Risk Of Severe Maternal Morbidity Research Articles

Delivery-Related Maternal Morbidity and Mortality Among Patients With Cardiac Disease.

To assess the risk of severe maternal morbidity (SMM) and mortality among pregnant patients with cardiovascular disease (CVD). This was a retrospective cohort study of U.S. delivery hospitalizations from 2010 to 2020 using weighted population estimates from the National Inpatient Sample database. The primary objective was to evaluate the risk of SMM and maternal mortality among patients with CVD at delivery hospitalization. International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations, CVD, and SMM events. Multivariable logistic regression analyses were performed to compare SMM and mortality risk among patients with CVD and those without CVD. Given the substantial racial and ethnic disparities in SMM, mortality, and CVD burden, secondary objectives included evaluating SMM and mortality across racial and ethnic groups and assessing the population attributable fraction within each group. Lastly, subgroup analyses of SMM by underlying CVD diagnoses (eg, congenital heart disease, chronic heart failure) were performed. Variables used in the regression models included socioeconomic and demographic maternal characteristics, maternal comorbidities, and pregnancy-specific complications. Among 38,374,326 individuals with delivery hospitalizations, 203,448 (0.5%) had CVD. Patients with CVD had an increased risk of SMM (11.6 vs 0.7%, adjusted odds ratio [aOR] 12.5, 95% CI, 12.0-13.1) and maternal death (538 vs 5 per 100,000 delivery hospitalizations, aOR 44.1, 95% CI, 35.4-55.0) compared with those without CVD. Patients with chronic heart failure had the highest SMM risk (aOR 354.4, 95% CI, 301.0-417.3) among CVD categories. Black patients with CVD had a higher risk of SMM (aOR 15.9, 95% CI, 14.7-17.1) than those without CVD with an adjusted population attributable fraction of 10.5% (95% CI, 10.0-11.0%). CVD in pregnancy is associated with increased risk of SMM and mortality, with the highest risk of SMM among patients with chronic heart failure. Although CVD affects less than 1% of the pregnant population, it contributes to nearly 1 in 10 SMM events in the United States.

Association between socioeconomic disadvantage and severe maternal morbidity and mortality in high-income countries: a systematic review

BackgroundSocioeconomic position (SEP) is among the most important determinants of variations in health outcomes. This systematic review aimed to summarise the association between socioeconomic disadvantage and the risk of severe...

Antenatal pyelonephritis hospitalisation trends, risk factors and associated adverse outcomes: A retrospective cohort study.

To analyse trends, risk factors and adverse outcomes associated with antenatal pyelonephritis hospitalisations. Retrospective cohort. A national sample of US delivery hospitalisations with associated antenatal hospitalisations. US delivery hospitalisations in the Nationwide Readmissions Database from 2010 to 2020. Antenatal hospitalisations with a pyelonephritis diagnosis within the 9 months before delivery hospitalisation were analysed. Clinical, demographic and hospital risk factors associated with antenatal pyelonephritis hospitalisations were analysed with unadjusted and adjusted logistic regression models with unadjusted and adjusted odds ratios as measures of effect. Temporal trends in antenatal pyelonephritis hospitalisations were analysed with Joinpoint regression to determine the relative measure of average annual percent change (AAPC). Risk for severe maternal morbidity and sepsis during antenatal pyelonephritis hospitalisations was similarly analysed with Joinpoint regression. Of an estimated 10.2 million delivery hospitalisations, 49 140 (0.48%) had an associated antenatal pyelonephritis hospitalisation. The proportion of deliveries with a preceding antenatal pyelonephritis hospitalisation decreased by 29% from 0.56% in 2010 to 0.40% in 2020 (AAPC -2.9%, 95% CI -4.0% to -1.9%). Antenatal pyelonephritis decreased, but risk for sepsis diagnoses increased during these hospitalisations from 3.7% in 2010 to 18.0% in 2020 (AAPC 17.2%, 95% CI 14.2%-21.1%). Similarly, risk for severe morbidity increased from 2.6% in 2010 to 4.4% in 2020 (AAPC 5.5%, 95% CI 0.8%-10.7%). Antenatal pyelonephritis admissions appear to be decreasing in the USA. However, these hospitalisations are associated with a rising risk for sepsis and severe maternal morbidity.

