Composite Adverse Maternal Outcome Research Articles

Early pregnancy high normal HbA1c: a high risk group?

To determine if high normal early pregnancy HbA1c (35-40mmol/mol), in the absence of diabetes, was associated with increased risk of adverse perinatal outcomes compared to normal HbA1c (<35mmol/mol). A retrospective chart review was carried out on all singleton births in the Wellington region from 1 July 2019 to 31 December 2019. Exclusion criteria were participants domiciled outside the Wellington region, HbA1c ≥50mmol/mol, pre-existing diabetes, gestational diabetes in current pregnancy, no HbA1c performed <20 weeks or the first HbA1c was taken at ≥20 weeks. Baseline characteristics, HbA1c and pregnancy outcomes were obtained. The primary outcome was birth weight and was analysed using multiple linear regression. There were 1,067 participants in the normal HbA1c (nHbA1c) group and 186 in the high normal HbA1c (hnHbA1c) group. There was no difference in birth weight between hnHbA1c and nHbA1c. hnHbA1c had significantly lower odds of post-partum haemorrhage and composite maternal adverse outcomes compared to nHbA1c (OR 0.52, 95% CI 0.35-0.76) and (OR 0.64, 95% CI 0.46-0.89). High normal HbA1c was not associated with increased risk of adverse perinatal outcomes in pregnant people who did not develop gestational diabetes.

Nulliparous Individuals with Class III Obesity: Adverse Outcomes with Labor versus Planned Cesarean Delivery.

Individuals with class III obesity (body mass index [BMI] ≥ 40 kg/m2) are at increased risk of cesarean delivery (CD) and peripartum complications. We ascertained compositive neonatal and maternal adverse outcomes among individuals with class III obesity who labored versus had planned CD. This was a retrospective cohort study from 2016 to 2021 using the National Vital Statistics System database. Nulliparous individuals with class III obesity prepregnancy were included if they had singleton, nonanomalous pregnancies and delivered at 37 to 41 weeks of gestation. Individuals were excluded if they had hypertensive disorders or diabetes. The primary outcome was a composite neonatal adverse outcome (CNAO), consisting of Apgar score less than 5 at 5 minutes, assisted ventilation > 6 hours, neonatal seizure, or neonatal death. The secondary outcome was a composite maternal adverse outcome (CMAO) that included admission to the intensive care unit, maternal transfusion, uterine rupture, or unplanned hysterectomy. A sensitivity analysis using a CMAO without transfusion was performed. A multivariable Poisson regression model was performed to calculate adjusted relative risks (aRRs) with 95% confidence intervals (CIs). Of 192,298 individuals who met inclusion criteria, 169,676 (88.2%) labored and 22,622 (11.8%) had a planned CD. Compared with neonates delivered by planned CD, the risk of CNAO was significantly lower in those who delivered after labor (aRR: 0.79, 95% CI: 0.71-0.87). There was no significant difference in the risk of CMAO between groups (aRR: 1.11, 95% CI: 0.87-1.41). However, the risk of CMAO without transfusion was lower in individuals who labored (aRR: 0.57, 95% CI: 0.40-0.83). In nulliparous individuals with class III obesity, the risk of CNAO and of CMAO without transfusion were significantly lower in individuals who labored, versus those who had a planned CD. · Labor in class III obesity: 21% fewer adverse neonatal outcomes.. · Class III obesity: 43% less maternal morbidity with labor.. · Labor in nulliparous individuals with class III obesity is safe..

Comparison of Obstetric Outcomes Among Various Weight Strata in a Teaching Hospital in Southwest, Nigeria

AIM:The aim of the study is to evaluate the trend in adverse obstetric outcomes of parturients across the spectrum of body mass index.METHODS:This is a cohort study of pregnant women who received obstetric care at the Obstetrics and Gynecology Department of the Ekiti State University Teaching Hospital, Ado-Ekiti, between January 2015 and December 2015. The data were prospectively collected into the Obstetric Data Registry of the department. Composite adverse maternal outcomes and composite adverse fetal outcomes were obtained for each group. Data were analyzed with SPSS version 24, and ap-value of less than .05 was considered statistically significant.RESULTS:Out of the 1,006 parturients, 334 (33.2%) were obese. Composite adverse maternal outcome increased from 35.1% for women with normal weight to 62.3% for obese women (p&lt; .001). Composite adverse fetal outcome also increased from 25.9% for women with normal weight to 30% for obese women (p&lt; .001). The odds of composite adverse maternal outcome were increased in overweight women (adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] [1.12, 3.49]) and obese women (aOR 1.65, 95% CI [1.21, 2.24]) compared with women with normal weight. Also, the odds of composite adverse fetal outcome were reduced in overweight (aOR 0.64, 95% CI [0.44, 0.93]) but increased in underweight (aOR 4.78, 95% CI [2.00, 11.44]) and obese (aOR 1.16, 95% CI [1.03, 12.39]) women.CONCLUSION:Composite adverse obstetric outcomes were increased in underweight, overweight, and obese women when compared with women with normal weight.

