Society For Maternal-Fetal Medicine Research Articles

Assessing hospital differences in low-risk cesarean delivery metrics in Florida

Unnecessary cesarean deliveries lead to increased maternal and neonatal morbidities and mortalities. In 2020, Florida had a cesarean delivery rate of 35.9%, the third highest in the nation. An effective quality improvement strategy to reduce overall cesarean delivery rates is to decrease primary cesarean deliveries in low-risk births (nulliparous, term, singleton, vertex). Of note, 3 nationally accepted hospital measures of low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics. Comparing metrics is necessary because accurate and timely measurement is essential to support multihospital quality improvement efforts to reduce low-risk cesarean delivery rates and improve the quality of maternal care. This study aimed to assess differences in hospital low-risk cesarean delivery rates in Florida using 5 different metrics of low-risk cesarean delivery rate based on (1) risk methodology, nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics, and (2) data source, linked birth certificate and hospital discharge records and hospital discharge records only. This was a population-based study of live Florida births from 2016 to 2019 to compare 5 approaches to calculating low-risk cesarean delivery rates. Analyses were performed using linked birth certificate data and inpatient hospital discharge data. The 5 low-risk cesarean delivery measures were defined as follows: nulliparous, term, singleton, vertex birth certificate; Joint Commission-linked used Joint Commission exclusions; Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions; Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions. Nulliparous, term, singleton, vertex birth certificate was based on data from birth certificates and not using linked hospital discharge data. Designated as nulliparous, term, singleton, vertex, it does not exclude other high-risk conditions. The second and third measures (Joint Commission-linked used Joint Commission exclusions and Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions) use data elements from the full-linked dataset to designate nulliparous, term, singleton, vertex and excluded several high-risk conditions. The last 2 measures (Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions) were based on data from hospital discharge data only and not using linked birth certificate data. These measures generally reflect term, singleton, and vertex because parity could not be assessed adequately on hospital discharge data. Hospital differences between these 5 measures were calculated overall and by neonatal intensive care unit level. Overall, the median of hospital low-risk cesarean rates decreased across the measures, from NTSV-BC 30.7%, to Joint Commission linked 29.1%, and Society for Maternal Fetal Medicine hospital discharge 29.2% with a large decrease to Joint Commission hospital discharge 19.4% and Society for Maternal Fetal Medicine hospital discharge 18.1%. A similar trend was seen by neonatal intensive care unit level. For each of the measures, level II had the highest median low-risk cesarean rates (nulliparous. term, singleton, vertex birth certificate) 32.7%, Joint Commission linked (31.4%), Society for Maternal Fetal Medicine linked: 31.1%, Society for Maternal Fetal Medicine hospital discharge 19.3%), except for level III Joint Commission hospital discharge (20.0%). A comparison of the median number of low-risk births overall and by neonatal intensive care unit level showed a decreasing number across the linked and hospital discharge measures. Again, a wide gap in low-risk cesarean delivery rates was identified between linked measures and hospital discharge measures. However, this gap narrowed as hospital rates increased. Quality monitoring of low-risk cesarean delivery rates measured by the nulliparous, term, singleton, vertex metric using the birth certificate was fairly accurate and provided timely assessment for use by Florida hospitals. The nulliparous, term, singleton, vertex birth certificate rates were comparable with low-risk metrics using the linked data source. Overall, metrics used within the same data source had similar rates, with the Society for Maternal-Fetal Medicine metric having the lowest rates. Across data sources, metrics using hospital discharge data only resulted in substantially underestimated rates because of the inclusion of multiparous women and should be interpreted with caution.

