Higher Rates Of Preterm Delivery Research Articles

Demographic characteristics and pregnancy outcomes in adolescents - Experience from an Australian perinatal centre.

Adolescent pregnancy is defined as pregnancy in girls aged 10-19years and can be associated with increased risks. To investigate obstetric and perinatal outcomes in a cohort of adolescent girls from a major Australian tertiary centre. This was a nine-year retrospective cohort study of women who birthed at the Mater Mother's Hospital (MMH) in Brisbane, Australia between 1 January 2007 and 31 December 2015. The adolescent cohort was aged <19years and the control group was aged 20-24years. Over the study period the total study cohort comprised 8904 women. Of these, the adolescent cohort consisted of 1625 girls (18.2%) and the control group consisted of 7279 women (81.8%). Adolescents were more likely to be nulliparous, single, of Indigenous ethnicity or to have refugee status. They had higher rates of smoking, asthma, diabetes mellitus and thyroid disease. They were more likely to have an uncomplicated spontaneous vaginal delivery but were less likely to have an intact perineum and had higher rates of pre-term delivery and low birth weight babies. There were no differences in rates of postpartum haemorrhage. Teenage pregnancy results in poorer obstetric and perinatal outcomes. A focus on optimising maternal health care and providing culturally appropriate antenatal and intrapartum care is imperative to improving outcomes.

Confirmed Severe Maternal Morbidity is Associated With High Rate of Preterm Delivery

(Am J Obstet Gynecol 2016;215:233.e1–233.e7) Approximately 2% of all births (50,000 women) in the United States are affected by severe maternal morbidity (SMM) with this number growing every year. It is not surprising that this increase in SMM mirrors a similar increase in maternal mortality. SMM events include things like hemorrhage ≥4 units, disseminated intravascular coagulation leading to a hysterectomy, sepsis, and critical care unit admission. It is imperative we better understand the risks and develop interventions to help prevent SMM, with the hope of also reducing maternal mortality. In order to achieve this goal, there have been recent efforts to screen for women who suffer SMM and perform a detailed review of these cases. This has been in an effort to better understand the causes of SMM and ultimately prevent poor maternal outcomes. The purpose of this study was to identify the risks factors associated with true SMM including the relationship between SMM and preterm delivery.

Maternal and Neonatal Outcomes in Multiple Gestations With Elevated Antenatal Edinburgh Depression Scale (EDS) [6R

INTRODUCTION: The purpose of this study was to determine the association of elevated antenatal Edinburgh Depression Scale (EDS) and maternal and neonatal outcomes in multiple gestations, in particular the rate of preterm delivery. METHODS: This is a retrospective study examining multiple gestations delivering at UC San Diego between 2010-2014. Patients were included if they completed an antepartum EDS. An EDS score of &gt;10 was considered positive. The primary outcome was rate of preterm delivery (GA at delivery of &lt; 37 weeks). Other maternal and neonatal outcomes of interest included history of preterm delivery, birth weight percentage and discordance, Apgar score, and maternal weight gain. Data was analyzed using SPPS v.23. RESULTS: 102 women with multiple gestations completed an antepartum EDS. 22.5% (23/102) had a positive EDS score and 77.5% (79/102) had a negative score. Preterm delivery rate in the entire cohort was 61.8% (N=63). Women with an elevated EDS score had a trend toward higher preterm delivery rate (73.9%, N=17) compared to women with lower EDS scores (58.2%, N=46), p-value=0.23. A higher proportion of neonates born to mothers with elevated EDS had an Apgar score less than 7 at 5 minutes (27.3% vs 12.1%, p-value=0.1) although this was not statistically significant. No differences were noted in maternal weight gain or birth weight discordance. CONCLUSION: There is a trend toward an increased rate of preterm delivery and lower Apgar score in multiple gestations with a positive antepartum maternal EDS score. Further studies are needed to assess if treating these high-risk patients reduces their rate of preterm delivery.