Trial of labor following cesarean among patients with polyhydramnios: a multicenter retrospective study.

This study aimed to assess maternal and neonatal outcomes in patients with polyhydramnios attempting trial of labor after cesarean (TOLAC) compared to those undergoing planned repeat cesarean delivery (PRCD). A multi-center retrospective cohort study was conducted and included women with term singleton viable pregnancies following a single low-segment transverse cesarean delivery (CD) with a polyhydramnios diagnosis (maximal vertical pocket > 8cm and/or Amniotic Fluid Index > 24cm) within 14days before birth who delivered between the years 2017 and 2021. Maternal and neonatal outcomes were compared between those attempting TOLAC and those opting for PRCD. The primary outcome was composite adverse maternal. Univariate analysis was followed by multivariate analysis to control for potential confounders. Out of 358 included births with a previous CD, 208 (58.1%) attempted TOLAC, while 150 had PRCD (41.9%). The successful vaginal birth after cesarean (VBAC) rate was 82.2%, and no cases of uterine rupture, hysterectomy, or maternal intensive care unit admission occurred in either group. After controlling for potential confounders, no independent association between TOLAC and composite adverse maternal (adjusted odds ratio [aOR] 0.62, 95% confidence interval [CI] 0.32-1.20, p = 0.16) and neonatal (aOR 0.89, 95% CI 0.51-1.53, p = 0.67) adverse outcomes was demonstrated. In patients with a term diagnosed polyhydramnios, TOLAC appears to be a reasonable alternative associated with favorable outcomes. Larger prospective studies are needed to refine management strategies and enhance maternal and neonatal outcomes in this context.

The Implications of a "Flat" Oral Glucose Tolerance Test Curve in Pregnancy.

To determine whether pregnant women with "flat" oral glucose tolerance test (OGTT) curves are at increased risk of adverse perinatal outcomes. We conducted a retrospective cohort study comparing the perinatal outcomes of pregnant women whose 100g OGTT curve was "flat" (fasting serum glucose below 95 mg/dl and the remaining values below 100 mg/dl) to those of women whose OGTT curve was "normal". Primary outcomes compared were the prevalence of macrosomic and small for gestational age (SGA) neonates. Secondary outcomes included hypertensive disorders of pregnancy (HDP), intrauterine fetal demise, placental abruption, induction of labor, meconium-stained amniotic fluid (MSAF), mode of delivery, postpartum hemorrhage (PPH), blood product transfusion, postpartum readmission, umbilical artery pH <7.1, Apgar score <7 at 5 minutes, neonatal intensive care unit (NICU) admission, neonatal respiratory and infectious morbidity, and hypoglycemia. Composite adverse maternal and neonatal outcomes were also evaluated. There were 1,060 patients in the study group and 10,591 patients in the control group. Patients with a flat OGTT had a reduced risk of delivering a macrosomic neonate (11.4% vs. 15.1% OR 0.7 [0.58-0.89] p=0.001) and having an unplanned cesarean delivery (7.5% vs 10.2% OR 0.8 [0.58-0.96] p=0.002). There was no difference in the rate of composite adverse maternal (14.0% vs 15.4% OR 0.9 [0.7-1.0] p=0.1) or neonatal outcome (5.3% vs. 4.5% OR 1.2 [0.9-1.5] p=0.15). Neonates had a slightly lower mean birthweight (3474g vs. 3505g, p=0.04), but the rate of SGA was similar in the two groups (2.5% vs.1.8% OR 1.3[0.9-2.0] p=0.08). Conclusions Pregnant women whose OGTT curve is flat have a lower risk of delivering macrosomic neonates and undergoing unplanned cesarean delivery and are not at increased risk of adverse maternal or neonatal outcomes. More research is required to evaluate the relationship between different OGTT curves and th.

