These differences may be driven by neonatal complications, such as infant hypoglycemia and NICU admissions, rather than maternal cognitive and social factors.
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Affiliation(s)
- Kimberly N Doughty
- Egan School of Nursing and Health Studies, Public Health Fairfield University, Fairfield, Connecticut, USA
| | - Dhatri Abeyaratne
- Yale School of Medicine, Department of Pediatrics, Division of Neonatology, New Haven, Connecticut, USA
| | - Audrey A Merriam
- Yale School of Medicine, Department of Pediatrics, Division of Neonatology, New Haven, Connecticut, USA
| | - Sarah N Taylor
- Yale School of Medicine, Department of Pediatrics, Division of Neonatology, New Haven, Connecticut, USA
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Greenberg VR, Lundsberg LS, Reddy UM, Grobman WA, Parker CB, Parry S, Post RJ, Shanks AL, Silver RM, Simhan H, Wapner RJ, Merriam AA. Perinatal Outcomes in Obese Women with One Abnormal Value on 3-Hour Oral Glucose Tolerance Test. Am J Perinatol 2022; 39:464-472. [PMID: 34972230 DOI: 10.1055/s-0041-1740005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to determine if one abnormal value of four on the diagnostic 3-hour oral glucose tolerance test (OGTT) is associated with adverse perinatal outcomes in obese women. STUDY DESIGN This is a secondary analysis of a prospective study of nulliparous women in eight geographic regions. Women with body mass index <30 kg/m2 and pregestational diabetes mellitus (GDM) were excluded. Four groups were compared: (1) normal 50-g 1-hour glucose screen, (2) elevated 1-hour glucose screen with normal 100-g 3-hour diagnostic OGTT, (3) elevated 1-hour glucose screen and one of four abnormal values on 3-hour OGTT, and (4) GDM. Using multivariable logistic regression adjusting for covariates, the women in the groups with dysglycemia were compared with those in the normal screen group for maternal and neonatal outcomes. RESULTS Among 1,713 obese women, 1,418 (82.8%) had a normal 1-hour glucose screen, 125 (7.3%) had a normal 3-hour diagnostic OGTT, 72 (4.2%) had one abnormal value on their diagnostic OGTT, and 98 (5.7%) were diagnosed with GDM. The one abnormal value group had increased risk of large for gestational age (LGA) neonates (adjusted odds ratio [aOR] = 2.24, 95% confidence interval [CI]: 1.31-3.82), cesarean delivery (aOR = 2.19, 95% CI: 1.34-3.58), and hypertensive disorders of pregnancy (aOR = 2.19, 95% CI: 1.32-3.63) compared with normal screens. The one abnormal value group also had an increased risk of preterm birth <37 weeks (aOR = 2.63, 95% CI: 1.43-4.84), neonatal respiratory support (aOR = 2.38, 95% CI: 1.23-4.60), and neonatal hyperbilirubinemia (aOR = 2.00, 95% CI: 1.08-3.71). There was no association between one abnormal value with shoulder dystocia and neonatal hypoglycemia. CONCLUSION For obese women, one abnormal value on the 3-hour OGTT confers increased perinatal adverse outcomes. These women should be studied further to determine if nutrition counseling and closer fetal monitoring improve outcomes even in the absence of a diagnosis of GDM. KEY POINTS · Study of obese women with one abnormal value on OGTT.. · Adverse maternal and neonatal outcomes were found, including more LGA neonates.. · Neonates were not at increased risk of hypoglycemia..