Association between iron deficiency anemia and severe maternal morbidity: A retrospective cohort study

PurposeWe examined the association between iron deficiency anemia (IDA) and severe maternal morbidity (SMM) during delivery and up to 1-year postpartum. MethodsIn a retrospective cohort study across 3 states, we computed adjusted relative risks (aRR) for SMM comparing individuals with IDA versus those without, using modified Poisson regression models. ResultsAmong 2459,106 individuals, 10.3 % (n = 252,240) had IDA. Individuals with IDA experienced higher rates of blood transfusion and non-transfusion SMM (329 and 122 per 10,000 deliveries, respectively) than those without IDA (33 and 46 per 10,000 deliveries, respectively). The risk of blood transfusion (aRR: 8.2; 95 % CI 7.9–8.5) and non-transfusion SMM (aRR: 1.9; 95 % CI: 1.8–2.0) were higher among individuals with IDA. The attributable risk per 10,000 deliveries due to IDA for blood transfusion and non-transfusion SMM during delivery were 29.5 (95 % CI: 28.9–30.0) and 5.7 (95 % CI: 5.3–6.2), respectively. Within 1-year postpartum, the relative risk of non-transfusion SMM (aRR:1.3; 95 % CI: 1.2–1.3) was 30 % higher among individuals with IDA. ConclusionIDA is associated with increased SMM risk. Addressing IDA in pregnant individuals may reduce SMM rates.

Trends in severe maternal morbidity following an institutional team goal strategy for disparity reduction

BackgroundRacial disparities in maternal pregnancy outcomes, specifically in morbidity and mortality, are persistent in the U.S., and a multifaceted approach to mitigating these disparate outcomes is critical. In 2020, our health system committed to reducing severe maternal morbidity (SMM) in Black patients, employing multiple strategic interventions including implicit bias training, regular reporting of a composite SMM metric stratified by race and ethnicity, standardization of best practices, focused efforts for hemorrhage risk reduction, and system-wide team building. ObjectiveThe goal of this study is to investigate trends in SMM by race across this period of concentrated interventions to improve maternal outcomes overall, and specifically for Black patients. Study DesignThis is a retrospective cohort study evaluating all delivery admissions at an academic, urban, tertiary-care hospital in Philadelphia—one site of a health system encompassing five delivery hospitals—over a 3-year period from 2019 to 2021. Data including patient demographics, clinical features, and outcomes were extracted from the electronic medical record (EMR). Self-reported race was categorized as Black vs non-Black as documented in the EMR. SMM was defined according to established CDC indicators as well as additional codes identified by Vizient for common sources of SMM including hemorrhage, infection, and embolism. Data were analyzed by year with a multivariable logistic regression model including insurance type and obstetric comorbidity index (OB-CMI), a weighted scoring system accounting for numerous chronic medical conditions and antepartum pregnancy complications. ResultsIn total, 12,339 deliveries were included, 64.6% (N=8012) of which were to Black patients. Median OB-CMI score was higher for Black patients at 3 (interquartile range [IQR] 1–5) compared to 2 (IQR 1–4) for non-Black patients, P<.01. There was a significant decrease in SMM for the entire cohort over the study period (8.5% in 2019 to 6.5% in 2021, P=.001), driven by a decreased rate specifically among Black patients (8.9% in 2019 to 6.6% in 2021, P=.005) with a nonsignificant decrease for non-Black patients (7.8% in 2019 to 6.3% in 2021, P=.21). The adjusted model similarly demonstrated decreased risk of SMM over time for Black patients (2020 vs 2019 adjusted odds ratio [aOR] = 0.81, 95% confidence interval [CI] 0.69–0.96; 2021 vs 2019 aOR 0.73, 95% CI 0.62–0.86). ConclusionDedicated efforts to improve equity in maternal outcomes over a 2-year period (2020–2021) in this hospital serving a Black patient majority were associated with a significant decline in SMM, especially among Black patients. This finding demonstrates the success of a high-level, coordinated, and systematic approach in reducing SMM and associated disparities, and is highly consequential in light of the ongoing major epidemic of racial disparities in obstetric outcomes.

