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Brown JA, Huff ML, Arboleda BL, Louis JM. The Relationship between Body Mass Index and Operative Complications in Patients undergoing Immediate Postpartum Tubal Ligation. Am J Perinatol 2024; 41:909-914. [PMID: 35253112 DOI: 10.1055/a-1788-4900] [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 The objective of this study is to examine the relationship between body mass index (BMI) and complications for patients undergoing postpartum permanent contraception. STUDY DESIGN Retrospective cohort study of patients aged 18 or older who had a vaginal delivery at an academic hospital between 2011 and 2016 and underwent a postpartum tubal ligation during the delivery admission. There were three comparative groups: nonobese (BMI ≤ 29 kg/m2), obese (BMI 30-39 kg/m2), and morbidly obese BMI (≥40 kg/m2). The outcome of interest was composite operative complications which included any occurrence of an intraoperative, postoperative, or anesthesia complication. RESULTS A total of 921 patients were included for analysis. Average operative time was statistically longer for patients in the morbidly obese group (33 minutes) vs. the nonobese (25 minutes) and obese (29 minutes) groups (p < 0.0001). Composite complications were greater for the obese groups, but not statistically significant (5.1 vs. 6 vs. 16%, p = 0.06). Wound complications were significantly greater for the obese groups (0.8 vs. 1.5 vs. 5.5%, p = 0.01). A logistic regression model demonstrated that only operative time was predictive of operative complications. CONCLUSION Overall complications of postpartum tubal complications are low; however, our study did demonstrate significantly longer operative time and wound complications for patients with obesity. The findings of our study indicate that postpartum permanent contraception can remain as an option for these patients. Further studies may help identify the best practices to decrease operative time and subsequent wound complications. This study contributes to the limited data regarding obesity and postpartum permanent contraception. We found increased operative time and wound complications for obese patients. Additional studies may identity best practices to decrease these complications. Given our findings of overall low operative complications, postpartum permanent contraception can remain an option for obese patients.
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Affiliation(s)
- Jewel A Brown
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
- Tampa General Circle, STC, Tampa, Florida
- Department of Obstetrics and Gynecology, University of California Davis Health, Sacramento, California
| | - Mallorie L Huff
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Bianca L Arboleda
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, Kentucky
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
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Prabhu M, Louis JM, Kuller JA. Society for Maternal-Fetal Medicine Statement: RhD immune globulin after spontaneous or induced abortion at less than 12 weeks of gestation. Am J Obstet Gynecol 2024; 230:B2-B5. [PMID: 38417536 DOI: 10.1016/j.ajog.2024.02.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
Guidelines for the management of first-trimester spontaneous and induced abortion vary in terms of rhesus factor D (RhD) testing and RhD immune globulin (RhIg) administration. These existing guidelines are based on limited data that do not convincingly demonstrate the safety of withholding RhIg for first-trimester abortions or pregnancy losses. Given the adverse fetal and neonatal outcomes associated with RhD alloimmunization, prevention of maternal sensitization is essential in RhD-negative patients who may experience subsequent pregnancies. In care settings in which RhD testing and RhIg administration are logistically and financially feasible and do not hinder access to abortion care, we recommend offering both RhD testing and RhIg administration for spontaneous and induced abortion at <12 weeks of gestation in unsensitized, RhD-negative individuals. Guidelines for RhD testing and RhIg administration in the first trimester must balance the prevention of alloimmunization with the individual- and population-level harms of restricted access to abortion.
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Alex RM, Mann DL, Azarbarzin A, Vena D, Gell LK, Wellman A, Grobman WA, Facco FL, Silver RM, Pien GW, Louis JM, Zee PC, Rueschman M, Sofer T, Redline S, Sands SA. Adverse Pregnancy Outcomes and Pharyngeal Flow Limitation during Sleep: Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-be (nuMoM2b). Eur Respir J 2024:2301707. [PMID: 38575160 DOI: 10.1183/13993003.01707-2023] [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] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024]
Abstract
RATIONALE Pharyngeal flow limitation during pregnancy may be a risk factor for adverse pregnancy outcomes but was previously challenging to quantify. OBJECTIVE To determine whether a novel objective measure of flow limitation identifies an increased risk of preeclampsia (primary outcome) and other adverse outcomes in a prospective cohort: Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-be. METHODS Flow limitation severity scores (0%=fully obstructed, 100%=open airway)- quantified from breath-by-breath airflow shape-were obtained from home sleep tests during early (6-15 weeks) and mid (22-31 weeks) pregnancy. Multivariable logistic regression quantified associations between flow limitation (median overnight severity, both time-points averaged) and preeclampsia, adjusting for maternal age, body mass index (BMI), race, ethnicity, chronic hypertension, and flow limitation during wakefulness. Secondary outcomes were hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), and infant birthweight. RESULTS Of 1939 participants with flow limitation data at both time-points (age: 27.0±5.4 yr [mean±sd], BMI: 27.7±6.1 kg·m-2), 5.8% developed preeclampsia, 12.7% developed HDP, and 4.5% developed GDM. Greater flow limitation was associated with increased preeclampsia risk: adjusted Odds Ratio (OR) 2.49, 95% Confidence Interval [1.69, 3.69], per 2SD increase in severity. Findings persisted in women without sleep apnea (apnea-hypopnea index <5 events·hr-1). Flow limitation was associated with HDP (OR: 1.77 [1.33, 2.38]) and reduced infant birthweight (83.7 [31.8, 135.6] g), but not GDM. CONCLUSIONS Greater flow limitation is associated with increased risk of preeclampsia, HDP, and lower infant birthweight. Flow limitation may provide an early target for mitigating the consequences of sleep disordered breathing during pregnancy.
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Affiliation(s)
- Raichel M Alex
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Dwayne L Mann
- Institute for Social Science Research, The University of Queensland, Brisbane, Australia
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Francesca L Facco
- Department of Obstetrics and Gynecology, University of Pittsburgh, Magee-Women's Hospital, Pittsburgh, PA, USA
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Grace W Pien
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Phyllis C Zee
- Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael Rueschman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Tamar Sofer
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Schenone CV, Ashley Cain M, Schenone AL, Smith T, Tsalatsanis A, Louis JM, Crousillat DR. Changes in rate-pressure product associated with pregnancy. Am J Obstet Gynecol MFM 2024; 6:101338. [PMID: 38453019 DOI: 10.1016/j.ajogmf.2024.101338] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND In nonpregnant individuals, the rate-pressure product, the product of heart rate and systolic blood pressure, is used as a noninvasive surrogate of myocardial O2 consumption during cardiac stress testing. Pregnancy is considered a physiological cardiovascular stress test. Evidence describing the impact of pregnancy on myocardial O2 demand, as assessed by the rate-pressure product, is limited. OBJECTIVE This study aimed to describe changes in the rate-pressure product for each pregnancy trimester, during labor and delivery, and the postpartum period among low-risk pregnancies. STUDY DESIGN This was a retrospective cohort study that assessed uncomplicated pregnancies delivered vaginally at term. We collected rate-pressure product (heart rate × systolic blood pressure) values preconception, during pregnancy for each trimester (at ≤13 weeks + 6/7 days, at 14 weeks + 0/7 days through 27 weeks + 6/7 days, and at ≥28 weeks + 0/7 days), during the labor and delivery encounter (hospital admission until complete cervical dilation, complete cervical dilation until placental delivery, and after placental delivery until hospital discharge), and during the outpatient postpartum visit at 2 to 6 weeks after delivery. We calculated the percentage change at each time point from the preconception rate-pressure product (delta rate-pressure product). We used a mixed-linear model to analyze differences in the mean delta rate-pressure product over time and the influence of prepregnancy age, prepregnancy body mass index, and neuraxial anesthesia status during labor and delivery on these estimates. RESULTS Our cohort comprised 316 patients. The mean rate-pressure product increased significantly from preconception starting at the third trimester of pregnancy and during labor and delivery (P≤.05). The mean delta rate-pressure product peaked at 12% and 38% in the third trimester and during labor and delivery, respectively. Prepregnancy body mass index was inversely correlated with the mean delta rate-pressure product changes (estimate, -0.308; 95% confidence interval, -0.536 to -0.80; P=.008). In contrast, neither the prepregnancy age, nor neuraxial anesthesia status during labor had a significant influence on this parameter. CONCLUSION This study validates the transient but significant increase in the rate-pressure product, a clinical estimate of myocardial O2 demand, during uncomplicated pregnancies delivered vaginally at term. Pregnant individuals with lower prepregnancy body mass index experienced a sharper increase in this parameter. Patients who receive neuraxial anesthesia during labor and delivery experience similar changes in the rate-pressure product as those who did not.
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Affiliation(s)
- Claudio V Schenone
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat).
| | - M Ashley Cain
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat)
| | - Aldo L Schenone
- Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY (Dr A Schenone)
| | - Teagen Smith
- Department of Research Methodology and Biostatistics Core, University of South Florida Morsani College of Medicine, Tampa, FL (Ms Smith)
| | - Athanasios Tsalatsanis
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL (Dr Tsalatsanis)
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat)
| | - Daniela R Crousillat
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat); Division of Cardiovascular Sciences, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL (Dr Crousillat)
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5
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Joseph NT, Kuller JA, Louis JM, Hughes BL. Society for Maternal-Fetal Medicine Statement: Clinical considerations for the prevention of respiratory syncytial virus disease in infants. Am J Obstet Gynecol 2024; 230:B41-B49. [PMID: 37914061 DOI: 10.1016/j.ajog.2023.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Respiratory syncytial virus is a leading cause of lower respiratory tract illness globally in children aged <5 years. Each year, approximately 58,000 hospitalizations in the United States are attributed to respiratory syncytial virus. Infants aged ≤6 months experience the most severe morbidity and mortality. Until recently, prevention with the monoclonal antibody, palivizumab, was only offered to infants with high-risk conditions, and treatment primarily consisted of supportive care. Currently, 2 products are approved for the prevention of respiratory syncytial virus in infants. These include the Pfizer bivalent recombinant respiratory syncytial virus prefusion F protein subunit vaccine, administered seasonally to the pregnant person between 32 0/7 and 36 6/7 weeks of gestation, and the monoclonal antibody, nirsevimab, administered to infants aged up to 8 months entering their first respiratory syncytial virus season. With few exceptions, administering both the vaccine to the pregnant person and the monoclonal antibody to the infant is not recommended. All infants should be protected against respiratory syncytial virus using one of these strategies. Key considerations for pregnant individuals include examining available safety and efficacy data, weighing accessibility and availability, and patient preferences for maternal vaccination vs infant monoclonal antibody treatment. It will be critical for maternal-fetal medicine physicians to provide effective and balanced counseling to aid patients in deciding on a personalized approach to the prevention of respiratory syncytial virus in their infants.