Operationalizing risk-appropriate perinatal care in a rural US State: directions for policy and practice

BackgroundRisk-appropriate care improves outcomes by ensuring birthing people and infants receive care at a facility prepared to meet their needs. Perinatal regionalization has particular importance in rural areas where pregnant people might not live in a community with a birthing facility or specialty care. Limited research focuses on operationalizing risk-appropriate care in rural and remote settings. Through the implementation of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe), this study assessed the system of risk-appropriate perinatal care in Montana.MethodsPrimary data was collected from Montana birthing facilities that participated in the CDC LOCATe version 9.2 (collected July 2021 – October 2021). Secondary data included 2021 Montana birth records. All birthing facilities in Montana received an invitation to complete LOCATe. LOCATe collects information on facility staffing, service delivery, drills, and facility-level statistics. We added additional questions on transport.ResultsNearly all (96%) birthing facilities in Montana completed LOCATe (N = 25). The CDC applied its LOCATe algorithm to assign each facility with a level of care that aligns directly with guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM). LOCATe-assessed levels for neonatal care ranged from Level I to Level III. Most (68%) facilities LOCATe-assessed at Level I or lower for maternal care. Close to half (40%) self-reported a higher-level of maternal care than their LOCATe-assessed level, indicating that many facilities believe they have greater capacity than outlined in their LOCATe-assessed level. The most common ACOG/SMFM requirements contributing to the maternal care discrepancies were the lack of obstetric ultrasound services and a physician anesthesiologist.ConclusionsThe Montana LOCATe results can drive broader conversations on the staffing and service requirements necessary to provide high-quality obstetric care in low-volume rural hospitals. Montana hospitals often rely on Certified Registered Nurse Anesthetists (CRNA) for anesthesia services and telemedicine to access specialty providers. Integrating a rural health perspective into the national guidelines could enhance the utility of LOCATe to support state strategies to improve the provision of risk-appropriate care.

Executive summary: Workshop on developing an optimal maternal-fetal medicine ultrasound practice, February 7–8, 2023, cosponsored by the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Registry for Diagnostic Medical Sonography, International Society of Ultrasound in Obstetrics and Gynecology, Gottesfeld-Hohler Memorial Foundation, and Perinatal Quality Foundation

Executive summary: Workshop on developing an optimal maternal-fetal medicine ultrasound practice, February 7–8, 2023, cosponsored by the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Registry for Diagnostic Medical Sonography, International Society of Ultrasound in Obstetrics and Gynecology, Gottesfeld-Hohler Memorial Foundation, and Perinatal Quality Foundation

A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine

(Anesth Analg. 2022;135:912–925) Opioid use disorder (OUD) has been on the rise over the past decade and is the leading cause of mortality among pregnant women in the United States. Information and evidence-based recommendations on how to best treat pain in parturients with OUD is lacking. The aim of this scoping review was to highlight existing literature on peripartum pain management for women with OUD, both untreated and treated with medications for opioid use disorder (MOUD), and provide a summary of the information.

Changes in use of 17-OHPC after the PROLONG trial: a physician survey.

To determine if 17α-hydroxyprogesterone caproate (17OHPC) or vaginal progesterone use for patients at risk for preterm birth has changed since the publication of the 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG) trial, and to assess which organizations' (Food and Drug Administration's [FDA], American College of Obstetrics and Gynecology's [ACOG] or Society of Maternal Fetal Medicine's [SMFM]) statements most influenced change. Through a vignette-based physician survey, we sought to measure (by Likert scale) how counseling tendencies regarding 17OHPC and vaginal progesterone have changed since the PROLONG trial publication. Participants were also asked which organizations' statements most influenced change. With response rate of 97 % (141/145), a pre-to-post PROLONG trial comparison revealed significant changes in counseling for progesterone. Respondents were less likely to recommend 17OHPC (p<0.001) and more likely to recommend vaginal (p<0.001). The FDA statement most influenced the decision not to recommend 17OHPC for the prevention of preterm birth (r=-0.23, p=0.005). Providers have made significant changes in their counseling regarding progesterone use for patients at risk for preterm birth after the publication of the PRLONG trial.

Examining Antenatal Corticosteroid Administration at a Single Center via a New Proposed Quality Metric [ID: 1375947

