Maternal-fetal Medicine Specialists Research Articles

Implementation of an interprofessional model for the management of postpartum hypertension.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Postpartum hypertension (PPHTN) poses increased risks, including of stroke. Timely assessment and management by clinicians is imperative but challenging. Team-based care involving pharmacists has shown promise in improving blood pressure control, yet its application in PPHTN management remains unexplored. The objective of this study was to determine the impact and feasibility of an interprofessional model for PPHTN management. This initiative implemented a novel interprofessional model at a safety-net hospital to address previous workflow limitations. Ambulatory care pharmacists collaborated with an obstetric nurse (OBRN) and a maternal fetal medicine specialist to manage high-risk patients with PPHTN utilizing electronic consults (e-consults). Data collection and symptom assessment were completed by an OBRN via telemedicine appointments. Pharmacists employed a collaborative practice agreement based on a preestablished algorithm to initiate medications. Data on patient demographics, consult volume, prescriptions, and pharmacist comfort were collected during the first quarter of full integration. Pharmacists completed 55 e-consults and generated 54 prescriptions. The average time spent per chart review was 12.5 minutes, and the average time to completion of e-consults was 54 minutes. Forty-five unique patients received care, who were primarily non-English-speaking and non-Hispanic Black patients. Pharmacists reported moderate to high comfort levels in managing PPHTN based on the algorithm and provided feedback leading to workflow adjustments. Integration of pharmacists into PPHTN care enables prompt medication initiation and titration. This innovative model, involving remote blood pressure monitoring, telemedicine visits with an OBRN, and e-consults completed by pharmacists, ensures delivery of timely and equitable care and improved access across a diverse population.

Postural orthostatic tachycardia syndrome during pregnancy, labor, and post-delivery: A case series

Postural orthostatic tachycardia syndrome (POTS) is an autonomic condition characterized by the presence of a >30 bpm increase in heart rate, accompanied by orthostatic symptoms, including heart palpitations, light-headedness, weakness, blurred vision, nausea, and headache. Females are commonly affected by POTS at childbearing age. This case series aims to compare the clinical presentations, autonomic dysfunction management, and pregnancy outcomes of four women with POTS. In our autonomic neurology clinic, the goal for our patients is consistent blood pressure during pregnancy. The patients were all interviewed retrospectively to determine pregnancy outcomes. Our study indicates the need for neurologists to collaborate with a team of maternal-fetal medicine specialists with advanced training in high-risk pregnancies to optimize autonomic function throughout the course of pregnancy. In addition, our results suggest that reducing medications to minimize harm can be achieved through regular monitoring at 1 – 3 month intervals during pregnancy, with a 6-week postpartum evaluation.

Review of nutrition and hydration in relation to physical exercise during pregnancy

Studies on nutritional recommendations for pregnant women who exercise are scarce. The objective of this article is not to focus on the diet of pregnant women as a whole, but to review those aspects of it that may be related to physical exercise. To this end, the nutritional and hydration recommendations contained in the main clinical practice guides on physical exercise during pregnancy are collected, including the first Spanish guides. Likewise, the energy requirements required by pregnant women who perform physical exercise during pregnancy for adequate gestational weight gain are addressed, aspects related to macronutrients in the aforementioned population group, and two specific topics, such as nutritional needs in the adolescent who practices physical exercise during pregnancy and eating disorders in pregnant athletes It is concluded by stating that pregnant women who exercise regularly should eat a varied and balanced diet, such as the Mediterranean diet, avoid long periods of fasting to avoid the appearance of hypoglycemia and maintain adequate fluid intake before, during and after physical exercise. Pregnant adolescents who engage in physical exercise require nutritional supervision to achieve adequate gestational weight gain. The pregnant athlete with an eating disorder has a higher risk of complications during pregnancy and childbirth, gynecological, fetal and neonatal, and, therefore, requires close monitoring by specialists in maternal-fetal medicine.