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Pressman K, Kendle AM, Randis TM, Donda K, Salemi JL, Louis JM. Risk of birth defects in pregnant persons with sleep-disordered breathing during pregnancy. Birth Defects Res 2024; 116:e2268. [PMID: 37929317 DOI: 10.1002/bdr2.2268] [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] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/28/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION As many as one in four pregnant women may experience sleep-disordered breathing (SDB) during pregnancy. The same sequelae of SDB, such as insulin resistance and inflammation, have been implicated in the development of certain birth defects. METHODS This is a secondary analysis of the SDB substudy of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be study, which included 2106 participants who had a sufficiency sleep study at two visits at different time points in pregnancy. SDB was based on a self-administered home sleep apnea test with data scored by trained, blinded research polysomnologists. SDB was defined as an apnea-hypopnea index (AHI) ≥5. The primary outcome of this analysis was any of the 45 non-chromosomal birth defects included in the National Birth Defects Prevention Network Annual Report. RESULTS In this cohort, the overall rate of birth defects was 3.1%. The prevalence was similar between those without SDB (3.0%) and those with only mid-pregnancy SDB (3.4%), but was higher in those with early-pregnancy SDB (6.7%). After adjusting for maternal age, chronic hypertension, pregestational diabetes, and body mass index (BMI), there were no statistically significant differences in the risk of birth defects by subject SDB status. CONCLUSIONS Further studies to evaluate the effect of prepregnancy and early-pregnancy SDB on the fetus, as well as the risk of specific birth defects and neonatal outcomes in those with an objectively measured diagnosis of SDB, are still needed.
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Affiliation(s)
- Katherine Pressman
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Anthony M Kendle
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Tara M Randis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Keyur Donda
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Jason L Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- College of Public Health, University of South Florida, Tampa, Florida, USA
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Connery S, Tanner JP, Odibo L, Raitano O, Nikolic-Dorschel D, Louis JM. Effect of Using Silver Nylon Dressings on Postoperative Pain after Cesarean Delivery. Am J Perinatol 2023; 40:1811-1819. [PMID: 34839470 DOI: 10.1055/s-0041-1739521] [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: 10/19/2022]
Abstract
OBJECTIVE Silver dressings have been associated with a decrease in postoperative pain in selected populations, but it is unknown if the benefit can be observed after cesarean deliveries. We sought to evaluate the impact of silver nylon dressings in reducing postoperative pain after cesarean delivery. STUDY DESIGN A secondary analysis of data from a blinded randomized clinical trial of women undergoing cesarean delivery scheduled and unscheduled at a single site was conducted. Women were recruited for participation from a single site and randomized to a silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient clinic at 1 and 6 weeks after delivery and patient responded to the modified patient scar assessment scale. The primary outcome of this analysis was inpatient opioid and nonopioid analgesic dispensed. The secondary outcome was patient-reported pain at the 1- and 6-week postpartum visits. Data were analyzed using chi-square test, Student's t-test, Fisher's exact test, Wilcoxon-Mann-Whitney's test, and logistic regression where appropriate. A p-value of < 0.05 was considered significant. RESULTS Among the 649 participants, women allocated to the silver nylon dressing group, when compared with the gauze group, were similar in the amount of dispensed opioid and nonopioid analgesic medications (morphine equivalent milligrams of opioids dispensed [82.5 vs. 90 mg, p = 0.74], intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) [120 vs. 120 mg, p = 0.55], and oral NSAIDs [4,800 vs. 5,600 mg in the gauze group, p = 0.65]). After adjusting for confounding variables, postoperative wound infection (adjusted odds ratio [aOR]: 11.70; 95% confidence interval [CI]: 4.51-30.31) at 1-week postoperative and again at 6-week postoperative (aOR: 5.59; 95% CI: 1.03-30.31) but not gauze dressing was associated with patient-reported postoperative pain. CONCLUSION Among women undergoing cesarean delivery, silver nylon dressing was not associated with a reduction in postoperative pain. KEY POINTS · Silver dressings showed no decrease in pain medications.. · Wound infection is associated with pain postoperatively.. · Silver dressings did not reduce postoperative pain..
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Affiliation(s)
- Sheila Connery
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jean Paul Tanner
- College of Public Health, University of South Florida, Tampa, Florida
| | - Linda Odibo
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Olivia Raitano
- Creighton University School of Medicine, Omaha, Nebraska
| | | | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida
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Abstract
Sleep is a critical aspect of one's daily life for overall health, with a recommended 7 to 9 hours in adulthood (ages 26-64). Up to a third of women do not sleep sufficiently, and pregnant women are at an increased risk for sleep deficiency. Throughout pregnancy, sleep is affected in differing ways. For example, in the first trimester, hormones affect sleep cycles, but by the third trimester, physical complaints such as increasing frequent urination and fetal movement create frequent awakenings. Associations between sleep deficiency and gestational diabetes, hypertensive disorders, depression, and some evidence regarding preterm birth exist. A woman's labor course and perception of delivery are also negatively affected by short sleep duration.
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Affiliation(s)
- Arlin Delgado
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA.
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Son M, Culhane JF, Louis JM, Handley SC, Burris HH, Greenspan J, McKenney KM, Dysart K. Severe maternal morbidity rates in a US-based electronic health record database, 2018-2022. J Perinatol 2023; 43:1316-1318. [PMID: 37640810 DOI: 10.1038/s41372-023-01765-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Moeun Son
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.
| | - Jennifer F Culhane
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
| | - Sara C Handley
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Heather H Burris
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Jay Greenspan
- Division of Neonatology, Nemours Children's Hospital, Wilmington, DE, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kathryn M McKenney
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kevin Dysart
- Division of Neonatology, Nemours Children's Hospital, Wilmington, DE, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Shields AD, Plante LA, Pacheco LD, Louis JM. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis. Am J Obstet Gynecol 2023; 229:B2-B19. [PMID: 37236495 DOI: 10.1016/j.ajog.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).
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Dominguez JE, Cantrell S, Habib AS, Izci-Balserak B, Lockhart E, Louis JM, Miskovic A, Nadler JW, Nagappa M, O'Brien LM, Won C, Bourjeily G. Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology Consensus Guideline on the Screening, Diagnosis, and Treatment of Obstructive Sleep Apnea in Pregnancy. Obstet Gynecol 2023; 142:403-423. [PMID: 37411038 PMCID: PMC10351908 DOI: 10.1097/aog.0000000000005261] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/16/2023] [Accepted: 03/02/2023] [Indexed: 07/08/2023]
Abstract
The Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology tasked an expert group to review existing evidence and to generate recommendations on the screening, diagnosis, and treatment of patients with obstructive sleep apnea during pregnancy. These recommendations are based on a systematic review of the available scientific evidence and expert opinion when scientific evidence is lacking. This guideline may not be appropriate for all clinical situations and patients, and physicians must decide whether these recommendations are appropriate for their patients on an individual basis. We recognize that not all pregnant people may identify as women. However, data on non-cisgendered pregnant patients are lacking, and many published studies use gender-binary terms; therefore, depending on the study referenced, we may refer to pregnant individuals as women. This guideline may inform the creation of clinical protocols by individual institutions that consider the unique considerations of their patient populations and the available resources.
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Affiliation(s)
- Jennifer E Dominguez
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
| | - Sarah Cantrell
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Ashraf S Habib
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Bilgay Izci-Balserak
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Ellen Lockhart
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Judette M Louis
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Alice Miskovic
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Jacob W Nadler
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Mahesh Nagappa
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Louise M O'Brien
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Christine Won
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
- From the Department of Anesthesiology, Duke University Medical Center Library & Archives, and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; the Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois; AMN Healthcare, Dallas, Texas; the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida; Anesthesiology, Great Ormond Street Hospital for Children, London, United Kingdom; the Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York; the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Toronto, Ontario, Canada; the Departments of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan; the Department of Medicine, Yale School of Medicine, New Haven, Connecticut; and the Department of Medicine, Brown University, Providence, Rhode Island
| | - Ghada Bourjeily
- Jennifer E. Dominguez, MD, MHS, and Ghada Bourjeily, MD, are the Guideline Committee Co-Chairs
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Delgado A, Kendle A, Randis TM, Donda K, Salemi JL, Facco FL, Parker C, Reddy UM, Silver RM, Basner RC, Chung JH, Schubert FP, Pien GW, Redline S, Parry S, Grobman W, Zee PC, Louis JM. Association between sleep disordered breathing and neonatal outcomes in nulliparous individuals. Am J Perinatol 2023. [PMID: 37380034 DOI: 10.1055/a-2115-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND To determine whether objectively measured Sleep-Disordered Breathing (SDB) during pregnancy is associated with an increased risk of adverse neonatal outcomes in a cohort of nulliparous individuals. METHODS Secondary analysis of the nuMom2b- sleep disordered breathing substudy was performed. Individuals underwent in-home sleep studies for SDB assessment in early- (6-15 weeks' gestation) and mid-pregnancy (22-31 weeks' gestation). SDB was defined as an apnea-hypopnea index ≥5 events/hour at either time point. Primary outcome was a composite outcome of respiratory distress syndrome, transient tachypnea of the newborn, or receipt of respiratory support, treated hyperbilirubinemia or hypoglycemia, large-for-gestational age (LGA), seizures treated with medications or confirmed by electroencephalography, confirmed sepsis, or neonatal death. Individuals were categorized into 1) early pregnancy SDB (6-15 weeks' gestation), 2) new onset mid-pregnancy SDB (22-31 weeks' gestation), and 3) no SDB. Log-binomial regression was used to calculate adjusted risk ratios (RR) and 95% confidence intervals (CI) representing the association. Adjustments were made for maternal age, chronic hypertension, pregestational diabetes, progesterone use and Body Mass Index (BMI), new onset mid-pregnancy SDB to establish if a relationship was still present. RESULTS Among 2,106 participants, 3% percent (n=75) had early pregnancy SDB and 5.7% (n=119) developed new onset mid-pregnancy SDB. The incidence of the primary outcome was higher in offspring of individuals with early- (29.3%) and new onset mid- pregnancy SDB (30.3%) compared to individuals with no SDB (17.8%). After adjustment for maternal age, chronic hypertension, pregestational diabetes, progesterone use and BMI, new onset mid-pregnancy SDB conferred increased risk (RR=1.42, 95% CI: 1.05, 1.92), where there was no longer statistically significant association between early pregnancy SDB and the primary outcome. CONCLUSION New Onset, Mid- pregnancy SDB is independently associated with neonatal morbidity.
