Sodium intake and the development of hypertensive disorders of pregnancy.

BACKGROUND: In nonpregnant populations, sodium intake has been associated with the development of chronic hypertension, and sodium restriction has been identified as a strategy to reduce blood pressure. Data regarding the relationship between sodium intake and the development of hypertensive disorders of pregnancy are limited and conflicting. OBJECTIVE: This study aimed to assess the association between daily periconceptional sodium intake and the risk of hypertensive disorders of pregnancy. STUDY DESIGN: This was a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be study. Individuals with nonanomalous, singleton pregnancies who completed food frequency questionnaires with recorded sodium intake in the 3 months before pregnancy were included in the analysis. Individuals whose pregnancies did not progress beyond 20 weeks of gestation were excluded from the analysis. Sodium intake was categorized as low (<2 g per day), medium (2 to <3 g per day), or high (≥3 g per day), based on thresholds used in the nonpregnant population. The primary outcome was the development of a new-onset hypertensive disorder of pregnancy, including gestational hypertension; preeclampsia; hemolysis, elevated liver enzymes, and low platelet count syndrome; superimposed preeclampsia; or eclampsia. Bivariable analyses were performed using Kruskal-Wallis and chi-square tests. Poisson regression was used to estimate adjusted incidence risk ratios with 95% confidence intervals after controlling for potentially confounding factors. RESULTS: Among 7458 individuals included in this analysis, 2336 (31%) reported low sodium intake, 2792 (37%) reported medium sodium intake, and 2330 (31%) reported high sodium intake. Individuals with high sodium intake were more likely to have chronic hypertension, to use tobacco, and to be living with obesity. The risk of developing a hypertensive disorder of pregnancy was similar among groups (medium vs low adjusted incidence risk ratio: 1.10 [95% confidence interval, 0.94-1.28]; high vs low adjusted incidence risk ratio: 1.17 [95% confidence interval, 1.00-1.37]). There was no difference in neonatal outcomes by sodium intake, including preterm birth, small-for-gestational-age neonate, and admission to the neonatal intensive care unit. CONCLUSION: Sodium intake was not associated with the risk of developing a hypertensive disorder of pregnancy. This lack of association contrasts with that between sodium intake and hypertension in the nonpregnant state and may reflect differences in the pathophysiology underlying pregnancy- vs non-pregnancy-related hypertensive disorders.

Challenges in Conducting Therapeutic Trials in Pregnancy: Emphasizing Recent Lessons Learned.

Pregnant people have traditionally been excluded from therapeutic research by restrictions intended for fetal protection. Despite a movement toward inclusion, concerns for the feasibility and safety of including pregnant people in studies continue to limit this research. This article reviews the history of research guidelines in pregnancy and illustrates ongoing challenges, as seen in the development of vaccines and therapies during the coronavirus disease 2019 pandemic and investigation of statins for preeclampsia prevention. It explores new approaches that may be used to improve therapeutic research in pregnancy. A major cultural shift is needed to balance potential maternal and/or fetal risks with potential benefits from participation in research, as well as harm from withholding treatment or providing one that is not evidence-based. Finally, it is important to honor maternal autonomy in decision-making regarding participation in clinical trials.

The "30-minute rule" for expedited delivery: fact or fiction?

Initially developed from hospital feasibility data from the 1980s, the "30-minute rule" has perpetuated the belief that the decision-to-incision time in an emergency cesarean delivery should be <30 minutes to preserve favorable neonatal outcomes. Through a review of the history, available data on delivery timing and associated outcomes, and consideration of feasibility across several hospital systems, the use and applicability of this "rule" are explored, and its reconsideration is called for. Moreover, we have advocated for balanced consideration of maternal safety with rapidity of delivery, encouraged process-based approaches, and proposed standardization of terminology regarding delivery urgency. Furthermore, a standardized 4-tier classification system for delivery urgency, from class I, for a perceived threat to maternal or fetal life, to class IV, a scheduled delivery, and a call for further research with a standardized structure to facilitate comparison have been proposed.

Risk factors for postoperative ileus after cesarean delivery.

