The Association between Psychosocial Stressors and Gestational Weight Gain: Analysis of the National Pregnancy Risk Assessment Monitoring System (PRAMS) Results from 2012 to 2015

OBJECTIVE

Both psychosocial stress and gestational weight gain are independently associated with adverse maternal and fetal outcomes. Studies of the association between psychosocial stress and gestational weight gain (GWG) have yielded mixed results. The objective of this study was to evaluate the association between psychosocial stress and GWG in a large population-based cohort.

METHODS

Data from the nationally representative Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7 questionnaire 2012-2015 was utilized. Maternal psychosocial stress was assessed through response to questions designed to examine four domains of psychosocial stress (i.e., traumatic, financial, emotional, partner-related) three months prior to or during pregnancy. GWG was categorized using pre-pregnancy BMI and total GWG into inadequate, adequate, or excessive according to the Institute of Medicine's GWG guidelines. Multinomial logistic regression was used to evaluate the association between psychosocial stressors and adequacy of GWG. Analyses took into account complex survey design.

RESULTS

All respondents who delivered ≥ 37 weeks gestation with GWG information available were included in the analysis (n = 119,183). After adjusting for confounders, patients who reported financial stress were more likely to experience excessive versus adequate GWG (RRR 1.09 [95%CI: 1.02-1.17]). Exposure to any of the stressor groups did not significantly increase the risk of inadequate GWG.

CONCLUSIONS

This large, population-based study revealed that among pregnant people in the US, exposure to financial stress is associated with higher risk of excessive GWG. Understanding the role stress plays in GWG will help to inform initiatives targeting this important aspect of prenatal care.

Nutrition Education and Nutrition Knowledge Among Obstetrics and Gynecology Residents

Background: Nutrition in pregnancy is a component of the Council on Resident Education in obstetrics and gynecology core curriculum; however, no studies currently examine adherence to this goal. Objectives: Our objective was to assess obstetrics and gynecology (Ob/Gyn) residents' education and knowledge surrounding nutrition in pregnancy, including (1) amount of dedicated didactic time to and attitudes toward, (2) subjective comfort in counseling patients on, and (3) objective knowledge of pregnancy-related nutrition. Materials and Methods: This is a cross-sectional electronic survey-based study. A 28-item questionnaire was distributed to residents enrolled in Ob/Gyn training programs across the United States in 2022. Results: From 247 Ob/Gyn residency programs, 218 residents across postgraduate years and from geographically diverse locations consented to participation and completed all survey questions. Almost half (48%) of participants reported 0 hours per year of dedicated nutrition-related education, 49% reported 1-2 hours, and 3% reported >2 hours. Most residents (92%) strongly agreed or agreed that education regarding pregnancy-related nutrition guidelines would be useful for clinical practice. However, less than one-third (31%) of residents reported feeling comfortable counseling patients on nutrition in pregnancy. On assessment of residents' objective knowledge of pregnancy-related nutrition, mean percentage of correct responses was 74%. Conclusions: This study identifies a gap in graduate medical education, specifically a disconnect between the recognized impact of nutrition on pregnancy outcomes and residents' ability to confidently and effectively counsel patients on nutrition in pregnancy. Results demonstrate a need to develop curriculum and interventions to educate Ob/Gyn residents about pregnancy-related nutrition.

Feasibility and Acceptability of Home-Delivered Medically Tailored Meals for Treatment of Diabetes in Pregnancy

BACKGROUND

Diabetes complicates ≤7% of pregnancies in the United States. Although medical nutrition therapy is the mainstay of diabetes treatment, many barriers exist to the successful implementation of dietary modifications. Home-delivered medically tailored meals (MTMs) are promising to overcome such barriers.

OBJECTIVE

The objective of this study was to evaluate the feasibility and acceptability of home-delivered MTM in pregnant patients with diabetes.