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Affiliation(s)
- Arlin Delgado
- Obstetrics and Gynecology, South University - Tampa, Tampa, United States
| | - Anthony Kendle
- Obstetrics and Gynecology, University of South Florida College of Medicine, Tampa, United States
| | - Tara M Randis
- Pediatrics and Molecular Biology, University of South Florida, Tampa, United States
| | - Keyur Donda
- Pediatrics, South University - Tampa, Tampa, United States
| | | | | | | | - Uma M Reddy
- Yale University School of Medicine, New Haven, United States
| | - Robert M Silver
- Obstetrics & Gynecology, The University of Utah School of Medicine, Salt Lake City, United States
| | - Robert C Basner
- Obstetrics and Gynecology, Columbia University, New York, United States
| | - Judith H Chung
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, United States
| | - Frank Paul Schubert
- Obstetrics and Gynecology - Division of Maternal Fetal Medicine, Indiana University School of Medicine, Indianapolis, United States
| | - Grace W Pien
- Johns Hopkins University, Baltimore, United States
| | - Susan Redline
- Beth Israel Deaconess Medical Center, Boston, United States
| | - Samuel Parry
- Maternal-Fetal Medicine, University of Pennsylvania, Philadelphia, United States
| | - William Grobman
- Obstetrics and Gynecology, The Ohio State University, Columbus, United States
| | - Phyllis C Zee
- Neurology, Northwestern University, Evanston, United States
| | - Judette M Louis
- Obstetrics & Gynecology, University of South Florida, Tampa, United States
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Kendle AM, Swanson J, Salemi JL, Louis JM. Association of Insomnia with 30-Day Postpartum Readmission: A Retrospective Analysis. Int J Environ Res Public Health 2023; 20:5955. [PMID: 37297559 PMCID: PMC10252679 DOI: 10.3390/ijerph20115955] [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] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023]
Abstract
Insomnia is prevalent in pregnancy and is associated with increased use of health services. We aimed to evaluate the association between insomnia diagnosed at the delivery hospitalization and risk of 30-day postpartum readmission. We conducted a retrospective analysis of inpatient hospitalizations from the 2010-2019 Nationwide Readmissions Database. The primary exposure was a coded diagnosis of insomnia at delivery as determined by ICD-9-CM and ICD-10-CM codes. Obstetric comorbidities and indicators of severe maternal morbidity were also determined through coding. The primary outcome was all-cause 30-day postpartum readmission. Survey-weighted logistic regression was used to generate crude and adjusted odds ratios representing the association between maternal insomnia and postpartum readmission. Of over 34 million delivery hospitalizations, 26,099 (7.6 cases per 10,000) had a coded diagnosis of insomnia. People with insomnia experienced a 3.0% all-cause 30-day postpartum readmission rate, compared to 1.4% among those without insomnia. After controlling for sociodemographic, clinical, and hospital-level factors, insomnia was associated with 1.64 times higher odds of readmission (95% CI 1.47-1.83). After adjustment for obstetric comorbidity burden and severe maternal morbidity, insomnia was independently associated with 1.33 times higher odds of readmission (95% CI 1.18-1.48). Pregnant patients with insomnia have higher rates of postpartum readmission, and diagnosis of insomnia is independently associated with increased odds of readmission. Additional postpartum support may be warranted for pregnancies affected by insomnia.
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Affiliation(s)
- Anthony M. Kendle
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA; (J.L.S.); (J.M.L.)
| | - Justin Swanson
- College of Public Health, University of South Florida, Tampa, FL 33612, USA;
| | - Jason L. Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA; (J.L.S.); (J.M.L.)
- College of Public Health, University of South Florida, Tampa, FL 33612, USA;
| | - Judette M. Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA; (J.L.S.); (J.M.L.)
- College of Public Health, University of South Florida, Tampa, FL 33612, USA;
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Miele K, Kim SY, Jones R, Rembert JH, Wachman EM, Shrestha H, Henninger ML, Kimes TM, Schneider PD, Sivaloganathan V, Sward KA, Deshmukh VG, Sanjuan PM, Maxwell JR, Seligman NS, Caveglia S, Louis JM, Wright T, Bennett CC, Green C, George N, Gosdin L, Tran EL, Meaney-Delman D, Gilboa SM. Medication for Opioid Use Disorder During Pregnancy - Maternal and Infant Network to Understand Outcomes Associated with Use of Medication for Opioid Use Disorder During Pregnancy (MAT-LINK), 2014-2021. MMWR Surveill Summ 2023; 72:1-14. [PMID: 37130060 PMCID: PMC10154076 DOI: 10.15585/mmwr.ss7203a1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Problem Medication for opioid use disorder (MOUD) is recommended for persons with opioid use disorder (OUD) during pregnancy. However, knowledge gaps exist about best practices for management of OUD during pregnancy and these data are needed to guide clinical care. Period Covered 2014-2021. Description of the System Established in 2019, the Maternal and Infant Network to Understand Outcomes Associated with Medication for Opioid Use Disorder During Pregnancy (MAT-LINK) is a surveillance network of seven clinical sites in the United States. Boston Medical Center, Kaiser Permanente Northwest, The Ohio State University, and the University of Utah were the initial clinical sites in 2019. In 2021, three clinical sites were added to the network (the University of New Mexico, the University of Rochester, and the University of South Florida). Persons receiving care at the seven clinical sites are diverse in terms of geography, urbanicity, race and ethnicity, insurance coverage, and type of MOUD received. The goal of MAT-LINK is to capture demographic and clinical information about persons with OUD during pregnancy to better understand the effect of MOUD on outcomes and, ultimately, provide information for clinical care and public health interventions for this population. MAT-LINK maintains strict confidentiality through robust information technology architecture. MAT-LINK surveillance methods, population characteristics, and evaluation findings are described in this inaugural surveillance report. This report is the first to describe the system, presenting detailed information on funding, structure, data elements, and methods as well as findings from a surveillance evaluation. The findings presented in this report are limited to selected demographic characteristics of pregnant persons overall and by MOUD treatment status. Clinical and outcome data are not included because data collection and cleaning have not been completed; initial analyses of clinical and outcome data will begin in 2023. Results The MAT-LINK surveillance network gathered data on 5,541 reported pregnancies with a known pregnancy outcome during 2014-2021 among persons with OUD from seven clinical sites. The mean maternal age was 29.7 (SD = ±5.1) years. By race and ethnicity, 86.3% of pregnant persons were identified as White, 25.4% as Hispanic or Latino, and 5.8% as Black or African American. Among pregnant persons, 81.6% had public insurance, and 84.4% lived in urban areas. Compared with persons not receiving MOUD during pregnancy, those receiving MOUD during pregnancy were more likely to be older and White and to have public insurance. The evaluation of the surveillance system found that the initial four clinical sites were not representative of demographics of the South or Southwest regions of the United States and had low representation from certain racial and ethnic groups compared with the overall U.S. population; however, the addition of three clinical sites in 2021 made the surveillance network more representative. Automated extraction and processing improved the speed of data collection and analysis. The ability to add new clinical sites and variables demonstrated the flexibility of MAT-LINK. Interpretation MAT-LINK is the first surveillance system to collect comprehensive, longitudinal data on pregnant person-infant dyads with perinatal outcomes associated with MOUD during pregnancy from multiple clinical sites. Analyses of clinical site data demonstrated different sociodemographic characteristics between the MOUD and non-MOUD treatment groups. Public Health Actions MAT-LINK is a timely and flexible surveillance system with data on approximately 5,500 pregnancies. Ongoing data collection and analyses of these data will provide information to support clinical and public health guidance to improve health outcomes among pregnant persons with OUD and their children.
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Gantt A, Metz TD, Kuller JA, Louis JM, Cahill AG, Turrentine MA. Obstetric Care Consensus #11, Pregnancy at age 35 years or older. Am J Obstet Gynecol 2023; 228:B25-B40. [PMID: 35850202 DOI: 10.1016/j.ajog.2022.07.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those found in younger pregnant populations, even in healthy individuals with no other comorbidities. There are several studies that suggest that advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetrical care with anticipated delivery at the age of 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.
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Redline RW, Roberts DJ, Parast MM, Ernst LM, Morgan TK, Greene MF, Gyamfi-Bannerman C, Louis JM, Maltepe E, Mestan KK, Romero R, Stone J. Placental pathology is necessary to understand common pregnancy complications and achieve an improved taxonomy of obstetrical disease. Am J Obstet Gynecol 2023; 228:187-202. [PMID: 35973475 PMCID: PMC10337668 DOI: 10.1016/j.ajog.2022.08.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 01/28/2023]
Abstract
The importance of a fully functioning placenta for a good pregnancy outcome is unquestioned. Loss of function can lead to pregnancy complications and is often detected by a thorough placental pathologic examination. Placental pathology has advanced the science and practice of obstetrics and neonatal-perinatal medicine by classifying diseases according to underlying biology and specific patterns of injury. Many past obstacles have limited the incorporation of placental findings into both clinical studies and day-to-day practice. Limitations have included variability in the nomenclature used to describe placental lesions, a shortage of perinatal pathologists fully competent to analyze placental specimens, and a troubling lack of understanding of placental diagnoses by clinicians. However, the potential use of placental pathology for phenotypic classification, improved understanding of the biology of adverse pregnancy outcomes, the development of treatment and prevention, and patient counseling has never been greater. This review, written partly in response to a recent critique published in a major obstetrics-gynecology journal, reexamines the role of placental pathology by reviewing current concepts of biology; explaining the most recent terminology; emphasizing the usefulness of specific diagnoses for obstetrician-gynecologists, neonatologists, and patients; previewing upcoming changes in recommendations for placental submission; and suggesting future improvements. These improvements should include further consideration of overall healthcare costs, cost-effectiveness, the clinical value added of placental assessment, improvements in placental pathology education and practice, and leveraging of placental pathology to identify new biomarkers of disease and evaluate novel therapies tailored to specific clinicopathologic phenotypes of both women and infants.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology and Reproductive Biology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center and Cleveland, OH.