Maternal and Neonatal Outcomes after Vaccination with SARS-CoV-2: A Systematic Review and Meta-analysis of Cohort Studies

: SARS-CoV-2 infection among pregnant women causes maternal and neonatal complications. Professional societies endorse the vaccination among pregnant women. This review of the cohort studies aims to assess the short-term maternal and neonatal outcomes among vaccinated vs. non-vaccinated pregnant women with SARS-CoV-2 vaccination. We searched Cochrane Central Registry of Controlled Trials, Scopus, Google Scholar, and PubMed databases. The observational cohort studies published from July 2021 to December 2022 were included. The eligibility criteria were assessed. The studies documenting maternal and neonatal outcomes and the relative risk, and 95% confidence interval were considered. Joanna Briggs Institute data extraction form was used, and the quality assessment of the included study was conducted using the Newcastle-Ottawa quality assessment scale. The quality of the grading was summarised with GradePro software. Data from the five cohort studies are considered. 56% of the un-vaccinated pregnant women experience composite adverse maternal outcomes (RR: 3.97; 95% CI:0.73,21.49; p-value: ˂0.11). There was a reduced risk of occurrence of the meconium-stained amniotic fluid who are vaccinated (RR: 0.89; 95% CI:0.71, 1.12; p value=0.33). The unvaccinated group is 3.16 times more likely to take infertility treatment (RR: 3.54; 95% CI:2.04, 6.12; p-value: ˂0.00001). There was no significant difference concerning neonatal outcomes between both groups. The pregnant women who were not vaccinated against SARS-CoV had an increased risk for a composite adverse maternal outcome and meconium-stained amniotic fluid. The vaccine has effectively prevented the disease in the first six months. Additional studies are needed to understand the safety of the SARS-CoV vaccine.

Maternal Morbidity following Trial of Labor after Cesarean in Women Experiencing Antepartum Fetal Death

This study aims to investigate whether trial of labor after cesarean delivery (TOLAC) in women with antepartum fetal death, is associated with an elevated risk of maternal morbidity. A retrospective multicenter. TOLAC of singleton pregnancies following a single low-segment incision were included. Maternal adverse outcomes were compared between women with antepartum fetal death and women with a viable fetus. Controls were matched with cases in a 1:4 ratio based on their previous vaginal births and induction of labor rates. Univariate analysis was followed by multiple logistic regression modeling. During the study period, 181 women experienced antepartum fetal death and were matched with 724 women with viable fetuses. Univariate analysis revealed that women with antepartum fetal death had significantly lower rates of TOLAC failure (4.4% vs. 25.1%, p < 0.01), but similar rates of composite adverse maternal outcomes (6.1% vs. 8.0%, p = 0.38) and uterine rupture (0.6% vs. 0.3%, p = 0.56). Multivariable analyses controlling for confounders showed that an antepartum fetal death vs. live birth isn't associated with the composite adverse maternal outcomes (aOR 0.96, 95% CI 0.21–4.44, p = 0.95). TOLAC in women with antepartum fetal death is not associated with an increased risk of adverse maternal outcomes while showing high rates of successful vaginal birth after cesarean (VBAC).

Large for Gestational Age and Adverse Outcomes: Stratified By Diabetes Status.

To examine the association of adverse outcomes among parturients with large for gestational age (LGA; birth weight ≥ 90th) newborns, stratified by diabetes status. Additionally, we described the temporal trends of adverse outcomes among LGA neonates. This retrospective cohort study used the U.S. Vital Statistics dataset between 2014 and 2020. The inclusion criteria were singleton, nonanomalous LGA live births who labored and delivered at 24 to 41 weeks with known diabetes status. The coprimary outcomes were composite neonatal adverse outcomes of the following: Apgar score < 5 at 5 minutes, assisted ventilation > 6 hours, seizure, or neonatal or infant mortality, and maternal adverse outcomes of the following: maternal transfusion, ruptured uterus, unplanned hysterectomy, admission to intensive care unit, or unplanned procedure. Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CI). Average annual percent change (AAPC) was calculated to assess changes in rates of LGA and morbidity over time. Of 27 million births in 7 years, 1,843,467 (6.8%) met the inclusion criteria. While 1,656,888 (89.9%) did not have diabetes, 186,579 (10.1%) were with diabetes. Composite neonatal adverse outcomes (aRR = 1.48, 95% CI = 1.43, 1.52) and composite maternal adverse outcomes (aRR = 1.37, 95% CI = 1.36, 1.38) were significantly higher among individuals with diabetes, compared with those without diabetes. From 2014 to 2020, the LGA rate was stable among people without diabetes. However, there was a downward trend of LGA in people with diabetes (AAPC = - 2.4, 95% CI = - 3.5, -1.4). In pregnancies with LGA newborns, composite neonatal and maternal morbidities were higher in those with diabetes, compared with those without diabetes. · Large for gestational age stratified by diabetes status.. · Composite neonatal and maternal adverse outcomes are worse among individuals with diabetes as compared to those without.. · During 2014 to 2020, the trend of LGA in individuals without diabetes increased..