INTRODUCTION: The Society for Maternal-Fetal Medicine (SMFM) proposed a new quality metric in 2022 to increase the rate of antenatal corticosteroid (ACS) provision for early preterm deliveries and minimize ACS for pregnancies ending in term deliveries. This study evaluates compliance with this quality metric and examines which delivery indications are associated with suboptimal ACS timing. METHODS: This is a single-center retrospective cohort of patients receiving ACS from January 2017 to September 2022. The primary outcome, measuring compliance with the SMFM ACS quality metric, is the proportion of all early preterm deliveries that received optimally timed ACS (one dose of ACS within 6 hours–7 days before birth). The secondary outcome is the proportion of term deliveries that had previously received ACS compared to all patients who received ACS. A sample of convenience of 500 patients was investigated to determine the indication for ACS. RESULTS: Of the 36,080 deliveries between 2017 and 2022, 2,022 patients received ACS (initial or rescue) and delivered at this center. There were 3,720 early preterm deliveries. Of early preterm deliveries, 14.67% received ACS in the optimal window. Of all the patients that received ACS, 20.9% delivered at term. ACS were more optimally dosed for hypertension relative risk (RR) 1.71 (95% CI 1.36–2.14) and preterm prelabor rupture of membranes RR 2.08 (95% CI 1.67–2.59). CONCLUSION: Based on the SMFM quality metric, rates of optimal ACS administration remain lower than minimum realistic benchmarks. Continuing efforts are needed to optimize ACS administration for preterm deliveries. In order to meet these goals, institutions may examine which clinical situations lead to suboptimal ACS.

Maternal exercise improves markers of metabolic signaling and reduces inflammation in brown adipose tissue of offspring

Maternal obesity impacts approximately one-third of pregnant people and impacts offspring through the transmission of obesogenic and diabetic traits. Pregnant patients often spend considerable time sedentary, which has been associated with harmful cardiometabolic changes. Our recent data show that compared with sedentary conditions, voluntary exercise during pregnancy in mice shifts adipose distribution of offspring away from energy storing white adipose tissue towards energy burning brown adipose tissue (BAT), which could improve energy metabolism over the lifespan. The objective of this study was to test the hypothesis that voluntary exercise in pregnant mice improves metabolic signaling pathways and reduces markers of inflammation in BAT from offspring. To test this, female C57BL/6J mice were placed on control diet and allocated to sedentary versus voluntary running wheel exercise cages. Voluntary wheel running was allowed for two weeks prior to breeding and throughout weaning. When offspring were 16 weeks of age, they were euthanized for collection of BAT. The study groups were male sedentary (n=9), female sedentary (n=11), male exercise (n=12), female exercise (n=8). Quantitative real-time polymerase chain reaction was used to measure mRNA of fibroblast-growth factor receptors (β-klotho, Fgfr1, Fgfr2) and inflammation markers (IL10, IL1β, TNFα) in BAT. Outcomes were analyzed by two-way ANOVA to assess effects of exercise, sex, and their interaction. Offspring from exercised mothers had a significant decrease in mRNA of IL1β (1.4±0.4 male sedentary vs. 0.4±0.1 male exercise vs. 1.1±0.2 female sedentary vs. 0.8 ±0.2 female exercise; PSex=0.668, PEX=0.006, PInt=0.098) and TNFα (0.9±0.1 male sedentary vs. 0.5±0.1 male exercise vs. 1.3±0.3 female sedentary vs. 0.6 ±0.1 female exercise; PSex=0.126, PEX=0.007, PInt=0.562) and an increase in Fgfr2 (1.1±0.2 male sedentary vs. 1.7±0.3 male exercise vs. 1.3±0.3 female sedentary vs. 3.8 ±1.2 female exercise; PSex=0.063, PEX=0.011, PInt=0.096) in BAT, which was largely independent of sex. There was no significant main effect of either sex or exercise on IL10, Fgfr1, or β-klotho mRNA in BAT. These data suggest that maternal exercise is associated with decreased inflammation and increased protective metabolic signaling in BAT. This could impact energy metabolism given increasing evidence for advantageous metabolic adaptations with increased BAT health and signaling. Additional studies are needed to further understand the impact of maternal exercise on adipose health, energy metabolism, and cardiovascular outcomes in offspring over the lifespan. American Heart Association Undergraduate Summer Fellowship, Department of Obstetrics and Gynecology at Penn State Milton S Hershey Medical Center, and Dani Peress MD Memorial Fund from the Society of Maternal Fetal Medicine This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Late-Onset Severe Fetal Growth Restriction and Isolated Severely Small Abdominal Circumference: Do Neonatal Outcomes Differ? [ID: 1377666