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Affiliation(s)
- Victoria R Greenberg
- Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, Connecticut
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, Connecticut
| | - Uma M Reddy
- Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, Connecticut
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | | | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Rebecca J Post
- Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - Anthony L Shanks
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Hyagriv Simhan
- Department of Obstetrics, Gynecology, and Reproductive Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Audrey A Merriam
- Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, Connecticut
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Deshmukh US, Lundsberg LS, Culhane JF, Partridge C, Reddy UM, Merriam AA, Son M. Factors associated with appropriate treatment of acute-onset severe obstetrical hypertension. Am J Obstet Gynecol 2021; 225:329.e1-329.e10. [PMID: 34023314 DOI: 10.1016/j.ajog.2021.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/03/2021] [Accepted: 05/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists recommends that pregnant patients receive expeditious treatment with first-line antihypertensive agents within 1 hour of confirmed severe hypertension to reduce the risk for maternal stroke. However, it is unknown how often this guideline is followed and what factors influence a patient's likelihood of receiving guideline-concordant care. OBJECTIVE We aimed to identify factors associated with receiving guideline-concordant treatment for an obstetrical hypertensive emergency. STUDY DESIGN We present a case-control study of all pregnant and postpartum patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, or both within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from October 1, 2013, to August 31, 2020. Data were extracted from the hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined receipt of the recommended treatment as administration of a first-line antihypertensive agent (intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine) within 60 minutes of the first or second severe-range blood pressure measurement during their delivery hospitalization. Delayed treatment was defined as the administration of a first-line agent >60 minutes after the second elevated blood pressure measurement. Patients were considered untreated if a first-line agent was never administered. Maternal sociodemographic, clinical and pregnancy factors, and time and day of the week of the hypertensive emergency were compared among patients who received the recommended treatment, those who received delayed treatment, and those who were untreated. Bivariate analyses were performed, and multinomial and multivariable logistic regression models were used to adjust for potential confounders. RESULTS Of the 39,918 deliveries in the cohort, 1987 (5.0%) were complicated by severe, persistent obstetrical hypertension. Of these patients, 532 (26.8%) received the recommended treatment, 356 (17.9%) received delayed treatment, and 1099 (55.3%) did not receive any first-line antihypertensive therapy. The multinomial regression models that were used to compare these 3 groups indicated that patients who received the recommended treatment were more likely to be Black (adjusted odds ratio, 1.85; 95% confidence interval, 1.36-2.51), Hispanic (adjusted odds ratio, 1.77; 95% confidence interval, 1.28-2.52), or pregnant and at <37 weeks of gestation (adjusted odds ratio, 6.65; 95% confidence interval, 5.08-8.72). Treatment was less likely if the severe obstetrical hypertension emergency occurred overnight (7:00 PM to 6:59 AM) (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.97) or during the postpartum period (adjusted odds ratio, 0.66; 95% confidence interval, 0.51-0.86). CONCLUSION Approximately half of obstetrical patients with at least 2 documented severely elevated blood pressure measurements did not receive the recommended antihypertensive treatment. Of those who did receive treatment, about 40% had delayed treatment. Black and Hispanic race and preterm gestation were associated with an increased likelihood of receiving the recommended treatment when compared with White race and term pregnancies. Patients whose severe obstetrical hypertension emergency occurred overnight and those who were postpartum were less likely to receive any first-line antihypertensive treatment. Overall, patients without sociodemographic and clinical risk factors for severe obstetrical hypertension or other pregnancy complications were less likely to be treated. However, treatment improved significantly over time with the implementation of targeted quality measures and specific institutional policies based on the American College of Obstetricians and Gynecologists' latest severe obstetrical hypertension management guidelines.