Investigation of health inequities in maternal and neonatal outcomes of patients with placenta accreta spectrum: a multicenter study

BackgroundPlacenta accreta spectrum (PAS) is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in outcomes of patients with PAS. ObjectiveTo investigate health inequities in maternal and neonatal outcomes of pregnancies with PAS. Study DesignThis multicentered retrospective cohort study included patients with histopathological diagnosis of PAS at four regional perinatal centers between 1/1/2013 – 6/30/2022. Maternal race and/or ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. Primary outcome was a composite adverse maternal outcome: transfusion of 4+ units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury or mortality. Secondary outcomes were composite adverse neonatal outcome (APGAR < 7 at 1-minute, morbidity, or mortality), gestational age at PAS diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race/ethnicity with maternal and neonatal outcomes. Results408 pregnancies with PAS were included. In 218 patients (53%), the diagnosis of PAS was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, BMI, income and parity, there was no difference in composite adverse maternal outcome among racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team and cesarean hysterectomy were similar between groups. ConclusionIn our multicenter PAS cohort, race and/or ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis and planned multi-disciplinary care. We hypothesize that comparable incidence of individual risk factors for perinatal morbidity as well as geographic proximity reduce potential inequities that may exist in the larger population.

Induction of labor in term pregnancies with isolated polyhydramnios: Is it beneficial or harmful?

To compare rates of adverse pregnancy outcomes in term pregnancies complicated by polyhydramnios between women who had induction of labor (IOB) versus women who had expectant management. This multicenter retrospective study included term pregnancies complicated by isolated polyhydramnios. Patients who underwent IOB were compared with those who had expectant management. The primary outcome was defined as a composite adverse maternal outcome, and secondary outcomes were various maternal and neonatal adverse outcomes. Univariate analyses were followed by multivariate logistic regression. A total of 865 pregnancies with term isolated polyhydramnios were included: 169 patients underwent IOB (19.5%), while 696 had expectant management and developed spontaneous onset of labor (80.5%). Women who underwent IOB had significantly higher rates of composite adverse maternal outcome (23.1% vs 9.8%, P < 0.01), prolonged hospital stay, perineal tear grade 3/4, intrapartum cesarean, postpartum hemorrhage, blood products transfusion, and neonatal asphyxia compared with expectant management. While the perinatal fetal death rate was similar between the groups (0.6% vs 0.6%, P = 0.98), the timing of the loss was different. Four women in the expectant management group had a stillbirth, while in the induction group one case of intrapartum fetal death occurred due to uterine rupture. Multivariate analyses revealed that IOB was associated with a higher rate of composite adverse maternal outcome (adjusted odds ratio, 2.22 [95% CI, 1.28-3.83]; P < 0.01). IOB in women with term isolated polyhydramnios is associated with higher rates of adverse maternal outcomes in comparison to expectant management. Further research is needed to determine the optimal approach for the management of isolated polyhydramnios at term.

Indicated vs universal third-trimester ultrasound examination in low-risk pregnancies: a pre-post-intervention study

In low-risk pregnancies, a third-trimester ultrasound examination is indicated if fundal height measurement and gestational age discrepancy are observed. Despite potential improvement in the detection of ultrasound abnormality, prior trials to date on universal third-trimester ultrasound examination in low-risk pregnancies, compared with indicated ultrasound examination, have not demonstrated improvement in neonatal or maternal adverse outcomes. The primary objective was to determine if universal third-trimester ultrasound examination in low-risk pregnancies could attenuate composite neonatal adverse outcomes. The secondary objectives were to compare changes in composite maternal adverse outcomes and detection of abnormalities of fetal growth (fetal growth restriction or large for gestational age) or amniotic fluid (oligohydramnios or polyhydramnios). Our pre-post intervention study at 9 locations included low-risk pregnancies, those without indication for ultrasound examination in the third trimester. Compared with indicated ultrasound in the preimplementation period, in the postimplementation period, all patients were scheduled for ultrasound examination at 36.0-37.6 weeks. In both periods, clinicians intervened on the basis of abnormalities identified. Composite neonatal adverse outcomes included any of: Apgar score ≤5 at 5 minutes, cord pH <7.00, birth trauma (bone fracture or brachial plexus palsy), intubation for >24 hours, hypoxic-ischemic encephalopathy, seizure, sepsis (bacteremia proven with blood culture), meconium aspiration syndrome, intraventricular hemorrhage grade III or IV, periventricular leukomalacia, necrotizing enterocolitis, stillbirth after 36 weeks, or neonatal death within 28 days of birth. Composite maternal adverse outcomes included any of the following: chorioamnionitis, wound infection, estimated blood loss >1000 mL, blood transfusion, deep venous thrombus or pulmonary embolism, admission to intensive care unit, or death. Using Bayesian statistics, we calculated a sample size of 600 individuals in each arm to detect >75% probability of any reduction in primary outcome (80% power; 50% hypothesized risk reduction). During the preintervention phase, 747 individuals were identified during the initial ultrasound examination, and among them, 568 (76.0%) met the inclusion criteria at 36.0-37.6 weeks; during the postintervention period, the corresponding numbers were 770 and 661 (85.8%). The rate of identified abnormalities of fetal growth or amniotic fluid increased from between the pre-post intervention period (7.1% vs 22.2%; P<.0001; number needed to diagnose, 7; 95% confidence interval, 5-9). The primary outcome occurred in 15 of 568 (2.6%) individuals in the preintervention and 12 of 661 (1.8%) in the postintervention group (83% probability of risk reduction; posterior relative risk, 0.69 [95% credible interval, 0.34-1.42]). The composite maternal adverse outcomes occurred in 8.6% in the preintervention and 6.5% in the postintervention group (90% probability of risk; posterior relative risk, 0.74 [95% credible interval, 0.49-1.15]). The number needed to treat to reduce composite neonatal adverse outcomes was 121 (95% confidence interval, 40-200). In addition, the number to reduce composite maternal adverse outcomes was 46 (95% confidence interval, 19-74), whereas the number to prevent cesarean delivery was 18 (95% confidence interval, 9-31). Among low-risk pregnancies, compared with routine care with indicated ultrasound examination, implementation of a universal third-trimester ultrasound examination at 36.0-37.6 weeks attenuated composite neonatal and maternal adverse outcomes.