Mothers’ childhood hardship forecasts adverse pregnancy outcomes: Role of inflammatory, lifestyle, and psychosocial pathways

Research suggests the health consequences of economic hardship can be transmitted across generations. Some of these disparities are thought to be passed to offspring during gestation. But this hypothesis has not been tested in contemporary American samples, and the mechanisms of transmission have not been characterized. Accordingly, this study had two goals: first, to determine if women exposed to economic hardship during childhood showed higher rates of adverse birth outcomes; and second, to evaluate the contribution of inflammation, psychosocial, lifestyle, and obstetric characteristics to this phenomenon. This prospective study enrolled 744 women with singleton pregnancies (59.1% White; 16.3% Black; 18.7% Latina; 5.9% Other). Childhood economic hardship was measured by self-report. Birth outcomes included length of gestation and incidence of preterm birth; birth weight percentile and small for gestational age; length of hospital stay and admission to Special Care Nursery. Analyses revealed that mothers’ childhood economic hardship was independently associated with multiple adverse birth outcomes, even following adjustment for demographics, maternal education, and obstetrical confounders. Women raised in economically disadvantaged conditions had shorter gestation length and higher preterm delivery rates. Their babies had lower birth weights, were more likely to be small for gestational age, stayed in the hospital longer, and had more Special Care Nursery admissions. Mediation analyses suggested these associations arose through multiple pathways, and highlighted roles for inflammation, education, adiposity, and obstetric complications. Collectively, these findings suggest that childhood economic hardship predisposes women to adverse birth outcomes, and highlights likely behavioral and biological mechanisms.

Impact of microbial invasion of amniotic cavity and the type of microorganisms on short-term neonatal outcome in women with preterm labor and intact membranes.

The objective of this study was to evaluate the impact of microbial invasion of the amniotic cavity and the type of microorganisms on pregnancy and short-term neonatal outcomes in women with preterm labor. Prospective observational cohort study including women with preterm labor from 22.0 to 36.0 weeks. Microbial invasion of the amniotic cavity was defined based on amniotic fluid aerobic/anaerobic/mycoplasma cultures, and intra-amniotic inflammation on amniotic fluid interleukin-6 levels. Demographic data and pregnancy outcomes were compared among women exposed to microbial invasion of the amniotic cavity by Ureaplasma spp., women with microbial invasion of the amniotic cavity by other microorganisms, and a No-microbial invasion of the amniotic cavity/No-intra-amniotic inflammation group. The short-term neonatal outcome was evaluated in women delivering after 24.0 weeks. We included 228 women with preterm labor. Microbial invasion of the amniotic cavity occurred in 35% (80/228), 28% (22/80) being caused by Ureaplasma spp. Gestational age at admission and at delivery were significantly earlier and the rate of delivery at <24.0 weeks' gestation and of women who further developed clinical chorioamnionitis were significantly higher in women with microbial invasion of the amniotic cavity by microorganisms other than Ureaplasma spp. However, after 24 weeks, regardless of the microorganisms isolated, the short-term neonatal outcome was similar between women exposed to microbial invasion of the amniotic cavity and the No-microbial invasion of the amniotic cavity/No-intra-amniotic inflammation group when gestational age was considered. Microbial invasion of the amniotic cavity by microorganisms other than Ureaplasma spp. was associated with earlier gestational age at admission and at delivery, and a higher rate of preterm delivery <24.0 weeks and of women who developed clinical chorioamnionitis. However, we did not find differences in the short-term neonatal outcome between women exposed to microbial invasion of the amniotic cavity and the no-microbial invasion of the amniotic cavity/no-intra-amniotic inflammation group delivering after 24.0 weeks' gestation when adjusted by gestational age at delivery.

Delivery Outcomes of Patients with Acute Migraine in Pregnancy: A Retrospective Study.