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Affiliation(s)
- Uma S Deshmukh
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Jennifer F Culhane
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Caitlin Partridge
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Uma M Reddy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Moeun Son
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
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Perlman BE, Merriam AA, Lemenze A, Zhao Q, Begum S, Nair M, Wu T, Wapner RJ, Kitajewski JK, Shawber CJ, Douglas NC. Implications for preeclampsia: hypoxia-induced Notch promotes trophoblast migration. Reproduction 2021; 161:681-696. [PMID: 33784241 PMCID: PMC8403268 DOI: 10.1530/rep-20-0483] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/30/2021] [Indexed: 01/15/2023]
Abstract
In the first trimester of human pregnancy, low oxygen tension or hypoxia is essential for proper placentation and placenta function. Low oxygen levels and activation of signaling pathways have been implicated as critical mediators in the promotion of trophoblast differentiation, migration, and invasion with inappropriate changes in oxygen tension and aberrant Notch signaling both individually reported as causative to abnormal placentation. Despite crosstalk between hypoxia and Notch signaling in multiple cell types, the relationship between hypoxia and Notch in first trimester trophoblast function is not understood. To determine how a low oxygen environment impacts Notch signaling and cellular motility, we utilized the human first trimester trophoblast cell line, HTR-8/SVneo. Gene set enrichment and ontology analyses identified pathways involved in angiogenesis, Notch and cellular migration as upregulated in HTR-8/SVneo cells exposed to hypoxic conditions. DAPT, a γ-secretase inhibitor that inhibits Notch activation, was used to interrogate the crosstalk between Notch and hypoxia pathways in HTR-8/SVneo cells. We found that hypoxia requires Notch activation to mediate HTR-8/SVneo cell migration, but not invasion. To determine if our in vitro findings were associated with preeclampsia, we analyzed the second trimester chorionic villous sampling (CVS) samples and third trimester placentas. We found a significant decrease in expression of migration and invasion genes in CVS from preeclamptic pregnancies and significantly lower levels of JAG1 in placentas from pregnancies with early-onset preeclampsia with severe features. Our data support a role for Notch in mediating hypoxia-induced trophoblast migration, which may contribute to preeclampsia development.
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Affiliation(s)
- Barry E Perlman
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Audrey A. Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences Yale University, New Haven, CT, USA
| | - Alexander Lemenze
- Department of Pathology, Immunology and Laboratory Medicine, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
- Center for Immunity and Inflammation, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Qingshi Zhao
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Salma Begum
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Mohan Nair
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Tracy Wu
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Division of Reproductive Sciences, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jan K. Kitajewski
- Department of Physiology & Biophysics, University of Illinois Chicago, Chicago, IL, USA
| | - Carrie J. Shawber
- Department of Obstetrics and Gynecology, Division of Reproductive Sciences, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Nataki C. Douglas
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
- Center for Immunity and Inflammation, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
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Deshmukh U, Son M, Lundsberg LS, Culhane JF, Partridge C, Reddy UM, Merriam AA. 506 Factors associated with appropriate treatment of obstetric hypertensive emergency. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Leon-Martinez D, Bank TC, Lundsberg LS, Culhane JF, Son M, Silasi M, Partridge C, Reddy UM, Hoffman M, Merriam AA. 748 Does antenatal progesterone administration modify the risk of neonatal intraventricular hemorrhage? Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Merriam AA, Nhan-Chang CL, Huerta-Bogdan BI, Wapner R, Gyamfi-Bannerman C. A Single-Center Experience with a Pregnant Immigrant Population and Zika Virus Serologic Screening in New York City. Am J Perinatol 2020; 37:731-737. [PMID: 31146294 DOI: 10.1055/s-0039-1688819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Our institution is in an area of New York City with a large population of immigrants from Zika virus endemic areas. With the recent Zika virus outbreak, we sought to examine our center's experience with screening for Zika virus and outcomes among patients who tested positive for the disease during pregnancy. STUDY DESIGN We performed a chart review of all pregnant patients who tested positive (positive serum or urine polymerase chain reaction [PCR]) or presumed positive (immunoglobulin M [IgM] enzyme-linked immunosorbent assay [ELISA] positive or IgM ELISA equivocal with positive plaque reduction neutralization test) for Zika virus. All tests were performed by the Department of Health (DOH) and followed Centers for Disease Control and Prevention guidelines in effect at the time of specimen collection. Testing of cord blood, placenta, and/or neonatal blood were/was performed by the DOH for New York County. Prenatal ultrasounds for fetal head size and surveillance for calcifications were performed by maternal-fetal medicine specialists. Infant head ultrasound results were included when available. RESULTS Between March 2016 and April 2017, 70 pregnant patients were positive or presumed positive for Zika infection during pregnancy. Of those, 16 women had positive urine or serum PCR and the remaining 54 were presumed positive. Among positive cases, five women tested positive via urine PCR only, nine women tested positive via serum PCR only, and two women had both positive urine and serum PCR. Fifteen of 67 infants (22%) born during the study period were born to mothers with positive urine or serum PCR testing. Sixty-five newborns were clinically normal with normal head measurements. Of the intracranial ultrasound performed, one infant had a grade 1 intraventricular hemorrhage, four had incidental choroid plexus cysts, and one had severe ventriculomegaly that was also noted antenatally. There were 2 positive and 15 equivocal infant serum IgM samples and 1 positive placental PCR from these pregnancies. There were four pregnancy terminations and two cases with fetal anomalies in this population that were split evenly between patients who tested positive and those who tested presumed positive for Zika virus during pregnancy. CONCLUSION We found no differences in pregnancy or neonatal outcomes between women who tested positive and presumed positive for Zika virus during pregnancy. Testing of infants and placenta tissue after delivery was largely inconclusive. Improvement in testing for Zika virus infection is needed to determine which pregnancies are at risk for congenital anomalies. Further research is still needed to determine which children are at risk for poor neurodevelopmental outcomes related to Zika virus and how to best coordinate care among the immigrant population during a new disease epidemic.
