Composite Adverse Maternal Outcome Research Articles

Disparities between US Hispanic and non-Hispanic women in obesity-related perinatal outcomes: a prospective cohort study

Background Mortality figures and national health surveillance data have demonstrated that Hispanics have a 24% lower risk of all-cause mortality compared to their non-Hispanic counterparts despite increased rates of obesity and related illnesses. Objective The aim of this study is to evaluate if this paradox exists for obesity-related perinatal outcomes in otherwise low-risk Hispanic women. Materials and methods A prospective cohort study of low-risk women across all BMI classes with a singleton, non-anomalous term pregnancy admitted in active labor or undergoing induction of labor between May 2014 and April 2017. All demographic, obstetric, and neonatal outcomes were recorded, and the body mass index (BMI) closest to delivery was used for analysis. Data including composites of adverse maternal and neonatal outcomes were compared across BMI classes and between individuals of Hispanic and non-Hispanic ethnicity. Women with antenatal complications, prior cesarean delivery, and cesarean for non-reassuring fetal status were excluded. Results Of the 11,369 women who met inclusion criteria, 6303 (55%) were Hispanic. Eight percent of Hispanic women were normal weight (BMI: 18.5–24.9), 34% were overweight (BMI: 25–29.9), and 58% were obese (BMI > 30). Fourteen percent of non-Hispanic women were normal weight, 42% were overweight, and 44% were obese. The majority (65%) of women were multiparous. Rate of induction and birthweight increased across BMI for Hispanic and non-Hispanic groups, however the route of delivery was not significantly different (p = .22, 0.16, respectively). Although the association between BMI and composite perinatal complications did not differ by BMI class and ethnicity, the newborns of non-Hispanic women were more likely to be admitted to the neonatal intensive care unit with increasing maternal weight class (<0.001), even after adjusting for age, parity, marital status, prenatal visits, current tobacco use, type of labor, mode of delivery, and birthweight. Conclusion There were no demonstrable differences in composite adverse maternal or neonatal outcomes between Hispanic and non-Hispanic obese women. However, newborns of non-Hispanic obese women were more likely to be transferred to the neonatal intensive care unit with increasing maternal BMI.

Neonatal and maternal outcomes with trial of labor after two prior cesarean births: stratified by history of vaginal birth

Introduction To determine the impact of prior vaginal birth on neonatal and maternal outcomes among individuals undergoing a trial of labor after two cesarean births. Materials and methods This was a cross-sectional study using the U.S. National Vital Statistics 2014–2018 period linked birth and infant death data. Inclusion criteria were term, cephalic, singleton pregnancies with two prior cesarean births. The primary exposure variable was a trial of labor after cesarean vs prelabor repeat cesarean birth. Cohorts were defined by the presence or absence of a prior vaginal birth. The primary outcome was a composite of adverse neonatal outcomes (Apgar score <5 at 5 min, assisted ventilation >6 h, neonatal seizures, or neonatal death within 27 days). Secondary outcomes included a maternal composite and the cesarean birth rate. Propensity score matching was used to account for baseline differences in treatment allocation within each cohort, and conditional logistic regression assessed the association between the exposure and outcomes. Results The composite neonatal adverse outcome was significantly higher in those undergoing a trial of labor after cesarean compared to prelabor repeat cesarean birth in both individuals without a prior vaginal birth (8.2 vs 11.6 per 1000 live births, OR 1.41; 95% CI 1.12–1.70) and with a prior vaginal birth (9.6 vs 12.4 per 1000 live births, OR 1.30; 95% CI 1.08–1.57). The composite maternal adverse outcome was significantly higher among individuals without a prior vaginal birth undergoing trial of labor after cesarean (6.0 vs 9.5 per 1000 live births, OR 1.59; 95% CI 1.26–2.09), but was similar in those with a prior vaginal birth (7.9 vs 9.3 per 1000 live births, OR 1.18; 95% CI 0.97–1.46). Conclusion In individuals with two prior cesarean births, trial of labor after cesarean was associated with increased neonatal adverse outcomes when compared to prelabor repeat cesarean birth, irrespective of a history of vaginal birth. In individuals with a prior vaginal birth, the composite maternal adverse outcome was not elevated in the trial of labor cohort.

Angiogenic markers and their longitudinal change for predicting adverse outcomes in pregnant women with chronic hypertension