METHODS

We performed a prospective cohort study of home-delivered MTM for pregnant patients with diabetes using a mixed-methods approach. Participants <35 wk of gestation at the time of enrollment received weekly home delivery of diabetes-specific meals. Qualitative semistructured interviews were conducted to gain insight into participants' experience. Diabetes self-efficacy was assessed pre- and postintervention using the Diabetes Self-Efficacy Scale and 2-Item Diabetes Distress Screening Scale. The difference in mean scores was compared using t-tests with P value of <0.05 considered significant. Feasibility and acceptability were evaluated through participants' attitude toward MTM in qualitative interviews and indirectly evaluated through diabetes self-efficacy surveys.

RESULTS

Twenty pregnant people with diabetes who received home-delivered MTM during pregnancy were interviewed postpartum. Participants found this program convenient for various reasons, including reduced time for grocery shopping and preparing meals. Participants were satisfied with meals, citing a positive impact on diabetes management, accessibility of healthy foods, reduced stress with meal planning, and greater perceived control of blood glucose. Most participants shared meals with their families or received specific meals for their dependents, which was positively received. Reduced financial and mental stress was also widely reported. Diabetes self-efficacy was significantly improved postintervention with MTM.

CONCLUSION

Home-delivered MTM is feasible and acceptable in pregnant patients with diabetes and may improve diabetes self-efficacy. Individual experiences offered insight into various barriers overcome by using this service. Home-delivered MTM may help ensure an accessible, healthy diet for pregnant patients with diabetes.

Point-of-Care Ultrasonography in the Intensive Care Unit for the Obstetric Patient

Point-of-care ultrasonography (POCUS) is a tool that can be used to evaluate critically ill obstetric patients, in the same way as for nonpregnant patients. With knowledge of the physiology and anatomical changes of pregnancy, POCUS can provide meaningful information to help guide clinical management. A POCUS cardiothoracic evaluation for left and right ventricular function, pulmonary edema, pleural effusion, and pneumothorax can be performed in pregnancy. A Focused Assessment with Sonography in Trauma examination in pregnancy is performed similarly to that in nonpregnant patients, and the information obtained can guide decision-making regarding operative versus nonoperative management of trauma. POCUS is also used to glean important obstetric information in the setting of critical illness and trauma, such as fetal status, gestational age, and placental location. These obstetric evaluations should be performed rapidly to minimize delay and enable pregnant patients to receive the same care for critical illness and trauma as nonpregnant patients.

Contemporary Obstetric and Neonatal Outcomes in Sickle Cell Disease: A Retrospective Cohort Study

OBJECTIVE

 Sickle cell disease is associated with adverse perinatal outcomes. Aspects of sickle cell disease in pregnancy, such as health care utilization and neonatal abstinence syndrome, are understudied. We aimed to describe contemporary sickle cell disease outcomes in a U.S. hospital system to improve perinatal counseling.

STUDY DESIGN

 We conducted a retrospective cohort study of patients with sickle cell disease who delivered at >20 weeks' gestation at two sites within the University of Pennsylvania Health System from May 1, 2017 to August 30, 2020. Descriptive statistics were utilized.

RESULTS

 Over the study period, 48 patients with sickle cell disease had 52 deliveries of 53 neonates. Sickle cell disease-related morbidity was prevalent prior to pregnancy; 27% had a history of avascular necrosis, and 58% had experienced acute chest syndrome. In the year prior to pregnancy, 52% used daily opioids. During pregnancy, more than half of patients were admitted at least once for sickle cell disease-related complications, spending a median 3 days admitted interquartile range (0-23); >10% spent >70 days of pregnancy admitted. New daily opioids were prescribed during pregnancy for 10% to manage pain crises. Acute chest syndrome was experienced by 23% of patients during pregnancy, and 8% required placement of long-term intravenous access. Preterm delivery <37 weeks occurred in 48%. The primary cesarean rate in nulliparas was 43%. Additionally, 50% experienced a hypertensive disorder of pregnancy, 35% underwent transfusion during delivery admission, and 10% had a perinatal venous thromboembolism. Finally, 53% of neonates were admitted to the intensive care unit. Low birth weight was noted in 34%, severe respiratory distress in 15% of infants, and neonatal abstinence syndrome in 21%.