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Affiliation(s)
- Audrey A Merriam
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - B Isabel Huerta-Bogdan
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ronald Wapner
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
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Fiol AG, Fardelmann KL, McGuire PJ, Merriam AA, Miller A, Alian A. The Application of ROTEM in a Parturient With Antiphospholipid Syndrome in the Setting of Anticoagulation for Cesarean Delivery: A Case Report. A A Pract 2020; 14:e01182. [DOI: 10.1213/xaa.0000000000001182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Merriam AA, Huang Y, Wright JD, Goffman D, D'Alton ME, Friedman AM. Use of Uterine Tamponade and Interventional Radiology Procedures During Delivery Hospitalizations. Obstet Gynecol 2020; 135:674-684. [PMID: 32028498 PMCID: PMC7040521 DOI: 10.1097/aog.0000000000003722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To characterize use of uterine tamponade and interventional radiology procedures. METHODS This retrospective study analyzed uterine tamponade and interventional radiology procedures in a large administrative database. The primary outcomes were temporal trends in these procedures 1) during deliveries, 2) by hospital volume, and 3) before hysterectomy for uterine atony or delayed postpartum hemorrhage. Three 3-year periods were analyzed: 2006-2008, 2009-2011, and 2012-2014. Risk of morbidity in the setting of hysterectomy with uterine tamponade and interventional radiology procedures as the primary exposures was additionally analyzed in adjusted models. RESULTS The study included 5,383,486 deliveries, which involved 6,675 uterine tamponade procedures, 1,199 interventional radiology procedures, and 1,937 hysterectomies. Interventional radiology procedures increased from 16.4 to 25.7 per 100,000 delivery hospitalizations from 2006-2008 to 2012-2014 (P<.01), and uterine tamponade increased from 86.3 to 158.1 (P<.01). Interventional radiology procedures use was highest (45.0/100,000 deliveries, 95% CI 41.0-48.9) in the highest and lowest (8.9/100,000, 95% CI 7.1-10.7) in the lowest volume quintile. Uterine tamponade procedures were most common in the fourth (209.8/100,000, 95% CI 201.1-218.5) and lowest in the third quintile (59.8/100,000, 95% CI 55.1-64.4). Interventional radiology procedures occurred before 3.3% of hysterectomies from 2006 to 2008 compared with 6.3% from 2012 to 2014 (P<.05), and uterine tamponade procedures increased from 3.6% to 20.1% (P<.01). Adjusted risks for morbidity in the setting of uterine tamponade and interventional radiology before hysterectomy were significantly higher (adjusted risk ratio [aRR] 1.63, 95% CI 1.47-1.81 and aRR 1.75 95% CI 1.51-2.03, respectively) compared with when these procedures were not performed. CONCLUSION This analysis found that uterine tamponade and interventional radiology procedures became increasingly common over the study period, are used across obstetric volume settings, and in the setting of hysterectomy may be associated with increased risk of morbidity, although this relationship is not necessarily causal.