Pregnancy Loss: A Comparative Analysis of Information Delivery Between ACOG FAQs and ChatGPT [ID 2683594

INTRODUCTION: Pregnancy loss is a sensitive topic, and clear, reliable information is crucial. This study compares the readability and accuracy of ChatGPT's responses to ACOG's frequently asked questions (FAQ) sheets on the subject. METHODS: Within the five FAQ sheets under “Pregnancy Loss,” 66 questions were assessed using ChatGPT-3.5. Readability scores, ie, Flesch–Kincaid Reading Ease, Flesch–Kincaid Grade Level, Gunning Fog Score, Smog Index, Coleman Liau Index, and Automated Readability Index were computed for each response. The quality of responses were also graded by two maternal–fetal medicine specialists using a 1–4 scale, where 1 represents a comprehensive response and 4 indicates an incorrect response. Statistical analysis utilized a two-tailed t-test. A weighted Cohen’s kappa coefficient evaluated interrater reliability. RESULTS: ACOG attained better readability scores over ChatGPT across all six metrics with statistical significance (P<.001). Among grading, ACOG also outperformed ChatGPT in quality of information with a summative mean of 1.53 (SD 0.60) versus 1.85 (SD 0.90) with statistical significance (P<.001). Grading for ACOG possessed a Cohen's kappa coefficient of 0.493, implying moderate agreement between graders. Grading for ChatGPT possessed a Cohen's kappa coefficient of 0.744, implying substantial agreement between graders. CONCLUSION: The responses by ACOG to frequently asked questions on pregnancy loss were both clearer and more comprehensive than those of ChatGPT with consistent agreement between graders. Although ChatGPT can be a convenient source of medical queries, further improvements ought to be made to these large-language models to provide clear and accurate information regarding pregnancy loss to patients.

Is it time to end the use of base deficit for fetal well-being assessment?

Authors have expressed reservations regarding the use of base deficit measured in umbilical artery blood samples to assess fetal well-being during the course of labor and to predict neonatal neurologic morbidity. Despite its integration into clinical practice for more than 50 years, obstetricians and maternal-fetal medicine specialists may not realize that this marker has significant limitations in accurately identifying neonatal metabolic acidosis as a proxy for fetal well-being. In brief, there are 2 large families of base deficit, namely whole blood and extracellular fluid. Both rely on equations that use normal adult acid-base characteristics (pH 7.40 and partial CO2 pressure of 40 mm Hg) that overlook the specificity of the normal in utero acid-base status of pH 7.27 and partial CO2 pressure of 54 mm Hg. In addition, it ignores the unique characteristic of the in utero fetal response to acute hypoxia. The dependence on placental circulation for CO2 elimination may lead to extremely high values (up to 130 to 150 mm Hg) during hypoxic events, a phenomenon that is absent in adults with acute metabolic acidosis who can hyperventilate. The dispute over if to include a correction for high partial CO2 pressure in the bicarbonate estimation, as presented in the Great Trans-Atlantic Debates, remains unresolved. The key constants computed for adult acid-base physiology in the current base deficit algorithms, without accounting for the impact of high partial CO2 pressure or other fetal characteristics of buffering capacity (eg, differences in body water content composition, plasma protein, and hemoglobin attributes), may lead to an overestimation of metabolic acidosis, especially in newborns who are experiencing hypercarbia during the early stages of the hypoxic response. These unrecognized limitations impact the base deficit results and may mislead clinicians on fetal well-being assessments when discussing the management of fetal heart rate monitoring and neonatal outcomes. Based on our arguments, we believe that it is prudent to consider an alternative to base deficit for drawing conclusions regarding fetal well-being during the course of birth management. We propose a marker specifically related to the newborn acid-base physiology--the neonatal eucapnic pH correction. This marker can be added to arterial cord blood gas analysis, and we have described how to interpret it as a marker of neonatal metabolic acidosis.

Cell-Free DNA Screening for Single-Gene Disorders.