| | - Drucilla J Roberts
- Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Mana M Parast
- Department of Pathology, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA
| | - Linda M Ernst
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Terry K Morgan
- Department of Pathology and Obstetrics and Gynecology, Center for Developmental Health, Oregon Health Sciences University, Portland, OR
| | - Michael F Greene
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University South Florida, Tampa, FL
| | - Emin Maltepe
- Department of Pediatrics, University California, San Francisco, San Francisco, CA
| | - Karen K Mestan
- Department of Pediatrics and Neonatology, University of California, San Diego, School of Medicine and Rady Children's Hospital, San Diego, CA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI
| | - Joanne Stone
- Raquel and Jaime Gilinski Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
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Elmore AL, Boghossian NS, McDermott S, McLain AC, Louis JM, Kendle A, Salemi JL. Postpartum mental health hospital encounters among mothers with prenatal opioid use. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.470] [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: 01/09/2023]
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Giugni CS, Cain M, Tsalatsanis A, Kumar A, Louis JM, Crousillat D. Myocardial oxygen consumption in pregnancies complicated by hypertensive disorders of pregnancy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.235] [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: 01/09/2023]
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Giugni CS, Cain M, Tsalatsanis A, Kumar A, Louis JM, Crousillat D. Myocardial oxygen consumption among low-risk pregnancies. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.236] [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: 01/09/2023]
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Kendle A, Louis JM, Whittum M. Non-race-based anemia protocol reduces disparity in prenatal iron replacement therapy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.478] [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: 01/09/2023]
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Giugni CS, Cain M, Tsalatsanis A, Kumar A, Louis JM, Crousillat D. Differences in myocardial oxygen consumption between low-risk pregnancies and pregnancies with hypertensive disorders of pregnancy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.783] [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: 01/08/2023]
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de Assis V, Cain M, Louis JM, Crousillat D. Trends in lipid values among obese women in pregnancy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.711] [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: 01/09/2023]
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Jarman ML, Bennett MM, Louis JM, Clark RH, Tolia VN, Ahmad KA. Changing Tocolytic Exposures among Neonatal Intensive Care Unit Admitted Preterm Infants. Am J Perinatol 2022; 39:1745-1749. [PMID: 35045576 DOI: 10.1055/a-1745-3262] [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: 01/28/2023]
Abstract
OBJECTIVE Since 2010, the American College of Obstetrics and Gynecology have released three committee opinions to recommend and reaffirm the utility of magnesium sulfate for neuroprotection and later for tocolysis to achieve antenatal steroid course completion in preterm labor. We sought to determine changes in antenatal magnesium sulfate exposure and other tocolytic agents for pregnancies resulting in neonatal intensive care unit (NICU)-admitted preterm infants. STUDY DESIGN Using the Pediatrix Clinical Data Warehouse, we evaluated all inborn infants delivered between 22 and 33 weeks' gestation and admitted to the intensive care units from 2009 to 2018. We classified patients based on antenatal exposure to tocolytic medications: calcium channel blockers (nifedipine and amlodipine), betamimetics (terbutaline, theophylline, and ritodrine), prostaglandin inhibitors (indomethacin), and magnesium sulfate. RESULTS A total of 229,781 patients met inclusion criteria. During the study period, magnesium sulfate exposure increased from 27.6 to 57.7% of births while betamimetic exposure decreased from 10.2 to 5.2%. Increasing magnesium sulfate exposure over time was seen at all gestational ages examined and magnesium exposure was most common between 23 and 31 weeks' gestation. By 2017 to 2018, 70.5% of 24 to 29 weeks' gestation NICU infants received exposure to at least one tocolytic agent while this remained at 53.7% of 32 to 33 weeks' NICU admitted infants. Antenatal steroid exposure increased from 74.8 to 87.4% during the study period. CONCLUSION For NICU-admitted preterm infants, prenatal exposure patterns to tocolytic agents has shifted since 2009 with prenatal magnesium sulfate exposure increasing significantly. Antenatal steroid exposure has risen concurrently. Exposure to tocolytic agents is the highest among preterm infants born between 24 and 29 weeks' gestation. KEY POINTS · Exposure to magnesium sulfate significantly increased from 2009 to 2018 for NICU admitted infants.. · Concurrently, the use of other tocolytics decreased significantly.. · The use of antenatal steroids has been rising over time..
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Affiliation(s)
- Meghan L Jarman
- Department of Pediatrics, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Monica M Bennett
- Research Analytics and Development Cores, Baylor Scott and White Research Institute, Dallas, Texas
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Reese H Clark
- MEDNAX Center for Research Education, Quality, and Safety, Sunrise, Florida
| | - Veeral N Tolia
- Department of Pediatrics, Baylor University Medical Center, Dallas, Texas.,Pediatrix Medical Group, Dallas, Texas
| | - Kaashif A Ahmad
- Department of Pediatrics, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas.,MEDNAX Center for Research Education, Quality, and Safety, Sunrise, Florida.,Pediatrix Medical Group of San Antonio, San Antonio, Texas.,Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas.,Pediatrix and Obstetrix Specialists of Houston, Houston, Texas.,Department of Neonatology, The Woman's Hospital of Texas, Houston, Texas
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Thadhani R, Lemoine E, Rana S, Costantine MM, Calsavara VF, Boggess K, Wylie BJ, Moore Simas TA, Louis JM, Espinoza J, Gaw SL, Murtha A, Wiegand S, Gollin Y, Singh D, Silver RM, Durie DE, Panda B, Norwitz ER, Burd I, Plunkett B, Scott RK, Gaden A, Bautista M, Chang Y, Diniz MA, Karumanchi SA, Kilpatrick S. Circulating Angiogenic Factor Levels in Hypertensive Disorders of Pregnancy. NEJM Evid 2022; 1:EVIDoa2200161. [PMID: 38319832 DOI: 10.1056/evidoa2200161] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Circulating Angiogenic Factor in Hypertension in PregnancyThis study measured serum soluble fms-like tyrosine kinase 1 to placental growth factor values in pregnant women hospitalized with hypertension. In women with a hypertensive disorder of pregnancy presenting between 23 and 35 weeks' gestation, a soluble fms-like tyrosine kinase 1:placental growth factor ratio ≥40 provided stratification of the risk of progressing to severe preeclampsia within 2 weeks.
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Affiliation(s)
- Ravi Thadhani
- Cedars-Sinai Medical Center, Los Angeles
- Massachusetts General Hospital, Boston
| | - Elizabeth Lemoine
- Cedars-Sinai Medical Center, Los Angeles
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Sarosh Rana
- University of Chicago Medical Center, Chicago
| | | | | | - Kim Boggess
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | | | - Jimmy Espinoza
- Baylor College of Medicine and Texas Children's Hospital, Houston
| | | | - Amy Murtha
- University of California at San Francisco, San Francisco
| | | | - Yvonne Gollin
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA
| | | | | | | | | | - Errol R Norwitz
- Tufts Medical Center, Boston
- Newton-Wellesley Hospital, Newton, MA
| | | | | | | | - Anna Gaden
- Cedars-Sinai Medical Center, Los Angeles
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25
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Louis JM, Parchem J, Vaught A, Tesfalul M, Kendle A, Tsigas E. Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2022.06.038] [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: 11/16/2022]
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26
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Kendle AM, Salemi JL, Jackson CL, Buysse DJ, Louis JM. Insomnia during pregnancy and severe maternal morbidity in the united states: nationally representative data from 2006 to 2017. Sleep 2022; 45:zsac175. [PMID: 35901516 PMCID: PMC9548669 DOI: 10.1093/sleep/zsac175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 06/08/2022] [Indexed: 07/30/2023] Open
Abstract
STUDY OBJECTIVES Using a large, nationally representative database, we aimed to estimate the prevalence and trends of insomnia among pregnant women over a 12-year period. In addition, we aimed to examine the interplay among insomnia, maternal comorbidities, and severe maternal morbidity (SMM). METHODS We conducted a serial cross-sectional analysis of pregnancy-related hospitalizations in the United States from the 2006 to 2017 National Inpatient Sample (NIS). ICD-9 and ICD-10 codes were used to capture diagnoses of insomnia and obstetric comorbidities during delivery and non-delivery hospitalizations. The primary outcome was the diagnosis of SMM at delivery. We used logistic regression to assess the association between insomnia and SMM. Joinpoint regression was used to estimate trends in insomnia and SMM. RESULTS Of nearly 47 million delivery hospitalizations, 24 625 women had a diagnosis of insomnia, or 5.2 per 10 000 deliveries. The annual incidence increased from 1.8 to 8.6 per 10 000 over the study period. The crude rate of insomnia was 6.3 times higher for non-delivery hospitalizations. Patients with insomnia had more comorbidities, particularly neuromuscular disease, mental health disorders, asthma, and substance use disorder. Prevalence of non-blood transfusion SMM was 3.6 times higher for patients with insomnia (2.4% vs. 0.7%). SMM increased annually by 11% (95% CI = 3.0% to 19.7%) in patients with insomnia. After adjusting for comorbidities, there remained a 24% increased likelihood of SMM for patients with insomnia. CONCLUSIONS Coded diagnosis of insomnia during pregnancy has increased over time, and this burden disparately affects women of low socioeconomic status. Diagnosis of insomnia is an independent predictor of SMM.
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Affiliation(s)
- Anthony M Kendle
- Corresponding author: Anthony M. Kendle, 2 Tampa General Circle, Tampa, FL 33606, USA.
| | - Jason L Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa FL, USA
- College of Public Health, University of South Florida, Tampa FL, USA
| | - Chandra L Jackson
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Department of Health and Human Services, Bethesda, MD,USA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA,USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa FL, USA
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27
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Abstract
Sleep is a critical aspect of one's daily life for overall health, with a recommended 7 to 9 hours in adulthood (ages 26-64). Up to a third of women do not sleep sufficiently, and pregnant women are at an increased risk for sleep deficiency. Throughout pregnancy, sleep is affected in differing ways. For example, in the first trimester, hormones affect sleep cycles, but by the third trimester, physical complaints such as increasing frequent urination and fetal movement create frequent awakenings. Associations between sleep deficiency and gestational diabetes, hypertensive disorders, depression, and some evidence regarding preterm birth exist. A woman's labor course and perception of delivery are also negatively affected by short sleep duration.
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Affiliation(s)
- Arlin Delgado
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA.
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28
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Facco FL, Redline S, Hunter SM, Zee PC, Grobman WA, Silver RM, Louis JM, Pien GW, Mercer B, Chung JH, Bairey Merz CN, Haas DM, Nhan-Chang CL, Simhan HN, Schubert FP, Parry S, Reddy U, Saade GR, Hoffman MK, Levine LD, Wapner RJ, Catov JM, Parker CB. Sleep-disordered Breathing in Pregnancy and after Delivery: Associations with Cardiometabolic Health. Am J Respir Crit Care Med 2022; 205:1202-1213. [PMID: 35144521 PMCID: PMC9872809 DOI: 10.1164/rccm.202104-0971oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/28/2023] Open
Abstract
Rationale: Knowledge gaps exist regarding health implications of sleep-disordered breathing (SDB) identified in pregnancy and/or after delivery. Objectives: To determine whether SDB in pregnancy and/or after delivery is associated with hypertension (HTN) and metabolic syndrome (MS). Methods: nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be Heart Health Study) (N = 4,508) followed participants initially recruited during their first pregnancy. Participants returned for a visit 2-7 years after pregnancy. This study examined a subgroup who underwent SDB assessments during their first pregnancy (n = 1,964) and a repeat SDB assessment after delivery (n = 1,222). Two SDB definitions were considered: 1) apnea-hypopnea index (AHI) ⩾ 5 and 2) oxygen desaturation index (ODI) ⩾ 5. Associations between SDB and incident HTN and MS were evaluated with adjusted risk ratios (aRRs). Measurements and Main Results: The aRR for MS given an AHI ⩾ 5 during pregnancy was 1.44 (95% confidence interval [CI], 1.08-1.93), but no association with HTN was found. ODI ⩾ 5 in pregnancy was associated with both an increased risk for HTN (aRR, 2.02; 95% CI, 1.30-3.14) and MS (aRR, 1.53; 95% CI, 1.19-1.97). Participants with an AHI ⩾ 5 in pregnancy that persisted after delivery were at higher risk for both HTN (aRR, 3.77; 95% CI, 1.84-7.73) and MS (aRR, 2.46; 95% CI, 1.59-3.76). Similar associations were observed for persistent ODI ⩾ 5 after delivery. Conclusions: An AHI ⩾ 5 in pregnancy was associated with an increased risk of MS. An ODI ⩾ 5 in pregnancy was significantly associated with both HTN and MS. Participants with persistent elevations in AHI and ODI during pregnancy and at 2-7 years after delivery were at the highest risk for HTN and MS. Clinical trial registered with www.clinicaltrials.gov (NCT02231398).