Machine learning-enabled maternal risk assessment for women with pre-eclampsia (the PIERS-ML model): a modelling study

Affecting 2-4% of pregnancies, pre-eclampsia is a leading cause of maternal death and morbidity worldwide. Using routinely available data, we aimed to develop and validate a novel machine learning-based and clinical setting-responsive time-of-disease model to rule out and rule in adverse maternal outcomes in women presenting with pre-eclampsia. We used health system, demographic, and clinical data from the day of first assessment with pre-eclampsia to predict a Delphi-derived composite outcome of maternal mortality or severe morbidity within 2 days. Machine learning methods, multiple imputation, and ten-fold cross-validation were used to fit models on a development dataset (75% of combined published data of 8843 patients from 11 low-income, middle-income, and high-income countries). Validation was undertaken on the unseen 25%, and an additional external validation was performed in 2901 inpatient women admitted with pre-eclampsia to two hospitals in south-east England. Predictive risk accuracy was determined by area-under-the-receiver-operator characteristic (AUROC), and risk categories were data-driven and defined by negative (-LR) and positive (+LR) likelihood ratios. Of 8843 participants, 590 (6·7%) developed the composite adverse maternal outcome within 2 days, 813 (9·2%) within 7 days, and 1083 (12·2%) at any time. An 18-variable random forest-based prediction model, PIERS-ML, was accurate (AUROC 0·80 [95% CI 0·76-0·84] vs the currently used logistic regression model, fullPIERS: AUROC 0·68 [0·63-0·74]) and categorised women into very low risk (-LR <0·1; eight [0·7%] of 1103 women), low risk (-LR 0·1 to 0·2; 321 [29·1%] women), moderate risk (-LR >0·2 and +LR <5·0; 676 [61·3%] women), high risk (+LR 5·0 to 10·0, 87 [7·9%] women), and very high risk (+LR >10·0; 11 [1·0%] women). Adverse maternal event rates were 0% for very low risk, 2% for low risk, 5% for moderate risk, 26% for high risk, and 91% for very high risk within 48 h. The 2901 women in the external validation dataset were accurately classified as being at very low risk (0% with outcomes), low risk (1%), moderate risk (4%), high risk (33%), or very high risk (67%). The PIERS-ML model improves identification of women with pre-eclampsia who are at lowest and greatest risk of severe adverse maternal outcomes within 2 days of assessment, and can support provision of accurate guidance to women, their families, and their maternity care providers. University of Strathclyde Diversity in Data Linkage Centre for Doctoral Training, the Fetal Medicine Foundation, The Canadian Institutes of Health Research, and the Bill & Melinda Gates Foundation.

Does the combination of four OGTT values enhance the prediction of adverse pregnancy outcomes? Insights from a retrospective cohort study.

To explore the correlation between a singular value of additive OGTT scores and adverse maternal and neonatal outcomes. We postulated that a higher additive OGTT score would predict poorer maternal and neonatal outcomes. In this retrospective cohort study, data were collected from all women with a documented complete OGTT result and subsequent diagnosis of GDM. The additive OGTT score was calculated by adding each individual hourly glucose measurement. Maternal demographics, pregnancy and labor characteristics, and neonatal outcomes were compared between the lower-sum and higher-sum OGTT groups. A multivariate regression analysis was performed to identify confounders associated with adverse outcomes. In this study, a total of 1497 patients were assessed. The group with higher-sum OGTT scores was characterized by increased rates of GDMA2 (p = 0.008), higher insulin doses (p = 0.009), and higher rates of composite maternal and neonatal adverse outcomes (p = 0.021 and p = 0.030, respectively) compared to the lower-sum OGTT group. The additive OGTT score may aid in predicting the need for insulin treatment, labor course, and neonatal outcomes in GDM patients.