CONCLUSION

 Sickle cell disease remains associated with significant perinatal morbidity and need for hospitalization. These data provide contemporary outcomes to target improvements in the care of patients with sickle cell disease.

KEY POINTS

· SCD was associated with significant perinatal morbidity and healthcare utilization.. · Most patients with SCD required hospitalization during pregnancy.. · Neonates of patients with SCD experienced preterm birth, NICU admission, and neonatal abstinence syndrome..

Patterns in Food Insecurity During Pregnancy, 2004 to 2020

This survey study assesses patterns in food insecurity during pregnancy among individuals in 14 US states participating in the Pregnancy Risk Assessment Monitoring System from 2004 to 2020.

Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance

OBJECTIVE

There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity.

STUDY DESIGN

This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used.

RESULTS

Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation.

CONCLUSION

Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

Feasibility of Lipid Screening During First Trimester of Pregnancy to Identify Women at Risk of Severe Dyslipidemia

Background Dyslipidemia is an important risk factor for atherosclerotic cardiovascular disease, especially when disease presents at a young age. Despite national screening guidelines to perform a lipid profile test in children and young adults, many reproductive-age women have not undergone lipid screening. Our objective was to assess the feasibility of lipid screening during the first trimester of pregnancy as a strategy to increase lipid screening rates among women receiving prenatal care. Methods and Results A nonfasting lipid panel was incorporated into routine prenatal care among obstetricians at a single academic clinic. Educational materials and a clinical referral pathway were developed for patients with abnormal results. Over 6 months, 445 patients had a first prenatal care visit. Of the 358 patients who completed laboratory testing, 236 (66%) patients completed lipid testing. Overall, 59 (25%) patients had abnormal results. One patient with previously undiagnosed suspected familial hypercholesterolemia was identified. Barriers to ordering lipid tests included the burden of reviewing additional laboratory results and uncertainty about patient counseling. Conclusions Implementation of nonfasting lipid screening as part of routine prenatal care during the first trimester is feasible and may play a crucial role in timely diagnosis and management of lipid disorders in women of reproductive age. Future work should focus on optimizing health system workflow to minimize burden on clinical staff and facilitate follow-up with appropriate specialists.

A Call for Development of Point-of-Care Ultrasound Training Recommendations in Obstetrics and Gynecology Residency

Point-of-care ultrasound (POCUS) skillsets are now taught throughout training levels from medical school through fellowship given the broad utility in assisting with bedside procedures and triaging clinical presentations for expedited workup. This is reflected in training curricula for emergency medicine, internal medicine, and general surgery residencies. However, these skillsets are not formally taught or required in obstetrics and gynecology residency. We present the opinion that these skillsets and curricula should be developed for obstetrics and gynecology trainees given their exposure to patients with similar clinical presentations in which the clinical management would be aided by POCUS.

Risk of Cesarean Delivery for Women with Obesity Using a Standardized Labor Induction Protocol

OBJECTIVE

We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol.

STUDY DESIGN

This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m²) and nonobese (<30 kg/m²) women. Indication for cesarean was also evaluated.

RESULTS

A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34-2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol.

CONCLUSION

Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity.

KEY POINTS

· Even with a standardized induction protocol, women with obesity are at higher risk of cesarean.. · In particular, women with obesity are at increased risk of cesarean for failed induction.. · These findings support a possible biologic relationship between obesity and failed induction..