In pregnancy, cell-free DNA (cfDNA) represents short fragments of placental DNA released into the maternal blood stream through natural cell death. Noninvasive prenatal screening with cfDNA is commonly used in pregnancy to screen for common aneuploidies. This technology continues to evolve, and laboratories now offer cfDNA screening for single-gene disorders. This article aims to review cfDNA screening for single-gene disorders including the technology, current syndromes for which screening may be offered, limitations, and current recommendations. Original research articles, review articles, laboratory white papers, and society guidelines were reviewed. Cell-free DNA screening for single-gene disorders is not currently recommended by medical societies. There may be a role in specific circumstances and only after comprehensive pretest counseling. It can be considered in the setting of some fetal ultrasound anomalies, and usually only after diagnostic testing is offered and declined. Given the limitations of using cfDNA screening for single-gene disorders, caution is recommended when considering these tests. It should only be offered with involvement of a reproductive genetic counselor, medical geneticist, or maternal fetal medicine specialist to ensure comprehensive counseling and appropriate utilization.

Prevention of Preeclampsia in Saudi Arabia: Knowledge about Risk Factors and Aspirin Use among Obstetrical Care Physicians - A National Survey

Objectives: To assess the level of awareness among obstetrical care providers about preeclampsia prevention including risk factors, good practice in aspirin prophylaxis, and to analyze the associated factors. Methods: A cross-sectional study conducted among gynecologists and obstetricians, maternal and fetal medicine specialists, and internal or family medicine physicians working in public or private care centers whom involved in obstetric care in Saudi Arabia. An online-administered questionnaire was designed to assess familiarity of aspirin role in prevention of preeclampsia and fetal growth restriction including proper dose, timing of intake, gestational age to start and discontinuation of treatment as well as the risk factors of PE among set of 13 conditions. An awareness score was calculated and divided into two levels: adequate and inadequate familiarity and knowledge. Practice in PE prevention and attitude towards aspirin use, in addition to participants’ demographic and professional factors, were investigated and analyzed as profound factors. Results: Hundred sixty physicians were participated, 85% were obstetrician/gynecologists and 13.1 were maternal fetal medicine Specialists. Less than half of participants have adequate knowledge and awareness in aspirin role and a minority provided correct answers regarding the recommended aspiring dose, timing of intake, gestational age to start and discontinuation of treatment. However, knowledge about preeclampsia risk factors was relatively acceptable. Maternal fetal medicine specialist and physicians working in teaching hospitals were remarkably with better knowledge compared to their respective counterparts in primary and secondary centers. The existence of institutional guidelines about ASA use in pregnancy did not improve the knowledge level. Conclusion: The overall familiarity and knowledge in that regard was relatively poor, associating misconceptions about the risk factors and substantial gaps regarding the optimal timing and prescribing practice. Formal and continuous medical education curricula should be reviewed to promote good clinical practice in preeclampsia prevention as an essential dimension of maternal and fetal care.

Fetal urinary tract dilation: What to tell the parents.

Urinary tract dilation (UTD), which refers to the abnormal dilation of the urinary collection system, is the most common finding on prenatal ultrasound and presents with varying severity, presentation, etiology, and prognosis. Prenatal classification and risk stratification aim to prevent postnatal complications, such as urinary tract infections and further kidney dysfunction. Parents expecting a child with UTD should be counseled by a multidisciplinary team consisting of maternal-fetal medicine specialists, and pediatric urology and nephrology providers. This review summarizes the key points in the diagnostic evaluation and management during the prenatal and initial postnatal period, focusing on the information that should be provided to future parents. We address frequently asked parental questions and concerns that our multidisciplinary clinical practice faces.

Absence of Ductus Venosus: A Comparison of 2 Distinctive Fetal Autopsy Cases and Embryologic Perspectives.