Women with chronic hypertension are at increased risk for adverse maternal and perinatal outcomes. Maternal serum angiogenic markers, such as soluble fms-like tyrosine kinase 1 and placental growth factor, can be used to triage women with suspected preeclampsia. However, data about these markers in pregnant women with chronic hypertension are scarce. We aimed to evaluate the predictive accuracy of maternal serum levels of soluble fms-like tyrosine kinase 1, placental growth factor, and their ratio for predicting adverse maternal and perinatal outcomes in women with chronic hypertension. This was a retrospective analysis of prospectively collected data from January 2013 to October 2019 at the University of Vienna Hospital, Vienna, Austria. The inclusion criteria were pregnant women with chronic hypertension and suspected preeclampsia. The primary outcome of this study was the prognostic performance of angiogenic markers for the prediction of adverse maternal and perinatal outcomes in pregnant women with chronic hypertension. The accuracy of angiogenic markers for predicting adverse composite outcomes was assessed with a binomial logistic regression. The accuracy of each marker was assessed using receiver operating characteristics curves and area under the curve values. Area under the curve values were compared using De Long's test. Of the 145 included women with chronic hypertension and suspected superimposed preeclampsia, 26 (17.9%) women developed complications (ie, composite adverse maternal or fetal outcomes) within 1 week of assessment (average gestational age at assessment, 29.9 weeks) and 35 (24.1%) developed complications at any time (average gestational age at assessment, 30.1 weeks). In women who developed complications at any time, the median maternal serum soluble fms-like tyrosine kinase-1 to placental growth factor ratio was 149.4 (interquartile range, 64.6-457.4) compared with 8.0 (interquartile range, 3.37-41.2) for women who did not develop complications (P<.001). The area under the curve values for the maternal serum soluble fms-like tyrosine kinase-1 to placental growth factor ratio Z-score (0.95; 95% confidence interval, 0.90-0.99) and placental growth factor level Z-score (0.94; 95% confidence interval, 0.88-0.99) for predicting complications within 1 week of assessment were very high. The area under the curve values for new-onset edema (0.61; 95% confidence interval, 0.52-0.70), proteinuria (0.62; 95% confidence interval, 0.52-0.71), high mean arterial pressure (0.52; 95% confidence interval, 0.50-0.54), and other symptoms of preeclampsia (0.57; 95% confidence interval, 0.49-0.65) were all significantly lower than for the angiogenic markers (P<.001 for all). Women who had an angiogenic imbalance and/or proteinuria had the highest rate of complications (28/57, 49.1%). The rate of complications in women with an angiogenic imbalance and/or proteinuria was significantly higher than in women with either proteinuria, other symptoms, or intrauterine growth restriction in the absence of an angiogenic imbalance (49.1% vs 16.7%; P=.039). The highest positive and negative predictive values for predicting adverse outcomes were demonstrated by an angiogenic imbalance and/or proteinuria criteria with a positive predictive value of 49.1% (95% confidence interval, 50.4%-57.9%) and a negative predictive value of 92% (95% confidence interval, 85.5%-95.8%). Longitudinal changes in measurements of the gestational age-corrected ratio of soluble fms-like tyrosine kinase-1 to placental growth factor up to the last measurement had a significantly higher area under the curve value than the last measurement alone (area under the curve, 0.95; 95% confidence interval, 0.92-0.99 vs 0.87; 95% confidence interval, 0.79-0.95; P=.024) CONCLUSION: Maternal serum angiogenic markers are superior to clinical assessment in predicting adverse maternal and perinatal outcomes in pregnant women with chronic hypertension. Repeated measurements of the ratio of soluble fms-like tyrosine kinase-1 to placental growth factor seems beneficial given the better predictive accuracy compared with a single measurement alone. The use of angiogenic makers should be implemented in clinical management guidelines for pregnant women with chronic hypertension.

Severe maternal morbidity associated with cerclage use in pregnancy

Objective To quantify the frequency of serious maternal complications associated with cerclage use during pregnancy. Study design We performed a retrospective population-based cohort study of all live births in Ohio from 2006 to 2015. Maternal sociodemographic, medical, and obstetric characteristics were compared for births in which cerclage was utilized during the pregnancy versus those without cerclage. The primary outcome for the study was a composite of adverse outcome including maternal intensive care unit (ICU) admission, blood product transfusion, uterine rupture and unplanned hysterectomy in all births. Secondary outcomes included each of the individual adverse outcomes as well as maternal hospital transfer to a tertiary facility, unplanned operation after delivery and chorioamnionitis. Each outcome was also analyzed separately in singleton and twin births. Generalized linear modeling was used to estimate the relative risk of adverse maternal outcomes associated with cerclage placement after adjustment for coexisting risk factors. Results Of the 1,428,655 singleton and twin live births in Ohio from 2006 to 2015, 4595 [0.3%] were recorded on the birth certificate as having cerclage during pregnancy. Of those, 11.7% experienced a serious adverse maternal outcome, compared to 3.7% without cerclage, adjRR 2.7 [95% CI 2.5, 3.0]. The rate of the composite maternal adverse outcome was significantly increased for pregnancies with cerclage versus those without overall, and in singleton and twin pregnancies when measured individually [all p ≤ .001]. Even after adjustment for coexisting risk factors, cerclage remained significantly associated with composite adverse outcome in each of these groups. Conclusions Over 1 in 10 women with cerclage experience an adverse maternal outcome. Even after adjusting for gestational age at delivery and other risk factors, maternal risk for serious adverse event remains over twofold increased for pregnancies with cerclage. This information may be helpful in counseling women regarding potential maternal risk when considering neonatal benefit of cerclage in pregnancies at high risk of preterm birth.