Pregnant and hungry: addressing food insecurity in pregnant women during the COVID-19 pandemic in the United States

Food insecurity is a major social determinant of health affecting more than 10% of Americans. Social determinants of health are increasingly recognized as a driving force of health inequities. It is well established that food insecurity leads to adverse health outcomes outside of pregnancy, such as obesity, hypertension, diabetes mellitus, and mental health problems. However, limited data exist about the impact of food insecurity during pregnancy on maternal and neonatal outcomes. Food insecurity and other social determinants of health are rarely addressed as part of routine obstetrical care. The COVID-19 pandemic has only exacerbated the crisis of food insecurity across the country, disproportionally affecting women and racial and ethnic minorities. Women's health providers should implement universal screening for maternal food insecurity and offer resources to women struggling to feed themselves and their families. Reducing maternal health inequities in the United States involves recognizing and addressing food insecurity, along with other social determinants of health, and advocating for public policies that support and protect all women's right to healthy food during pregnancy.

Racial/Ethnic Disparities in Screening for and Awareness of High Cholesterol Among Pregnant Women Receiving Prenatal Care

Background Atherosclerotic cardiovascular disease remains a leading cause of morbidity and mortality among women, with younger women being disproportionately affected by traditional cardiovascular risk factors such as dyslipidemia. Despite recommendations for lipid screening in early adulthood and the risks associated with maternal dyslipidemia during pregnancy, many younger women lack access to and utilization of early screening. Accordingly, our objective was to assess the prevalence of and disparities in lipid screening and awareness of high cholesterol as an atherosclerotic cardiovascular disease risk factor among pregnant women receiving prenatal care. Methods and Results We invited 234 pregnant women receiving prenatal care at 1 of 3 clinics affiliated with the University of Pennsylvania Health System to complete our survey. A total of 200 pregnant women (86% response rate) completed the survey. Overall, 59% of pregnant women (mean age 32.2 [±5.7] years) self-reported a previous lipid screening and 79% of women were aware of high cholesterol as an atherosclerotic cardiovascular disease risk factor. Stratified by racial/ethnic subgroups, non-Hispanic Black women were less likely to report a prior screening (43% versus 67%, P=0.022) and had lower levels of awareness (66% versus 92%, P<0.001) compared with non-Hispanic White women. Non-Hispanic Black women were more likely to see an obstetrician/gynecologist for their usual source of non-pregnancy care compared with non-Hispanic White women (18% versus 5%, P=0.043). Those seeing an obstetrician/gynecologist for usual care were less likely to report a prior lipid screening compared with those seeing a primary care physician (29% versus 63%, P=0.007). Conclusions Significant racial/ethnic disparities persist in lipid screening and risk factor awareness among pregnant women. Prenatal care may represent an opportunity to enhance access to and uptake of screening among younger women and reduce variations in accessing preventive care services.

Use of point-of-care ultrasound to diagnose spontaneous rupture of fibroid in pregnancy

Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.

Prenatally diagnosed vasa previa: association with adverse obstetrical and neonatal outcomes

BACKGROUND

Vasa previa represents a rare prenatal finding with potentially life-threatening risk to the fetus.

OBJECTIVE

This study aimed to describe the natural history of prenatally diagnosed vasa previa and evaluate the association between antenatally diagnosed vasa previa and adverse obstetrical and neonatal outcomes.

STUDY DESIGN

This was a multicenter descriptive and retrospective study of patients diagnosed prenatally with vasa previa on transvaginal ultrasound in the New York City Maternal-Fetal Medicine Research Consortium centers between 2012 and 2018. Outcomes evaluated included persistence of vasa previa at the time of delivery, gestational age at delivery, indications for unplanned unscheduled delivery, and neonatal course.

RESULTS

A total of 165 pregnancies with vasa previa were included, of which 16 were twin gestations. Forty-three cases (26.1%) were noted to resolve on subsequent ultrasound. Of the remaining 122 cases with persistent vasa previa, 46 (37.7%) required unscheduled delivery. Twin gestations were nearly 3 times as likely to require unscheduled delivery as singleton gestations (73.3% vs 25.2%; P<.001). Most infants (70%) were admitted to the neonatal intensive care unit. There was 1 neonatal death (0.9%) because of complications related to prematurity.