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Affiliation(s)
- Audrey A Merriam
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, Connecticut; and the Department of Obstetrics and Gynecology, Columbia University, New York, New York
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Grechukhina O, Lundsberg LS, O'Bryan J, Merriam AA, Raab C, Lipkind HS, Campbell K. 122: Leading causes and preventability of severe maternal morbidity cases in a large urban referral center. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Greenberg VR, Lundsberg LS, Reddy UM, Grobman WA, Silver RM, Simhan H, Chung JH, Haas DM, Mercer BM, Wapner RJ, Merriam AA. 547: Perinatal outcomes in obese women with 1 abnormal value on 3-hour glucose tolerance test. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lipkind HS, Zuckerwise LC, Turner EB, Collins JJ, Campbell KH, Reddy UM, Illuzi JL, Merriam AA. Severe maternal morbidity during delivery hospitalisation in a large international administrative database, 2008-2013: a retrospective cohort. BJOG 2019; 126:1223-1230. [PMID: 31100201 DOI: 10.1111/1471-0528.15818] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study utilized the Dr. Foster Global Comparators database to identify pregnancy complications and associated risk factors that led to severe maternal morbidity during delivery hospitalisations in large university hospitals based in the USA, Australia, and England. DESIGN Retrospective cohort. SETTING Births in the USA, England and Australia from 2008 to 2013. SAMPLE Data from delivery hospitalisations between 2008 and 2013 were examined using the Dr. Foster Global Comparators database. METHODS We identified delivery hospitalisations with life-threatening diagnoses or use of life-saving procedures, using algorithms for severe maternal morbidity from the Center for Disease Control. Frequency of severe maternal morbidity was calculated for each country. MAIN OUTCOME MEASURES Multivariable analysis was used to examine the association between morbidity and socio-demographic and clinical characteristics within each country. Chi-square tests assessed differences in covariates between countries. RESULTS From 2008 to 2013, there were 516 781 deliveries from a total of 18 hospitals: 24.5% from the USA, 57.0% from England and 18.4% from Australia. Overall severe maternal morbidity rate was 8.2 per 1000 deliveries: 15.6 in the USA, 5.0 in England, and 8.2 in Australia. The most common codes identifying severe morbidity included transfusion, disseminated intravascular coagulation, acute renal failure, cardiac events/procedures, ventilation, hysterectomy, and eclampsia. Advanced maternal age, hypertension, diabetes, and substance abuse were associated with severe maternal morbidity in all three countries. CONCLUSION Rates of severe maternal morbidity differed by country. Identification of geographical, socio-demographic, and clinical differences can help target modifications of practice and potentially reduce severe maternal morbidity. TWEETABLE ABSTRACT Rates of severe maternal morbidity vary, but risk factors associated with adverse outcomes are similar in developed countries.
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Affiliation(s)
- H S Lipkind
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - L C Zuckerwise
- Division of Maternal-Fetal Medicine, Vanderbilt University, Nashville, TN, USA
| | - E B Turner
- Dr Foster - Global Comparators Ltd, London, UK
| | - J J Collins
- Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK
| | - K H Campbell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - U M Reddy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - J L Illuzi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - A A Merriam
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Walker CL, Merriam AA, Gyamfi-Bannerman C, Adams Waldorf KM. Reply. Am J Obstet Gynecol 2018; 219:514-515. [PMID: 30025831 DOI: 10.1016/j.ajog.2018.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/03/2018] [Indexed: 11/25/2022]