To describe labor and delivery outcomes in pregnant patients presenting to the hospital setting with an acute severe migraine headache attack earlier in the same gestation. We retrospectively reviewed pregnancy and delivery records from a database of consecutive inpatient neurology consultations for acute headache in pregnant women over a 5 year period. We identified 86 pregnant women with acute migraine. The mean age was 29.3 (±6.4) years. Nearly half had migraine with aura (35/86 [40.7%]), 12.8% (12/86) had chronic migraine, and 31.4% (27/86) presented in status migrainosus. Complication rates included 54.7%([41/75], 95% CI 29.87, 52.13) for at least one adverse outcome, 28.0% ([21/75], 95% CI 11.78, 30.22) for preterm delivery, 21.3% ([16/75], 95% CI 7.7, 24.3) for preeclampsia, 30.6% ([23/75] 95% CI 13.48, 32.52) for cesarean delivery, and 18.7% ([14/75] 95% CI 6.15, 21.85) for low birthweight. Pregnant women seeking treatment for acute migraine headache experienced a higher rate of preterm delivery, preeclampsia, and low birthweight but a lower rate of cesarean delivery than the local and general populations. More than half (54.7% [41/75] 95% CI 29.87, 52.13) of the study patients experienced some type of adverse birth outcome, suggesting that pregnancies in migraine patients presenting to an acute care setting may benefit from more intense surveillance.

GESTATIONAL DIABETES MELLITUS (BASED ON THE RESULTS OF A SCREENING STUDY IN THE MOSCOW REGION)

Background: New diagnostic criteria for gestational diabetes mellitus (GDM) are being currently implemented into clinical practice. GDM prevalence and pregnancy outcomes in women with GDM diagnosed according to the new criteria have not been studied in Russia.Aim: To evaluate prevalence of GDM and pregnancy outcomes in women with GDM based on the Russian consensus criteria 2012 ("Gestational diabetes mellitus: diagnosis, treatment and postpartum follow-up") in the population of the Moscow Region.Materials and methods: The study included 176 pregnant women living in the Moscow Region. We retrospectively analyzed 100 pregnant women (mean age±SD – 28.3±6 years) who delivered before 2013 with collection of data on blood glucose and gestational age of its measurement, body mass index (BMI) at conception and pregnancy outcomes. The prospective part of the study conducted from January to July 2015 included screening of 820 pregnant women helped to identify 76 cases of GDM (mean age±SD – 30.4±5.5 years); their follow-up included monitoring of glucose levels, gestational term, and pregnancy outcomes.Results: In the retrospective part of the study, 19 women (19%) were identified with their fasting glucose levels≥5.1 mmol/L (5.39±0.29 mmol/L) at 14.4±9.3 weeks of gestation, that corresponds to diagnosis of GDM with 2012 criteria. The comparison of pregnant women with and without fasting hyperglycemia showed no difference in age and pre-pregnancy BMI values. Women with fasting hyperglycemia had high total rates of adverse pregnancy outcomes than those without (52.6% vs 24.6%, respectively, p&lt;0.017), as well as higher rates of fetal asphyxia during delivery and clavicle fractures (15.8% vs 3.7%, p=0.04 and 10.5% vs 0%, p=0.03). In the prospective part of the study, 820 pregnant women were screened for GDM, and it was found in 76 (9.2%) of them. Among those, in 50 (65.8%) the diagnosis of GDM was based on fasting glucose in venous plasma (5.5±0.3 mmol/L) at 11.3±6.1 weeks of gestation. Pregnant patients with fasting hyperglycemia in the retrospective and prospective parts of the study did not differ in their age, pre-pregnancy BMI, fasting glucose levels and terms of assessment; however, in the prospective study, the rate of fasting hyperglycemia was lower than in the retrospective (6% vs 19%). The second phase of the screening performed at 20 to 30 weeks of gestation helped to identify 26 women (34.2%) with GDM: in 15 of them (19.7%) the diagnosis was based on repeatedly high fasting glucose (5.5±0.3 mmol/L) and in 11 (14.5%), on the results of the oral glucose tolerance test. To all pregnant women with GDM, diet and blood glucose self-monitoring were recommended. Pregnancy outcomes were assessed in 64 GDM patients, with their comparison in compliant patients (n=30) vs non-compliant (n=34). Patients with poor compliance had higher rates of preterm delivery (11.4% vs 0%, р=0.05), macrosomia (32.3% vs 6.6%, р=0.01) and other adverse outcomes (76.5% vs 50%, р=0.03) than those with good compliance.Conclusion: The prevalence of GDM in a district of the Moscow Region in the prospective study was 9.2%. The retrospective analysis showed an overestimated rate of fasting hyperglycemia (19%). In the majority of GDM patients, the diagnosis was based on an increased fasting glucose level in venous plasma (85.5%). Treatment of GDM patients helps to reduce adverse pregnancy outcomes.