CONCLUSION

Despite the low neonatal mortality rate with prenatal detection of vasa previa, one-third of patients required unscheduled delivery, and more than half of neonates experienced complications related to prematurity.

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study

Background

The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited.

Objective

This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2.

Study Design

This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported.

Results

Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m². Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission.

Conclusion

In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.

Total and trimester-specific gestational weight gain and infant anthropometric outcomes at birth and 6 months in low-income Hispanic families

OBJECTIVE

To describe total and trimester-specific gestational weight gain (GWG) among low-income Hispanic women and determine whether these GWG exposures are associated with infant anthropometric outcomes at birth and 6 months.

STUDY DESIGN

Data were from 448 mother-infant pairs enrolled in the Starting Early child obesity prevention trial. Prenatal weights were used to calculate total GWG and 2^nd and 3^rd trimester GWG rates (kg/week) and categorized as inadequate, adequate, and excessive according to the 2009 Institute of Medicine recommendations. Multivariable linear and modified Poisson regressions estimated associations of infant anthropometric outcomes (birthweight, small-for-gestational age [SGA], large-for-gestational age [LGA], rapid weight gain, and weight-for-age, length-for-age, and weight-for-length z-scores at 6 months) with GWG categories.

RESULTS

For total GWG, 39% and 27% of women had inadequate and excessive GWG, respectively. 57% and 46% had excessive GWG rates in the 2^nd and 3^rd trimesters, respectively, with 29% having excessive rates in both trimesters. Inadequate total GWG was associated with lower infant weight and length outcomes (ß range for z-scores = -0.21 to -0.46, p < 0.05) and lower risk of LGA (adjusted Relative Risk, aRR = 0.38; 95% confidence intervals, CI: 0.16, 0.95) and rapid weight gain (aRR = 0.72; 95%CI: 0.51, 1.00). GWG rates above recommendations in the 2^nd trimester or 2^nd /3^rd trimesters were associated with greater weight outcomes at birth and 6 months (ß range for z-scores = 0.24 to 0.35, p < 0.05).

CONCLUSIONS

Counseling women about health behaviors and closely monitoring GWG beginning in early pregnancy is necessary, particularly among populations at high-risk of obesity.

Association between time interval from bariatric surgery to pregnancy and maternal weight outcomes

BACKGROUND

The majority of patients having bariatric surgery are reproductive-age women who are advised to delay pregnancy for at least 12 months after surgery. Many women become pregnant sooner and the association between gestational weight gain (GWG) and maternal long-term weight is unknown.

OBJECTIVES

The primary objective of this study was to compare weight outcomes in pregnancies occurring < 12 months versus ≥ 12 months after bariatric surgery. The secondary objectives were to determine the association between time interval from bariatric surgery to pregnancy and maternal nutritional status and maternal and neonatal outcomes.

STUDY DESIGN

This is a retrospective cohort study of women with singleton livebirths after bariatric surgery who received care at a single tertiary care center between 2009 and 2017. GWG was the difference in weight between the first prenatal visit and delivery. GWG adequacy was determined by the IOM 2009 guidelines according to prepregnancy BMI (inadequate, adequate, excessive). Postpartum weight retention was calculated as the difference between weight at first prenatal visit and measured postpartum weight. Weight outcomes along with maternal nutritional status and maternal and neonatal outcomes were compared between < 12 months versus ≥ 12 months after bariatric surgery with t-tests, Mann-Whitney U and chi-square tests, as appropriate.