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Walker CL, Merriam AA, Ohuma EO, Dighe MK, Gale M, Rajagopal L, Papageorghiou AT, Gyamfi-Bannerman C, Adams Waldorf KM. Femur-sparing pattern of abnormal fetal growth in pregnant women from New York City after maternal Zika virus infection. Am J Obstet Gynecol 2018; 219:187.e1-187.e20. [PMID: 29738748 DOI: 10.1016/j.ajog.2018.04.047] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/06/2018] [Accepted: 04/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Zika virus is a mosquito-transmitted flavivirus, which can induce fetal brain injury and growth restriction following maternal infection during pregnancy. Prenatal diagnosis of Zika virus-associated fetal injury in the absence of microcephaly is challenging due to an incomplete understanding of how maternal Zika virus infection affects fetal growth and the use of different sonographic reference standards around the world. We hypothesized that skeletal growth is unaffected by Zika virus infection and that the femur length can represent an internal standard to detect growth deceleration of the fetal head and/or abdomen by ultrasound. OBJECTIVE We sought to determine if maternal Zika virus infection is associated with a femur-sparing pattern of intrauterine growth restriction through analysis of fetal biometric measures and/or body ratios using the 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project and World Health Organization Fetal Growth Chart sonographic references. STUDY DESIGN Pregnant women diagnosed with a possible recent Zika virus infection at Columbia University Medical Center after traveling to an endemic area were retrospectively identified and included if a fetal ultrasound was performed. Data were collected regarding Zika virus testing, fetal biometry, pregnancy, and neonatal outcomes. The 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project and World Health Organization Fetal Growth Chart sonographic standards were applied to obtain Z-scores and/or percentiles for fetal head circumference, abdominal circumference, and femur length specific for each gestational week. A novel 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project standard was also developed to generate Z-scores for fetal body ratios with respect to femur length (head circumference:femur length, abdominal circumference:femur length). Data were then grouped within clinically relevant gestational age strata (<24, 24-27 6/7, 28-33 6/7, >34 weeks) to analyze time-dependent effects of Zika virus infection on fetal size. Statistical analysis was performed using Wilcoxon signed-rank test on paired data, comparing either abdominal circumference or head circumference to femur length. RESULTS A total of 56 pregnant women were included in the study with laboratory evidence of a confirmed or possible recent Zika virus infection. Based on the Centers for Disease Control and Prevention definition for microcephaly after congenital Zika virus exposure, microcephaly was diagnosed in 5% (3/56) by both the 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project and World Health Organization Fetal Growth Chart standards (head circumference Z-score ≤-2 or ≤2.3%). Using 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project, intrauterine fetal growth restriction was diagnosed in 18% of pregnancies (10/56; abdominal circumference Z-score ≤-1.3, <10%). Analysis of fetal size using the last ultrasound scan for all subjects revealed a significantly abnormal skewing of fetal biometrics with a smaller abdominal circumference vs femur length by either 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project or World Health Organization Fetal Growth Chart (P < .001 for both). A difference in distribution of fetal abdominal circumference compared to femur length was first apparent in the 24-27 6/7 week strata (2014 International Fetal and Newborn Growth Consortium for the 21st Century Project, P = .002; World Health Organization Fetal Growth Chart, P = .001). A significantly smaller head circumference compared to femur length was also observed by 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project as early as the 28-33 6/7 week strata (2014 International Fetal and Newborn Growth Consortium for the 21st Century Project, P = .007). Overall, a femur-sparing pattern of growth restriction was detected in 52% of pregnancies with either head circumference:femur length or abdominal circumference:femur length fetal body ratio <10th percentile (2014 International Fetal and Newborn Growth Consortium for the 21st Century Project Z-score ≤-1.3). CONCLUSION An unusual femur-sparing pattern of fetal growth restriction was detected in the majority of fetuses with congenital Zika virus exposure. Fetal body ratios may represent a more sensitive ultrasound biomarker to detect viral injury in nonmicrocephalic fetuses that could impart long-term risk for complications of congenital Zika virus infection.