The eGFRcystatin C/eGFRcreatinine-ratio is associated with maternal morbidity in hypertensive disorders in pregnancy and may indicate optimal timing of delivery

A low eGFRcystatin C/eGFRcreatinine-ratio is characteristic of a group of serious kidney disorders called ‘Selective Glomerular Hypofiltration Syndromes’. This study examines if such a low ratio can also be used to evaluate the risk for women with hypertensive disorders in pregnancy to develop severe maternal morbidity. All women discharged from the perinatal ward at the Skåne University Hospital in Lund during the period of 1-9-2016 to 31-8-2017 under one of the diagnoses within hypertensive disorders in pregnancy were considered for inclusion in the study. After delivery and discharge from the hospital, records from included patients were reviewed and all registered measures of renal function were analysed. An eGFRcystatin C/eGFRcreatinine-ratio ≤0.60 in a sample drawn not earlier than three days before delivery was considered as defining a high risk for severe maternal morbidity. A strong association (p-value: 0.035) between severe maternal morbidity and an eGFRcystatin C/eGFRcreatinine-ratio ≤0.60 was found in a subgroup of 32 women diagnosed with ‘preeclampsia with severe features’. A total of 69 women were included in the study. Fifty were defined as high-risk and seventeen of them (34%) developed severe maternal morbidity. Among the nineteen women defined as low-risk only two (10.5%) developed severe maternal morbidity (p-value: 0.051). A low eGFRcystatin C/eGFRcreatinine-ratio seems promising as a predictive marker for maternal morbidity in hypertension in pregnancy. Its performance as a tool in the monitoring of progressing disease should be evaluated further in larger cohorts. Delivery before the eGFRcystatin C/eGFRcreatinine-ratio decreases to, or below, 0.60 might help avoid maternal complications.

Emergency Care Use During Pregnancy and Severe Maternal Morbidity

Pregnant individuals who repeatedly use emergency care during pregnancy represent a population who could be disproportionately vulnerable to harm, including severe maternal morbidity (SMM). To explore patterns of unscheduled care visits during pregnancy and ascertain its association with SMM at the time of birth. This cohort study used data from a statewide database that linked hospital records to births and fetal deaths occurring between October 1, 2002, and March 31, 2020, in Massachusetts. Pregnant individuals experiencing births or fetal deaths during the study period were included. Data analysis was conducted from June 2022 to September 2024. The exposure was 4 or more cases of emergency use, defined as either an emergency department visit or observational stay during pregnancy not resulting in hospital admission. Pregnancy episode was ascertained by subtracting the gestational age at birth from the date of birth. The outcome of interest was the odds ratio (OR) for SMM at the time of birth. The algorithm includes 20 conditions or procedures (excluding transfusion) identified through International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes across the study period. A total of 774 092 pregnant individuals (mean [SD] age, 31.2 [5.8] years; 16.8% Hispanic, 9.3% non-Hispanic Asian or Pacific Islander, 9.5% non-Hispanic Black, 63.1% non-Hispanic White) with emergency care visits during the pregnancy were included; 31.3% of these individuals had at least 1 visit. Overall, 18.1% had 1 visit and 3.3% had 4 or more visits. Four or more unscheduled visits were common among those younger than age 25 years (8.7%), with Hispanic (5.7%) or non-Hispanic Black (4.9%) race and ethnicity, with public insurance (6.5%), or with a comorbidity (19.0%) or an opioid use-related hospitalization (26.8%) in the year prior to pregnancy. Of those with 4 or more unscheduled visits, 43.8% visited more than 1 hospital during pregnancy. In a multivariable analysis of the likelihood of SMM, those with 4 or more unscheduled visits had an adjusted OR of 1.46 (95% CI, 1.29-1.66) compared with those with 0 visits. This cohort study found that high emergency care use during pregnancy was associated with an increased risk for SMM. With a significant proportion of those with frequent unscheduled visits also using multiple hospitals, solutions that are community-based and integrated across health systems may be most beneficial.