INTRODUCTION: Updated guidelines from the Society for Maternal-Fetal Medicine (SMFM) define severe fetal growth restriction (sFGR), or an estimated fetal weight (EFW) less than 3rd percentile, as a distinct entity due to higher perinatal morbidity in this group. Whether an isolated abdominal circumference (AC) less than 3rd percentile similarly portends adverse outcomes remains unclear. METHODS: This is a single-institution, retrospective cohort study of singleton gestations with late-onset FGR and normal Doppler studies from 2012 to 2022. Pregnancies affected by AC less than 3rd percentile (but EFW≥3rd percentile) and EFW less than 3rd percentile were compared using univariable analysis and multivariable logistic regression. The primary outcome was neonatal intensive care unit (NICU) admission. RESULTS: Among eligible participants, 78 (63%) had an isolated AC less than 3rd percentile and 45 (37%) had sFGR. Neonates prenatally diagnosed with sFGR were more likely to be admitted to the NICU than those with isolated AC less than 3rd percentile (68.9% versus 23.1%, P&lt;.001). After adjusting for gestational age, birth weight, race, maternal age, and medical comorbidities, sFGR was still associated with an increased odds of NICU admission (adjusted odds ratio 4.9, 95% CI 1.37–17.48, P=.014). Rates of cesarean delivery (46.7% versus 26.9%; P=.03), small for gestational age (86.7% versus 67.9%, P=.02), and 5-minute Apgar score less than 7 (6.7% versus 0.0%, P=.02) were also higher in the sFGR group. There were no significant differences in NICU length of stay or perinatal death between groups. CONCLUSION: Adverse neonatal outcomes were more prevalent in pregnancies affected by sFGR compared with isolated AC less than 3rd percentile, providing support for the updated SMFM guidelines.

Effect of the New Diagnostic Criteria of Fetal Growth Restriction on Obstetric and Neonatal Outcomes [ID: 1376466

INTRODUCTION: The diagnostic criteria of fetal growth restriction (FGR) was modified by the Society of Maternal-Fetal Medicine in 2020 to include both an abdominal circumference (AC) and estimated fetal weight (EFW) less than the 10th percentile as opposed to previous definition using only the EFW. We sought to evaluate the outcomes of this criteria modification. METHODS: This retrospective study compared the incidence, obstetrical and neonatal outcomes before (group 1, 2020) and after (group 2, 2021) the implementation of the modified diagnostic criteria at a single institution. This is an IRB-approved study. RESULTS: Of the 459 pregnancies with FGR included in this study, 100 were diagnosed in 2020 (group 1) and 359, in 2021 (group 2). An increase in the incidence of FGR was noted after the modification, 1.5% versus 5.3% (P&lt;.05). Median gestational age (weeks) at delivery decreased from 38.1 (Q1, 37.1; Q3, 39.1) in 2020 to 37.4 (Q1, 36.1; Q3, 38.3) in 2021 (P&lt;.05). There were no statistically significant differences in obstetrical outcomes. An increase in the frequency of respiratory distress syndrome was observed, 6 (6%) versus 51 (14.2%), P&lt;.05, and median length of neonatal stay 2.0 (Q1, 1.0; Q3, 3.0) and 2.0 (Q1, 2.0; Q3, 12.0) in group 1 compared to group 2 (P&lt;.05). CONCLUSION: The new diagnostic criteria for FGR is associated with increased incidence of diagnosis, neonatal respiratory distress, longer neonatal hospital admissions, and lower gestational age of delivery with no difference in obstetrical outcomes. It remains uncertain whether this modification will translate to improved outcomes, and larger multicenter prospective studies are needed.

Genetic counseling for fetal sex prediction by NIPT: Challenges and opportunities.