Shoulder dystocia and composite adverse outcomes for the maternal-neonatal dyad

Although the neonatal morbidity associated with shoulder dystocia are well known, the maternal morbidity caused by this obstetrical emergency is infrequently reported. This study aimed to assess the composite adverse maternal and neonatal outcomes among vaginal deliveries (at 34 weeks or later) with and without shoulder dystocia. This is a secondary analysis of the Consortium of Safe Labor, an observational obstetrical cohort of all vaginal deliveries occurring at 19 hospitals (from 2002-2008) and for which data on the occurrence of shoulder dystocia were available. The composite adverse maternal outcome included third- or fourth-degree perineal laceration, postpartum hemorrhage (>500 cc blood loss for a vaginal delivery and >1000 cc blood loss for cesarean delivery), blood transfusion, chorioamnionitis, endometritis, thromboembolism, admission to intensive care unit, or maternal death. The composite adverse neonatal outcome included an Apgar score of <7 at 5 minutes, a birth injury, neonatal seizure, hypoxic ischemic encephalopathy, or neonatal death. A multivariable Poisson regression was used to estimate the adjusted relative risks with 95% confidence intervals. The area under the receiver operating characteristic curve was constructed to determine if clinical factors would identify shoulder dystocia. Of the 228,438 women in the overall cohort, 130,008 (59.6%) met the inclusion criteria, and among them, shoulder dystocia was documented in 2159 (1.7%) cases. The rate of composite maternal morbidity was significantly higher among deliveries with shoulder dystocia (14.7%) than without (8.6%; adjusted relative risk, 1.71; 95% confidence interval, 1.64-2.01). The most common maternal morbidity with shoulder dystocia was a third- or fourth-degree laceration (adjusted relative risk, 2.82; 95% confidence interval, 2.39-3.31). The risk of composite neonatal morbidity with shoulder dystocia (12.2%) was also significantly higher than without shoulder dystocia (2.4%) (adjusted relative risk, 5.18; 95% confidence interval, 4.60-5.84). The most common neonatal morbidity was birth injury (adjusted relative risk, 5.39; 95% confidence interval, 4.71-6.17). The area under the curve for maternal characteristics to identify shoulder dystocia was 0.66 and it was 0.67 for intrapartum factors. Although shoulder dystocia is unpredictable, the associated morbidity affects both mothers and newborns. The focus should be on concurrently averting the composite morbidity for the maternal-neonatal dyad with shoulder dystocia.

The association of adverse outcomes with pregnancy conception methods among low-risk term pregnancies

To compare composite neonatal and maternal adverse outcomes among low-risk singleton pregnancies at 37-41 weeks among conception methods: spontaneously-conceived (SC) pregnancy; infertility medications and/or intrauterine insemination (IFM/IUI); and assisted reproductive technology (ART). Population-based retrospective cohort study. US Vital Statistics datasets 2013-2017. Low-risk pregnancies (without hypertensive disorders, pregestational or gestational diabetes, or history of preterm birth) of women ≥20 years with nonanomalous singletons, who labored, delivered at 37-41 weeks, and had data on pregnancy conception method. None. The primary outcome was the composite neonatal adverse outcome (CNAO). The secondary outcome was the composite maternal adverse outcome (CMAO). Of the 19.7 million deliveries during the study period, 54.0% (N = 10,676,184) met the inclusion criteria, with 99.0% (N = 10,573,741) being conceived spontaneously, 0.4% (N = 47,227) by IFM/IUI, and 0.5% (N = 55,216) by ART. The overall rate of CNAO was 6.68 per 1,000 live births. Compared with SC, the risk of CNAO was significantly higher among IFM/IUI (adjusted relative risk [aRR], 1.29; 95% CI, 1.18-1.41) and ART (aRR, 1.29; 95% CI, 1.18-1.39). The overall rate of CMAO was 2.50 per 1,000 live births. Compared with SC, the risk of CMAO was significantly increased among IFM/IUI (aRR, 1.72; 95% CI, 1.50-1.97) and ART (aRR, 2.40; 95% CI, 2.17-2.65). Among low-risk term singleton pregnancies, IFM/IUI and ART have modestly higher rates of adverse outcomes to maternal-neonatal dyad than SC.

Association between time of delivery and composite adverse outcomes in pregnancies complicated by diabetes

Objectives To compare the composite neonatal and maternal adverse outcomes among women with diabetes who labor and deliver at 37–41 weeks at distinct time shifts. Methods This population-based retrospective cohort study using the US Vital Statistics dataset on Period Linked Birth-Infant Death Data from 2013–2017. The study population was restricted to non-anomalous singleton live births from women with pregestational or gestational diabetes, who labored and delivered at 37 0/7 to 41 6/7 weeks of gestation. The time of delivery was categorized as the first shift (7:00–15:00), the second shift (15:00–23:00), and the third shift (23:00–7:00). The primary outcome was a composite neonatal adverse outcome; the secondary outcome was a composite maternal adverse outcome. Multivariable Poisson regression models were used to estimate the association between the time of delivery and adverse outcomes (using adjusted relative risk [aRR] and 95% CI). Results Of 19.8 million live births during the study period, 3.3% (643,610) met the study inclusion criteria. The overall rate of composite neonatal and maternal adverse outcomes were 9.62 and 3.63 per 1000 live births, respectively. Multivariable adjusted regression analysis showed that, compared to newborns delivered at the first shift, the risk of composite neonatal adverse outcome was modestly but significantly higher (aRR 1.19, 95% CI 1.12–1.27) in the third shift (23:00–7:00). There was no significant difference in the risk of composite maternal adverse outcomes between time shifts. In the sensitivity analysis stratified by the day of the week (weekday vs weekend), the results were consistent with the primary analyses. Conclusion Among term pregnancies complicated by diabetes, compared with delivery at 7:00–15:00, the risk of a composite neonatal adverse outcome is marginally but significantly higher if delivery occurs at the third shift (23:00–7:00).