Severe maternal morbidity in high income countries

IntroductionWith declining maternal mortality rates in high income countries (HICs), severe maternal morbidity (SMM) is becoming an important quality measure of maternal care. However, there is no international consensus on the definition and types of SMM. This study aims to critically analyze published literature on SMM in HICs. ObjectivesTo compare definitions and criteria used to identify SMM, and to identify the main types and risk factors contributing to SMM in eight HICs. MethodsThree databases were searched, results were filtered, and ten studies were critically appraised. ResultsSix of the articles discussed SMM identification criteria and proposed definition modifications. Longer hospital stay and admission to intensive care unit were suggested as additional criteria. Disease-based criteria was shown to be superior to organ dysfunction criteria. Seven articles detailed common types of SMM as severe haemorrhage, hypertensive disorders, and pre-eclampsia/eclampsia. Six articles described SMM risk factors, of which advanced maternal age and caesarean delivery were most common. DiscussionThis literature review identified disease-based criteria and Canadian study criteria as promising measures of SMM. It also identified several types and risk factors of SMM common between HICs. These findings can help physicians identify women at risk of SMM. The study is however limited to eight HICs and ten studies. Further research should aim to investigate how the measures compare with previous sources of criteria, and to discern the association of weight and race risk factors with SMM.

Severe Maternal and Neonatal Morbidity Among Gestational Carriers : A Cohort Study.

Use of a gestational ("surrogate") carrier is increasingly common. Risk for maternal and neonatal adversity is largely unknown in this birthing population. To determine the risk for severe maternal morbidity (SMM) and severe neonatal morbidity (SNM) in gestational carriers. Population-based cohort study. All of Ontario, Canada. All singleton births at more than 20 weeks' gestation, from 2012 to 2021. Exposure was type of conception, namely, gestational carriage (main exposure), unassisted conception (comparison group 1), and in vitro fertilization (IVF) (comparison group 2). Main composite outcomes were SMM and SNM. Modified Poisson regression models generated weighted relative risks (wRRs) using propensity score-based overlap weighting. Secondary outcomes included hypertensive disorders of pregnancy, cesarean delivery, preterm birth, and postpartum hemorrhage. Of all eligible singleton births, 846 124 (97.6%) were by unassisted conception, 16 087 (1.8%) by IVF, and 806 (0.1%) by gestational carriage. Respective risks for SMM were 2.3%, 4.3%, and 7.8%. The wRRs were 3.30 (95% CI, 2.59 to 4.20) comparing gestational carriage with unassisted conception and 1.86 (CI, 1.36 to 2.55) comparing gestational carriage with IVF. Respective risks for SNM were 5.9%, 8.9%, and 6.6%, generating wRRs of 1.20 (CI, 0.92 to 1.55) for gestational carriage versus unassisted conception and 0.81 (CI, 0.61 to 1.08) for gestational carriage versus IVF. Hypertensive disorders, postpartum hemorrhage, and preterm birth at less than 37 weeks were also significantly higher contrasting gestational carriers to either comparison group. Absence of information about indications for choosing a gestational carrier, and oocyte or sperm donor source. Among singleton births of more than 20 weeks' gestation, a higher risk for SMM and adverse pregnancy outcomes was seen among gestational carriers compared with women who conceived with and without assistance. Although gestational carriage was associated with preterm birth, there was less clear evidence of severe neonatal morbidity. Potential mechanisms for higher maternal morbidity among gestational carriers require elucidation, alongside developing special care plans for gestational carriers. The Canadian Institutes of Health Research.

Introduction of advanced maternal age based on mortality-specific severe morbidity.

SynopsisRe‐defining advanced maternal age based on the risk of severe maternal morbidity at delivery may be of value in obstetric medicine.

Severe Maternal Morbidity: The Impact of Race on Tricare Beneficiaries.

Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate impact on women of color. While numerous factors contribute to the inequities in pregnancy-related mortality, access to health insurance is among the most significant. Military Tricare models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzed maternal delivery outcomes for all women with Tricare coverage, including deliveries in the civilian sector. We analyzed data from6.2 million births in the Centers for Disease Control (CDC) Wide-ranging Online Data for Epidemiology Research (WONDER) Linked Birth/Infant Death Records for 2017-2019. Data included all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and ICU admissions), severe maternal morbidity (SMM) excluding lacerations, and SMM excluding transfusion. Risk ratios were calculated by comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race. In conclusion, there is an increased risk for women identifying as racial minorities for SMM and SMM excluding transfusion. While Tricare coverage seems to decrease the risk, the decrease is not significant and disparities in outcomes persist among women identifying as minorities. The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.

Severe Maternal Morbidity by Disability Status and Type in the United States

OBJECTIVE: To estimate the risk of severe maternal morbidity (SMM) among women with disabilities compared with those without disabilities in a nationally representative sample of U.S. delivery hospitalizations. METHODS: We conducted a retrospective cohort analysis using the 2016–2021 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. We identified delivery hospitalizations and disability status using International Classification of Diseases, Tenth Revision diagnosis codes. The primary outcome was SMM, which was determined using 21 indicators specified by the Centers for Disease Control and Prevention. We used Poisson regression to estimate unadjusted and adjusted relative risks (aRRs) and 95% CIs for the association between disability status and type with SMM outcomes. RESULTS: Among 4,331,457 delivery hospitalizations, 128,413 (3.0%) were to women with disabilities. Women with disabilities had significantly higher rates of SMM compared with those without disabilities (396/10,000 deliveries vs 177/10,000 deliveries). In fully adjusted models, women with disabilities had an aRR of 1.86 (95% CI, 1.80–1.91) for one or more SMM indicators. The risk of SMM varied by disability type, with the highest risks observed for women who had vision disabilities (aRR 3.02, 95% CI, 2.70–3.38) or had physical disabilities (aRR 2.44, 95% CI, 2.34–2.55). Women with disabilities had the highest risk for other medical complications (puerperal cerebrovascular disorders and sickle cell disease with crisis), followed by other obstetric complications, respiratory complications, cardiovascular complications, acute renal failure, sepsis, and bleeding complications compared with women without disabilities. CONCLUSION: Women with disabilities have a significantly higher risk of SMM during delivery compared with those without disabilities, with the magnitude of risk varying by disability type. Efforts to reduce SMM and maternal mortality in the United States must prioritize the unique needs of this population and ensure equitable, disability-competent care for all women.

Association of in vitro fertilization with severe maternal morbidity in low-risk patients without comorbidities

To determine whether an association exists between invitro fertilization (IVF) and severe maternal morbidity among low-risk pregnant patients. Retrospective cohort study. Academic healthcare system. Low-risk pregnant patients who delivered between January 2019 and December 2022. Low-risk was defined as having an obstetric comorbidity index score of 0. Invitro fertilization. The primary outcome (dependent variable) was any severe maternal morbidity. The secondary outcome was the need for a cesarean delivery. A modified Poisson regression with robust error variance was used to model the probability of severe maternal morbidity as a function of IVF. Risk ratios and their associated 95% confidence intervals (CIs) were computed. An α value of 0.05 was considered statistically significant. A total of 39,668 pregnancies were included for analysis, and 454 (1.1%) were conceived by IVF. The overall severe maternal morbidity rate was 2.4% (n = 949), with the most common indicator being blood transfusion. The overall cesarean delivery rate was 18.8% (n = 7,459). On modified Poisson regression, IVF-conceived pregnancies were associated with 2.56 times the risk of severe maternal morbidity (95% CI, 1.73-3.79) and 1.54 times the risk of having a cesarean delivery (95% CI, 1.37-1.74) compared with non-IVF pregnancies. Invitro fertilization is associated with higher rates of severe maternal morbidity, primarily the need for a blood transfusion, and cesarean delivery in low-risk pregnancies without major comorbidities. Recognizing this association allows healthcare providers to implement proactive measures for better monitoring and tailored postpartum care.

Obstetric outcomes among rural parturients across US urban and rural hospitals.