Non-invasive prenatal testing (NIPT) has grown in ubiquity in the last decade and is now endorsed by Society for Maternal Fetal Medicine and American College of Obstetricians and Gynecologists as a screening tool for aneuploidy in all patients. Past studies have demonstrated a tendency among obstetrics patients to focus on the ability of NIPT to predict fetal sex chromosomes; however, data on the experiences of genetic counselors (GCs) counseling on NIPT and fetal sex prediction are limited. This mixed-methods study aimed to explore how GCs counsel about NIPT and fetal sex prediction, as well as the use of gender-inclusive language in this setting. A 36-item survey with multiple choice, Likert scale, and open-ended questions was distributed to GCs who currently offer NIPT to patients. Quantitative data were analyzed using R and qualitative data were manually analyzed and coded via inductive content analysis. A total of 147 individuals completed at least some portion of the survey. A majority of participants (68.5%) reported frequent interchangeable use of the terms 'sex' and 'gender' by patients. A majority (72.9%) of participants reported that they rarely or never discuss the difference between these terms in sessions (Spearman's rho = 0.17, p = 0.052). Seventy-five respondents (59.5%) indicated that they had taken continuing education courses on inclusive clinical practices for trans and gender-diverse (TGD) patients. Several themes arose from free responses; the most frequently identified themes were the need for thorough pretest counseling that properly describes the scope of NIPT and the challenge of discrepant pretest counseling by other healthcare providers. Results from our research identified challenges and misconceptions GCs face when offering NIPT and various tactics implemented to mitigate these. Our study highlighted the need for the standardization of pretest counseling regarding NIPT, additional guidance from professional organizations, and continuing education focused on gender-inclusive language and clinical practices.

Use of contraceptive implants at 12 months in women who intended to undergo immediate versus delayed postpartum insertion following high-risk pregnancy.

To assess the correlation between the intention to undergo immediate versus delayed postpartum contraceptive implant insertion following high-risk pregnancy, and the proportion of utilization and adverse effects. We conducted a retrospective cohort study of women who gave birth after a high-risk pregnancy (according to the criteria defined by the Society for Maternal-Fetal Medicine) and intended to use contraceptive implants. The participants were classified into two groups based on whether they underwent immediate or delayed insertion. The primary outcome was the proportion of utilization of contraceptive implants at 12 months postpartum. We performed multivariate analyses to determine the relationships between the timing of insertion, characteristics, and methods used. Of the 482 women classified as having high-risk pregnancies, 103 intended to use contraceptive implants (54 immediate and 49 delayed insertions). Women in the immediate group were more likely to use contraceptive implants than those in the delayed group at 6 (95.2% vs. 26.2%, P<0.01) and 12 months (92.7% vs. 26.2, P<0.01). A higher proportion of participants in the immediate group reported spotting and prolonged bleeding at 12 months (51.1% vs. 23.8%, P=0.01 and 26.8% vs. 7.1%, P=0.01; respectively). However, satisfaction at 12 months was higher in the immediate group than in the delayed group. Intention to undergo implant insertion during the immediate postpartum period appears to improve the utilization of highly effective contraception. Patients who underwent immediate implantation experienced more spotting, prolonged bleeding, and dysmenorrhea. This study supports the recommendation to provide immediate postpartum contraceptive implants to women following high-risk pregnancies.

Association of Vaginal Progesterone Treatment With Prevention of Recurrent Preterm Birth

Association of Vaginal Progesterone Treatment With Prevention of Recurrent Preterm Birth

The Cesarean Scar of Pregnancy: Ultrasound Findings and Expectant Management Outcomes.

The nomenclature has evolved from low implantation to cesarean scar pregnancy (CSP) and criteria are recommended for identification and management. Management guidelines include pregnancy termination due to life-threatening complications. This article applies ultrasound (US) parameters recommended by the Society for Maternal Fetal Medicine (SMFM) in women who were expectantly managed. Pregnancies were identified between March 1, 2013 and December 31, 2020. Inclusion criteria were women with CSP or low implantation identified on US. Studies were reviewed for niche, smallest myometrial thickness (SMT), and location of basalis blinded to clinical data. Clinical outcomes, pregnancy outcome, need for intervention, hysterectomy, transfusion, pathologic findings, and morbidities were obtained by chart review. Of 101 pregnancies with low implantation, 43 met the SMFM criteria at < 10 weeks and 28 at 10 to 14 weeks. At < 10 weeks, SMFM criteria identified 45out of 76 women; of these 13 required hysterectomy; there were 6 who required hysterectomy but did not meet the SMFM criteria. At 10 to < 14 weeks, SMFM criteria identified 28 out of 42 women; of these 15 required hysterectomy. US parameters yielded significant differences in women requiring hysterectomy, at < 10 weeks and 10 to < 14 weeks' gestational age epochs, but the sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of these US parameters have limitations in identifying invasion to determine management. Of the 101 pregnancies, 46 (46%) failed < 20 weeks, 16 (35%) required medical/surgical management including 6 hysterectomies, and 30 (65%) required no intervention. There were 55 pregnancies (55%) that progressed beyond 20 weeks. Of these, 16 required hysterectomy (29%) while 39 (71%) did not. In the overall cohort of 101, 22 (21.8%) required hysterectomy and an additional16 (15.8%) required some type of intervention, while 66.7% required no intervention. SMFM US criteria for CSP have limitations for discerning clinical management due to lack of discriminatory threshold. · The SMFM US criteria for CSP at <10 or <14 weeks have limitations for clinical management.. · The sensitivity and specificity of the ultrasound findings limit the utility for management. · The SMT of <1 mm is more discriminating than <3 mm for hysterectomy..