Maternal and perinatal outcomes in women with advanced maternal age affected by SARS-CoV-2 infection (Phase-2): The WAPM (World Association of Perinatal Medicine) Working Group on COVID-19

Objective To elucidate the role of advanced maternal age (AMA) in determining the outcome of pregnancies complicated by SARS-CoV-2 infection. Methods Multinational cohort study included women with laboratory-confirmed SARS-CoV-2 infection from 76 centers in 27 different countries in Europe, United States, South America, Asia and Australia from 04 April 2020 till 28 October 2020. The primary outcome was a composite measure of maternal mortality and morbidity including admission to intensive care unit (ICU), use of mechanical ventilation (defined as intubation, need for continuous positive airway pressure, extra-corporeal membrane oxygenation), severe respiratory symptoms (including dyspnea and shortness of breath) or death. Results Eight hundred and eighty seven pregnant women were included in the study who were positive SARS-CoV-2 results by RT-PCR (reverse transcriptase-polymerase chain reaction) on their nasal and pharyngeal swab specimens (352 with and 652 with no AMA). The risk of composite adverse maternal outcome was higher in AMA group compared to that of under 35 years of age group, with an OR of 1.99 (95% CI 1.4–2.9; p=0.002). Likewise, women &gt;35 years were also at higher risk of hospital admission (OR: 1.88, 95% CI 1.4–2.5; p&lt;0.001), presence of severe respiratory symptoms (OR: 1.53, 95% CI 1.0–2.3; p=0.04) and/or admission to ICU (OR: 2.00, 95% CI 1.1–3.7; p=0.003); however, no difference was observed in terms of perinatal outcome risk. Conclusion Advanced maternal age is an independent risk factor for adverse maternal outcome in pregnancies complicated by SARS-CoV-2 infection. Accurate risk stratification of women presenting with suspected SARS-CoV-2 infection in pregnancy is warranted in order to identify a subset of women who may benefit from a personalized management, including elective hospitalization and/or prolonged surveillance in order to improve maternal outcome.

Association between mode of delivery and infant survival at 22 and 23 weeks of gestation

Cesarean delivery is currently not recommended before 23 weeks' gestation unless for maternal indications, even in the setting of malpresentation. These recommendations are based on a lack of evidence of improved neonatal outcomes and survival following cesarean delivery and the maternal risks associated with cesarean delivery at this early gestational age. However, as neonatal resuscitative measures and obstetrical interventions improve, studies evaluating the potential neonatal benefit of periviable cesarean delivery have reported inconsistent findings. This study aimed to compare the survival rates at 1 year of life among resuscitated infants delivered by cesarean delivery with those delivered vaginally at 22 and 23 weeks of gestation. We conducted a population-based cohort study of all resuscitated livebirths delivered between 22 0/7 and 23 6/7 weeks of gestational age in the United States between 2007 and 2013. The primary outcome was the rate of infant survival at 1 year of life for different routes of delivery (cesarean vs vaginal delivery) at both 22 and 23 weeks of gestation. The secondary outcome variables included infant survival rates for neonates who survived beyond 24 hours of life, neonatal survival, and the length of survival. A secondary analysis also included a comparison of the infant survival rates between the different routes of delivery cohorts stratified by fetal presentation, steroid exposure, and ventilation. Information about composite adverse maternal outcomes were limited to infants who were delivered between 2011 and 2013 (when these items were first reported) and were defined as a requirement for blood transfusion, an unplanned operating room procedure following delivery, unplanned hysterectomy, and intensive care unit admission; the composite adverse maternal outcomes were also compared between the different delivery route cohorts for deliveries occurring between 22 and 23 weeks of gestation. Multivariable logistic regression analysis was used to determine the association between cesarean delivery and infant survival and other neonatal and maternal outcomes. Resuscitated infants delivered by cesarean delivery had higher rates of survival at 22 weeks (44.9 vs 23.0%; P<.001) and at 23 weeks (53.3 vs 43.4%; P<.001) of gestation regardless of fetal presentation. Multivariable logistic regression analysis demonstrated that infants who were delivered by cesarean delivery at 22 weeks (adjusted relative risk, 2.3; 95% confidence interval, 1.9-2.8) and 23 weeks (adjusted relative risk, 1.4; 95% confidence interval, 1.2-1.5) of gestation were more likely to survive than those delivered vaginally. When the cohort was limited to neonates who survived beyond the first 24 hours of life, vertex neonates born by cesarean delivery were not more likely to survive at 22 weeks (adjusted relative risk, 1.2; 95% confidence interval, 0.9-1.7) or 23 weeks (adjusted relative risk, 1.1; 95% confidence interval, 0.9-1.3) of gestation. An increased risk for composite adverse maternal outcomes (adjusted relative risk, 1.7; 95% confidence interval, 1.1-2.7) was associated with cesarean delivery at 22 to 23 weeks of gestation. Cesarean delivery is associated with increased survival at 1 year of life among resuscitated, periviable infants born between 22 0/7 and 23 6/7 weeks of gestation, especially in the setting of nonvertex presentation. However, cesarean delivery is associated with increased maternal morbidity.