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Affiliation(s)
- Francesca L. Facco
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Susan Redline
- Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | - William A. Grobman
- Department of Obstetrics, Gynecology-Maternal Fetal Medicine and Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Judette M. Louis
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Grace W. Pien
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Brian Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve, MetroHealth, Cleveland, Ohio
| | - Judith H. Chung
- Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - David M. Haas
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Frank P. Schubert
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Uma Reddy
- Department of Obstetrics, Gynecology & Reproductive Services, Yale University, New Haven, Connecticut
| | - George R. Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, University of Texas, Galveston, Texas; and
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware
| | - Lisa D. Levine
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Janet M. Catov
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Abstract
OBJECTIVE The study aimed to evaluate the impact of obesity on the management and outcomes of postpartum hemorrhage. STUDY DESIGN We conducted a retrospective cohort study of women who delivered at a tertiary care center between February 1, 2013 and January 31, 2014 and experienced a postpartum hemorrhage. Charts were reviewed for clinical and sociodemographic data, and women were excluded if the medical record was incomplete. Hemorrhage-related severe morbidity indicators included blood transfusion, shock, renal failure, transfusion-related lung injury, cardiac arrest, and use of interventional radiology procedures. Obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese women were compared. Data were analyzed using Chi-square, Student's t-test, Mann-Whitney U test, and linear regression where appropriate. The p-value <0.05 was significant. RESULTS Of 9,890 deliveries, 2.6% (n = 262) were complicated by hemorrhage. Obese women were more likely to deliver by cesarean section (55.5 vs. 39.8%, p = 0.016), undergo a cesarean after labor (31.1 vs. 12.2%, p = 0.001), and have a higher quantitative blood loss (1,313 vs. 1,056 mL, p = 0.003). Both groups were equally likely to receive carboprost, methylergonovine, and misoprostol, but obese women were more likely to receive any uterotonic agent (95.7 vs. 88.9%, p = 0.007) and be moved to the operating room (32.3 vs. 20.4, p = 0.04). There was no difference in the use of intrauterine pressure balloon tamponade, interventional radiology, or decision to proceed with hysterectomy. The two groups were similar in time to stabilization. There was no difference in the need for blood transfusion. Obese women required more units of blood transfused (2.2 ± 2 vs. 2 ± 5 units, p = 0.023), were more likely to have any hemorrhage-related severe morbidity (34.1 vs. 25%, p = 0.016), and more than one hemorrhage related morbidity (17.1 vs. 7.9, p = 0.02). After controlling for confounding variables, quantitative blood loss, and not BMI was predictive of the need for transfusion. CONCLUSION Despite similar management, obese women were more likely to have severe morbidity and need more units of blood transfused. KEY POINTS · Obese women were more likely to have a higher quantitative blood loss and require more units of blood transfused.. · Obese women were more likely to experience any hemorrhage-related severe morbidity.. · Although obese women were more likely to be moved to the operating room for intervention, the rates of intrauterine pressure balloon tamponade, interventional radiology or hysterectomy were the same for obese and non-obese women..
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Affiliation(s)
- Aleksandra Polic
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Tierra L Curry
- Department of Internal Medicine, Hospital Corporations of America/Citrus Memorial Hospital, Inverness, Florida
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida
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30
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Johnson JD, Louis JM. Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature. Am J Obstet Gynecol 2022; 226:S876-S885. [PMID: 32717255 DOI: 10.1016/j.ajog.2020.07.038] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [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: 06/11/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 12/15/2022]
Abstract
The burden of preeclampsia, a substantial contributor to perinatal morbidity and mortality, is not born equally across the population. Although the prevalence of preeclampsia has been reported to be 3% to 5%, racial and ethnic minority groups such as non-Hispanic Black women and American Indian or Alaskan Native women are widely reported to be disproportionately affected by preeclampsia. However, studies that add clarity to the causes of the racial and ethnic differences in preeclampsia are limited. Race is a social construct, is often self-assigned, is variable across settings, and fails to account for subgroups. Studies of the genetic structure of human populations continue to find more variations within racial groups than among them. Efforts to examine the role of race and ethnicity in biomedical research should consider these limitations and not use it as a biological construct. Furthermore, the use of race in decision making in clinical settings may worsen the disparity in health outcomes. Most of the existing data on disparities examine the differences between White and non-Hispanic Black women. Fewer studies have enough sample size to evaluate the outcomes in the Asian, American Indian or Alaskan Native, or mixed-race women. Racial differences are noted in the occurrence, presentation, and short-term and long-term outcomes of preeclampsia. Well-established clinical risk factors for preeclampsia such as obesity, diabetes, and chronic hypertension disproportionately affect non-Hispanic Black, American Indian or Alaskan Native, and Hispanic populations. However, with comparable clinical risk factors for preeclampsia among women of different race or ethnic groups, addressing modifiable risk factors has not been found to have the same protective effect for all women. Abnormalities of placental formation and development, immunologic factors, vascular changes, and inflammation have all been identified as contributing to the pathophysiology of preeclampsia. Few studies have examined race and the pathophysiology of preeclampsia. Despite attempts, a genetic basis for the disease has not been identified. A number of genetic variants, including apolipoprotein L1, have been identified as possible risk modifiers. Few studies have examined race and prevention of preeclampsia. Although low-dose aspirin for the prevention of preeclampsia is recommended by the US Preventive Service Task Force, a population-based study found racial and ethnic differences in preeclampsia recurrence after the implementation of low-dose aspirin supplementation. After implementation, recurrent preeclampsia reduced among Hispanic women (76.4% vs 49.6%; P<.001), but there was no difference in the recurrent preeclampsia in non-Hispanic Black women (13.7 vs 18.1; P=.252). Future research incorporating the National Institute on Minority Health and Health Disparities multilevel framework, specifically examining the role of racism on the burden of the disease, may help in the quest for effective strategies to reduce the disproportionate burden of preeclampsia on a minority population. In this model, a multilevel framework provides a more comprehensive approach and takes into account the influence of behavioral factors, environmental factors, and healthcare systems, not just on the individual.
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Affiliation(s)
- Jasmine D Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Judette M Louis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL.
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31
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Matas JL, Mitchell LE, Sharma SV, Louis JM, Salemi JL. Severe maternal morbidity at delivery and postpartum readmission in the United States. Paediatr Perinat Epidemiol 2021; 35:627-634. [PMID: 33738822 DOI: 10.1111/ppe.12762] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/06/2021] [Accepted: 02/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about the extent to which severe maternal morbidity (SMM) at delivery impacts early and late postpartum readmission. OBJECTIVES We examined readmission rates for women with and without SMM (and their 18 subtypes) at delivery and characterised the most common medical reasons for readmissions. METHODS We conducted a retrospective cohort study utilising the 2016-2017 Nationwide Readmissions Database among women giving births in the United States. Deliveries were classified according to the presence or absence of 18 SMM indicators defined by the Centers for Disease Control and Prevention using the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnosis and procedure codes. The primary outcome of this study was all-cause early (≤7 day) and late (8 to 42 day) postpartum readmission. Survey-weighted Poisson regression with robust error variance was used to generate adjusted risk ratios (RR) and 95% confidence intervals (CI) to investigate the association between SMM and early and late postpartum readmission. Additionally, we compared principal diagnoses codes during readmission hospitalisations among women with and without SMM at delivery. RESULTS Of the 6 193 852 women examined, 4.9% (n = 4928) with any SMM and 1.4% (n = 83 995) with no SMM were readmitted within 42 days after delivery. After adjusting for obstetric co-morbidities and sociodemographic factors, women with any SMM were 57% (RR 1.57, 95% CI 1.47, 1.67) more likely to have an early readmission and 69% (RR 1.69, 95% CI 1.57, 1.82) more likely to have a late readmission compared to women with no SMM at delivery. However, the risk was attenuated when excluding women with blood transfusion only. Women with and without SMM were readmitted predominantly for obstetric complications and infections. CONCLUSIONS Women with SMM at delivery were more likely to experience both early and late postpartum readmission, independent of their obstetrical co-morbidity burden and sociodemographic factors.
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Affiliation(s)
- Jennifer L Matas
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth, School of Public Health, Houston, TX, USA
| | - Laura E Mitchell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth, School of Public Health, Houston, TX, USA
| | - Shreela V Sharma
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth, School of Public Health, Houston, TX, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jason L Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.,College of Public Health, University of South Florida, Tampa, FL, USA
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32
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Abstract
Obesity and diabetes increase hypertensive disorders of pregnancy (HDP) risk, thus preventive interventions are heavily studied. How pregestational prediabetes and related interventions impact HDP risk is less characterized. Therefore, we searched and reviewed the literature to assess the impact on HDP risk of prediabetes and varied interventions. We identified 297 citations related to pregnancy, prediabetes, and early pregnancy interventions. We also reviewed the references and citations of included articles. We included five studies assessing HDP outcomes in women with first trimester hemoglobin A1c in the prediabetes range (5.7-6.4%). One prospective observational study demonstrated first trimester hemoglobin A1c (5.9-6.4%) is associated with increased HDP risk, while another prospective observational study and one retrospective observational study had similar trends without statistical significance. A small and underpowered randomized controlled trial demonstrated initiating gestational diabetes mellitus treatment (i.e., diet, monitoring, ± insulin) in response to first trimester hemoglobin A1c (5.7-6.4%) did not statistically reduce HDP compared with standard care. One retrospective observational study suggested metformin, when started early, may reduce HDP risk in patients with prediabetes. Pregestational prediabetes appears to increase HDP risk. Interventions (i.e., metformin, diet/glucose monitoring, and/or exercise) to reduce HDP risk require additional study with long-term follow-up.
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Affiliation(s)
- Nicholas W. Carris
- University of South Florida; College of Pharmacy, Department of Pharmacotherapeutics and Clinical Research; Morsani College of Medicine, Department of Family Medicine
| | - Chinedu Nwabuobi
- University of South Florida; Morsani College of Medicine, Department of Obstetrics and Gynecology
| | - Weiwei He
- University of South Florida; College of Public Health, Department of Epidemiology & Biostatistics
| | - Krystal Bullers
- University of South Florida; Shimberg Health Sciences Library
| | - Roneé E. Wilson
- University of South Florida; College of Public Health, Department of Epidemiology & Biostatistics
| | - Judette M. Louis
- University of South Florida; Morsani College of Medicine, Department of Obstetrics and Gynecology
| | - Ronald R. Magness
- University of South Florida; Morsani College of Medicine, Department of Obstetrics and Gynecology
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33
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Lappen JR, Pettker CM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B2-B15. [PMID: 33309560 DOI: 10.1016/j.ajog.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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34
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Hawkins M, Parker CB, Redline S, Larkin JC, Zee PP, Grobman WA, Silver RM, Louis JM, Pien GW, Basner RC, Chung JH, Haas DM, Nhan-Chang CL, Simhan HN, Blue NR, Parry S, Reddy U, Facco F. Objectively assessed sleep-disordered breathing during pregnancy and infant birthweight. Sleep Med 2021; 81:312-318. [PMID: 33756281 DOI: 10.1016/j.sleep.2021.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) in pregnancy is associated with adverse maternal outcomes. The relationship between SDB and infant birthweight is unclear. This study's primary aim is to determine if objectively measured SDB in pregnancy is associated with infant birthweight. METHODS We measured SDB objectively in early (6-15 weeks' gestation) and mid (22-31 weeks' gestation) pregnancy in a large cohort of nulliparous women. SDB was defined as an Apnea-Hypopnea Index ≥5 and in secondary analyses we also examined measures of nocturnal hypoxemia. We used a modified Poisson regression approach to estimate relative risks (RR) of large-for-gestational-age (LGA: >90th percentile for gestational age) and small-for-gestational-age (SGA: <10th percentile for gestational age) birthweights. RESULTS The prevalence of early-pregnancy SDB was nearly 4%. The incidence of mid-pregnancy SDB was nearly 6.0%. The prevalence of LGA and SGA was 7.4% and 11.9%, respectively. Early-pregnancy SDB was associated with a higher risk of LGA in unadjusted models (RR 2.2, 95% CI 1.3-3.5) but not BMI-adjusted models (aRR 1.0, 95% CI 0.6-1.8). Mid-pregnancy SDB was not associated with SGA or LGA. Mid-pregnancy nocturnal hypoxemia (% of sleep time <90% oxygen saturation) and increasing nocturnal hypoxemia from early to mid-pregnancy were associated with a higher risk of LGA in BMI-adjusted models. SDB and nocturnal hypoxemia were not associated with SGA. CONCLUSIONS SDB in pregnancy was not associated with an increased risk of LGA or SGA birthweight, independent of BMI. Some measures nocturnal hypoxemia were associated with an increase in LGA risk, independent of BMI. ClinicalTrials.gov Registration number NCT02231398.