The REDUCED trial: a cluster randomized trial for REDucing the Utilization of CEsarean delivery for Dystocia

To reduce cesarean delivery rates in nulliparous women, guidelines for diagnosing nonprogressive labor have been developed by the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. These are mainly based on data from the Consortium for Safe Labor study. The guidelines have not been tested in a clinical trial, so the efficacy and safety of this new approach is uncertain. This study aimed to assess whether adoption of new guidelines for diagnosing nonprogressing labor would reduce cesarean delivery rates. We conducted a cluster randomized controlled trial of a knowledge translation program of the guidelines in 26 Canadian hospitals (13 control sites and 13 intervention sites). The sites included all intrapartum care sites in Alberta that perform cesarean delivery and deliver at least 70 nulliparous women annually. The baseline period started on January 1, 2015. The intervention was initiated at the first intervention site in January 2017. The follow-up period began at the first intervention site in February 2017 and lasted till February 2020. The primary outcome was the rate of cesarean delivery in nulliparous women with vertex presentation in labor at term. The secondary outcomes included spontaneous vaginal birth and maternal and neonatal safety. The main data source for the primary and secondary outcomes was the Alberta Perinatal Health Program database. The cesarean delivery rates were assessed using repeated measures mixed effects logistic regression applied to individual births. The analysis was based on 45,193 deliveries at intervention sites and 43,725 deliveries at control sites. There was no evidence of a decrease in the rate of cesarean delivery in association with the intervention (baseline-adjusted odds ratio, 0.94; 95% confidence interval [0.85-1.05]; P=.259). The rate of spontaneous vaginal delivery increased slightly (baseline-adjusted odds ratio, 1.10; 95% confidence interval, [1.01-1.18]; P=.024). We did not observe any differences in adverse maternal or neonatal outcomes. Cesarean delivery rates in nulliparous women were not reduced by the application of recent guidelines for the diagnosis of nonprogressive labor. Spontaneous vaginal delivery-a secondary outcome-was increased in the intervention group. The intervention appears to be safe.

Perinatal Care during the COVID-19 Pandemic

Background: Following the pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), and considering its capacity for rapid mutation, there have been many studies and articles on this novel coronavirus over the past three years. Therefore, providing knowledge and directions for management of SARS-CoV-2, for hospital staff is crucial. Hence, we collected the research information from different perspectives and summarized the guidelines for perinatal care on the topic of SARS-CoV-2, and for possible future viral pandemics. Methods: A systematic review aimed at assessing the publications written in English and Chinese, offering different perspectives on the topic of perinatal care concerning SARS-CoV-2, was conducted using PubMed and Google Scholar from 2020 to 2022. In addition, we summarized the guidelines from the Taiwan Association of Obstetrics and Gynecology, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Maternal Immunization Task Force and Partners, and Academy of Breastfeeding Medicine. Results: Due to physiological changes, pregnant patients may be prone to have complications, especially pre-eclampsia, affecting morbidity and mortality. Most neonates of coronavirus disease (COVID-19) infected mothers did not show any clinical abnormalities due to the infection. However, compared to the general population, infected neonates needed more invasive ventilation care, while the proportion of asymptomatic neonates was less than that in the general population. Further, long term complications are still under investigation. Evidence of vertical transmission via the placenta and umbilical cord is rare but not absent. Paxlovid (nirmatrelvir/ritonavir) can be administered to patients with comorbidities, and indications for cesarean delivery does not include COVID-19 infection. Vaccination against COVID-19 should not be delayed during pregnancy and lactation. Conclusions: Obstetricians and gynecologists should pay more attention to pregnant women with SARS-CoV-2 because of the physiological changes and higher risks of complications, morbidity, and mortality. Early prevention with vaccination in pregnant women is the key to controlling the COVID-19 pandemic, from which we can learn how to manage the next pandemic.