BACKGROUND: Despite extensive data regarding risk factors for postoperative ileus in the general and colorectal surgery literature, few studies have identified risk factors specific to the obstetrical population. OBJECTIVE: This study aimed to identify factors associated with postoperative ileus following cesarean delivery. STUDY DESIGN: This retrospective case-control study identified women who underwent cesarean delivery at a single hospital between January 2000 and January 2020 and subsequently developed postoperative ileus. Cases were matched in a 1:2 ratio with controls who underwent cesarean delivery and did not develop postoperative ileus. They were matched by age (±1 year) and body mass index (±1 kg/m2). Demographics, common comorbidities, obstetrical history, and delivery characteristics were analyzed. RESULTS: A total of 147 cases and 294 controls were identified. Cases and controls were similar in terms of parity, number of previous cesarean deliveries, labor preceding their cesarean delivery, incidence of chorioamnionitis, and presurgical diagnosis of hypothyroidism or chronic hypertension. Cases tended to have a diagnosis of preeclampsia (cases 23.1% vs controls 10.5%; P<.001) and were more likely to have been exposed to magnesium sulfate (cases 34.0% vs controls 15.0%; P<.001). Surgical considerations that were common in cases were exposure to general anesthesia (cases 37.4% vs controls 4.1%; P<.001), midline vertical skin incisions (cases 13.6% vs controls 1.4%; P<.001), classical hysterotomy (cases 8.8% vs controls 1.7%; P=.001), estimated blood loss >1000 mL (cases 44.4% vs controls 11.6%; P<.001), transfusion of blood products (cases 25.8% vs controls 2.0%; P<.001), and hysterectomy at the time of cesarean delivery (cases 6.1% vs controls 0.7%; P=.001). After a multivariable modeling using stepwise logistic regression of all variables found to be statistically significant, transfusion of blood products, estimated blood loss >1000 mL, and exposure to general anesthesia were the remaining surgical factors associated with the development of ileus. These variables reflect both the complexity and most likely the duration of surgery that was required, although we note that we did not have operative time as a variable to explore. Preeclampsia was also identified as a comorbidity linked to the development of ileus. CONCLUSION: A diagnosis of preeclampsia, exposure to general anesthesia, estimated blood loss >1 L, and transfusion of blood products were identified as potential risk factors for postcesarean ileus.

Outcomes associated with antibiotic administration for isolated maternal fever in labor.

BACKGROUND: The American College of Obstetricians and Gynecologists currently recommends that antibiotic treatment should be considered for women with isolated maternal fevers during labor. However, there is little known about the maternal and neonatal impact of antibiotic treatment in this scenario. OBJECTIVE: We sought to assess the outcomes in women with a nonsustained, isolated maternal fever treated with antibiotics and compare it with expectant management. STUDY DESIGN: This was a retrospective cohort study of laboring women with a singleton gestation at term and a single temperature of between 38.0°C and 38.9°C without other evidence of infection (leukocytosis >15,000/mm3, fetal tachycardia, malodorous amniotic fluid, suspected alternate source of infection) at a tertiary teaching hospital. A contemporaneously maintained, validated obstetrical database was used to identify women for our cohort. Women with rheumatologic or renal disease, nongestational diabetes, preterm labor, placental abruption, vaginal bleeding, HIV, malpresentation, and fetal anomalies were excluded. The primary outcome was a postpartum fever above 38.0°C. Secondary maternal outcomes were treatment for postpartum endometritis, uterine atony, postpartum hemorrhage, admission to the intensive care unit, and postpartum length of stay. Secondary neonatal outcomes were neonatal intensive care unit admission, 5-minute Apgar score of <7, 5-minute Apgar score of <4, neonatal intensive care unit length of stay, and neonatal antibiotic administration. The results were compared using univariable and multivariable analyses. RESULTS: From January 1, 2015, to December 31, 2018, 359 women were identified; 85 received antibiotics and 274 did not. The baseline characteristics were similar between the groups, except for gestational age at the time of delivery (39.2 weeks vs 39.5 weeks for the antibiotic and no antibiotic groups, respectively; P=.02). The incidence in postpartum fever showed a downward trend in the antibiotic group (10.59% for the antibiotic group vs 18.98% for the no antibiotic group; P=.07). Significantly fewer women in the antibiotic group were treated for postpartum endometritis (3.53% vs 11.31%; P=.03). Neonatal intensive care unit admission and neonatal antibiotic administration rates were higher in the antibiotic group (41.18% vs 17.88%; P<.001 and 36.47% vs 12.41%; P<.001, respectively). The incidence of 5-minute Apgar score of <7 was higher in the antibiotic group (8.25% vs 2.19%; P=.016). After controlling for age, gestational age, body mass index, group B streptococci status, delivery method, parity, administration of epidural, and receipt of acetaminophen, the odds for postpartum fever were reduced by a factor of 0.42 (95% confidence interval, 0.18-0.99) among women who received antibiotics when compared with those who did not receive antibiotics. Outcome results are presented in Table 2. CONCLUSION: Although there was a lower rate of treatment for endometritis among women who received antibiotics for a single isolated maternal fever, there was a higher rate of neonatal intensive care unit admissions and 5-minute Apgar score of <7. This indicates that there likely is maternal benefit associated with antibiotic use, however, there are concerns about the neonatal risk.