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Affiliation(s)
- Marquis Hawkins
- University of Pittsburgh, Department of Epidemiology, Pittsburgh, PA, USA.
| | | | - Susan Redline
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Jacob C Larkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Phyllis P Zee
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - William A Grobman
- Department of Obstetrics, Gynecology-Maternal Fetal Medicine & Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Judette M Louis
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Grace W Pien
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert C Basner
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Judith H Chung
- Department of Obstetrics and Gynecology, University of California, Irvine, CA, USA
| | - David M Haas
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, IN11, USA
| | | | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Uma Reddy
- Department of Obstetrics, Gynecology & Reproductive Services, Yale University, New Haven, CT, USA
| | - Francesca Facco
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Johnson JD, Melvin E, Srinivas SK, Louis JM, Hughes B, Han CSC, Norton ME, Werner EF. COVID-19 Testing, Personal Protective Equipment, and Staffing Strategies Vary at Obstetrics Centers across the Country. Am J Perinatol 2020; 37:1482-1484. [PMID: 32979850 PMCID: PMC7724575 DOI: 10.1055/s-0040-1718401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Jasmine D. Johnson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina,Address for correspondence Jasmine D. Johnson, MD Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine3010 Old Clinic Building, Campus Box 7516, Chapel Hill, NC 27599
| | - Emilie Melvin
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judette M. Louis
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Brenna Hughes
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Christina Shih-chi Han
- Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, California
| | - Mary E. Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Erika F. Werner
- Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island
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Pluym ID, Rao R, Ballas J, Ramos GA, Cross SN, Zapata M, Srinivas S, Louis JM, Werner E, Afshar Y, Han CS. Obstetrical Unit Response to the COVID-19 Pandemic: OUR Study. Am J Perinatol 2020; 37:1301-1309. [PMID: 32892329 DOI: 10.1055/s-0040-1715861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/23/2022]
Abstract
OBJECTIVE This study aimed to describe the response of labor and delivery (L&D) units in the United States to the novel coronavirus disease 2019 (COVID-19) pandemic and determine how institutional characteristics and regional disease prevalence affect viral testing and personal protective equipment (PPE). STUDY DESIGN A cross-sectional survey was distributed electronically through the Society for Maternal-Fetal Medicine e-mail database (n = 584 distinct practices) and social media between April 14 and 23, 2020. Participants were recruited through "snowballing." A single representative was asked to respond on behalf of each L&D unit. Data were analyzed using Chi-square and Fisher's exact tests. Multivariable regression was performed to explore characteristics associated with universal testing and PPE usage. RESULTS A total of 301 surveys (estimated 51.5% response rate) was analyzed representing 48 states and two territories. Obstetrical units included academic (31%), community teaching (45%) and nonteaching hospitals (24%). Sixteen percent of respondents were from states with high prevalence, defined as higher "deaths per million" rates compared with the national average. Universal laboratory testing for admissions was reported for 40% (119/297) of units. After adjusting for covariates, universal testing was more common in academic institutions (adjusted odds ratio [aOR] = 1.73, 95% confidence interval [CI]: 1.23-2.42) and high prevalence states (aOR = 2.68, 95% CI: 1.37-5.28). When delivering asymptomatic patients, full PPE (including N95 mask) was recommended for vaginal deliveries in 33% and for cesarean delivery in 38% of responding institutions. N95 mask use during asymptomatic vaginal deliveries remained more likely in high prevalence states (aOR = 2.56, 95% CI: 1.29-5.09) and less likely in hospitals with universal testing (aOR = 0.42, 95% CI: 0.24-0.73). CONCLUSION Universal laboratory testing for COVID-19 is more common at academic institutions and in states with high disease prevalence. Centers with universal testing were less likely to recommend N95 masks for asymptomatic vaginal deliveries, suggesting that viral testing can play a role in guiding efficient PPE use. KEY POINTS · Heterogeneity is seen in institutional recommendations for viral testing and PPE.. · Universal laboratory testing for COVID-19 is more common at academic centers.. · N95 mask use during vaginal deliveries is less likely in places with universal testing..
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Affiliation(s)
- Ilina D Pluym
- Department of Obstetrics and Gynecology, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Rashmi Rao
- Department of Obstetrics and Gynecology, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Jerasimos Ballas
- Department of Obstetrics and Gynecology, University of California San Diego School of Medicine, San Diego, California
| | - Gladys A Ramos
- Department of Obstetrics and Gynecology, University of California San Diego School of Medicine, San Diego, California
| | - Sarah N Cross
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Mya Zapata
- Department of Obstetrics and Gynecology, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sindhu Srinivas
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Erika Werner
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Christina S Han
- Department of Obstetrics and Gynecology, University of California Los Angeles School of Medicine, Los Angeles, California.,Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
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Werner EF, Louis JM, Hughes B, Han CSC, Norton ME, Srinivas SK. Community Obstetrical Units Less Likely than Academic Units to Have Universal COVID-19 Testing. Am J Perinatol 2020; 37:1074-1076. [PMID: 32428963 PMCID: PMC7416201 DOI: 10.1055/s-0040-1712454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Erika F. Werner
- Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island,Address for correspondence Erika F. Werner Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School101 Dudley Street, Providence, RI 02906
| | - Judette M. Louis
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Brenna Hughes
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Christina Shih-chi Han
- UCLA School of Medicine, Los Angeles, California,Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
| | - Mary E. Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Salemi JL, Hansen MA, Modak S, Matas JL, Germanos GJ, Raza SA, Agana DFG, Louis JM. Estimating the obstetric co-morbidity burden using administrative data: The impact of the pregnancy-related assessment window. Paediatr Perinat Epidemiol 2020; 34:440-451. [PMID: 31976579 DOI: 10.1111/ppe.12593] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite increased research using large administrative databases to identify determinants of maternal morbidity and mortality, the extent to which these databases capture obstetric co-morbidities is unknown. OBJECTIVE To evaluate the impact that the time window used to assess obstetric co-morbidities has on the completeness of ascertainment of those co-morbidities. METHODS We conducted a five-year analysis of inpatient hospitalisations of pregnant women from 2010-2014 using the Nationwide Readmissions Database. For each woman, using discharge diagnoses, we identified 24 conditions used to create the Obstetric Comorbidity Index. Using various assessment windows for capturing obstetric co-morbidities, including the delivery hospitalisation only and all weekly windows from 7 to 280 days, we calculated the frequency and rate of each co-morbidity and the degree of underascertainment of the co-morbidity. Under each scenario, and for each co-morbidity, we also calculated the all-cause, 30-day readmission rate. RESULTS There were over 3 million delivery hospitalisations from 2010 to 2014 included in this analysis. Compared with a full 280-day window, assessment of obstetric co-morbidities using only diagnoses made during the delivery hospitalisation would result in failing to identify over 35% of cases of chronic renal disease, 28.5% cases in which alcohol abuse was documented during pregnancy, and 23.1% of women with pulmonary hypertension. For seven other co-morbidities, at least 1 in 20 women with that condition would have been missed with exclusive reliance on the delivery hospitalisation for co-morbidity diagnoses. Not only would reliance on delivery hospitalisations have resulted in missed cases of co-morbidities, but for many conditions, estimates of readmission rates for women with obstetric co-morbidities would have been underestimated. CONCLUSIONS An increasing proportion of maternal and child health research is based on large administrative databases. This study provides data that facilitate the assessment of the degree to which important obstetric co-morbidities may be underascertained when using these databases.
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Affiliation(s)
- Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Michael A Hansen
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sanjukta Modak
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer L Matas
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - George J Germanos
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Syed Ahsan Raza
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Denny Fe G Agana
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Cain MA, Brumley J, Louis-Jacques A, Drerup M, Stern M, Louis JM. A Pilot Study of a Sleep Intervention Delivered through Group Prenatal Care to Overweight and Obese Women. Behav Sleep Med 2020; 18:477-487. [PMID: 31130005 DOI: 10.1080/15402002.2019.1613995] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 01/01/2023]
Abstract
OBJECTIVES We sought to investigate the feasibility of a behavioral sleep intervention for insomnia, delivered through group prenatal care and the relationship of this intervention to improvements in insomnia symptoms and sleep quality. PARTICIPANTS Women receiving prenatal care and reporting a pre-pregnancy BMI of ≥25 kg/m2 and sleep duration of <6.5 h per night. METHODS Participants were randomized to group prenatal care or group prenatal care with a behavioral sleep intervention, adapted from cognitive behavioral therapy for insomnia (CBT-I) online program Go! to Sleep®. In the second trimester (T1), late third trimester (T2) and 6-8 weeks postpartum (T3) study assessments were completed including the Insomnia Severity Index, Pittsburgh Sleep Quality Index, fasting glucose and insulin and weight and height. Data were analyzed using independent samples t-tests, chi-square tests, correlations, and two-way repeated measures ANOVA where appropriate. P < .05 was set as the level of significance. RESULTS From May 2014 to April 2015, 311 women were evaluated for inclusion and 53 women were randomized to participate (27 intervention; 26 control), 15% were lost to follow up. The intervention group had lower third trimester and postpartum levels of moderate to severe insomnia (T2 50.0% vs 85.0% (p = .018) and T3 13.6% vs 52.4% (p-.008)) and mean insomnia severity scores (T2 (14.7 (±6.6) vs 19.3 (± 6.0) p = .02) and T3 (9.7 (±5.4) vs 15.1(±7.2) p = .01)) when compared to the control group. CONCLUSION A randomized controlled trial of a behavioral sleep intervention for insomnia delivered through group prenatal care led to improvements in insomnia symptoms.