Placental Morphology in Fetal Alcohol Spectrum Disorders.

Aims Maternal alcohol drinking adversely affects pregnancy outcome. Although fetal health and development are highly dependent upon the integrity of placentation, little is known about placental morphology following gestational exposure to alcohol in humans. Methods In this clinical study, subjects were recruited between 2010 and 2013 from an outpatient substance abuse and mental health treatment center for women. Data collected included maternal age, substance abuse history, comorbidities, pregnancy outcomes, gestational age at delivery, birth weight and placental weight. Placental histopathological lesions associated with uteroplacental malperfusion (UPM) were scored under code. Villous cytotrophoblasts reflecting another measure of UPM were immunostained with E-cadherin and quantified using stereology. Inter-group comparisons were made using univariate or multivariate analysis. Results Of the 92 women enrolled in the study, 61 (66%) had histories of alcohol use during the pregnancy while the remaining 31 served as controls. The alcohol-exposed group significantly differed from controls based on (a) higher rates of smoking and polydrug use during pregnancy, (b) lower mean gestational age and birth weight of their infants, (c) elevated UPM scores, (d) increased densities of villous cytotrophoblastic cells and (e) more extensive chorangiosis in placenta. Logistic regression analysis demonstrated alcohol to be the only significant predictor of these outcomes and responses. Conclusions Gestational alcohol exposure is significantly associated with UPM, which could account for the higher rates of preterm delivery and reduced mean birth weights. Since chorangiosis reflects altered placental oxygen dynamics, the greater abundance of this abnormality could represent a compensatory response to UPM. Short Summary In this clinical study, we assessed the effects of maternal alcohol drinking on placental morphology. Applying a cumulative scoring system, we determined that gestational alcohol exposure is significantly associated with uteroplacental malperfusion, which could account for the higher rates of preterm delivery and reduced mean birth weights.

Neighborhood Context and Preterm Delivery among African American Women: the Mediating Role of Psychosocial Factors.

Preterm delivery (PTD), or birth before 37 completed weeks of gestation, is a serious public health issue, and racial disparities persist. In a recently published study, perceptions of the residential environment (or neighborhood context) were associated with PTD rates among urban African American women with low educational attainment (≤12years); however, the mechanisms of these associations are unknown. Given this gap in the literature, we used data from the Life Influences on Fetal Environments Study of postpartum African American women from Metropolitan Detroit, Michigan (2009-2011; n = 399), to examine whether psychosocial factors (depressive symptomology, psychological distress, and perceived stress) mediate associations between perceptions of the neighborhood context and PTD. Validated scales were used to measure women's perceptions of their neighborhood safety, walkability, healthy food availability (higher=better), and social disorder (higher=more disorder). The psychosocial indicators were measured with the Center for Epidemiologic Studies-Depression Scale, Kessler's Psychological Distress Scale (K6), and Cohen's Perceived Stress Scale. Statistical mediation was assessed using an unadjusted logistic regression-based path analysis for estimating direct and indirect effects. The associations between perceived walkability, food availability, and social disorder were not mediated by psychosocial factors. However, perceptions of neighborhood safety were inversely associated with depressive symptoms which were positively associated with PTD rates. Also, higher perceived neighborhood social disorder was associated with higher PTD rates, net of the indirect paths through psychosocial factors. Future research should identify other mechanisms of the perceived neighborhood context-PTD associations, which would inform PTD prevention efforts among high-risk groups.