Definitions matter: detection rates and perinatal outcome for infants classified prenatally as having late fetal growth restriction using SMFM biometric vs ISUOG/Delphi consensus criteria.

Fetal growth restriction (FGR) is often secondary to placental dysfunction and is suspected prenatally based on biometric or circulatory abnormalities detected on ultrasound. The aims of this study were to compare the screening performance of the Society for Maternal-Fetal Medicine (SMFM) biometric criteria (estimated fetal weight (EFW) or abdominal circumference (AC) < 10th centile) with that of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)-endorsed Delphi consensus criteria for late FGR for delivery of a small-for-gestational-age (SGA) infant at term, emergency Cesarean section (CS) for non-reassuring fetal status (NRFS), perinatal mortality and composite severe neonatal morbidity. We classified retrospectively non-anomalous singleton infants as having late FGR (diagnosed ≥ 32 weeks) according to SMFM and ISUOG/Delphi criteria in a cohort of women who had been referred to the Mater Mother's Hospital, Brisbane, Australia and who delivered at term between January 2014 and December 2020. The study outcomes were delivery of a SGA infant (birth weight (BW) < 10th or < 3rd centile), emergency CS for NRFS, perinatal mortality (defined as stillbirth or neonatal death within 28 days of a live birth) and a composite of severe neonatal morbidity. We assessed the screening performance of various ultrasound variables by calculating the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, false-positive and false-negative rates, positive likelihood ratio (LR+) and negative likelihood ratio. The SMFM and ISUOG/Delphi consensus criteria collectively classified 1030 cases as having late FGR. Of these, 400 cases were classified by both SMFM and ISUOG/Delphi criteria, whilst 548 cases were classified using only SMFM criteria and 82 cases were classified only by ISUOG/Delphi criteria. Prenatal detection of late FGR by SMFM and ISUOG/Delphi criteria was associated with increased odds of delivery of an infant with BW < 10th centile (SMFM: adjusted odds ratio (aOR), 133.0 (95% CI, 94.7-186.6); ISUOG/Delphi: aOR, 69.5 (95% CI, 49.1-98.2)) or BW < 3rd centile (SMFM: aOR, 348.7 (95% CI, 242.6-501.2); ISUOG/Delphi: aOR, 215.4 (95% CI, 148.4-312.7)). Compared with the SMFM criteria, the ISUOG/Delphi criteria were associated with lower odds (aOR, 0.5 (95% CI, 0.3-0.8)) of predicting a SGA infant with BW < 10th centile, but higher odds of predicting emergency CS for NRFS (aOR, 2.30 (95% CI, 1.14-4.66)) and composite neonatal morbidity (aOR, 1.22 (95% CI, 1.05-1.41)). Both SMFM and ISUOG/Delphi criteria were associated with high LR+, specificity, PPV and NPV for the prediction of infants with BW < 10th and BW < 3rd centile. However, both methods functioned much less efficiently for the prediction of composite severe neonatal morbidity or emergency CS for NRFS, with LR+ < 10. The SMFM biometric criteria alone, particularly AC < 3rd centile, had the highest LR+ values for the prediction of perinatal mortality. Both the SMFM and ISUOG/Delphi criteria had strong screening potential for the detection of infants with BW < 10th or < 3rd centile but not for adverse neonatal outcome. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Coronavirus Disease 2019 (COVID-19) Vaccination in Pregnancy.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy is associated with significant maternal morbidity and mortality, and its risks can be mitigated with coronavirus disease 2019 (COVID-19) vaccination. Vaccination against COVID-19 in pregnancy results in protection against both maternal and neonatal SARS-CoV-2 infection, as well as maternal critical illness. Vaccination during pregnancy is safe, with no documented risks of pregnancy loss, preterm delivery, congenital anomalies, or other adverse perinatal outcomes. For these reasons, COVID-19 vaccination is recommended in pregnancy by the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine, as well as other national and international professional organizations. In this review, we will summarize the published literature demonstrating the benefit and safety of these vaccines.