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Abstract
OBJECTIVE This article evaluates trends in venous thromboembolism (VTE) prophylaxis during delivery hospitalizations in the United States. METHODS We utilized an administrative database to determine if women hospitalized for vaginal or cesarean delivery received pharmacologic VTE prophylaxis, mechanical VTE prophylaxis, or both from January 2011 through March 2015. Mechanical prophylaxis included sequential compression devices, graduated compression stockings, and other pneumatic devices. Pharmacologic prophylaxis included unfractionated heparin, low molecular weight heparin, or fondaparinux. Probability of use of thromboprophylaxis for individual hospitals was estimated in an adjusted model. RESULTS A total of 956,428 women who underwent cesarean and 1,914,142 women who underwent vaginal delivery were included in the analysis. Cesarean VTE prophylaxis declined between 2011 (50.3%) and 2015 (47.7%; p < 0.01). Of women undergoing vaginal delivery, 2.9% received prophylaxis. Delivery hospital was an important determinant of cesarean prophylaxis: in the adjusted model, one-third of hospitals used prophylaxis for less than 20% of deliveries, one-third of hospitals used prophylaxis for 20 to 80% of deliveries, and the final third of hospitals used prophylaxis in greater than 80% of deliveries. CONCLUSION While many hospitals appear to be following best clinical practices, some do not provide routine cesarean VTE prophylaxis. Minimizing care quality variation may improve maternal safety.
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Affiliation(s)
- Audrey A Merriam
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York.,Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York.,Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
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Abstract
OBJECTIVE Our primary objective was to compare the differential contribution of fetal number and maternal age to the risk of hypertensive disorders of pregnancy (HDP). STUDY DESIGN This was a secondary analysis of a large study of primary cesarean delivery. Women with singleton, twin, or triplet gestations were included. Women were divided into groups based on fetal number and maternal age. The primary outcome was HDP. A logistic regression model was fit to adjust for confounders. The incidence of HDP was compared with the reference group and within exposure groups. RESULTS Of the 70,417 women included, HDP occurred in 8,079 (12%) women. The frequency of HDP among the comparison groups ranged from 11 to 38%. Nearly all groups had significantly increased risk of HDP compared with young maternal age singletons. Twin and triplet gestations increased the risk of HDP over singletons irrespective of maternal age after adjusting for baseline disease and race. The risk of HDP did not significantly increase with maternal age when fetal number was similar. CONCLUSION Fetal number significantly increased the risk of HDP and contributed more to that risk than maternal age. Maternal age became significant in groups with age greater than 40 years.
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Affiliation(s)
- Devin D Smith
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Audrey A Merriam
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Julley Jung
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
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Sones JL, Merriam AA, Seffens A, Brown-Grant DA, Butler SD, Zhao AM, Xu X, Shawber CJ, Grenier JK, Douglas NC. Angiogenic factor imbalance precedes complement deposition in placentae of the BPH/5 model of preeclampsia. FASEB J 2018; 32:2574-2586. [PMID: 29279353 DOI: 10.1096/fj.201701008r] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Preeclampsia (PE), a hypertensive disorder of pregnancy, is a leading cause of maternal and fetal morbidity and mortality. Although the etiology is unknown, PE is thought to be caused by defective implantation and decidualization in pregnancy. Pregnant blood pressure high (BPH)/5 mice spontaneously develop placentopathies and maternal features of human PE. We hypothesized that BPH/5 implantation sites have transcriptomic alterations. Next-generation RNA sequencing of implantation sites at peak decidualization, embryonic day (E)7.5, revealed complement gene up-regulation in BPH/5 vs. controls. In BPH/5, expression of complement factor 3 was increased around the decidual vasculature of E7.5 implantation sites and in the trophoblast giant cell layer of E10.5 placentae. Altered expression of VEGF pathway genes in E5.5 BPH/5 implantation sites preceded complement dysregulation, which correlated with abnormal vasculature and increased placental growth factor mRNA and VEGF164 expression at E7.5. By E10.5, proangiogenic genes were down-regulated, whereas antiangiogenic sFlt-1 was up-regulated in BPH/5 placentae. We found that early local misexpression of VEGF genes and abnormal decidual vasculature preceded sFlt-1 overexpression and increased complement deposition in BPH/5 placentae. Our findings suggest that abnormal decidual angiogenesis precedes complement activation, which in turn contributes to the aberrant trophoblast invasion and poor placentation that underlie PE.-Sones, J. L., Merriam, A. A., Seffens, A., Brown-Grant, D.-A., Butler, S. D., Zhao, A. M., Xu, X., Shawber, C. J., Grenier, J. K., Douglas, N. C. Angiogenic factor imbalance precedes complement deposition in placentae of the BPH/5 model of preeclampsia.