The Effects of Turner Syndrome, 45,X on Obstetric and Neonatal Outcomes: A Retrospective Cohort Evaluation.

Objective This study aims to evaluate the perinatal and neonatal outcomes associated with prenatal diagnosis of 45,X, both with and without fetal cardiac anomalies. Study Design A retrospective cohort of singleton pregnancies in California, 2005 to 2008, using vital statistics and International Classification of Diseases, Ninth Revision data, identifying prenatally diagnosed 45,X. Outcomes included preterm delivery, preeclampsia, intrauterine fetal demise (IUFD), cesarean section, small for gestational age (SGA), neonatal death, and infant death. Bivariate and multivariate analyses were used to compare pregnancies and neonates with and without 45,X. Prenatally diagnosed cardiac anomalies were also considered. Results Of the 2,029,000 deliveries, 138 had prenatally diagnosed 45,X. Out of these 138 deliveries, 22 had a prenatally diagnosed cardiac anomaly. Compared with unaffected pregnancies, those with fetal 45,X had higher rates of preterm delivery (19.5 vs. 9.9%, p = 0.001), cesarean section (44.2 vs. 30.2%, p < 0.0001), and SGA (21.5 vs. 6.3%, p < 0.0001). The affected cohort had no IUFDs. Neonatal death was 14.5 times higher in the 45,X cohort (p < 0.0001). Of only infants with cardiac anomalies, neonatal death was significantly more likely in those with 45,X (p = 0.005). In adjusted analysis, risk of SGA (< 3rd percentile), neonatal death, and infant death remained increased for infants with 45,X while controlling for fetal cardiac anomalies. Conclusion Prenatally diagnosed 45,X was associated with increased risk of cesarean section, and adverse neonatal outcomes, including mortality.

The impact of prenatally diagnosed Klinefelter Syndrome on obstetric and neonatal outcomes

ObjectiveThe objective of this study was to examine the obstetric and neonatal outcomes as well as the as the associated hospital costs for pregnancies complicated by prenatally diagnosed Klinefelter Syndrome, 47,XXY. Study designWe conducted a retrospective cohort study of all of the singleton deliveries in California from 2005 to 2008 using vital statistics and ICD-9 data, specifically identifying cases of fetal Klinefelter Syndrome. Specifically, we were interested in the outcomes of preterm delivery, preeclampsia, intrauterine fetal demise, cesarean delivery, neonatal death, respiratory distress syndrome (RDS), small for gestational age, large for gestational age, neonatal death, and infant death. Bivariate and multivariate analyses were used to compare pregnancies and neonates affected by prenatally diagnosed Klinefelter Syndrome to those that were not affected with 47,XXY. ResultsThere were 2,029,000 deliveries in the cohort, including 52 women with prenatally diagnosed 47,XXY. Advanced maternal age, completion of 12th grade, and private insurance were all associated with a prenatal diagnosis of Klinefelter Syndrome. Compared to unaffected deliveries, pregnancies complicated by prenatally diagnosed Klinefelter Syndrome had higher rates of preterm delivery (23.1% vs 9.9%, p=0.0004), cesarean delivery (50.0% vs 30.2%, p=0.004), and RDS (9.6% vs 1.2%, p=<0.0001). Infants with 47,XXY were markedly more likely to be small for gestational age, including less than the 10th, 5th and 3rd percentile (aOR 5.86 (95% CI 2.99, 11.46), 6.03 (95% CI 2.52, 14.43), and 8.28 (95% CI 3.22, 21.25), p≤0.001). Rates of neonatal death were 9.5 times higher (1.9% vs 0.2% p<0.0001) in the 47,XXY cohort, and rates of infant death were more than 50 times higher (5.8% vs 0.1%, p<0.0001). In the adjusted analysis, prenatally diagnosed 47,XXY was associated with increased odds of preterm delivery <32 weeks (OR 6.81, 95% CI 2. .38, 19.52), IVH (OR 9.08, 95% CI 1.22, 67.7), RDS (OR 8.32, 95% CI 3.22, 21.49), neonatal death (OR 9.77, 1.33, 71.79), and infant death (OR 62.73, 95% CI 19.34, 203.4). ConclusionPregnancies affected by prenatally diagnosed Klinefelter Syndrome are at an increased risk of adverse fetal and neonatal outcomes. These findings may be helpful when counseling families with pregnancies affected by fetal 47,XXY.