Maternal and perinatal outcomes in high compared to low risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection (phase 2): the World Association of Perinatal Medicine working group on coronavirus disease 2019

BACKGROUNDIt has still to be ascertained whether severe acute respiratory syndrome coronavirus 2 infection in pregnancy is associated with worse maternal and fetal outcomes compared to low risk gestations.OBJECTIVEThis study aimed to evaluate maternal and perinatal outcomes in high- and low-risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection.STUDY DESIGNThis was a multinational retrospective cohort study involving women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection from 76 centers from 25 countries in Europe, the United States, South America, Asia, and Australia from April 4, 2020, to October 28, 2020. The primary outcome was a composite measure of maternal mortality and morbidity, including admission to the intensive care unit, use of mechanical ventilation, or death. The secondary outcome was a composite measure of adverse perinatal outcome, including miscarriage, fetal loss, neonatal and perinatal death, and admission to the neonatal intensive care unit. All outcomes were assessed in high- and low-risk pregnancies. Pregnancies were considered high risk in case of either preexisting chronic medical conditions in pregnancy or obstetrical disorders occurring in pregnancy. The Fisher exact test and logistic regression analysis were used to analyze the data.RESULTSA total of 887 singleton pregnancies who tested positive for severe acute respiratory syndrome coronavirus 2 infection using reverse transcription-polymerase chain reaction of nasal and pharyngeal swab specimens were included in the study. The risk of composite adverse maternal outcomes was higher in high-risk pregnancies than in low-risk pregnancies (odds ratio, 1.52; 95% confidence interval, 1.03–2.24; P=.035). In addition, women carrying high-risk pregnancies were at higher risk of hospital admission (odds ratio, 1.48; 95% confidence interval, 1.07–2.04; P=.002), presence of severe respiratory symptoms (odds ratio, 2.13; 95% confidence interval, 0.41–3.21; P=.001), admission to the intensive care unit (odds ratio, 2.63; 95% confidence interval, 1.42–4.88), and invasive mechanical ventilation (odds ratio, 2.65; 95% confidence interval, 1.19–5.94; P=.002). When exploring perinatal outcomes, high-risk pregnancies were at high risk of adverse perinatal outcomes (odds ratio, 1.78; 95% confidence interval, 0.15–2.72; P=.009). However, such association was mainly because of the higher incidence of miscarriage in high-risk pregnancies compared with that in low-risk pregnancies (5.3% vs 1.6%, P=.008); furthermore, there was no difference in other explored outcomes between the 2 study groups. At logistic regression analysis, maternal age (odds ratio, 1.12; 95% confidence interval, 1.02–1.22; P=.023) and high-risk pregnancy (odds ratio, 4.21; 95% confidence interval, 3.90–5.11; P<.001) were independently associated with adverse maternal outcomes.CONCLUSIONHigh-risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection were at higher risk of adverse maternal outcomes than low-risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection.

Chorioamnionitis and adverse outcomes in low-risk pregnancies: a population-based study

Objective To compare the composite neonatal and maternal adverse outcomes among low-risk pregnancies with versus without chorioamnionitis. Methods We conducted a retrospective cohort study using U.S. Vital Statistics Data. The study population was restricted to full term, low-risk, singleton pregnancies. Pregnancies were categorized into those affected and unaffected by chorioamnionitis. The primary outcome was composite neonatal adverse outcome and the secondary outcome was composite maternal adverse outcome. Multivariable Poisson regression models with robust error variance were used to examine the factors associated with chorioamnionitis and to evaluate the association between chorioamnionitis and adverse outcomes [using adjusted relative risk (aRR) and 95% confidence interval (CI)]. Results Of 19.7 million live births, 59.4% met inclusion criteria; among them, 1.7% were complicated by chorioamnionitis. The risk of composite neonatal adverse outcome was higher in newborns delivered by women with chorioamnionitis (aRR = 3.40; 95% CI = 3.30–3.49). Compared to women without chorioamnionitis, those with chorioamnionitis had a higher risk of composite maternal adverse outcome (aRR = 2.42; 95% CI = 2.31–2.55). Infant mortality was also higher in affected pregnancies (aRR = 1.23; 95% CI = 1.09–1.38). Conclusion Among low-risk pregnancies, chorioamnionitis is associated with a higher risk of composite neonatal and maternal adverse outcomes. Infant death is also increased.

798 Timing of delivery and associated outcomes in pregnancies complicated by maternal congenital heart disease

To evaluate timing of delivery for pregnancies complicated by maternal congenital heart disease (CHD) and determine if early-term delivery is beneficial. Retrospective cohort study of singleton gestations with maternal CHD that delivered after 37 weeks at a single tertiary care center between March 2013 and August 2020. Patients were categorized by gestational age (GA) at delivery: 37 weeks, 38 weeks, and greater than or equal to 39 weeks. The primary outcomes were composite adverse cardiovascular, maternal, and neonatal outcomes. Demographics, primary outcomes, and selected secondary outcomes, including hypertensive disease of pregnancy, indication for delivery, mode of delivery, and additional neonatal outcomes were compared by GA at delivery with Chi-squared (or Fisher’s exact) and Kruskal-Wallis tests. Multivariate logistic regression was conducted to calculate adjusted odds ratio for GA at delivery. 82 pregnancies with maternal CHD delivered after 37 weeks with known neonatal outcomes. Of these, 23 (28.0%) had a composite adverse cardiovascular outcome, 13 (15.8%) had a composite adverse maternal outcome, and 11 (13.4%) had a composite adverse neonatal outcome. Development of adverse cardiovascular outcome (p=0.13) and adverse maternal outcome (p=0.24) were not significantly different by GA at delivery. Early-term deliveries had significantly more adverse neonatal outcomes (p=0.01), NICU admissions (p=0.002), and small for GA infants (p=0.03). Multivariate logistic regression demonstrated that adverse cardiovascular and maternal outcomes were not significantly associated to GA at delivery, but earlier GA at delivery was associated with an increased odds of adverse neonatal outcomes (p=0.01). Early-term deliveries for pregnancies with maternal CHD are associated with an increased risk of adverse neonatal outcomes without a decreased rate in adverse maternal cardiovascular outcomes. In the absence of maternal or fetal indications for early delivery, consider avoiding induction of labor prior to 39 weeks for pregnancies complicated by maternal CHD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