In fetal circulation, oxygenated blood from the placenta flows through the umbilical vein into the ductus venosus (DV), then enters the inferior vena cava, and subsequently reaches the right atrium of the heart. The DV serves as a shunt, allowing this oxygen-rich blood to bypass the liver. The absence of the DV (ADV), also known as agenesis of the DV, is a rare congenital anomaly. Without a DV, blood from the umbilical vein must follow alternative routes to the heart. In ADV cases, blood from the umbilical vein must follow 1 of 2 primary drainage patterns: either an extrahepatic shunt or an intrahepatic shunt. This report details the antenatal ultrasound and postmortem findings of 2 fetuses diagnosed with ADV by prenatal imaging studies. The first case involved a fetus with a persistent right umbilical vein connected directly to the suprahepatic IVC, accompanied by early obliteration of the left umbilical vein and true agenesis of the DV. This fetus also had additional congenital anomalies. In contrast, the second case involved a fetus with a normal left umbilical vein that entered the liver. However, despite an ultrasound diagnosis of "absence" of the DV, a DV was present, though markedly hypoplastic and probably minimally functional or non-functional. In this case, blood from the umbilical vein likely followed an alternate intrahepatic route through the portal and hepatic veins, before reaching the heart (intrahepatic shunt). These contrasting cases emphasize the heterogeneity of vascular anomalies and embryologic origins captured by the term "ADV." Additionally, the terminology of "absence" or "agenesis" may be misleading in some purported ADV cases. Specifically, in the second case, the DV was not absent; it was markedly hypoplastic instead. This also appears to be the first reported case of a hypoplastic DV in a fetus. Both cases underscore the importance of effective collaboration and clear communication between maternal-fetal medicine specialists and pathologists.

Utility of Fetal Cardiac Resonance Imaging in Prenatal Clinical Practice: Current State of the Art

The field of prenatal cardiac imaging has revolutionized the way we understand and manage congenital heart diseases (CHD) in the developing fetus. In the prenatal period, cardiac imaging plays a pivotal role in the diagnostic pathway, from screening to classification and follow-up of CHD. The ability to visualize the fetal heart in utero allows healthcare professionals to detect abnormalities early, thus enabling timely interventions and informed decision-making processes for both the mother and the medical team. Early CHD detection improves preparation for delivery, postnatal care, and postnatal outcomes. Advancements in medical technology and imaging techniques have provided clinicians with insights into the fascinating workings of the fetal heart. Several imaging modalities have proven to be helpful in this field, with echocardiography undoubtedly representing the primary modality for evaluating the fetus. By providing detailed anatomical and functional information, fetal cardiac magnetic resonance (CMR) imaging contributes to better prenatal counseling and enhances the coordination of care between obstetricians, maternal–fetal medicine specialists, and pediatric cardiologists. Shortcomings of fetal CMR are due to technical concerns related to the intrauterine position of the fetus and subsequent challenges to following a standard scan protocol. The aim of this paper was to revise the current state-of-the-art in the field of fetal CMR and its clinical applications and to delve into methods, challenges, and future directions of fetal CMR in prenatal imaging.

Prevalence of anomalies on the routine mid-trimester ultrasound: 3172 consecutive cases by a single maternal-fetal medicine specialist.

The routine mid-trimester fetal anatomy ultrasound (FAS) is offered to every pregnant woman and remains critical in the detection of structural fetal anomalies. Our study aimed to determine the prevalence of abnormalities on routine FAS performed by a single operator, who is an experienced sub-specialist in maternal-fetal medicine. A retrospective analysis of all routine FAS performed a tertiary private obstetric ultrasound practice in metropolitan Sydney over a 7-year period, August 2015-July 2022. An advanced ultrasound protocol including detailed cardiac views was used in every case. Second opinion scans for suspected abnormalities were excluded. Fetal anomalies were classified into major and minor, based on the likely need for neonatal intervention. Among 14,908 obstetric ultrasound examinations, routine FAS were performed on 3172 fetuses by a single operator. More than 99% of women had screened low-risk for fetal aneuploidy. Structural anomalies were identified in 5% (157/3172) of fetuses; the prevalence of major anomalies was 1% (30/3172). Almost 60% of total anomalies were either cardiac or renal. No differences were identified in anomaly rates for singletons compared with twins (5.0% vs. 4.2%; P = 0.75). The prevalence of placenta previa and vasa previa was 10% and 0.1%, respectively. The prevalence of fetal anomalies on routine FAS by a single operator using a standardised protocol was higher in our practice (5%) than in previously published studies. Although most anomalies were minor, the rate of major abnormality was 1%. The routine mid-trimester FAS remains an integral component of prenatal ultrasound screening.