Delivery Outcomes After Acute Migraine Treatment in Pregnancy

INTRODUCTION: Experiencing acute severe migraine attacks during pregnancy may indicate particularly severe and active disease. Data regarding delivery outcomes in this population is lacking. We aimed to describe birth outcomes in pregnant patients presenting to the hospital setting with acute severe migraine attacks. METHODS: We reviewed pregnancy and delivery records of consecutive inpatient neurology consultations for acute headache in pregnant women at a tertiary hospital over a 5 year period. RESULTS: Ninety pregnant women with acute migraine had a mean age of 29.3 years. Nearly half had migraine with aura (40.7%), 12.8% had chronic migraine, and 31.4% presented in status migrainosus. Delivery complications included 54.4% for at least one adverse outcome, 28.2% for preterm delivery, 20.5% for preeclampsia, 30.8% for Cesarean delivery, and 19.2% for low birthweight. In binary logistic regression analysis, migraine with aura was associated with a lower rate (OR 0.28, 95% CI 0.09–0.86) but chronic migraine (OR 1.59, 95% CI 0.29–8.78) and status migrainosus (OR 0.66, 95% CI 0.22–2.02) were not associated with adverse pooled outcomes. Age at or above 35 was independently associated with adverse outcomes (OR 7.37, 95% CI 1.97–30.4). CONCLUSION: Pregnant women seeking acute migraine treatment experienced a higher rate of preterm delivery, preeclampsia and low birthweight but a lower rate of cesarean delivery than the general population. However, there were no independent associations with chronic migraine or status migrainosus. Nonetheless, with more than half of patients in this study experiencing some type of adverse birth outcome pregnancies in such patients should be considered high risk.

Outcomes and Characteristics of Women That Refuse Universal Transvaginal Cervical Length Screening [22R

INTRODUCTION: In America 11.5% of infants are born prematurely, 15% to women without a history of preterm delivery. At St. Francis Hospital we offer transvaginal cervical length screening to all patients between 18 and 24 weeks gestation, as there is strong evidence to suggest screening may prevent preterm birth by identifying high-risk women earlier in pregnancy. As many women still refuse the test, our study compared obstetrical outcomes and characteristics of women who accept or decline transvaginal cervical length screening. METHODS: We conducted a retrospective medical record review of women undergoing second trimester anatomy scans between 18 and 24 wga from March 1, 2014 to September 31, 2014. Women with uterine anomalies, multiple gestations or prior preterm delivery were excluded. To assess the primary outcome, delivery <37 weeks, the screened group was compared to those who declined. Statistical analysis included Student's t test, Chi square analysis, and Fisher's exact test. RESULTS: Of 826 women, 420 (51%) accepted and 406 (49%) women declined screening. Nulliparous women were more likely to accept screening than multiparous women (P<.05). There was no difference in ethnicity between those that accepted or declined screening. There was a higher rate of preterm delivery in the group that declined screening than in the screened group (16% versus 12.4%, P<.05). CONCLUSION: We noted more rejections for cervical length screening than anticipated. Reasons for declining included prior term deliveries, cost concerns, and lack of adequate counseling. Further study will address the influence sonographers have in the acceptance of screening.