209 Association of antenatal corticosteroid exposure and infant survival at 22 and 23 weeks

Antenatal corticosteroid (ANCS) administration between 22 0/7 – 22 6/7 wks is not recommended by SMFM and ACOG given current existing evidence. We sought to evaluate whether ANCS exposure was associated with improved survival among resuscitated newborns delivered at 22 and 23 wks. We conducted a population-based cohort study of all resuscitated livebirths delivered between 22 0/7 and 23 6/7 wks in the United States from 2009-2014. The primary outcome was difference in rate of survival to 1 year of life (YOL) based on ANCS exposure. Secondary outcomes included neonatal survival (< 28 days of life), cesarean delivery, and composite adverse maternal outcome (CAMO) associated with ANCS utilization. Multivariable logistic regression provided confounder adjusted effect estimates. In the United States between 2009-2014, there were 2,635 and 7,992 infants who received postnatal resuscitation after delivery between 22 0/7 – 22 6/7 and 23 0/7 – 23 6/7 wks, respectively. Few infants who were resuscitated after birth between 22 0/7 – 22 6/7 (15.9%) and 23 0/7-23 6/7 (26.0%) wks received ANCS. Infant survival to 1 YOL was 45.2 vs 27.8% (aRR 1.6, 95% CI 1.2-2.1) among infants exposed to ANCS compared to those who did not receive ANCS at 22 wks. Survival to 1 YOL was 57.9 vs 47.7% (aRR 1.3, 95% CI 1.1-1.5) among infants exposed to ANCS compared to those who did not receive ANCS at 23 wks. When stratified by 100g birthweight category (400-499g, 500-599g, 600-699g, and 700-799g), ANCS was associated with increased survival among neonates weighing 500-599g (aRR 1.9, 95% CI 1.3-2.9) and 600-699g (aRR 1.7, 95% CI 1.1-2.6) at 22 wks. ANCS exposure had a positive association with cesarean delivery (aRR 2.1, 95% CI 1.4-3.0) and composite adverse maternal outcome (aRR 2.3, 95% CI 1.2-4.3) among infants born at 22 wks. Exposure to ANCS was associated with increased survival to 1 YOL among infants born at 22 and 23 wks. Counseling regarding the utilization of ANCS at the limits of viability should be investigated further given emerging evidence of benefit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

986 Increasing number of scheduled repeat cesarean delivery and adverse outcomes among low-risk individuals

With each repeat cesarean delivery (CD) there is an increase in adverse outcomes, however the rate of these outcomes is inadequately evaluated in a contemporary low-risk population. We sought to investigate maternal and neonatal adverse outcomes among low risk pregnancies delivered at term by scheduled repeat cesarean deliveries. We conducted a retrospective cohort study using the U.S vital statistics datasets from 2014-2018 using the 2003 revision of birth certificates. Inclusion criteria were non-laboring, non-anomalous singletons at term (37-41 weeks gestation) undergoing scheduled repeat cesarean delivery without diabetes (pre-gestational and gestational) or hypertensive disorders of pregnancy. The primary outcome was composite maternal adverse outcome (CMAO). The secondary outcome was composite neonatal adverse outcome (CNAO). Multi-variable Poisson regression models with robust error variance were used to estimate the association with increasing number of cesarean deliveries and adverse outcomes (using adjusted relative risks [aRR] and 95% confidence intervals [CI]). Of the 19 million births during the study period, over 1.7 million (8.7%) met the inclusion criteria. Among the cohorts 65.5% had 1 prior CD, 26.0% had 2 prior CD, 6.8% with 3 prior CD and 1.7% with 4 or more prior CD. Compared with individuals with at least 1 prior cesarean delivery, 4 or more cesarean delivery the aRR of CMAO was 2.98 (2.69-3.29). The adjusted relative risk for all four components of CMAO and all five components of CNAO increased significantly with increasing number of repeat cesarean deliveries. Among non-laboring non-anomalous singletons at term (37-41 weeks gestation) undergoing scheduled repeat cesarean delivery, increasing number of repeat cesarean delivery is a significant risk factor for adverse maternal and neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

126 Association of mode of delivery on infant survival at 22 and 23 weeks of gestation

Selecting the optimal route of delivery in the setting of periviable birth is a complex decision balancing both maternal and fetal outcomes. ACOG and SMFM do not recommend cesarean delivery prior to 23 0/7 wks for fetal indications based on available, limited evidence. We sought to compare survival rates at 1 year of life (YOL) among resuscitated infants at 22 and 23 wks based on route of delivery. We conducted a population-based cohort study of all resuscitated live births between 22 0/7 and 23 6/7 wks in the United States (US) from 2007-2013. The primary outcome was rate of infant survival to 1 YOL based on delivery route (cesarean vs vaginal). Secondary outcomes included survival rates for neonates surviving beyond 1 day of life (DOL), neonatal survival (beyond 28 days), length of survival, and survival stratified by fetal presentation, steroid exposure, and ventilation. Composite adverse maternal outcome (CAMO) (blood transfusion, unplanned operation or hysterectomy, ICU admission) was also compared between mode of delivery cohorts. Multivariable logistic regression analysis estimated the association of cesarean on these outcomes. There were a total of 11,146 resuscitated neonates delivered between 22 0/7 – 23 6/7 wks in the US during 2007-2013. Resuscitated infants delivered by cesarean had higher rates of survival at 22 (44.9 vs 23.0%, p<0.001) and 23 (53.3 vs 43.4%, p<0.001) wks regardless of fetal presentation. Survival remained significantly improved after adjustment for coexisting risk factors for infants delivered by cesarean at 22 (aRR 2.3, 95% CI 1.9-2.8) and 23 (aRR 1.4, 95% CI 1.2-1.5) wks compared to those delivered vaginally. When limited to neonates surviving beyond 1 DOL, vertex neonates born by cesarean were not more likely to survive at 22 or 23 wks. Cesarean delivery increased risk for CAMO (aRR 1.7, 95% CI 1.1-2.7) with births at 22-23 wks of gestation. Cesarean delivery is associated with increased survival at 1 YOL among resuscitated infants born between 22 0/7 – 23 6/7 wks gestation and increased maternal morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Foley catheter vs oral misoprostol for induction of labor: individual participant data meta-analysis.