General Principles for Counseling and Management of Triplet Pregnancies.

Compared with singleton pregnancies, triplet pregnancies are associated with a significantly increased risk of adverse pregnancy outcomes. Early ultrasound examination is the best way to diagnose triplets, establish dating, and determine the number of placentas to provide appropriate counseling and monitoring. Dichorionic placentation adds risks specifically associated with a shared placenta, and limits options for intervention. Multifetal reduction is an option that can significantly improve pregnancy outcomes compared with non-reduced triplet pregnancies. Integration of a Maternal-Fetal Medicine specialist in the prenatal care for a triplet pregnancy reduces the risk of preeclampsia, preterm birth, low birthweight infants, perinatal mortality, and major neonatal morbidity.

Abstract 15722: Developing a Patient-Centered Roadmap to Reduce Maternal Morbidity/Mortality for Individuals With Congenital Heart Disease

Background: Individuals with congenital heart disease (CHD) face higher rates of pregnancy-related complications and interventions, however, few studies have assessed ways to improve outcomes. Goal: Improve reproductive care and reduce maternal morbidity and mortality for pregnant individuals with CHD. Methods: We formed a diverse consortium of CHD patients, providers, and advocates to identify knowledge deficits. Survey responses were solicited through social media and professional and advocacy networks. Results: As of 6/2/23, respondents included 815 (11% male, 88% female) patients from 48 states DC, and 216 providers (19% male, 81% female). Providers included 90 (42%) midwives, 59 (28%) adult congenital cardiologists, and 41 (19%) maternal-fetal medicine specialists. Most patient respondents are CHD patients (n=781, 96%) with complex CHD anatomy (n=606, 81%) between the ages of 30 and 44 (52%) with 72% reporting an annual household income over $75,000. Some patients reported they had received contraception counseling (n=262); counseling was provided by a physician (n=149, 57%), registered nurse (n=37, 14%), or parent (n=36, 14%). Of 189 CHD patients, the top reasons cited for not pursuing a pregnancy included not being ready (n=80, 42%), concerns about their heart condition (n=78, 41%), and physician advice due to potential complications (n=59, 31%). More than half of the patient respondents (n=231, 51%) reported a pregnancy, and 147 (64%) reported their pregnancy caused stress and anxiety. Cost and provider education are top priorities for improving care for pregnant individuals with CHD for respondents with household incomes under $49,000 per year while access to specialized heart care and obstetrics are top priorities for those with incomes over $50,000 (see Figure 1). Conclusions: CHD patients and providers are eager to provide their experiences relating to pregnancy and patient-centered research is an important tool to bridge the knowledge gap.

The impact of increasing body mass index on in vitro fertilization treatment, obstetrical, and neonatal outcomes