The objective of this study is to evaluate severe maternal morbidity (SMM) of rural parturients delivering at rural compared to urban hospitals in the US. We identified patients aged 18-40 years in a multi-institutional claims database who lived in a rural ZIP code and delivered at a rural or urban hospital between October-December of 2015 and October-December of 2022. The primary outcome was SMM, and the secondary outcome was SMM exclusive of blood transfusions. We combined exact ZIP code matching and propensity score matching to compare SMM risk among patients living in the same rural community and delivering in urban as compared to rural hospitals. A total of 214 296 patients from 571 ZIP codes were identified, including 47% delivering at rural facilities and 53% delivering at urban facilities. The SMM rate was 1.1% (0.3% excluding blood transfusions). After matching, urban versus rural delivery was associated with increased odds of SMM other than blood transfusion (odds ratio 2.44; 95% confidence interval 1.81-3.28), but was not associated with differences in risk of any SMM. There was no evidence of reduced SMM for rural patients delivering at an urban rather than a rural hospital. SMM exclusive of blood transfusions was increased for rural patients delivering at urban hospitals after matching on ZIP code and predictors of urban hospital delivery. Our findings undermine the assumption that delivery at a rural facility has inherently greater risks relative to delivery at an urban facility. As some health systems face challenges to maintain rural labor and delivery units, patient safety must be considered if confronted with the possibility of unit or hospital closures.

Associations between neighbourhood deprivation, ethnicity and maternal health outcomes in England: a nationwide cohort study using routinely collected healthcare data

BackgroundIn the United Kingdom, pregnant women who live in the most deprived areas have two times the risk of dying than those who live in the least deprived areas. There...

Maternal implications of fetal anomalies: a population-based cross-sectional study

BackgroundAlthough it is well-known that the presence of fetal anomalies is associated with maternal morbidity, granular information on these risks by type of anomaly is not available. ObjectiveTo examine adverse maternal outcomes according to the type of fetal anomaly. Study DesignThis was a repeated cross-sectional analysis of US vital statistics Live Birth/Infant Death linked data from 2011 to 2020. All pregnancies at 20 weeks or greater were included. Our primary outcome was severe maternal morbidity (SMM), defined as any maternal intensive care unit admission, transfusion, uterine rupture, or hysterectomy. Outcomes were compared between pregnancies with a specific type of fetal anomaly and pregnancies without any fetal anomaly. Fetal anomalies that were available in the dataset included anencephaly, meningomyelocele/spina bifida, cyanotic congenital heart disease, congenital diaphragmatic hernia, omphalocele, gastroschisis, cleft lip and/or palate, hypospadias, limb anomaly, and chromosomal disorders. If a fetus had more than one anomaly, it was classified as multiple anomalies. Adjusted relative risks (aRR) with 99% confidence intervals (99% CI) were calculated using modified Poisson regression. Adjusted risk differences (aRDs) were calculated using the marginal standardization form of predictive margins. ResultsOf 35,760,626 pregnancies included in the analysis, 35,655,624 pregnancies had no fetal anomaly and 105,002 had isolated or multiple fetal anomalies. Compared to pregnancies without fetal anomaly, all fetal anomalies were associated with an increased risk of SMM except for gastroschisis and limb anomaly in order of aRRs (99% CI): 1.58 (1.29–1.92) with cleft lip and/or palate; 1.75 (1.35–2.27) with multiple anomalies; 1.76 (1.18–2.63) with a chromosomal disorder; 2.19 (1.82–2.63) with hypospadias; 2.20 (1.51–3.21) with spina bifida; 2.39 (1.62–3.53) with congenital diaphragmatic hernia; 2.66 (2.27–3.13) with congenital heart disease; 3.15 (2.08–4.76) with omphalocele; and 3.27 (2.22–4.80) with anencephaly. Compared to pregnancies without fetal anomaly, all fetal anomalies were associated with an increased absolute risk of SMM except for gastroschisis and limb anomaly in order of aRDs (99% CI): 0.26 (0.12–0.40) with cleft lip and/or palate, 0.34 (0.13–0.55) with multiple anomalies, 0.34 (0.02–0.66) with a chromosomal disorder, 0.54 (0.36–0.72) with hypospadias, 0.54 (0.17–0.92) with spina bifida, 0.63 (0.21–1.05) with congenital diaphragmatic hernia, 0.75 (0.56–0.95) with congenital heart disease, 0.97 (0.38–1.56) with omphalocele, and 1.03 (0.46–1.59) with anencephaly. ConclusionThe presence of fetal anomalies is associated with adverse maternal health outcomes. The risk of SMM varies according to the type of fetal anomaly. Counseling mothers about the maternal implications of fetal anomalies is paramount to help them make informed decisions regarding their pregnancy outcome.