To compare the effectiveness and safety of Foley catheter and oral misoprostol for induction of labor (IOL). The Cochrane Review on Mechanical Methods for Induction of Labour and Ovid MEDLINE, EMBASE via Ovid, Ovid Emcare, CINAHL Plus, ClinicalTrials.gov and Scopus, from inception to April 2019, were searched for randomized controlled trials (RCTs) comparing Foley catheter to oral misoprostol for IOL in viable singleton gestations. Eligible trials for which raw data were obtained were included and individual participant data meta-analysis was performed. Primary outcomes were vaginal birth, a composite of adverse perinatal outcome (including stillbirth, neonatal death, neonatal seizures, admission to the neonatal intensive care unit, severe respiratory compromise or meconium aspiration syndrome) and a composite of adverse maternal outcome (including admission to the intensive care unit, maternal infection, severe postpartum hemorrhage, maternal death or uterine rupture). The quality of the included RCTs was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was evaluated using the GRADE approach. A two-stage random-effects model was used for meta-analysis according to the intention-to-treat principle and interactions between treatment and baseline characteristics were assessed. Of seven eligible trials, four provided individual participant data for a total of 2815 participants undergoing IOL, of whom 1399 were assigned to Foley catheter and 1416 to oral misoprostol. All four trials provided data for each of the primary outcomes in all 2815 women. Compared with those receiving oral misoprostol, Foley catheter recipients had a slightly decreased chance of vaginal birth (risk ratio (RR), 0.95 (95% CI, 0.91-0.99); I2 , 2.0%; moderate-certainty evidence). A trend towards a lower rate of composite adverse perinatal outcome was found in women undergoing IOL using a Foley catheter compared with oral misoprostol (RR, 0.71 (95% CI, 0.48-1.05); I2 , 14.9%; low-certainty evidence). Composite adverse maternal outcome did not differ between the groups (RR, 1.00 (95% CI, 0.97-1.03); I2 , 0%; moderate-certainty evidence). Meta-analyses of effect modifications did not show significant interactions between intervention and parity or gestational age for any of the primary outcomes. For women undergoing IOL, Foley catheter is less effective than oral misoprostol, as it was associated with fewer vaginal births. However, while we found no significant difference in maternal safety, Foley catheter induction may reduce adverse perinatal outcomes. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

249 Labor length and adverse cardiac outcomes among women with congenital heart disease

Women with congenital heart disease (CHD) are at high risk for peripartum morbidity, yet data is limited on the impact of labor on morbidity. Our objective was to evaluate whether exposure to labor and duration of labor were associated with rates of adverse maternal cardiac outcomes among women with CHD. This was a secondary analysis of a retrospective cohort study of women ≥18 years with CHD who received prenatal care and delivered at the Hospital of the University of Pennsylvania between 1998-2014 with a singleton gestation. Only the first pregnancy was counted for women who delivered more than once. Pregnancies that ended in termination or loss <24 weeks gestation were excluded. A composite adverse maternal cardiac outcome included any cardiac event during pregnancy or <6 months post-partum (specific outcomes listed in Figure), compared among women who did and did not labor. 168 women were included; 34 (20.2%) underwent planned cesarean delivery (CD) without labor and 134 (79.8%) labored. The overall rate of adverse cardiac outcome was 20.2%; 23.5% in the planned CD group and 19.4% in those that labored, regardless of mode of delivery (p=0.6). The most common adverse events were heart failure (13.7%) and arrhythmia (7.7%). As shown in the Figure, women who delivered in <24 hours (regardless of mode of delivery) had a lower rate of adverse cardiac outcome than those that delivered after ≥24 hours of labor, though not statistically significant (p=0.06). When adjusting for confounders including NYHA class, systemic ventricular dysfunction, and mode of delivery, women with labor length ≥15 hours had a 3.7-fold higher odds of adverse cardiac outcome (aOR 3.7 [1.1-12.9]). In this retrospective cohort of women with CHD, exposure to labor was not associated with an increased risk of adverse cardiac outcome. However, among those who labored, longer labor was associated with an increased risk, regardless of mode of delivery. Attention should be paid to the duration of labor in women with CHD, as achieving a vaginal delivery does not mitigate the risks of prolonged labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