BackgroundCiting the risks of administering anesthesia to patients with obesity, few fertility centers offer IVF as a treatment modality for patients with BMIs ≥ 40 kg/m2. Although previous studies have assessed clinical pregnancy and cumulative live birth rates in patients who spontaneously conceive with BMIs ≥ 50 kg/m2, there is a paucity of IVF, obstetric, and neonatal outcome data in patients with severe obesity who conceive after IVF. ObjectiveTo evaluate the impact of increasing BMI on IVF, obstetrical, and neonatal outcomes in patients with obesity undergoing IVF. Study DesignThis was a retrospective cohort study within an academic fertility center including 2,069 fresh IVF/ICSI and frozen embryo transfer cycles from January 1, 2012 to April 30, 2020: this cohort was utilized to determine IVF treatment outcomes. A second embedded cohort of 867 fresh IVF/ICSI and frozen embryo transfer cycles which resulted in ongoing clinical pregnancies and deliveries within a single tertiary hospital system was utilized to determine pregnancy, maternal, and neonatal outcomes. All patients with a BMI ≥ 40 kg/m2 underwent consultation with a maternal fetal medicine specialist prior to starting treatment and a preoperative evaluation with an anesthesiologist prior to oocyte retrieval. Cycles were grouped by body mass index at cycle start: BMI 30-34.9 kg/m2, BMI 35-39.9 kg/m2, BMI 40-44.9 kg/m2, BMI 45-49.9 kg/m2, and BMI > 50 kg/m2. Log-binomial Poisson regression and Poisson regression with an offset models were performed with BMI 30-34.9 kg/m2 as the reference group, adjusting for potential confounders including oocyte age, patient age, embryo quality, transfer type, and coexisting comorbidities. The primary outcome was live birth rate. Secondary outcomes included fertilization rate, blastulation rate, miscarriage rate, incidence of preeclampsia with severe features, gestational diabetes, labor induction, cesarean section, preterm delivery, and birth weight. ResultsThere were 2,069 fresh IVF/ICSI and frozen embryo transfer cycle starts from January 1, 2012 to April 30, 2020. Of these, 1008 cycles were in the BMI 30-34.9 kg/m2 group, 547 in the BMI 35-39.9 kg/m2 group, 277 in the BMI 40-44.9 kg/m2 group, 161 in the BMI 45-49.9 kg/m2 group, and 76 in the BMI > 50 kg/m2 group. Live birth rate was not significantly different between groups. The BMI > 50 kg/m2 group was significantly more likely to experience preeclampsia with severe features when compared to the BMI 30-34.9 kg/m2 group (aRR 2.75, 95% CI 1.13-6.67). Fertilization rate, blastulation rate, miscarriage rate, incidence of gestational diabetes, labor induction, cesarean section, preterm delivery, and neonatal birth weights were not significantly different between groups. Conclusion(s): Among patients with BMIs 30-60 kg/m2 who conceived via IVF and received comprehensive prenatal care at a tertiary care hospital, IVF, obstetrical, and neonatal outcomes were largely comparable. These data support a collaborative care approach with maternal fetal medicine specialists and skilled anesthesiologists, reinforcing the notion that IVF should not be withheld as a treatment modality from patients with obesity.

Care and Monitoring of Pregnant Patients With Left Ventricular Assist Devices.

Cardiovascular disease is one of the leading causes of maternal mortality in the United States. Although still rare, pregnancy in patients with left ventricular assist devices (LVADs) is becoming more common. Typical indications for the use of LVADs in reproductive-aged females include ischemic cardiomyopathy, nonischemic (familial) dilated cardiomyopathy, peripartum cardiomyopathy, and some forms of myocarditis. An LVAD drains blood through a cannula placed into the apex of the left ventricle and then returns it to the proximal aorta bypassing the aortic valve allowing hemodynamic support in parallel with the native circulation. The physiologic changes associated with pregnancy, mainly increased blood volume and hypercoagulability, may adversely affect patients with LVADs, leading to many experts recommending against pregnancy. Maternal-fetal medicine specialists should have a central role within a multidisciplinary team required to provide optimal care for this high-risk group of patients.

Assessment of a Brief Standardized Obstetric Ultrasound Training Program for Individuals Without Prior Ultrasound Experience.