Pregnancy-related cardiac outcomes among patients with congenital heart disease after formalization of a cardio-obstetrics program

The prevalence of pregnant patients with congenital heart disease (CHD) is increasing, and these patients are at high risk for cardiac morbidity. This study aimed to examine the pregnancy outcomes in patients with congenital heart disease before and after the establishment of formal cardio-obstetrics collaboration between adult congenital heart disease and maternal-fetal medicine programs. This was a retrospective cohort study of pregnant patients with congenital heart disease from 2002 to 2020 at a single urban academic institution in the United States. This study included patients with a singleton pregnancy who continued a pregnancy beyond 20 weeks of gestation. The primary outcome was a composite adverse maternal cardiac outcome, compared before (2002-2010) and after (2011-2020) the program. The secondary outcomes included gestational age at delivery, mode of delivery, rate of labor induction, use of diuresis after delivery, and a composite maternal morbidity outcome. The number of pregnant patients with congenital heart disease increased after formalization of the cardio-obstetrics program (200 [postprogram group] vs 84 [preprogram group]; 0.48% of all deliveries in the postprogram group vs 0.25% of all deliveries in the preprogram group; P<.001). The postprogram group was more likely to undergo labor induction than the preprogram group (126 [63%] vs 34 [41%], respectively; P<.001). There were fewer patients in the postprogram group than in the preprogram group who were New York Heart Association class II to IV (23 [12%] vs 17 [22%], respectively; P=.04) or with systemic ventricular dysfunction (8 [4%] vs 12 [16%], respectively; P=.001). There was no difference in the primary outcome (38 [19%] in the postprogram group vs 14 [17%] in the preprogram group; P=.64), even after adjusting for confounders, including New York Heart Association class >I and systemic ventricular dysfunction (adjusted odds ratio, 2.3; 95% confidence interval, 0.96-5.4). Patients in the postprogram group were more likely to receive diuresis after delivery than patients in the preprogram group, even in the absence of heart failure or pulmonary edema (9 [4.5%] vs 0 [0.0%], respectively; P=.04). In the period after the establishment of a formal cardio-obstetrics program between adult congenital heart disease and maternal-fetal medicine, the number of patients with congenital heart disease delivering at our institution increased significantly. Overall, fewer patients entered pregnancy with advanced-stage heart failure or systemic ventricular dysfunction, possibly suggesting improved prepregnancy cardiac care or improved preconception counseling. Composite maternal cardiac outcomes were similar, but the rates of postpartum diuresis increased significantly, suggesting increased attention to volume status in the postpartum period. Formalized collaboration between congenital heart disease and maternal-fetal medicine may help better optimize patients' care before conception, during pregnancy, and after delivery.

Association between fetal fraction of cell-free DNA and adverse pregnancy outcomes.

To determine the association between fetal fraction (FF) levels in cell-free fetal DNA (cffDNA) testing and adverse pregnancy outcomes. This retrospective cohort study, conducted at a single center, involved 2063 pregnant women with normal 1st and 2nd trimester non-invasive prenatal test (NIPT) results between 2016 and 2021. Pregnancy outcomes were examined by determining the < 4% and < 5th percentile (3.6%) cut-off values for low fetal fraction (LFF). Pregnancy outcomes were also examined by dividing the FF into population-based quartiles. Adverse pregnancy outcomes were pregnancy-induced hypertensive diseases (PIHD), gestational diabetes mellitus (GDM), spontaneous preterm birth (PTB), intrahepatic cholestasis of pregnancy (ICP), small for gestational age (SGA), large for gestational age (LGA), low birth weight (LBW), macrosomia, and 1st and 5th minutes low APGAR scores (< 7). PIHD was significantly higher in LFF (< 4% and < 5th percentile) cases (p = 0.015 and p < 0.001, respectively). However, in population-based quartiles of FF, PIHD did not differ significantly between groups. Composite adverse maternal outcomes were significantly higher in the FF < 4% group (p = 0.042). When analyzes were adjusted for maternal age, BMI, and gestational age at NIPT, significance was maintained at < 4%, < 5th percentile LFF for PIHD, and < 4% LFF for composite adverse maternal outcomes. However, there was no significant relationship between LFF with GDM, ICP and PTB. Additionally, there was no significant association between low APGAR scores, SGA, LGA, LBW, macrosomia, and LFF concerning neonatal outcomes. Our study showed that LFF in pregnant women with normal NIPT results may be a predictor of subsequent PIHD.