Impact of new labor management guidelines on Cesarean rates among low-risk births at New York City hospitals: A controlled interrupted time series analysis

To examine the impact of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG-SMFM) 2014 recommendations for preventing unnecessary primary Cesareans. In a population-based cohort of births in New York City from 2012 to 2016, we used controlled interrupted time series analyses to estimate changes in age-standardized Cesarean rates among nulliparous, term, singleton vertex (NTSV) deliveries. Among 192,405 NTSV births across 40 hospitals, the age-standardized NTSV Cesarean rate decreased after the ACOG-SMFM recommendations from 25.8% to 24.0% (Risk ratio [RR]: 0.93; 95% CI 0.89, 0.97), with no change in the control series. Decreases were observed among non-Hispanic White women (RR: 0.89; 95% CI 0.82, 0.97), but not among non-Hispanic Black women (RR: 0.97; 95% CI 0.88, 1.07), Asian/Pacific Islanders (RR: 1.01; 95% CI 0.91, 1.12), or Hispanic women (RR: 0.94; 95% CI 0.86, 1.02). Similar patterns were observed at teaching hospitals, with no change at nonteaching hospitals. While low-risk Cesarean rates may be modifiable through changes in labor management, additional research, and interventions to address Cesarean disparities, are needed.

Isolated abdominal circumference vs. estimated fetal weight, which matters more?

Fetal growth restriction (FGR) is a leading cause of neonatal morbidity and mortality. In 2020, the Society of Maternal Fetal Medicine and the American College of Obstetricians and Gynecologists redefined fetal growth restriction from estimated fetal weight (EFW) less than the 10th percentile to EFW or abdominal circumference (AC) less than the 10th percentile. In our study, we seek to assess the rate of abnormal umbilical artery Doppler velocimetry in fetuses with FGR diagnosed by isolated AC less than the 10th percentile versus those diagnosed by EFW less than the 10th percentile.

The impact of COVID-19 vaccinations on stillbirth rates among pregnant women in the Metro-Detroit area

Infection by COVID-19 increases maternal morbidity and mortality prompting both the American College of Obstetrics and Gynecology and the Society of Maternal Fetal Medicine to strongly recommend vaccination during pregnancy. Limited data exist assessing the risk of intrauterine fetal death (IUFD) associated with COVID vaccination during pregnancy.This was a retrospective chart review at a large multisite hospital system in Metro Detroit which reviewed data from 13,368 pregnancies. We compared IUFD rates between vaccinated and unvaccinated patients. The rate of stillbirths among unvaccinated women (0.75%) was not statistically different from those who were vaccinated (0.60%). Individuals with government insurance were less likely to be vaccinated and more likely to have IUFD in comparison to patients with private insurance. The rate of stillbirths among Black women was significantly higher than among White women at a rate of 1.1% compared to 0.53% (p=0.008) with no difference in stillbirth rates among vaccinated vs unvaccinated racial distribution. Lastly, it is worth noting that the overall vaccination rate at our healthcare system in pregnancy was very poor (0.26%).In conclusion, this is a large population of highly diverse patients which indicates that COVID-19 vaccination does not lead to IUFD. We plan to use this data to help drive an educational vaccination campaign to try to increase our COVID-19 vaccination rate in our pregnant patients. Systemic racism and social determinants of health have played a large factor in COVID-19 outcomes, and our data highlights that this is the case for IUFD in Black women. Improvements must be made to identify barriers for these women to allow for better pregnancy outcomes. We acknowledge that individuals with government insurance may also have other barriers to healthcare or face healthcare inequity which leaves room for improvement on getting these individuals vaccinated and getting the resources they need to have better pregnancy outcomes.