Obstetric volume sweep imaging (OB VSI) is a simple set of transducer movements guided by external body landmarks that can be taught to ultrasound-naive non-experts. This approach can increase access to ultrasound in rural/low-resources settings lacking trained sonographers. This study presents and evaluates a training program for OB VSI. Six trainees without previous formal ultrasound experience received a training program on the OB VSI protocol containing focused didactics and supervised live hands-on ultrasound scanning practice. Trainees then independently performed 194 OB VSI examinations on pregnancies >14 weeks with known prenatal ultrasound abnormalities. Images were reviewed by maternal-fetal medicine specialists for the primary outcome (protocol deviation rates) and secondary outcomes (examination quality and image quality). Protocol deviation was present in 25.8% of cases, but only 7.7% of these errors affected the diagnostic potential of the ultrasound. Error rate differences between trainees ranged from 8.6% to 53.8% (P < 0.0001). Image quality was excellent or acceptable in 88.2%, and 96.4% had image quality capable of yielding a diagnostic interpretation. The frequency of protocol deviations decreased over time in the majority of trainees, demonstrating retention of training program over time. This brief OB VSI training program for ultrasound-naive non-experts yielded operators capable of producing high-quality images capable of diagnostic interpretation after 3 hours of training. This training program could be adapted for use by local community members in low-resource/rural settings to increase access to obstetric ultrasound.

Neonatal outcomes and rationale for timing of birth in perinatal diabetes: a retrospective cohort study

The American College of Obstetricians and Gynecologists recommends delivery in the 39th week of pregnancy for patients with pregestational and medication-controlled gestational diabetes with consideration for earlier delivery among those with poor glucose control. We sought to evaluate the impact of birth before 39 weeks' gestation exclusively for diabetes-related indications on neonatal outcomes and clinician rationale for these recommendations. This was a retrospective cohort study of all singleton, nonanomalous pregnancies complicated by diabetes. Patients were identified through an obstetrical database containing information of 90,185 births from 2011 to 2021. Patients who delivered in a given week of gestation exclusively for diabetes-related indications were compared with ongoing pregnancies. Recommended births for other obstetrical indications were excluded from the diabetes-related indications cohorts. The primary outcome was neonatal intensive care unit admission. Secondary outcomes included neonatal intensive care unit length of stay, stillbirth, neonatal death, hypoglycemia, respiratory distress syndrome, and shoulder dystocia. For all births before 39 weeks' gestation, the electronic medical records were reviewed to confirm the rationale for the intervention for a diabetes-indicated condition. From the 90,185 recorded births that occurred in 2011 to 2021, 4750 patients with diabetes were identified. Of those, 30.5% (n=1449) had a recommended birth for a diabetes-related indications with 2.2% of those (n=32) occurring at 36 weeks' gestation, 7.9% (n=114) at 37 weeks' gestation, 9.7% (n=141) at 38 weeks' gestation, and 63.0% (n=913) at 39 weeks' gestation. Births that occurred at 36 and 37 weeks' gestation exclusively for diabetes-related indications had higher rates of neonatal intensive care unit admission than the respective ongoing pregnancies (62.5% vs 8.7%; P<.001 and 25.4% vs 7.2%; P<.001). There was no difference in neonatal intensive care unit admission for births at 38 or 39 weeks' gestation when compared with ongoing pregnancy. For neonates born at 36 and 37 weeks' gestation in comparison with ongoing pregnancies, the median neonatal intensive care unit length of stay was 11.0 vs 2.8 days, (P<.001) and 4.4 vs 2.6 days (P=.026), respectively. There were significantly increased rates of neonatal hypoglycemia and respiratory distress syndrome among births that occurred at 36, 37, and 38 weeks' gestation when compared with ongoing pregnancies. There were no differences in the rate of stillbirth in this cohort. Primary factors cited for early birth were poor glycemic control (71.4%), recommendation by a maternal-fetal medicine specialist (38.7%), and suspected fetal macrosomia (27.9%). Overall, 46.7%, 32.8%, and 20.6% of patients had 1, 2, or ≥3 indications, respectively, listed as rationale for early birth. Overall, few objective measures were used to recommend birth before 39 weeks' gestation owing to diabetes. In pregnancies complicated by diabetes, early birth exclusively for diabetes-related indications was associated with increased neonatal intensive care unit admission and length of stay and with neonatal morbidity. Little objective data are documented by clinicians to support their recommendations for early birth associated with diabetes. Additional clinical guidelines are needed to define suboptimal glucose control necessitating birth before 39 weeks' gestation.