Vaginal misoprostol versus vaginal dinoprostone for cervical ripening and induction of labour: An individual participant data meta-analysis of randomised controlled trials.

Induction of labour (IOL) is common practice and different methods carry different effectiveness and safety profiles. To compare the effectiveness, and maternal and perinatal safety outcomes of IOL with vaginal misoprostol versus vaginal dinoprostone using individual participant data from randomised clinical trials. The following databases were searched from inception to March 2023: CINAHL Plus, ClinicalTrials.gov, Cochrane Pregnancy and Childbirth Group Trial Register, Ovid Embase, Ovid Emcare, Ovid MEDLINE, Scopus and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). Randomised controlled trials (RCTs), with viable singleton gestation, no language restrictions, and all published and unpublished data. An individual participant data meta-analysis was carried out. Ten of 52 eligible trials provided individual participant data, of which two were excluded after checking data integrity. The remaining eight trials compared low-dose vaginal misoprostol versus dinoprostone, including 4180 women undergoing IOL, which represents 32.8% of all participants in the published RCTs. Of these, 2077 were assigned to low-dose vaginal misoprostol and 2103 were assigned to vaginal dinoprostone. Compared with vaginal dinoprostone, low-dose vaginal misoprostol had a comparable rate of vaginal birth. Composite adverse perinatal outcomes did not differ between the groups. Compared with vaginal dinoprostone, composite adverse maternal outcomes were significantly lower with low-dose vaginal misoprostol (aOR 0.80, 95% CI 0.65-0.98, P = 0.03, I2 = 0%). Low-dose vaginal misoprostol and vaginal dinoprostone for IOL are comparable in terms of effectiveness and perinatal safety. However, low-dose vaginal misoprostol is likely to lead to a lower rate of composite adverse maternal outcomes than vaginal dinoprostone.

Labor Induction in Women with Isolated Polyhydramnios at Term: A Multicenter Retrospective Cohort Analysis.

Background: With the increasing popularity of elective induction after 39 + 0 weeks, the question of whether induction of labor (IOL) is safe in women with isolated polyhydramnios has become more relevant. We aimed to evaluate the pregnancy outcomes associated with IOL among women with and without isolated polyhydramnios. Methods: This was a multicenter retrospective cohort that included women who underwent induction of labor at term. The study compared women who underwent IOL due to isolated polyhydramnios to low-risk women who underwent elective IOL due to gestational age only. The main outcome measure was a composite adverse maternal outcome, while the secondary outcomes included maternal and neonatal adverse pregnancy outcomes. Results: During the study period, 1004 women underwent IOL at term and met inclusion and exclusion criteria; 162 had isolated polyhydramnios, and 842 had a normal amount of amniotic fluid. Women who had isolated polyhydramnios had higher rates of the composite adverse maternal outcome (28.7% vs. 20.4%, p = 0.02), prolonged hospital stay, perineal tear grade 3/4, postpartum hemorrhage, and neonatal hypoglycemia. Multivariate analyses revealed that among women with IOL, polyhydramnios was significantly associated with adverse composite maternal outcome [aOR 1.98 (1.27-3.10), p < 0.01]. Conclusions: IOL in women with isolated polyhydramnios at term was associated with worse perinatal outcomes compared to low-risk women who underwent elective IOL. Our findings suggest that the management of women with polyhydramnios cannot be extrapolated from studies of low-risk populations and that clinical decision-making should take into account the individual patient's risk factors and preferences.

Gestational diabetes mellitus and late preterm birth: outcomes with and without antenatal corticosteroid exposure