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Affiliation(s)
- Jennifer L Sones
- Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Audrey A Merriam
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Angelina Seffens
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Dex-Ann Brown-Grant
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Scott D Butler
- Department of Biomedical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA; and
| | - Anna M Zhao
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Xinjing Xu
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Carrie J Shawber
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jennifer K Grenier
- RNA Sequencing Core, Center for Reproductive Genomics, Department of Biomedical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Nataki C Douglas
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Friedman A, Merriam AA, Ananth CV. Authors' reply re: Trends in operative vaginal delivery, 2005-2013: a population-based study. BJOG 2017; 125:97. [PMID: 28994503 DOI: 10.1111/1471-0528.14932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Alexander Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Audrey A Merriam
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Merriam AA, Wright JD, Siddiq Z, D'Alton ME, Friedman AM, Ananth CV, Bateman BT. Risk for postpartum hemorrhage, transfusion, and hemorrhage-related morbidity at low, moderate, and high volume hospitals. J Matern Fetal Neonatal Med 2017; 31:1025-1034. [PMID: 28367647 DOI: 10.1080/14767058.2017.1306050] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study was to characterize risk for and temporal trends in postpartum hemorrhage across hospitals with different delivery volumes. STUDY DESIGN This study used the Nationwide Inpatient Sample (NIS) to characterize risk for postpartum hemorrhage from 1998 to 2011. Hospitals were classified as having either low, moderate or high delivery volume (≤1000, 1001 to 2000, >2000 deliveries per year, respectively). The primary outcomes included postpartum hemorrhage, transfusion, and related severe maternal morbidity. Adjusted models were created to assess factors associated with hemorrhage and transfusion. RESULTS Of 55,140,088 deliveries included for analysis 1,512,212 (2.7%) had a diagnosis of postpartum hemorrhage and 361,081 (0.7%) received transfusion. Risk for morbidity and transfusion increased over the study period, while the rate of hemorrhage was stable ranging from 2.5 to 2.9%. After adjustment, hospital volume was not a major risk factor for transfusion or hemorrhage. DISCUSSION While obstetric volume does not appear to be a major risk factor for either transfusion or hemorrhage, given that transfusion and hemorrhage-related maternal morbidity are increasing across hospital volume categories, there is an urgent need to improve obstetrical care for postpartum hemorrhage. Those risk factors are able to discriminate women at increased risk supports routine use of hemorrhage risk assessment.
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Affiliation(s)
- Audrey A Merriam
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Jason D Wright
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Zainab Siddiq
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Mary E D'Alton
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Alexander M Friedman
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Cande V Ananth
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA.,b Department of Epidemiology , Joseph L. Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Brian T Bateman
- c Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital; the Department of Anesthesiology, Critical Care, and Pain Medicine , Harvard Medical School , Boston , MA , USA
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Merriam AA, Ananth CV, Wright JD, Siddiq Z, D'Alton ME, Friedman AM. Trends in operative vaginal delivery, 2005-2013: a population-based study. BJOG 2017; 124:1365-1372. [DOI: 10.1111/1471-0528.14553] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2016] [Indexed: 11/28/2022]
Affiliation(s)
- AA Merriam
- Department of Obstetrics and Gynecology; College of Physicians and Surgeons; Columbia University; New York NY USA
| | - CV Ananth
- Department of Obstetrics and Gynecology; College of Physicians and Surgeons; Columbia University; New York NY USA
- Department of Epidemiology; Mailman School of Public Health; Columbia University; New York NY USA
| | - JD Wright
- Department of Obstetrics and Gynecology; College of Physicians and Surgeons; Columbia University; New York NY USA
| | - Z Siddiq
- Department of Obstetrics and Gynecology; College of Physicians and Surgeons; Columbia University; New York NY USA
| | - ME D'Alton
- Department of Obstetrics and Gynecology; College of Physicians and Surgeons; Columbia University; New York NY USA
| | - AM Friedman
- Department of Obstetrics and Gynecology; College of Physicians and Surgeons; Columbia University; New York NY USA
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