Maternal cardiac disease and perinatal outcomes in a single tertiary care center

Objective Maternal mortality in the U.S. has increased, with a substantial contribution from maternal cardiac disease. As a result of improved childhood survival, more women with congenital heart disease are reaching reproductive age leading to a growing high-risk obstetric population. We sought to determine the obstetrical and neonatal outcomes of women with maternal cardiac disease, including acquired cardiovascular disease and congenital heart disease. Methods We studied a retrospective cohort study of women that delivered from 2008 to 2013 (N = 9026). Singleton pregnancies without preexisting conditions were established as the unexposed group for this study. Maternal and neonatal outcomes were compared between the unexposed group (N = 7277) and women exposed to maternal (acquired or congenital) cardiac disease (N = 139) as well as only congenital heart disease (N = 85). Statistical comparisons used univariate/multivariable logistic and linear regression analysis controlling for confounders with p < .05 and 95% confidence intervals indicating statistical significance. Results Pregnancies complicated by maternal cardiac disease were associated with increased odds of preterm birth (<34 weeks, <37 weeks), intrauterine growth restriction (IUGR), need for assisted vaginal delivery, maternal ICU admission, and prolonged maternal hospitalization (>7 d). Neonatal outcomes including small for gestational age and Apgar score <7 at 5 min were increased in the pregnancies complicated by maternal cardiac disease. When pregnancies complicated by congenital heart disease were analyzed as a sub-group of the cohort, the results were similar. There were increased odds of preterm birth (<37 weeks), early-term delivery, need for assisted vaginal delivery, and prolonged hospitalization. Neonatal outcomes were only significant for small for gestational age. Conclusion We observed that in a select cohort of pregnancies complicated by maternal cardiac diseases (acquired or congenital), there were significant increases of adverse perinatal outcomes. Therefore, a multidisciplinary approach including maternal-fetal medicine specialists, cardiologists, obstetric anesthesia, and dedicated ancillary support is imperative for optimal care of this high-risk obstetrics population.

“We All Want to Be Able to Tell You Something Hopeful”: Clinicians’ Experiences Providing Maternal-Fetal Surgery Counseling

Introduction: Prenatal counseling about maternal-fetal surgery can be traumatic and confusing for pregnant people. It can also be technically and emotionally complex for clinicians. As maternal-fetal surgery rapidly advances and becomes more common, more evidence is needed to inform counseling practices. The objective of this study was to develop a deeper understanding of the methods clinicians currently use to train for and provide counseling, as well as their needs and recommendations for future education and training. Methods: We used interpretive description methods and interviewed interprofessional clinicians who regularly counsel pregnant people about maternal-fetal surgery. Results: We conducted 20 interviews with participants from 17 different sites who were maternal-fetal medicine specialists (30%), pediatric surgeons (30%), nurses (15%), social workers (10%), a genetic counselor (5%), a neonatologist (5%), and a pediatric subspecialist (5%). Most were female (70%), non-Hispanic white (90%), and practiced in the Midwest (50%). We identified four overarching themes: (1) contextualizing maternal-fetal surgery counseling; (2) establishing shared understanding; (3) supporting decision-making; and (4) training for maternal-fetal surgery counseling. Within these themes, we identified key practice differences among professions, specialties, institutions, and regions. Conclusion: Participants are committed to practicing informative and supportive counseling to empower pregnant people to make autonomous decisions about maternal-fetal surgery. Nevertheless, our findings indicate a dearth of evidence-based communication practices and guidance. Participants identified significant systemic limitations affecting pregnant people’s decision-making options related to maternal-fetal surgery.

Contraceptive counseling and choices in pregnancies with maternal cardiac disease

Objective Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy. Methods All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score. Results Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was ‘excellent’ or ‘good’ in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options. Conclusion Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.