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Affiliation(s)
- Mary Ashley Cain
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of South Florida Morsani College of Medicine , Tampa, Florida, USA
| | - Jessica Brumley
- Department of Obstetrics and Gynecology, Division of midwifery, University of South Florida Morsani College of Medicine , Tampa, Florida, USA
| | - Adetola Louis-Jacques
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of South Florida Morsani College of Medicine , Tampa, Florida, USA
| | - Michelle Drerup
- Department of sleep disorders, Cleveland Clinic Sleep Disorders Center , Cleveland, OH
| | - Marilyn Stern
- Department of Child and Family Studies, University of South Florida , Tampa
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of South Florida Morsani College of Medicine , Tampa, Florida, USA
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Abstract
Rates of obesity continue to be a cause of morbidity and mortality, requiring intervention. Excessive gestational weight gain is related to postpartum weight retention and subsequent development of obesity, which translates into higher risk of adverse maternal and neonatal outcomes in future pregnancies and long-term excess cardiovascular disease and cancer for the mothers. Limiting gestational weight gain to within recommended limits prevents postpartum weight retention. This article provides an overview of methods and practices aimed at helping women achieve a healthy weight between pregnancies by improving gestational weight gain. These interventions include lifestyle behavioral changes, diet and exercise, and motivational interviewing.
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Affiliation(s)
- Peeraya Sawangkum
- Department of Obstetrics and Gynecology, University of South Florida, 6th Floor, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida, 6th Floor, 2 Tampa General Circle, Tampa, FL 33606, USA.
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Abstract
Uterine artery pseudoaneurysm in pregnancy is a dangerous condition as rupture can be catastrophic due to the large volume of uterine blood flow. We present a case of a healthy, young woman with a desired pregnancy at 15 weeks of gestation incidentally discovered to have a pseudoaneurysm of the uterine artery during a routine prenatal ultrasound. She underwent initial thrombin injection followed by endovascular coil embolisation of the left uterine artery and carried the pregnancy to term without further complications.
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Affiliation(s)
- Jared T Roeckner
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Adetola F Louis-Jacques
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Bruce R Zwiebel
- Department of Vascular and Interventional Radiology, Tampa General Hospital, Tampa, Florida, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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Blackwell S, Louis JM, Norton ME, Lappen JR, Pettker CM, Kaimal A, Landy U, Edelman A, Teal S, Landis R. Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning. Am J Obstet Gynecol 2020; 222:B2-B18. [PMID: 32252942 DOI: 10.1016/j.ajog.2019.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Brown JA, Sinkey RG, Steffensen TS, Louis-Jacques AF, Louis JM. Neonatal Abstinence Syndrome among Infants Born to Mothers with Sickle Cell Hemoglobinopathies. Am J Perinatol 2020; 37:326-332. [PMID: 31756755 DOI: 10.1055/s-0039-1700865] [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: 10/25/2022]
Abstract
OBJECTIVE The objective of this study is to examine risk factors for neonatal abstinence syndrome (NAS) among infants born to mothers with sickle cell hemoglobinopathies (SCH). STUDY DESIGN Retrospective cohort study of nonanomalous, singleton infants born to mothers with laboratory confirmed SCH. Infants were included if they were diagnosed with NAS prior to hospital discharge. The outcome of interest was the association of maternal variables with NAS. RESULTS Of 131 infants born to mothers with SCH, 4% (n = 5) were diagnosed with NAS. Mothers of infants with NAS were more likely to have SC disease (80%) compared with other SCH (20%), p = 0.001. Fifteen women had antepartum (AP) admissions for pain and/or sickle crisis. Of these patients, four infants (29%) were diagnosed with NAS. The median (5th and 95th percentile) maternal AP length of stay for women with infants diagnosed with NAS to mothers with sickle cell disease was 132 (5, 180) days (p = 0.02). CONCLUSION Incidence of NAS among mothers with SCH is low; severe disease characterized by AP sickle cell crisis requiring prolonged AP admission for pain control significantly increases the risk of NAS. Further studies are needed to investigate the association of maternal opioid dose and NAS.
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Affiliation(s)
- Jewel A Brown
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Rachel G Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | | | - Adetola F Louis-Jacques
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Judette M Louis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida
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Blackwell SC, Gyamfi-Bannerman C, Biggio JR, Chauhan SP, Hughes BL, Louis JM, Manuck TA, Miller HS, Das AF, Saade GR, Nielsen P, Baker J, Yuzko OM, Reznichenko GI, Reznichenko NY, Pekarev O, Tatarova N, Gudeman J, Birch R, Jozwiakowski MJ, Duncan M, Williams L, Krop J. 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG Study): A Multicenter, International, Randomized Double-Blind Trial. Am J Perinatol 2020; 37:127-136. [PMID: 31652479 DOI: 10.1055/s-0039-3400227] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [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: 10/25/2022]
Abstract
BACKGROUND Women with a history of spontaneous preterm birth (SPTB) are at a significantly increased risk for recurrent preterm birth (PTB). To date, only one large U.S. clinical trial comparing 17-OHPC (17-α-hydroxyprogesterone caproate or "17P") to placebo has been published, and this trial was stopped early due to a large treatment benefit. OBJECTIVE This study aimed to assess whether 17-OHPC decreases recurrent PTB and neonatal morbidity in women with a prior SPTB in a singleton gestation. STUDY DESIGN This was a double-blind, placebo-controlled international trial involving women with a previous singleton SPTB (clinicaltrials.gov: NCT01004029). Women were enrolled at 93 clinical centers (41 in the United States and 52 outside the United States) between 160/7 to 206/7 weeks in a 2:1 ratio, to receive either weekly intramuscular (IM) injections of 250 mg of 17-OHPC or an inert oil placebo; treatment was continued until delivery or 36 weeks. Co-primary outcomes were PTB < 35 weeks and a neonatal morbidity composite index. The composite included any of the following: neonatal death, grade 3 or 4 intraventricular hemorrhage, respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, or proven sepsis. A planned sample size of 1,707 patients was estimated to provide 98% power to detect a 30% reduction in PTB < 35 weeks (30% to 21%) and 90% power to detect a 35% reduction in neonatal composite index (17%-11%) using a two-sided type-I error of 5%. Finally, this sample size would also provide 82.8% power to rule out a doubling in the risk of fetal/early infant death assuming a 4% fetal/early infant death rate. Analysis was performed according to the intention-to-treat principle. RESULTS Baseline characteristics between the 1,130 women who received 17-OHPC and 578 women who received placebo were similar. Overall, 87% of enrolled women were Caucasian, 12% had >1 prior SPTB, 7% smoked cigarettes, and 89% were married/lived with partner. Prior to receiving study drug, 73% women had a transvaginal cervical length measurement performed and <2% had cervical shortening <25 mm. There were no significant differences in the frequency of PTB < 35 weeks (17-OHPC 11.0% vs. placebo 11.5%; relative risk = 0.95 [95% confidence interval (CI): 0.71-1.26]) or neonatal morbidity index (17-OHPC 5.6% vs. placebo 5.0%; relative risk = 1.12 [95% CI: 0.68-1.61]). There were also no differences in frequency of fetal/early infant death (17-OHPC 1.7% vs. placebo 1.9%; relative risk = 0.87 [95% CI: 0.4-1.81]. Maternal outcomes were also similar. In the subgroup of women enrolled in the United States (n = 391; 23% of all patients), although the rate of PTB < 35 weeks was higher than the overall study population, there were no statistically significant differences between groups (15.6% vs. 17.6%; relative risk = 0.88 [95% CI: 0.55, 1.40]. CONCLUSION In this study population, 17-OHPC did not decrease recurrent PTB and was not associated with increased fetal/early infant death.
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Affiliation(s)
- Sean C Blackwell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School-UTHealth, Houston, Texas
| | - Cynthia Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Joseph R Biggio
- Section of Maternal Fetal Medicine, Women's Services, Ochsner Health Systems, New Orleans, Louisiana
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School-UTHealth, Houston, Texas
| | - Brenna L Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Tracy A Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Hugh S Miller
- Valley Perinatal Services, Watching Over Mothers and Babies Foundation, Tucson, Arizona
| | | | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, University of Texas, Galveston, Texas
| | - Peter Nielsen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and The Children's Hospital of San Antonio, San Antonio, Texas
| | - Jeff Baker
- Clinical Research Prime, Idaho Falls, Idaho
| | - Oleksandr M Yuzko
- Department of Obstetrics and Gynecology, Bukovinian State Medical University, Chernivtsi, Ukraine
| | - Galyna I Reznichenko
- Department of Obstetrics and Gynecology, Clinical Maternity Hospital # 4, Zaporizhzhya, Ukraine
| | - Nataliya Y Reznichenko
- Department of Obstetrics and Gynecology, Clinical Maternity Hospital # 4, Zaporizhzhya, Ukraine
| | - Oleg Pekarev
- Department of Obstetrics and Gynecology, State Government-financed Healthcare Institution of Novosibirsk Region, Novosibirsk, Russia
| | - Nina Tatarova
- Department of Obstetrics and Gynecology, Saint-Petersburg Government-financed Healthcare Institution "Maternity Hospital #17," Saint-Petersburg, Russia
| | - Jennifer Gudeman
- AMAG Pharmaceuticals, Inc, Medical Development, Waltham, Massachusetts
| | - Robert Birch
- Formerly at AMAG Pharmaceuticals, Inc, Medical Development, Waltham, Massachusetts
| | | | - Monique Duncan
- AMAG Pharmaceuticals, Inc, Medical Development, Waltham, Massachusetts
| | - Laura Williams
- AMAG Pharmaceuticals, Inc, Medical Development, Waltham, Massachusetts
| | - Julie Krop
- AMAG Pharmaceuticals, Inc, Medical Development, Waltham, Massachusetts
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Facco FL, Parker CB, Hunter S, Reid KJ, Zee PP, Silver RM, Pien G, Chung JH, Louis JM, Haas DM, Nhan-Chang CL, Simhan HN, Parry S, Wapner RJ, Saade GR, Mercer BM, Bickus M, Reddy UM, Grobman WA. Later sleep timing is associated with an increased risk of preterm birth in nulliparous women. Am J Obstet Gynecol MFM 2019; 1:100040. [PMID: 33345835 DOI: 10.1016/j.ajogmf.2019.100040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/06/2019] [Accepted: 08/26/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although uterine contractions have a diurnal periodicity and increase in frequency during hours of darkness, data on the relationship between sleep duration and sleep timing patterns and preterm birth are limited. OBJECTIVE We sought to examine the relationship of self-reported sleep duration and timing in pregnancy with preterm birth. STUDY DESIGN In the prospective Nulliparous Pregnancy Outcome Study: Monitoring Mothers-to-be cohort, women completed a survey of sleep patterns at 6-13 weeks gestation (visit 1) and again at 22-29 weeks gestation (visit 3). Additionally, at 16-21 weeks gestation (visit 2), a subgroup completed a weeklong actigraphy recording of their sleep. Weekly averages of self-reported sleep duration and sleep midpoint were calculated. A priori, sleep duration of <7 hours was defined as "short," and sleep midpoint after 5 am was defined as "late." The relationships among these sleep characteristics and all preterm birth and spontaneous preterm birth at <37 weeks gestation were examined in univariate analyses. Multivariable logistic regressions that controlled for age and body mass index alone (model 1) and with additional covariates (race, smoking, insurance, and employment schedule) following a backward elimination process (model 2) were performed. RESULTS Of the 10,038 women who were enrolled, sleep survey data were available on 7524 women at visit 1 and 7668 women at visit 3. The rate of short sleep duration was 17.1% at visit 1 and 20.7% at visit 3. The proportion with a late sleep midpoint was 11.6% at visit 1 and 12.2% at visit 3. There was no significant relationship between self-reported short sleep and preterm birth across all visits. However, self-reported late sleep midpoint (>5 am) was associated with preterm birth . Women with a late sleep midpoint (>5 am) in early pregnancy had a preterm birth rate of 9.5%, compared with 6.9% for women with sleep midpoint ≤5 am (P=.005). Similarly, women with a late sleep midpoint had a higher rate of spontaneous preterm birth (6.2% vs 4.4%; P=.019). Comparable results were observed for women with a late sleep midpoint at visit 3 (all preterm birth 8.9% vs 6.6%; P=.009; spontaneous preterm birth 5.9% vs 4.3%; P=.023). All adjusted analyses on self-reported sleep midpoint (models 1 and 2) maintained statistical significance (P<.05), except for visit 1, model 2 for spontaneous preterm birth (P=.07). The visit 2 objective data from the smaller subgroup (n=782) demonstrated similar trends in preterm birth rates by sleep midpoint status. CONCLUSION Self-reported late sleep midpoint in both early and late pregnancy, but not short sleep duration, is associated with an increased rate of preterm birth.