Racial/ethnic disparity in severe maternal morbidity among women who conceived by in vitro fertilization

BackgroundIn vitro fertilization (IVF) as a fertility treatment is associated with adverse perinatal outcomes. Racial/ethnic disparity in severe maternal morbidity (SMM) in women who conceived by IVF is understudied. ObjectiveTo examine differences in the association between race/ethnicity and SMM between women who conceived spontaneously and those who conceived using IVF. MethodsWe included all singleton live births and stillbirths in the United States, 2016–2021; data were obtained from the National Center for Health Statistics. Maternal race/ethnicity included non-Hispanic White (NHW), non-Hispanic Black (NHB), American Indian and Alaska Native (AIAN), Asian, Pacific Islander (PI), Hispanic, and mixed-race categories. The SMM composite outcome included eclampsia, uterine rupture, peripartum hysterectomy, blood transfusion, and intensive care unit (ICU) admission. We used logistic regression to adjust for potential confounders (such as age, education, parity, prepregnancy body mass index, smoking during pregnancy, chronic hypertension, and preexisting diabetes) and to assess modification of the association between race/ethnicity and SMM by IVF. ResultsThe study population included 21,585,015 women: 52% were NHW, 15% NHB, 0.8% AIAN, 6% Asian, 0.2% PI, 24% Hispanic, and 2% were of mixed race. IVF was used by 183,662 (0.85%) women; the rate of the SMM composite outcome was 18.5 per 1000 deliveries and 7.9 per 1000 deliveries in the IVF and spontaneous conception groups, respectively (unadjusted rate ratio 2.34, 95% confidence interval [CI] 2.26–2.43). In women with spontaneous conception, NHB, Asian and mixed-race women had elevated odds of SMM compared with NHW women (adjusted odds ratio [aOR]=1.39, 95% CI 1.37–1.41; aOR=1.04, 95% CI 1.02–1.07; and aOR=1.42, 95% CI 1.38–1.46, respectively). Racial/ethnic disparities in SMM and its components were not different between the IVF and spontaneous conception groups for the mixed-race category. NHB and Hispanic women had significantly higher aORs for uterine rupture/intrapartum hysterectomy compared with NHW women in the IVF group, while Asian women had a higher aOR for ICU admission compared with NHW women in the IVF group. ConclusionWomen who conceived by IVF have a greater than two-fold higher risk of SMM and this higher risk is evident across all racial/ethnic groups. However, NHB and Hispanic women who conceived by IVF had a higher risk of uterine rupture/hysterectomy, and Asian women who conceived by IVF had a higher risk of ICU admission. Our results warrant further investigation examining pregnancy and postpartum care issues among racial/ethnic minority women who conceive using IVF.

Neighborhood-level Fatal Police Violence and Severe Maternal Morbidity in California.

Police violence is a pervasive issue that may have adverse implications for severe maternal morbidity (SMM). We assessed how the occurrence of fatal police violence (FPV) in one's neighborhood before/during pregnancy may influence SMM risk. Hospital discharge records from California between 2002-2018 were linked with the Fatal Encounters database (N=2,608,682). We identified 2,184 neighborhoods (census-tracts) with at least one FPV incident during the study period and used neighborhood fixed-effects models adjusting for individual sociodemographic characteristics to estimate odds of SMM associated with experiencing FPV in one's neighborhood anytime within the 24-months before childbirth. We did not find conclusive evidence on the link between FPV occurrence before delivery and SMM. However, estimates show that birthing people residing in neighborhoods where one or more FPV events had occurred within the preceding 24-months of giving birth may have a mildly elevated odds of SMM than those residing in the same neighborhoods with no FPV occurrence during the 24-months preceding childbirth (Odds Ratio (OR)=1.02; 95% Confidence Interval (CI): 0.99-1.05), particularly among those living in neighborhoods with fewer (1-2) FPV incidents throughout the study period (OR=1.03; 95% CI:1.00-1.06). Our findings provide evidence for the need to continue to examine the health consequences of police violence.