796 Eclampsia and associated adverse outcomes in singleton versus multifetal gestations

Multifetal gestation is a known risk factor for pre-eclampsia, but the degree of increased risk for eclampsia has not been quantified. Our objectives were to: 1) compare rates of eclampsia in singleton versus twin and higher order multifetal gestations and 2) investigate whether eclampsia in multifetal gestations is associated with higher maternal morbidity. We conducted a cross-sectional study using the US Vital Statistics birth certificate data to identify cases of eclampsia in live-born singleton, twin and higher order multifetal gestations between 2014 and 2018. We excluded subjects with fetal anomalies, gestational age < 24 or > 42 weeks, or missing maternal comorbidity or outcome data. Multivariable Poisson regression with robust error variance was used to compare rates of eclampsia between pregnancies with singleton, twin, and higher order multifetal gestations. Similarly, rates of composite adverse maternal outcome (CMAO; includes any of the following: blood transfusion, ICU admission, unplanned cesarean hysterectomy, and uterine rupture) were compared between groups among pregnancies with eclampsia. Among the 18.8 million pregnancies identified that met inclusion criteria, the rates of eclampsia increased with increasing degree of multiple gestation (Table 1). Twin pregnancies were more than twice as likely (aRR 2.55, 95% CI 2.47-2.63) to be affected by eclampsia compared to singleton gestations, while triplets and higher order multiples were nearly four times as likely to be affected by eclampsia (RR 3.71, 95% CI 3.20-4.31). Among those with eclampsia, CMAO was higher in multifetal gestations compared to singletons (aRR 1.38, 95% CI 1.16-1.64; Table 2). Multifetal gestations are at increased risk of eclampsia compared to singletons, and risk is increased in higher order pregnancies. Among pregnancies affected by eclampsia, multifetal gestation is associated with higher rates of adverse maternal outcomes compared to singletons.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Parity and Interval from Previous Delivery-Influence on Perinatal Outcome in Advanced Maternal Age Parturients.

Objective: To investigate the effect of parity and interpregnancy interval (IPI) on perinatal outcomes in advanced maternal age (AMA) parturients. Methods: A population-based retrospective cohort study of all women older than 40 years, who had a singleton live birth after 24 weeks in the United States in 2017 Women were categorized to three groups by parity and interval from last delivery: primiparas, multiparas with IPI ≤ 5 years, and multiparas with IPI > 5 years. Primary outcome was composite adverse neonatal outcome (preterm delivery <34 weeks, birthweight <2000 g, neonatal seizure, neonatal intensive care unit admission, Apgar score <7 at 5 min, or assisted ventilation >6 h). Secondary outcome was composite adverse maternal outcome and other adverse perinatal outcomes. Univariate and multivariate analysis were used to compare between groups. Results: During 2017, 3,864,754 deliveries were recorded into the database. Following exclusion, 109,564 AMA gravidas entered analysis. Of them, 24,769 (22.6%) were nulliparas, 39,933 (36.4%) were multiparas with IPI ≤ 5 years, and 44,862 (40.9%) were multiparas with IPI > 5 years. Composite neonatal outcome was higher in nulliparas and in multiparas with IPI > 5 years, in comparison to multiparas with IPI ≤ 5 years (16% vs. 13% vs. 10%, respectively, p < 0.05). Maternal composite outcome was similar between groups. In the multivariable analysis, relative to nulliparas, only multiparity with IPI ≤ 5 years had a protective effect against the composite neonatal outcome (aOR 0.97, 95% CI 0.95–0.99, p < 0.001). Conclusion: Among AMA gravidas, multiparity with IPI ≤ 5 years has a significant protective effect against adverse neonatal outcomes when compared to nulliparas. Multiparity with IPI > 5 years is no longer protective.

Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection.

To evaluate the maternal and perinatal outcomes of pregnancies affected by SARS-CoV-2 infection. This was a multinational retrospective cohort study including women with a singleton pregnancy and laboratory-confirmed SARS-CoV-2 infection, conducted in 72 centers in 22 different countries in Europe, the USA, South America, Asia and Australia, between 1 February 2020 and 30 April 2020. Confirmed SARS-CoV-2 infection was defined as a positive result on real-time reverse-transcription polymerase chain reaction (RT-PCR) assay of nasopharyngeal swab specimens. The primary outcome was a composite measure of maternal mortality and morbidity, including admission to the intensive care unit (ICU), use of mechanical ventilation and death. In total, 388 women with a singleton pregnancy tested positive for SARS-CoV-2 on RT-PCR of a nasopharyngeal swab and were included in the study. Composite adverse maternal outcome was observed in 47/388 (12.1%) women; 43 (11.1%) women were admitted to the ICU, 36 (9.3%) required mechanical ventilation and three (0.8%) died. Of the 388 women included in the study, 122 (31.4%) were still pregnant at the time of data analysis. Among the other 266 women, six (19.4% of the 31 women with first-trimester infection) had miscarriage, three (1.1%) had termination of pregnancy, six (2.3%) had stillbirth and 251 (94.4%) delivered a liveborn infant. The rate of preterm birth before 37 weeks' gestation was 26.3% (70/266). Of the 251 liveborn infants, 69/251 (27.5%) were admitted to the neonatal ICU, and there were five (2.0%) neonatal deaths. The overall rate of perinatal death was 4.1% (11/266). Only one (1/251, 0.4%) infant, born to a mother who tested positive during the third trimester, was found to be positive for SARS-CoV-2 on RT-PCR. SARS-CoV-2 infection in pregnant women is associated with a 0.8% rate of maternal mortality, but an 11.1% rate of admission to the ICU. The risk of vertical transmission seems to be negligible. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.