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Affiliation(s)
- Francesca L Facco
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | | | | | - Kathryn J Reid
- Department of Neurology, Northwestern University, Chicago, IL
| | - Phyllis P Zee
- Department of Neurology, Northwestern University, Chicago, IL
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare, Salt Lake City, UT
| | - Grace Pien
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Judith H Chung
- Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, CA
| | - Judette M Louis
- University of South Florida Morsani College of Medicine, Tampa FL
| | - David M Haas
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, IN
| | | | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, IN
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, University of Texas, Galveston, TX
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH
| | - Melissa Bickus
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - William A Grobman
- Department of Obstetrics, Gynecology-Maternal Fetal Medicine & Preventive Medicine, Northwestern University, Chicago, IL
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Vricella LK, Gawron LM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications. Am J Obstet Gynecol 2019; 220:B2-B12. [PMID: 30738885 DOI: 10.1016/j.ajog.2019.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 02/06/2023]
Abstract
Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality and is a preventable cause of maternal death. The purpose of this guideline is to summarize what is known about sepsis and to provide guidance for the management of sepsis in pregnancy and the postpartum period. The following are SMFM recommendations: (1) we recommend that sepsis and septic shock be considered medical emergencies and that treatment and resuscitation begin immediately (GRADE 1B); (2) we recommend that providers consider the diagnosis of sepsis in pregnant patients with otherwise unexplained end-organ damage in the presence of an infectious process, regardless of the presence of fever (GRADE 1B); (3) we recommend that empiric broad-spectrum antibiotics be administered as soon as possible, ideally within 1 hour, in any pregnant woman in whom sepsis is suspected (GRADE 1B); (4) we recommend obtaining cultures (blood, urine, respiratory, and others as indicated) and serum lactate levels in pregnant or postpartum women in whom sepsis is suspected or identified, and early source control should be completed as soon as possible (GRADE 1C); (5) we recommend early administration of 1-2 L of crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (6) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period in sepsis with persistent hypotension and/or hypoperfusion despite fluid resuscitation (GRADE 1C); (7) we recommend against immediate delivery for the sole indication of sepsis and that delivery should be dictated by obstetric indications (GRADE 1B).
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Kendle AM, Salemi JL, Tanner JP, Louis JM. Delivery-associated sepsis: trends in prevalence and mortality. Am J Obstet Gynecol 2019; 220:391.e1-391.e16. [PMID: 30786257 DOI: 10.1016/j.ajog.2019.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 11/10/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sepsis is a leading cause of pregnancy-related mortality. Previous studies have reported an increased prevalence of sepsis during pregnancy. Despite national campaigns to increase sepsis awareness, there is a lack of pregnancy-specific guidelines. OBJECTIVE We aimed to provide updated national estimates of the prevalence and trends of sepsis, sepsis-related in-hospital mortality, and factors associated with in-hospital mortality among women with sepsis at delivery. STUDY DESIGN We conducted a serial, cross-sectional analysis using data from the 2002-2015 National Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. We used International Classification of Diseases, ninth edition, Clinical Modification diagnosis and procedure codes to identify the study sample of delivery-associated hospitalizations and to capture diagnoses of sepsis (defined as infection with associated end-organ dysfunction). The primary outcome was in-hospital mortality. Obstetric comorbidities and pregnancy-related outcomes were also analyzed. Logistic regression was used to explore factors associated with sepsis during pregnancy and, among those with sepsis, to identify predictors of in-hospital mortality. Joinpoint regression was used to estimate the temporal trends in both sepsis and in-hospital mortality. RESULTS Of the more than 55 million delivery-associated hospitalizations, 13,129 women met criteria for sepsis, corresponding to a rate of 2.4 per 10,000 deliveries. This rate increased from 1.2 to 3.7 per 10,000 over the study period, representing an annual increase of 6.6% (95% confidence interval, 4.2-9.1). The highest crude rates of sepsis (per 10,000) were among deliveries paid for by Medicare (14.8), deliveries to women aged 40 years or older (8.0), and deliveries to non-Hispanic black women (4.6). Compared with women without sepsis, women with sepsis had a greater than 10-fold increased prevalence of most selected obstetric comorbidities. One in 11 women with sepsis died prior to discharge, compared with 1 death in every 15,411 deliveries without sepsis. The sepsis-related mortality rate decreased 21.8% each year from 2010 through 2015. Maternal age greater than 40 years and nonprivate insurance demonstrated the highest odds of sepsis-related in-hospital mortality. CONCLUSION While rates of delivery-associated sepsis have increased, case fatality has decreased.
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Affiliation(s)
- Anthony M Kendle
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL.
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Jean Paul Tanner
- College of Public Health, University of South Florida, Tampa, FL
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL
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Blackwell SC, Gyamfi-Bannerman C, Biggio JR, Chauhan SP, Hughes BL, Louis JM, Manuck T, Miller HS, Das AF, Birch R, Jozwiakowski MJ. PROLONG Clinical Study Protocol: Hydroxyprogesterone Caproate to Reduce Recurrent Preterm Birth. Am J Perinatol 2018; 35:1228-1234. [PMID: 29702708 DOI: 10.1055/s-0038-1642062] [Citation(s) in RCA: 6] [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: 10/17/2022]
Abstract
The objective of this commentary is to describe the background, rationale, and methods of the PROLONG (Progestin's Role in Optimizing Neonatal Gestation) trial, which is a multicenter, multinational, placebo-controlled, randomized clinical trial (RCT) designed to assess the safety and efficacy of Makena (hydroxyprogesterone caproate injection, 250 mg/mL) in reducing the risk of preterm birth (PTB) and neonatal morbidity/mortality in women pregnant with a singleton gestation who had a previous singleton spontaneous PTB. The total sample size of the RCT will include 1,707 women. The trial has two coprimary outcomes: PTB less than 35 weeks and a composite neonatal morbidity and mortality index. This study sample size will provide 90% power to assess for a 35% reduction in neonatal morbidity and mortality. Secondary outcomes will include 2-year follow-up of infants. The trial is ongoing and targeted to complete recruitment in 2018.
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Affiliation(s)
- Sean C Blackwell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Preterm Birth Prevention Center, Columbia University Medical Center, New York, New York
| | - Joseph R Biggio
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Brenna L Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Tracy Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Hugh S Miller
- Watching Over Mothers and Babies Foundation, Tucson, Arizona.,Valley Perinatal Services, Tucson, Arizona
| | | | - Robert Birch
- AMAG Pharmaceuticals, Inc, Waltham, Massachusetts
| | - Michael J Jozwiakowski
- Department of Research and Development, AMAG Pharmaceuticals, Inc., Waltham, Massachusetts
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50
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Louis JM, Koch MA, Reddy UM, Silver RM, Parker CB, Facco FL, Redline S, Nhan-Chang CL, Chung JH, Pien GW, Basner RC, Grobman WA, Wing DA, Simhan HN, Haas DM, Mercer BM, Parry S, Mobley D, Carper B, Saade GR, Schubert FP, Zee PC. Predictors of sleep-disordered breathing in pregnancy. Am J Obstet Gynecol 2018; 218:521.e1-521.e12. [PMID: 29523262 PMCID: PMC5916044 DOI: 10.1016/j.ajog.2018.01.031] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/22/2017] [Accepted: 01/23/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is common in pregnancy, but there are limited data on predictors. OBJECTIVES The objective of this study was to develop predictive models of sleep-disordered breathing during pregnancy. STUDY DESIGN Nulliparous women completed validated questionnaires to assess for symptoms related to snoring, fatigue, excessive daytime sleepiness, insomnia, and restless leg syndrome. The questionnaires included questions regarding the timing of sleep and sleep duration, work schedules (eg, shift work, night work), sleep positions, and previously diagnosed sleep disorders. Frequent snoring was defined as self-reported snoring ≥3 days per week. Participants underwent in-home portable sleep studies for sleep-disordered breathing assessment in early (6-15 weeks gestation) and mid pregnancy (22-31 weeks gestation). Sleep-disordered breathing was characterized by an apnea hypopnea index that included all apneas, plus hypopneas with ≥3% oxygen desaturation. For primary analyses, an apnea hypopnea index ≥5 events per hour was used to define sleep-disordered breathing. Odds ratios and 95% confidence intervals were calculated for predictor variables. Predictive ability of the logistic models was estimated with area under the receiver-operating-characteristic curves, along with sensitivities, specificities, and positive and negative predictive values and likelihood ratios. RESULTS Among 3705 women who were enrolled, data were available for 3264 and 2512 women in early and mid pregnancy, respectively. The corresponding prevalence of sleep-disordered breathing was 3.6% and 8.3%, respectively. At each time point in gestation, frequent snoring, chronic hypertension, greater maternal age, body mass index, neck circumference, and systolic blood pressure were associated most strongly with an increased risk of sleep-disordered breathing. Logistic regression models that included current age, body mass index, and frequent snoring predicted sleep-disordered breathing in early pregnancy, sleep-disordered breathing in mid pregnancy, and new onset sleep-disordered breathing in mid pregnancy with 10-fold cross-validated area under the receiver-operating-characteristic curves of 0.870, 0.838, and 0.809. We provide a supplement with expanded tables, integrated predictiveness, classification curves, and an predicted probability calculator. CONCLUSION Among nulliparous pregnant women, logistic regression models with just 3 variables (ie, age, body mass index, and frequent snoring) achieved good prediction of prevalent and incident sleep-disordered breathing. These results can help with screening for sleep-disordered breathing in the clinical setting and for future clinical treatment trials.
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Affiliation(s)
| | | | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD
| | | | | | | | | | | | | | - Grace W Pien
- Johns Hopkins University School of Medicine, Baltimore, MD
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