Obstetric outcomes of women with congenital uterine anomalies in the United States

BackgroundDue to the rarity, congenital uterine anomaly type-specific evaluation of pregnant women has been relatively understudied. ObjectiveTo describe national-level obstetric outcomes in women with congenital uterine anomalies. Study DesignThis cross-sectional study queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Pregnant women with diagnosis of congenital uterine anomalies who had hospital delivery between 2016 and 2019 were examined. The World Health Organization's International Classification of Disease, 10th revision coding was used to delineate type of congenital uterine anomaly, diagnoses, and procedures performed during the index admission. Primary outcomes included pregnancy outcome, which was classified as full-term live birth, preterm live birth, abortion/stillbirth, or ectopic pregnancy. Secondary outcomes included obstetric comorbidities and severe maternal morbidity, which were compared between different subtypes of congenital uterine anomalies with multivariable logistic regression model. ResultsA total of 50,180 pregnant women with congenital uterine anomalies were identified. Bicornuate was the most common subtype (73.5%), followed by arcuate (13.5%) and unicornuate (10.0%). 70.6% of women with congenital uterine anomalies had a full-term live birth, 26.8% had a preterm live birth, 2.1% had an abortion or stillbirth, and 0.4% had an ectopic pregnancy. 61.8% of preterm births occurred between 33 and 36 weeks, 16.9% between 30 and 32 weeks, and 21.3% at <30 weeks. There were 1,440 (2.9%) periviable births. The preterm (34.5%) and periviable (6.9%) birth rates were highest in the uterine didelphys group. Overall, two-thirds (65.7%) of patients with congenital uterine anomalies were delivered via cesarean section. When compared to arcuate uterus, risk of severe maternal morbidity in septate uterus (4.8% vs 2.6%, adjusted-odds ratio [aOR] 2.60, 95% confidence interval [CI] 1.49-4.52) was increased, including hemorrhage (14.5% vs 7.7%, aOR 2.16, 95% CI 1.51-3.07). This was followed by uterine didelphys (4.2% vs 2.6%, aOR 1.75, 95% CI 1.24-2.47), unicornuate uterus (3.8% vs 2.6%, aOR 1.61, 95% CI 1.29-2.01), and bicornuate uterus (3.0% vs 2.6%, aOR 1.23, 95% CI 1.04-1.47). ConclusionWhile the majority of patients with congenital uterine anomalies result in full-term viable deliveries, each subtype of congenital uterine anomalies confers different obstetric risks. Uterine didelphys was associated with the highest risk of preterm birth, while septate uterus was associated with the highest risk of severe maternal morbidity. While this hospital delivery dataset likely overrepresents bicornuate uteri, this populational data may help inform patients with congenital anomalies considering pregnancy.El resumen está disponible en Español al final del artículo.

Endometriosis, Severe Maternal Morbidity, and the Effect of Infertility: Population-Based Cohort Study

This population-based cohort evaluated the association between endometriosis and severe maternal morbidity (SMM), and the mediating effect of infertility and fertility treatment. Included were all singleton deliveries in Ontario between 2006 and 2014. Modified Poisson regression generated adjusted relative risks. Mediation analysis estimated the direct effect of endometriosis and indirect effect through infertility and mode of conception. 787 449 deliveries were included (19 099, 2.4% with endometriosis). SMM occurred in 29.0 per 1000 deliveries among women with endometriosis, in contrast to 18.2 per 1000 deliveries among those without endometriosis—corresponding to an adjusted relative risk of SMM of 1.43 (95% CI 1.31–1.56). Mediation analysis demonstrated that the effect of endometriosis on SMM was independent of infertility or fertility treatment. We conclude that SMM in women with endometriosis appears to be due to the disease itself and not to infertility or related treatments.