Cost-Effectiveness of Pre-Pregnancy Bariatric Surgery [9C

INTRODUCTION: We sought to determine if bariatric surgery is a cost-effective pre-pregnancy approach to reduce pregnancy complications in obese women. METHODS: We assessed the cost-effectiveness of bariatric surgery prior to becoming pregnant in a theoretical cohort of obese women age 20–39 in the United States. Outcomes included gestational diabetes (GDM), preeclampsia, preterm delivery, cesarean delivery, maternal mortality, and neurodevelopmental disability. All model inputs were derived from the literature. We calculated quality-adjusted life years (QALYs) to compare strategies, accounting for maternal and neonatal utilities. We ran our models with and without consideration of anovulation rates given its substantial impact on QALYs. RESULTS: Pre-pregnancy bariatric surgery led to lower rates of GDM, preeclampsia, and large-for-gestational-age infants, but more small-for-gestational-age (SGA) infants. Overall, no bariatric surgery was the preferred strategy with lower costs and better outcomes. However, when considering the impact on fecundity from improved ovulation rates after bariatric surgery, it would then become cost effective at $2,528 per QALY. Women who underwent pre-pregnancy bariatric surgery had higher rates of preterm delivery, SGA infants, cesarean delivery, maternal death and neonates with neurodevelopmental disabilities. Univariate sensitivity analyses showed that pre-pregnancy bariatric surgery became the preferred strategy when the probability of having an SGA baby became less than 0.121 from a baseline probability of 0.156. CONCLUSION: Bariatric surgery reduces the risk of GDM, preeclampsia and LGA infants, but it is not a cost-effective intervention in obese women of reproductive age. However, in women who are anovulatory, it may be a reasonable approach to improve overall pregnancy outcomes.

Confirmed severe maternal morbidity is associated with high rate of preterm delivery

Because severe maternal morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce maternal morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care. Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery. In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation. In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P < .0001), be African American (14.1 vs 7.9%; P < .0001), have had a multiple gestation (9.7 vs 2.1%; P < .0001), and, for the multiparous women, have had a prior cesarean delivery (58 vs 30.2%; P < .0001). Preterm delivery was significantly more common in SMM women compared to SMM-negative women (41 vs 8%; P < .0001), including delivery <32 weeks (18 vs 2%; P < .0001). The most common underlying disease was obstetric hemorrhage (42%) followed by hypertensive disorders (20%) and placental hemorrhage (14%). Only 1.6% of women with SMM had cardiovascular disease as the underlying disease category. An extremely high proportion of women with severe morbidity (42.5%) delivered preterm with 17.8% delivering <32 weeks, which underscores the importance of access to appropriate-level care for mothers with SMM and their newborns. Further, the extremely high rate of preterm delivery (75%) in women with placental hemorrhage in combination with their 63% prior cesarean delivery rate highlights another risk of prior cesarean delivery: subsequent preterm delivery. These data provide a reminder that a cesarean delivery could be a contributing factor to not only hemorrhage-related SMM, but also to increased subsequent preterm delivery, more reason to continue national efforts to safely reduce initial cesarean deliveries.

41: Severe maternal morbidity is associated with high rate of preterm delivery

41: Severe maternal morbidity is associated with high rate of preterm delivery

Assisted Reproductive Technology Surveillance - United States, 2013.

Assisted Reproductive Technology Surveillance - United States, 2013.

Contraception Practices and Pregnancy Outcome in Patients after Fontan Operation.