BackgroundUnlike pregestational diabetes, ACOG recommends antenatal corticosteroids in those with GDM at risk for preterm birth. However, this recommendation is based on limited data, only 10.6% of the Antenatal Late Preterm Steroids (ALPS) study sample had GDM. There is a paucity of data on the risk of neonatal respiratory and other morbidity in this population. ObjectiveTo examine respiratory outcomes in parturients with GDM who received antenatal corticosteroids and delivered during the late preterm period versus those who did not. Material and MethodsThis population-based cohort study used the U.S. Vital Statistics dataset between 2016 to 2020. The inclusion criteria were singleton, non-anomalous individuals who delivered between 34.0 to 36.6 weeks with GDM and known status of antepartum corticosteroid exposure. The primary outcome, a composite neonatal adverse outcome (CNAO), included: Apgar score < 5 at 5 minutes, immediate assisted ventilation, assisted ventilation> 6 hours, surfactant use, seizure, or neonatal mortality. The secondary outcome was composite maternal adverse outcome (CMAO) including maternal blood transfusion, ruptured uterus, unplanned hysterectomy, and admission to the intensive care unit (ICU). Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CI). Average annual percent change (AAPC) was calculated to assess changes in rates of corticosteroid exposure over the study period. ResultsOf 19 million births during the study period, 110,197 (0.6%) met inclusion criteria, and among them, 23,028 (20.9%) individuals with GDM received antenatal corticosteroids. The rate of antenatal steroid exposure remained stable over the 5 years (APC=10.7, 95% CI: -5.4, 29.4). The CNAO was significantly higher among those who received corticosteroids than those who did not (137.1 versus 216.5 per 1,000 live births; aRR 1.24, 95% CI 1.20-1.28). Three components of the CNAO—immediate assisted ventilation, intubation > 6 hours, and surfactant use—were significantly higher with exposure than without. Additionally, the CMAO was significantly higher among those who received corticosteroids (aRR 1.34, 95% CI 1.18-1.52). Three components of CMAO—admission to ICU, blood transfusion, and unplanned hysterectomy—were significantly higher among the exposed group. Subgroup analysis, among large-for-gestational age, by gestational age, and race and ethnicity, confirm the trend of increased likelihood of adverse outcomes with exposure to corticosteroid. ConclusionIndividuals with GDM and antenatal corticosteroid exposure versus those unexposed, who delivered in the late preterm were at higher risk of neonatal and maternal adverse outcomes.

Does delayed vacuum-assisted delivery harbor greater maternal or neonatal complications?

To compare maternal and fetal outcomes between early (<2 h) and delayed (>2 h) vacuum extraction (VE) deliveries. We performed a retrospective cohort study in a single, university-affiliated medical center (2014-2021). We included term singleton pregnancies delivered by VE, allocated into one of two groups according to second stage duration: <2 h or >2 h. Primary outcome was maternal composite adverse outcome (included chorioamnionitis, 3-4 degree lacerations, and postpartum hemorrhage [PPH]). We included 2521 deliveries: 2261 (89.6%) with early VE and 260 (10.4%) with delayed VE. Study groups' characteristics were not different, except of parity. Maternal composite outcome almost reached a significance (P = 0.054) comparing between the groups. Comparing second stage length up to 2 h versus more, there was similar rate of advance maternal lacerations. However, extending the second stage to more than 3 h was associated with third degree lacerations compared to 2-3 h (9.8% vs 3%, P = 0.011). There were significantly more PPH events in the later VE group (P = 0.004), but the need for blood transfusions was similar. The rates of 5 min Apgar score ≤7 (P = 0.001) and umbilical artery pH <7.0 were significantly higher in group 2 compared with group 1. The effect was much more pronounced when second stage was >3 h. After conducting multiregression analysis, the results became insignificant. Our study suggests that VE performed in the late second stage of labor, up to 3 h, is safe as VE performed in the early stages regarding maternal and neonatal outcomes. Extra caution is needed with extended second stage to more than 3 h.

Proteinuria in predicting adverse outcomes in women with severe features of pre-eclampsia from a developing country: Aprospective cohort study.

To study the adverse maternal and perinatal outcomes in women with severe pre-eclampsia (SPE) among different ranges of proteinuria. This prospective cohort study was conducted in Jawaharlal Institute of Postgraduate Medical Education and Research, India. After obtaining informed written consent, the 202 singleton women fulfilling the criteria of severe features of pre-eclampsia were stratified based on the value of urine protein-creatinine ratio (UPCR) as mild, moderate, severe, and massive proteinuria during pregnancy. Clinical outcomes were assessed and patients were followed up until 12 weeks postpartum to identify persistent proteinuria and hypertension. Of the 202 women with SPE, adverse maternal outcomes were seen in 34.65% (n = 70) and adverse perinatal outcomes in 75.74% (n = 153). The demographic and clinical factors were similar among women with increasing severity of proteinuria, except for mean systolic blood pressure, serum creatinine and total serum protein. UPCR was found to have a significant correlation with composite adverse perinatal outcome (P < 0.001) and individual outcomes of neonatal intensive care unit admission for >48 h (P = 0.01) and neonatal sepsis (P = 0.02) but not adverse maternal outcomes (P = 0.201). The optimum UPCR cutoff for adverse perinatal outcomes was 1.6 (sensitivity, 73.2%; specificity, 52.7%). In addition, 14.85% of the women had a persistently elevated UPCR and 3.96% had hypertension at 3 months postpartum. In women with SPE, severe and massive proteinuria were related to composite adverse perinatal outcome but not composite adverse maternal outcome. Moreover, antenatal 24-h proteinuria was significantly associated with persistent proteinuria. Significant proteinuria in women with SPE poses a risk for chronic renal dysfunction, requiring follow-up.