RESULTS

Of the 76 pregnancies that met inclusion criteria, 36.8% occurred < 12 months (median 7.2 months) and 63.2% occurred ≥ 12 months after surgery (median 26.9 months). Of those with pregnancies < 12 months from surgery, 34% had a restrictive procedure (adjustable gastric band or sleeve gastrectomy) while 66% had a combined restrictive-malabsorptive procedure (Roux-en-Y gastric bypass). In the ≥ 12 months group, 42.3% had a restrictive procedure while 57.7% had a combined restrictive-malabsorptive procedure. There were no significant differences in maternal age, ethnicity or nulliparity between groups, but there were more women with obesity in the < 12 months group (75 vs. 52%, p = .03). The mean prepregnancy BMI in the < 12 months group was 34.3 vs. 31.2 kg/m² in the ≥ 12 months group. The < 12 months group had lower mean GWG (4.9 vs. 10.9 kg, p = .01) and higher frequency of weight loss during pregnancy (28.6 vs. 4.2%, p < .01) compared to the ≥ 12 months group. The < 12 months group had significantly less postpartum weight retention at 6 months compared to the ≥ 12 months group (-1.3 vs. 8.3 kg, p = .02). The < 12 months group had a higher prevalence of vitamin B12 deficiency (23.1 versus 4.9%, p = .05). There were no differences in hyperemesis, hypertensive disorders, gestational diabetes or delivery mode between groups (p > .05). There were no differences in gestational age at delivery, birth weight and small for gestational age infants between groups (p > .05).

CONCLUSION

Pregnancy < 12 months after bariatric surgery is associated with significantly lower mean GWG and a higher frequency of weight loss during pregnancy as well as less postpartum weight retention at 6 months. Although there were no differences birthweight, weight loss during pregnancy and its accompanying metabolic changes are concerning for a developing fetus. Further study is needed to determine the optimal timing of pregnancy after bariatric surgery with respect to both maternal and infant short and long-term outcomes.

Recurrent Cholangiocarcinoma in Pregnancy: A Case Report

Hepatobiliary malignancies during pregnancy are extremely rare and portend a poor prognosis. There are only seven published cases of cholangiocarcinoma in an obstetrical patient, all are cases of primary cholangiocarcinoma (1-7). Herein, we describe the first case of recurrent cholangiocarcinoma during pregnancy. The patient did not receive chemotherapy during pregnancy and required prolonged hospitalizations for nutritional and intensive medical support. She delivered preterm, at 30 ^2/7 weeks gestation, after developing pre-eclampsia with severe features. The infant was healthy, with no malformations, and currently exhibits no neurological or behavioral sequelae at 8months of age. We discuss themanagement considerations inherent to this complex clinical scenario including metastatic disease severity, ethical considerations, and palliative care treatment options.

Pregnancy in Women with Obesity

Pregnancy in women with obesity is an important public health problem with short- and long-term implications for maternal and child health. Obesity complicates almost all aspects of pregnancy. Given the growing prevalence of obesity in women, obstetric providers need to understand the risks associated with obesity in pregnancy and the unique aspects of management for women with obesity. Empathic and patient-centered care, along with knowledge, can optimize outcomes for women and children.

Folic Acid Supplementation to Prevent Recurrent Neural Tube Defects: 4 Milligrams Is Too Much

Some medical practices have been ingrained in custom for decades, long after "proof" that they were effective was established. It is necessary to periodically reevaluate these practices, as newer theories and research may challenge the evidence upon which they were based. An example is the decades' old practice of recommending a 4-mg (4,000-µg) supplement of folic acid to women who are at risk for recurrent neural tube defect (NTD) during pregnancy. This recommendation was based on findings from a randomized clinical trial in 1991. Since then, multiple studies have confirmed the utility of 400-800 µg of folic acid in lowering both primary and recurrent risks of NTDs, but no studies have established any further reduction in risk with doses over 1 mg. Current understanding of folic acid metabolism during pregnancy suggests that at higher doses, above ∼1 mg, there is not increased absorption. Recent evidence suggests that 4 mg folic acid supplementation may not be any more effective than lower doses for the prevention of recurrent NTDs. Thus, we recommend that it is time for clinicians to reexamine their reliance on this outdated recommendation and consider using current recommendations of 400-800 µg per day for all patients in conjunction with assessment of maternal folate status.