The feasibility and safety of pregnancy after the Fontan operation is not well understood. We sought to determine contraception practices and early and late outcomes of pregnancy after the Fontan operation. We performed a retrospective review of medical records to identify women of childbearing age from the Mayo Clinic Fontan database. A follow-up questionnaire was mailed to all patients not known to be deceased at the time of study. Patients with available contraception and pregnancy data were included in the study. Of the 138 women with available contraception data, 44% used no contraception, 12% each used barrier methods, combination hormone therapy or sterilization, 8% used Depo-Provera, 7% had intrauterine devices, 4% had a partner with a vasectomy and 1% used progestin pills. Six women had thrombotic complications (only one using oral contraceptives). Thirty-five women had pregnancy data available. Prior to the Fontan operation there were 10 pregnancies (8 miscarriages, 2 therapeutic abortions, and no live births). After the Fontan operation there were 70 pregnancies resulting in 35 miscarriages (50%), 29 live births (41%), and 6 therapeutic abortions (9%). There were no maternal deaths during pregnancy. During long-term follow up (26 ± 6 years since the Fontan), 1 death, and 1 cardiac transplant occurred. Mean gestational age of the newborns (n = 22/29) was 33.1 ± 4.0 weeks; mean birth weight (n = 20/29) was 2086 ± 770 g. There was 1 neonatal death because of prematurity and two children were born with congenital heart disease (one patent ductus arteriosus and one membranous ventricular septal defect). Pregnancy after the Fontan operation is associated with a high rate of miscarriages, preterm delivery, and low birth weight. Further studies are needed to identify specific variables influencing risk stratification of pregnancy in this patient population.

Effect of asymptomatic vaginal colonization with Candida albicans on pregnancy outcome.

Vaginal infection is a major causative factor of preterm delivery. The present study was performed to evaluate the effect of asymptomatic vaginal colonization with Candida albicans at early gestation on pregnancy outcome. From 2005 to 2014, a total of 8447 women with singleton pregnancies between 10(+0) and 16(+0) gestational weeks were routinely subjected to an antenatal infection screen-and-treat program. Vaginal smears were Gram-stained and microscopically evaluated, and data were retrospectively analyzed. Women exposed to Candida received clotrimazole and were re-tested after 4-6 weeks. Treatment was repeated in case of recurrence. Women with normal or intermediate vaginal flora were considered as non-exposed. Bacterial vaginosis and trichomoniasis were assessed and treated as well. Descriptive data analysis, chi-squared testing and multiple regression analysis with adjustment for potential confounders were performed. Rates of asymptomatic vaginal infections, preterm delivery and low birthweight served as the main outcomes measures. A normal or intermediate flora was found in 6708 (79.4%) of the screened women; 1142 women (13.5%) showed asymptomatic C. albicans infection. Of this group, 185 women (2.2%) had a recurrence of Candida on vaginal smears. Compared with the non-exposed women with normal or intermediate flora, those with recurrent candidiasis had higher rates of preterm delivery (11.9% vs. 9.5%) and of low birthweight (10.8% vs. 8.0%), as confirmed in the multiple model (p = 0.02). Recurrent asymptomatic vaginal colonization with Candida in early pregnancy is associated with preterm delivery and low birthweight. Routine screening and consequent treatment for candidiasis could improve pregnancy outcomes.

Perceived Physical and Social Residential Environment and Preterm Delivery in African-American Women.

Perceptions of the residential environment may be associated with preterm delivery (PTD), though few studies exist. Data from the Life-course Influences on Fetal Environments (LIFE) Study (metropolitan Detroit, Michigan, 2009-2011) were used to examine whether perceptions of the current social and physical environment were associated with PTD rates among postpartum African-American women (n = 1,411). Perceptions of the following neighborhood characteristics were measured with validated multi-item scales: healthy food availability, walkability, safety, social cohesion, and social disorder. No significant associations between perceived residential environment and PTD were found in the total sample. However, education significantly modified 4 of the 5 associations (all interaction P's < 0.05). In women with ≤12 years of education, significant inverse associations were observed between PTD rates and perceptions of the following neighborhood characteristics: healthy food availability (unadjusted prevalence ratio (uPR) = 0.81, 95% confidence interval (CI): 0.68, 0.98), walkability (uPR = 0.77, 95% CI: 0.64, 0.95), and safety (uPR = 0.73, 95% CI: 0.56, 0.95). Women with ≤12 years of education also had higher PTD rates with higher social disorder (age-adjusted PR = 1.54, 95% CI: 1.10, 2.17). Null associations existed for women with >12 years of education. The PTD rates of women with lower education may be significantly affected by the physical and social residential environment.